The On-line Journal of Mary Esther Malloy

As You Consider What Is Right For You

Epidurals

We all have different bodies, histories, and mindsets about how we will work with the sensations of labor. And every labor is unique. Epidurals are simply tools, neither good nor bad. Of the thousand births I have supported as a doula in New York City, about forty percent of my clients have used epidurals while approximately sixty percent haven’t. Whether you choose an epidural at some point in your labor or you don’t… and just keep on keepin’ on until the baby is born, it is a deeply personal decision that will depend on many factors. 

I hope this compilation of pros, cons, and frequently asked questions helps you contemplate what feels right for you. More than anything, though, I hope the information here helps you feel good about whatever decision you ultimately make.

Everyone is a Hero

No matter how your baby arrives, there is hard physical and emotional work to be done to birth your baby and recover. Whether you give birth with a hand from technology or not, everyone gets the hero’s badge. No question!

I think it’s helpful to appreciate that most people with epidurals will still feel stuff. I don’t know if this sounds like good or bad news to you, but getting an epidural does not mean birth will be 100% pain-free. Most moms 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 do before an epidural). It’s also common for a degree of sensation to return a few hours after the epidural is placed. Plus, you still have to do the exciting work of pushing a baby out and it often goes better if you can feel contractions, at least partially. So it’s not like getting an epidural means you bypass birth somehow. Or that a cesarean means you didn’t really give birth. You gave birth. You are a hero. Period.

Pros

Pros of epidurals include the possibility of rest during a long or unusually progressing labor, or an 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 the anxious, worry-mind – there’s no room for apprehension. You just work!). There may be circumstances where an epidural is the best support to get 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 needed, as it sometimes really is.

A few suggestions if you do get an epidural:

• Wait until 4, 5 or 6 cm, if possible, to establish a strong labor pattern that may be less interrupted by the epidural. This will minimize the time on the epidural, reduce the likelihood of needing pitocin to keep labor going, and limit the amount of medication a baby is exposed to.
• Stay mobile! Keep rotating from side-to-side, using a peanut ball to keep the pelvis open. Sit up for periods. Try kneeling backwards or squatting with a squat bar if you have the strength in your legs. You won’t be able to walk or get out of bed with an epidural, but you still (and should!) change positions frequently. (Wondering about how you will use the bathroom? They place a catheter to empty your bladder.)
• Stay on top of smaller increases in pain by hitting the patient-controlled button (PCEA). If you experience strong breakthrough pain, ask anesthesia to come in for a top-off. The bigger dose via the top-off 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 turning down or 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!
• Because you probably won’t feel a strong pushing urge, ask your doula, nurse, midwife or OB to help you identify the “pushing muscles” before the pushing begins. Go for it and birth your baby with strength!
• Stay positive and kind to yourself.
• Get a doula. Even if you are planning on an epidural, I highly recommend working with a doula. A doula can help you cope well for longer without the epidural. She can help you manage the epidural. And perhaps most crucially, she can help you stay mobile with creative positioning in the bed. My clients have avoided many cesareans because of the work we’ve done to help a baby rotate and descend. The research backs this up.

Cons

As the saying goes, you don’t get something for nothing. Most epidurals go quite well, but to make an informed decision, have a glance here at some of the potential trade-offs. 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 things you are – possibly – trading for. It’s also fair if you don’t want to know. That’s a fine choice too. Again, this 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 the following. (I will not attempt to be exhaustive here. I’m sharing fairly common effects I see with some regularity as a doula. I will not include the category of very rare occurrences).

