Statistics show that 70% of birthing women will take an epidural during the labor and delivery process. That being the case, it is important to discuss how to be pro-active and assure a good chance at a successful vaginal delivery with an epidural.
In a recent blog entry, I outlined the pros and cons of taking an epidural, with one of the main drawbacks being the lack of movement available to a laboring mother. When the mother is moving, it allows her pelvic bones to shift and better accommodate the baby, a baby that is hopefully gently moving into an optimal fetal position. Because of the lack of movement an epidural brings, it is easy for the baby to get stuck in one position in the pelvis. One way to combat the baby getting too relaxed in an unfavorable position is to make sure that the mother is frequently shifting from one side to the other. If possible, she should alternate between truly side-lying (with the hips stacked and a pillow between the knees, supporting the upper knee and ankle) and semi-prone (lying more toward the belly, with the top leg supported and the bottom leg straight). Since the heaviest part of the baby is its back and the back of its head, gravity will naturally pull the baby toward the mother’s belly, guiding the baby to an anterior position.
If the mother is resting on her back for a long period of time, it is more likely that the baby will shift toward the mother’s back, which is the posterior position. In this position, it is harder for the baby’s head to effectively apply pressure to the cervix and encourage it to dilate. “There is evidence to suggest that if the mother lies flat on her back then vena caval compression is increased, resulting in hypotension. This can lead to reduced placental perfusion and diminished fetal oxygenation. The efficiency of uterine contractions may also be reduced”¯. (Humphrey et al. 1974, Kurz et al. 1982) If the contractions are inadequate, then pitocin will be introduced into the labor scenario to strengthen the contractions and the frequency of the contraction. Without going into an explanation of the “cascade of interventions”, let’s just say it would be better not to rely on pitocin too much to drive the labor forward. Point being: stay off your back.
Another helpful idea to keep in mind is that once the epidural is in place, the mother is going to continue to receive IV fluids. For some women, this creates a lot of swelling in the lower body. It can be nice to have someone massage and rub the mother’s legs and feet to help prevent the edema from pooling in the lower extremities.
As research has shown, the second stage of labor, the pushing stage, is often longer with an epidural than without. That can be because the mother does not feel the urge to push or can feel a bit clumsy when it is time to push since she has less awareness and coordination of the lower part of her body. Also the epidural often slows second stage by reducing or eliminating the normal surge of oxytocin, and by reducing pelvic floor muscle tone, which may lead to more deep transverse arrests or persistent occiput posteriors. I usually suggest two things, first: ask to have the epidural turned down (or at least resist the urge to self-administer more). Secondly, since the pain is greatly diminished, why not take the time to “labor down,” meaning that the contractions are going to continue to move the baby further down the birth canal; the mother may as well let the baby continue to descend. When it is time to push - which requires a lot of effort and energy - the baby has less distance to travel to be born.
In the ideal birthing position, the pelvic outlet is as spacious as possible. An “all 4″ position is great since there is not any pressure on the back, pressure which might push the sacrum into the birth canal and require the baby to maneuver around the tailbone. Also, the rectum, which is elasticized, has somewhere to go when it is pushed out of the way as the baby passes by. I have also seen variations on the “all 4″, like standing and leaning over the bed, or a half-squat. All these positions allow for maximum space.
I also believe that forcefully pulling the knees back to the arm pits, while it may spread the sit bones, compresses the pubis, making it more difficult for the baby to come under the pubis and uphill towards the vaginal opening. On a side note: if the mother is doing this forceful movement for a very long period of time, she may create a diastasis (separation) of the pubis symphysis which can become painful.
How can a mother birth effectively with an epidural? One of the best options is side-lying. In this position, the mother is on her side while holding her top leg up. This gives the sacrum, rectum and tailbone space and mobility, and creates a nice amount of room for the baby to pass through. This position is really ideal if the baby is posterior. If the mother tries to push her posterior baby out on her back, the baby’s occiput can get caught on the mother’s sacrum. Another option is to think of slightly pointing the tailbone up. Many years ago, I heard a nurse give this advice to a mother who had been pushing for nearly 5 hours. We tried EVERYTHING and that really helped! Just last week, I attended a birth and gave that advice to a mother who was on the verge of needing vacuum assistance to birth her baby. The tailbone trick worked. (Let me backtrack and say that the baby was very close to getting under the pubis and this trick just allowed a little bit more space for the tailbone to move out of the way. This maneuver also pushed the top of the sacrum down towards the bed and out of the birth canal.) I don’t think I would advise this from the get-go of pushing, but it certainly helped for those last few pushes.
