epidural issue...

I had a client in 2008 who desired a natural birth but after several hours without any change in dilation, interventions were begun and she ended up with a cesarean birth. She was my only doula client who ended up with a primary cesarean last year. She had stayed at 8 cm for several hours and then received an epidural. The effects of the epidural dropped her blood pressure causing the baby to go into distress and her cesarean was immediate. I hate that it happened. I am not sure we could have done any more than we did. Perhaps if she had been able to relax more- given more time before getting the epidural... I don't know. But the thing that caused me the real problem with this birth was not the outcome per se.

This hospital, Emory Crawford Long, does not allow a laboring woman to have anyone stay with her if she chooses to get an epidural. NO ONE- as in not her husband or her doula or her friend or her mom... only medical staff. Why?

Let's hear from the nurses...on allnurses.com the forum had these comments:
"I have heard of a case where the husband was holding his wife during the procedure, fainted and hit his head and died!! (i believe this was a Kaiser case in california, dont know the exact details but this is the base of the story).The family then sued (GO FIGURE!) the hospital for negligence in using him as staff in supporting his wife during the procedure. As a CRNA, im very concerned about this as my new job allows the husband to hold the wife, and of course my last job did not!"
"If the laboring mom wishes to have her partner present during epidural placement, and he is able to be of comfort to her without getting in the way or compromising the sterile field, then I think that is fine. But to have him physically hold her is not safe, in my opinion."
"I think it's a shame we're unable to trust our patients anymore. We can't let dad hug mom or hold her hand because he might pass out and sue? If that's the case we better start banning dads from the delivery room altogether lest they pass out at the birth."
"They aren't doing anything to ensure proper positioning. They are there for emotional support. Even as the nurse "holding" the mom, I wasn't holding her to ensure she stayed in position. I was just supporting her. Me being there wasn't going to stop her from moving. She was the one who had to listen to us and respond when we said "Bend your back out like a cat", I couldn't make her do it. We also let dads hold moms' legs up when they were pushing. It doesn't require an RN license. "

I could not find an article regarding protocol for anesthesiologists. The articles are all membership only access articles. But several hospitals had protocols and it would state that it was up to the anesthesiologist at the time of placement as to who would be allowed to be support for the laboring mom.

So, is it they don't want to possibly have someone get in the sterile field? Hmmm then why are dads allowed in for a cesarean birth? Is it because if they make a mistake they don't want a witness? Is it because having a person there makes them nervous? Is it because they do not see any value to having a support person be with the mom? I do not do well by hearing, "it is our policy." What does that mean?

So... back to why this birth outcome made me upset. The anesthesiologist arrived and explained that it would take about 45 minutes to get the mom anesthetized with her epidural and we would not be allowed to stay during the placement. It was not my battle to fight- and the dad looked at me. I just shook my head and asked again why and was told it was policy of this particular anesthesiologist. Since we had been without a break for over 12 hours, the nurse suggested we step downstairs and get something to eat. So, we did.

We returned to the lock down unit and picked up the phone to be allowed back in after only 40 minutes. There seemed to be some hesitation on the part of the staff to allow us back in. But when they did I could see the client's room. The door was open and the cleaning staff was cleaning the room. I thought- oh no!

I asked where the mom was, although I kinda already knew. They said that after the epidural placement, there had been a reaction that caused the baby to "crash" so there had been an emergency cesarean. I asked had they thought to call the dad to alert him? They said they did not have his number and do not page overhead for such things. I was so upset. This mom had been wide awake- frightened- and alone during the surgical birth of her baby. The dad had not been included at all.

The dad was dressed in scrubs and led to the OR to meet up with his wife and baby. They were both doing good. Seems the mom's drop in blood pressure as a result of the epidural had caused the baby to have a sudden drop in blood pressure as well- therefore causing the "sudden crash."

What would I do differently? Well one thing is I tell all moms and dads that they can insist on a support person staying or ask for an anesthesiologist who does allow it to replace the one who will not. I suggest that if it is hospital protocol to write letters questioning the policy. I ask dads to stay close by- only as far as the waiting room at most. I suggest taking out a pen and writing the cell number of the dad really large on the sheet or white board for all to have access to.

The dad had been so relieved that everyone was okay that he stated he guessed that it was okay- healthy mom and healthy baby. I encouraged him to remember that it was also about her experience and he needed to acknowledge his disappointment of not being present with her during the birth as well as hear her disappointments before being dismissive of those feelings. I also encouraged him to write a letter to the administrator and anesthesiology department.