• It is common for labor to slow down after an epidural. We then use Pitocin, a synthetic oxytocin, to get labor going again. Some labors do not slow. 
• It is somewhat common to see a drop in the maternal blood pressure after an epidural that can sometimes cause a drop in the baby’s heart rate. If this happens, a team of providers will run in. They may change your position and give you medicine to boost your blood pressure. Your best prevention is to make sure the nurse gives you one or two bags of fluids before the epidural is administered.
• Some epidurals only partially work and we have to get help from anesthesia until coverage improves. 
• With the decrease in mobility, it can sometimes be challenging for the baby to rotate, tuck their chin, and descend. A doula, nurse, or midwife on your team can help you with positioning. Use a peanut ball!
• You’ll be working with lots of wires. I often joke that you need an advanced degree in electrical engineering to flip from one side to the other. You’ll have the epidural tubing clipped to your gown, a blood pressure cuff on your arm, a pulse oximeter on your finger, monitors to pick up the baby’s heart rate and contractions on your belly, an IV in your arm, and a urinary catheter in your urethra. Each of these runs wires or tubing from your body. You can always ask for wireless monitoring (although they often reserve these for women without epidurals). Additionally, ask for the pulse oximeter to be placed on your toe, instead of your finger. A doctor from a recent birth laughingly referred to all these wires and tubes as “accessories.” The mom appreciated the reframe.
• If you need a higher-dose top-off, they are associated with a greater likelihood of the presence of medication in the baby’s system (see below). If possible, manage the return of pain with the PCEA (see above).
• The greater number of hours on the epidural, the higher the chance of a maternal fever. If you feel hot for any reason (including the hormones of labor), keep your body cool by eating ice chips, sipping cool water, placing cool wash cloths or ice packs on your chest or brow, and running a fan.
• With epidurals, it sometimes takes longer to push. Many moms on an epidural will ask to “labor down,” or wait to start active pushing until the baby is very low in the pelvis, at +2 or +3 station. 
• Epidurals may increase the likelihood of tearing or the use of vacuum or forceps.
• It is rare, but sometimes a mom or baby just doesn’t respond well to the epidural (or Pitocin) and a cesarean is needed. 
• Epidurals are associated with delayed onset of lactogenesis II (the mature milk coming in), and other breastfeeding challenges, possibly from the edema with the additional fluid needed for the safe administration of an epidural.

To repeat, most epidurals go just fine, but families with epidurals may work with one or more of these challenges, to varying degrees. Of course, an unmedicated labor does not guarantee zero challenges. 

Women Give Birth Without Epidurals All The Time

For those looking to avoid or delay an epidural, I will remind you that the sensations you feel in labor are the normal physiologic work of a body birthing a baby. There is nothing wrong. In fact, 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, but the pharmacy in the brain helps you cope as labor intensifies. Interestingly, the Listening to Mothers survey found that when surveyed after their babies were born, women with epidurals reported a higher perception of pain in childbirth than women without epidurals (likely due to the hormonal physiology and pain-coping high of an unmedicated labor that gets interrupted by an epidural). 

All the hard work of an unmedicated labor is not for nothing! What happens in labor primes you for breastfeeding and bonding. The payoffs can be great. I did not have an epidural with any of my three 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 training in mindful presence really help.

For those leaning toward birthing without an epidural, I will say that because of the potential downsides of an epidural, 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 truth play out many times. 

Get a Doula and Consider Midwifery Care

If you are looking to avoid or delay an epidural, get a doula! Oh my gosh. Get. A. Doula. As I mentioned, I myself never gave birth with an epidural and having a doula at each of my children’s births was a game changer. 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 children’s births made a huge difference in my ability to go as deeply as I needed to meet the work as softly as I could. 

If you want an unmedicated labor, you might consider working with midwives as well. Why? They know how to support moms through normal, physiologic birth. For them, an unmedicated labor is run-of-the-mill, not highly unusual. If you are hiring an OB who has only 5% of moms birthing without epidurals (and most of them second-timers who walk in too late for an epidural), you are much more likely to end up with an epidural. Midwives will have anywhere from 50 to 96% of their families birth without epidurals, depending where they practice.

Remember, your work is to meet each contraction, one at a time, as softly as you can, as best you can. You can do this.

You might read my article about a client’s labor: “Mindfulness for Labor – A Story.” 

Frequently Asked Questions

When is it too late to get an epidural? I am often asked this question. If you can sit still, you can get an epidural. Honestly, even if you can’t sit still during contractions, they can do their best to work between contractions. But, if you are fully bearing down and the baby is literally coming, it is basically too late for the epidural. If you do get the epidural at this point, there is a fair chance it will kick in after the baby is born. If you’ve made it so far in your labor that someone is telling you it’s too late, it means you are at the place where the epidural isn’t going to offer you much and you are close to meeting your baby. This scenario is much more common with moms having their second, third, fourth (or whatever number subsequent) baby. If this happens, just go for it and you will be done soon. Being told you are too late for an epidural is highly unlikely with a first baby. Repeat: highly unlikely! Most likely you’ll have plenty of time to decide for an epidural. 

