Secondly, not to be contrary, but from what you wrote about the nurse and the patient you sound like the interfering one. You said the woman wanted a natural childbirth, and to me it sounds like the nurse was trying to encourage her to do that, while you were insistent she have the epidural catheter placed.
Okay to be contrary (and bitchy, when necessary).
The point is (and details I hadn't included beforehand) that I had discussed all the options at length with this patient before the nurse interfered. She (the patient) had had an epidural for her first delivery with very satisfactory results. It's not that she didn't want the
option of having an epidural for this one. She wanted it as "back-up" in case she couldn't handle the pain, but wasn't completely sure that she couldn't at the time we discussed it. I totally respected that, and this is why I offered to place one - discussed at length prior to this particular nurse's interloping - without putting any medication in it if/when/until the time came she felt she needed it.
Please understand that an epidural can be placed without any medication, except for the small "test dose" used to confirm placement, which is equivalent to having no epidural at all. The difference between putting the
catheter (and not necessarily the medication) in early versus late boils down to someone having a somewhat uncomfortable procedure without the background of progressing contraction pain and someone having a somewhat uncomfortable procedure amidst painful contractions late in the labor when you are then faced with trying to play "catch up" against the contraction pains. I've done it both ways. Early placement is far better than late both for the patient as well as the performing anesthetist.
Again, we discussed the options at length, and I believed that the patient understood this at the time it was explained. Then the nurse intervened much later, did not understand (or hear) the prior doctor-patient conversation, and subsequently served to do nothing more than unncessarily confuse the patient, a job that was actually counter to her perceived role as a "patient advocate" (the term she threw out later when I tried to educate her on what exactly placement of a "dry" epidural meant). Turns out the patient had unexpectedly severe pain from her contractions, as I anticipated when I interviewed and assessed her as "hyperalgesic", and decided that she wanted the epidural dosed.
This is not a matter of supervening the patient's wishes, but instead using education and experience to know when the best time to advocate for and help someone choose to make the right decision. It is amazing how quickly one can be undermined and confused by bad information given by a supposed "advocate" and perceived authority figure on the healthcare team.
In fact, just today I had another patient who was on her third child and did not want an epidural (hadn't had one for the first two). Completely fine. She knew and understood what she was in for. And, I completely respected that. But, I still interviewed and assessed her in case (1) she later changed her mind, and (2) she needed to be taken to the OR urgently for a spinal if she failed to progress and required a cesarian. That is my job: to medically assess and then lay out the best course of action for a particular patient, given their wishes and intercurrent illnesses (etc.), which is based on my clinical impressions along my experience and training. It is not to force people to do things they don't want to do. But, part of being a doctor is also educating (look up the etymology of the word "doctor") as well as advoacting in the best interests for a patient. Sadly, I'm already far enough along in my post-graduate training to have learned the hard lesson that earning the respect of and often battling the personal, anecdotal opinions of certain "seasoned" nursing staff is nothing more than one of the many daily challenges facing a resident.
-Dr. Imago