I still feel sad about this birth. Not that she had to have an epidural that caused the sudden emergency- because this mom and I both know she worked long and hard and was at the point where an epidural could have proven helpful... but because instead of birthing with her partner by her side, she experienced this alone with mostly strangers around her. This is not ever ideal.

epidural safety

Epidurals have become so common place that I think many folks feel they must have no risks at all. So, I thought I would write about some of the risks you need to consider. First let me give you a definition of an epidural from an anesthesiology website "Epidural anesthesia is most commonly placed in the low back (lumbar region). Unlike Spinal this technique may also be accomplished in the mid-back (thoracic region) for surgery in the area of the chest. After a sterile prep and draping, local anesthetic is placed in the skin numb the area where the Epidural need will be placed. The needle for Epidural passes between the vertebrae of the Spinal column to the Epidural space. Once the position is verified, a very small catheter(tube) is placed via the needle. The needle is then removed and the catheter remains in the Epidural space. The catheter is then taped to the patients back. Local anesthetics and narcotics given epidurally via this catheter. The procedure usually takes 10 - 25 minutes."

One great website with a fabulous article is http://www.healing-arts.org/mehl-madrona/mmepidural.htm

The doctor writing the article posts these concerns. A possible increase to having a cesarean birth, Hypotension- a drop in your blood pressure. Fetal Distress, Toxic issues, Trauma to blood vessels, Dura punctures causing spinal headaches, Infection, Backache, Pitocin being needed and causing abnormal contractions, Inability to push effectively, Mothers expecting great pain relief and not getting it, Medication getting into spinal area instead causing issues, heart attack and heart issues, Drug interactions, Fever, Respiratory issues, Nuerological issues, Fever, and more...

"Local anesthetics rapidly cross the placenta, and when used for epidural, caudal or pudendal anesthesia, can cause varying degrees of maternal, fetal and neonatal toxicity....

Adverse reactions in the parturient, fetus and neonate involve alternations of the central nervous system, peripheral vascular tone and cardiac function....

Neurologic effects following epidural or caudal anesthesia may include spinal block of varying magnitude (including high or total spinal block); hypotension secondary to spinal block; urinary retention; fecal and urinary incontinence; loss of perineal sensation and sexual function; persistent anesthesia, paresthesia, weakness, paralysis of the lower extremities and loss of sphincter control all of which may have slow, incomplete or no recovery; headache; backache; septic meningitis; meningismus; slowing of labor; increased incidence of forceps delivery; cranial nerve palsies due to traction on nerves from loss of cerebrospinal fluid. "

So, if you think this guys is off his rocker- let's list the issues that an anesthsiology abstract stated http://journals.lww.com/anesthesiology/pages/articleviewer.aspx?year=2006&issue=08000&article=00023&type=fulltext

"Of the 4 million annual births in the United States, 2.4 million involve epidural analgesia. Serious adverse events are rare but are important in young women. Robust estimates for the risk of harm are not available. Data for superficial and deep infections, hematoma, and transient and permanent neurologic injury were obtained from studies reporting adverse events with obstetric epidural analgesia, and incidence presented as individual risk for a woman, number of events per million women, and percentage incidence. A total of 1.37 million women received an epidural for childbirth, reported in 27 articles. Most information (85% of women) was in larger (> 10,000 women) studies published after 1990, with risk estimates as follows: epidural hematoma, 1 in 168,000; deep epidural infection, 1 in 145,000; persistent neurologic injury, 1 in 240,000; and transient neurologic injury, 1 in 6,700. Earlier and smaller studies produced significantly higher risk estimates for transient neurologic injury plus injury of unknown duration."

Another good website to share information from is http://www.americanpregnancy.org/labornbirth/epidural.html

"What are the Disadvantages of epidural anesthesia?