It is such a fine dance of the mechanics of the female pelvis to birth a baby. Small adjustments can make a huge difference for both you and your baby. The best thing you can do for you and your baby is to know your options and be educated about your choices. No matter whether you are medicated or un-medicated, there are ways to birth your baby in a healthy, supportive manner.
Whether or not to opt for pain medication during labor and delivery is a personal choice. In making these choices, it may be helpful to understand the pros and cons of epidural anesthesia. It is not my job as a teacher to lead you in one direction or another, but to simply present factual information and give you the opportunity to decide what is best for you.
The epidural is, for the most part, very successful in eliminating the pain of labor contractions while allowing the mother to stay alert. It will not compromise her state of mind the way other medications like stadol or demoral do.
In my experience, the women who tend to hire me as a doula usually request that I help them avoid the use of drugs or help them get to a certain point before taking the epidural. However, there have been times when I have suggested, for the sake of the mother, that she consider taking the epidural.
For example:
*If the mother has been laboring for a very long time and is completely exhausted, this will give her the opportunity to sleep and get re-energized so that she can push her baby out.
*If the mother’s labor has been long and difficult, her body can become very tight and tense which can prevent the baby from descending. The epidural can allow her pelvic muscles to relax, the baby to descend, and cervix to dilate.
*Along these lines, if the mother is paralyzed by the fear of pain, the epidural will help her relax.
*An epidural is a good choice for those opting for a cesarean birth, since it will allow the mother to remain awake and alert during her surgery and for the birth of her baby.
Difficulty Pushing With an epidural or without, I recommend “laboring down” which means: even once the cervix if fully dilated to 10cm, wait until you have the urge to push before starting the second stage of labor - the pushing stage. The contractions will continue to help move your baby further down the birth canal and lessen the time you are actually pushing. Because of the lack of sensation with an epidural, it may be difficult for the laboring woman to access and utilize the muscles needed to push her baby out. If you have the epidural, you may want to consider letting it wear down so that there is some sensation and muscle recognition that will help in pushing. Also - why not take advantage of not having a lot of pain (although there still will be pressure) and let the baby continue to descend on its own?
Attachments and Lack of Mobility One of the main reasons I am writing this particular post is because I overheard some students talking about their plans for the “walking epidural”. What most people don’t know is that once you receive the epidural, you are not leaving that bed! Once the epidural is placed, the mother is restricted from getting out of bed. This lack of mobility does not allow the mother’s pelvic bones to move, which would help the baby to find the best fit. I would recommend shifting frequently from one side to the other. Do not give the baby too much of an opportunity to snuggle into place for too long.
The birthing mother is often hooked up to numerous machines:
*The epidural catheter is taped to her back for the remainder of labor and that catheter is attached to the machine dispensing the medication.
*External Fetal Monitor (EFM) or sometimes Internal Fetal Monitor if the EFM is not adequately picking up the baby’s heart beat.
*External contraction monitor, measuring the timing the contractions. If the care provider is not sure the contractions are adequate, an intrauterine-pressure catheter (IUPC) may be inserted to measure the strength of the contractions.
*Urine catheter
*Continuous IV drip
*Blood pressure cuff
*Pulse oximeter
Maternal and Fetal Side Effects There are several possible side effects to consider when taking the epidural.
For those considering the epidural, here is a short, animated video demonstrating how the epidural is placed in the body. Please note: the last 45 seconds can be ignored (it is an ad for Episure AutoDetect Loss of Resistance Syringe). But I do think the beginning portion is worth watching!
This blog entry was recently given to me from a New York City Midwife. The topic of Group B Strep is often confusing to people and not usually explained very well. I invite you to read about what Group B Strep is and how you can prevent it.
I hope you enjoy!
What is GBS?
Group B Streptococci (GBS, Group B strep, Beta Strep) can be present asymptomatically in the vagina. It can cause inflammation of the amniotic sac, the uterine lining or lead to a urinary tract infection in the mother. Occasionally a newborn will have a local infection, septicemia or meningitis as a result of Group B strep. There are five serotypes of Group B strep, with type III as the most associated with meningitis. However, all types may cause disease.
What is the risk?
Between 15-40% of all women have GBS present in the vagina. As many as 75% of their babies contract strep, but only 3 to 4 percent per 1000 get sick as a result. Of these sick babies, 7% of them are under 1000 gm (around 2 lbs). Babies born before 37 weeks gestation are at much higher risk of infection than full term babies. There is an increased risk for the baby with premature rupture of membranes (PROM) or surgical delivery. In other words: Of the 15-40% of mom’s who test + only 2-3 babies will actually become ill (15-40% is between 150 - 400 babies and out of those 75% or 142 -300 will contract GBS but only 3-4% will get ill or somewhere around 4-12 babies.)
