StorkNet interview with
William Camann, MD
and
Kathryn J. Alexander, MA

Authors of:
Easy Labor: Every Woman's Guide to Choosing Less Pain and More Joy During Childbirth

Easy LaborEasy Labor, Every Woman's Guide to Choosing Less Pain and More Joy During Childbirth is a comprehensive guide to all methods of labor pain relief available in most hospitals today. The goal of this book is to provide women with the information needed to make confident, informed choices regarding pain relief preferences well before the day of your baby's birth. Once labor begins, a thorough understanding of the pain relief choices available will help women feel reassured and empowered to keep all options open and determine which pain relief methods reflect your own values, priorities and personal preferences.

The authors begin the book with a discussion entitled "A New Philosophy, A New Approach." The popularly promoted notion that less (or no) medical pain relief intervention is the ideal goal often collides with an unanticipated reality, when women who wish to avoid pain relief medications or an epidural, discover their labor pain is far greater than they had prepared for, and their non-medical pain management methods provide inadequate relief. Women who prepare for an entirely medication free childbirth, but who do not learn about their medical pain relief options, are faced with having to make pain relief choices, in the midst of labor, without the benefit of knowledge and preparation.

"Women today enjoy more pain control choices than during any other time in history", says Kathryn Alexander, co-author of Easy Labor. "Many moms discover they have a variety of options available to them, and those options often include a combination of both medical and non-medical (alternative) pain control interventions. Once labor begins, many women find that their own particular course of labor will determine which of those options are most effective in providing a comfortable birth experience."

Dr. Camann comments: "Women preparing for childbirth no longer have to think in terms of Lamaze or epidural, narcotics or massage. For many women the most effective pain management strategy uses techniques from either side of the fence. Both can offer benefits and both can help you through your labor. The ideal pain relief approach leaves it up to you to determine, with the support of your caregivers, which of the natural and medical pain relief options work for you throughout the course of your labor."

The authors have reviewed and summarized the latest research on all the topics discussed in this book; using clear concise language, Easy Labor is an up-to-date resource for all women about to experience childbirth - for the first time, the last time, or anything in between. Easy Labor includes an in-depth discussion of modern and advanced epidural anesthetic techniques and all the latest research on this popular and highly effective form of pain relief. In addition, all varieties of all the commonly used natural and alternative methods of pain relief are discussed, including waterbirths, hypnobirthing, sterile water injections, birth balls, the use of doulas, and much more.

The book reads like a veritable "who's who" and "what's what" and "why that" for the delivery room. There is a comprehensive discussion of the differences between hospital and birth center births, and the differences between doctors, midwives, nurses, and doulas. The book includes interesting and even bizarre stories of the colorful and often very controversial history of pain relief during childbirth. (Did you know that in the sixteenth century, a Scottish midwife was burned at the stake for being so bold as to offer a woman pain relief during labor?) Pain relief during and after a cesarean section is discussed. At present, nearly a third of all deliveries in the United States are by cesarean section, thus this is a valuable addition to the information women need to be familiar with before childbirth.

Dr. Camann and Ms. Alexander's research for the book included conducting extensive interviews with a variety of birth professionals. One of the highlights of Easy Labor is the inclusion of pain relief stories and commentary from these professionals themselves, including physicians, nurses, midwives, and doulas. Read their advice on how not to go wrong in the informative chapter "Don't Let this Happen to You." In the unique chapter "Birth Stories From the Other Side of the Stirrups!" read about what they chose for their own labor pain relief!

The authors firmly believe that the fully informed patient is the best and smartest patient. This book will give women all the information they will need to be the most educated consumers in the delivery room.

About the Authors:
Dr. William CamannWILLIAM CAMANN, M.D. is the director of obstetric anesthesia at the Brigham and Women's Hospital in Boston, one of the most respected health care institutions in the world. Dr. Camann is an associate professor of anesthesia at Harvard Medical School, and president of the Society for Obstetric Anesthesia and Perinatology. Dr. Camann is an internationally recognized authority on obstetric anesthesia and pain control during childbirth. He has published hundreds of articles in respected medical journals and has won numerous awards for his teaching skills. He has appeared on various local and national news programs including The Today Show with Katie Couric, ABC World News Tonight, and Good Morning America. He lives with his wife and two sons in Boston, Massachusetts.
Kathryn J. AlexanderKATHRYN J. ALEXANDER, M.A., is a former child and family therapist and worked in the health care field for over 15 years. Now a freelance writer, her work has appeared in many national parenting publications and women's health web sites. She is currently a contributing writer for ePregnancy Magazine. Ms. Alexander lives with her husband and two daughters in Charlotte, North Carolina.


Easy LaborEasy Labor, Every Woman's Guide to Choosing Less Pain and More Joy During Childbirth by William Camann, MD and Kathryn J. Alexander, MA
published by Ballantine Books, January 31, 2006

To Purchase:
 • Amazon U.S.
 • Amazon UK
 • Amazon Canada

StorkNet advocates learning as much as possible about all facets of the labor process. When women are informed, they can make the best decisions possible regarding their birth, including when things are going as they had originally planned. We're very pleased to welcome Dr. William Camann and Kathryn Alexander as our guests. They're here to discuss how you can make confident, informed choices regarding pain relief preferences well before the day of your baby's birth. Feel free to ask them questions. They will answer a variety of questions, and replies will be posted as we receive them. Thank you for participating! We'll be choosing four winners at random to receive a copy of Easy Labor!


From Sharlene: I really want to have a natural childbirth, but a friend of mine said that the epidural saved her baby's life, because she had to have an emergency c-section and since she already had an epidural in place she was able to have one without any delay. I know this is not common, but I was just wondering what the procedure would be if an epidural wasn't already in place and what the time difference would be between the two methods.

Dear Sharlene: When there is already a functioning epidural catheter in place during labor, and an emergency cesarean is needed, a stronger dose of the anesthetic medication can be used to provide very rapid anesthesia for the surgery, usually within a few minutes.

Although the same thing can also be done using general anesthesia (unconsciousness), and usually just as quickly, the general anesthesia involves additional risks. These include that the mother is asleep and thus unable to be alert for the birth, the dad is generally not allowed in the operating room, and the mother must have a breathing tube inserted into her lungs, which can cause additional difficulties in the pregnant patient and especially if there are any other medical problems with the mother. Also, the drugs used for the general anesthesia can cross the placenta, and cause the baby to be a little sleepy. The epidural allows the mother to be wide awake and comfortable for the delivery, and the dad (or partner) is usually allowed into the operating for the birth when an epidural is used.

However, if you desire a natural birth, and are generally otherwise healthy, I would not use this reason alone to be the deciding factor in whether or not you get an epidural, as that is a very personal decision, and a variety of other factors must be considered.

From Robyn: I am pregnant with my second child. I had an epidural with my first delivery. During the epidural placement a nerve was hit and my whole body jerked. My dura was punctured, the left side of my face was numb and sagging and I had a spinal headache 2 hours later which lasted for 2 weeks. I never received any answer as to what happened to me, why my face went numb, and is this likely to happen again if I choose an epidural with this pregnancy? I am terrified!!!

Dear Robyn: It sounds like you had a very severe spinal headache, a complication occurring in about 1% of epidurals, although usually not as severe or long-lasting as the symptoms you describe. The facial numbness is a bit unusual, but almost any kind of facial or cranial nerve symptoms can, in rare cases, be associated with spinal headaches.

Regarding if it is likely to occur again, it is hard to predict, but you should have a frank discussion with your anesthesiologist before labor begins. It is impossible to tell without a personal physical examination of your back to see if there are any anatomical reasons why you might have had the puncture of the dura. While a repeat dural puncture is certainly possible, my best guess is that it would be less likely if the anesthesiologist is aware of the previous puncture.

From Amber: Our hospital offers ITNs in place of epidurals. Can you tell me if the risks and benefits are the same for the two? What are the risks and benefits for an ITN if they are not?

Dear Amber: (See also answer to "Storey" earlier on). An ITN is an "intrathecal narcotic." Intrathecal is the same as spinal, thus this is a spinal narcotic. It is injected into the spinal space, and in general, no epidural catheter is inserted. The pain relief can be similar to an epidural, but often less numbness and less effects on ability to move the legs than a standard epidural. The main problem is that the duration of the pain relief is limited, to usually to one or two hours, because no catheter is used to allow additional medication. If you have not delivered by then, you need to have another spinal injection, or else use a different means of pain control.

From Jeanna: I have had one child with an epidural and one without any pain medicines at all. My question, is that after I had my epidural, my healing time over the next several weeks was hard. My back hurt horribly, and I had a huge bruise where the needle had been inserted. It took as long if not longer for my back to heal from the injection as it did for me to heal from having birth. Is this normal? This experience completely kept me from having any pain meds the second time out of fear.

Dear Jeanna: While this is certainly not typical, it may be related to the anesthesiologist having a difficult time inserting the epidural. As with other answers in this forum, it is impossible to tell without a personal examination, but there may be anatomical reasons the insertion was difficult. While it is certainly possible this would happen again, the chances are less if the anesthesiologist who cares for you is aware of the previous experience.

