Epidurals: Real World Doula Talk

While epidurals are not guaranteed to always work perfectly, they are our best option for longterm, comprehensive pain relief during birth. A well timed and well placed epidural can be a very helpful tool in some birth journeys, but as with every other medical intervention, problems can arise when they are used indiscriminately, or when no steps are taken to mitigate the potential risks associated with their use.

You know who should have an epidural? Anyone who decides they want one!

Some of our clients and students choose to have epidurals, sometimes out of medical necessity, and sometimes just because they want one. MyBirth and the MyBirth doulas are not “anti-epidural” by any means, recognizing that there is no “right” way to birth your baby, just what’s right for you. That being said, these are the facts regarding epidurals that help our students and clients give confident and informed consent.

Before You Get Your Epidural:

Using an epidural means that you will be confined to your bed until at least a few hours after you give birth. You may have heard of a “walking epidural” but honestly, that’s a misnomer because the overwhelming majority of hospitals will consider you a fall risk once the anesthesia is in place, and they won’t be open to your getting up and moving around.

Once you get your epidural, please sleep! Especially if you’ve been laboring for a long period of time prior to your getting pain relief. You may feel better once the medication starts to work, and you may feel interested in chatting and getting back to “normal”, but remember that you still have to push out a baby! Get your doula, nurse, or partner to shut off the lights and set a calm environment that’s conducive to sleep.

Epidural_Anesthesia.png

Having an epidural necessitates the use of further interventions. These medications/procedures always come along with an epidural:

  • IV and IV Fluids: attempt to prevent a drop in blood pressure

  • Continuous monitoring to measure frequency of contractions - since an epidural can slow down your labor, and you need contractions to come about every 2 to 3 minutes for cervical change, your provider and nurse will keep track of frequency so they can determine whether or not you need medicine to make more contractions.

  • Continuous monitoring of fetal heart tones - changes in your blood pressure can negatively impact the baby so they have to keep them on the monitor at all times

  • Blood pressure cuff - must be taken and recorded every 15 minutes

  • Maternal pulse-ox

  • Catheter for bladder - no bathroom trips with an epidural! They’ll drain your bladder for you.

These medications/procedures are frequently employed with an epidural:

  • Pitocin to stimulate more frequent or stronger contractions

  • Epinephrine to increase your blood pressure if it gets too low

  • Internal pressure catheter to measure strength of contractions - this is to more accurately dose your pitocin

  • Internal fetal monitor to obtain accurate tracing of fetal heart tones - for various reasons, it can be difficult to employ continuous monitoring of babies via external monitoring

    *Special Note: Anything placed in your vagina or uterus increases your risk of infection. Ideally, you want to limit vaginal exams and anything else being inserted into your vagina/cervix/uterus and left in place.

  • Compression cuffs on lower legs to prevent Deep Vein Thrombosis

  • Vacuum and Forceps - people with epidurals are more likely to require assistance with vacuum or forceps, so talk to your provider about their experience and recommendations with instrumental birth.

Once Your Epidural Is Placed:

  • Insist on a peanut ball! Evidence shows that when peanut balls are utilized for patients with epidurals, the risk of cesarean goes down by more than 30%! No peanut ball? A stack of pillows and a judiciously placed tray table can do the trick!

  • Just because you’re 10cm dilated doesn’t mean it’s time to push. Consider letting the baby “labor down” further into your pelvis before you begin pushing. Ideally, people with epidurals can get a few centimeters of descent through “passive” pushing -contractions of the uterus move the baby down to or beyond the midpoint of the pelvis- while you get some well-deserved rest.

  • An epidural will not always take away the sensation of the baby crowning. A super dense epidural - one where you can’t even wiggle your toes or move your legs - will sometimes mask the sensation of crowning, but that also means you’ll push longer and be more likely to need vacuum or forceps assistance for the birth. To get relief from the sensation of your baby crowning, advocate to push in positions other than flat on your back (puts lots of pressure on your bottom!) and request warm compresses when baby starts to crown.

