"Maybe we should bring in the senior anesthesiologist." I could hear the midwife's words in between my agonized screams. "They probably have more experience with patients of all sizes." She was speaking to the junior doctor currently trying, and repeatedly failing, to place an epidural into my back. The doctor wanted practice, though. How else was she going to learn about performing epidurals on clinically obese patients? So, I became her guinea pig. Six, seven, eight attempts later, she got the needle in.
When my eldest was born nearly three years ago, I didn't feel like I had much control over my birth, in much the same way that I didn't feel like I had much control over my pregnancy. I didn't know that I could say "no" to certain medical suggestions. I didn't know it was within my power to ask that the senior anesthetist perform my epidural. I didn't know I could tell the doctor playing trial and error games on my spine that I'd really like her to stop now.
So, I didn't ask her, and she didn't stop. Unfortunately, my back has never recovered. If ever I bring up the chronic pain I'm experiencing to my general practitioner, I'm advised that losing weight will surely help — but, in reality, it wasn't my weight in and of itself that caused the problem. It was the multiple failed attempts at getting an epidural.
"One of the big things that’s thrown at plus-size pregnant people is that they should have an anesthetic review before labor to establish whether an epidural can be done," says Hannah Beety, an independent midwife based in the UK, where I live. (Unfortunately, this wasn't something I was ever offered.) "But built into that is the expectation, and almost a push, for epidural earlier in labor for plus-size people because the procedure is deemed to be harder to do," she adds. "It's also a preemption in trying to avoid a general anesthetic cesarean section. But if you have carers with that mindset, who are expecting to go into a cesarean section, you’re on a bit of a sticky wicket anyway," Beety says, invoking a cricket term for a situation that is difficult any way you play it.
Beety explains that the reason epidurals might be harder to insert properly in plus-size patients simply comes down to the fact that there is more body to contend with. "Anesthetists are looking for a particular point on the spine, so they’re actually feeling down the vertebrae of the spine," she says. "If it’s difficult to identify the correct space or the correct vertebrae, then it may be more difficult to put in."
The trouble is that despite the potential risks of getting an epidural when you are fat, many medical practitioners funnel you toward this pain relief option while denying you most others. "There are some studies that say water birth is just as effective in pain management," Beety says. "Water birth has the added benefits of reducing blood pressure, encouraging mobility, and supporting ligaments. So, actually, it’s fantastic for people who are plus-size and are told they’re at risk of higher blood pressure, or decreased mobility. And yet, we’re denying plus-size people access to the birthing pools." Practitioners typically advise against home birth for plus-size people, while also denying us entry into certain midwife-led birthing centers where we'd have access to pools on the basis of BMI alone.
What I've learned since my first pregnancy, however, is that fat pregnant people's experiences of labor and epidurals are just as varied and nuanced as thin pregnant people's. I spoke to seven self-identified fat mamas about their birth stories and epidurals, ultimately confirming my suspicions. Things can go wrong in a fat person's pregnancy and delivery (as they do for folks of any size), but they don't always.
Lena had been in labor for 12 hours by the time she was admitted into the hospital. Once there, her midwife suggested that if she wanted an epidural, she get one early. "Best advice I ever got," Lena tells Romper.
"She called the anesthesiologist for me [and] he arrived within 15 minutes. When he walked in he said, 'I know you,' and it turned out I’d served him pints at my job at a local pub. We had a laugh about how now he was going to give me drugs in return for all the beer I’d served him."
Lena feels lucky. Her doctor was open with her, asked plenty of questions about her wishes, and answered any questions she had in return. "I asked if there was any truth in what I’d heard about it being more difficult to place an epidural in fat women like myself," she remembers. "He said, 'It can be, but there are multiple things that can make it difficult in people of all shapes and sizes. Really, I just need you to stay very still.'"
It took only two attempts for the epidural to be placed correctly, at which point Lena enjoyed a cup of tea and some grapes. Even though the epidural wore off by the time her daughter was born, she says that if ever she were to have another child, she would "100% have another epidural [...] Even though it didn’t numb the pain completely, I could not have made it through without it."
Lena has never suffered any side effects from the epidural, and was actually up and about and walking only half an hour after it was removed.
Echo Aronica, Seattle
For Echo Aronica, things weren't quite as straightforward. Getting the epidural inserted wasn't difficult, in and of itself, but her back has never been the same since labor.
"I was 19, so this was 11 years ago, and I still can’t lay on my back or stomach," she tells Romper. "Having an epidural kept me laying on my back for several hours and ultimately caused me to give birth laying on my back, which I wouldn’t have chosen to do otherwise because of the risk of muscle damage."
Aronica had wanted to educate herself on epidurals before labor, but the process of doing so was complicated. "My doctor did not explain the risks, the mechanics of how it works, or how long they last," she recalls. "They really pushed an epidural on me and after I gave birth, a nurse said to me, 'I can’t believe you had a vaginal birth, what with your weight and the epidural.'"
If she were to have another child, she'd do her best to avoid the procedure entirely.
Elise, New York City area
"The process was smooth but terrifying," Elise tells Romper of her epidural. "Honestly, the worst part was them putting in the catheter afterwards as well as the initial putting in of the tube for the epidural."
Even though it was scary — have you seen the size of those needles? — Elise didn't have any side effects. "No back pain or bad headaches," she says.
She has no doubt that she'd get an epidural again. Her child was born via cesarean, so the procedure was necessary regardless, but in the time before birth ("after 30 plus hours of labor") it relaxed her pelvis enough to allow for more dilation, and provided suitable pain relief.
