(Can we inform women of their options with an epidural while they’re in labor? How and when? How do we do so without overstepping our bounds with nursing staff and providers?)
Pain vs. Suffering Pain Versus Suffering in Labor [PSfromPenny Video] (1) “If we consult the scientific literature, there is a distinction among pain, suffering and trauma. As described in Lowe’s fine paper on the nature of labor pain (1), pain has been defined as, ‘an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage.’ (2) The emphasis is on the physical origins of pain. “Lowe also points out that ‘suffering,’ can be distinguished from pain, in that by definition, it describes negative emotional reactions, and includes any of these: perceived threat to body and/or psyche; helplessness and loss of control; distress; inability to cope with the distressing situation; fear of death of mother or baby. If we think about it, one can have pain without suffering and suffering without pain.” (2)
Pain Coping Scale (as opposed to pain intensity scale) (3)
“Rather than asking her to rate her coping on a scale…, the supporter observes her behavior for the 3 Rs….If she does not maintain the 3 Rs, she might very well suffer and feel traumatized by her labor. “A second way to assess coping is to ask the woman, after a contraction, “What was going through your mind during that contraction?” If her answer focuses on positive thoughts, or helpful activities, she is coping. If she focuses on how long or difficult it is, or how tired or discouraged, or how much pain she feels, she is not coping well and may be suffering.” (3)
See also Penny Simkin’s Pregnancy, Childbirth, and the Newborn, pg. 180-181 (4th ed.)
Code Word The Code Word – Ensure Your Pain Management Wishes are Followed [PSfromPenny Video] (4) “Consider having a code word to communicate that you’ve changed your mind and you no longer want to labor without medications. Women with a strong desire for a non-medicated birth…often use a code word so they’re free to complain, vocalize, cry, or curse without others misunderstanding their actions as a plea for pain medications.For example, one woman told her support team that if she said, ‘I can’t’ or ‘This is too hard,’ she was really saying, ‘I need more support.’ But if she said her code word uncle, her partner knew to help her get pain medications.” (5)
“A code word or phrase can help your support team distinguish between ‘give me reassurance’ or ‘come up with something else’ and ‘get me pain medication.’” (6)
What to Expect with an Epidural (Preparing the Woman) How it’s administered o The nurse or anesthesiologist can come explain the procedure to the woman. o See Penny Simkin’s The Birth Partner, pg. 280-281 or Pregnancy, Childbirth, and the Newborn, pg. 198-199 (4th ed.); see also Henci Goer’s The Thinking Woman’s Guide to a Better Birth, pg. 129-132 o For your own benefit (not to show a woman in labor) search for videos on YouTube, such as this one. (7) 1|Page
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Risks and side-effects (measures taken to mitigate) o i.e. drop in blood pressure (IV fluids); slowing of labor progress (Pitocin); epidural may only effect one side (change of position) o The nurse or anesthesiologist can/may help to explain risks, side-effects, and hospital procedures (see next) The “Epidural Package of Safety” (hospital policies and procedures) o IV Fluids o Contraction Monitor o Bladder Catheter (external or internal) o Blood Pressure Cuff o Epidural catheter o O2 Mask o Infusion pump(s) o EFM (external or internal) o Pulse Oximeter o “To minimize the side effects of neuraxial medications, various additional precautions and interventions must be used to maintain safety. For example, an epidural is accompanied by IV fluids, a bladder catheter, and continuous monitoring of blood pressure, contractions, and your baby’s heart rate. Eating and drinking are restricted and you’re confined to bed. Along with the effects of the medications, the accompanying medical equipment significantly reduces mobility (you might not be able to move your legs or change positions in bed without assistance) and contributes to the feeling that the birth has become a medical event.” (8)
Other considerations o If You’re Planning an Epidural [PSfromPenny Video] (9) o Is an Epidural My Only Option? [Lamaze Infographic] (10)
Which (if any) of these would you address with a laboring woman? When and how would you address them? (Inclusion of nursing staff?)
“The mother will need you to help her remain still and calm, to acknowledge the difficulty of what she is being asked to do, and to tell her how well she is doing.” (11)
What can a doula do to support a woman during epidural administration (to remain still and calm)?
