Are Doulas Anti-Epidural?
NO! We support women in the choices they make. But… we do hope women are making informed decisions. This week one of my doulas had a mom with a long induction and the mom received an epidural after many long hours of labor. The midwife told her when the baby was born that she was pleased that the doula had stayed for the birth. The doula was shocked by the comment and inquired as to why that was shocking. She then went on to say that most often doulas did not stay once the mom received her epidural. We stay with the mom throughout her labor and birth irregardless if she chooses to be medicated.
We had a mom recently told that she was pre-pre-eclamptic- meaning that he felt she was going to end up with an induction due to her having one symptom of possibly having a future of pre-eclampsia. It is difficult to have moms have a care provider who seems to diagnose this six weeks before she is due and with only one symptom. But she was considering not having a doula since she felt an induction would mean she would need to have an epidural. This is not always true- in fact we have several moms who are induced every year and are still able to have an epidural free birth.
But speaking of informed decisions- Leigh William just sent me a document that is worth reposting so you can make sure you understand the risks of an epidural. There is a time and a place for epidurals. You may have your reasons for getting one that we do not understand or know- that is okay- it is your choice. But don’t make it uninformed or due to your friends or family telling you to get it- or feeling you will need it before you go into labor- give yourself an opportunity to labor before you make that decision.
Common Side Effects of Epidurals: Minimizing the Risks
|Side Effect / Who affected||Incidence: What percentage of moms or babies experience this||What medical staff does to prevent this.||What you can do which may help prevent this.||What other interventions this side effect could lead to.|
|Limited Mobility / Mom||100% Some studies indicate that women may have more muscle mobility than they realize, but required monitoring equipment tends to make movement difficult.||Can’t prevent it once you have an epidural. Can give a lower dose of medicine to minimize.||You may choose to delay epidural so you can move around a lot in early labor to help prevent problems due to immobility||Could lead to a posterior baby or other malpositioning, or could lead to failure to progress at any stage in labor, which may lead to cesarean.|
|Low Blood Pressure / Mom||0 – 50% †
Relative risk (RR) 74.2 *
|Give extra IV fluids before epidural is given.||Rather than lying flat on your back, prop one hip up on a pillow.||More fluids, oxygen, or medication. If mom’s BP drops too much, baby’s heart rate can decrease, oxygen supply to baby can decrease.|
|Fever / Mom||4 – 24% **
RR 5.6 *
The longer mom has epidural in place, the higher the fever risk.
|Monitor mom’s temp.||Keep cool: eat ice chips, use cool cloths under arms or between legs, on forehead and back of neck. Fan.||May lead to elevated heart rate for baby, which may indicate fetal distress, which may lead to c-section. Mom may be given antibiotics for possible infection.|
|Urinary retention in labor / Mom||0 – 68% †||Bladder catheter||Wait as long as possible for epidural. Urinate (pee) just before getting epidural. Try using a bed pan if you can…||A full bladder can prevent cervical dilation and fetal descent. Increased risk of infection, postpartum urinary problems.|
|Postpartum urinary incontinence / Mom||Immediate postpartum: 27% with epidural, 13% without||Keeping bladder drained during labor.||See above. Kegel exercises before & after labor. Biofeedback can be used to treat.||May last for weeks. (At 3 months, was 16% for women who had used epidural, 4% for those who had not.)|
|Shivering / Nausea / Vomiting / Itching||Shivering 33% (Thorp)
Nausea 0 – 30% †
Vomiting 0 – 13% †
Itching 8 – 100% †
|“Harmless”. No need to prevent.||Blankets, massage for shivering. Support.||Can give medication for nausea and itching. May make mom very sleepy.|
|Backache after birth / mom||Immediately after birth: 53% with epidural, 43% without||Proper placement of catheter.||Try to avoid awkward positions and muscular strain during labor||Postpartum pain medications.|