Evelyn: I don't know if you can help with this question but I'm someone who likes to research and keep my options open. My husband is insisting that we have an unmedicated birth, and I'm starting to go a bit nuts. I will disappoint him terribly if I can't make it through without pain medication. It's not like I can't scream or whatever, he just feels that I will be irreparably harming our baby if I use medication. So, the pressure is on and I keep getting more and more upset and worried that I'll be disappointing everyone. Do you have any suggestions? I know it's my body and my choice but I do have to live with him afterwards and I can see the finger pointing if anything is ever wrong with the baby.

Dear Evelyn: Modern-day anesthesia techniques, such as epidural and combined spinal-epidurals, use extremely small doses of medication compared to what was used many years ago. Although some controversy still exists about neonatal effects of any type of pain medication during labor, the fact is that modern epidural techniques expose the baby to far less medication than narcotic injection techniques.

Kate in the UK: How can I make sure I get an epidural this time? Last time the midwife kept putting me off, saying there wasn't time and the baby would be out in 20 minutes. This went on for four hours. The birth was long (58 hours from first contraction) and traumatic. I couldn't even talk about it afterwards without uncontrollably shaking. I really want an epidural this time but I can't afford to go private.

Dear Kate in the UK: My best advice in this situation is to be sure your desires are known to your midwife, and preferably to an obstetrician, well before labor begins. In addition, you should investigate the epidural availability in your hospital. This varies from hospital to hospital, and some places have full-time anesthesiologists in the maternity ward ready to give an epidural at any time, and other places it is more dependent on the schedule of other surgeries and other factors. Find out how your hospital works before delivery, so you won't be surprised when in labor.

Sara: This is my first pregnancy and I am very scared of the pain!! How painful is it to get an epidural? How long does it take to put in and how big is the needle?

Dear Sara: See also answer to Shannon, earlier, and partially repeated here: All epidurals are inserted using a local anesthetic in the skin before the needle is placed. We describe the entire process in detail in Easy Labor, Chapter 4, (p. 77) in a section entitled "Your epidural step-by-step: how it is done and how it feels." Once the initial injection of local anesthetic is made into the skin, the actual insertion of the epidural is generally not that uncomfortable.

Hannah: I'm 30 weeks pregnant with my fourth child. My first was an emergency c-section; I already had an epidural and was fine. My second was a vbac with a epidural at 2 centimeters because I was in so much pain. The first two were induced but the second was way worse. Recovery was easier with the vbac but for the third I opted for another c-section. That time I received a spinal and hated it. Whatever narcotics they gave me were horrible. Could I have an epidural by itself with no narcotics mixed?

Dear Hannah: You can certainly ask your anesthesiologist for a specialized mixture without narcotics, but in general this may not always be the wisest choice. First of all, it is important to determine if the side-effects you experienced last time were due to the spinal narcotics, or due to other narcotics given by injection after the cesarean. Secondly, if one omits the narcotics out of the epidural, then higher doses of the local anesthetic are required. This can have problems of its own, as we describe in the "Don't let this happen to you!" chapter of Easy Labor.

Ashley: I am 39 weeks pregnant with my first baby and my platelet count is lower han average. With my platelet count being low and with the possibility of not being able to get an epidural what other pain medicines are available to me? I know natural birth will kill me so what is safe for me and my baby?

Dear Ashley: See also answer to Jennifer, earlier, and repeated here: this is a very common question, and unfortunately one for which there is no definite answer. In the past, almost all anesthesiologists used a platelet count of 100,000 as a lower limit for receiving epidurals; many anesthesiologists are now allowing epidurals in patients with slightly lower platelet counts. However, exactly how low is a matter of some discussion and personal preference among anesthesiologists. There is no "standard" or "guideline" or nationally agreed upon number for this. The 45,000-60,000 range is one where most anesthesiologists would still feel uncomfortable inserting an epidural. In addition, the reason why your platelet count is low, and any medications you may be taking, and any other associated symptoms (such as easy bruising, nosebleeds, etc) may influence the decision. My advice is to be sure both your obstetrician is aware, and also that you request to speak to an anesthesiologist at your hospital prior to arriving in labor so they are aware of your situation and can discuss options fully with you.

Marina: I have heard a lot about walking epidurals. Can you explain what they are and how they're different than other epidurals?

Dear Marina: Basically, a "walking epidural" is one where extremely low doses of medication are used so that there is still ability to walk. Although one reads about this frequently, the fact is that really very few places offer truly walking epidurals. Much more common, is just the use of a low-dose epidural and the ability to move in bed, to sit up, to help with pushing, and just generally be more physically involved with the entire experience than if your legs were totally numb. Most modern-day epidurals are very low-dose, and most patients retain the ability to move, at least in bed.

Laurel: I have heard that moms who have epidurals have babies that can be slow to suck well for breastfeeding, that they're just not alert enough. How much of the drugs in an epidural get into the baby's system and do these babies really have a harder time learning to breastfeed?

Dear Laurel: Although some epidural medication is absorbed in the mother's blood, and subsequently to the baby, the key here is that the amounts are very small. Breastfeeding is a very complex dynamic, and there are a variety of reasons that there may be difficulty. Although there is some research, often quoted by lactation consultants, about epidurals being associated with difficulties with breastfeeding, the fact is that this research is extremely confounded by many other variables, and at present, no definitive conclusions are possible. One thing that is quite clear is that use of narcotics, by injection, during labor, produces much higher drug levels in mother's blood than when the pain-relieving drugs are given by the epidural. Thus, avoiding an epidural but using narcotic injections instead is actually far worse for the initiation of successful breastfeeding.

Maddie: I am pregnant with twins and hoping for an unmedicated birth. I've heard that some hospitals insist on placing an epidural in twin moms just in case of a c-section. Is this standard practice?

Dear Maddie: While this is not "standard" practice, it is very common practice, and there is good reason for this. Many problems can occur with twin vaginal deliveries, most commonly related to the second twin becoming stuck, or a problem with the umbilical cord, or presenting in an unusual or difficult manner, causing difficult or impossible vaginal delivery. In these cases, often a cesarean is needed, and often quickly. Having an epidural in place would allow a rapid cesarean to be done without using general anesthesia. In addition, if certain maneuvers are necessary to assist with the delivery of the twin, such as forceps, episiotomy, or internal rotations, then the epidural will make this more safe and comfortable.

From Nikki: I have a really bad phobia of being sick. Luckily I have had no morning sickness but I'm very worried that when I'm in labour I might have some drugs to help the pain but I'm worried they may have side effects that could make me sick. Do you know of any that are least likely to make you feel sick?

Dear Nikki: Many women in labor get sick, drugs or no drugs! But to answer your specific question, the drugs most likely to cause nausea are any of the narcotics. These are drugs such as demerol, nubain, stadol, morphine, and dilaudid. Although epidurals do usually contain a narcotic (most commonly fentanyl) in addition to the local anesthetic, the amount of drug that reaches your bloodstream is not quite the same as when the other narcotics are given by injection. As I said above, many women in labor get sick, even without any drugs, and sometimes it is only pain relief that also relieves the nausea. If you do experience nausea, there are several very effective anti-nausea medications that can help. In addition, sucking on hard candy, such as "preggie pops" can be helpful.

From Mia: I'm planning a vbac. What has been your personal experiences with epidurals being used during a vbac birth?

Dear Mia: An epidural can be very helpful during a VBAC. In addition to all the considerations regarding an epidural during any labor, the particular advantages to an epidural during VBAC include that if a cesarean is needed, particularly in an emergency, this can usually be done with the epidural and not require general anesthesia. A concern often raised against epidurals in VBAC labors is that the pain relief may mask the symptoms of a uterine rupture. In fact though, most of the research on this shows that uterine rupture is very frequently felt even if there is an epidural in place, and also that uterine rupture is most commonly diagnosed by the fetal heart pattern, which would be unaffected by an epidural.

From Heather: I am epileptic and I would like to know if having an epidural is known to bring on seizures?

Dear Heather: No. The epidural itself will not influence a seizure due to epilepsy. If you are taking medications for your seizure disorder, be sure to carefully follow the advice of your obstetrician and neurologist about continuing (or not) these medications during pregnancy.

From Elissa: I'm pregnant now with my first child. I have 5 sisters and I'm a nurse so I am very familiar with the whole birth process. I know that I don't want to be induced unless ABSOLUTELY necessary; I feel that induction is done way too often and I also feel that induction will cause me increased pain. I also would like to try labor without an epidural. Am I being irrational? I just feel it's best to let my body do what it knows how to do as long as me and my child are not in jeopardy.

Dear Elissa: There is no question that induced labors are generally more painful than a labor that begins spontaneously. But women are different in their pain tolerance, and you just never know until you get there! In Easy Labor, we describe a variety of non-drug methods for pain relief. You would be well advised to become familiar with these techniques. However, most women who are induced do indeed end up with an epidural, so please consider this as a likely outcome, and do not feel like a failure if you end up with an epidural. You may also want to consider hiring a doula, who can be very helpful during your labor - whether induced, epiduralized or natural.

