January 18, 2010

Epidurals: The Pros and The Cons

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.

*Moms with high blood pressure can benefit from the epidural, since the epidural tends to lower the blood pressure. The British Medical Journal states “It prevents the exacerbation of hypertension and the rise in noradrenaline concentration that may be associated with pain.”

*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.

Like anything that has advantages, there are also disadvantages that need to be examined. With epidural anesthesia a birthing mom may experience one or several of the following situations:

Windows of pain.
Some women may not get full pain relief from the epidural. There can be a ‘window’ or small area on the woman’s body that still feels the pain. One of my clients had the experience where only half her body had pain relief. It is thought to result from an inability to deliver the epidural medication to the corresponding location of the spinal column. To overcome the window, the anesthesiologist or CRNA may decide to administer additional medication, adjust the catheter, or replace the catheter.

Slows down the progress of labor.
There is some discussion among doctors, midwives, and childbirth educators about the validity of this statement. There have been many studies supporting the theory that epidurals can slow down labor, especially in the second stage (pushing), which may result in the need for pitocin to help regain adequate contractions. A study from the Department of Obstetrics and Gynecology, Rambam Medical Center, Technion-Faculty of Medicine, Haifa, Israel, concluded “Women should be informed that prolongation of labor and increase in nonspontaneous deliveries should be expected when choosing epidural analgesia in labor.”

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.

*Itchiness as a reaction to from the medication
*Slight to severe headaches
*Drop in blood pressure
*Residual back pain at needle insertion site
*Inability to experience the natural high of oxytocin, or “the love hormone”
*Necessity of instrumental birth (forceps, vacuum extraction or cesarean birth)
*Rare complications, such as residual numbness or weakness from needle injury to nerves (almost 1 in 10,000)10, delayed respiratory depression with epidural narcotics (up to 12 hours later)8, and brain damage and death (extremely rare)

Fetal Side Effects
*Increased likelihood of newborn septic workup, IV antibiotics and isolation in the nursery if the mother develops an “epidural fever” that causes fetal tachycardia or newborn fever.
*A study by M. Walker in the Journal of Human Lactation, the lingering effects of epidural anesthesia on the newborn can cause difficulty suckling and sleepiness, both of which interfere with early breastfeeding.

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!




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