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Epidurals For Labor: Telling It Like It Is

11 Feb

A national survey of women who gave birth in U.S. hospitals in 2011-2012 reported that 6 out of 10 mothers had an epidural for pain relief in labor. An epidural is a very effective form of pain relief, but it can also lead to complications that eventually makes it necessary for the mother to have a cesarean.

At Spectrum Health Gerber Memorial in Fremont, Michigan expectant mothers are educated about the benefits and risks of using an epidural in labor and their informed choice is respected. Dr. Tami Michele, DO, FACOG, OB/GYN, Medical Director CassieEhard3746461480_ba31648524_zand Obstetrics and Gynecology Department Chair is a strong advocate of women’s informed choices. Mothers are educated about the benefits and risks of epidural anesthesia for labor and also given a Plan for Vaginal Birth form that includes many options for pain relief: massage; hypnosis techniques; use of whirlpool or  shower; use of a birth ball and freedom of movement and positions for birth.

This is the information that women are currently given if they are considering an epidural for pain relief.

 

Epidural Anesthesia

Expected Results

A temporary decrease or loss of feeling and or movement to lower part of the body, which may provide relief from pain during a prolonged or difficult labor. This type of anesthesia/analgesia does not alter the mental status as occurs with IV or injection pain medications. Occasionally the anesthesia does not completely take away the pain, or only provides numbness on one side.

Technique

Medication is injected through a needle, and a catheter is placed outside the spinal canal in the epidural space.

RISKS FOR MOTHER:

  1. HIGH SPINAL BLOCK: you could experience shortness of breath, respiratory depression or respiratory/cardiac arrest. You may need an emergency cesarean section and resuscitation.
  2. ADVERSE REACTION TO ANESTHETIC AGENT: May lead to respiratory paralysis, cardiac arrest, brain damage, heart attack, convulsions, stroke or death.

RISKS FOR BABY:

  1. Reduced blood supply to the placenta may cause fetal distress, brain damage, or death.

OTHER CONSIDERATIONS:

  1. Continuous electronic fetal monitoring will be used to check for signs of fetal stress.Epidural anesthesia/analgesia may cause slow, less effective labor contractions. Pitocin may have to be added to the IV to stimulate stronger contractions.
  2.  More epidural medicine may be needed to relieve the pain of stronger Pitocin induced contractions. Pitocin can cause more risk to the baby. Arrested labor may result in cesarean section, which is a major abdominal surgery and poses increased risk for the mother.
  3. If an epidural is given in early labor, it increases the chance that the baby is in the wrong position as it comes into the pelvis. This may increase the need for a cesarean delivery.
  4. Epidural anesthesia decreases the mother’s ability to push and increases the need for forceps, vacuum, or cesarean section. Forceps or vacuum assisted deliveries have a greater need for an episiotomy and deep tears into the perineal muscle. This can increase the pain and healing time after giving birth.
  5. Back strain or injury to the hips and knees may occur due to the inability to feel if the body is in an awkward position.
  6. The mother cannot respond naturally to labor cues, and may not feel as much control over the birth process.
  7. You will not be able to walk around, or use the tub, shower, or toilet.
  8. The epidural may cause the mother’s temperature to rise requiring additional tests for you and the baby to evaluate for possible infections.
  9. You may need a catheter inserted into your bladder if you are unable to urinate.
  10. You will be limited to a clear liquid diet only after an epidural because of increased surgical risk if a cesarean is needed.
  11. You will be monitored often for vital signs after an epidural, so a blood pressure cuff will be placed on your arm, a pulse oximeter will be placed on a finger, and you will receive intravenous fluids.

POSTPARTUM EFFECTS:

  1. Epidurals may cause severe headaches, migraines, temporary or permanent nerve damage, muscle weakness in legs, numbness or tingling sensation, and long term backache.

NEWBORN EFFECTS:

The epidural may decrease the newborn baby’s ability to nurse well for the first 12-72 hours.

_____ All forms of anesthesia or medications have some risk, and rare unexpected complications other than what is listed here may occur.

_____I understand that it is my choice to choose the type of pain relief method I feel is appropriate for my baby’s birth including an epidural, IV pain medications, or comfort measures as listed on my birth plan.

_____If I choose an epidural, I understand that every effort will be made to get an epidural administered in a timely manner. I understand an epidural may not be appropriate if the labor is advancing quickly and the procedure cannot be done safely.

_____If a cesarean delivery becomes necessary, the epidural may be adequate anesthesia for surgery but general anesthesia may be necessary if complete pain relief is not achieved.