From Andrea: I am pregnant with my second child and was wondering how I can avoid a episiotomy. With my first I had an epidural which went well but it was turned off towards the end when he told me to push, because I did not push well enough I needed to be cut and my son was vacuum extracted as well. The cut did not hurt at the time but the recovery (6 weeks) was unbearable. What can you suggest to avoid this? I have also read that an epidural can lead to an episiotomy, is this true?

Dear Andrea: The evidence is really unclear about epidurals leading to an episiotomy. In general, episiotomies are used far less frequently than in years past. In addition, many second labors are easier and quicker than a first labor, so that is a factor on your side now. Many other factors influence this also, including the size of the baby, the baby's heart rate near delivery, and the specific location of the baby's head as it enters the birth canal. These are issues best discussed with your obstetrician.

From TK: I'm 19 weeks pregnant with my first child. I wanted a child badly otherwise I would have never done this at all. I do not like hospitals, needles, or related discussion matter amongst comrades. I overcame getting my blood drawn for the first time ever in my life last March. I put a sheet over my head, held my husband's hand, and sang hymns. I call it see no evil, hear no evil, speak no evil. I got through it without passing out. Needless to say the idea of an IV stuck in my arm longer than a minute terrifies me. The epidural does not appeal to me either. Am I going to have to suffer excruciating pain or are there other alternatives given by pill or a quick shot that can be used with a numbing agent? Please make suggestions, I only plan to do this one time.

Dear TK: Please see the answers below to both Shannon and Jeana about "needle phobias"!

There indeed are many non-drug alternatives to an epidural, and these are all discussed in Easy Labor. My best advice in this circumstance is to consider taking a childbirth course that offers hypnosis. My personal recommendation is the "hypnobabies" technique, you can learn more about this at: http://www.storknet.com/cubbies/childbirth/hypnobirthing.htm. Consider also hiring a doula, using a water tub or shower, or walking around as much as possible during labor.

From AJ: In the 1950's my grandma was put under, gave birth vaginally, and woke up with a baby. Is this practice ever used today and how does it actually work? How can an unconscious woman give birth vaginally?

Dear AJ: For all practical purposes, the kind of birth your grandmother experienced is almost unheard of today! With an epidural you can be awake, alert, pain-free and be a complete and active participant in the birth. Even if you do not use an epidural the other medications used by injection for labor pain relief will not put you to sleep the way your grandmother experienced many years ago.

From Carla: Is it possible to have just an epidural for the pushing part of labor? With my last birth, I didn't have any pain meds and did fine through the whole labor but the pushing was so incredibly painful and no one would give me anything. I'm really scared about that part this time.

Dear Carla: Please ask to meet with the anesthesiologist as early in labor as possible to discuss these concerns. If your hospital uses the "patient-controlled epidural" (PCEA) then you can have great control over how intense the pain relief is in the various stages of your labor. If you wish to wait until later in labor to receive the epidural, then ask if the combined spinal-epidural (CSE) is available at your hospital. The CSE is excellent for use in the later stages of labor, and both PCEA and CSE are completely discussed in Easy Labor. Please also see the answer to Heather below, she asked a very similar question!

From Kerry: I had a very traumatic C-section birth with my first daughter. I am totally blind and had some special needs that were not given any consideration by my doctors. I was terrified to be separated from my husband while being prepped for the section and given the spinal. Although I tried to ask for him to be allowed to remain with me, the doctors wouldn't even listen to me and just kept saying "no, we'll take care of you." Although they meant well, no one really told me what was going on, and my husband was not there to help. Is this always done, or is a woman's partner sometimes allowed to remain with her if there are special circumstances? How is it done where you practice?

Dear Kerry: In some cases, it is reasonable to ask for exceptions based on special needs. The most common practice is for the husband to wait outside the operating room while the spinal is administered, and then for him to come in after the anesthesia is satisfactory and the sterile preparations for surgery are complete. Advance discussion (prior to the day of delivery!) with your obstetrician and an anesthesiologist at your hospital about this request would be recommended if you have another cesarean delivery. You may also want to consider hiring a doula, if possible. A doula provides labor support to women throughout labor and birth. In particular, some doulas will be of specific assistance to women with a variety of special needs. This additional resource may be particularly helpful to both you and your husband, to ensure that your specific needs are met.

From Heather: I am 5 months pregnant with my second child. My first child was born five years ago. Labor with him was manageable and did steadily progress as the day went on even though in the last hour and a half I was encouraged to have an epidural. This time I am seriously thinking about trying to have no epidural because half of my lower body I could not move last time and I felt that made labor more difficult. I felt that I was dealing with the pain both mentally and physically. I am preparing myself for more pain. My question is that I have heard that there is a point in labor when you can no longer receive an epidural. Is this true? Is there a point in which I will have to make a choice?

Dear Heather: It is reasonable to ask for a "lighter" epidural; this might make it less likely that you would not be able to move your lower body. In most cases, an epidural can be administered right up until minutes before birth, but this largely depends on the resources of the particular hospital and the specifics of just how fast your labor is progressing. Sometimes, if the baby is just about to come out, it is hard to remain still for the actual process of insertion of the epidural. Also, if you do get an epidural very late in labor, the combined spinal-epidural (CSE) is a good choice, if offered at your hospital. The more standard epidural often takes 10-20 minutes to take full effect, so if the baby is only minutes away, there may not be time for it to work completely. Please ask your obstetrician or anesthesiologist about the CSE.

From Gina: I am pregnant with my fourth child. With all of my previous labors I received an epidural. The first time it worked, the second and third times they gave me relief for about 2 hours and then stopped working. The staff increased the epidurals but they still did not have an effect. I did not mind having the sensations back once I had those couple hours rest to help me regroup and gain some strength (my labors have been 26 hours, 24 hours and 15 hours). My doctor says that she won't let me have the epidural this time, but that I should find other alternatives. What do you think would be a good alternative for temporary relief during the hardest parts, but would allow me to feel it all in the end?

Dear Gina: First, in my opinion, there is no reason not to try another epidural, especially if your anesthesiologist is aware of what happened with the previous 2 epidurals. Second, if offered at your hospital, this might be a reasonable situation for a combined spinal-epidural anesthetic. The CSE is described in detail in Easy Labor, and often avoids some of the problems you mention. If you prefer to use an epidural, meet with an anesthesiologist at your hospital, prior to your delivery date, and discuss your doctor's concerns. If you decide you want to skip an epidural this time around, I would recommend water immersion during labor, or, even the use of self hypnosis, as an effective pain management technique. You will need to find someone who offers training in the use of hypnosis during childbirth, and your childbirth education department can refer you to a certified hypnotist who specializes in pain management during childbirth. For more information on this technique go to: www.storknet.com/cubbies/childbirth/hypnobirthing.htm.

From Redhead: Do women have a right to an epidural? I have 3 children. With my first delivery, I finally got an epidural at 9 cm. The entire labor and delivery was a total nightmare; the pain was beyond excruciating. With my second and third children, I walked through the door at 6cm in light labor and had epidurals placed when they broke my water; I was grateful. I'm 32 weeks right now; I usually walk through the door at 6cm. Do I have a right to ask for an epidural before the pains get bad and it's too late for an epidural? With my first delivery, they broke my water and the contractions came on within 10 minutes. It was like being hit with sledgehammers and I was curled up in a ball for hours suffering. The hospital staff was too busy helping other patients. I'm afraid I'll go fast and not get an epidural. I am terrified of missing out on an epidural. If I can't have an epidural, I don't want to live through this experience again. My first was a nightmare that haunts me to this day and it's been 9 years since my first child was born. Do I have to bring a survival knife with me and threaten to cut myself open before anyone will listen? I'm dead serious about wanting an epidural. I've been through an unmedicated labor . . . it's not for me!!!!

Dear Redhead: Consider discussing this with your obstetrician and also be sure to tell your labor nurse about your desires as soon as you are admitted to the L&D unit of your hospital. In many cases, they can arrange for you to be seen by an anesthesiologist very rapidly. In some cases, an epidural can be placed very early in someone who has a history of fast labors. This would depend to some extent on available resources at your hospital. Contact the anesthesia department at your hospital and ask to meet with an anesthesiologist - prior to your delivery - to discuss your options for early epidural placement once you've arrived at the hospital. In situations such as yours, it's best to plan ahead!

From Helle: I would like to ask you, which would be the best pain relief option for my second birth. My first birth was extremely fast (4 hours from the first, mild contraction to holding the boy in my arms) and the active phase was only about 20 minutes. Even the pain of the strongest contractions was bearable for me without any pain relief at all, but the final 15 minutes or so gave me a real shock. I had never expected a pain as intense as when my labia and clitoris started tearing. It actually made me stop pushing for a while, until I went into a trance and just did it - and tore myself badly. My question is: Can you recommend any pain relief that might work locally in the vagina and its external parts in the very final stage of the birth? This seems to be my achilles heel . . . Before my first birth, I didn't worry about the pain at all, but you live to learn. Thank you for a great Q&A!

