Empowering Birth Blog

Wait on the Epidural

I don't know why I couldn't get epidurals off the brain last night, probably the conversation I had with a wonderful friend walking home from School Information Night.  Too often I feel that if I can just find the right way to put things, the perfect example, people will understand my point of view on an issue.  Not that they have to agree with me, but they will say, "oh, I see what you are trying to say, that makes sense."  Of course I cause myself a lot of grief with this particular way of looking at the world, but I must admit, I am quite satisfied with the latest gimic I used in my prenatal yoga class.  It wasn't my idea, a friend and fellow midwifery apprentice suggested it, took me a bit to figure out how to pull it off, but it worked!

So here's what I did.  At some point in the class I have the women kneel, tuck their toes under, and then sit back on their heels (yes, it puts a LOT of pressure on those tucked toes, if this is easy for you, wait a minute, it probably won't be after awhile).  The pain caused by sitting on your tucked toes simulates a contraction, and I help the moms work through the pain using different breathing techniques, etc.  It was the last class and we have been working on this for awhile so I had them sit through a couple minute and thirty second contractions instead of the usual minute contractions.  On the last "contraction," as I could see the face grimacing begin and sense the shooting pain that was going through each mom's toes, I pulled out a bottle of Vodka and offered everyone a shot.

The first reaction, every mom burst into laughter.  Lesson one, humor can be a life-saver in labor.  Each mom stayed on her tucked toes and laughter rolled through the room.  The moms returned to sitting as I explained the second reason for offering the shot.  Pregnant moms should take the same wariness of having drugs in yoga class into the delivery room.  Is there a difference between having a shot or two of vodka at 36 weeks pregnancy or an epidural when you are only 3 centimeters dilated?

If you absolutely must get the epidural, choose it only if the benefits outweigh the risks.  In my opinion, the biggest risk is ending up with a cesarean for failure to progress or an OP baby that fails to rotate and can't find his way out because you have lost your mobility.  Once you have assessed that you really need an epidural to relax and give birth, FIRST make sure that:

1. you are at least 5 centimeters dilated (not 4-5 but a solid 5)
2. the baby is at 0 degrees station
3. the baby is in a favorable position for birth

Finding out the baby's position is going to be the hardest task ahead of you.  Chances are you might have a resident laboring with you because your doctor is in the OR performing a cesarean.  A resident is probably not going to be able to tell you your baby's position.  In this case, WAIT.  You don't want to get an epidural only to find that your baby is asynclitic or OP.  These positions require a mobile mom to facilitate turning the baby or, if the baby won't turn, finding the position that increases the width of the pelvis/hip squeezes etc., so that the baby can be born in the position he/she is in.  Yes you can turn a baby once the mom has had an epidural but you need a labor doula who knows her stuff and a partner and their job is a HECK of a lot harder with the epidural in place (the Labor Progress Handbook by Penny Simkin and Ruth Ancheta can show you how.) 

Here is a link that offers some more ideas for giving birth successfully with an epidural:
http://pregnancychildbirth.suite101.com/article.cfm/childbirth_with_an_epidural
Giving birth successfully with an epidural is a LOT of work.  I would argue that it requires having a doula present who knows her stuff because your hospital is most likely not going to have the time or the resources to provide you with a doctor who can hang out with you during your entire labor, catch a poorly positioned baby, and make sure all goes smoothly. 

So if you can do it without the epidural, I say GO FOR IT.  The the rewards are worth it.  Stay tuned for a clip of an AMAZING birth video tomorrow.  You only see the kind of glee and ecstasy shown by the mom in this video in normal, unmedicated birth.

That said, I it is definitely not useful to be completely against the use of drugs in labor.  There are times when an epidural might mean the difference between having a vaginal birth or a cesarean, in which case, go for the epidural.  I know a mom, for example, who had incredible sciatica during labor.  The intense pain of sciatica, which was far worse than labor pain, prevented her body from softening and opening up.  A light epidural helped her get some relief and birth her baby.  Do your research and choose a provider who will not push an epidural on you unless he/she feels it is TRULY necessary in your case.