* Epidurals may cause your blood pressure to suddenly drop. For this reason your blood pressure will be routinely checked to make sure there is adequate blood flow to your baby. If this happens you may need to be treated with IV fluids, medications, and oxygen
* You may experience a severe headache caused by leakage of spinal fluid. Less than 1% of women experience this side effect from epidural use. If symptoms persist, a special procedure called a “blood patch”, an injection of your blood into the epidural space, can be done to relieve the headache
* After your epidural is placed, you will need to alternate from lying on one side to the other in bed and have continuous monitoring for changes in fetal heart rate. Lying in one position can sometimes cause labor to slow down or stop
* You may experience the following side effects: shivering, ringing of the ears, backache, soreness where the needle is inserted, nausea, or difficulty urinating
* You may find that your epidural makes pushing more difficult and additional interventions such as Pitocin, forceps, vacuum extraction or cesarean may become necessary
* For a few hours after birth the lower half of your body may feel numb which will require you to walk with assistance
* In rare instances, permanent nerve damage may result in the area where the catheter was inserted.
* Though research is somewhat ambiguous, most studies suggest some babies will have trouble "latching on" which can lead to breastfeeding difficulties. Other studies suggest that the baby may experience respiratory depression, fetal malpositioning; and an increase in fetal heart rate variability, which may increase the need for forceps, vacuum, cesarean deliveries and episiotomies."


So, although they are sometimes necessary- realize that there is risk involved. Now you may think this entry to my blog is one sided. The truth is we all know the reasons why folks want to get an epidural- pain relief. But the risks are so overlooked I thought it was worth reviewing the risks.

If you truly need an epidural in your labor, you will be able to be informed and know the risks. Sometimes doing the next best thing does include an epidural. It will sometimes keep you from having more interventions. But realize that although it is common place it is not without risks.

Fear & Fatigue

the Two Big Factors in Labor and Birth

As a labor doula there are two factors that I think make the most difference in labors. The first one is fear. Pam England says that the work of pregnancy is worry. We need to get all our fears out on the table and address them one by one. That way when labor begins, we have gotten the fear factor out of the way and we can labor. When a woman is holding onto some hidden fears she does not allow her body to unfold and birth. This truly inhibits the mind-body connection that is so essential for birth to flow more easily.

Some of the greatest fears are not unique to most women. There is a fear of loosing control. The concern about pooping when they are pushing out their baby. There is concern that their behavior will be such that they will be embarrassed by it later. There is the issue of trust for their provider and the location where they will birth. Will their partner be supportive enough? Will this experience enhance their relationship or hurt it? Will their body "fail" them- not opening properly or not being able to withstand the pain? Will they have to fight for what they want? Will they allow something to happen that they will later regret? These are just a few of the concerns most women share with me. The answers or solutions are as varied and individual as the concerns. I do know that these concerns need to be addressed long before labor begins so that these same concerns won't inhibit the natural process of labor.

You mind has a lot of control over your body. Sometimes we don't even know some fears are lying just under the surface of our conscious mind. Some people find the use of journaling to help then get in touch with what they are feeling. Some use birth art to help them discover what is going on inside their heart. When you feel something don't squish it down, open it up and let it out. It is essential for you to have your mind and heart open to your birth experience. You can't plan it but you need to allow it to happen without fear being a controlling factor.

I think one way of addressing fears is to begin to talk about them. You need to talk about them to your partner. You need to talk to your provider about them. If you feel like you are having to defend or fight now with your provider on some issues, then you may want to consider if this is a relationship that needs to change now. If you don't feel comfortable addressing your concerns with the person who will be your care provider in labor before your labor begins, perhaps you need to consider if you will be able to once labor makes you feel even more vunerable.

The other factor that I see play a huge role in the way labor happens is fatigue.It is essential in the last weeks before birth that you stay active and fit. But it is also essential that you rest when you are tired. Going to bed earlier than normal after a soothing bath is a good ritural to begin. If you are having problems sleeping talk to your care provider about some homeopathic or natural remedies that they can suggest. A warm bath with lavendar scents and a soothing massage will do the trick for many moms. But creating the ability to at least rest even if sleep is hard, is important.

When labor begins, if it is late in the evening, try to rest. Stay in bed if you can. Cuddle on the sofa in front of a good chick flick. Don't feel the need to go out for a power walk if you are tired. If it begins after you have had a good nights sleep, then go about your day, but don't over do it. Women who have lost a lot of sleep or try to work themselves into a good labor pattern find that they usually don't have the stamina for a long labor. Labor can be exhausting. Save your energy. Stay upright and active but only if you have rested. Listen to your body. If it says lie down and rest, then do it!

My suggestion to women in early labor is to rest and keep themselves well hydrated. Go about doing what you would naturally do at that hour. If it is 2 am- then crawl back in bed. You won't have a baby while you are sleeping. If it is 2 pm, go about doing what you need to do- but don't over do and rest when you need to. I believe if you listen to your heart and body and address your fears and take care to not over do in prelabor and early labor, two factors that can cause labor to not flow smoothly will be taken out of the equation!