What if I wasn’t planning on an epidural but begin to change my mind in labor? How should my partner respond? I always think it’s a good idea to have a conversation ahead of time where you tell your partner how you would like them to respond, if such a scenario arises. (See my note below about agreeing ahead of time on a delay). If you start to talk about an epidural, 

• should they immediately get the epidural for you? Fine. Then that is their job.
• Should they remind you of something that feels important to you about labor? 
• Should they double down on support, seeing you are at a tough moment? 
• Should they switch things up and, say, help you use the shower? 
• What about agreeing on a delay? Something I find effective in this situation is when the mom and her birth partner have agreed ahead of time on a delay. If she begins talking about the epidural, the partner then reminds her of the 30 minute delay (or 15 minute, or one hour delay) they talked about before. It is common when a mom first raises the topic, it is often in a tone of “Maybe I should get the epidural.” Or, “I’m thinking about it.” If she is okay with a delay, she just might get through this hard patch and find her way back into a coping rhythm. In this case, she might never mention the epidural again. Or after 30 minutes, she might have great clarity that the epidural is the right decision for her, given circumstances. In this case, the delay often helps a mom feel better about the decision when she looks back on her birth experience.

What if I wasn’t planning on an epidural but at 8 or 9 centimeters I think I might want one? If the emotional signpost of early labor is excitement; and the emotional signpost of active labor is serious, focused, in-the-zone hard work; the classic signpost of 8 to 9 cm is self doubt: “Can I do this?” As hard as it is, a mom wobbling in her resolve, or questioning whether she can do this, it is a great sign of progress. You are almost there! And yet, this is the moment when an epidural can suddenly seem like a good idea. And you can certainly get one. But remember, if you are 8 or 9 cm, you are getting ever closer to the pushing, where the epidural isn’t such an asset. You might decide to hang on (see above suggestion for a delay), do more of what you’ve been doing, and get to the relief of pushing. You will get a second wind and usually it feels so much better to push than to finish the dilating. 

What about getting an epidural just for pushing? Generally, there are more downsides than upsides to the epidural with pushing. It usually lengthens pushing and may increase the likelihood of tearing or needing vacuum assistance. No promises here, but once the cervix has stretched back over the baby’s head (10 cm) and you are fully dilated, the pushing often much better than what preceded it. If your provider says an epidural may not be worth it, they are saying: you are so close, you can do this. It is right around the corner. But that said, if you want an epidural, you can get it, as long as you can sit still. 

Do the medications in an epidural get to the baby? The answer is yes they can. The factors that make it more likely the medication gets to your baby is if you have a  fentanyl epidural (as most are), you have the epidural for a long time, and you get a higher dose top-off. 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 ask many OBs or anesthesiologists if babies are exposed to epidural medication, they will say, “No.” I’ve included a few studies below that back up what I’ve shared here on this point. 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.

If you do need an epidural, you might really emphasize ongoing skin-to-skin with the baby in the hours and weeks following birth, get a lactation consultant if you are having breastfeeding problems, and consider delaying or avoiding a circumcision (it may also increase baby fussiness or sleepiness in the days following). Most of all, be kind to yourself. These suggestions can be helpful for everyone, no matter if you birth with an epidural or not.

And remember, the decision to get an epidural or not will be made on the day you give birth and will be informed by conditions you do not know at this point. 

Now, in this moment, you can just breathe.

References:

Listening to Mothers Survey

https://nationalpartnership.org/health-justice/maternal-health/listening-to-mothers/

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://www.prnewswire.com/news-releases/when-mothers-receive-fentanyl-epidurals-during-labor-the-fentanyl-gets-passed-on-to-their-babies-301029029.html
https://academic.oup.com/jalm/article/5/4/686/5809169?login=false
https://pubs.asahq.org/anesthesiology/article/83/2/300/35123/Placental-Transfer-and-Neonatal-Effects-of