Saturday, March 27, 2010

Epidural Anesthesia Can Be a Good Thing

This post, on the Unnecesarean blog (which I will address below), reminded me of a post by Public Health Doula that she called Stages of Birth Thinking. Its a great idea-in-draft about the thoughts that people have as they learn about the birth world and birth options. I highly suggest you check it out. 

There is Pre-contemplation:
This generally means that birth education comes from mass media portrayals of pregnancy and birth, as well as personal stories from friends and family that may vary greatly, but are usually filtered through the prism of our culture's main messages about birth: Painful and pathological; done in a hospital, with doctors. You might prefer a vaginal delivery or a c-section, but there's little you can do to control the outcome, and all hospitals/doctors practice more or less the same way,
then Initial learning and Revelation:
 "Wow! Nobody ever told me that birth could be amazing, not scary! These home births are beautiful. I didn't realize that my/my friend's/my aunt's c-section could have been prevented. I didn't know about all these harmful complications of interventions - I've only heard good things. And it's so clear how once you start one intervention, you get a cascade of them. Doctors don't have the best outcomes - midwives do! Breastfeeding has benefits I didn't know about, and they are so important."
then Validation (or not) through Experience:
A year of attending births nudged me yet farther away from my starry-eyed novice doula perspective. Not all c-sections can be avoided, even if you do everything "right". Sometimes epidurals are the best tool you have. Pitocin isn't fun, but it's not the end of the world. While it might be difficult to accomplish, you actually can have a great low-intervention birth in a hospital. This tempering is slow, and less personal - it's not happening to you, and it's happening over a multitude of experiences.
 and finally Integration: 
You recognize that every situation is individual, even though there are patterns and large-scale effects that are likely, because you have a chance to see many [births].

And through these stages you may have the following thought: "I thought the epidural was the devil itself, but when I got one it was actually awesome and helped me have a vaginal birth." 

And this is what my post is about.

For some time, I was in the Initial Learning and Revelation phase, and I was causing my good friends and readers of this blog to be in it with me. But the more I read and see I am coming to the "Validation" phase, and with it, I have realized that an epidural, though it has its faults, can be awesome for some people. This was partially triggered by the post on Stand and Deliver called Epidurals, and the 67 comments that readers left discussing their experiences with an epidural and if it perhaps made they feel empowered. The response was amazing: many women said they hated the epidural and has all sorts of complications with it and would never use it again.  A few were indifferent to their experience with it. Many said they LOVED their epidural and would not birth without it. Really? Yes, these are real experiences. 

And so we get to the recent post on the Unnecesarean showing when the use of an epidural may be beneficial, and how to heighten its positive effects and decrease negative ones:

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.

The Strategy:
  • Administering the epidural in late labor. This carries the benefit of minimizing risk of epidural fever 1 , and allows the body to benefit from the natural surge of oxytocin and endorphins that labor brings 2 .  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. 
  • 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”. 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


Rebecca said...

Thanks for the link! And belated congratulations on your USF acceptance! At the Breastfeedng & Feminism conference I met a PhD student there (in public health) who's interested in breastfeeding/birth and is starting a student group, so you should check them out...good way to get involved.

Emily, Anthro Doula said...

Awesome, thank you!

Kristi said...

This is wonderful! I am just now starting my doula journey and both moms that I've assisted at the hospital used epidurals at the end. I felt like I failed them b/c they wanted a natural birth, but it was their choice. In both cases, it was a very wise choice in my opinion, to get the epidurals when they did. I haven't been able to talk to them about how they feel about their birth experiences, so I hope they are happy with their choices!

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