9 Reasons I Chose Not to Get an Epidural

...including Side effects, Catheters, and Control Issues et cetera 

Here is the short version of my 9 reasons not to get an epidural for the birth of my first child:

1. The Urinary Catheter
2. What if it doesn't work?
3. Control Issues
4. For the Experience
5. We've come so far
6. The Natural High
7. Breastfeeding
8. Caesarean Section
9. Cascade of Interventions

Like many moms I thought: 'Will I be able to handle the pain? Why would a woman needlessly and willingly subject herself to the most excruciating torture ever experienced?' 

Good question!

At first the whole idea of an epidural sounds like a win-win-win situation, no pain, no pain and no pain! But no procedure is without risk. Learning about the risks of an epidural helped me make my decision to avoid an epidural as far as possible!

I've heard women say they'd rather give birth than pass kidney stones...

To start with, many women find the intensity of labour is actually not the worst pain in the world, despite what movies would have us believe. I've heard women say they'd rather give birth than pass kidney stones, for example. But every woman's experience is different, and I can only speak for myself and tell you why I decided to avoid an epidural as far as I could.

So, what follows were my reasons for not getting an epi, based on what I knew when I gave birth to my first daughter. There are others, but these were mine at the time:

1. The Urinary Catheter

...because when you're numb from the waist down, peeing by yourself poses a significant challenge.

Do you know how many women are unaware that an epidural is not just a needle in your spine and that's it? The moment you choose an epidural, you need an IV line, if you don't have one already, and you need a urinary catheter, because when you're numb from the waist down, peeing by yourself poses a significant challenge. Yeah, I know they usually only insert the catheter after you're numb, but just the thought of it makes me squirm.

On top of that you have to have a blood bressure cuff, and if you didn't have it already, and an electronic foetal monitoring device, and contraction monitor strapped onto your belly, or placed internally. I mean, are there any other orifices you'd like to invade? I may have one or two left that haven't been poked or prodded in the last couple of hours... So yes, we can have all the studies about side effects and neonatal and maternal morbidity in the world, but this was a biggie for me! So lets count those wires / tubes:

1. Epidural Catheter
2. Urinary Catheter
3. Blood Pressure Cuff
4. IV Line
5. Contraction Monitor
6. Baby's Heart Monitor 

The idea of 6 wires and tibes going into or stuck onto my body was a big part of my decision to exhaust any and all alternatives before resorting to an epidural!

An epidural catheter kit. (Link)
Those stripes on the needle are each 1cm wide.

Besides that, the idea of that big needle burying itself 4-6cm into my spine freaked me out more than the idea of pain did. (To be fair, the needle itself doesn't stay there, but still. For interest's sake, see how an epidural is done here - opens a new window.)

2. What if it doesn't work?

I didn't want to set my heart on an epidural and then have it not work sufficiently, which happens in about 5-20% of women.[1,2] Since I had my first baby a friend of mine had one that wore off as she was just reaching the peak of transition phase, and they generally won't top up the medication at that stage as it is much better for you to have sensation while pushing. She went smack bang into the most intense part of labour without warning and without any chance to stay on top of the pain psychologically or give her body a chance to build up its own endorphins naturally. Not fun!

As a doula I've had clients whose epidurals only took on one side - so they still had full sensation on one side without the option to move around to help relieve the discomfort.

3. Control Issues

Ok, so I am a control freak. Also, I'm a dancer, so my mobility is really important to me. I absolutely hate feeling restricted in my movements. If you were to watch me trying on clothes you'd think I was more than a little strange. I squat, touch my toes, do high kicks, swing my arms, and if I feel too restricted I don't buy the item.

I also dislike getting drunk and the whole idea of ingesting mind-altering substances irks me because I can't stand the thought that I won't be in control. Psychoanalyze me if you like, blame it on the fact that people used to hold me down and tickle me as a child, whatever, but don't give me an epidural! Actually, being a control freak was a major factor in my decision to have a home birth with #2!

4. For the Experience

In all honesty, I secretly wanted to know if I could handle the pain. Some people want to climb Everest, or run a marathon or some other strenuous yet satisfying experience just to have the satisfaction of achievement. So why go look for one, and have to pay for it, when I have a potentially life-altering event barrelling towards me?