_____I have had the opportunity to ask my OB physician or midwife questions regarding pain relief methods for labor and delivery.

____I understand this is NOT A CONSENT FORM FOR THE PROCEDURE OF THE EPIDURAL, but is confirmation that I have been educated on the effects of an epidural which may affect the obstetrical care I receive from my physician or midwife.   If I choose to have an epidural during my labor, the anesthesia provider who will be administering the epidural will also inform me of risks associated with the procedure.

Please initial the above statements, and sign below.

 

Patient Signature ____________________Date

OB Provider Signature________________ Date

Resources

To download a copy of the Epidural Anesthesia and Plan for Vaginal Birth Decision-Making Tools link to the American College of Nurse-Midwives’ BirthTOOLS.org website and click on Patient Education/Shared Decision Making

 

Take A Sneak Peak at The Mama Sherpas, a Documentary by Filmaker, Professor, and VBAC Mom

12 Dec

Brigid Maher, a tenured, associate professor of Film and Media Arts Division in the School of Communication at American University will soon be releasing a documentary about the health benefits and advantages of midwifery care for women with a prior cesarean.

The Mama Sherpas is a feature-length documentary film about women receiving their maternity care through midwife-doctor teams.  For two years Maher followed nurse midwives, the doctors they work with, and their patients to provide an investigative lens into how midwives work within the hospital system. The official TRAILER has just been released. Sherpaslogo

A Sherpa refers to a member of a Tibetan people living on the high southern slopes of the Himalayas in Eastern Nepal known for providing support for foreign trekkers and mountain climbers. Here, it is the midwives who are the sherpas or guides for the expectant mothers’ journey through pregnancy, labor and birth.

Evidence shows that collaborative care reduces interventions, lowers cesarean rates and improves health outcomes. Maher was inspired to make the film after her VBAC of a 9 pound 10 ounce daughter. She knew that the midwifery model of care she received made all the difference and wanted women with a prior cesarean to know about their options for care providers.

Why is this film important?

About one in three babies are born by C-section today, though the World HealthOrganization recommends that the best outcomes for mothers and babies are achieved when that rate remains below 15%.  Additionally, according to the Center for Disease Control, the U.S. has one of the highest infant mortality rates among industrialized countries.

How can these disturbing trends be reversed?

In recent years, the idea of a “collaborative care” practice where doctors and midwives manage women’s care together has begun to gain traction in the U.S.  So far, research has demonstrated that collaborative care models produce better outcomes for mother and baby, including fewer C-sections.

Maher and her team plan to release the film in the fall of 2015.  You can follow The Mama Sherpas on the film’s website where you can read several of the mothers’ birth stories and check Facebook and Twitter for updates on the film’s world premiere.

 

Resources

Find a Midwife

Citizens for Midwifery

Mothers Naturally

National Association of Certified Professional Midwives

Bringing Birth Back: A New Infographic for Parents on Lowering the Odds for a Cesarean

1 Oct

Bringing Birth Back: The Rise of Cesareans & the Movement to Safely Prevent Them is a review of the rise in U.S. cesarean rates, the risks of the surgical procedure and how parents can take advantage of the new practice guidelines to lower their odds for a medically unnecessary cesarean.

Mothers’ choices for how they want to give birth is theirs to make and should be respected. This easy-to-read format gives mothers information they may not have to help them make an informed decision on how they want to give birth. You can upload this helpful infographic from the nursing website.

Bringing Birth Back
Source: TopRNtoBSN.com/

If I Plan a VBAC, What Are the Odds that I’ll Have a Normal Birth?

7 Sep

There is research that tells us which women are more likely to have a VBAC than others, but we also know that having a normal birth depends greatly on a woman’s state of mind and how she is cared for during pregnancy, labor and birth.

Goer and Romano tell us that mothers and babies have healthier outcomes if their careproviders respect the natural (physiologic) process of labor. Introducing interventions only when medically necessary.

We know that mothers and babies have healthier outcomes when mothers are full participants in making decisions about how they want to give birth and when all careproviders work together to make sure that mothers and babies receive optimal care. The care that is best for them, not care that is beneficial or convenient for the careproviders or hospitals.

Simkin and Ancheta teach us that a woman’s psycho-emotional state can facilitate or complicate the progress of her labor. “ Labor is facilitated when a woman feels safe, respected, and cared for by the experts who are responsible for her clinical safety, when she can remain active and upright, and when her pain is adequately and safely managed.”

