Thursday, November 20, 2008

The "E" Word

The word for today is Epidural. Sometimes they call it “epi” for short, but it doesn’t have a ring to it like “pit”. Epidural anesthesia, a form of regional anesthesia. Drugs are injected through a catheter that is placed into the epidural space. This causes both a loss of sensation (anaesthesia) and a loss of pain (analgesia), by blocking the transmission of signals through nerves in or near the spinal cord. If done correctly you should have a numbing sensation in this area:
Most everyone knows what an epidural is, and most laboring women (in hospitals) ask for it by name. There are hospitals in the USA with a 98% epidural rate for laboring women. Our government statistics are hard to find, but according to polls - hospital epidural rates run between 70-98% (with many in the business saying their hospital has an 85% or higher rate).

When I had my first child 15 years ago, I was terrified. Our hospital was small and didn’t even offer epidurals back then. I asked for a cesarean just so I could avoid the pain of childbirth all together. . Thankfully, I had a doctor who didn’t just *do* cesareans out of patient request. I won’t go into my birth story, but in my case the fear was much worse than the contractions. My point is, that had my hospital offered epidurals -I would have had one placed weeks in advance. As it turns out, even if I could have had an epidural, I had no time to get one anyway. I went from 5cm to 10cm in 20 minutes. I can honestly understand the fear that many women feel, and I can relate to them wanting an epidural. I believe that our society has made birth such a scary event, and women are convincing themselves that they cannot endure a birth without pain relief. This is a sad thing.

If epidurals were risk free, they would be the best invention of all time!  I’d still cringe that women had lost the ability to trust their bodies, and strengths, but I could still live with it. I’ve actually heard stories of nurses telling mom’s that epidurals are RISK FREE! Hello! If they were risk free, you wouldn’t have to sign a waiver before the Anesthesiologist did the deed! Let us go over the pros and cons of epidural anesthesia:

One of the biggest concerns that I have is the increase risk of cesarean delivery which itself comes with a ton of other risks for both mom and baby.  I like this simple graph:

Here are you advantages to an epidural:
1. Almost always a complete relief in pain
2. Sometimes labor can progress more rapidly

The disadvantages are:
*Not always effective - 10-30% of women will not have adequate relief
A) Sometimes added boluses are needed and anesthesiologist needs to be called in
B) Sometimes anesthesiologist cannot make it in time so you labor without it anyway
* Stopping the progress of labor, increased need for Pitocin by about 90%
* hypotension (a drop in blood pressure) 12 - 23% -sometimes medication is needed to bring it back up.
* maternal fever - (then unnecessary antibiotic therapy - then the yeast infection - then.....)
An astounding 96% of all women who get a fever in labor have had an epidural. 86% of newborns are put on full-spectrum antibiotics, and have full septic workups while in the NICU have been born to mothers who had epidurals in labor. (This is just precautionary).
* inadvertent spinal (causing excruciating headaches, which a blood patch does not always a cure)
* nausea and vomiting.
* backache - this has become very common -and may last weeks and even months afterwards.
* fluid overload- because IV’s are needed and they run a risk of fluid overload that may lead to pulmonary edema.  Fluid overload can also cause your baby to weigh more at birth, and when they pee off that excess weight in those few days right after birth, your pediatrician may see that drastic weight loss as a reason to supplement with formula. 
* infection from epidural site
* respiratory arrest
* anaphylaxis
* nerve damage
*Decrease in the ability to push effectively. The build up of anesthetic simply weakens muscles to the point of ineffectiveness. Mother may not be able to push enough to effectively help the baby to rotate and descend.
*Cesarean: Eight primary studies revealed that the rate of cesarean section was 10 percentage points higher in the women who had received epidural anesthesia. One study actually found that the cesarean rate increased to 50 percent when the epidural was given at 2 cm dilation, 33 percent at 3 cm, and 26 percent at 4 cm. (The primary reason for section is fetal positioning is compromised).
*Mother feels detached from the process and becomes an observer; others may reduce emotional support. The nurse can no longer assess labor progress by observing the mother and must rely more on the monitor and vaginal exams. Sometimes mom may describe the birth as more cold - this can be due to mother not being in her left brain - where the birth memory is a little more ‘warm and fuzzy’.

Indirect increase in:
* operative delivery (forceps, vacuum, C/S) which all have their own risks
* episiotomy/tears (due to either the forceps, vacuum, or mom simply not being able to control the pushing stage effectively or move into a position that helps reduce tearing).
* oxytocin augmentation
* fetal scalp electrodes and intrauterine pressure catheters (IUPC)
* intrauterine infection - related to the increase in vaginal exams, IUPCs, etc.
*breastfeeding and infant behaviour - depending on amount of narcotic and anesthetic the baby has been exposed to. (Yes, they often use a narcotic for the local part of the epidural).