If recurrent prematurity has been a problem for the mother or a urinary tract infection (UTI) is present, a culture may be done to determine if strep B is present. In a hospital setting, when premature rupture of membranes is being checked, a culture can be done at that time. In clinical practice, vaginal strep culture is usually offered to women at 34-36 weeks.
If the client has a past medical history with a baby who was ill from Group B strep, or had a UTI with Group B strep, membranes ruptured more than 18 hours, this baby is less than 37 weeks gestation, then the risk to this baby is higher.
If the result is positive, the midwife should discuss management options.
Babies and Infection
Risk Factors that increase the likelihood of infection for the baby:
1. Labor is premature (less than 37 weeks)
2. A prolonged rupture of membranes, greater than 12 to 19 hours.
3. Maternal fever before or during labor.
4. There are signs or symptoms of maternal or fetal infection.
5. Group B strep in the urine of the Mom
6. Multiple vaginal exams in labor
In a hospital, if strep is present, the baby is cultured immediately after birth. If strep is found, antibiotics are begun. In a well-nourished mother the baby will be more resistant to infection. Remember, problems only manifest in a small number of cases.
How is it treated?
My preferred methods for treating GBS before labor are below. Begin treatment as soon as you know that you are GBS positive.
1) First to treat the vaginal area, there are two options. Both involve a vaginal suppository combined with an anti- bacterial wash. One is with tree oil suppositories & the other is with an antibiotic suppository. If you prefer to use tea tree oil suppositories, go to a health food store or Vitamin Shoppe to purchase it. At night, before you go to sleep, insert one tea tree oil suppository for 7 nights.
2) At the same time we must treat the source of the bacterial contamination. This is where the anti-microbial wash comes in. Go to a pharmacy with a good medical supply section and buy Hibiclens anti-bacterial soap. The generic name of the soap is chlorhexadine. It will be with first aid and medical supplies, not with bath soap. If you can’t find it, ask the pharmacist. To use the Hibiclens, you will also need an 8 ounce squeeze bottle or peri-bottle. Your birth kit comes with one, but if you have not received it you may be able to buy one at the pharmacy, or we can give you one. To use, pour one ounce of Hibiclens into the peri-bottle and fill the rest with clean water. After all bowel movements, squirt the soapy water from front to back, in the way that you wipe. Don’t rinse, just wipe gently (front to back). Do this until the baby is born. I also recommend the wash before sex.
Cultures will be repeated each week until the birth. If the first one is still positive, and tea tree oil suppositories were used, I recommend going right to the antibiotic suppository, Cleocin, and continuing the wash.
If the first culture is negative, continue the wash until the birth. But we will continue to culture at each visit to be sure we are still clear of the bacteria. I am usually comfortable with not using IV antibiotics if I have a negative cultures
What if the above treatment does not work?
If we do not have a negative culture for GBS before your labor begins, we will discuss the mainstream treatment, IV antibiotics during labor. If we get a negative culture and it returns to positive then I think this is an indication of a higher colony count of the bacteria and that alone increases the risk of illness for the baby. IV antibiotic treatment does not preclude homebirth. It does not mean you must walk around with an IV.
Nutritional and Lifestyle Recommendations for GBS
1. Boost Vitamin C in your diet, such as eating 2 grapefruit per day. Other good sources of Vit C: red peppers, oranges, kiwi fruit.
2. Drink a cup of Echinacea tea or take Grapefruit Seed daily.
3. Get extra sleep before midnight. Slow down your schedule. Take it easy and eat well. Follow a nutritious Pregnancy Diet.
3. As a precautionary measure, oral sex should be avoided whenever a strep infection is present in the throat of a partner (this is usually strep A).
4. Plan ahead for extra warmth after the birth for both you and baby. Hot water bottles, heating pads, hot packs, big towels dried in a hot dryer during the pushing phase–will all help you and baby keep extra toasty after birth and reduce stress. Have a friend or family member assigned to be in charge of the “Mother/baby warmth team”.
5. The colostrum from your breasts is the best antibiotic treatment your baby could ever get. The colostrum is very important for your baby. Breastfeeding your baby is the best thing you can do to keep your baby healthy since you pass on your immunities to your baby through the breastmilk.
6. Do not allow children of other families to visit the new baby for the first 3 weeks. Keep your older kids healthy so they are not sneezing and coughing on new baby.
The rest of this packet contains other techniques of treating GBS that I do not have personal experience with. The information is collected from other midwives.
HERBS
Propolus can be taken daily, either in capsules or tincture, 3 to 4 times daily.