Here Is What ACOG Tells Us About the Odds of Having a VBAC

Women who labor after a cesarean have a 60−80% chance for a vaginal birth. A mother is more likely to have a vaginal birth if:

She had a prior vaginal birth before her cesarean

She has a healthy pregnancy weight

Her prior cesarean was for malpresentation (for example a breech)

She goes into labor at or near term

Her cervix has started to dilate or her bag of water had already spontaneously ruptured when she is admitted to the labor and delivery unit at the hospital

Her VBAC labor is not induced or augmented, and if

She does not have a medical complication such as preeclampsia

Other Significant Factors That Can Increase the Odds for a VBAC

Each labor and birth is unique but the way a woman is cared for can make birth easier, safer and more satisfying for mothers.

A mother is more likely to have a vaginal birth if she has freedom of movement for labor and birth. Pregnat Woman in Hosptail Using Exercise BallIf she is free to walk, change positions during labor and if she doesn’t give birth on her back. Many tried and true labor positions can help make labor easier and less painful. Hospital-based careproviders can safely monitor a VBAC labor by using a hand-held Doppler or ambulatory telemetry monitors to provide fetal monitoring so the mother can move about and benefit from comfort measures.

If a mother can avoid an epidural in early labor she is less likely to end up with a cesarean. An epidural can slow down labor and make it necessary to use Pitocin to get labor going again. It can interfere with the baby’s ability to move through the pelvis and rotate to an anterior position for birth (easiest way for the baby to be born). An epidural can lower a mother’s blood pressure to a dangerous level and affect the baby’s heart rate. We now know that with an epidural, a mother can take up to two additional hours to give birth.

With the help of labor support from a doula (continuous emotional and physical support during labor and birth), careproviders that practice evidence-based care, and maternity care nurses who are trained in a variety of non-drug options for pain relief mothers are much more likely to have a normal birth. Evidence shows that with a midwife women have more prenatal education and counseling time, fewer labor interventions, fewer complications of birth, fewer cesareans and more VBACs.

Mothers can have safer and healthier births if their caregivers support Mother-Friendly care. The Ten Steps of Mother-Friendly Care was developed by The Coalition for Improving Maternity Services (CIMS). It is evidence-based, collaborative care that supports optimal, physiologic care for mothers, babies, and families. Mother-Friendly care has been shown to improve the odds for a VBAC, reduce complications, and improve health outcomes and satisfaction among mothers and their families. Mother-friendly care is the safest and most satisfying for mothers and families.

CIMS has published a brochure for parents to help them find a mother-friendly caregiver. It’s called, Having a Baby? Ten Questions to Ask.

To Increase Your Odds for a VBAC Look for a Supportive Maternity Care Team

How do your caregivers view VBAC? With confidence or fear?

Are they giving you enough information to help you make decisions about your birth?

Are your careproviders taking the time to answer your questions? To discuss the benefits and risks of treatments, procedures,  and drugs?

What are their VBAC rates? Repeat cesarean rates? Routine intervention rates?

Are they treating you with respect?

Are they supportive of your wishes?

Do they make you feel safe?

Do they view labor and birth as a normal process?

Do they encourage doulas, family members or partners to help you when you give birth?

Are they offering you community resources that may be helpful to you?

What are your caregiver’s hesitations about VBAC? Can you discuss them so that you can labor with confidence?

If they are not comfortable with VBAC, are they giving you referrals to other providers, birth centers or hospitals that support VBAC?

If you don’t feel that your caregiver can give you full support to labor for a VBAC, are you willing to consider making a change?

Look for a Supportive Environment in which to Give Birth

žDo you have the space to walk? Sit? Kneel?

žDo you have furniture, pillows, a bed or rails to lean on?

žDo you have a squat bar, birth stool, rocking chair or birth ball?

žDo you have access to a bath or shower?

žDo you have access to light foods and drink?

žCan the light be dimmed? Can noise be eliminated?

žCan you listen to the music of your choice?

žDo you have privacy?

It may take much more time and effort than you anticipated to find the right caregiver and birth place to have your VBAC. But, it will probably be the most important work you would have done to help you have a safe and normal birth.

Resources

Pain Relief During Labour

Short Videos on Labor and Birth Positions,Birth Pool, Birth Ball

Preparing for Vaginal Birth: Pushing Past a Previous Cesarean,a webinar

Healthy Birth Your Way: Six Steps to a Safer Birth

Rebecca Dekker, Friedman’s Curve and Failure to Progress: A Leading Cause of Unplanned C-sections

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