If you must get the epidural...

wait until you've had one normal vaginal birth.  Once you've popped a baby out, your body knows the ropes, you don't have all that first time mom (or VBACing) anxiety and so you won't have to stress so much about the whole epidural, pitocin, more pitocin, baby in distress due to pitocin, c-section cycle.  If you don't try it once, you will never know what you are missing.  I know, there are so many stories out there about how epidurals are wonderful, but that is only because there is such a SMALL percentage of the population out there experiencing normal birth.  I was just discussing normal birth vs. medicated birth with a fellow mom and the lack of incentive for a normal birth because it almost seems myth-like.  Moms read about it in books but don't know anyone who has actually had one.  This mom had an out-of-body experience giving birth that was WILD. How do you share the power of a birth that is beyond words?  And what impact does your story have when the mom who hears it has heard 100 stories of medicated births to your one story of normal birth.  So if you are considering the epidural, why not choose it after your body has learned the rhythm of birth (and try and make it to 7 centimeters).*  And normal birthing moms, we HAVE to share our stories!

*If you opt for the epidural for medical reasons or other, waiting until your body is fully in active labor and assuring that baby is in a good position for birth will help you avoid unnecessary interventions. Studies looking at the link between early epidurals and cesarean delivery report a higher rate of cesarean delivery with earlier epidural.1

1 Ellice Lieberman, MD, DrPH and Carol O'Donoghue, MPH,MSN. "Unintended effects of epidural analgesia during labor: A systematic review" in The Nature and Management of Labor Pain: Peer-Reviewed Papers from An Evidenced-Based Symposium, edited by Judith P. Rooks, Carol Sakala, and Maureen Corry, Supplement to American Journal of Obstetrics and Gynecology (New York: Mosby, Inc. 2002).

It's the baby's birth too

I just attended a beautiful birth (whenever I am not blogging, it usually means I am attending a birth, and then catching up on sleep).  I don't usually attend births where the mom has decided from the get-go that she will choose an epidural but if my intuition says go for it, I make an exception for some couples/moms and of course for VBACers (moms pursuing vaginal birth after cesarean).  This birth clarified my reasons for being choosy about the moms I work with and affirmed that though I am definitely not a fan of epidurals (primarily because they are abused) in some cases they are appropriate and don't always seem to impede the bonding process between mom and baby. 

Mind you, this is purely speculative, I have only recently started down the path to midwifery, but I have been thinking a lot about a recent blog, where I posted a quote from Dr. Sarah Buckley about the effect of epidurals on mom's hormones.  Dr. Buckley hypothesizes (see referenced blog entry) that even when feeling returns in an epidural, mom might miss out on that cocktail of hormones that help with bonding.  Now I haven't talked things over with the mom at yesterday's birth yet but I know when those hormones are present and when they aren't.  As I mentioned in that blog post, I missed out on the cocktail of hormones because I stayed behind to clean up in a hospital transport.  But there was NO mistaking the presence of hormones at this birth.  I was fighting hard to keep back the tears as I felt the waves of hormones wash over me, through me and wrap around the room and mom looked ecstatic (of course baby went right to mom's chest and chord was not clamped until it stopped pulsating).  I have to speculate that perhaps if you back off on the epidural and feeling is allowed to return (which we did in this birth) that those stretch receptors do indeed send the message to the brain to release those good end of birth drugs. 

So why am I so "choosy"?  I guess deep down inside, and I am being completely honest, it is because I get very frustrated with our culture's tendency to choose the option that represents instant self-gratification over the option which is harder thing but is better for us/our kids in the long run.  The best example that comes to mind has nothing to do with birth but perhaps it will resonate with some of you moms out there.  You are at a friend's house (this just happened to me by the way, sigh) for lunch and after several warnings your child continues to misbehave (harshly pinching her brother, screaming and yelling etc.).  After you have issued your call for better behavior, your child will no doubt insist that she should have YET another chance.  You can A, give her another chance (easier for you, you get to stay and enjoy lunch and chat with your friend)  B, say, I am sorry, you have had your chances and were informed of the consequences, we are going home, and then promptly leave, or C, can bribe your child with icecream if they behave and stay.  Too often I see parents choosing option A or C. 