My dad summiting Mount Kilimanjaro at age 60...
Maybe being a sucker for punishment runs in the family ;-)

You know what, it was hard work, but I can honestly say that I see the births of my three children - all without drugs, one at hospital and two at home - as three of my greatest experiences ever. They were by no means easy, but it was so completely worth it to be there, fully and wholly there, not sedated or nauseous or dizzy or disorientated as I could have been under the influence of drugs, but really and truly present! The sensation of a baby moving down the birth canal where you can actually feel your child squirming and working with you to be born - that is truly miraculous!

5. We've come so far

I could never understand why I would avoid caffeine, sushi, painkillers, swordfish, hair dye, blue cheese, alcohol and chicken liver pate for 9 months and then pump myself full of powerful drugs that do cross the placenta and have not been tested on babies, without being informed of the risks. It made no sense to me whatsoever, especially considering there are alternatives that don't carry the same risks or side effects. How can you make a choice, and take responsibility for that choice, if you aren't aware of the benefits and the risks of a procedure?

6. The Natural High

Yeah, the epidural can take away the pain, but they don't tell you that it can also take away the pleasure. Did you know in the natural course of labour you and your baby produce beta-endorphins in response to the discomfort experienced? Mom's endorphins cross the placenta as well, so baby gets an extra dose.

When mom experiences no pain as a result of anaesthesia or other drugs, the baby doesn't get those endorphins and it stands to reason that the baby then experiences birth as more traumatic than a baby receiving the full dose of endorphins. Also, as soon as the baby is born and you are no longer in pain, you experience the endorphin rush as euphoria.

The levels of oxytocin in a woman's body in the hour after an undisturbed birth are the highest they will ever be in her whole life. Yes, even higher than they could be after the best multiple extended super ginormous orgasm ever.

An epidural also disrupts the production of oxytocin, known as the love hormone, which is the same hormone that causes contractions, the hormone released in orgasm, and the hormone that is necessary for successful breastfeeding. The levels of oxytocin in a woman's body in the hour after an undisturbed birth are the highest they will ever be in her whole life. Yes, even higher than they could be after the best multiple extended super ginormous orgasm ever. Who would want to miss out on that? Not me!

7. Breastfeeding

Getting an epidural affects your central nervous system. Epidural drugs cross the placenta. Epidural drugs affect your baby's central nervous system. Sucking is a reflex action. A compromised central nervous system can result in a compromised sucking reflex. Compromised sucking reflex impacts breastfeeding success. Capiche?

I wanted to give myself the best chance possible.

Unfortunately, pethidine and other intravenous drugs have a similar effect, so no help there! I was so passionate about breastfeeding that even the thought that the epidural could possibly be related to a decrease in my chances of breastfeeding was enough to put me off completely. [3] I felt that having an AA cup to start with put me at a disadvantage so I wanted to give myself the best chance possible.

8. Caesarean section risk

I was desperate to avoid a caesarean. Epidurals are known to increase the chances of needing a caesarean because of something known as the cascade of interventions. When an epidural is given before active labour starts, the risk of needing a caesarean section more than doubles. [4]

9. Cascade of Interventions

An epidural often slows labour down, so you may need medication (usually Pitocin) to speed things up. Use of Pitocin is known to cause respiratory distress in babies, often causing the doctor to suggest a caesarean section. Even if you don't end up having a caesarean, getting an epidural increases your chances of the baby being in a bad position (because the muscles in the pelvic floor relax too much and you are on your back) and increases your chances of requiring forceps or a ventouse (vacuum) to get the baby out. It also increases your chances of needing an episiotomy, which, like me, you may want to avoid.

Having said all that, if you think I would never get an epidural, you are mistaken. There are times when the risks of getting an epidural are less that the risks of not getting an epidural. (See Use Your Brain for tips on assessing relative risk).

Our bodies produce catecholamines in response to discomfort, stress, bright light and noise. While a certain level is helpful toward the end of labour, when catecholamine levels are too high, labour can be inhibited. Sometimes an epidural can give mom a break so that catecholamine levels can drop and labour can continue.

