The On-line Journal of Mary Esther Malloy
Epidurals: Pros, Cons, and Questions
Epidurals
We all have different bodies, different histories, and different mindsets about working with the sensations of labor. And of course everyone has a unique experience of labor. Epidurals are simply tools, neither good nor bad. Choosing an epidural at a certain point in your labor, or just keep on keepin’ on until the baby is born is a very personal and individual decision that will depend on many factors.
Everyone’s a Hero
I think it’s helpful to know ahead of time that most people with epidurals will still feel stuff. Often a degree of sensation usually reappears a few hours following the placement of the epidural. So you might lose the idea that an epidural means birth will be 100% pain-free. Plus, most people will want to wait a good while into labor before getting the epidural to minimize some of its potential downsides (i.e. there’s lots of juicy work to get to a place where an epidural makes sense). And you still have to do the exciting work of pushing a baby out! So it’s not like getting an epidural means you bypass birth somehow. Or that a cesarean means you didn’t really give birth. No matter how your baby arrives, there is hard physical and emotional work to be done to birth and heal. As I always say, everyone gets the hero’s badge, no matter how these babies arrive, hand from technology or not. Absolutely!
Pros
Pros of epidurals include the possibility of rest during a long, or unusually progressing labor, or if you are having a long induction. An epidural might be helpful if you are having a hard time coping or are experiencing a lot of fear (although sometimes working with the intensity of labor is the greatest gift to our anxious, worry-minds – there’s no room for apprehension. You just work!). There may be circumstances where an epidural is the best support to get to a vaginal birth – say, with a long induction where the mom is losing her ability to relax through contractions. We talk about a compassionate or therapeutic use of an epidural when it is really needed, as it sometimes really is.
A few suggestions if you get an epidural:
- Wait until 5 or 6 cm, if possible, to establish a strong labor that may be less interrupted by the epidural. This will minimize the time on the epidural, reducing the likelihood of maternal fever from epidural and the amount of medication baby is exposed to.
- Stay mobile! Keep rotating from side-to-side, using a peanut ball to keep the hips open. Sit up for periods. Try kneeling backwards or squatting if you have the strength in your legs. You will not walk or get out of the bed if you get an epidural. (They place a catheter to empty the bladder).
- Stay on top of smaller increases in pain by hitting the patient controlled anesthesia button. If you experience strong breakthrough pain, get anesthesia in to do a top off, a bigger dose usually zaps sensation for about 1 to 2 hours. Don’t be hard on yourself if it is difficult to handle a return of sensation. Minus the coping hormones, it can be challenging to experience a return of strong sensations. However, if you are close to pushing, you may not want to be fully numb as you will benefit from sensation as a guide. Many providers will in fact suggest shutting off the epidural at the end for just this reason.
- It is common to feel great after you first get the epidural. You are now able to really appreciate the “labor high” from your labor-coping hormones. As this passes, get sleep, meditate, and stay connected to your labor and your baby, who is very much still experiencing labor!
- Stay positive and kind to yourself.
Cons
You don’t get something for nothing, as they say. Most epidurals go quite well and you may not experience any of these downsides, but to make an informed decision it’s a good idea to have a glance here. My experience as a doula is that epidurals often displace the work from one part of the labor experience to another. The rest you get from the epidural may be an excellent trade off for you, but you might want to know the possible things you are trading for. It’s also possible that you might not want to know the potential trade offs, and that’s a fine choice too. If so, just stop reading here and bring any questions to class.
Because of the potential downsides of an epidural, plowing ahead, moment-by-moment and doing labor under your own steam without an epidural may actually be the easiest – yes, easiest! – , fastest, and most straightforward way to birth your baby. I have seen this many, many times as a doula. Interestingly, the Listening to Mothers survey found that women with epidurals had a higher perception of the pain than women without epidurals (likely due to the hormonal physiology and pain-coping high of an unmedicated labor that can get interrupted by an epidural). Again, it is a very individual decision and everyone should feel great about what they need to do to cross the finish line.
Epidural cons may include a slowing of labor and the increased likelihood of needing pitocin to get labor back. It’s rare, but sometimes a mama or baby just doesn’t respond well to the epidural (or pitocin) and a cesarean is needed. Some epidurals only partially work and we have to keep getting help from anesthesia until coverage improves. The higher-dose top-offs in this case are associated with a greater likelihood of the presence of the opioid fentanyl in the baby’s system (see below). The greater number of hours on the epidural, the higher the chance of a maternal fever. With the decrease in the mama’s mobility, it can sometimes be more challenging for the baby to rotate, tuck its chin, and descend (a doula or midwife on your team can help you with creative positioning). Cons can also include a longer second stage or pushing (“labor down” or wait to start actively pushing until the baby is very, very low in the pelvis at +2 or +3 station), an increased likelihood of an instrumental delivery, delayed onset of lactogenesis II (the mature milk coming in), and other breastfeeding challenges.