Care of a Woman with an Epidural – 5 Rules for Good Support [PSfromPenny Video] (12) “Treat a woman as much as possible like a person who does not have an epidural.” 1. Keep her moving: Positioning 2. Keep her cool: If there is a trend for an increasing temperature, start cooling her down (the parts of her that are not numb). 3. Keep her company: Don’t abandon her 4. Keep her from pushing too early: “Laboring Down”—wait until the head is visible at the vaginal outlet, or she feels the urge to push 5. Keep her skin to skin with her baby Positions The “Rollover” Technique o “Keep the woman moving as safety permits; for example, us the ‘rollover,’ in which she spends 30 minutes in each of the following positions: 1) semi-reclining; 2) left side-lying; 3) left Sims’ (semi-prone,
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with upper hip and knew flexed); 4) kneeling on the lowered foot of the bed and leaning onto a pile of pillows, or kneeling over a birth ball; 5) right Sims’; and 6) right side-lying. Of course, if she has too little muscle tone or the fetus does not tolerate one or more positions, use the other positions. Pelvic shape and gravity effects are altered with the rollover. Recruit her support team to help her with position changes. If she is exhausted and needs to sleep, you should not waken her to change positions so often.” (13)
o See “Penny Simkin’s Safe Positions for the Mother with an Epidural” [graphic] (14), or Penny Simkin’s The Birth Partner, pg. 284 for graphic.
Peanut Balls o Peanut Ball in Labour – What you need to know!!! [AcuBaby Video] (15) o Using the Peanut Ball by Your Birth [Your Birth Video] (16) o Peanut Balls for Labor—A Valuable Tool for Promoting Progress? [Science and Sensibility blog post] (17)
***When helping to position mom, do not injure her or yourself. Her ear, shoulder, hip and knee should move at the same time. Protect your back and joints. “If you’re holding up one of her legs as she pushes, be careful not to pull it back too far. Think about her hips’ normal range of motion, and don’t force her leg beyond that point so you avoid straining her hips, thighs, or lower back. (Your partner will be unable to tell you when her muscles are straining because the medications will have numbed all sensation.” (18)
Other Considerations: o
Labor Positions—Epidural Before Pushing [The Birthing Channel Video] (19)
o “Even though your partner may be more comfortable physically, she still needs your emotional support. If
o
o o
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you shift your attention away from her once the epidural has taken effect, she may feel as though you’re abandoning her. “To reassure your partner that you’ll continue to provide support, stay with her and relax together. Do things that soother her such as holding her hand or brushing her hair. And epidural may leave your partner feeling disconnected from her body and the birth experience; talk with her about the labor and your baby to help her reconnect with events…. If she’s worried or anxious, listen to her fears, acknowledge them, and reassure her.” (20) “Once the mother is comfortable, she will no longer need intense support and close physical contact, but she may feel suddenly alone and unimportant if you turn on the TV, leave to get a meal, or take a nap. Unless you have a doula or other family member to remain with her, don’t leave the room. Continue to show support by bringing the mother things to make her comfortable—warm blankets, ice chips, her comb and toothbrush—and asking questions and making conversation with the nurse. Watch the monitor from time to time, and point out contractions when they occur…. If the mother goes to sleep, she will probably sleep lightly and fitfully. When she wakes up, she may feel quite alone if you are out of the room or sound asleep. If you are exhausted, of course, you may not be able to stay awake. Before you drift off, tell her to be sure to wake you if she needs anything or if the doctor comes in.” (21) “If natural childbirth was your goal and you have had to abandon it, a review of the measures you tried, praise for what you accomplished, and sympathy for your disappointment can help you accept this change of plans in the most positive manner.” (22) “There are occasional challenges with epidurals. Your partner might not initially receive sufficient pain relief, she might experience “windows” of pain, or the pain might return after initial relief….Be sure to alert the staff if any of these situations occur. They may be able to fix it by adjusting the epidural or by having her change positions. If your partner is among the few women for whom an epidural doesn’t provide effective pain relief, even after multiple attempts to correct the problem, she’ll need your support to help cope with the pain and to deal with the disappointment that the epidural failed her. “Your partner may also experience discomforts that are caused by the medications, such as itching,
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o
nausea, and feeling overheated or chilled. Make her more comfortable by giving her a massage, helping her change positions, covering her with a warm blanket, placing a cool cloth on her forehead, or giving her ice chips (if allowed). Do not, however, place heating pads or ice packs on any part of her body that’s affected by the epidural. The medications will affect her sense of temperature, and she might not be able to tell if a heating pad or cold pack is damaging her skin.” (23) “The research shows that epidurals inhibit fetal rotation from posterior to anterior. When you lie on your back, even semi-reclining, gravity keeps the baby from shifting to the favorable anterior position. Lie on your side or sit up instead, or if you have the strength and control of your legs, as you may with a lowdose epidural, try hands and knees, the optimal position for rotating a posterior baby, for a few contractions.” (24)
How would you approach a woman with the suggestion of these positions? How would you liaison with nursing staff about them?
What other physical/emotional support might a woman need after receiving an epidural?