Echinacea root (Augustofloria) can be taken either as a tea or tincture, 3 times daily. To make the tea, use 1 oz of the root to 1 pint of boiling water and steep for 6 to 8 hours. Echinacea root is specific to staph and strep infections. It stimulates the body’s defense mechanisms as well. A strong tea may also be diluted and used as a douche. When douching in pregnancy, extra care must be taken to avoid forcing water up into the uterus, causing infection and other problems.
Safe Douching During Pregnancy:
Fill douche bag with cooled tea, attach cleaned vaginal tip. Hang bag 10 inches or less from the floor. Lay in the bathtub and gently insert the nozzle into the vagina no more than half way in.
Very gently release the hose clamp and allow tea to run in and out of the vagina, do NOT attempt to retain water in the vagina in pregnancy.
When finished, clean the equipment thoroughly.
Douching should never be attempted if there is any question that cervical dilation, placenta previa or prematurely ruptured membranes are present.
At home, Echinacea tincture can be given prophylactically if desired. The infant dose is 1 drop tincture every 3 hours. Symptoms of neonatal infection often begin with respiratory distress which gradually worsens. Evaluate other signs of infection, e.g., alertness, nursing, etc., and if the midwife suspects trouble, the client’s pediatrician should be consulted by the client immediately.
ESSENTIAL OILS
Essential Oil Protocol to get rid of GBS (From: www.thebirthsource.homestead.com/gbs.html )
It’s imperative that the oils are of highest quality. Young Living oils from Essential Oils R Us are one source that has been recommended.
Put the following in a Double “O” gelatin or vegetable capsule:
Take one capsule 3 times daily.
Additionally do the following:
Soak an ORGANIC tampon in…
15 drops Lemon Essential oil
9 drops Oregeno Essential oil
15 drops Mountain Savory Essential oil
1 tsp carrier (V-6) oil
Leave soaked tampon in overnight. Insist on being retested. Do this daily for the last six weeks of pregnancy.
Insert a small ORGANIC tampon or a cotton ball, whichever is more comfortable, soaked in a combination of 10 drops of tea tree essential oil and Olive oil. Leave the tampon in for 4 hours each day for 6 days. There are Tea Tree Oil suppositories in most health food stores.
MISCELLANEOUS
V-6 Mixing Oil combines food-grade vegetable oils for mixing with essential oils to create blends, formulas and massage oils. Grape seed oil, wheat germ oil and vitamin E are nurturing to the skin as natural antioxidants. V-6 is also excellent for cooking and making salad dressings. Blendi 15-30 drops of an essential oil to 1 oz. mixing oil. V-6 is good for mixing massage oils, creating your own blends and formulas, for cooking and making salad dressings, etc. The ingredients of V-6 Mixing Oil are sesame seed oil, grape seed oil, almond oil, wheat germ oil, sunflower seed oil and vitamin E.
Another GBS Remedy (From the archives at http://www.gentlebirth.org/archives/gbs.html :
3 capsules of Congaplex by Standard Brands 3 times a day for a week, then reculture. If negative, no more Congaplex. If positive, 1 cap a day until the end of pregnancy.
Congaplex Ingredients: Bovine thymus Cytosol™ extract, carrot root, ribonucleic acid, bovine bone, nutritional yeast, defatted wheat, bovine adrenal, dried alfalfa juice, oat flour, alfalfa flour, bovine kidney, veal bone PMG™ extract, mushroom, dried buckwheat juice, buckwheat, peanut, soy bean lecithin, mixed tocopherols and carrot oil.
Do not take if you have food allergies to any of these ingredients.
Congaplex is available at:
http://www.humandiamond.com/hdpub3/store/store0100.html (1-800-366-5992) Congaplex Supplier
Take 500 mg Vitamin C every 4 waking hours.
1 acidophilus (4 billion micro-organisms or higher) capsule every 4 waking hours.
Acidophilus is available as:
Probiotics High Potency Acidophilus
Friendly Colonizer Acidophilus Powder
Take Congaplex, vitamin C and acidophilus daily for the last six weeks.
:
EHB by NF Formulas given over a 10 day period (6 caps per day) (E.H.B. by NF Formulas, Inc.), and Tea tree oil vaginal suppositories 3 to 4 x daily for that time (see above). This mom was re-tested at two weeks after positive culture (3 to 4 days after last EHB taken), two weeks after that (2 1/2 weeks after first positive culture), and on one occasion was tested again 2 1/2 weeks later (5 weeks after positive culture) because of a prolonged ROM with no labor.
Then insist on retesting to see if the GBS has gone away. Midwives have seen heavy colonization completely cleared with these treatments, although there is no scientific study to support it.