|Incomplete Pain Relief / Mom||5 – 10%||Proper placement of catheter. Adequate levels of pain meds.||Tell caregivers if relief is incomplete, or if you have painful spots. Change positions.||May be more stressful than no pain relief at all. Epidural can be re-positioned; medication can be increased.|
|Slower first stage / labor||Most studies show this effect. -.4 – 4.8 hours longer. ** Average is 26 minutes longer.*||Pitocin (artificial oxytocin through IV). 3 times more common with epidural||Wait as long as possible to have epidural||If first stage stalls, you may require a c-section for failure to progress. Also, Pitocin can cause longer, stronger contractions. May lead to fetal distress, which may lead to c-section.|
|Longer second stage (pushing) / Labor||All studies show this effect. 0 to 55 minutes longer.** Average is 15 minutes longer.*||Pitocin and/or Second stage interventions||Ask for a “light-weight” epidural, so you still have some mobility. Change positions. Turn down epidural for 2nd stage. Delay pushing till baby’s head crowns.||22 out of 24 studies indicate a higher risk of instrumental delivery (forceps, vacuum) With IV narcotic pain medication, chance was 3-7%. With epidural, chance was 15-53%.|
|Fever / Baby||30%||Monitor mom’s temp.||Try to keep mom’s temperature down.||May cause elevated heart rate. If baby has fever, may be assumed to have an infection: can lead to observation or isolation, blood tests, antibiotics.|
|Fetal distress due to Pitocin, mom’s low BP, maternal fever, or other causes/ baby||10 – 15% of babies||Monitor baby, attempt to avoid maternal conditions which may lead to fetal distress.||Stay off your back, change positions frequently. Breathe.||Oxygen for mom. Treat maternal conditions. Decrease pitocin, which may lead to failure to progress. May lead to cesarean section.|
|Baby in posterior position, other malpresentation / Baby||One study showed 20 – 26%. Another showed that all but 4% of babies rotate without epidural. With epi. 19% will stay posterior.||Change positions frequently in early labor, especially using positions that bring weight of baby forward. Wait until baby is engaged in pelvis (0 station or +1) before getting epidural.||Greater chance of c-section or instrumental delivery.|
|Cesarean Birth / Effects mom and Baby||Studies consistently show that c-section is 2-3 times more likely with epidural. One study showed that risk was 26% if epidural at 4 cm, 33% at 3 cm, 50% if epidural given at 2 cm dilation.||Pitocin to aid dilation. Forceps or vacuum extractor to aid delivery.||Delay the epidural as long as possible in labor. Follow all other recommendations given above.||Risks of c-section for mom include: risks of infection, increased bleeding, longer postpartum stay, possible anesthesia effects, more postoperative pain, and possible impact on future pregnancies. Effects on baby may include respiratory distress syndrome and other impacts of surgical birth.|
By Janelle Durham, 2004.
* Leighton, B.L., and S.H. Halpern. 2002. The effects of epidural anesthesia on labor, maternal, and neonatal outcomes: A systematic review. American Journal of Obstetrics and Gynecology 186: S69-77.
** Lieberman, E., and C. O’Donoghue. 2002. Unintended effects of epidural anesthesia during labor: A systematic review. American Journal of Obstetrics and Gynecology 186: S31-68.
† Mayberry, L.J., D. Clemmens, and A De. 2002. Epidural analgesia side effects, co-interventions, and care of women during childbirth: A systematic review. American Journal of Obstetrics and Gynecology 186: S81-93.
Additional Sources: “Epidural Anesthesia in Labor: An Evaluation of the Risks and Benefits” by Thorp and Breedlove, Birth, June 1996. This was a literature review article, which summarized the results of numerous studies involving thousands of births. Other information from: Pregnancy, Childbirth, and the Newborn by Simkin, Whalley, and Keppler (2001 edition). Maternity & Women’s Health Care by Lowdermilk, Perry, and Bobak (6th Edition, 1997). Family-Centered Maternity and Newborn Care by Celeste R. Phillips (Fourth edition, 1996). “Epidural Epidemic” by Dozer and Baruth, Mothering, July-August 1999. “What no one tells you about Epidurals” by Penny Simkin; “The Cascade of Interventions” by Pam England; and Epidural’s Effects on Babies” by Beverley Lawrence Beech, in Mothering, March-April 2000. “Epidural Express” by Nancy Griffin, Mothering, Spring 1997; “So you Want an Epidural” website by Kim James.
Additional data from the most recent studies can be found on the childbirth educator resources page.