Circus of the Epidurals

My husband and I are long-time fans of the British TV sitcom "Coupling," which ran for four seasons from 2000 to 2004. The fourth and final season followed one of the character's pregnancy and eventual delivery, and one episode, entitled "Circus of the Epidurals" discusses the character's desire for a natural childbirth, and her boyfriend's inability to understand why in the world she would want to forego drugs.

"There's pain, and there's pain relief," he says. "This is not a test anyone should fail!"

The episode is hilarious, and there's no question that it accurately reflects the basic tension between those who desire natural childbirth and those who can't understand why you'd want to "be a martyr" and refuse an epidural when it's right there and available to you. Why would you want to experience pain when you don't have to?

While I enjoy watching this and all of the other episodes of "Coupling," the amount of education I've had on this particular subject does make me want to throw things at the screen. First of all, the female character makes no effort to explain to any interested party why she wants a natural childbirth. (I'm avoiding names to try and limit the spoileriness, in case you decide to investigate the show - available streaming on Netflix!) The closest she comes is, "The pain of childbirth is part of being a woman," to which her boyfriend replies, "Yes! And it's the part we can fix!"

Now, since about the 1970s, there has been a movement toward "natural childbirth," as we well know. It became a trend to eschew any available methods of pain relief, including twilight sleep, Demerol, other narcotics, and epidural, in order to be fully present for the birth of your baby. Medical research has also demonstrated that the use of interventions such as epidurals may attach risks to the birth that otherwise would not exist. While, certainly, "Because I want to experience natural childbirth" is a perfectly valid reason for refusing pain relief, there are also scientifically sound arguments for avoiding or delaying interventions during birth and instead turning to "natural" methods of coping with the pain of labor and delivery.

The prevailing attitude of Western medicine is that our lives are substantially improved by removing pain and treating disease. And I have absolutely no argument with that stance in most cases. However, birth is not a disease, and the pain associated with childbirth is not necessarily an indication that something is wrong. Thus, while normally I'm all about feeling better, experiencing less pain, and reducing discomfort, the process of childbirth, when allowed to progress without intervention, without medication, without probes and monitors, and without interruption, has better outcomes than if we try to "treat" it.

I'm not saying we should never use pain relief, never do surgery, never use the available technology to assist in birth. No one is arguing that infant and maternal morbidity and mortality have not plummeted over the last century, largely due to improvements in medical technology and knowledge surrounding pregnancy and childbirth. However, there is still room for improvement, and mounting evidence suggests that likely over 90% of women will be able to give birth safely and successfully to healthy babies without any medical intervention at all. Allow her the space and time to labor, give her a clean and safe environment in which to birth her baby, have an experienced and well-trained birth attendant by her side, give her a supportive labor coach or two, and she will birth her baby in the most natural and ideal way possible, which will benefit her in her recovery and her baby in his development.

Studies have shown that the use of epidural, especially when in place for a long period of time (more than 10 hours), can interfere with a baby's ability to effectively breastfeed in the first day or two of life. Studies have shown that the use of epidural increases the "need" for Pitocin to augment labor, as the use of the epidural drugs and the fact that the woman is then required to remain on her back may slow labor contractions. Restricting a woman's movement during labor, forcing her to give birth lying on her back, and the use of sensation-dulling medications make it more difficult to push effectively and get the baby into an ideal birthing position. This increases the risk of c-section due to "failure to progress", "long labor", or "large baby." In addition, even if the baby is birthed vaginally, the risks of perineal tearing or episiotomy are increased, which may complicate the mother's recovery. The drugs in the baby's system may dull his sucking reflex and make him more lethargic, contributing to early breastfeeding difficulties. And, finally, the need to push IV fluids to maintain the mother's blood pressure when an epidural is administered may cause edema (swelling) in the mother's breasts within 12 to 24 hours of the birth, making it more difficult for her tiny new baby to latch and suck effectively at the breast, which can delay increased milk production and create a need for formula supplementation where none would otherwise have existed.

