Getting a “good” epidural

Think you might be interested in an epidrual for labor, here are some things to keep in mind to help you have a good epidural experience.

Understand the availability

To have an epidural you need an anesthesiologist or a nurse anesthetist to perform the technique. If no one is available, you can not get an epidural. Small hospitals may not have 24 hour in-house anesthesiology. This means if you decide to have an epidural in the middle of the night it either may not be available or you have to wait for the anesthesiologist to wake up and get to the hospital. A similar situation can occur in very busy hospitals when several women want an epidural at the same time or if the anesthesiologist is assisting a cesarean surgery. For some women, the wait is unacceptable and they choose other forms of pain relief.

To find out about the policies at the hospital you plan to give birth in, attend a tour or information night. You can ask questions about their anesthesiology coverage, how they handle busy days and what other options are available if an epidural is not immediate. You will also learn about any other policies that may limit your access to an epidural such as results from blood testing or progress in labor. Your midwife can also let you know any health issues you may have that could limit your access to an epidural.

Have realistic expectations

For most women an epidural does an extremely good job of relieving their pain. 81% of the women in the Listening to Mothers II survey said an epidural was very helpful. But keep in mind that 10% said it was only somewhat helpful and another 9% said it was either not very helpful or not helpful at all. Be sure to alert the medical staff if you feel the epidural is not as effective as you expected so they can work with you to improve your comfort.

Because an epidural is a technique, not a medication, there is a wide range of pain relief that you may feel. In general, the lower doses that allow you the ability to have some strength and movement in your legs provide less pain relief then the stronger doses that make it difficult or impossible to move your legs. Find out if you will be given the choice between more relief and lack of mobility and less relief (generally feeling pressure of contractions but not strong enough to be called painful) and some mobility.

Some hospitals offer what is called a walking epidural. The idea of using such low dose medication to allow pain relief and mobility is a good one. However, in practice very few mothers who use a walking epidural actually get up and walk. For 35-85% of mothers they either feel too weak and shaky, do not have assistance or are unable to walk because of wires and tubes attached to their body.

Understand the process

Although the image of laboring with an epidural is that it is blissfully easy and relaxing, the reality is most mothers using an epidural look more like they are in an intensive care unit than a birth center. Because of the risk an epidural adds to labor, your baby’s heart rate will be monitored with an electronic fetal monitor. Most often this is accomplished with an external unit, but sometimes an internal monitor is used. The medications used in epidurals increase the risks for you too, so your blood pressure and pulse will be monitored during labor. This means in addition to the tube attached to your back you will have wires attached to either your abdomen or your vagina, a blood pressure cuff on your arm and a pulse meter on your finger.

The numbing effect of an epidural prevents you from feeling the need to empty your bladder. To ensure a full bladder does not block your baby’s progress, you may require a urinary catheter (between 30 and 60% of mothers are catheterized). Because an epidural can decrease the available oxygen for your baby, you may need to wear an oxygen mask over your nose and mouth. When narcotics are used in an epidural (common in a combined spinal/epidural) about 62% of mothers experience itching all over their body.

Hospitals have different policies about eating and drinking during labor. Be sure to ask how having an epidural will affect your ability to nourish yourself.

Keep the epidural for pushing

It was once believed that an epidural needed to be shut off for pushing. Studies now lead doctors to believe there is no benefit to turning off the epidural and it causes more pain for mothers. In fact, if you keep the epidural and wait until your baby’s head descends enough to be visible you not only decrease your fatigue from pushing, you also decrease the risk you will need a cesarean, forceps or a vacuum.

Accept the limitations

Epidurals are only able to change the way your body physically processes the sensations of labor. Presumably, removing the pain of contractions will improve your satisfaction with childbirth, but not always.

Four factors are consistently related to a woman’s satisfaction with childbirth. These are:

  • The amount of support she receives from caregivers;
  • The quality of her relationship with her caregivers;
  • Her involvement in decision making;
  • Her personal expectations.

The fact that pain relief is missing from this list was a surprise to the researchers, who naturally assumed pain relief was the most important factor in a satisfying birth. Instead, it appears the relationship you have with your midwife is significantly more important to your having a good birth than how effective an epidural may be. Because of this, part of having the best epidural experience possible is ensuring you have chosen a supportive caregiver who is a partner as you make decisions for birth.

References
Declercq ER, Sakala C, Corry MP, Applebaum S.
Listening to Mothers II: Report of the Second National U.S. Survey of Women’s Childbearing Experiences. New York: Childbirth Connection, October 2006.

Enkin, Keirse, Nilson, Crowther, Duley, Hodnett and Hofmeyr. A guide to effective care in pregnancy and childbirth Third Edition. 2000. Oxford: Oxford University Press.

Goer, Henci. The Thinking Woman’s Guide to a Better Birth. 1999. New York: The Berkley Publishing Group.

Simkin, Penny. The Birth Partner: Everything You Need to Know to Help a Woman Through Childbirth. 2001. Boston: Harvard Common Press.

The Nature and Management of Labor and Pain Symposium Steering Committee. The Nature and Management of labor Pain: Executive Summary. Journal of Obstetrics and Gynecology. May 2002; 186:5 S1-S15.