So while there are other reasons not to get an epidural, these were the biggies for me. Before you get upset with me, I don't judge ladies who do choose to get an epidural, but I do believe that many of them go into it without knowing any of the risks or the alternatives, and then afterwards say they wish they had known. So now you know!

Now that you are considering not getting an epidural, I'm sure you'd like to know about some alternative methods of pain relief! I have a post on that in the pipeline so make sure you subscribe to the blog via email or like our Diary of a Durban Doula Facebook page so you don't miss it when it hits the press!

References:

This is not an exhaustive list - but include the most comprehensive / specific links I could find on each issue.
1. Agaram R, Douglas MJ, McTaggart RA, Gunka V. Inadequate pain relief with labor epidurals: a multivariate analysis of associated factors. International Journal of Obstetric Anesthesia, 2009, Vol 18,10-14.
2. Le Coq G, Ducot B, Benhamou D. Risk factors of inadequate pain relief during epidural analgesia for labor and delivery. Canadian Journal of Anaesthesia, 1998, Aug Vol 45(8),719-23.
3. Riordan J, Gross A, Angeron J, Krumwiede R, Melin J. The Effect of Labor Pain Relief Medication on Neonatal Suckling and Breastfeeding Duration. Journal of Human Lactation, 2000, Vol 16(1),7-12.
4. Klein MC. Does epidural analgesia increase the rate of cesarean section? Canadian Family Physician 2006 Vol 52,419-421.

Thoughts on supporting young or vulnerable mothers and mothers-to-be

Young, unmarried or otherwise unprepared woman gets pregnant, family has conniptions about 'irresponsible behaviour', family accepts the situation and steps in to help, family ends up taking over and mom lets them, confirming family's perception of mom as irresponsible.

I see variations of this story reasonably often in my line of work.

The young mom carries the stigma of 'irresponsible' pregnancy, very visibly for the term of her pregnancy; partner / sperm donor / rapist is usually unscathed by such societal strictures. Well meaning family steps in to save the day - which is all good and well, except that the help usually comes at a price, and that price is often compliance.

It is truly a challenge to be strong and make good choices when you have been labelled as 'irresponsible' and you feel like you have become everyone's problem, which is often how these young moms feel.

'How are you going to look after this child?' 

'What about your studies?'

'What were you thinking?' 

'I told you he wasn't good for you.'

Once everyone is done asking questions, completely overwhelming the young mom to be, breaking down every last shred of confidence she has, then the moment comes for her own mom and dad to step and and fix it all. As if her 'failure' becomes their 'failure' and they have to do their utmost to 'fix it.'

She hands over more and more power as she feels less and less capable.

I'm sure that the delight in being the rescuer, the rock, the provider, isn't a conscious thing, but I sometimes feel that sense of power that comes with being the rescuer ends up causing disempowering situations for the mom to be.

I've seen moms given absolutely no choice about the circumstances of the birth, not because of the actual costs of her choices, but purely because mom's choices didn't line up with the choices of the financier. Mother's options are not even a point of discussion, because the perception is that she has already proven herself incapable of making good decisions so decision-making needs to be taken out of her hands. To be honest, it's not only the young or otherwise unprepared moms who experience this. Moms who are experiencing domestic abuse or marital difficulties or financial strain get similar treatment.

Often these moms are left with little to no autonomy,  as implicit or explicit threats of withdrawal of finance and / or accommodation and / or acceptance are enough to keep her toeing the line. Her parents speak on her behalf, pay on her behalf and decide on her behalf. 

I have yet to see a grandmother-to-be present her daughter with options, encourage her to research those options for herself and find a solution that makes the best of the situation, with the resources at hand, and most importantly, accepts and supports those decisions even if they weren't necessarily the decisions she would make.

I understand that a young mom may choose options that add extra strain to a family, but I'm suggesting that those who are willing to help be honest about the degree of help they are willing to provide, be it financial or otherwise, and then allow the mom to decide how to use the resources that have been made available to her.

Stepping in and fixing everything often seems to end up paralysing the mom-to-be. She may be overwhelmed at the task ahead of her and steps back, confirming the prevailing perception of her as irresponsible and not up to the task of parenting. This then requires family to step in even more, creating a cycle of disempowerment and resentment.

