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 2nd and 3rd 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 2nd and 3rd 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 threated 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 fiancé 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 inEasy 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.
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 8th 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 3rd. 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
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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Easy Labor, Every Woman's Guide to Choosing Less Pain and More Joy During Childbirth
WILLIAM 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. 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.