January 28, 2010

Labor and Birth With An Epidural

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.

It is not uncommon for women to hear that the baby is too big or that the mother has CPD (Cephalic Pelvic Disproportion). Basically, this is the determination that the baby’s head is too big for the mother’s pelvis. True CPD is rare and often seen in cases where there is a maternal birth defect involving the pelvis, where the mother has experienced a major accident in which the pelvic was severely damaged, or when it is a teenage mother whose pelvis has not fully developed. What is most likely the case for women hearing this diagnosis is they were giving birth on their back. Janet Balaskas, author of Active Birth says” “In the semisitting position the mother’s weight rests on her coccyx and the pelvic capacity is reduced. In the semireclining position the sacrum is immobile and the pelvic outlet narrows. Your coccyx is designed to move out of the way as your baby’ss head descends. Sitting on your coccyx during birth restricts the pelvic outlet and can also lead to dislocation of the coccyx, which can be extremely painful for months after the birth.”

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.




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