Belly Up

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Tuesday, March 8, 2011

I Want My Epidural! (but not fetal distress please...)

So you want an problem!  Actually I can't promise no problems as epidurals do carry inherent risks.  However, I want to make some suggestions for the mom who feels that in her labor an epidural is the way to go, but all things being equal, she would prefer to minimize these risks as much as possible.

Let me briefly discuss a few of the risks.  Epidurals are known to lower mom's blood pressure which can mean less oxygen for baby and this may result in fetal distress (and fetal distress often leads to surgical birth....).  Another concern involving the baby's oxygen is the supine position that mom is encouraged to assume after an epidural is placed.  The reason mom is told to lay down is because an epidural uses gravity to circulate its drugs, thus sitting up will produce a numb tush but not a numb cervix or uterus...which kinda defeats the whole point.  However, laying down can constrict the vena cava which is the blood flow to mom's lower body and to her baby so its constriction can lead to less oxygen for baby and possible fetal distress.  Epidurals often necessitate (or facilitate) the use of pitocin which, surprise!, also can cause fetal distress. Getting max O2 to baby is definitely one of the risks to try to overcome when choosing an epidural.

The 2nd group of risks surrounds the progress of labor.  Epidurals produce slightly longer labors, but many moms consider an extra few hours of pain free labor a fair trade.  However, an epidural given early in labor can slow contractions down significantly.  Obviously in this case pitocin is given to compensate which brings us back to the previous paragraph.  Often pitocin is used after mom gets an epidural not because labor is slow, but why not move things along as mom is comfortable.  Unfortunately this does not take the baby's concerns into account.  Epidurals also can encourage poor fetal positioning as the pelvic tone becomes flaccid and baby can no longer use it to aid in his rotation or to straighten an asynclitic head. Mom also loses much of her ability to partner with her baby to bring about rotation and descent.

Finally, an epidural can interfere with descetion in the 2nd stage in a few ways - mom may have trouble pushing effectively, she must remain in a position that reduces the size of her pelvic outlet and mom may push too hard and too fast.  Sounds like I just contradicted myself right?  When mom can't feel her muscles it can be hard for her to know which muscles to use and which ones are actually being used when pushing is happening.  Mom also doesn't get the bio feed back that is provided when a baby is stretching her perineum.  So some moms find it hard to move baby down and will need the assistance of forceps/vacuum and then, at the very end when the normal (and often uncomfortable) sensation of crowning would tell mom to slow down to allow her to stretch, an epidural mom can just push right through her perineum causing more tearing than may have occurred otherwise.

So what's a girl to do?  Here a few ways that might help to avoid fetal distress, surgical birth, extended tears and provide for a better overall epidural experience.

1.  Stay home until labor is well established and then some.  Get in the tub, eat, facebook each contraction if you want, but if all goes well you will arrive at the hospital close to the time that it is best to get an epidural.
2.  Wait to get an epidural until you are 5 cm or beyond.  This makes it less likely that cervical dilation will be significantly slowed and also makes it less likely labor augmentation drugs (pit) will be used.
3.  Ask if the nurse (or your doula) can tell the position of your baby.  If your baby is not anterior, do not get an epidural until he rotates. 
4.  After the epidural is in, do not lay on your back.  Lay on your side and flip to the other side every 15 mins.  This will aid in the baby's rotation and help the baby get oxygen. 
5.  Do not consent to pit augmentation unless your contractions significantly slow down.  Try nipple stim first.
6.  When you reach 10cm dilation, ask to labor down and have your epidural cut back.  As it wears off you may feel more of an urge to push and hopefully laboring down will have brought baby down a bit.
7.  Ask your careprovider to provide perineum support in the form of hot compresses and ask him to guide you in pushing your baby out slowly.  If a vacuum assist is used above the pubic bone, ask that after the vacuum has brought baby past that area if you may push again.

1 comment:

  1. Thanks so much for this article! Labor is unbelievably painful for me so I want my epidural, but I definitely want to avoid an unnecessary C-section! Hospitals love to cut you open at the slightest sign of fetal distress or "failure to progress". And half the time, these conditions are caused by hospital interventions implemented in a thoughtless way. It is a shame women are given pitocin, epidurals, pain drugs, and have their water artificially broken without being fully informed of all the risks of these procedures like fetal distress, failure to progress, or uterine rupture. Women are never informed of procedures which would minimize the risks of these medical interventions! I mean - it's common sense! If fetal distress is caused by lack of oxygen, and lying on your back for an epidural diminishes this oxygen supply, then why not rotate side to side instead??? Maybe this full reasoning process is avoided in modern medicine because OBGYN's would be afraid women would turn around and sue them for complications from their unnecessary C-sections! I'm sure a simple change in protocal like rotating a woman on her side after an epidural would lower the rate of C-sections by about 10% - and that would lower the profit margins of OB's and hospitals or make it harder to monitor 5 women giving birth simultaneously. But anyway, I think waiting til 5 cm, asking to be moved around, avoiding pitocin, and avoiding other pain-drugs is the way to go! I will hire a doula to implement this slightly more complicated birth procedure.