Epidural birth and doula support

An unfortunate reality is when women in labor choose to have epidural anesthesia administered, they are usually abandoned by their birth partners.  Erroneously, birth partners think: Why stick around?  There is no more pain, and hence, nothing for a support person to do.

This could not be farther from the truth.

What follows is my account of supporting a couple through a normal, vaginal birth, with epidural anesthesia.

Meeting

I met Lucy at a breastfeeding support meeting through La Leche League International.  I go to these monthly meetings to, well, support my habit, and to offer support to mothers with children younger than mine.  Lucy was one of the two pregnant women that came to learn more about breastfeeding in preparation for their births.  After the session, I approached her; we met that weekend with her husband, Mike, and seemed to get along well.  Lucy and Mike desired a normal birth but with pain relief, hoping to delay it as much as possible, but keeping in mind that Lucy was not interested in experiencing a lot of discomfort.  Over the next weeks, Lucy and I talked by e-mail, and when Mike was out of town, I went with her to her prenatal class at the nearby hospital.

Then, there was an interesting shift in how Lucy and Mike felt about the upcoming birth.  After taking the childbirth class, Lucy said that they really did a 180: they would really like to try natural childbirth, without the use of pain medications and instead using natural comfort measures.  I glanced at Mike.

"And how do you feel about this?" I asked him.

"Well, whatever Lucy wants," Mike shrugged.

I asked Lucy, "What do you think I should do or tell you when, at some point in labor, you happen to request drugs?"

She thought a moment.  "Remind me of the baby," she said.  "Tell me about the cute clothes we have lined up for him.  Tell me about the baby."

"OK, so, distract you.  If you call out for pain medications, I should take it as a sign that you want more support."

"Yes," she said.

Stripped membranes and early labor

On the first day of her 39th week of gestation, Lucy went to her doctor for her regular prenatal check-up.   A week before, we met again at the LLL meeting; the other woman that had been pregnant two months ago was there with her six-week-old infant, but Lucy was still very pregnant.  The topic turned to birth stories, and to how my doctor had stripped my membranes at my 38-week appointment, triggering my labor.  Stripping (sometimes called sweeping) the membranes is done during a vaginal exam, when the doctor inserts one or two fingers into the uterus and lifts the amniotic sac from the cervix.  I was resentful for having my membranes stripped because my doctor neither warned me nor asked my permission to do the procedure.  Nevertheless, the topic of triggering labor was hot on Lucy's mind at this appointment, and she asked her doctor for advice.

"Would you like me to try stripping your membranes while I examine you?" he asked Lucy, washing his hands.

"Will it hurt?" she asked.

"No more than a vaginal exam," he said.  "But there's only about a 50% chance that it will work.  If it does, it will probably trigger labor in one to three days."

Lucy agreed to try it, and, six hours later, at 6pm, called me in labor.

"These contractions are so different than the Braxton-Hicks I was feeling earlier," she explained when I asked what the contractions feel like.  "The best way to describe the difference is that these hurt.  I thought they weren't supposed to hurt until much later."

Knowing that early labor for first-time moms can last several hours, I told her to eat, drink water after every contraction, and rest.  Take a shower, use a heat pack on her back if it is sore.  Over the phone, I described how to toast rice in the oven and place it in a sock.  I told her to call back whenever she wanted me to come.

A mere two hours later, Mike called back.

"We want to go to the hospital," he said.  I could hear Lucy moaning in the background: low, beautiful birth sounds.

"Can you wait until I come meet you at your house?" I said.  "Get Lucy in the shower.  Have her take a bath.  I will put my kid to bed, get my stuff together, and come right over."

The biggest hurdle for all three of us --- Mike, Lucy, and me --- was the long drive ahead.  Not wanting to switch obstetricians after moving, we were affiliated with a hospital 50 minutes away by vigorous driving.  We had talked previously about what it would be like to labor in the car, and, for a while, Mike and Lucy had a plan of renting a hotel room during early labor.  The long, unpleasant car trip to the hospital was the determining factor in Lucy and Mike's haste in getting on the road.  If the contractions were barely manageable now, what would they be like in the car, and what would they be like an hour later?

Twenty minutes had gone by; my son was nursing happily and humming in bed when the phone rang again.  Lucy's bellow was heard in the background when Mike talked.  The contractions were three minutes apart; Mike and Lucy were leaving.

"I'm on my way," I said.  Hanging up the phone, I unceremoniously decoupled myself from my son, who started crying.  "Sorry," I said, "mama has to go to work."  I picked up my bag, grabbed the car key, and was off.

Hospital admittance and the nurse from hell

On the way to the hospital, I had a lot of time to worry.  What if labor was progressing very fast, and I was wrong to be so dismissive of Lucy's early labor?  Judging by the contractions and their intensity, Lucy was likely entering active labor, and I was not there for her.  I was already failing her as a doula, and I was not even there yet!

When I arrived, Lucy had changed into the hospital gown.  She was pacing around her room, stopping for contractions to hug Mike.  Rather than bending forward at the waist during contractions, she bent backwards, closing her eyes, and moaning.  Nurse Gwen was coming in and out, gruffly collecting intake information on the patient.  She did not stop for contractions nor offer any sympathy to Lucy's discomfort.