When it comes to the epidural I think moms are too quick (and this is reinforced by the medical industry) to opt for the comfortable option of an epidural (but later wonder why they end up with the fourth degree tear or have trouble bonding with baby or why they have trouble breastfeeding etc. etc. etc.).  Mom chooses the easiest/best option for her but not the best option for baby.  Yesterday's birth represented a beautiful compromise.  Mom chose what was best for mom AND baby.  Mom spent most of her labor upright using gravity to help her body open and got the epidural 12 hours after labor had begun, as she was nearing transition.  Mom also backed off on the epidural when it was close to pushing time so that she could feel the stretching and the contractions for more effective pushing.  I ask that the moms I work with seek to be fully informed, primarily because informed moms, after carefully processing what they have learned about birth, tend to instinctively choose the option that is best for mom AND baby. 

Birthing Hormones, The GOOD drugs

A recent birth has gotten me thinking about those good birthing hormones.  I supported a laboring woman but missed the birth.  There was a hospital transport at the very end and I stayed back to clean up stuff at home while the midwife's assistant accompanied the couple to the hospital.  What was remarkable was that because I missed the actual birth, I missed that shot of adrenalin (part of the family of hormones called catecholamines) and oxytocin that floods through mom during the pushing phase and as baby is being born.  Those powerful birthing hormones allow me to make it through the day while caring for my two youngsters on zero hours of sleep.  Since I missed the birth, I dragged my tail all day and ended up with a cold.  Purely anecdotal of course but I attended a birth while recovering from an illness, stayed up all night long, and was so high on birthing hormones that I woke up the next morning without the faintest sensation of illness (powerful stuff, huh). 

Speaking of birthing hormones, my first labor was medication-free up until the point of preparation for the cesarean, but I missed out on that good cocktail of drugs that comes with a vaginal birth.  I remember feeling like a train had run over me for at least a few days after the birth.  I tore during Fen's birth and had a pretty darn sore bottom but still felt completely ecstatic and was drinking champagne and planning a trip to the park shortly after I pushed him out.  If I have the time I will come back and post the pictures after both births, they tell the story.

Dr. Sarah Buckley explains why we don't get that cocktail of hormones when an epidural is in place:

When an epidural is in place, the oxytocin peak that occurs at birth is also inhibited, because the stretch receptors of a birthing woman's lower vagina, which trigger this peak, are numbed.  This effect probably persists even when the epidural has worn off and sensation has returned, because the "proprioceptive" nerve fibres involved are smaller than the sensory nerves and therefore more sensitive to drug effects.....

The use of epidurals also inhibits catecholamine release for the mother and, to a lesser extent, for her baby.1

There hasn't been a lot of research on the effects of epidurals on birthing hormones but I think that any mom who has given birth both with an epidural/spinal and without can tell you, there is a big difference. 

1Dr. Sarah J. Buckley Gentle Birth, Gentle Mothering (Brisbane: One Moon Press, 2005 ), 1301

Why you shouldn't just "get the drugs"

Women giving birth need:

• freedom of movement (read Active Birth by Janet Balaskas)
• hydrotherapy (using water for pain relief, women should have the freedom to move in and out of tubs and birthing pools and have hand-held shower heads to direct on their belly and lower back),
• a strong labor support team (that can give massage, aromatherapy, words of strength and encouragement when times are tough, place hot and cold packs on mom, help you on the birthing ball etc. etc. etc.). 
• to feel safe and comfortable during labor (which might mean no medical students at your birth, laboring in your favorite pajamas, keeping the lights off, laboring and birthing in the privacy of your own home etc. etc.)

I believe the reason the epidural rate is so high is that most moms are missing one or all of the above methods that contribute to women staying on top of the pain of labor.  In the Listening to Mother's Survey1 while close to 50% of the moms used breathing techniques and position change to relieve pain only a small percentage of moms (only between 4 and 7%!) used a birth ball, immersion in a tub or pool, hot or cold compresses, shower, music or aromatherapy.  I can't imagine giving birth without having my choice of music filing the room or the use of hydrotherapy.  I am sure there are exceptions to the rule but I dare to argue that the majority of moms who advocate "getting the drugs," have not had a strong labor support team providing a variety of techniques to help them cope with the pain of labor.   As a result, many moms have a negative labor experience and are only too happy to get the drugs.  Trust me, I've been there.  When I got the epidural before my cesarean with Khady I was EXTREMELY grateful.  My epidural arrived after hours of forced pushing without any drugs while lying on my back hooked up to the monitor with the doctor coming in and out exclaiming "that baby isn't coming out."  I had had enough!

