Birthrites: Healing After Caesarean.

Epidural Express.

From the Website: http://wospace.cnation.com/Health/Hlth_Epidural.html

The Epidural Express:
Real Reasons Not to Jump On Board
by Nancy Griffin, M.A., AAHCC

A first-time expectant mom, anxious to find out the inside scoop on the pain of childbirth, approaches a couple of experienced mothers for the truth…

"Have an epidural right away, as soon as you get to the hospital. It was wonderful!" insists one.

"You've got to be kidding!" says the other, "Don't you want to experience natural childbirth and protect your baby from drugs?"

"Yeah, right," counters the first. "You'll have the labour from hell without one. Don't be a martyr. Have one in the parking lot if possible!"

One of the most emotionally charged issues in childbirth is how to deal safely and effectively with pain during birth. Women who had been hoping to give birth naturally and end up with an epidural may be left with the nagging feeling that they somehow "failed" at childbirth, while those who go without an epidural today are often viewed as "martyrs" by their peers.

Statistics vary widely, showing that between 75 and 90 percent of all women giving birth in the US today get an epidural, and these numbers seem to be increasing every year. 1, 2, 3, 5, 8 Epidurals are so commonplace that most hospitals automatically include them in their standard billing protocol for all vaginal deliveries.

Is it possible that modern women have been left in the dust by their forbears of the past, who gave birth all the time without epidurals? Has the epidural, along with the episiotomy, become a panacea, a rite of passage in order to belong to the modern cultural "sisterhood of motherhood" in the US? Is an epidural truly safe and effective or have birthing women bought into a type of cultural myth and, in doing so, do they continue to pass along the deeply rooted belief that childbirth is dangerous, horribly painful, and fraught with perils from which they must be "delivered" by the doctor? Do these questions even matter?

What is an epidural?

There are actually several kinds of epidurals. The type that most people refer to is, in fact, a lumbar epidural -- the administration of a regional anaesthetic agent, or a combination of an anaesthetic agent with a narcotic and/or antihypertensive, which is injected into the lumbar region of the labouring woman's back by a qualified anaesthetic care provider. (This could be an anaesthesiologist, obstetrician, or nurse-anesthesiologist.) It is performed by inserting a long needle into the epidural space of the spine, through which a soft catheter is threaded. The needle is then removed and the catheter taped in place. Doses of anaesthetic can then be periodically or continuously administered through this catheter.

The mother must lie curled on her side without moving during this procedure, which takes from 20 to 30 minutes to complete and take effect. Once it is in effect, she will be numb from her ribs to her toes, and sensations of pain usually will be eliminated. Epidurals can be strong enough to provide complete loss of sensation and all pain during a cesarean, or minimal enough that the mother can still feel when to push in a vaginal birth. A "walking" epidural is a lumbar epidural in which the dosage of narcotics is higher and the regional anaesthetic dosage is lower, creating pain relief without total numbness in the lower body.

The history of the epidural

The first-known epidural attempt on a human was in 1901 but was unsuccessful until performed in Spain in 1921. By 1935 single-injection lumbar epidural regional anaesthesia was introduced in the US, and the continuous lumbar epidural was developed 11 years later. By the late 1960s lumbar epidurals had begun to replace spinal anaesthesia, thereby eliminating the devastating side effect of spinal headaches. 2, 4

The epidural at first appeared to be a magic bullet for pain in childbirth. The mother could remain "awake and aware" without suffering, and she could still partially assist in pushing her baby out during second-stage Labor. At the time it was widely believed that the drugs used during a lumbar epidural did not reach or affect the baby, because placentral transfer seemed to be minimised as a result of the drugs' binding to maternal plasma proteins or staying confined to the dura-space of the spine. Many women are still told that the medication used in an epidural is completely safe and that it does not reach the baby--a notion that their physicians have traditionally been taught in medical school.

The passage of time, combined with new research, has begun to reveal a different picture. By taking a closer look at the drugs used in epidurals and their risks and benefits to both mother and baby, women can make an informed choice about this important issue for themselves and their unborn children.

Which drugs are used?

In an informal survey of mothers attending childbirth classes, none of them knew what drugs are used in an epidural. There are basically three Caine-derivative anaesthetics used in epidurals. Caine derivatives block nerve impulses (in the case of an epidural, specifically the sympathetic nerve fibres found in the lumbar region of the spine), and anaesthetise blood vessels, causing them to relax and dilate. These Caine derivatives include the slower-acting Bupivacaine, which tends to last from an hour and a half to three hours, and two faster-acting derivatives: Chloroprocaine, which lasts from 40 to 60 minutes; and lidocaine, which lasts from 60 to 75 minutes. The Caine derivatives we are most familiar with are Novocaine, which we routinely receive in the dentist's office, and the drug cocaine. Epidural dosages fall somewhere in between these two extremes.