Rather, family should give resources as they are willing and able, and thereafter empower and equip the young mom to make the best plan she can with those resources. She is, after all, about to be a parent, and that is, after all, what good parents do. They do the best they can with what they have.

And it's not just about the birth, often these young moms are kept in check or subdued for many years with the 'Remember how much you owe me because I saved you' line.

Which brings me to the party we haven't yet considered - the baby. That baby will be the one living with the consequences of the mother's choices, as a baby, and into its future as an adult. Surely a dynamic of rescue and disempowerment is not the example one would want to set, as I have seen where the grandmother continually criticised the mother's parenting in front of the child. How is that helpful for this little person who ends up cscond guessing their mother's every move? In one particular case the child became horribly confused and acted out in the most impossible ways, never sure who to listen to or who to be loyal to, and grandmother's perception of her own daughter as a lousy mom was confirmed, thus justifying her intervention in her own mind.

Rather than disempowering moms, let's remind them that as mothers they have the most powerful influence over that child's life, equaled only perhaps by the father's influence if he is around. Let's show them the power they have and support them in exercising that power to make the decisions that will carry them and their children into the future as responsible individuals, confident in the knowledge that they are equipped to deal with whatever life gives them.

Obviously this isn't the situation for every vulnerable mom, but I do see it quite often. Congratulations to all the families and grandparents who have made the effort to encourage and support vulnerable or single moms rather than 'rescuing' them!

Have you experienced something like this?
Share your thoughts below...

Just 'cos he looked at your cookie...

'Just 'cos he looked at your cookie doesn't mean he's the one!'

I wish I had actually said that out loud. 

A pregnant mom was telling me about how she was considering a midwife-assisted birth but was leaning towards staying with her gynae, even though she knew his shocking C-section stats, because, you know, he had done her pap smears for the last 7 years. 

What is it with us that we don't want to disappoint people? We don't want our gynaes to feel rejected? Is that it? Because really, I don't think it's mutual. 

That a woman will stick with a gynae she is unsure of, because he has poked around 'down there' a bit, because he wrote a script for some Clomid, because he did the job that she paid him to do, even though she knows his C-Section rate is over 80%, I can't understand.

Like every abused woman contemplating whether or not she should leave, she believes him when he says, 'Natural birth is Plan A,' (even though the numbers say otherwise) and she believes that this time it will be different. 'I'm not like those other girls,' she says. 

I love gynaes, I really do. I especially love it when they do what they are good at - and it's not a stretch of the imagination to think they also enjoy doing what they are good at. What they are good at is dealing with situations when something is not quite as it should be, where there is a problem, or an emergency, or a real risk. To be honest, they are not trained to deal with plain old physiology. It is unfair to expect them to recognise it.

Like the teller at the bank who can recognise a counterfeit because of years of experience with authentic bank notes, so a provider with experience in physiology can recognise a problem before it becomes a problem.

Everything looks like a nail...

If you want surgery, you hire a surgeon. 

Otherwise, find someone who understands the difference between dealing with disease or trauma and supporting a physiological function.

Everything looks like a nail if you have a hammer in your hand.

But this is not the point I want to make. Where should your loyalty lie? With your care provider? I'm not so sure. Like I said, I'm not convinced the feeling is always mutual. You are one of many. In short:

The axe forgets, the trees remembers.

Should it lie with your family, your community, society at large? Again, I'm not so sure. Will they have to deal with the fallout of any problems? Probably not as acutely as you would have to. As the parent/s, you alone are held accountable in the end. If you leave the decisions up to others without knowing the facts for yourself, you are not making a free choice, but you will have to deal with the consequences of that choice.

This may come as a shock to many, but primarily you need to be loyal to your baby, and yourself. You, plural, are the priority here. A doctor's busy schedule or fear of litigation, or your mother-in-law's fear issues, the friend who referred you to that doctor to start with, the fact that the gynae saw your vagina already so what the hell - these do not deserve your loyalty. 

What is best for you, the motherbaby unit? Are you being treated as an individual or a number? A person or a potential litigator? An rational being or an irritation? Are you a participant or a patient?

