Alternatives to Epidurals

Epidurals are popular, but they are not the only means of pain relief during labor. Here are other effective methods, sorted roughly by my own preference:

• Hire a doula! Doulas know many strategies for dealing with labor. They can massage arms and legs and backs and help with breathing, movement and positioning, and emotional support. Their presence reduces the need for additional help.
• Get in the water. My doula trainer said that for fussy children and laboring moms, water always helps. Baths, showers, anything that's available, is usually helpful. Labor pools are sometimes called "wet epidurals" because of the pain relief they can provide.
• Change positions. Sometimes women find a position during labor that feels better than others. While in labor almost anything feels better than laying flat on a bed! Some women prefer to squat or sway or be on all fours, or sit on a birth ball, or a rocking chair...

Apart from getting medication injected into one's spine, there are other pharmacological approaches. I hesitate to mention them, because to me their side effects are unacceptable.
Narcotics (such as Demerol, Sublimaze, Stadol, Nubain, meperidine, Narcan; also called opioids), given by injection to the mother during labor. They do not provide complete pain relief; many people say they take the edge off the pain. They are also relatively short-lived. A quick web search found these results from a study on the effects of narcotics on newborns: "opioids are associated with neonatal respiratory depression, decreased alertness, inhibition of sucking, lower neurobehavioral scores, and a delay in effective feeding." Mothers have also reported feeling groggy, delirious, or goofy, as a result of narcotics during labor. (Note: if, when you are in labor, you are offered a shot to 'take the edge off the pain', it is a narcotic.)

Paracervical block: an injection of Lidocaine directly into the cervix, to numb the cervix and adjoining tissues during the first stage of labor. Its effects are short, but it doesn't require the presence of an anesthesiologist. Its use is associated with infant bradycardia (slow heart rate).

Though I know many women prefer medical management of labor, I feel safer with psychological and emotional support.

The Psychology of Labor

Most of what I have written about labor involves the physiological progression and can be found in any book on pregnancy. I think it is important to know what is happening and what it might feel like to be in those phases. But there is more to labor than phases. What I'm going to write about here is mostly based on my experience, and I hope it will give insight and alleviate any fears and feelings of being overwhelmed that all the information of the previous entries may have caused.

The first thing I want to say is going to sound strange. I want to tell pregnant women to not be afraid of the pain. Women in labor are not being injured. The only thing that is happening - the only thing - is that the uterus is contracting to open up the cervix. This does not cause injury; barring malposition, the only pain felt is due to the hard work of the uterus, that it is working up to and sometimes past the point of muscle fatigue that we feel when we lift weights. It feels like menstrual cramps at first because it is the same mechanism: during menstruation, our uterus contracts to get rid of the blood-rich uterine lining, so much so that the muscle rapidly uses up a lot of oxygen, causing cramps. The same thing is happening during labor.

This is why it is so important to find ways to relax during contractions. If we can relax our bodies, we are not using up oxygen anywhere extra to maintain tense muscles, and we are also not fighting against the hard work our bodies are doing. When we tense up during a contraction, we are counteracting the uterine contraction, as if we are trying to stop it from happening, and this results in serious pain.

Let me use an example from my first labor. With the help of a doula, I was doing great, not feeling the need for anything else. I had a difficult time progressing from 4 to 7 centimeters. Around the end of this time, I was getting weary of dealing with contractions, of having to stay so focused, and I decided I didn't want to do it anymore. Unfortunately I made that decision in the middle of a contraction. I panicked and tensed up, fighting against the contraction. Suddenly the manageable amount of pain I was experiencing, increased by about 100 or more, and it instantly became more than I could handle. I learned my lesson and tried hard to stay relaxed during the rest of the labor; it went back to being well within what I could take.

From that I learned that relaxation is tied to how much pain we feel during labor. With the help of my doula and several family members, I had enough support that I never even considered asking for drugs. (I remember in the few minutes after my baby was born, I had the thought, I wonder if I'll need pain medication? It took me a moment to realize, Oh my goodness, I did it already!)

Do not be afraid of the pain. The pain is temporary, it comes and goes, and you just need to get from one contraction to the next. It is well within your ability to manage, especially if you have a support person who is dedicated to making you comfortable during labor. The bodies of laboring women are doing the work all by themselves, and all the women need to do is let it happen. If you get to the point where you don't feel like you want to do this anymore, try hard to regain your composure. If you're exhausted but your contractions are still going strong, try to let it keep going; if you're overworked, have had a long labor, have been restricted from eating and drinking for a long time, or your contractions are weakening instead of progressing, you may need something like an epidural just so you can get some rest. This is not failure; this is dealing with the labor as it has happened. Labor is not intended to be a path into the depths of hell, and I hope that women never experience it as this.

