Why doesn't everyone get epidurals

This was a question I came across when I was looking at search terms that came to my site.  It struck me, because it comes from a completely different mindset than mine.  What is happening here is the clash of cultures.  This comes from the mindset that getting rid of pain is the most important factor in childbirth.  For many women though, this is not the case.

For me, when women would look at me after getting their epidural, often times they would ask, "why would you not get this".  I would just smile, because I knew it wouldn't make sense to them at this point.  I understood that for them the pain was the paramount problem of labor, thus the epidural was wonderful.  For me, though, that was not, nor is it still the case.  In fact, when I see women unable to move, with monitors, a cathetor, an iv, and little sensation to their lower limbs, I know I could not do that.  Pain for me is not the paramount factor, the ability to move and be free of iv's and other tubes is.  For me, that is more important than the pain.

I am not putting down those who choose an epidural, I'm just explaining what is more important to me.  I took care of another lady that was terrified of needles...for her that was of more importance.  For another she was claustrophobic and having an epidural was more frightening for her(she had had it both ways too and still preferred natural).  Some appreciate being able to move and feel right afterwards.  Some have had bad epidural experiences.  Some are more afraid of the effects that the epidural might have on them and the baby(and there are some bad side effects that can happen).  Again, it comes down to which plays a more important factor in how we view birth, and really, neither view should be deemed better or worse than the other.  It comes down to our own personal feelings.

Pro's and con's of an epidural

This was  a post I wrote from awhile ago that I thought I'd dig up since I just wrote about supporting breastfeeding and epidurals.  Enjoy:)


December 13, 2008


First off, I should share with you that I am more biased towards a
natural birth, but I certainly understand why women use epidurals and
feel like there is a place for them even for those who would like to
have a natural birth.

Second, I am concerned for the safety and well being of all mothers
and babies, as well as their emotional and psychological state during
birth. Thus, I address both of these issues in this blog.

Ok, so I'm sure everyone knows the biggest reason why you would want
an epidural... pain control. Most people do not like pain. Ok, I don't
know anyone that likes pain. So that is pro number one. An epidural is
an easy fairly routine way to achieve great pain control. It is also
well understood and endorsed in the hospital setting.

It also does not require much effort on your part and it has a high
level of satisfaction. Most women who get epidurals say they would use
them again. I have even heard some who had at first wanted a natural
birth decide to get an epidural and wondered why they didn't do that
in the first place:)

Some problems with these areas, though, are that women tend to get
more frustrated if epidural doesn't take (because sometimes they
don't work well), and studies have shown that satisfaction with labor
has more to do with how in control you feel rather than your level of
pain. So, if not having pain makes you feel in control, then an
epidural would be helpful in that respect.

From my perspective, having watched births, I didn't want the epidural
because it then made it very unlikely that I could move around or feel
like a part of my birth. To me that seemed to give less control. So a
lot of it depends on your own personality and your view of pain and
your body.


There are also some medical reasons to use an epidural. If a mother
has been laboring for a long time and has reached exhaustion, her body
needs a rest. There are ways to do this naturally, but it is hard and
not as well supported in the hospital. At this point an epidural
would be useful from a medical stand point. Sometimes a body just
needs to sleep.

There are also some medical considerations, though, when choosing to
use an epidural. Studies have shown that epidurals can cause a lower
blood pressure, which could cause a decrease blood flow to the baby.
On the other hand, if you usually have high blood pressure, then that
might not be a bad thing.

Epidurals can also cause an increase in body temperature. This can
have effects on both the infant and what the doctors decide to do to
treat the tempurature (ie give antibiotics).

If you have an epidural, you will need a catheter... a tube that is
placed inside to help you pee. This also decreases your mobility.
This catheter may stay inside of you until after the baby is born and
sometimes they have to replace it if it is taking a long time for you
to finally use the bathroom.

Tearing is more common with epidurals. Some studies have also shown
that labors are longer with epidurals. Backaches and headaches after
the baby is born are also more common with epidurals.


The bottom line is, if you can deal with the pain I would absolutely
suggest you try and go natural. It is difficult, though and requires
a lot of help, which hospitals are not always good at giving. An
epidural does make it so that the mother needs more monitoring, it is
difficult to feel what your body is doing so trying to position
correctly is hard, and pretty much you are in bed. These factors all
lead up to needing more interventions from the medical team. You'll
need an IV, the machines are the ones that really tell the nurse what
is going on, and there is a higher instance of forceps use and
vacuums. Most babies and moms do absolutely fine, though, with an
epidural. As long as you understand that getting an epidural will
mean more interventions, and if all this is ok with you and you still
would rather be out of pain, then I would suggest going with the
epidural.