Helle: An alternative to the epidural for a situation you describe is a pudendal block, usually administered by the obstetrician. However, this type of anesthetic may not completely relieve the pains of the contractions. Consider also the epidural or CSE, as with your history of a severe vaginal tear, a more controlled and calm birthing environment might help prevent this from happening again.

From Melissa: I know it sounds crazy, but being that I have always been self-conscious about my body and other people looking at me, I have to admit that I am terrified to give birth! I cannot imagine laying in the vulnerable position with the whole world there to watch. Not to mention what my fiance will have to witness. The sights, sounds and smells that come with labour must be absolutely mortifying! How on earth can a man find you sexy after watching THAT! Everyone says it won't matter any more after being in pain for hours, but the thought of delivering my baby in a few weeks terrifies me.

Dear Melissa: Your concerns are very common and very normal. In fact, we have a chapter in Easy Labor entitled: "Your Very Common, Very Normal, Fears of Childbirth." In this chapter, we discuss some of these common concerns, and what you can do about them. Exactly as you mention, concerns about loss of dignity, people seeing you naked, and the various bodily fluids associated with childbirth are extremely common. Rest assured, the staff of the labor and delivery unit have seen it all, and they will do all they can to calm and reassure you that all that is happening to your body is normal and appropriate. Is your fiancÚ attending childbirth classes with you? If so, then he will be somewhat prepared for what to expect. And in any case, if there is something he does not want to observe, it's perfectly appropriate if he wishes to turn away or step out of the room. I sometimes think we put excessive expectations on the men in the delivery room, and in some cases, they'd just rather not watch. This is ok, and does not mean he feels any less love toward you or the child.

From Meagan: Soon I will be having my first baby. I live a 1 hour drive away from the nearest hospital that delivers babies. I was wondering what pain relief methods I can use between the time that I go into labour and the time I reach the hospital. I am also concerned that the bumpy drive will be quite irritating and uncomfortable. Any suggestions?

Dear Meagan: One thing to consider is that the bumpy drive may actually be soothing and distracting! It's hard to tell, and first labors are very unpredictable. The degree of pain you will be experiencing during the drive is very dependent on just how active the labor is at the time. However - your question is important as many women often ask what types of pain control methods can be used before entering the hospital. In Easy Labor, we describe a variety of methods, from position changes to mental imagery to breathing techniques, which may be effective. How effective these techniques are while enduring an hour-long car ride is questionable, but at least you'll have something to use as a guide.

From Julia: Have you noticed that any particular childbirth method works better than another? For example, have your patients had better luck with the Bradley method over Lamaze?

Dear Julia: Bradley vs. Lamaze is a common question, and one that is the subject of much debate among childbirth educators (and we describe both of these methods in detail in Easy Labor) While I don't like to be evasive, the real answer to your question is "it depends!" Seriously, what works for one woman may not work or even be appropriate for another. To gain perspective on this topic, it is useful to hear from women who have given birth using either of these approaches. Try to speak with women who have given birth using the Bradley Method, and to those who subscribe to the Lamaze philosophy, to see what is most appealing to you.

From Christy: I'm really interested in a waterbirth. Can you tell me, how does the baby breathe under water? I'm scared it's bad for the baby even though I'm sure it'll feel good to be in the birthing tub. My nephew aspirated amniotic fluid during his birth (wasn't a waterbirth) and I'm worried that there could be more potential for that during a waterbirth.

Dear Christy: In a waterbirth, the baby is lifted above the water immediately after birth and does not take its first breath until after it reaches the surface. We have an extensive discussion of waterbirth in Easy Labor. To calm your fears, there are research studies that indicate the safety of waterbirth for the baby - specifically indicating that babies born under controlled conditions underwater do not have any higher rate of admission to special care nurseries or problems related to the water, compared to babies born on dry land. However, you can also consider that many women will stay in a tub or bath for much of their labor, but then come out for the actual delivery. The water immersion seems to have moderate pain-relieving properties, or at least soothing, relaxing, and distracting properties, even if the actual birth does not take place in the water.

From Rebekkah: I've heard a lot about nitrous oxide. In your book, you quote Dr. Rosen . . . "I believe, much like narcotics, the pain may seem the same, but the patient doesn't care as much about it." If that's the case, will I care about anything while using it? I'm worried I'll feel so out of it that I won't care about the baby or birth.

Dear Rebekkah: Very good question, but I need to add some perspective. As we mention in Easy Labor, nitrous oxide is not commonly available in the USA, although it is indeed very common in Canada and the UK. So before preparing for this, be sure to ask if it is available at your place of delivery. But to answer your question, most women who use nitrous oxide may feel a little tired or sleepy, but generally not so "out of it" that they are unaware of the surroundings or the birth. Nitrous oxide, if available, may be of use to some women and others find that it provides no relief at all. But it is a very short-acting gas, and after stopping breathing it, the effects wear off very quickly (within minutes).

From Susie: I am 26 weeks with my second pregnancy. When delivering my first I was induced and had an epidural. I have a very ticklish back just where the epidural goes in and I kept flinching when they tried to get it in and the nurse anesthetist was getting upset with me. She finally got it in but it didn't "take" all the way and I still experienced significant pain so they ended up giving me more of something through the epidural line every 30 minutes or so. I am concerned about getting another epidural, although I would like to consider it as an option. Is there anything I, or the anesthesiologist, can do to increase the effectiveness and decrease the risk of me flinching/moving while inserting the line? Thanks.

Dear Susie: The best advice I can give to you is to tell your anesthesiologist about this before he/she starts the procedure! Regarding being ticklish, if the anesthesiologist is aware, they can keep this in mind when doing things such as scrubbing your back with the antiseptic prior to the procedure (sometimes the scrub brushes used for this can indeed be a little tickly - kind of like a loofa sponge!) They can also try to use some additional local anesthetic at the site of the epidural insertion, which might help ease the discomfort of the procedure.

Regarding the success of the procedure itself, this is something you should also tell your anesthesiologist about in as much detail as you can recall. It is possible that slight modifications of the procedure can be done (such as use of a combined spinal-epidural technique) to help make this a better experience for you. One thing to keep in mind is that second labors tend to be a bit faster than first labors, and this might influence the success of the procedure.

From Tina: I've heard a doula can help during labor. Are doctors and nurses comfortable with this, and what exactly does a doula do to help?

Dear Tina: A doula absolutely can help! Doulas will provide emotional support, reassurance and other means to keep you as comfortable as possible during labor. These other means include massages, helping with positioning during labor, warm or cold compresses depending on your needs and desires, etc. Most doctors and nurses are very comfortable with doulas, but yes, there are some who are not and it is best to discuss these plans with your obstetrician prior to labor. Although traditionally doulas tended to care almost exclusively for patients who were attempting natural childbirth, today many women who utilize an epidural also will avail themselves of the valuable support of a doula - something I call an "epi-doula". In my opinion, the use of doulas and epidurals together is entirely compatible and can contribute to a very nice birth experience. More information about doulas can be found here: http://www.storknet.com/cubbies/childbirth/exag1.htm.

From Joan: I have scheduled a planned cesarean for later this month. I would like to know if there is a substitute for Morphine for post operative pain management as I have read that it increases the risk of oral Herpes (which I have had in the past, and which I would hate to have while I'm trying to breastfeed) -- and also that it affects breastfeeding more negatively than postoperative epidural infusion of anesthetic bupivacaine (marcaine alone). If I am having a regional spinal anesthesia -- I think the standard practice at my hospital is to include a morphine additive to spinal injection -- with the intention that it will last for 16 hours or so to prevent post-operative pain. My main goal is to find something that has the least impact as far as trace elements in the breast milk, and impact on the mother and child -- What do you recommend?

Dear Joan: You are correct that epidural or spinal morphine can increase the chance of an outbreak of oral herpes, so your concern is valid. On the other hand, epidural/spinal morphine has almost no absorption into the bloodstream, (because the doses used are so low) which is why it is so useful and popular after a cesarean - almost none of the medication will go to the baby. However, other options do exist - drugs such as demerol and dilaudid are also effective pain relievers and do not seem to have the same risk of a herpes outbreak as morphine. Drugs such as ibuprofen (motrin) and other drugs in that class of medications can also be used after a cesarean to help reduce the dose of narcotics you will be receiving. We discuss these options in Easy Labor in the chapter (Chapter 7) on "Pain Relief for a Cesarean Delivery." Please discuss these concerns with your anesthesiologist when he/she meets with you prior to your surgery!

From Amber: Is waterbirth safe? Can I have any pain medication if I labor in water?