Bailey Forbes, Canada
Although it is believed that performing epidurals on fat patients is difficult, many doctors will still push those patients toward getting one anyway because "women who are very overweight can have a higher chance of forceps delivery or caesarean section," explains the pamphlet Obesity in Pregnancy: Pain Relief and Anesthesia from the UK's National Health Service. Such was the case for Bailey Forbes, who never really wanted one.
"I was induced, and even before I was feeling contractions, I had the doctor telling me I needed to get an epidural right away," she tells Romper. "I had wanted to try without the epidural first and the doctor started to guilt me about it. She said that she always hoped things would go smooth, but she liked to plan ahead for complications. I felt like she already had me pegged for a C-section the second I walked in. I decided to refuse an epidural for the time being and she rolled her eyes and walked away."
Several more hours into labor, Forbes was told that there were no more pain management options for her (even though, previously, she'd been advised that she could try narcotics). "I decided to go for the epidural because I hadn’t slept in 24 hours and wanted the chance to get a bit of rest," she remembers.
"During the insertion, I kept telling [the doctor] that I felt this awful aching only on the left side," she adds. "After it was placed, I could still feel contractions on the left. They had me switch sides in the bed but nothing helped it. A few hours later, I was told I had to have a C-section."
The dosage had to be upped several times before it worked — Forbes was even told she may have to be put under anesthesia if the final dose didn't take. "I get upset thinking that I could have missed the birth of my child just because it was done incorrectly," she says. "I also feel like from the beginning, I was railroaded into having an epidural I did not want, and made to feel guilty for not following the doctor’s advice."
Thankfully, the epidural didn't result in any issues postpartum. Forbes would like to avoid the procedure if ever she has another child, but admits that she still gets anxious thinking about going through it all again.
Brook Gallegos, California
For Brook Gallegos, one of the worst things about getting an epidural was being shown the needle even though she specifically said she didn't want to see it. Then, she was given precise instructions for how to sit while it was being placed, lest she was to be paralyzed.
Gallegos notes that her back hasn't been the same in functionality since labor, "but it isn’t so drastic that I can’t function completely. [It] just aches here and there."
If she were to have another child, she says that she'd definitely opt for another epidural should she need one. "There is such a bad stigma that getting one makes you less of a woman — that you need to take all the pain," she muses. "I’ve never seen it that way. We all need some type of comfort or help during that time. Some women can do it without it and some can’t. If you feel you need to, do it, don’t worry about what others say. You’re pushing a little being out of you!"
Although Diane, who asked to be identified by her first name only, is no stranger to the myriad horror stories out there regarding the mistreatment of fat patients by the medical community, she says that "none of [my] providers ever said anything about my weight. I know that I got lucky with that."
She was diagnosed with preeclampsia and gestational diabetes during pregnancy, but those complications didn't result in issues with the birth or postpartum period. "I didn’t have any problems with my epidural," she tells Romper. "My anesthetist was amazing. Maybe it was because he was also heavier, I’m not sure. All of my providers were very kind and never made mention of my weight throughout my entire pregnancy."
She finds it incredibly "frustrating that so many doctors can treat their patients poorly," but is happy to report that this was not the case for her.
Amanda Crowe, Louisiana
Much like Bailey Forbes, Amanda Crowe feels she was "coerced" into getting an epidural. "I was made scared that if I waited too long, I wouldn’t be able to get one because labor had progressed too far," she tells Romper. "I feel like if I had the chance to go back, I wouldn’t have gone for one straight away."
At this point, Crowe has actually had two epidurals. "The amount of scar tissue in my back is absurd," she explains. "The shot itself wasn’t painful, but the effects caused so much pain. It feels like my back is breaking in half, literally, at the point where the needle went in."
Despite experiencing severe back pain postpartum, however, Crowe thinks she'd do it all over again. "I wouldn’t let some rude doctor with bad bedside manner scare me into it," she says. "I’d do it on my own terms."
Ultimately, "obese" patients have more backside to navigate than those of a lower weight. We have more skin, more fat, and simply more body to contend with. There's nothing inherently "impossible" about performing epidurals on us, though, as all of these mamas can attest to.
Beety, the midwife I spoke to, suggests that plus-size pregnant people seek as many second opinions as possible — from local home-birth groups, independent midwives, and of course obstetricians.
"We prefer to talk about chance rather than risk, because risk is already a loaded word," she says of how midwives like herself approach the decision. "Try to have frank conversations with your care providers. Ask your providers, if they are limiting your options based on your size, to explain the rationale behind it. Ask to see the literature and the research. Ask, 'Can we talk about this in terms of my relative risk?'"
When my anesthesiologist finally figured out where my spine was and got the needle in, she told me that I was a "difficult" patient. Really, though, in 2019 the "average" woman in the U.S. and UK is plus-size. What is truly "difficult" is the fact that, despite this reality, so many practitioners choose to treat us like problem cases from the moment we conceive.
Hannah Beety, Independent Midwife at Nest Midwifery
Daemers, D., Wijnen, H., van Limbeek, E., Budé, L., Nieuwenhuijze, M., Spaanderman, M., de Vries, R. (2014) The impact of obesity on outcomes of midwife‐led pregnancy and childbirth in a primary care population: a prospective cohort study. BJOG, https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.12684
(2017) Obesity in pregnancy: pain relief and anaesthesia. National Health Service pamphlet, https://www.midyorks.nhs.uk/download.cfm?doc=docm93jijm4n5270.pdf&ver=6465