O.k., why am I not using an epidural? (sorry long)

[Jude Rose]

I am getting fuzzy on my reasons for not using an epidural for my twin birth.
I have a feeling I’m just getting the OB work-over, but what if I’m not seeing things clearly?

Here’s the situation. My OB’s group is a dream for our region. Episiotomies are rare, they have a strong feeling that a woman should hold off on pushing until she really needs to, not just because she’s at 10 cms, he’s completely comfortable birthing twins vaginally even if the 2nd one is breech (and actually has). I mean, I could go on & on. Everyone at the hospital and at the clinic support and ask me to give a detailed birthplan so they can try to give me the birth I want, etc.

I guess I’m saying all this because homebirth is no longer an option (M/W won’t do it) and I don’t want to find another OB cuz he's one of the least invasive around.

This is my first birth and with twins the second baby is the wild card cuz it can flip after the first leaves. Dr. is concerned about me not having any pain relief if he has to insert his arm up me to extract Baby B if it turns breech. He also knows that an epi will help make an emergency c-section on Baby B easier and at least I’d be awake for it. I said I want to take my chances that both babies will present fine and if things go to hell, I’ll have a general. He says a general is less safe, especially in a life and death situation, when they have to administer it so fast.

He asked me why I hate epis. I started listing whatever I could remember from here and good ol’ Henci’s “What Every Woman Should Know” book.

I said, “First-time moms tend to not push right on epi and end up with more c-sections”
He said, “His experience has epis creating more vag births-the secret is to not turn the dose up too high. He said the C/S rate in his practice is very low, especially compared to nationwide”

I said, “Women have had permanent back damage from their epi.”
He said, “That has been studied and refuted. There is just as good of chance that the birth itself can create permanent back damage/pain.”

I said, “There have been even worse results from an epi. It’s dangerous. It affects the babies”
He said, “Listen to common sense. Do you realize how litigious this country is? If epidural were that dangerous, we wouldn’t do it so readily. Honest, doctors are extremely cautious to a fault for avoiding anything too risky.”

I said, “Natural labor is easier because women release endorphins that aid with the process. I would deny myself that with epi.”
He said, “Who says? Your body will still release that stuff.”

My husband was completely swayed. (of course: ) Even my midwife-who’s truly on my side, I KNOW this-wants me to consider it because being knocked out during a delivery is worse than at least being conscious.
Never mind I’m working my ass off on my Hypnobabies course. Never mind that they’re all setting a stage for a possibility-my birth could also end up as two vaginal deliveries. Never mind that I’m in charge here.

But I’m also at a loss because I have never done birth before. I don’t know if this is a good decision anymore. Help?

[CEG]

I guess I am a little confused about this doc "reaching up inside you" if the baby turns breech. Does he mean to turn the baby? If you just deliver Baby B breech I don't understand the need to "extract." You will already have a "proven pelvis" at that point because Baby A has to get out somehow.

Also, another side to consider is that if he keeps his epidural dose so low that women can push you would probably need an epidual bolus prior to having surgery. That takes time. Would he consider you having a spinal instead? A spinal takes effect more quickly and is often used for surgery.

Another option I have heard of is having the epidural catheter inserted with nothing running into it. Then you can quickly start the med (since you would have to wait for a bolus anyway) and have pain relief.

A general is more dangerous since pregnant women tend to de-sat very quickly and baby's oxygenation status gets questionable pretty quickly.

Keep us posted, I would curious to hear what you decided.

[alegna]

Wow- scary.

Okay, off the top of my head:

*epidurals slow down labor- increasing the "need" for pitocin
*epidurals require an IV- increasing your fluids, causing swelling, increasing chance of tearing
*epidurals mean your stuck on your back- BAD position for birthing
*epidurals increase the chance of maternal fever- increasing the chance of un-needed antibiotics in baby (increasing chance of thrush, increasing chance of breastfeeding problems....)
*epidurals mean continuous monitoring- increasing the chance of interventions


How's that for a start? And I would NEVER let a care-giver extract the second baby unless there was an URGENT medical need. (does he really "allow" breech birth for the second, or does he just pull him out if he's breech? yikes)

-Angela

[Spark]

I just linked a twin mama with similar experience to your thread. hopefully she'll have two hands to chime in.

Just reading your post, it sounds like you're feeling unsupported right now. I want to tell you that I support you. I believe it is not only possible but probable that you can have the healthy happy twin vaginal birth that you're dreaming of.

Do you want us to find you a WI MW who attends twin homebirths? Is that your first choice still?