Dear Amber: Waterbirth, in general, is very safe! However, you should first check to see if these facilities are available at your hospital. Also, some complications of pregnancy may preclude you from giving birth in water. In general, no other medications are given if you are going to immerse yourself in water. This is for your own safety - you don't want to be sleepy or have any degree of inability to move or balance yourself while in a water tub! We have an extensive discussion of laboring in water in the chapter (Chapter 6) on "Alternative and Complementary" methods of pain relief in Easy Labor. Also, keep in mind that while many hospitals do indeed allow laboring in water, only a few allow the actual delivery to take place in the tub or bath. There is quite a difference between laboring in water and actually birthing in water. Check with your own intended place of birth (and with your obstetrician/midwife) for their particular policies on this.

From Gloria: Can you explain TENS? I've heard a few moms talking about it and they seemed to love it but I'm really ignorant how it works. My first labor was so awful that I think I'm in the mood to try anything to avoid a labor like that. Thanks.

Dear Gloria: Transcutaneous electrical nerve stimulation (TENS) is a device that emits electrical stimulation to specific nerves for the purpose of providing comfort or distraction from pain. This device is used to treat various types of pain and discomfort, including labor pain. The TENS is a small, hand held device about the size of the remote control for your television. It has wires and electrode pads that are placed at or near the site of the pain. Most TENS devices use two different types of stimulation: a "burst" type of stimulation typically used for chronic or more moderate pain, and a constant mode for acute, short-lived pain (like the pain of contractions). TENS sends electrical stimulation to your nerves which blocks labor pain signals to the brain and may also stimulate your body's production of natural pain-killers, endorphins.

The TENS device is operated by you, and when it is turned on it will deliver mild electrical impulses to the area under the electrodes. The electrical stimulation may feel like a buzzing or tingling sensation. Some women report that TENS reduces their pain and the distraction makes coping with the contractions more tolerable. Others report that the use of TENS makes no difference at all in their comfort level. It may be a good technique to try if you do not want medications or an epidural. Or, you may choose to use TENS for relief in early labor to delay your use of medications or until you are ready to receive an epidural.

On a related matter - why was your first labor so awful? It would be helpful to focus on the specifics of what went wrong, so those specific factors could possibly be addressed this time. We hope you have a better experience this time.

From Kiki: This may sound like a crazy question but I'm completely serious. My husband is a wimp and terrified of the birth process. I'm hoping to have a non-medicated labor and I've prepared myself for that. My husband wants to know, however, if the anesthesiologist could give him something during the labor so he can stay with me but not freak out at what he sees. Is that possible? Please don't laugh!

Dear Kiki: I promise not to laugh! But seriously, your question is a good one, not crazy at all, and in general, we tend not to pay as much attention as we should to the father - after all he's a very important part of this whole process. However, anesthesiologists do not give any medications to the husbands. I hope your husband is participating with you in childbirth classes and learning as much as possible - knowledge of what is actually going on may help him cope with the situation. Moreover, if you really think that your husband may really not deal well the situation, or possibly even faint or become a burden on others during your labor, you may wish to consider another support person in addition to him. For example, a close friend, relative, or a doula - particularly one with whom you can discuss the situation with prior to labor, and possibly the doula may be able to help your husband as well as help you.

From Courtney: Does anybody ever read a birth plan? My doc gave it a once over during one of my appointments, and when I handed it to my nurse at the hospital once labor started, she stuck it in my chart and I never saw it again. I'm sure the anesthesiologist never saw it and none of the nurses after the first shift change seemed to be aware of it either. I guess I'm wondering what's the point of doing one if nobody is going to look at it. I was too focused on handling my pain to waste the energy asking each new person who came into my room if they'd seen my birth plan.

Dear Courtney: The most important part of a birth plan is not that anyone actually reads it, but that it is reasonable and flexible. This document is simply a guideline about our general preferences during labor and delivery; being too specific and unreasonable can actually be counterproductive. We have an extensive discussion of birth plans in Easy Labor in Chapter 11 - in fact this section is entitled "Your Birth Plan - Does Anyone Actually Read it?" So - your question reflects a valid and common concern. But birth plans are not worth much if they (and you!) do not embrace some degree of flexibility. Remember, one of the most predictable things about labor is that it is unpredictable - so be prepared for something to happen that you did not expect.

From Sheila: I'm a rather quiet and shy person. The thing that scares me the most about labor is making noises, especially loud ones, even screaming, in front of strangers. I want to go for a non-medicated birth but I'm afraid of making a complete fool out of myself. Any suggestions for me?

Dear Sheila: You are having a baby - go ahead and scream!!! Trust me, there is nothing you can say or do during labor that would make any experienced labor nurse or obstetrician view you as a "fool." They have seen it all! However, not all women scream during labor. Rest assured that many women vocalize in a variety of ways other than loud screaming. You will be respected and supported during labor without regard to what kind of noises you may or may not be making. Have a great birth!

From Karie: My question revolves around what to expect for a second birth after my first child was born during a horrible labor and delivery experience. I had a fourth degree episiotomy, also tore, and they had to break my pelvis to use the forceps to deliver. I am very concerned about this birth because I want to have more control, especially after the last one where the doctors told me little to nothing of what was happening and just kept doping me up. On top of that I am very scared about giving birth this time. Do you have any suggestions and does your book cover this angle of things?

and a similar question:
Rita: I am 26 years old and expecting my first child. The problem is that am so nervous about the whole process of labour. The more I read books on easy delivery the more nervous I become. What do you think is the best way of dealing with this problem of nervousness?

Dear Karie: We're sorry to hear of your previous difficult birth experience. It's hard to address specific issues related to your birth, as your letter does not give enough detail to allow comment. Specifically with regard to pain relief, you state that they "kept doping you up" during your previous delivery. While it's not clear to me exactly what that means, I am going to assume you were given medications such as narcotics, which will make you sleepy during labor. It might be reasonable to consider using epidural anesthesia during this delivery. An epidural will provide excellent pain relief, while also allowing you to remain fully awake, conscious, and in full control during the entire labor and delivery.

Response to both Karie and Rita: However, it is not uncommon to experience a variety of fears as one approaches childbirth, whether as a first-time mom or a repeat mom who has had a previous difficult or traumatic birth experience. In Easy Labor, we devote an entire chapter to this topic, Chapter 3, entitled: "Your Very Normal, Very Common Fears of Childbirth." In this chapter, we discuss which fears are reasonable, and why, and also which fears are less reasonable, and why, or so rare as to not be a significant concern to most women. We also discuss a variety of tips for addressing these fears, when counseling would be appropriate, as well as tips for stress-reduction and relaxation during pregnancy and delivery.

We'd also like to add that many women are often told to ignore their fears or disappointments as long as they have a healthy baby. While certainly a healthy baby is of paramount importance, we also believe that women's fears need to be validated. The emotional preparation for childbirth, as well as the emotional recovery after a difficult birth, can not simply be erased by the presence of a healthy baby. We also encourage you to speak with your obstetrician regarding the specific circumstances of your previous birth, as this may help you understand what to expect this time.

Sarah Buckley MD: I can't figure out why you are suggesting that less pain in labour means more joy. All the research, and many women's experiences (my own included) conclude that women who use no pain relief are the most satisfied afterwards. Using painkillers, especially epidurals, reduces our hormones of love, pleasure and excitement that Mother Nature provides to GIVE us joy. I am pleased that you have included non-drug pain relief, but please note that research also shows that women who have the highest expectations are the most likely to have a good experience of birth. Thank you.

Dear Dr. Buckley: Thank you for this interesting question. For most women, both today and throughout history, relief of pain does indeed allow for a more joyful experience. The relief of pain is one of the oldest and most basic of human desires. Since ancient times, women have sought out means to provide relief of pain during childbirth - we discuss some of these means in Easy Labor, Chapter 8, "Want to avoid painful suffering? So did they!" In fact, over the years, many women's groups have politically petitioned for access to pain relief for all during childbirth.

With regard to women being satisfied when they do not use pain-relieving medicines during labor, this statement needs some clarification. The real issue is what are a woman's pre-labor expectations? Among women who enter labor philosophically committed to a nonmedicated childbirth experience, and in fact are able to achieve this, then we quite agree - satisfaction is quite high. This is even acknowledged in the introduction to the book, where I state: "Over the years I have worked with women who have dealt with the pain of childbirth in almost every way possible, and the differences in choice and preference for pain relief is sometimes striking. I have seen women committed to giving birth using absolutely no medical pain relief, who endured hours of extraordinary pain during labor and delivery, and who described their birth experience as wonderful and rewarding. I have worked with women who have come into the labor and delivery room frightened and overwhelmed by their pain (and perhaps by the entire birth experience), who requested, demanded or pleaded for pain relief and were unable to feel a sense of control and satisfaction until their pain was completely eliminated. But, most often, I see women who arrive on the labor and delivery unit with a strong preference for pain control, who prefer safe and effective medical pain relief methods, combined with the successful use of non-medical pain management techniques." (Easy Labor, page XV).

To make a blanket statement that no pain relief during labor leads to higher satisfaction is to simply deny reality. Of the 4 million women per year who deliver in the USA, nearly 90% ask for some sort of medical pain relief, and roughly 65% ask for and receive epidural anesthesia. Your authors of Easy Labor are strong advocates of informed choice during labor. If someone wants a natural childbirth experience, we believe they should have all the means of support and encouragement necessary to help them successfully achieve this goal, and their choice for natural childbirth should not be ridiculed or mocked in any way. However, the converse is also true - for the majority of women who seek out and receive pain relief during labor, their choices should also be supported, appropriate pain relief should be available and offered, and their intense joy should be acknowledged.