The point is, while many women desire a natural childbirth for non-medical reasons, many, many women have solid, evidenced-based reasons to eschew medical intervention and strive for a drug-free birth, for their safety and the health of their babies. Epidurals aren't going away, and many of the risks are manageable or can be mitigated by taking other steps such as allowing immediate skin-to-skin, encouraging rooming-in, and providing in-hospital breastfeeding support, but when women are made aware of these risks, they can make an educated decision as to how much risk they are willing to take on.

My personal desire to avoid the epidural is not a point of pride; it is not a hippier-than-thou exhibition; it is not out of an "I am woman; hear me roar" attitude. It is fear. Plain old fear that getting an epidural might cause a cascade of other interventions that would lead to an undesirable outcome for ME. It's important to note that what I find to be an undesirable outcome, other women may not. This is why women need to be informed, listened to, and included in the decisions made during their births.

So, thanks, "Coupling," for the laughs, but I'll stick to science, and not sitcoms, for birth education!

Writing a "Birth Plan"

At some point near the end of your pregnancy, you will likely come upon the term "birth plan" or "birth preferences." Typically, it's a good idea to spend some time thinking through your ideal birth scenario and how you might react to various unexpected complications or changes during your labor and birth. Knowing in advance what your preferences are regarding pain relief, birthing position, birth location, various other medical procedures, monitoring, breastfeeding plans, and surgical interventions is helpful for you, your partner, any other labor coach who might be present (a doula, another family member, a friend), and your care provider, as well as anyone else who might be in attendance (a hospital labor and delivery nurse, for example). Many women choose to have a written document prepared and handed out to anyone who is present during the labor and birth process, while others simply like to have in mind answers to some of the questions that might come up throughout the process.

I don't like to talk about a birth "plan" so much, because birth often does not go according to anyone's plan, even if it all goes smoothly and you are satisfied with the outcome. I believe it's important to have two ideas in mind: (1) What is your ideal birth scenario? and (2) What are your preferences regarding certain questions in the event that something doesn't go according to your ideal? Instead of calling it a birth plan, I like calling it birth "preferences," as in, this is what I'd like to see happen, and here's what I've thought about in case this happens instead.

These are the major areas you'll want to think about when coming up with your birth preferences:

• Where will you give birth? (hospital, home, birth center)
• Who will attend the birth? (care provider, partner, nurse(s), doula, friend, relative)
• How will you give birth? (vaginal or surgical)
• What kind of pain relief do you expect to use? (epidural, narcotics, breathing techniques, birthing classes, birthing methods)
• How do you feel about the use of certain routine interventions? (fetal monitoring, IV, Pitocin, antibiotics, vacuum, forceps, episiotomy)
• Do you want the option to be mobile? (walking around, birthing ball, shower/bath, changing positions)
• What do you want to happen as soon as the baby is delivered? (immediate skin-to-skin, immediate breastfeeding, use of Pitcoin to deliver placenta/contract uterus, who will cut the cord, timing of cord cutting (delayed, immediate), preservation of placenta (for encapsulation or burying, for example), baby bath, vitamin K injection, protective antibiotics for newborn's eyes, weighing and measuring)
• Do you want to breastfeed? (immediate (within first hour) latch-on, rooming-in versus nursery, skin-to-skin)

Once you've figured out some of the basic direction you'd like to go, be sure to run these preferences by your care provider to make sure these desires are compatible with his/her policies, hospital policies (if applicable), and are realistic in your specific case.

You'll also want to come up with alternative preferences. For example, your desire may be for a spontaneous, vaginal birth without any medical intervention, but what if a complication arises during labor, such as fetal heart decelerations, maternal blood pressure spikes, or infection? You'll need to know what might happen and have a plan in place in case a surgical birth is warranted, for example. You don't have to write up a separate plan for every potential complication or question, but you should have a general idea of a what-if scenario.