Do whatever it takes to find someone who will treat you as a person, an autonomous individual capable of making good decisions. Someone who will give you all the relevant information - the pros and cons of every procedure, who takes your concerns seriously and is not threatened when you volunteer information that may be contrary to the current suggestion. Are your fears treated flippantly and your desires with disdain?  It is never too late to change providers.

If you need a second opinion, get one. Don't stall for fear of offending.

Do what it takes to get the options and opportunities that you and your family deserve. 

Whatever you do, remember that just because he looked at your cookie, it doesn't mean he's the one!

(In case you thought I was totally anti-gynae, I have some thoughts to share in an upcoming post. In short, I sometimes think our gynaes and obstetric nurses are the most disempowered of all...)

But until then, How did you find your care provider for your birth? Were you happy? Would you rather have changed? What advice would you give to moms who are having doubts about the person they've chosen to assist in the birth of their baby? Let us know below...

Hindrances to Natural Birth #52 : Tickets

Image courtesy of Arvind Balaraman / FreeDigitalPhotos.net

I'm pretty sure that if I were to ask you about some of the top hindrances to natural birth, 'tickets' would not be high on your list. Pitocin, lithotomy position, hospitals, a medical model of care, our culture of fear around birth: these are all pretty obvious. But I believe some of the real hindrances to natural birth may be somewhat more banal.

Labour is a shifty thing sometimes. One of the hormones that keep labour going - oxytocin - is considered to be a 'shy' hormone. It is not easily released under pressure. It is the hormone most intricately involved in lovemaking and released during orgasm. It is also the hormone that causes 'let down' or a fast flow of milk when breastfeeding. In short, oxytocin is the hormone of love, labour and lactation. 

Couples struggling to get pregnant who have to do the 'baby dance' on a particular day or even at a particular time will often attest that being 'forced' to make love on schedule kind of kills the vibe. 

Let's take it a bit further. Imagine you are in the middle of lovemaking and someone knocks on the door, peeks around it, and switches on the main light, just to check how you're doing. Are you there yet? Shall we check to see how far you've got to go? It seems to be taking some time. If you're not done in x amount of time we may need to help you along. I'll be back shortly. As you were. Toodles! 

Vibe. Officially. Dead.

Now that sounds ridiculous when applied to lovemaking, but the same hormone, oxytocin, is what induces and keeps labour going. 

So imagine: you are at the end of your pregnancy and your mom has booked her ticket from across the country, or across the globe, for the day before your expiration due date. She only has three weeks off work. The pressure is on. The clock is ticking.   

The thing is, when a pregnant mom has a perceived time limit within the labour process, her body is far less likely to release sufficient oxytocin to keep labour going effectively. On a larger scale, when a mom feels under pressure to go into labour to begin with, it actually makes it much harder for her to do so. 

And so she starts looking at induction options. Inductions can be helpful when there is a genuine medical need for them, but often then lead to a cascade of interventions as illustrated below.

There is lots I could say about inductions that would give some evidence for the diagram above - but that is a whole other post on its own! Let's rather look at some solutions to avoiding inductions altogether. Firstly, let people know that 'estimated due dates' are just that, estimates - there is about a 4-6 week window of 'normal'. I've got another post in this series looking at the notion of due dates as a hindrance to natural birth. I'll link to it here once it's up.


I know you get better prices if you book tickets long before the time and I know grannies-to-be would love to be around at the when babies are born - but I would really encourage you to find a way to not have time pressure around the time of your birth, especially if you are aiming to have a natural or low intervention birth.

Do you have creative ideas on how to avoid time pressure around your labour day? Please share them with us!

The doula as a witness

I love that I learn from every single birth I have the privilege to attend. Each family and each birth requires different things from me - different words, different actions, different energies. Part of the skill in being a doula is knowing when to use which words, actions and energies. 

At times I stand by as a quiet presence, at other times I am in constant contact. Some moms prefer silence, while others want distraction. I rub feet, hands, hips, legs, backs and shoulders, I stroke hair,  I whisper encouragement, I turn down the lights, I turn up the heat, I fill the pool, I bring cool washcloths, I hold the space, I keep everyone fed and watered - doing my best to remove any hindrances to the birthing mother. 