See Penny Simkin’s The Birth Partner, pg. 285-286 (“Complete Dilation” section) for discussion of three pushing options. Review and discuss pushing options with woman and nurse before completely dilated? Delay pushing: Wait until fetal head is visible in vaginal outlet or mother feels the urge to push o “The mother rests or up to an hour or more, while the staff monitors the baby, until the mother begins to feel an urge to push or the baby’s head appears at her vaginal opening. Then she pushes with her contractions. Although this option may lengthen the birthing stage, it is the easiest on mother and baby, and it results in fewer instrumental deliveries.” (25)
Model physiologic pushing: As contraction builds, hold breath and strain for 5-7 seconds, take 4 to 6 quick breaths, and bear down again. Repeat until contraction wanes. Positions for pushing: See “Penny Simkin’s Safe Positions for the Mother with an Epidural” [graphic] (14) , or Labor Positions – Epidural Pushing [The Birthing Channel Video] (26) Give her feedback (contraction monitor, mirror, help her to touch baby’s head) o “Keep an eye on the contraction monitor and give her feedback on how the numbers go up as she bears down, and how much she adds to the intensity of the contractions.” (13) ; see also, Penny Simkin’s The Birth Partner, pg. 286-287 (“Help With Pushing” section). Keep mom and baby skin to skin
How/when would you approach a woman with these suggestions? How would you liaison with nursing staff about them?
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Sources: (1) PSfromPenny. “Penny Simkin – Pain Versus Suffering in Labor.” YouTube. (2) Simkin, Penny. “Pain, Suffering, and Trauma in Labor…” Part 1. Science and Sensibility. (3) Simkin, Penny. “Pain, Suffering, and Trauma in Labor…” Part 2. Science and Sensibility. (4) PSfromPenny. “The Code Word – Ensure Your Pain Management Wishes Are Followed.” YouTube. (5) Simkin, Penny. Pregnancy, Childbirth, and the Newborn, 4th ed., pg. 189. (6) Goer, Henci. The Thinking Woman’s Guide to a Better Birth. Pg. 141. (7) “Epidural anesthesia.” YouTube. (8) Simkin, Penny. Pregnancy, Childbirth, and the Newborn, 4th ed., pg. 196. (9) PSfromPenny. “If You’re Planning an Epidural.” YouTube. (10) Lamaze International. “Is an Epidural My Only Option?” www.lamaze.org (11) Simkin, Penny. The Birth Partner. Pg. 283 (12) PSfromPenny. “Care of a Woman with an Epidural—5 Rules for Good Support.” YouTube. (13) Simkin, Penny. “Moving Beyond the Debate: A Holistic Approach to Understanding and Treating Effects of Neuaxial Analgesia,” Birth, 39:4. Dec. 2012. Pg. 331. (14) Simkin, Penny. “Penny Simkin’s Safe Positons for the Mother with an Epidural.” Accessed through Lamaze International. “If You Have an Epidural: How to Keep your Body and Labor Moving.” Giving Birth With Confidence. (See also The Birth Partner, pg. 284) (15) AcuBaby. “Peanut Ball in Labour – What you need to know!!!” YouTube. (16) Your Birth. “Using the Peanut Ball by Your Birth.” YouTube. (17) Lythgoe, Andrea D. “Peanut Balls for Labor – A Valuable Tool for Promoting Progress?” Science and Sensibility. (18) Simkin, Penny. Pregnancy, Childbirth, and the Newborn, 4th ed. Pg. 201. (19) The Birthing Channel. “Labor Positions – Epidural Before Pushing.” YouTube. (20) Simkin, Penny. Pregnancy, Childbirth, and the Newborn, 4th ed. Pg. 201. (21) Simkin, Penny. The Birth Partner. Pg. 283. (22) Goer, Henci. The Thinking Woman’s Guide to a Better Birth. Pg. 145. (23) Simkin, Penny. Pregnancy, Childbirth, and the Newborn, 4th ed. Pg. 201. (24) Goer, Henci. The Thinking Woman’s Guide to a Better Birth. Pg. 144. (25) Simkin, Penny. The Birth Partner. Pg. 286. (26) The Birthing Channel. “Labor Positions – Epidural Pushing.” YouTube. See Also: Simkin, Penny. “Holistic Care of The Woman Laboring with and Epidural.” www.awhonnwa.org. (powerpoint presentation.) (Find another version called “Supporting the Woman with an Epidural” found at https://www.pennysimkin.com/articles-resources/ under in the “Presentations & Slide Decks” folder beneath the heading “File Library.) Yourdoulabag.com. “Epidural? 6 Ways a Doula Can Support.” www.yourdoulabag.com.
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