Keep in mind, that you never know what an experience is like until
you've experienced it. I never thought having natural births could
mean so much to me, but I have found great meaning in my births. To
me, that has been a great blessing. With or without an epidural,
birth can be a wonderful experience as long as you take ownership of
it. Learn what you can, figure out why you want what you want, and
talk to your doctor about what you want and how he is willing to
support you in this. Last of all, take some time to explore your own
fears and ideals of birth and pain. Whether you use an epidural or
not, you can find some insight in doing this.

Breastfeeding and Epidurals-supporting women's decisions in labor

This is a paper that I started writing for a nursing journal, but decided I wanted to make this available for a broader audience.

If you type in epidural and breastfeeding into a search engine, you will probably chance upon a growing debate about how one affects the other. Many women find it confusing because much of the research has conflicting answers. Many are small studies and often have biases in either direction as well as being poorly designed. So where do we get the right answer and how does an epidural really effect breastfeeding? We also should ask, as providers who support women in labor and help with breastfeeding, what can we do to help support the woman who has chosen to get the epidural, but still needs help breastfeeding?

The thought among researchers is that epidural medication may affect the infants ability to suck and thus decrease their ability to nurse effectively after birth. Research has shown both a negative and a neutral affect of the epidural on breastfeeding. Another interesting study showed that the lower the dose of fentyl, the more success there is with breastfeeding. So we can see that the evidence for a link between these two things is unclear, but what we do know is that epidural medications do enter the baby. Fentanyl, a drug used often in epidurals, quickly crosses the placenta is metabolized slower in the infant than an adult. Because of this, and the effects of the epidural on the mom, there may be a more indirect impact of epidurals on the baby.

Epidurals have been linked with a greater chance of maternal fever, a longer second stage, a greater chance of  forceps or a birth, and increased use of Pitocin. All of these things may affect the initial breastfeeding experience between the mother and the baby, and the initial experiences are indicators of early weaning.

A fever will often lead to the need for a separation between mom and baby soon after birth. This is due, in part, because blood tests may be required to make sure the baby does not have an infection. A longer second stage labor could possibly cause the mother to be more tired, and thus not be able to nurse or be as attentive to nursing. Both forceps and vaccuum have the potential for harm that could cause a baby to be separated from the mom. And Pitocin is associated with an increase in abnormal heart rates which may or may not affect how well the infant is doing after birth.

Because of this, those who are assisting with the initial breastfeeding experience should be able to support a woman who is considering using the epidural. We can do this is numerous ways. Providing information is one of the first things we should do to help a woman understand what the implications of having an epidural are, but also understand that the research is still limited. We should also be prepared to support her regardless of her decision.

For a woman that truly desires to have a medication free birth, adequate labor support should be the mainstay. Any woman who is working for a natural labor should have access to adequate non-pharmacologic labor support. More and more research is showing the benefit of having trained labor support, sometimes called a doula, to help a woman in labor. Women who have had continuous uninterrupted support, have fewer c-sections, use less Pitocin, and have less infants admitted to the NICU. Less of all three of these things could lead to better bonding and breastfeeding after birth.

If an epidural becomes medically necessary or the woman decides that she would like one, there are a few things we can do to help increase the chance of breastfeeding success. One is to encourage the lowest dose possible of fentanyl added to the epidural. At least one study has shown an association between the amount of fentanyl added and the rate of breastfeeding success. If we could even provide non medicated means of labor support along with low dose fentanyl, it might do something to increase the success of breastfeeding. Interventions like counter pressure, relaxation, and visualization might work well along with low dose epidural to provide the greatest amount of comfort with the least amount of side effects.

Women also need access to adequate breastfeedomg support, along with baby-friendly practices. Hospitals should provide access to a lactation consulant, and nurses should be trained to help support breastfeeding. A list of the 10 steps for a baby friendly hospital can be found at http://www.unicef.org/programme/breastfeeding/baby.htm#10 .

This protocol includes support such as rooming-in, unrestricted mother-infant contact, and encouraging skin-to-skin. If these steps are followed, breastfeeding continuation rates for women who use epidurals have been found to be similar to those who are unmedicated.