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Dhara: I am going to have my first baby and my doctor says that I would have to be induced because I am diagnosed with gestational diabetes. I am currently on oral glucose lowering med so my doctor doesn't want to take any risks. He says that the labor would be induced about 38-39th week. My glucose is under control. My question is the doctor says that there are 25% chances that it could lead to c-section. Is there any way or anything I could do to avoid this C-section? I am really scared about this C-section thing; I wanted to do a natural childbirth and I wouldn't mind having an epidural. Can you make any suggestions?

Dear Dhara: Regarding the specific issue of a cesarean delivery, we would encourage you to pursue this with your obstetrician. Regarding an epidural, there is no reason why your diabetes would not allow you to have an epidural. In fact, as women with diabetes are indeed at slightly higher risk of needing a cesarean for a variety of reasons, an epidural would help allow this to be done with you awake, alert, and a full participant in the entire process. If a cesarean is necessary, the epidural would also be best for baby (compared to general anesthesia) for someone who has diabetes.

Lisa: Do you talk about the complications from an epidural? I have heard that it increases the rate of having a c-section. Also everyone that I know that had one had a very long labor that ended with complications due to the epidural. I would also like to know about narcotics; I have heard that they cause failure to thrive, a sleepy baby that won't eat or interact with mom. My childbirth class advised that if you are going to take meds just get the epidural because those drugs don't affect your baby. I just always thought it was strange to avoid medication for 9 months and then dope your baby up right before they are born. I have also heard that it can take up to 3 months for the drugs to get out of their system.

Dear Lisa - all excellent and very common questions! All the current medical research shows that epidurals during labor do not lead to an increased chance of a cesarean. Regarding narcotics, you are correct - narcotics used during labor can indeed result in a baby that is a bit less alert after delivery, and may not feed as well as one who has not been exposed to narcotics. Although the metabolism of a baby is a bit less developed than an adult, it does not take 3 months for a baby to clear these medications from their bodies. In general, it would depend on precisely how much medication one receives during labor, but most drugs should be fully cleared from a baby by several hours to at most one or two days after delivery.

Misty: I am currently pregnant with my third child and have had to travel to receive an epidural. Unfortunately my local hospital does not offer this type of pain management and the hospital staff are very much hard core into natural labor which is not for me. My question is how can I fight for women in my area to receive the pain management they would like and not get intimidated or saddened when the staff imply I'm not a real women for not going natural?

Dear Misty: I can't help you with the lack of availability of epidural anesthesia in your hospital. Perhaps you can speak to your obstetrician or an anesthesiologist on staff at the hospital to discuss this matter. Although uncommon, there are indeed some hospitals, typically in rural areas, where epidural pain relief is not available.

Regarding intimidation for not going "natural" - please remember that nearly 90% of the women who deliver their babies in the USA today ask for and receive some sort of medical pain relief, and nearly 65% of these receive an epidural - you are not alone!

Denise: I will be a first time mom this May and have no idea about what pain I will go through. I don't want to have an epidural but as far as narcotic injections, do they work almost as good as an epidural and could there be any harmful side effects?

Dear Denise: As a first time mom, it is impossible to know how much pain you will experience during labor. In fact, one of the important messages of Easy Labor is that keeping an open mind, and being prepared for the unexpected, is the healthiest way to approach childbirth. Narcotic pain relieving drugs are discussed in detail in Easy Labor, in chapter 5 entitled: Easing the Pain: "Medications to Relieve (but not eliminate) Your Pain."

While every woman has different experiences, the general consensus is that narcotic injections do not provide the same intense degree of pain relief as an epidural. Also, as noted in the previous answer to Lisa (above), narcotics, especially if given in large doses, can indeed make the baby a bit sleepy after delivery, and many moms do not like the feeling of drowsiness and nausea that sometimes accompanies narcotic use during labor.

Shannon: This is my first pregnancy and I am really nervous about the delivery. A couple of things really concern me: 1. I am DEATHLY afraid of needles to the point that I use a topical anesthetic before all needles. How intrusive and/or painful is the actual inserting of the epidural? 2. After the epidural has been given, how quickly does it work and how long does it last? 3. What degree of pain should I anticipate after receiving the epidural?

Dear Shannon: All epidurals are inserted using a local anesthetic in the skin before the needle is placed. We describe the entire process in detail in Easy Labor, Chapter 4, (p. 77) in a section entitled "Your epidural step-by-step: how it is done and how it feels." Once the initial injection of local anesthetic is made into the skin, the actual insertion of the epidural is generally not that uncomfortable. After the epidural is inserted, most women begin to feel comfortable within 10-20 minutes. A newer variety of the epidural, which is increasing in popularity, is the combined spinal-epidural (CSE). With a CSE, the onset of pain relief is usually within a minute or two. I use CSE very frequently in my own practice, but it is not available at all hospitals, so I encourage you to speak with your anesthesiologist when you are in labor to discuss specific options available at your hospital.

Seema: When, according to you, is the optimal timing to receive an epidural such that it does not prolong the second stage of labour and yet effectively control pain?

Answer: Seema, your concern about prolongation of the second stage of labor should not be part of the decision about when to get an epidural. The most recent, most scientifically rigorous studies, using modern-day type epidural medications, demonstrate that the second stage of labor, in women having their first baby, is prolonged by roughly 15-30 minutes. (There is likely even less of an effect, if an effect at all, in women having their second or more baby). So the best advice I can offer using the most recent up-to-date research data says that you should get your epidural when you are feeling ready for it, without regard to how early or how late in labor you may be.

Crystal: I had scoliosis as a kid. I've been told I'm not a good candidate for an epidural. If I need pain relief during labor, what other types of medications are options?

Answer: I'm going to assume from your question that you have not had surgery on your back, and that your scoliosis is mild. In that case, you are definitely a candidate for an epidural! You should try to speak with an anesthesiologist at the hospital where you plan to give birth, prior to labor, if possible, so they can examine your back and offer personal suggestions. In some cases, scoliosis may make it a bit more difficult to do an epidural, but in most cases it can still be done. Likewise, in some cases, the epidural may not work as well as in someone without scoliosis; for example the anesthesia may be more intense on one side or there may be certain spots that receive less pain relief, but this is unusual. In my personal experience, most patients with scoliosis do perfectly well with epidural pain relief.

On the other hand, if you have had surgery on your back, particularly if you had metal rods or other devices used to straighten the scoliosis curve, then, although an epidural is still possible, it is much less likely to be effective. In this case, you should definitely make an appointment to see an anesthesiologist, and if possible have with you any available x-rays of your back and, if available, a detailed report of the specific kind of surgery that you had.

If it turns out that an epidural cannot be done, then a wide variety of other pain relieving techniques can be used. Injections of narcotics can provide some pain relief, but can also make you (and your baby!) a bit sleepy and nauseous. Sometimes it is easier to do a spinal anesthetic than an epidural in patients who have had surgery on their back, so this may be an option as well; you just need to speak to your local anesthesiologist about these options. A variety of non-drug methods are also available. In Easy Labor, we discuss these options in Chapters five and six. Consider the use of soaking in a warm tub or shower, walking as much as possible during labor, using a doula, or even hypnotic techniques.

Good luck!

Grace: What are the real risks of having an epidural? I've heard stories of women that have had ongoing back issues afterwards as well as women where the epidural actually affected the top half of their body instead of the lower half. Are there any documented percentages of these sorts of issues?

Answer: Regarding the risks of an epidural - the most common occurrences are a slight drop in the woman's blood pressure (which can always be rapidly and safely corrected); a feeling of itchiness, which is a common side effect of the drug fentanyl which is added to many epidurals - it is NOT an allergic reaction; and the possibility of a headache a day or so after the delivery - this occurs roughly 1% of the time. In some women, particularly if this is the first labor and the length of labor is long, a small elevation in temperature may occur.

It is common to have back pain after childbirth. This is something that will be experienced by roughly half of women who give birth. All the recent studies indicate that back pain occurs just as frequently in women who have had epidurals as those who have not. While it is possible to have some tenderness for a day or a few days at the site where the epidural is inserted, long-term backache is quite clearly a frequent occurrence related to the act of childbirth itself, rather than as a result of the epidural.

Regarding an epidural affecting only certain portions of the body, this can happen, but it is not common. In fact, when using epidurals for labor, this is a very unusual side-effect, and can virtually always be fixed by adjusting the position of the epidural catheter or the dose of medications. On the other hand, when using an epidural (or a spinal) for a cesarean, the intended effect is to achieve anesthesia of the entire abdomen and up to the middle of the chest. In this case, sometimes a woman may feel some difficulty breathing due to numbness in the chest. In my experience, this happens roughly maybe 5-10% of the time during a cesarean. I can certainly understand that this is a distressing feeling, and can cause some degree of apprehension and anxiety. Rest assured that true breathing difficulties are exceedingly rare during a cesarean, and the anesthesiologist will be with you for the entire duration of the surgery monitoring your breathing and oxygen levels.