I was never sure I could have a drug-free natural birth, not until it happened. I was worried during the last parts of both of my pregnancies about needing medication, mostly because I didn't know what to expect. I didn't know how much I could handle, and I didn't know what labor would be like. It was different from how I imagined. It was a much more psychological, introspective experience. Hours flew by without me being aware of how much time had passed (my first labor was 20+ hours but felt like 3-4 hours to me).

In the fantastic book Birth Reborn, Dr. Michel Odent talks about the need for laboring women to be able to get in touch with their natural instincts, that they already know what to do during labor and birth. He says that birth is in the primal realm, not the cerebral, intellectual world we usually live in, and to get in touch with that part of ourselves, we should ideally be in an environment with little or no interruption, low light, a place where we feel comfortable being uninhibited.

I want to say two things about this. First, a word about our intellects. This part of our minds, makes lists and organizes calendars, plans and arranges, and works logically and rationally through decisions. This is not the part of our minds we want to listen to during labor. Here is one example of why: It might take us fourteen hours to dilate to a 7, and our minds will tell us that we cannot endure another (quick math: one centimeter every 2 hours, means 6 more hours of labor) 6 hours of labor before the baby is born! While that is mathematically reasonable, labor does not follow that pattern. After 6 or 7 centimeters, the woman enters transition, labor speeds up, and by 7 centimeters she might have less than one hour before she is holding her baby. It should be clear that if we listen to this voice, we will be misled, feel discouraged, and might make decisions we will regret. A better gauge is something like, How am I doing? Is this bearable right now?

The second thing I wanted to address is the need for the laboring woman to feel comfortable using her coping techniques. My favorite during my first labor was low moaning - the low tone keeps the body relaxed, while making noise helped me to feel like I was doing something other than just sitting there. I could moan as loudly as I needed to, so long as I kept the tone low. Sometimes I roared and yelled, lowly of course. I can't imagine what I would have done if I hadn't been allowed to make noise or if I had been worried about disturbing other people. I believe that women should feel free to do whatever it is that helps them during labor, whether that's walking around, being completely naked, on all fours, moaning, chanting, wiggling, making horse noises, or anything else. There are so many techniques that have helped laboring women, and while pregnant women might look into those things and be familiar with them, there is a chance that they will not know what the most effective one(s) will be until they are in labor.
To read about some of those, and for lots of knowledge and confidence in the power of women in childbirth, read Ina May's Guide to Childbirth by Ina May Gaskin. This is a great book, and essential reading for pregnant women.

More about Labor

The previous entry detailed the basics. There is, of course, so much more to say about labor and birth.

Back Labor

I have never experienced back labor, but I have heard plenty of times that it is excruciating. Back labor is most often caused by the baby being in the wrong position for birth. The normal position is head down with the baby turned towards the mother's back and the baby's back facing outwards towards the mother's abdomen. If the baby is reversed - that is, with the baby's spine facing the mother's spine - the bony part of the baby's skull presses down on the mother's tender nerves, causing pain that shouldn't be there. Sometimes this can be remedied with walking and rotating the hips, or swaying on a birth ball. The pain can be partly relieved by getting on all fours and taking the pressure of the baby's head off of the mother's nerves. Counter-pressure - having an assistant press hard on the lower back - usually helps. If the baby does not rotate to the favorable anterior position, the baby will be born "sunny side up", and this might extend the pushing phase.

Epidurals

Epidurals are an extremely common form of pain relief for labor. They are typically administered between 4 and 7 centimeters of dilation. The mixture of drugs used is unique to every woman, and epidurals must be given by an anesthesiologist. The process usually takes about 45 minutes to an hour and a half to complete. The epidural is given directly to the spine. The procedure is basically as follows: an area on the mother's lower back is cleansed and a thin catheter is threaded between two spinal vertebrae into the column of fluid surrounding the spinal cord. The anesthesiologist gives a test dose to ensure the placement is correct, then tapes the catheter cord to the mother's skin. The epidural mixture is either given in doses by the anesthesiologist as needed, or it is given in a drip that can be controlled by the mother.
I am not altogether opposed to epidurals. I think they are overused, and I am stunned to hear of women who want epidurals before they have ever felt a single contraction. It seems to me that these women would be better served in facing their fears of childbirth instead of beginning motherhood in a drugged-up state. I believe that epidurals ought to be administered when the mother is overtired and her exhaustion is affecting the progress of labor, or if she suffers from back labor. I wish they were not given as a matter of course, giving women the impression that they are unable to endure labor and need drugs to help them through it. For the women for whom this is true, they should be available, but I refuse to believe that this is the case for most pregnant women.

