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Wednesday
Mar242010

Minimizing the Negative Effects of Epidural Anesthesia

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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.

 

Notes:

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. 

 

Related posts at Birth Sense:

Minimizing Negative Effects of Interventions: “I’m connected to so many things!”

Minimizing Negative Effects of Interventions: I’m Overdue!

Minimizing Negative Effects of Interventions: “I have fast labors”

 

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Reader Comments (41)

Two women in my Bradley class had light epidurals (to sleep/rest during long labors) and it seemed to have worked really well for them.

March 24, 2010 | Unregistered CommenterEmily

What a helpful post. I wonder how many other techniques like this one (vertically supporting laboring woman w/ an epidural) are out there but no one is promoting? A technique like this one could be a useful tool for women too afraid (even if not injured) to push without pain relief but not wanting to give up the help of gravity.

Of course, the sad part of your story is that if she hadn't been so mistreated the first time, she might not have needed so much help the second! I have heard stories of broken pelvic bones before, but only recently have heard enough details to connect them to bad pushing procedures/laboring horizontally.

March 24, 2010 | Unregistered Commenteremjaybee

Hi! Nice blog. I am a labor and birth nurse in Saskatchewan, Canada and I my hospital all epidurals are "walking epidurals". pretty much every woman with an epidural is able to get out of bed, walk to the toilet to empty their bladder/bowels, walk around the room or even in the hallways if their legs are especially strong. they can also be in more varied positions like hands & knees or squatting. Of course the nurse must always be present and have a helped to help stabilize her if her legs 'give out'. In 2nd stage, the urge to push is almost always strong and women are able to push spontaneously without much guidance. Down side...they will feel the "ring of fire" etc, however I do believe that these
sensations also help the flow of hormones involved with bonding. I don't know why this kind of epidural isn't the norm!

March 24, 2010 | Unregistered CommenterHeather

This is a great article! This type of judicious use of a light epidural could spare a number of women unnecessary surgery! The baby can get into a better position and gravity aids the mom! This should be part of the standard of care, rather than numb from the waist down! Congrats to this midwife! :) thanks for posting this, Jill!

March 24, 2010 | Unregistered CommenterCathi

A great article, and at the same time heartbreaking personally. You know that scene in Good Will Hunting where Robin Williams is like "it's not your fault, it's not your fault." Yeah, it's like that. I try not to just go having feelings all over the internets, so this is a little unusual for me.

One of my points of friction with even my own birth advocacy is the whole anti-epidural thing. I don't think I have ever seen anyone actually be judgey about a woman having an epi like the movies would have you believe, but, like someone commented on the FB thread, I feel like there can be a tendency to write off a woman's birth experience. Like "ohhhh, I see what happened" - the Navel Gazing Midwife had a really good post on the armchair quarterbacking of birth. But of course women's experiences are varied. Sure, I consented to an epidural--one that I knew, and still believe, that I needed --but did that necessarily mean that I consented to a cesarean? It's really validating to hear again that epidurals have their place.

You want another unicorn, though? The walking epidural. It's like freaking sasquatch. I went into birth pretty damned well prepared (oh buddy, I read ALL the right stuff, took a class, had a midwife), but I never heard that term til recently. I think we could do a lot to help moms with extra-painful or prolonged labors (those poor OP mamas!) avoid surgery by letting them and the OBs and anesthesiologists know that there's a middle ground between "full tilt boogie" and "dead weight."

March 24, 2010 | Unregistered CommenterCourtroom Mama

Great post.

If we ever do have baby #3, and if we do decide to go back to the hospital, I think I would look into the walking epidural. Honestly, I have no desire to feel the pain of labor again -- definitely one downside to the homebirth -- and being able to eliminate or reduce some pain while still being able to move would be the best of both worlds, IMO. One of the reasons why I swore up and down I would not have an epidural if there ever was a next time, is because of the sheer fear of a repeat shoulder dystocia. Just the thought of having another SD, but not being able to move to resolve it, really scares me.

I would probably try med free, but if I felt I really needed some relief... a walking epidural... hmmm...

March 24, 2010 | Unregistered Commentermichele

@Courtroom Mama - that is why I was SO surprised to see Heather say that she actually works at a place that uses walking epidurals! Talk about a sasquatch. Women who use those "check-off" birth plans put them in there and just get laughed at. I have NEVER seen one used or even mentioned. People sometimes ask me about them and I just shrug and say that if they want to ask about it, they'd better be asking far in advance and prepared to, you know, be laughed at. I'd really like to understand why - is it a liability thing with not wanting women to get out of bed? (due to risk of falling?) Is it a technique thing, harder to place or monitor? Is it just that some places teach them and some don't?