Risks to baby:
* fetal distress- bradycardia - one study reported 11% occurrence within 5 - 20 minutes of administration. Can cause fetal heart to drop or become irregular (leading to emergency c-section)
* Medication crosses placenta -especially the narcotic
* Septic workup and NICU care if maternal fever develops (may include Lumbar Puncture)
* Complications due to forceps, vacuum or cesarean section delivery
* Respiratory depression
* Increased likelihood of fetal distress due to mother's low blood pressure
* Short-term neurobehavioral changes, including irritability and inconsolability
*Drowsiness at birth
*Poor sucking reflex
*Poor muscle tone and strength for the first few hours after birth

Very Rare Cases (really rare)!:
respiratory arrest
cardiac arrest
allergic shock
nerve injury (1 in 10,000) usually causing numbness in one leg that will subside in weeks or months afterwards - seldom is it a permanent side effect.
Epidural abcess
maternal death

There *are* benefits of a drug free birth. The pros for a drug free birth are much longer, and the cons are much shorter. In our society, women are convincing themselves that childbirth is like a dental procedure. You may have heard the comment “well you wouldn’t have a tooth filled or pulled without Novocaine”! Birth is no where near this type of procedure. Our bodies do not treat the pain the same way.  We were made to do this, and in most every case, it is very do-able. It takes a lot of things to make it do-able - and we need the support of our care-providers and hospitals to make it more manageable.  We need to reduce the induction rate, because Pitocin definitely makes the contractions harder to deal with for almost all women.  Women need to be able to move into positions that ease the intensity of labor, they need the option to labor in a tub and shower when everything is going well.  There are so many things that we can do to help ease the intensity of contractions - and many women not only find it bearable, some find it virtually painless.  Get a doula to help you manage those contractions! 

There is absolutely a time and a place for an epidural!  I like how Penny Simkin discusses the difference between pain and suffering.  You can have pain without suffering, and you can suffer without pain.  When the two merge together, it's time for an epidural.  I just mothers to be informed, to not fear labor, and take it one contraction at a time.  

Here are some ideas for those who would still like to have an epidural: 

  • Don't get an epidural until you are having nice, regular contractions
    (and try to wait until at least 5cm to get it).
  • Make sure baby is an optimal position before getting the epidural.  Head down is only half your battle, make sure that baby is facing the right way, etc.  You won't be able to get into many positions to help facilitate baby's rotation after the epidural.  
  •  Once the epidural is working, consider getting off your back and alternate laying on your left and right side, (providing that it doesn't interfere with baby's heart beat).
  •  Labor down:  This just means that even though your cervix may be fully dilated, your baby still needs come down a bit more.  If you wait until baby is lower into the vagina, you won't push as long, and you will also reduce your risk of needing an instrumental delivery.  "Laboring down" is common practice now at most hospitals, and it's something to take advantage of. 
  • Use a peanut ball!  A hospital in Arizona discovered it had some great benefits and the results were compelling:  "Those who used the ball decreased the first stage of labor by nearly 90 minutes and the second stage by 23 minutes compared with a control group that did not use the ball.
    The real payoff came through lower C-section rates. The C-section rate for the group of women who used the ball was 13 percentage points less than for the group that did not use the peanut ball."
    Read more:
  • (ignore this bullet it doesn't seem to want to go away)!
If you are still afraid to give birth without an epidural, remember that you do not have anything to lose by trying.  Take a quality out-of-hospital childbirth class, hire a doula, and you still don't have to make a decision until you are actually in labor.  Consider finding a hospital that will allow you to labor in the tub in an uneventful labor.  Talk to your care provider.  REALLY, talk to him or her.  You want their support no matter what you choose right?  Why not make sure your provider will truly support your decision either way.  During labor, take it one contraction at a time, and if you are doing well, just keep going until you hit the wall.  Consider waiting a little longer after you hit that wall, you are stronger than you think ;-)

I just want women to make informed choices.  I tell all of my doula clients that I have their back (no pun intended), no matter what their choices are!  I don't want anyone out there to feel like "a failure" because they could not endure labor. EVER.   I'm just proud of you for thinking about it!

Happy Birthing,

~The Birth Teacher

1 comment:

Stacey said...

I find this interesting as I had Cauda Equina Syndrome at age 24 and basically have no feeling in the area marked in blue in your diagram. I have put an Epidural down as a method of pain control should I need it, but it may be that I do not after all. It is not my first choice, I would like to do as much as I can without drugs, as I am not all that fond of side effects etc. I also feel I have pumped my system full enough of drugs during that time I was in the hospital before, so not really a fan of more.
Having all those side effects listed in one spot makes me even more leary now.