Effectiveness of Epidurals

For most people epidurals are a very effective way to obtain pain relief during labor. The epidural numbs the mother from the top of her uterus all the way down to her feet, and often the mother will feel pressure during contractions but no pain.

Potential Risks and Side Effects

Epidurals dramatically lower the mother's blood pressure, so an IV is given at the same time to counteract this effect. Because she is numb, the mother will no longer be able to walk or change positions unassisted. Epidurals tend to slow down the progression of labor, and so they are associated with an increased use of pitocin, an artificial oxytocin used to increase the rate and strength of contractions. Occasionally the mother will not be able to feel her pelvic muscles well enough to assist with pushing the baby out (another reason to practice those Kegels!), and forceps or a vacuum extractor will be required; at worst, she will need a cesarean.The rate of complications with epidurals is estimated to be 23%. Most complications are problems with administration and are not inherent to epidurals in general. Some are life-threatening, but those of course are extremely rare. In truth no medical procedure is free of risks.One of the common complications is punctured dura, meaning the spinal cord itself may be punctured during the administration of an epidural. Spinal headaches will result, which are extremely painful and can last for a very long time - I have heard of spinal headaches persisting for as long as a year after delivery.

Some medical practitioners tell women that the epidural does not pass to the baby and therefore cannot affect the baby, which is an outright lie. Epidurals given too close to the delivery of the baby tend to depress the baby's respiratory system, requiring some level of resuscitation. Having a drowsy, uninterested baby is not ideal during the crucial first hours after birth, when bonding between mother and child is so important and can be so beautiful.

Occasionally the epidural has no effect on the mother, which means she faces both the disappointment of not being able to obtain relief and the daunting task of having to deliver a baby naturally. I believe that it is in the mother's best interest to mentally prepare herself for a labor without pain medication, even if she plans to get an epidural, just in case the epidural has no effect on her. The judicious use of epidurals can make the difference between a mildly disappointing event during an otherwise joyous occasion, and a traumatic birth experience.

Labor!

On any pregnancy website you can find a list of the signs of impending labor: spotting, nesting, crampy regular contractions, bag of waters breaking, etc. First-time moms anticipate labor beginning hourly during their last weeks of pregnancy, thinking it could happen at any moment. This is an exciting time, especially since it is nearly a universal sentiment by this stage of pregnancy that the woman is ready to be done with being pregnant and move on to the next phase. And it could happen at any time, whenever the baby is done developing, that mysterious and unknowable timetable.

Most first-timers go beyond the 40 week mark. Some, like me, go way beyond it. Tests and ultrasounds can monitor the placenta and make sure it's still functioning, since one of the risks of being overdue is that the placenta will fail - it is, after all, only a temporary organ (amazing! the body grows this wondrous organ, only to dispose of it a few months later when it is no longer needed!). I haven't seen statistics on this occurrence, but with my first baby I was 18 days overdue. Everything was fine, and I chose not to be induced. When my baby was born, she was just fine, not huge, not peely and leathery like babies who have overstayed their time in the womb - just perfect. I think a lot of women, who are tired and feel huge and just want to meet their babies, go in for inductions before their babies are ready to be born... but more on inductions later.

The truth is that unless you are one of those very rare women who has a completely painless, unfeeling labor, you will know when labor starts. You will likely have been feeling contractions all through the third trimester, but there will probably be a distinct change in sensation when the real work begins. Labor carries an intensity with it, and a regularity, that is obvious to those who experience it. From that point, the issue becomes, how much longer will it last, and how much worse will it get?

I don't believe that most people can, even through relaxation techniques, experience a painless labor. I think that relaxation is important in helping the work to progress, and in making the pain manageable, but I believe the majority of women will still have pain during labor. So long as I was relaxed, every one of my labor contractions hurt less than, say, a stubbed toe. People endure stubbed toes without getting analgesics injected into their spines; so too can people endure labor, with the proper support and understanding of what's going on, without needing medical help.