I do all these things, but I feel they are all secondary to my role as a witness.   Of anyone involved in the birth process this one is almost unique to doulas. Partners are present but the birth is their own birth experience too. The midwife, the nurse, the doctor - they have their own responsibilities that often involve papers, numbers and tools - they have additional concerns that I don't have to carry. I am able to be there - truly present - with all my energy and attention focused on the birthing mom. I know midwives who choose to be fully present with the birthing mother, but these are rare.

And so I often get to see the things that others don't. I witness a birthing mother glowing serenely through yet another wave; the gentle interactions between a mom and her partner; the dad's face as he marvels at what he and his partner accomplished. I witness the mother's triumph as her dreams and expectations are clothed in flesh.

I am there for the disappointments too. I witness the moment when the gynae orders a second caesarean section after a long battle for a VBAC. I am there when her wishes are disregarded and her body violated with impunity by those with greater authority than me. 

In those moments something in the depth of me rages.  I don't dispute the medical justification for their actions, but too often there is little to no acknowledgement of her desires, her struggles, her strength, her autonomy, her personhood. 

Something in me rebels at the idea of being complicit in a system that routinely disregards evidence-based care in favour of convenience, that favours policy over personhood.

While this system rolls on, someone has to mop up the emotional fallout after institution has done its work. While there is little I can do on my own to improve the care women get while giving birth in our birthing institutions, I can bring empathy - the ability to sense, understand and share the feelings of another - because I was there.  

So to all my doula moms, thank you for the privilege of allowing me to witness your journey...

I was there when you believed you couldn't go any further but you did anyway. I was there when you felt your body would split itself apart but you kept it together. I was there when you found and accessed that primal power deep inside. I was there when you pushed past exhaustion. I was there when your hopes were shattered, when your deepest healing was won, when your darkest moments were met, and overcome. 

I saw what you did. 

Your triumph. Your power. Your vulnerability. Your pain. 

I saw it all.

And I want you to know: you are magnificent, you are fierce, you are breathtaking. 

I know because I was there, and I remember. 

Keep Calm and use your BRAIN!

This little acronym - BRAIN - is a powerful tool to increase your chances of getting evidence based care. So here goes - your care provider suggests a procedure, such as a stretch and sweep, or an induction, or even an internal exam at 38 weeks, or an episiotomy, or even a Cesarean birth - what do you do?

Sometimes medical decisions are based on outdated policy, financial or convenience factors rather than on what is best for mom and baby. Many parents are not sure how to question their care providers in a way that opens doors of communication rather than slamming them shut. The BRAIN acronym facilitates discussion in a non-threatening way.

What this really all boils down to is making sure that you are making informed choices and giving informed consent. This is a tricky field legally, and particularly in the area of labour and birth where there is a huge emotional component involved and families feel particularly vulnerable. 

Just remember, no one is allowed to do an internal exam or 'adjust' your cervix without your consent - if your care provider asks to do an internal exam and you give permission, and are informed afterwards that your cervix was manipulated or your membranes stripped - that is not informed consent and that is a violation of your patient autonomy. 

Furthermore, no one can inject you with anything or put anything in your drip, or cut into your flesh at any point without your informed consent - and if someone is busy doing something, an internal exam for example, and you say - STOP - you have withdrawn your consent and that person is required to stop what they are doing and withdraw their hand. 

You may be asked to sign a blanket consent when you are admitted to hospital (if you are birthing in hospital) - please read through it and discuss whatever you are concerned about. Perhaps you could get a copy before the time. It really is worth it! I have heard too many stories of women lying in bed for the duration of their labour because they believed that was just how it's done and didn't know they could request otherwise. Or women coerced into unnecessary inductions because of the doctor's leave schedule. For a first time mom, inducing labour drastically increases chances of having a Cesarean birth. If women truly knew the risks of the procedures they are apparently consenting to I think our phenomenally high Cesarean birth rate in our private hospitals would be a thing of the past.

There is much more I could say about this, but you get the idea. When in doubt, use your BRAIN!

Just so you know, I actually have a website dedicated to helping parents make informed choices along their birthing journey. Click here: http://www.giving-birth-naturally.net

When have you used the BRAIN acronym before? Please tell us!

Alternatively, was there a time you would have used the BRAIN acronym had you known about it? Tell us your story!