Additional drugs may be combined with Caine-derivative anaesthetics. In certain cases a vasoconstrictor, epinephrine, is added to prolong the Caine derivative's absorption. In other cases an opium-derivative narcotic is added for more prolonged or even postbirth or postoperative pain relief. These narcotics include Fentanyl and morphine. An antihypertensive drug, Clonidine, may be added to counteract the side effect of maternal blood pressure changes brought on by one or more of the other drugs administered.

All drug dosages are determined by the mother's body weight, and can be administered once, repeated, or in a continuous drip. Because the mother's body weight is approximately 20 times greater than that of her unborn baby at term, there is always a chance that the baby will receive an overdose -- perhaps the most compelling food for thought in any discussion on drug usage in childbirth. Following birth, the newborn must metabolise these drugs partly through liver function. Since the newborn arrives into the world with an immature liver, drug metabolism increases the likelihood and severity of newborn jaundice.

The Physician's Desk Reference (PDR), a well-respected guide to all drugs, their usage, cautions, and side-effects, states the following about the Caine derivatives used in epidurals:

"Local anaesthetics rapidly cross the placenta (by passive diffusion) and when used for epidural blocks, anaesthesia can cause varying degrees of maternal, foetal, and neonatal toxicity. Adverse reactions in the mother and baby involve alteration of the central nervous system, peripheral vascular tone, and cardiac function."

The PDR goes on to list the following possible maternal side effects for Caine derivatives: "Hypotension, urinary retention, faecal and urinary incontinence, paralysis of lower extremities, headache, backache, septic meningitis, slowing of Labor, increased need for forceps or vacuum delivery, cranial nerve palsies, allergic reactions, respiratory depression, nausea, vomiting, and seizures."

Research done in the last five years on the effects of epidural anaesthesia on newborns has shown that epidurals result in lowered neurobehavioral scores in the newborn; a decrease in muscle tone and strength, affecting the baby's sucking ability, which can lead to breastfeeding difficulties; respiratory depression in the baby; greater likelihood of foetal malpositioning; and an increase in foetal heart rate variability, thereby increasing the need for forceps, vacuum, and cesarean deliveries and episiotomies. 11, 12, 13, 14, 15, 16

A review of the literature reports that on average, 70 percent of women receiving an epidural during Labor experience side effects. The most common include postpartum urinary retention, severe backache, loss of motor power, prolonged first- and second-stage Labor, malpositioning of the baby at the end of second-stage Labor, hypotension, and in their babies, poorer motor organization. There is a need for well-organized, random controlled trials to bring this new knowledge into clear, scientific focus.

Very rare but possible risks of epidurals include trauma to nerve fibres if the epidural needle enters a nerve and the injection goes directly into that nerve; a drug overdose resulting in profound hypertension with respiratory and cardiac arrest and possible death; and central nervous system toxicity resulting from an injection directly into the epidural vein. Epidurals increase maternal and foetal healthcare costs and the professional liability of healthcare providers. Other medical interventions, such as IVs, continuous electronic foetal monitoring, the use of additional drugs, bladder catheterisation, frequent blood pressure monitoring, continuous administration of oxygen, and forceps, vacuum extraction, and episiotomies often become necessary as adjunct medical care to an epidural. Epidurals can prolong a Labor, leading to the possible need to augment Labor with Pitocen (an artificial hormone that mimics the action of oxytocin, the natural hormone that triggers Labor and causes uterine contractions). 7, 8, 9, 12, 15, 16

The PDR repeatedly states that "no adequate and well-controlled studies (exist) for use (of these drugs) in pregnant women" and that "it is not known whether (these drugs) can cause foetal harm when administered to a pregnant woman." The brain and heart of an unborn baby during Labor are vessel-rich, therefore hypoxemia (inadequate oxygen) and the resulting lactic acid buildup in the foetal blood during Labor and birth can increase the uptake of drugs given to the mother by the baby's heart and brain.

The result? Babies born to mothers receiving an epidural show poorer performance in orientation and motor skills on the Neonatal Behavioral Assessment Scale during their first month of life. As early as 1979 the Anaesthetic and Life Support Drug Advisor Committee for the Bureau of Drugs in the Food and Drug Administration had agreed that there seemed to be a likelihood of short-term effects on infants after their mothers were treated with drugs. 17

Side effects from epidurals are increased whenever a combination of Caine-derivative anaesthetics, opium derivatives, antihypertensives, or Pitocen are adrninistered together. The PDR summarises the administration and use of epidurals and related drugs by saying, "The safety and effectiveness of local anaesthetics depend on proper dosage, correct technique, adequate precautions and readiness for emergencies."