In any case - this was a GREAT post! I think epidurals are great tools and I tell my clients exactly that. You want to have them in your toolbox along with everything else, and just know when to use them appropriately. They can make a huge difference - I think they sometimes prevent c-sections by allowing a very tense and slow labor to progress, or a totally exhausted woman to sleep and regroup her energy for pushing.

March 24, 2010 | Unregistered CommenterRebecca

Ya, I don't know why the "walking epidural" is so rare....when I first started working 8 years ago, we had the regular, heavy epidurals that really made the legs weak and walking really wasn't a safe option and position changes were difficult. I really hated that, it's hard to even get the woman on her side to push when her legs are so dead...not to mention the lack of rectal pressure...at least she was able to happily wait and inadvertently "breathe the baby down" or "labor down" simply because most of us nurses were in no way interested in pushing with a patient for hours on end when there was absolutely no sensation. Even then we (nurses and most docs) had the sense to wait for the baby to come down on it's own, at least til mom could feel "something". Anyway, We've used this epidural "cocktail" for probably 5 years now, or more. It's great!

I've worked in a few other hospitals in the last few years and I have to say, my little city hospital is pretty sweet when it comes to low-intervention. Most of the nurses actually enjoy providing labor support and we pretty much encourage every woman to labor in the tub for as long as she can before she gets an epidural. We also don't use the electronic fetal monitor unless there's an indication like high blood pressure or decreased fetal movement. I once worked in a hospital where every woman had to have a 20 minute monitor tracing done...even if it was normal after 10 minutes, we had to leave it on for 20. It was so engrained in the nurses minds that when a lady arrived fully dilated and delivering precipitously, they were still trying to hook up the monitor when the head was crowning! Ridiculous!!

We're not perfect in my hospital, there's a lot that we can improve on. But Comparatively, I think that we're doing a pretty darn good job of letting birth happen.

March 24, 2010 | Unregistered CommenterHeather

Sigh.. I am one of those "natural birth zealots" but I have to say epidurals DO have their place.. just not in NORMAL birth.

NORMAL birth does not cause a woman to be so exhausted she can't stand or so tired she cries non-stop for an hour. NORMAL birth does not cause -severe- pain (like 12 on a scale of 10) or require a woman to push very, very, very, slowly so she does not re-break her fragile pubis.

In NORMAL birth, epidurals are not necessary.

Abnormal birth, on the other hand can end up requiring an epidural. And, if an epidural is needed -- then a walking epidural is usually the BEST option, for sure!

I personally ended up with an epidural. I was in labor for 72 hours (24 of which were very painful) before I got one so I could take a nap. I was so exhausted I could not function anymore and in so much pain I couldn't stop crying. It was not NORMAL and my son was mispositioned in a couple of manners causing this. He was posterior, and he had his hand on his face and this made my labor very long and very painful. I tried every trick to get him to turn from posterior.. but we were not aware his hand was on his head holding him there. Short of turning him manually (which would've required an epidural) they couldn't do anything. So, I got the darn epidural and wanted him rotated, knowing it might increase my risk of c-section.

It was a tough decision on my part because I am very anti-intervention and SWORE up and down I never would get an epidural.

It wasn't supposed to be a walking epidural, (they kept saying I should not be able to move my legs) but I'm a redhead and I could always move my legs with my epidural .. but I could also finally take a nap after he was re-positioned. About 4 hours later I was progressing and pushing.

In abnormal situations they should try to give women lower doses of epidural so they can be like me and move and feel. I think it helps labor continue to progress.

I do not think, in abnormal situations, that if a woman has an epidural and the epidural leads to failure to progress. it is the woman's fault at all.

In normal situations however I think someone should be suffering considerably before they get pain relief since that is what is best for the baby and mother's health. BUT, whatever. ;)

March 24, 2010 | Unregistered CommenterFogedaboudid

I had an epidural for my first birth due to preeclampsia; the OB thought the blood pressure drop that often follows getting one would help me keep from progressing to full eclampsia. After 5 days of every-three-minute contractions followed by an induction, the relief was unbelievable. Unfortunately it conked out right at transition, but I'm still glad I got it. Those 12 hours or so of relief probably saved me from a C-section. It frustrates me when I hear a few natural birth advocates rail against epidurals, because I know that mine was the factor that saved me from surgery!

March 25, 2010 | Unregistered CommenterAlice
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