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.
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