The first phase, early labor, begins with the onset of regular contractions. This is usually the easiest part, as the contractions are far apart (a few minutes) and the woman can talk and interact even while experiencing contractions. She will probably be very excited, knowing that "this is it" - but that excitement can lead to one of the most common major missteps that first-time moms are especially vulnerable to: using too much energy during this phase, when labor is easiest! The mother-to-be might decide that this is the time to clean the baby's space or cook a big dinner or even focus too deeply on the contractions when she doesn't really need to - any one of these things can lead to exhaustion. Labor probably won't feel very difficult at this point, but it is crucial that the mother get plenty of rest and not burn herself out.

The contractions will continue to get stronger and closer together. The uterus is working hard, and the sensation of cramping might turn into something that feels more painful and harder to handle. This is because the uterus, the strongest (and at this point largest) muscle in the body is being exercised, contracting and releasing, for several hours. Any muscle that is worked this much will begin to feel sore, and the same pain one gets from using an arm or leg muscle to its limits is the same as what the woman experiences - only to a larger degree. She will experience the unusual and uncomfortable sensation of moving beyond that. The uterus has a long way to go. What is happening physically is that the uterine contractions are pulling the cervix open. The cervix needs to be dilated to about 10 centimeters, or approximately the width of a human hand (this of course varies, as does the actual measurement of full dilation for each woman). When the cervix has reached 4 centimeters, the woman has entered the next phase of labor, the second stage. Contractions are typically demanding all her attention now, and usually are about 3 minutes apart and last about one minute. What this means to the woman is that she is going between contractions and rest at a rather fast pace! One minute of contractions, two minutes of rest, one minute, two minutes...it will be more challenging to stay atop the contractions. Most women cannot help but remain focused on their labor at this point, and do not want to be distracted, which is essential to getting through it.The last phase of this part of labor is transition. If women are going to panic, this is often where it happens. Here labor tends to be the most dramatic and requires the most from the woman. The good news is that it is also the shortest phase, lasting less than an hour and often only about 15 or 20 minutes, maybe 10 to 20 contractions long. The uterus is finishing its work of dilating the cervix, and contractions are hardest and closest together. Women often become overwhelmed during transition - they may decide they can no longer handle labor, or they might insult their partners or caretakers, or become nauseous and shaky. (During my first labor, transition was quite easy - it was getting from 4 centimeters dilated to 7 cm that was the tough part!)Fortunately this phase typically ends peacefully, with a period of quiet, where contractions stop completely. Sheila Kitzinger calls this the "rest and be thankful phase". With the cervix completely dilated and effaced, the body is resting in preparation for pushing the baby out. The kinds of contractions the woman endured before have ended, and the work the uterus does now to birth the baby are of a different sort and usually not painful. This restful period can last several minutes before the second stage of labor begins.

Pushing

Now the hard work begins! Up to this point, labor was characterized by endurance alone, by just getting through it, and allowing the body to do its work by not interfering. But with the second stage of labor, the woman can finally actively participate in the birth of her baby. This is the pushing stage, where the cervix is dilated and the body is ready for the passage and delivery of the baby. Even though labor may have been exhausting up to this point, a welcome surge of energy comes, and women again get excited to meet their babies.How this stage is experienced depends greatly on the woman's caretakers and environment. Some hospitals coach women through pushing, telling them how and when to push. But it is becoming more acceptable to let women push spontaneously, when they feel the urge. Most women will experience a deep primal and irresistable need to bear down as the baby descends. The uterus is still contracting, and the baby will be born whether she actively pushes it out or not, but she will probably not be able to control her desire to push. The baby makes a two-steps-forward-one-step-back progression. This is a natural way of reducing damage, to stretch out the tissues of the birth canal. Left to descend on their own, the movement of the baby down and out often prevents much damage and results in a gentler birthing than constant pushing from the moment of dilation.The head of the baby is the largest part of its body. Once it has stretched the perineal tissues to their maximum (often called the "ring of fire" because of the burning sensation this produces - to get a small idea of what this is like, place a finger at each corner of your mouth and pull hard), and is born, it will no longer retract and the baby will be born within moments. The head turns - the body is maneuvering itself down the birth canal, down the path of least resistance - and the shoulders emerge, often followed very quickly by the rest of the body. For first-time mothers, the second stage can last several hours, but for subsequent births it may be only minutes.All the hard work of labor has accomplished the most amazing thing, the birth of a baby. This time is crucial for bonding with the baby, for beginning breastfeeding, and welcoming the little one into the world.

