How I Teach Evidence-Based Epidural Information in a Hospital and Keep My Job

Abstract

A childbirth educator reveals her dilemma in teaching evidence-based practice in today's high-tech birth climate. She focuses on strategies to use when sharing epidural information with expectant parents.

I have been teaching Lamaze classes for almost 30 years, and for 20 of those years I have been in a hospital setting. I also teach some independent classes. So, how have I managed to teach normal-birth-focused classes and still have my job? Recently, I've had to make some choices.

A couple years ago, within a 9-month period, I was called into my supervisor's office three times to answer to complaints from couples in my classes who believed that I was biased against epidurals and pain medications. Well, I am biased. Birth trends have shifted since I began teaching classes many years ago, and the changes are evident in the statistics at the hospital where I work. For years, the epidural rate at the hospital hovered around 26%, and then, all of a sudden, it was 60%. (This hospital is a large, tertiary care center and a teaching hospital, but it also has private doctors attending births. I teach mostly the patients of the private doctors.)

So my dilemma was, how could I educate women about their choices if they believed I was biased and not presenting an even-keeled class? This was a fork in the road for me. Should I continue at the hospital and change my tune, or should I go back to my living room? Now, at this time, my supervisor was not telling me how to teach; instead, she said I was a good educator and I needed to figure out what to do. Obviously, she wasn't happy about the complaints. Subsequently, my annual review was not outstanding.

I have heard of other childbirth educators getting called on the carpet, and I have even counseled some of them. How was this happening to me? And how was I going to continue to present normal birth if the class members perceived my message as “biased” and “anti-epidural” (the words of the folks complaining)?

After some reflection, I decided that I like the challenge of teaching the hospital classes. In the geographical area where I work, expectant couples planning ahead for unmedicated births are more likely to search for classes outside a hospital, so I seem to be teaching families who haven't given much consideration to their options for birth or don't even know they have options. It is of great satisfaction to watch their expressions when they have an “Aha!” moment.

My next question for myself was, “How can I change my teaching and still maintain my principles?” And can I live with myself? So I began tweaking my classes. Up to this time, I had not mentioned epidurals in class until the evening of the intervention class—that is, unless someone asked a question, and then, I barely answered the question and said we would discuss epidurals in a later class.

I still have some class members tell me, “I never thought I could give birth without an epidural, but from what I've learned in your class, I think I can.” What an “Aha!” moment!

The following steps demonstrate how I tweaked my class and found I could live with the changes, because I still focus on normal birth and the Lamaze philosophy of birth:

1. On the first evening, when we discuss the discomforts of pregnancy, we attempt the exaggerated lateral Sims position as a good sleeping position. I also mention that it is a good laboring position if someone chooses an epidural.

2. When discussing the hormonal orchestration of birth and the powerful endorphins, I mention that if a woman chooses to use narcotics or an epidural that has narcotics in it, the medications will reduce or suppress the endorphin production. So it will be a choice for the woman.

3. During the presentation of fetal development and the role of the placenta, I discuss what the placenta blocks from the baby and what can pass through. It is the same in labor. If the mother has been avoiding alcohol, over-the-counter medications, caffeine, fish high in mercury, and other potential risks for the baby, she needs to understand that the medications given during labor and birth also will be transferred to the baby.

4. When presenting DVD- or VHS-formatted videos, I introduce each birth carefully and mention the mother's choice. For example, I say:

   We will view Everyday Miracles, a beautiful production of three women and their support team in labor and giving birth. All of the women in this video choose not to use pain medications in their births. But, at another time in class, we will have the opportunity to see a birth where the mother does choose pain medications and an epidural.

5. Before the intervention class, each class member has an opportunity to choose one of the interventions, research it, and present its benefits, trade-offs, alternatives, and the partner's role in each intervention. During their presentations, the participants become the “experts” on each intervention, and questions are filtered through them. In my experience, class participants present a balanced view of each intervention—and it is not coming out of my mouth. The hospital where I work wants its childbirth educators to show the brief segment on epidurals from the video Works of Wonder. So, after the presentation about epidurals, I say we will now see how an epidural is done. This production has a comprehensive list of the side effects of epidurals.

6. If an epidural is planned, we discuss how expectant mothers can minimize the trade-offs: delay the epidural until later in labor; push with the urge; monitor unusual-looking movements of the mother's body by her obstetrician or nurses (such as pushing her knees back too far when she doesn't have adequate, normal sensation to tell them, “Quit!”); turn from side to side while laboring and pushing; allow no separation of mother and baby after the birth; and get the baby to breast within the first 2 hours.

7. When presenting the topic of “pushing” in class, I advise women that it is easy. I advise them to just push when they feel the urge, whether they have an epidural or not. Also, when I conduct a tour of the birthing unit, I get in the bed, use the birth (squatting) bar, and demonstrate the various pushing positions, including positions that may help if an epidural is used.

Readers and other childbirth educators may want to know how my teaching adjustments have worked. Well, I still have my job. I received an outstanding annual review in 2006, and my class evaluations do not say I am biased. Often, participants report that the class was very balanced. I believe I am still teaching normal birth and, at the same time, introducing enough information so that expectant parents can make the decisions that are best for them.

And I still have some class members tell me, “I never thought I could give birth without an epidural, but from what I've learned in your class, I think I can.” What an “Aha!” moment!