Usage of any of these drugs is contraindicated when the mother has heart or neurological disease, spinal deformities, septicemia, or severe hypertension, and none are recommended for use in children under the age of 12.

When may an epidural become appropriate?

Given the risks to both mother and baby posed by epidural usage, it makes sense for the mother to first be well-educated and then to make an informed choice. While there are many options available for birthing women to deal with pain in a natural or nonmedicated manner, there are times when an epidural may be a positive alternative.

An epidural may become appropriate when any maternal determination of excessive pain is made as an informed choice. And an epidural can be a godsend when birth complications arise. When mother and baby are both doing fine from a purely medical point of view, it is only the mother herself who can, or should, make an informed choice for medicated pain relief during Labor or birth.

Many unnecessary epidurals are the result of a well-meaning healthcare provider or Labor coach telling the birthing mother that "It's time for an epidural now." Women in Labor are vulnerable and often easily influenced by the attitudes of those around them. Agreeing to an epidural then appears to be logical, and a relief. But a mother can still make a clear and informed choice.

Dr. Jeffrey Illeck, an obstetrician and gynecologist at Cedars-Sinai Medical Center in Los Angeles, feels that routine epidurals have "become a way of making the nurse's job in large hospitals easier," therefore increasing the number of epidurals that occur. "Nurses are extremely busy and often have lost their skills to coach a woman in Labor," he explains. "A lot of the problem is the patient's fear and helping them through these fears. It has become a reflex to offer an epidural."

What causes pain in a normal childbirth?

The main cause of pain in a normal childbirth is what Dr. Grantly DickRead (the "father" of modern natural childbirth) called the "Fear-Tension-Pain-Syndrome." Relaxation is the key to pregnancy, Labor, birthing, and breastfeeding.

Despite the fact that we have technology at our disposal, our biology provides us with powerful instincts during birth. The first is the need to feel safe and protected. All mammals will instinctively seek out a dark, secluded, quiet, and most of all, safe place in which to give birth. While birthing, mammals give the appearance of sleep and closed eyes to fool would-be predators, and they breathe normally. Some (those who don't perspire) will pant in order to cool down, but humans will most easily achieve a relaxed state through closed eyes and abdominal breathing. This relaxation slows down the birthing mother's brain waves into what is called an alpha state, a state in which it is virtually impossible to release adrenaline, the "fright-flight" hormone. Physical comfort becomes critical, along with the need to have a "nest" ready for the baby. Hospital environments often unintentionally disrupt the birthing atmosphere by introducing bright lights, lots of people, noise, and fear-inducing exams and machines. Put it all together and you have fear, and therefore stress, and stress causes pain.

The uterine muscles are beautifully designed to deal quite effectively with danger, fear, and stress in Labor. The uterus is the only muscle in the body that contains within itself two, opposing muscle groups one to induce and continue Labor and another to stop Labor if the birthing mother is in danger or afraid. Emotional or physical stress will automatically signal danger to a birthing mammal. Her Labor will slow down or stop completely so that she can run to safety. In modern times, this goes haywire. We can't run from our fears -- which may include the "horror story" our best friend told us about her birth -- or even from our hospital or physician. Instead, we may release adrenaline, which causes the short, circular muscle fibres in the lower third of the uterus to contract. These muscles are responsible for stopping Labor by closing and tightening the cervix. The result is that we literally "stew" in our own adrenaline. At the same time that the long, straight muscle fibres of the uterus are contracting to efface and dilate the cervix, the short, circular muscle fibres of the lower uterus are also contracting to keep the cervix closed and "fight" the Labor. The result? The very real pain of two powerful muscles pulling in opposite directions each time the birthing mother has a contraction.

Anything causing fear in the birthing mother will increase her pain, a pain often described later as "Labor from hell." The constant presence of a loving, supportive, and trained Labor coach; effective education about the birthing process; and a physician and birthing environment the birthing mother can trust can make all the difference in the world. By learning to deeply relax mentally, physically, and emotionally; actively dealing with fears about birth; and choosing a birthing environment that feels safe and protective, birthing women will not have to experience the traumatic pain caused by the "Fear-Tension-Pain-Syndrome." In such a positive mental, physical, and emotional environment, Labor can feel very, very different.

