Guest post by the anonymous CNM from Birth Sense
While the negative effects of epidural anesthesia are often discussed—whether they are evidence-based or experience-based—it’s important to recognize that there are occasions when an epidural is desired or needed. Clearly, an epidural or spinal anesthetic is preferable to general anesthesia for a cesarean birth, but there are other occasions during labor when an epidural may be a wise choice.
- When the laboring woman is exhausted and unable to rest.
- When labor pain becomes suffering, rather than coping
- When the mother is requesting repeated doses of IV pain medication; in this case, an epidural carries a smaller risk of causing the baby’s breathing to be depressed at birth
- When procedures are necessary which the mother cannot tolerate without pain relief. Examples might be manual rotation of the fetal head, maternal positions the mother cannot tolerate, or use of vacuum or forceps.
When a woman chooses to use epidural anesthesia, there are ways to minimize potential negative effects. The most common problems with epidurals are inability to move about freely and use a variety of birth positions, and inability to push effectively.
Fiona was having her second baby, and chose my practice for midwifery care. Her prior birth experience had been traumatic. She had gained a large amount of weight by the end of her pregnancy, and her baby weighed nearly ten pounds. During pushing, her physician had kept her in a semi-reclining position with her feet in footrests, despite Fiona’s repeated pleas to allow her to get into a squatting position. As Fiona tells it, “I had such pain in my pubic bone every time I pushed. I told the doctor I thought the bone was breaking, and I needed to get upright to give the baby more room. The doctor refused to let me get up, telling me he could not safely deliver the baby in any other position. At one point, a horrible pain shot through my pubic bone. The baby was born shortly after that. Following delivery, I could not walk at all for three days, and for weeks after that, I could only hobble a few steps with great pain and difficulty. Finally, my doctor got an x-ray, which confirmed my pubic bone had separated. He told me it would have to heal on its own over time.”
By the time Fiona came to my practice, she was already experiencing pain in the pubic bone again. She was terrified of a repeat separation, but committed to a normal birth without intervention. I assured her she could choose her own position for birth, and we discussed ways to minimize stress on the pubic bone. By her due date, Fiona was again experiencing difficulty walking. Her labor began with strong contractions and progressed quickly. When she arrived at the hospital, Fiona told me the pain was too great, and she wanted an epidural. Once the anesthesia took effect, she was much more comfortable, and began to express concern that she would have to push lying down—the one position we had learned was potentially most damaging to the pubic bone in her situation.
Fiona had requested a light epidural, and was able to freely move her legs, although she could not walk. We moved a birthing stool into the room, and braced it against the bed. Fiona sat up, position her legs one on either side of the stool, and then with her husband on one side and her me on the other, we were able to gently scoot her down onto the stool, where she could lean back against the bed. We remained on either side of her for support, but she was able to control her position quite well. We did not urge her to push forcefully, but let the baby slide down slowly to allow maximal time for molding of the head and minimal pressure against the pubic bone. This would have been very difficult, if not impossible, for Fiona to tolerate if she had been feeling an overwhelming urge to push. Once the baby crowned, Fiona was able to easily push the baby out, without tears. She was able to walk after her epidural wore off, and had much less pain than after her first delivery.
Fiona is an excellent example of judicious use of an epidural, with a strategy to minimize negative effects. Our strategy included:
- Administering the epidural in late labor. This carries the benefit of minimizing risk of epidural fever1, and allows the body to benefit from the natural surge of oxytocin and endorphins that labor brings2. There are theories that suggest these hormone surges promote maternal-infant bonding, breastfeeding, and possibly some pain relief for the fetus. Later administration of an epidural may also diminish the risk of needing an assisted vaginal delivery (forceps, vacuum) or cesarean delivery.3
- Administering a light dose of epidural anesthesia. For women who are able to tolerate some sensation, requesting a lighter dose of anesthesia may allow them to retain more ability to move their legs and to push with contractions. You can always request more anesthetic, but it is difficult to have sensation completely removed and then have to let the epidural wear off at the height of labor intensity in order to facilitate pushing. Many women can work with a light epidural, not needing total numbness, but moderate pain relief.
- Choosing a labor position that facilitates gravity. An upright position IS possible with an epidural. Most nurses have never seen this done, but with at least two people to support the laboring woman, she can be assisted onto a birth stool place against the side of the bed or on top of the bed with the back fully raised. Two people must remain, one on each side, at all times to ensure safety should she have difficulty supporting herself. With a lighter epidural, this should not be a problem, although she will not be able to reliably bear her own weight. If an upright position is not feasible, a side-lying position for delivery is the next best option. The upper leg may be supported by someone, or rested in a leg rest.
- Reducing the epidural dose during pushing. This may be helpful, but is difficult for many women to tolerate if they have not been feeling anything since the epidural was administered. For this reason, it is optimal to have a lighter dose of epidural anesthesia, rather than starting out completely numb.
- Allowing the baby to ‘“labor down”.4 This may extend the second stage of labor by several hours. Provided mother and baby are doing fine, there is no need to hurry this stage; indeed, beginning pushing before the mother feels rectal pressure can increase risk of fetal distress and need for forceps/vacuum. Allowing baby to labor down means that either you can see the baby’s head visible at the perineum with contractions, or the mother reports feeling a strong amount of pressure on the perineum, can feel when she is having a contraction, has the urge to bear down, and is able to move the baby’s head with pushing.
While it is generally wise to avoid interventions if labor is progressing normally, an epidural was a good choice for Fiona, and it may be a good choice for you. Consider discussing these tips with your OB care provider ahead of time to ensure that you will be supported in your desire to minimize potential negative effects of an epidural.
1 Klein MC. Does epidural analgesia increase rate of cesarean section? Can Fam Physician. 2006 April 10; 52(4): 419–421.
2 Buckley SJ. Ecstatic Birth. Retrieved 03/19/2010 from: http://rutgershmsexsummer09.files.wordpress.com/2009/04/ecstatic-birth.pdf.
3 Thorp JA, Hu DH, Albin RM, McNitt J, Meyer BA, Cohen GR, et al. The effect of intrapartum epidural analgesia on nulliparous labor: a randomized, controlled, prospective trial. Am J Obstet Gynecol. 1993;169:851–858.
4 Roberts J, Hanson L. Best practices in second stage labor care: maternal bearing down and positioning. Journal of Midwifery & Women’s Health, Volume 52, Issue 3, Pages 238-245.
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