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As an example of what you might want to think about, here are my birth preferences for my upcoming birth. You don't need to follow a specific chart or guideline or layout; you don't have to have an answer for every question. This is not a legal or official document. Simply talking with your care provider may be enough, or you may feel the need to put it all in writing, for yourself and for the others in attendance.

Location of Birth: [Local] Hospital.

Who will attend? My primary OB (if available), or other on-call doctor from the same practice; my husband; L&D nurse

Mode of birth: Vaginal birth (3rd VBAC)

Pain relief and other interventions: I prefer to avoid the use of any Pitocin during labor, as I have reacted poorly to it in the past (PP hemorrhage). I intend to avoid the use of any pain medications, including epidural or naroctics. I prefer to have an IV of saline placed for hydration and in case there is a need for additional IV meds (i.e., to prevent postpartum hemorrhage, of which I do have a history). I prefer to have assistance with breathing and relaxation techniques. I prefer not to be coached during pushing but to follow my body's cues. I prefer to use intermittent fetal monitoring if possible, and telemetry monitoring (wireless fetal monitoring) if available. I would like my waters to rupture spontaneously; I decline to have the amniotic sac artificially ruptured.

Mobility, pushing position: I would like the option to move around during labor, including walking, standing, sitting, squatting, depending on how I feel. I would like the option to use the shower. I would like to push in a "non-traditional" position, probably squatting, to open my pelvis, as my babies tend to have large heads. I prefer to avoid an episiotomy; if the care provider believes an episiotomy will be necessary, I prefer to be consulted first.

Upon delivery: I desire immediate skin-to-skin; please do not remove my baby from my person for any procedures, including weighing and measuring, until after the first breastfeeding has been accomplished. Please wipe him off with a towel but do not bathe, dress, or swaddle him (except a diaper) before he is put to my chest. All procedures, including Apgar scoring, vitamin K injection, etc., should be performed while I hold him. I prefer to delay cutting the umbilical cord. The doctor may cut the cord, unless my husband elects to. We have no plans to save the cord blood. If the doctor believes Pitocin is necessary after delivery for my safety and to prevent hemorrhage, I am open to this. Please use a local anesthetic when stitching up any tears or episiotomy. I do not wish to see or save the placenta; please dispose of it as usual.

Additional preferences: I decline to have the hepatitis B vaccination administered in the hospital. I decline to have him circumcised in the hospital. I insist on rooming-in to facilitate bonding and breastfeeding. I insist on delaying his bath until at least 12, preferably 24 hours of life.

Basically, my goal is a spontaneous, vaginal birth with little to no intervention. Because of my personal history of both pregnancy-induced hypertension and postpartum hemorrhage, I am aware that certain procedures or interventions may be desirable or necessary for my own safety. One of the decisions my husband and I have made in this regard is that I will always give birth in a hospital. Another is to allow an IV to be placed, as well as the use of Pitocin after delivery to help my uterus clamp down and slow the bleeding, if necessary. I am also aware (having given birth three times already) of both my capabilities and my limitations.

I have thought about possible complications. For most of these, I believe I and my husband are educated enough to make well-informed decisions if a situation should arise that is contrary to my stated preferences.

Surgical birth preferences: The most obvious less-preferable scenario would be a need for a cesarean section, either due to the baby's position or an emergency situation for me or the baby. The biggest concern if an emergency c-section is needed is that because I will most likely refuse an epidural in labor, a true emergency would require general anesthesia. If, however, it is possible to take the time to administer a spinal block, I would, of course, prefer to remain conscious during the surgery. I would then request immediate skin-to-skin and breastfeeding upon delivery of the baby, assuming baby is otherwise healthy once delivered. The rest of the surgery can be performed with the baby on my chest. I would want my husband in the OR with me.

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Did you write up birth preferences? How closely did your actual labor and delivery follow the "plan" you had in mind? Did you change your mind during labor about any of these preferences? Did you have a plan for any alternative scenarios? How open was your care provider to your birth preferences?