"What is the due date?" she asked.

"Uhhhhnnnnngggg," Lucy replied softly.  Mike answered the nurse.

Several contractions went by in this way: Nurse Gwen asked a question, Lucy tried to focus, Mike answered.  Finally, Nurse Gwen left for a few minutes.

"How was your ride over?" I asked.

"Terrible," Lucy replied.  "I was screaming the whole way."

"Windows up or down?"

"Down," Lucy replied, and went to the toilet.

When Nurse Gwen came back, she tried to start an IV, but somehow missed the vein.  I watched as she hastily, with trembling fingers, maneuvered the flexible needle under the skin, hoping to accidentally poke it and correct the mistake.  She apologized, removed the needle, and tried again on the opposite arm --- again missing.  She tried for a third time and missed again.  Frustrated, she offered a cervical exam, checking Lucy by having her lie down on the bed and lowering the back support all the way.  Luckily, the nurse was fast, because Lucy was in greatest discomfort in this position.  The reading came back: 3cm.  Early labor, with a long time to go.

"How many more contractions are left before the baby is born?" Lucy asked Nurse Gwen.

"About 314," I said, grinning.  "I counted."

Nurse Gwen shot me an annoyed glance, correcting me.  "It is impossible to know.  It is different for every woman, and every birth.  Just get through them one at a time."

The next time Lucy went to the toilet, Mike asked: "So, what is wrong with getting a little help?" --- meaning drugs.

"Nothing," I replied, "but it is not on your birth plan.  We agreed to try to labor naturally."

A few contractions passed well: Lucy's hips swayed from side to side as she hung on to Mike's shoulders.  She moaned.  She made all the right rhythmic movements and all the right low tones.  But she complained of pain.  My positive comments about how great she is doing and how wonderful she sounded and how her swaying is perfect --- they were not enough.

Nurse Gwen strutted back into the room and announced, during a contraction: "We need to get 20 minutes of tape on the monitor."  She had Lucy get back in the bed and applied the external fetal monitor and the contraction monitor paddles to her stomach.  Then she finally started an IV, in the vein between the thumb and forearm of Lucy's dominant hand, preventing any range of motion with it.

"Do you have wireless monitors, so we can keep walking around?" I asked.  The answer: No.

In bed, there was one contraction that Lucy handled particularly well.  Her head bobbed from side to side as she breathed.  But once she was able (and instructed) to get up again, to put on shoes and a robe and walk, she faltered.

"I need an epidural," she said during a contraction, and repeated after it subsided.  Over the next two contractions we argued about it --- rather, she insisted, providing compelling arguments, talked about suffering, repeated the pros and cons, and I tried to talk her into trying other things.  Let's get in the shower.  Let's go for a walk.  How about leaning against the wall.  I looked at Mike; he looked forlorn.

Then, I said:  "I am going to support you no matter what you decide.  I am here for you."

"Do you want to try the small help first?" asked Mike, meaning Fentanyl, the intravenous narcotic.

"No," Lucy replied, "the big help."

Thus, the decision was made.  The anaesthesiologist was summoned from his home 30 minutes away.

Choosing an epidural

The hardest part for a woman that has chosen to receive anesthetics in labor, but has not received them yet, is coping with the contractions that lie between her and her medicine.  During contractions, we counted up to ten, then back down.  Mike rubbed Lucy's shoulders.  We watched the clock, noting how long it had been since her request (and erring on too short of an interval).  We moaned.

It was midnight.  The anaesthesiologist was a tall man with small, funny, round glasses.  "I am very fast," he said when Lucy asked him to be swift.  Skillfully and quickly, he placed the epidural, and Lucy's sensation of her contractions slowly subsided.  First, they lessened in duration, then she felt only the peaks, and, finally, she felt nothing.

Intense joy swept over Lucy.  She chatted gaily; we watched the strip reading out contraction strengths.  We talked about the baby, about how wonderful it is to be able to focus again on what this is all about: having a baby, on the momentous, happy occasion.

"I had forgotten about all of that," Lucy said.  "It is so nice to be able to really enjoy having this baby again.  I was so unhappy."

After a while, I suggested we all sleep.  The annoying, gruff Gwen suggested the same, turning on the lights as she came in for a set of strip readings and another exam.  When she left, we dimmed the lights and tried to rest: Lucy in bed, Mike on the cot, and me in the armchair.

Breaking the waters and waiting to push

What does a woman do when she is in labor but feels very little of it?  What does she do while she waits for her chance to push?  Knowing it was hours away, and knowing we should all conserve our strength, we tried to rest.  But for a woman in labor, this period of waiting is intensely surreal and frightening.  She wants to know that everything is progressing normally, that her baby is all right, that she is still in labor, and she worries, in a sort of performance anxiety, about her ability to push effectively (women are said to be able to push more effectively if they can feel the pushing contractions).  She worries about her labor pains returning, as the epidural feels too good to be true.  She worries that the drugs from the epidural affect her baby and her baby's ability to breastfeed.