Another important factor in increasing breastfeeding rates is helping the mom herself to feel competent. A woman's personal perception of how she is doing with breastfeeding is a greater indicator of how long she will breastfeed than the perception of a lactation consultant regarding how she is doing. Therefore, if a woman is feeling frustrated with her experience, even if a nurse or lactation consultant feels she is doing fine, the mother is less likely to continue breastfeeding without additional support that builds her confidence. This can be done by education beforehand or during their hospital stay, as well as showing videos of successful breastfeeding attempts.

After birth, there needs to be some effort to reduce the pain and anxiety a mother feels as this may lead to difficultities breastfeeding immediately afterwards. Often times the pressure and intesity of the pushing stage of labor is difficult for a woman to work through, even with an epidural. Again, good labor support practices can help during this stage. Part of this may include allowing the woman to push in a more upright postion, even with an epidural. A side position can also be useful. The side position can also help to reduce the amount of truama to the perineum. Things such as ice packs and adequate pain control also help during this time.

The bottom line is, research has shown that epidurals may be linked to lower breastfeeding success in some instances, but that there are things we can do to help support a woman with any of her decisions. Labor support professionals can create a balance between controlling a woman's pain and decreasing the effects of the epidural.

References:

Courtney, K. (2007). Maternal Anesthesia: What Are the Effects on Neonates. Nursing for Women's Health. 5, 499-502.

Arnold, I., Beilin, Y., Bodian, C.A., Feierman, D.E., Holzman, I.,Hossain, S., Martin, G., Weuser, J. (2005). Effect of Labor Epidural Analgesia with and without Fentanyl on Infant Breast-feeding. Anesthesiology. 103, 1211-1217.

Baumgarder, D.J., Ficsher, M., Muehl, P., Pribbenow, B. (2003). Effect of Labor Epicural Anesthesia on Breast-Feeding of Healthy Full-Term Newborns Delivered Vaginally. Journal of the Amercian Board of Family Medicine. 1, 7-13.

Jordan, Sue. (2006). Infant feeding and analgesia in labour: the evidence is accumulating. International Breastfeeding Journal. 1:25.

Bassett, Vicki., Cragg, Betty., Noel-Weiss, Joy.(2006). Developing a Prenatal Breastfeeding Workshop to Support Maternal Breastfeeding Self-Efficacy. Journal of Obstetric, Gynecologic, & Neonatal Nursing. 35 , 349-357.

http://www2.cochrane.org/reviews/en/ab003766.html

"I can't do it anymore"

With all of my births I have thought that I just can't do this anymore, or "I'm never having anymore kids". (I have five:)) I have said how tired I am, how I just want it to stop. "Isn't there someway to make this stop?" The problem is, at this point in labor, you can't be reasoned with. Working through the contractions takes a lot out of you. But afterwards, I am quite happy that I didn't get any pain medication.

It was interesting to be on the other side with a laboring a patient I had. By the end of her labor I was sure she would absolutely never go without an epidural again. So I asked her...and low and behold, she told me how grateful she was for my help, and how she was glad she didn't get the epidural. And she had epidurals with her previous children. It made me pause for a second. There has to be more about how we perceive pain than just the actual sensations. There is also more to how we deal with it.

Here's a brief link to a site that talks about some of the things to expect during transition(one of the hardest parts of labor):http://nursingbirth.com/2009/02/08/top-ten-things-women-saydo-during-labor-and-trust-me…-they-are-totally-normal/

Epidural stats

Ok, here's some stats I found about epidural use. It looks like in Utah we are quite a bit different. I would take these stats with a grain of salt, though. I'm not sure how well researched they are.

25% of women in the UK use epidurals

66% of women in the USA

Reference: http://ceaccp.oxfordjournals.org/cgi/content/abstract/4/4/114

The epidural rates at the major hospitals in SLC are over 90%.

Reference: http://forums.obgyn.net/ob-gyn-l/OBGYNL.9709/1052.html

I would say that would be closer to 95-98% from my experience.

If these stats hold true, then in UT we use epidurals quite a bit more. I wonder if this has to do with the culture here or if this would hold out among LDS women everywhere. I would guess it is a little bit of both. Do we see it as a blessing to have this, or do we reject pain more? Why? This seems like sort of a "duh" question to me, because who wouldn't want to not have pain. But for some reason, in Utah (where the majority of people are LDS), we care a little bit more about having our epidurals.

Is this really an issue of pain control? Or is it more an issue of fear? None of this has been studied really.

There are a couple of things I would like to blog about in upcoming posts: the lds view of pain, and how often do we use prayer, blessings, and such in our decisions regarding labor/birth and the trials associated with it.