Vanessa: What is the best form of pain relief during labor? I am really concerned since I'm due soon.

Answer: What is best for pain relief during labor is the million dollar question! Seriously, this is an excellent question, but the fact is there is no one right answer. It all depends on your personal preferences, how much pain you are having at the time, whether this is your first or subsequent birth, and if the latter, how did your first experience go? Certainly the epidural will provide the most intense degree of pain relief, but the decision to use an epidural, or any form of pain relief, medical or otherwise, is a very personal choice - a choice made best by informing yourself of all the available options and entering labor with an open mind. In Easy Labor, we discuss all these options - from what we call "full-throttle" pain relief (epidurals and their various modifications) to other methods that can help decrease your pain, as well as a variety of non-drug methods that can help ease your pain or help you cope with the pain.

Chachi: I'm a plus-size woman, about 100 pounds overweight. I've had an uncomplicated healthy pregnancy so far and I'm due in 5 weeks. Is an epidural more complicated for an overweight woman? Are there more risks because of my size?

Answer: Yes, an epidural can be more difficult to insert in a plus-sized woman. This is because the anatomical landmarks, such as the bones of the spine, which are used to direct the placement of the epidural needle and catheter, may be more difficult to feel. However, once the epidural is inserted, there is no difference in the risk profile vs. a woman of more slender size. In fact, another way to look at this is that the risks of NOT having an epidural may increase in a large woman, The reason for this is that if an emergency cesarean is necessary, the lack of an epidural would likely require the use of general anesthesia. This requires placing a breathing tube into your lungs (while you are asleep) to assist with your breathing during the operation. The placement of the breathing tube may be more difficult in larger women, and difficulty in placing this breathing tube can indeed result in very serious consequences.

Rabia: I do not know what to do. I am in the eighth month and the idea of labour and delivery terrifies me, but I need pain relief. What can I do?

Answer: First of all, it's OK to be afraid! Many moms approach childbirth with a range of emotions ranging from fear, anxiety, uncertainty and just about everything and anything else one can imagine! In fact, this is such a common feeling, that we have devoted an entire chapter of Easy Labor (chapter 3) to "Your Very Normal, Very Common Fears of Childbirth".

We suggest that if your fears exceed what you would consider reasonable or normal for you, it may be useful to seek counseling from a professional. Prior to labor, I could suggest that you seek out the assistance of a professional doula. Doulas can be a great asset in situations such as yours, as they will work with you to help sort out your fears, address how to approach labor with confidence and assurance.

Rest assured that during labor you will be surrounded by professionals who deal with these emotions every day. Your nurse will be taking care of only you or at most one or two other patients, so she will have ample time to help you with your fears. During labor, your obstetrician or midwife, as well as an anesthesiologist, will be available to answer any of your questions and to help allay any fears you have. I can refer you to another StorkNet expert, who has several good suggestions and resources here: http://www.storknet.com/experts/obgyn/exag.htm

Courtney: I'm very interested in waterbirth and am thrilled to hear they have tubs available to labor and birth in at my hospital. My question is, do you know why laboring in water seems to help some women experience less pain?

Answer: Have you ever had a good strenuous athletic workout resulting in sore muscles? Doesn't it feel like a big relief to have a good warm soak in a tub? Labor is very similar, except the uterus is the sore muscle. Laboring while in water tends to relieve some of the crampy feeling of the contractions. In some women, the relaxation and calming effect of the water has a beneficial effect, allowing for rest, relaxation and distraction from the discomfort of the contractions. Although the exact mechanism is not fully understood, perhaps the buoyancy and feeling of flotation during water immersion allows for less painful contractions, as well as allowing for more easy and comfortable position changes.

Storey: I'm 34 weeks with my third. I wasn't scared of labor the first two times, but now I am. My first labor was 6 hours; 4 hours with the second. I had back labor both times. The first time I had an ITN shot and did great. The second time as soon as they finished giving me the shot, I had to push. The whole 4 hours of the second labor was horrible and felt so rushed that I couldn't focus. I've been told to forget the ITN because I won't have time. I don't know if I want an epidural if I have time for that anyway, and I don't know if I can stand another 4 hours of intense back labor. I've even considered asking to be induced so I could have some control over the situation. What should I do?

Answer: An ITN (also known as "intrathecal narcotic") can provide excellent pain relief, but only for a limited duration of time. It sounds like what you had was a single injection of the spinal drug, but no epidural catheter inserted. The problem with an ITN is that it is usually given in the very late phase of labor, in other words, very close to the pushing stage. It sounds like this is what happened with your second labor, thus you had to experience the pain of the labor until the ITN shot was given, and then you delivered very shortly after that. Second labors do tend to be faster than first ones, and you seem to have fast labors anyway. The injection was likely given a bit earlier in your first labor.

My advice for next time: Discuss this with your anesthesiologist as early in labor as possible, in fact, you could ask to see the anesthesiologist as soon as you are admitted to the Labor and Delivery unit, so there won't be a rush later on. Consider also asking for a combined spinal-epidural (CSE), if available at your hospital. The CSE combines the best of both worlds - the great pain relief from an intrathecal injection plus the presence of the epidural catheter to provide additional pain relief medication if needed.

Regarding an induction, this is something you should discuss with your obstetrician. Part of the decision will rest on what are the available resources for anesthesiology at your hospital. For a similar question on this topic, see: http://www.storknet.com/cubbies/childbirth/exdb27.htm

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Ray: How does the epidural work? Does it hurt as bad as contractions and how much of the needle do they put in your back?

Answer: The epidural is a type of nerve block - this means that an injection of a pain relieving medication is injected in the area (called the "epidural space") near the nerves that go to the lower half of the body. This involves placing a small thin plastic catheter in to this space, and the medications are injected through this catheter. The catheter is very small and remains in your back until the anesthetic is no longer needed. In Easy Labor, we discuss the mechanisms of how an epidural works. Briefly, the epidural relieves pain by blocking the nerves that carry pain sensations from your uterus and cervix to your brain. The medications given in the epidural prevent these pain messages from traveling through your spinal cord to your brain.

There is only minimal discomfort when inserting the epidural. A small area of the skin is numbed with an injection of local anesthesia before inserting the epidural catheter. This may feel like a small pinch or a mosquito bite. After the area of skin is numbed, the insertion of the epidural catheter should be relatively painless, although you can sometimes feel a little "zing", like hitting your funny bone, as the catheter goes in. This only lasts a few seconds, and then goes away. In most women, the epidural space is 4-8cm (2-3 inches) under the skin. In Easy Labor, chapter 4, we have an extensive discussion of "Your Epidural Step by Step: How it is Done and How it Feels".

Julie: I have delivered 2 children, one with an epidural and one without. I would really like to find a middle ground with this delivery--some effective pain relief without getting the epidural--and with both labors I found that it was the last hour or so before I entered transition, in which I needed help the most. Once I was in transition and knew I was progressing, I was able to handle the contractions again. Can you suggest some methods I could try this time?

Answer: Hi Julie, and congratulations on your third pregnancy! First of all, in general (but not always!) third labors are faster than first or second labors, but often just as intense with regard to pain. If you had any sort of pain relief methods in your non-epidural labor, then that would give you a good guideline of what your own body can tolerate. Small doses of narcotic injections are very common and very effective, and worth trying. If available at your hospital, a warm shower or bath is often very helpful to get through the middle stages of labor, before transition and pushing begins.

Regarding an epidural, you should try to arrange a discussion with an anesthesiologist at your particular hospital, either before labor if possible or when you arrive in labor. Perhaps a lower dose of epidural medication, or a technique called combined spinal-epidural (CSE) would be a good choice for you. These techniques are discussed in Easy Labor. In general, the trend among obstetric anesthesiologists in this country now is to use lower doses of medication in the epidurals. This allows good pain relief but you still retain the ability to move the legs, push, and in general be a more active participant in the entire process.

From Patti: How effective is hypnosis during labor? I've heard lots of good things but wonder how it really works.

Answer: Patti: In general these techniques are quite effective, assuming you have had good preparation prior to labor and are motivated to use these methods. Once you begin contracting is not the time to learn about hypnosis! Hypnotic techniques during labor require some advance preparation from a hypnosis instructor. Hypnosis during childbirth has become quite a popular technique in recent years, and many childbirth preparation courses offer separate classes or resources for those who are interested. In some cases, you can even hire a hypnosis coach to guide and assist you during the labor itself.

As with any of the wide variety of non-drug methods of pain relief, sometimes labor does not go as expected. Keeping an open mind and being aware that a variety of techniques in combination can help make for an ideal labor experience is a crucial perspective. In my personal experience as an anesthesiologist, I have encountered many patients who have tried hypnosis during childbirth. For some, it is very effective; for others, it has helped get through the early stages of labor, and then an epidural a bit later has helped with the remainder of the labor. One of the main messages of Easy Labor is that a combination of natural and medical techniques is wise and very appropriate and is often the approach that leads to the best outcomes.