Our goal was to wait for 10cm dilation and +2 station, indicating that the baby had dropped low enough that our pushing efforts would not be wasted.  At this point, Nurse Gwen was, to our pleasant surprise, was replaced by a much nicer, pleasant, and accommodating nurse named Maggie.  Maggie explained that the ballpark is one centimeter dilation per hour.  We calculated: if the epidural was started at 3cm at midnight, we should expect to be complete at 7am.

At 8cm, Maggie suggested that the doctor be summoned for AROM, or artificial rupture of the membranes or amniotomy.  These are equivalent names for breaking the bag of waters, a procedure sometimes used to speed labor along if the bag does not break on its own.  Given the good progress to this point, the 24-hour time limit usually imposed on birth after the bag has ruptured was not an issue.  Moreover, Lucy's position (in bed) was not likely to aid the bag in rupturing on its own.  We agreed.  The obstetrician made his first appearance, barely looking around the room.  I greeted him gaily, introducing myself as doula.  Ignoring me while giving me a sidelong glance, he announced his intention for amniotomy, and, before Lucy could ask if it would hurt, the procedure was done (it did not hurt).  The fluid was clear.  The obstetrician announced 7cm, and Maggie explained that it is normal for the cervix to "snap back" after the dilating pressure from the bulging bag was removed.  She assured Lucy and Mike that labor would progress normally.

Although I will skip ahead a bit, I will mention two other interventions that either happened independently or followed AROM.  The baby's heart rate would sometimes decelerate after some contractions, causing a bit of alarm for Nurse Maggie.  First, Lucy received oxygen nearly continuously for most of her labor, and every 20 minutes Nurse Maggie would come and move Lucy: if she was on her left, she would be flipped to her right, and vice-versa.  Second, at about 9cm, the obstetrician inserted an intrauterine pressure catheter (used to measure the strength of contractions, but in our case, this was largely ignored) and ran fluid into the uterus.  This procedure, called amnioinfusion, is, in the grand scheme of things, minimally invasive.  A catheter is placed next to the baby's head, and sterile saline solution is delivered into the uterus to replace the amniotic fluid which is, at this point, gone.

Birth

Three things clued us in on the upcoming pushing phase of labor.  First, Lucy began feeling pressure on the top of her uterus rather than all over, or even on the base of the uterus, as she did before the epidural. In early and active labor, a woman's cervix dilates.  Women can feel this low in the abdomen.  As active labor moves into transition and pushing, the contractions change into powerful presses from the top of the uterus, just under the breasts.  Second, contractions were close together --- two minutes apart --- and lasting over a minute, as measured on the strip.  Third, Nurse Alyssa (who replaced Nurse Maggie when her shift ended) performed gentle vaginal exams revealed bloody show and that she was complete and the baby at the +1 station, but the cervix had a "lip" which slowly dissipated over the course of about two hours.

What can I say about medicated pushing?  It happens in the traditional supine position, legs elevated and held back by two people.  Lucy felt the contractions; she pushed very effectively.  Her baby was born in just one hour: first, a squished, chubby, cone-shaped, purple head, and then a comparatively skinny white body.  Later, Lucy confided that she thought we were trying to be falsely encouraging when we said things like "I can see the baby's head" and "You are really making some progress," because it was impossible for her to feel the progress she was making.  She was a magnificent pusher.  Lucy: Pusher of Babies.

The baby was placed on her chest directly after birth.  Mike cut the cord; Lucy crooned at their new baby; we all cried as I took photos with Mike's camera.  The obstetrician sewed up Lucy's second-degree tear and helped Lucy deliver her placenta.

I stayed for about two more hours, trying to help the baby breastfeed.  He would put the nipple in his mouth, but would not suck.  I assured Mike and Lucy that it was just a matter of time; the baby was tired and sleepy.  "When the nipple slips out of his mouth, he cries.  This is a good sign," I said, "it means he is interested.  It will come in time."  And it did.  By evening, the baby nursed.

Conclusion

I was pleasantly surprised that the unfortunate cascade of interventions women fear yet anticipate after opting for an epidural did not happen for Lucy and Mike.  There was no need for pitocin; there was no need for C-section; there was no need for episiotomy nor instrumental delivery.

Natural birth is undisputedly the safest form of birth, both in terms of mother's postpartum health and the baby's health, but it is not the only kind of birth that is safe.  There is a definite need for medicated birth in our society.  It goes without saying that a healthy baby is the most desirable outcome of a birth, but the mother's experience with the birth is arguably just as important to the mother as the baby's health.  Her birth experience is her memory of this most momentous occasion, and should be regarded with as much care as such an occasion warrants --- that is to say, it is very important.  At no point should the mother be made to feel that she is suffering.  And, once requesting and accepting a medicated birth, at no point should she feel guilty for her decision: she is doing her absolute best, and should be applauded.  The mother should be able to look back on her birth and be proud of herself, to feel empowered.

It is OK to choose an epidural. Lucy did, and she had an amazing birth.