During the second birth experience, between the labor pool, my gospel music, the hands of my supportive doulas and husband, the back massage, the compassionate eyes of my midwife, pain medication was the furthest thought from my mind.  Moms, you can do it!  Labor can be TOUGH but with a good support team, it is manageable, and there are delicious parts of labor and after the birth where you are soaring high, feeling amazingly strong and invincible, as if you just might have super powers.  Many moms change their entire view of themselves as a woman based on a single empowering birth.  Look at the face of the mom in this group of photos.  Sometimes a picture says it all.  Please visit Women in Charge for some empowering birth stories and photos and make sure you have the freedom to use the above pain-relief methods if needed during your labor and birth.

11 Eugene R. Declerq et. al. "Listening to Mothers II, Report of the Second National U.S. Survey of Women's Childbearing Experiences." Childbirth Connection, October 2006. http://www.childbirthconnection.org/article.asp?ClickedLink=205&ck=10068&area=2.

How Times Have Changed...

I just found this quote in a mainstream pregnancy book under the section medication and anesthesia.

"the mother anticipating a multiple birth should avoid medication and anesthesia whenever possible.  Unless she has been well nourished, her babies may be small or premature and they will have less resistance to the dosages of medication and anesthesia, which will be calculated for the mother's body size.  All drugs pass through the sieve-like placentas.... A thorough consideration of this subject can be found in Drugs in Labor and Birth by Doris Haire, who points out that the package insert for the anesthetic marcaine (used for epidurals) contains five pages of adverse effects."1

The catch?  The book was last copyrighted in 1991.  Somewhere between 1991 and 2007 we seemed to have lost the ability to be very clear about the fact that a birth without medication and anesthesia is not best for mom and baby.  Even more interesting is the fact that this book is for moms having twins!  It is now standard procedure in many hospitals to place an epidural in a mom expecting twins, just in case.

1 Elizabeth Noble, Having Twins (Boston: Houghton Mifflin Company, 1991) 199.

Avoiding the Epidural

So in a normal birth scenario, we know epidurals are not best for mom and baby, but how do we get past that moment when we think we NEED one.
My first suggestion is to birth in a birth center or at home.  If it isn't there, you can't have it.  How many of you chocolate fiends out there (I'm guilty!) try to curb your chocolate lust by not buying it at the grocery store in the first place.  If your fix is out of control, you can always go to the grocery store and buy some (and if you really need the epidural, you can transfer to the hospital from the birth center).  Ok, strange analogy but you get the picture, if it isn't under your nose, it is a heck of a lot easier to avoid and if you have to go out of your way to get it (let me paint you the not so pretty picture of transferring from a home or birth center birth to the hospital while in transition, keep it at this, transition contractions in a car are NOT fun) you just might think twice about how dire your need really is.
Given the fact that our culture does not teach us that birth is normal, it can be hard to make the decision to birth at home or at a birth center.  For those of you birthing at the hospital, when you want the epidural, tell yourself you will first try a few different positions, massage, water, new labor support, explore how you are feeling emotionally etc., etc.  After you have done all of those things, you might even want to try and wait two more contractions, and then if you feel that you can't relax enough to open up and birth without the epidural, you know that when you call the anesthesiologist, that you have given it your best shot.  Isn't that what we teach our kids?  If you can't do something, try it again, try it a different way, get a new perspective on it, and then if you still can't do it, that is ok too?
But imagine, if our culture supported normal birth, we wouldn't have to worry about all that stuff because we would know epidurals were not for normal labor/birth.  We would have this belief growing up as a kid and we would take this total trust in natural childbirth with us into pregnancy.
Ok, this might not be very practical but it is good food for thought, here is a link to a group of midwives thoughts on how to lower the astronomically high epidural rate: Midwives call for epidurals fee.