Unnecessary or preventable pain can also be caused during Labor by simple things such as prohibiting the labouring mother from walking, changing positions, or moving around freely according to her instincts. Freedom of movement literally supports rotation and alignment, the process by which the baby turns and moves down through the pelvic inlet and outlet. Time-honoured traditions in birthing have always included walking, changing positions, rocking, and even floating in water. Anything that assists the rotation and alignment of the baby during Labor will automatically improve the efficiency of contractions, thereby shortening Labor and decreasing pain.

Avoiding unnecessary medical interventions during Labor will decrease pain because these interventions (such as breaking the water, or using Pitocen) actually cause pain themselves, leading to routine epidurals. The use of these regular interventions interferes with the natural process of birth, which is inherently safe and effective. When the natural process is interfered with, pain is the result. How is it possible to know whether medical interventions are unnecessary? The answer is surprisingly simple. If both mother and baby are doing fine during Labor, they're unnecessary.

Proper and adequate nutrition during pregnancy and eating and drinking to appetite during Labor can also dramatically decrease pain. A uterus that did not receive adequate nutrients for growth to full-term size can be weak and ineffective during Labor. A weak uterine muscle working far beyond its capacity will result in painful contractions. Inadequate consumption of complex carbohydrates and water during Labor can result in dehydration and low blood sugar, both of which cause more painful and less effective contractions similar to the way a marathon runner "hits the wall." And yet, often hospitals or physicians order routine IVs and "nothing by mouth" once a labouring woman is admitted to the hospital, whether she is at risk or not. If the mother and baby are both healthy and low-risk and are doing well during birth, the mother may experience a less painful Labor by eating and drinking lightly, guided by her appetite and thirst.

A safe and effective exercise program during pregnancy should include aerobic conditioning, to provide the mother with needed endurance during Labor, as well as pregnancy-specific exercises to prepare her body physically for Labor. When the mother's body is strong and prepared, pain is decreased. She will have the strength and endurance for pushing in second-stage Labor, perhaps decreasing the length of the pushing stage, and thereby decreasing pain. Pregnancy-specific exercises include pelvic rocking, Kegel exercises, squatting for Labor, "tailor" sitting (sitting "Indian style" on the floor), and abductor-strengthening (legs apart) exercises. These exercises are taught in good prenatal exercise and childbirth classes and should be done every day during pregnancy.

The most common causes of pain in childbirth

Pain occurs during a normal vaginal birth for basically three reasons. It can happen during transition, which is simply the most cervical dilation in the shortest period of time. Nature, however, makes the most painful period also the shortest. A typical transition rarely lasts more than about 15 minutes. If the labouring mother is told that she is in transition, and knows that she is almost through, she may be able to continue with out an epidural. If she were to have an epidural during transition, she would have to remain curled up on her side with a needle in her back, without moving, and would not receive any pain relief for transition itself, as an epidural takes 20 to 30 minutes to become effective. She would then have the added risk during second-stage Labor of not being able to push as effectively. Most doctors will recommend against having an epidural this late in Labor for that very reason. The key to dealing with the pain of transition is to know it doesn't last for long, and to choose one position that feels right; to relax completely, surrendering to and trusting in the process.

Another reason for pain in a normal childbirth is back Labor. Most women experience contractions low and in the front, similar to a menstrual cramp. But when the baby is in a posterior presenting position (the baby is facing the mother's pubic bone), pressure can be more intense on the mother's lower back and even tailbone during contractions (however, this is not always the case). By getting on her hands and knees, which pulls the baby away from her back, and having her coach give her counter-pressure (an intense circular pressure with the fist into the painful spot), the birthing mother can effectively minimise back Labor. Also, walking and changing positions can help to rotate the baby out of the posterior position, relieving back Labor completely.

Crowning -- the point at which the baby emerges from the vagina during secondstage Labor -- can also cause pain. During this time, the mother's perineum (the skin and muscles between the rectum and vagina) are being stretched to their maximum. Again, nature makes the most difficult moments the shortest. Crowning rarely lasts longer than one to three pushes in an unmedicated birth. By choosing her own birthing position and avoiding the traditional hospital pushing positions, the mother can make crowning far less painful. Squatting widens the pelvic outlet by up to 28 percent in a pregnant woman and utilises gravity to assist the birth. By using effective pushing techniques learned in a good childbirth class, staying in good physical condition, doing Kegel exercises during pregnancy, and having her healthcare provider perform perineal massage or support during the birth, the mother can minimise the pain of crowning.

Other reasons for pain during childbirth are the result of abnormal Labor and birth complications. It is during these circumstances that we can be truly thankful for medical technology.

Once women are educated about epidurals it becomes clear that avoiding one during childbirth may be well worth it to both mother and baby. Truly needing one, or deciding to have one as an informed choice at the time of the birth, on the other hand, need not leave the new mother feeling guilty.