For additional comments on hypnotic techniques during childbirth, see this excellent summary from an expert in this topic: http://www.storknet.com/cubbies/childbirth/hypnobirthing.htm

From Melanie: During my (failed) VBAC attempt, I was striving to avoid any pain meds or the epidural as I felt I should be totally "aware" of any signs of uterine rupture. Unfortunately, I was totally unprepared for the level of pain I experienced this time around. It was far worse than my Pitocin augmented labor with my first! To make a very long story short, I think the narcotics I was given played an enormous role in my unsuccessful VBAC, as I was then completely confined to the bed and was in no position to argue with the on-call OB who obviously just wanted to go home when he said (after only four hours of hard labor) that I would have to have a c-section for lack of progress. I don't know if I'll have another baby, but the fear of another c-section is part of that consideration. Is there particular pain advice you give to those attempting a vaginal birth after cesarean?

Answer: Melanie - excellent question and a very common concern! The typical signs of uterine rupture during labor are pain and changes in the fetal heart rate pattern. With regard to pain, the sensations experienced by someone who has had a uterine rupture include severe abdominal pain, often sensed all over the abdomen. The typical epidural anesthetic used during labor nowadays is a very light block, just enough to blunt the labor pain, but still allow some sensations and ability to feel mild aches or pressure with contractions. The pain of a uterine rupture will almost always still be able to be felt even if you have an epidural anesthetic during labor. In addition, a severe uterine rupture is most often accompanied by changes in the pattern of the baby's heart rate. As almost all patients attempting VBAC will have continuous fetal monitoring, these changes will be noted, even in the absence of any pain. So do not worry that the epidural will "mask" the signs or symptoms of uterine rupture.

From Jeana: I've always had problems with fainting when I'm nervous, haven't eaten well, and when I'm in a place where I feel uncomfortable and can't leave. When I get blood drawn I have to lay down. I was wondering what are the chances of when I'm in labor, I get so nervous or hurt so much that I pass out?

Answer: Jeana, your concerns are common and very real. Childbirth is an unknown experience for virtually all women, and a variety of fears and "nerves" are absolutely typical. One of the things that has always impressed me over my years of working in the labor and delivery unit is the kindness, dedication and professionalism of the nurses. While in labor, you will have a nurse dedicated to only you or at most one or two other patients. This is very different than on a typical hospital "ward" where a nurse may be caring for a dozen or more patients at the same time. The implications of this are that you will have very close and personal attention from your nurse. She will help you with all of your concerns. You will not be alone in this process! In addition, you may wish to consider hiring a doula. Professional doulas are of tremendous value in helping women with exactly the types of concerns you mention.

If you are considering an epidural during labor, it is important to mention these concerns to your anesthesiologist. An epidural can be inserted with you sitting up on the edge of the bed, or lying down on your side. The decision to use either position is generally determined by your own comfort and a discussion with the anesthesiologist. (In some cases, it may be easier, based on your anatomy, to use one or the other position, but discuss this with your anesthesiologist). Perhaps for an epidural, it would be better for you to have this done with you lying on your side, rather than sitting up.

Good luck!

From Diana: I heard soaking in hot/warm water just before labour eliminates a lot of pain for the mom...is that true?

Answer: Diana - Soaking in warm water indeed appears to be of great benefit. We interviewed many women for the preparation of Easy Labor who used water immersion, and most found it to be a big help. Depending on the resources of your hospital or birth center, warm water could be used in the form of a shower or a tub. It would be worthwhile for you find out what's available at your particular place of birth. Some birthing centers or hospitals allow you to bring in a self-rented tub - these are available from a variety of suppliers, but check first to be sure your place of birth allows this! Also, different places have different protocols; for example at some birth centers you can labor and actually deliver in the water, while at others you can labor but will need to get out to dry land for the actual delivery. Some women will find water-based techniques to be more or less effective than others, but virtually everyone we spoke to told us it was of some degree of benefit. Even among women who said the pain relief was only minimal, they did tell us that the warm soaking was helpful in achieving relaxation.

From Jennifer: I am getting ready to have my third baby. With 1 and 2, I was unable to have an epidural due to my platelets being low. With my first, the count was 45,000 and with the second, the count was 60,000 during labor/delivery. I was just curious to know, in general, what is the lowest platelet level that you would consider to be safe for a woman to have an epidural?

Answer: Dear Jennifer; this is a very common question, and unfortunately one for which there is no definite answer. In the past, almost all anesthesiologists used a platelet count of 100,000 as a lower limit for receiving epidurals; many anesthesiologists are now allowing epidurals in patients with slightly lower platelet counts. However, exactly how low is a matter of some discussion and personal preference among anesthesiologists. There is no "standard" or "guideline" or nationally agreed upon number for this. The 45,000-60,000 range is one where most anesthesiologists would still feel uncomfortable inserting an epidural. In addition, the reason why your platelet count is low, and any medications you may be taking, and any other associated symptoms (such as easy bruising, nosebleeds, etc) may influence the decision. My advice is to be sure both your obstetrician is aware, and also that you request to speak to an anesthesiologist at your hospital prior to arriving in labor so they are aware of your situation and can discuss options fully with you.

From Ashley: What alternatives to an epidural are the best for pain and keep me mobile?

In Easy Labor, we have several chapters devoted to non-epidural methods of pain relief. The list of options is long, and will also depend on what's available at your particular place of birth. However, some of the more common options include soaking in warm water (either in a tub or as a shower), changing positions, massage, hypnosis (requires some preparation prior to labor to be most effective), using a doula, or using narcotic injections, among others.

Also keep in mind that many of the modern-day epidurals allow you to retain a fair or even complete degree of mobility. While in most hospitals you won't be able to actually get up and walk, you will most likely still be able to move around in bed, change positions, sit up, and assist with pushing out the baby.

From Hedra: Hedra: Great! A book to reduce guilt and increase the range of tools a mom might have in her 'labor toolkit'! Just to preface - I'm an advocate of loading your labor toolbox with both natural/alternative and medical tools. I'm also an advocate of knowing when you might want to use one or the other (that is, benefits and risks, both!). I don't think a little pain is the worst thing in the world, but I know that traumatic levels of pain are a) individual, b) a real issue that can have repercussions long after the birth. I'm always looking for the balance point, between risk and benefit, comfort and safety, help now and implications for later.

I've had an extended labor with an epidural (no regrets), a Pitocin-augmented labor without medical pain management, and a high risk birth (twins) without pain meds but with many plans put in place for the various options depending on how labor proceeded. All vaginal births, and all learning experiences. So that's my basis, so you'll have an idea where I'm coming from.

Question - in the write-up, it sounds like your book is largely aimed at women who initially want a meds-free birth, and might avoid learning about medical approaches on the assumption that they won't need them. I've met a few women who started out thinking like that, but more of my peers are on the opposite side - they assume that natural is a bad idea (or is only for 'superwomen'), they don't think there are any risks from meds, and aren't interested in learning either more about the meds (to be able to choose wisely based on their labor), or adding any 'natural' tools (to bridge any gaps or reduce reliance on meds or help if there are other issues in labor). As a result, some of them have had some rather unpleasant experiences that affected their babies (fetal distress) and their first experience as moms (unable to interact with the baby for hours). I don't want to scare the moms on either side, but reality includes risks of interventions as well as challenges that may be more than one can handle without medical help, and understanding both the risks and benefits of every option helps, in my opinion, to navigate to the lowest-risk/highest-benefit zones more of the time. Does your book also cover how to avoid this kind of 'worst case' and guide women away from blindly assuming that medical help is a perfect default approach?

I don't regret my medical or non-medical pain management choices, either one, because I knew at least the major risks (if not all the implications of them), and could work with my providers to navigate an appropriate path based on what was going on in my labor, together with them. I *really* hope your book helps other moms get there, too - least risk, most benefit, and enough understanding at the outset to not end up looking back and saying 'I wish I'd known X', or feeling like a failure for choosing the most reasonable (but maybe not most hoped-for) option in a challenging situation.

Answer: Dear Hedra; thank you for this thoughtful and insightful question and your comments. One of the unique features of Easy Labor is a chapter entitled: "Don't Let This Happen To You!" For the preparation of this chapter, we interviewed a variety of birth professionals (midwives, obstetricians, doulas, nurses, anesthesiologists) and asked them to describe some stories indicating common mistakes they have seen people make with regard to their labor pain management plans. Many of these "mistakes" involved women who had unrealistic expectations or had entered labor with incorrect assumptions or particularly rigid plans for how they expected labor would be. Then, when hit with the reality of the situation, which was often not how it was "planned", these women were unprepared for the various pain relief options that may have actually made the experience much better for them. Whether you are leaning towards no medications or lots of medications or anything in between during labor, keeping an open mind, being aware of all the options, and being the most knowledgeable consumer is part of the message of Easy Labor.

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