A Second Birth

However, the woman's body isn't yet finished with its work. The third stage of labor is the expulsion of the placenta and the continuing contracting of the uterus to its prepregnancy size. The detachment and birth of the placenta is painless, and some women often do not even realize it has happened.With the detachment and delivery of the placenta and the uterus returning to its original state, labor is finally at an end, and motherhood is just beginning.

Choosing a Prenatal Care Provider

The type of care the pregnant woman wants should be reflected in who she chooses to provide her care. Unfortunately, though, not all varieties of care are found in all areas. Most women in the US go to an obstetrician for the duration of their pregnancies, and the highest number of patients admitted to hospitals in this country are women about to have a baby.

When I was pregnant for the first time, I signed up with an OB just like everyone else I knew. I picked a female because I had heard so many other women say that they felt more comfortable with female doctors, especially in this situation. Women are more sympathetic because we're all on the same side, right? I'm sure that's true for many female MDs. I can't say whether it was true for mine or not because I barely saw her. Halfway into my pregnancy, after I had done some research and decided that I wanted to try to have a natural birth, I was also considering a home birth. I spoke to another woman who had brought up the issue of home birth with our shared OB, whose reply was, "What, do you want your baby to die?"

I never went back to that OB, because I found a perfect combination of support for natural birth and quick medical attention if necessary. In a suburb of my community was a small hospital which had the ideal arrangement. The prenatal clinic was run by midwives in conjunction with OBs, but the doctors only saw the high-risk pregnant women; all "normal" (low-risk) pregnancies were directed to the midwives. The hospital had a birthing center attached, run by the midwives, and was equipped with labor pools, a doula program, and comfortable, single-patient labor rooms and a separate postpartum wing. If anything went wrong, the doctors were around the corner, and an emergency surgery room was not far. The emphasis, though, was on non-interference with the natural rhythms of labor and birth. Both of my babies were born there, the second in a warm pool of water.

This is an extremely rare arrangement. I don't believe many places like this clinic and hospital exist throughout the country. Most women will have to choose between doctors and midwives, between hospitals and home birth (or a freestanding birth center). Most of the time, that decision is between two different worlds.

My experience with obstetricians was rough, and I found mine to be cold and clinical, emphasizing the pathological side of birth. She stressed interventions (she tried to convince me to get an amniocentesis for my first pregnancy, even though I was young and wouldn't terminate even if the results showed anything) and rooted my fears that somehow birth is unnatural and needs to be carefully watched and managed. I believe that there is a place for obstetricians, and it is not with normal birth. Not many OBs have ever even seen a normal birth. Midwives specialize in this area, and their personalized support and desire to educate spreads enthusiasm instead of fear. I understand that this is an oversimplification, because of the polarization of doctors and midwives. In my current community, if a woman wants a natural birth without interventions but not a home birth, her best option is to see the only local OB who is sympathetic to this point of view. One local doula says that if you don't want a c-section here, you need to arrive at the hospital while you're pushing.

My point in telling all of this is that the person a pregnant woman chooses to give her care, does matter, especially for first-time mothers. As a society we keep believing that doctors always have our best interests in mind and always know the best things to do, and women having their first babies have been taught to be scared and to doubt their ability to handle giving birth. In some cases doctors do have expertise, but I don't believe as a whole that doctors should have so much jurisdiction in the area of normal birth. Doctors are trained to interfere, not to stand by and let nature take its course. Doctors are impatient and have schedules and many patients. They give stimulating or inhibiting drugs so that labor follows a prescribed course, an action especially dangerous for first-time mothers, who usually need more time to give birth. If a woman's OB disagrees with her about what kind of birth she wants, she will probably not get what she wants. I have very rarely seen or heard of anything that contradicts these statements.

I wish all communities had both doctors and midwives, but at least doulas can be found in most areas now. Doulas are a step towards filling the void in personalized care, but the same rule applies to them as applies to both doctors and midwives: the most important thing is that the pregnant woman feels comfortable in their presence, secure in the knowledge that her care provider will give her the kind of care she desires and will support her in her reasonable decisions.

Still more to come!