By taking responsibility for her health and the health of her baby long before Labor begins, there are a great many things a mother can do to tremendously improve her chances of successfully avoiding an epidural ... without being a martyr.

How To Avoid A Routine Epidural

  • Eat optimally and appropriately during your pregnancy for you and your baby. For a good guide to diet during pregnancy, consult The Truth About Diet and Drugs in Pregnancy... What Every Pregnant Woman Should Know, by Thomas Brewer, MD (New York, NY: Viking Penguin, 1985)
  • Choose a health-care provider who actively supports natural childbirth.
  • Choose a childbirth method and instructor with a high rate of epidural-free birth outcomes.
  • Exercise consistently, three times a week (with doctor's approval), in a qualified, professional prenatal exercise program that follows ACOG guidelines, and includes aerobic conditioning and pregnancy-specific exercises. (If there are no prenatal exercise programs in your area, try the Kathy Smith pregnancy exercise video).
  • Practice relaxation skills for Labor everyday, both alone and with your Labor coach. Become good enough at relaxation that nothing breaks your concentration.
  • Write a birth plan, outlining what is important to you at your baby's birth, and bring it with you to your hospital or birthing center. Tour your hospital or birthing center and make sure it is an environment that makes you feel safe.
  • Actively deal with your fears about birth.

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NOTES

1. "Epidural Anaesthesia for Labor," ICEA Position Paper, 1987

2. "Epidural Analgesia," ICEA Review 5, (August 1981): 2.

3. Doris Haire,"Drugs in Labor and Birth," Ckildbirdi Educator, Spring 1987.

4. Jacques Geles, History of Chi/dbirth (Boston: Northeastern University Press, 1991).

5. Davis-Floyd, Robbie E., Birtk As An American Rite of Passage (Berkeley, CA: University of California Press, 1992).

6. "The Effects of Maternal Epidural Anaesthesia on Neonatal Behavior During the First Month," Deve/opmental kfedicine and Ckild Neuro/ogy, 1992.

7. The Pkysician's Desk Reference (Oradel,NJ: Medical Economics Go., 1996).

8. G. A. Albright, Anaesthesia in Obstetrics: Afaterea/, Foetal, ana' Neonatal Aspects (Menlo Park, CA: AddisonWesley, 1978).

9. "Lumbar Epidural Analgesiathe Pursuit of Perfection with Special Reference to Midwife Participation," Anaesthesia (1975): 30.

10. "The Effect of Lumbar Epidural Analgesia on the Rate of Cervical Dilation and the Outcome of Labor of Spontaneous Onset," Britisk Journal of Obstetrics aea' Gyeecology (1980): 87.

11. "The Influence of Maternal Analgesia on Neonatal Behavior: Epidural Bupivacaine," Britisk Journal of Obstetrics and Gynecology (1981): 87.

12. "Obstetric Consequences of Epidural Analgesia in Nulliparous Patients," Luncet (1971): 7708.

13. "Lumbar Epidural Analgesia in Labour: Relation to Foetal Malpositioning and Instrument Delivery," British 3fedica/ Journa/ (1977): 1.

14. "The Effect of Continuous Lumbar Epidural Analgesia on the AcidBase Status of Maternal Arterial Blood During the First Stage of Labour," Journal of Obstetrics and Gynecology British Common, (1973): 80.

15. "Neurobehavioral Responses of Newborn Infants After Maternal Epidural Anaesthesia," Anesthesio/ogy, (1974): 40.

16. "Regional Obstetric Anaesthesia and Newborn Behavior: Effect Over the First Ten Days of Life," Pediatrics (1976): 58.

17. Anaesthetic and Life Support Drug Advisory Committee, Bureau of Drugs, Food and Drug Administration, First Meeting, March 1979.

BOOKS

Artal, Raul, MD. Pregnancy and Exercise. New York: Delacourt Press, 1992.

Bradley, Robert, MD. HusbaedCouched Cki/dbirth, fourth edition. New York: Bantam, 1996.

Dick-Read, Grantley, MD. Childbirth Witkout Feur, fifth edition. New York: Harper R Row, 1981.

Hartman, Rhonda. Exercises for True Natural Childbirth. New York: Harper R Row, 1975.

McCutcheon-Rosegg, Susan. Natura/ Ckldbirth tke Braa'ley Way. New York: E. P. Dutton, 1984.

Odent, Michel, MD. Birth Rebore. New York: Pantheon Books, 1984.

Panuthos, Glaudia. Transformation Tkrougk Birth. Boston: Bergin & Garvey, 1984.