  • Consider turning the epidural to half strength or off completely before pushing so that you can feel the contractions and time your pushing appropriately. You will ALWAYS push more effectively when you can feel when to push, rather than waiting to be told when you’re having a contraction.

  • Get off your back! As I mentioned before, pushing on your back puts SO much pressure on your perineum, you’re more likely to tear significantly, pushing takes longer, and it also has been shown to decrease oxygen to you and your baby (testing O2 levels in cord blood samples after birth proves this!).

  • Be ready to push in many different positions: semi-reclined, side-lying, tug-of-war, side-lying tug-of-war, hands and knees, squatting with the squat bar are just a few examples. Ask your doula, nurse, or provider for other pushing positions.

 Encouraging rotation and descent of the baby with a peanut ball

Encouraging rotation and descent of the baby with a peanut ball

Frequent Side Effects of an Epidural:

  • Epidural Fever

    • With an epidural, your body forgets to sweat even though it’s doing so much work! Have someone wipe you down periodically with a wet washcloth, eat ice chips, hydrate orally with an electrolyte drink and/or water. If you run a fever, your care team will be concerned that it could potentially stem from an infection and you will be given antibiotics to protect yourself and your baby.

  • Shaking/Trembling

    • As the anesthesia starts to work and your hormone levels shift, you will experience all over trembling/shaking that can be very disconcerting. It generally passes after 15-30 minutes.

  • Itchiness

    • Your epidural will likely be a combination of narcotics and analgesics. The narcotics used can make you feel very itchy, especially around your neck, arms, face, eyes, and nose. Ask one of your support team to sooth your skin with cold washcloths. If the itch is terribly persistent, you can ask your nurse for Benedryl or some other type of antihistamine.

  • Back Pain and/or Spinal Headache

    • Localized pain around where your epidural was inserted.

    • Spinal headaches are caused by leakage of spinal fluid through a puncture hole in the tough membrane (dura mater) that surrounds the spinal cord. Spinal headaches typically appear within 48 hours after an epidural or spinal anesthesia. Some people need to get a spinal patch in the week(s) following their birth.

  • Hip Pain or Injury

    • Because the nerves to the pelvis are numb, people are often unable to feel when their hip has been flexed too much by an enthusiastic leg-holder, leading to hyperflexion of joints while pushing. A small number of people every year experience a fracture of the femur or hip during birth. To avoid this complication, try to hold your own legs while pushing (your helpers can hold them for you in between contractions), and remind them to be gentle with your body! Keep your feet out of stirrups, as that places your legs and hips into an unnatural position for giving birth.

  • Stalled Labor

    • Labor can slow, stall, or “Fail to Progress” due to relaxed pelvic floor muscles and loss of muscle tone, or due to hypo-oxytocin (reduction in natural oxytocin levels). On average, people with epidurals require about an hour more to push out their babies than people without epidurals. Be ready to advocate for more time and assistance should your labor start to slow down.

 Blood Patch - used to treat spinal headaches

Blood Patch - used to treat spinal headaches

Like i said at the beginning, an epidural can be an excellent tool, especially when you need deep, long-lasting, pain relief, but it isn’t a magic bullet or panacea. I can say that it’s a good tool while also acknowledging that it leads to more interventions and complications. My goal for all birthing people is informed, confident decision making, and the best way to do that is to have all of the available info - the good, the bad, and the ugly. Labor and birth is rarely a straightforward, easy path; every birthing person will find themselves standing at a metaphorical crossroad, wondering what they might be required to do next. Rather than making decisions based in fear, I hope you can make decisions based in fact.

Special Note: After reading all this you may find yourself thinking, “Wow. This is a lot of info, I hope I can remember it all during my birth!” And to that I will say, “Yes, it is! Hire a doula!” Doulas aren’t just for “natural” birth, we’re experts in all types of birth! There’s no reason you can’t labor both comfortably and confidently, having a professional doula there to remind you of risks, benefits, and alternatives is helpful for ALL birthing people!