To repeat, most epidurals go just fine, but families with epidurals may work with one or more of these challenges, to varying degrees. And of course an unmedicated labor does not guarantee zero challenge, it’s just that labor and breastfeeding are more likely to be straightforward.
For those looking to avoid or delay an epidural, I will remind you that the sensations you feel in labor are the normal physiologic sensations of a body birthing a baby. There is nothing wrong. In fact, nice strong labor surges are exactly what your body calls up to create change in the body so that you get to meet your baby. Women do this all the time. It is intense work, but the pharmacy in the brain helps you cope as labor intensifies. And all that work is not for nothing! What happens in labor primes you for breastfeeding and bonding. It is extraordinary work. It is hard work. And the payoffs can be great. I did not have an epidural with any of my children’s labors. As a doula, I support families who birth without epidurals all the time. It is do-able. Supportive care, a peaceful environment, and mindful presence really help.
If you are looking to avoid or delay an epidural, get a doula! Oh my gosh! Get. A. Doula! I myself never gave birth with an epidural. The rhythm and ritual and feeling of safety I experienced with both my husband and my doula at my side for all three of my childrens’ births made a huge difference in my ability to go as deeply as I needed to meet the work as softly as I could. You might really think about working with midwives as well. Why? For them it is run-of-the-mill, not aberrant, to support moms through normal, physiologic birth. If you are hiring an OB who has only 5% of moms birthing without epidurals (and most of them second-timers), you are much more likely to end up with an epidural. Midwives will have anywhere from 70 to 97% of their families birth without epidurals, depending where they practice.
Remember, your work is to meet each contraction, one at a time, with breath, as softly as you can, as best you can. You might read my article about one of my client’s labors. One breath birth. You can do this.
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A few more questions
When is it too late to get an epidural? I am often asked this question. First of all, I wouldn’t worry about this ahead of time. If you’ve made it so far in your labor that someone is telling you it’s too late or borderline too late, it means you are at the place where you are either pushing or very close to pushing (AMAZING!) and the epidural isn’t going to offer you much. Generally, there are more downsides than upsides to the epidural with pushing. It usually extends the time of pushing, increases the likelihood you might need some help, increases likelihood of tearing. No promises here, but once the cervix has stretched back over the baby’s head (10 cm) and you are fully dilated and pushing, a mother is often more comfortable anyhow. Your provider is just saying, you are so close, you can do this. It is right around the corner. But if you want an epidural, you can get it, as long as you can sit still for it. (If you are having a second baby, just know that the epidural might be kicking in after your baby is out!). I haven’t had many moms get epidurals at the very, very end, but I have had a few. If that is what you need, it is never too late. Truly!
People often have questions about whether the medications in an epidural get to the baby. The answer is yes, especially if it is a fentanyl epidural, as most are, for longer periods of time and at higher doses (the top off I described). Other than a rare possible lowering of fetal heart rate, an increased likelihood of breastfeeding challenges in the early days, or increased fussiness for some babies, there is no pathology associated with this exposure that I know of. But still, it can feel yucky to think about bupivacaine or fentanyl in your baby’s system.
If you need an epidural, you might really emphasize on-going skin-to-skin with the baby in the hours and weeks following birth, get a lactation consultant if you are having problems, consider delaying or avoiding a circumcision (increases baby fussiness or sleepiness in the days following) and be kind to yourself. These are of course helpful for everyone, no matter if you birth with an epidural or not.
If you ask most OBs or anesthesiologists if babies are exposed to epidural medication, they will say, “No”. I share these and a few other studies.
You don’t need to read any of these if doing so will increase fear. You can trust yourself to make the decision that is right for you and your baby, given the circumstances of your labor.
Really.
Now, in this moment, you can just breathe.
References:
Epidurals and Labor
https://evidencebasedbirth.com/epidural-during-labor-pain-management/
Epidurals and Second Stage
https://evidencebasedbirth.com/effects-of-epidurals-on-the-second-stage-of-labor/
Epidurals and Breastfeeding
https://evidencebasedbirth.com/effect-of-epidurals-on-breastfeeding/
Epidural Medication and Babies
https://academic.oup.com/jalm/article/5/4/686/5809169?login=false