[Redifer]

I'm gonna step out on the limb here, and state that I had an epi. I didn't have a long labor (5 hours total, 45 minutes pushing)... I had no intervention, wasn't "stuck on my back", no c-sec, or anything else mentioned. Yes, in some to many cases, but not all. Just thought I'd play devil's advocate.

However, an epi was what I wanted for my birth. Clearly, it is something you do NOT want. And there is nothing wrong with that, nor should you feel you should HAVE to have one because it's a more comfortable scenario for your doctor. Yes, I would agree to keep it open for "consideration", but by no means should you start doubting and second-guessing your own decisions simply because it's what everyone ELSE thinks you're capable of.

In the end, the decision is yours, and yours alone. Your doc, m/w and husband won't have any hard feelings about the alteration in birth plans, but perhaps you may after the birth if you feel you were pressured into something you didn't want to do.

[Storm Bride]

Originally Posted by Jude Rose

I Even my midwife-who’s truly on my side, I KNOW this-wants me to consider it because being knocked out during a delivery is worse than at least being conscious.

For what it's worth, that's medically true, but not necessarily psychologically true. If it weren't that I wanted what was best for my baby, and wanted dh to able to be there, I'd have begged for a general, instead of a spinal with my second and third sections.

There is nothing in my life that has even come close to the terror and just...creepiness of knowing that they were cutting my body open and I couldn't feel it, except for a bit of tugging. My youngest is 16 months old, and I still get the creeps when I think about that.

Am I glad I did it that way? Yeah - I guess...I didn't get to see ds1 until he was 14 hours old. But, for me, I'd rather have the three-day sick hangover from a general anesthetic than the freaky numbness of the spinal.

(I know spinals aren't exactly the same as epis, but I think it's a valid comparison.)

[miriam]

Doctors lie about epidurals all of the time. Your doctor likes the epidural because it gives him alot of leeway and freedom in the delivery and you are still awake.

I have a cousin who was a twin. He was the second/aftercoming twin. The first was stillborn. Therefore, there is no guarantee that the second twin is the big problem.

As for back problems, as a chirpractor, osteopath or orthopedic doctor. A doctor who orders and prescribes epidurals for deliveries does not deal with the chronic backaches he causes nor does the anesthesiologist who inserts them.

I know of a doctor who told a mother in my mommy'n'me group years ago that he got the baby out of her so fast that the epidural drug never reached her baby, therefore, he told her, that her baby had the same advantage as a woman who did not have any drugs as in a natural birth.

I know physiologically how the epidural works and I gasped at her remark while all of the other mommies shook their heads like geese. How can a doctor lie like that to a mother? The mother just signed a release for this drug to be injected into her dura and waited for it to take effect before he cut the baby out. I presented her the information that the drug company shares with the doctor who did not share it with her when I saw her again, and she simply smiled.

Ignorance is really bliss.

So sad for all of the babies and mothers who blindly trust their HCPs.

[cottonwood]

I have a bad feeling that no matter what evidence you give him or how logically your reasoning, he'll pooh-pooh it.

I said, “First-time moms tend to not push right on epi and end up with more c-sections” He said, “His experience has epis creating more vag births-the secret is to not turn the dose up too high. He said the C/S rate in his practice is very low, especially compared to nationwide”

You're right. You're not going to feel everything you need to push spontaneously and instinctively with half your body numb and with your pelvix collapsed. It makes no sense that the body is going to give birth easier that way. Why might he see fewer c-secs with drugged mothers, then? I can think of a few things. First, it sounds like he likes moms to be on their backs. This makes birth more stressful and painful, as does the general hospital atmosphere -- bright lights, coaching, people walking in and out and talking to and watching you, the doctor putting his hands up you and sitting between your legs. The level of stress may be enough to stall or create a dysfunctional labor, and an epidural may be enough to relax the mother (and help her disassociate from that area of her body) that the labor can continue.

I said, “Women have had permanent back damage from their epi.”
He said, “That has been studied and refuted. There is just as good of chance that the birth itself can create permanent back damage/pain.”

Tell him you'd be interested in reading about how that was refuted, and the evidence that birth itself (that is, non-managed) can create permanent back damage. Or tell you'd like the information for a friend. I'm sure many of us at MDC (especially those who have had long-term problems from their epis, would be really interested in learning more about it.

I said, “There have been even worse results from an epi. It’s dangerous. It affects the babies” He said, “Listen to common sense. Do you realize how litigious this country is? If epidural were that dangerous, we wouldn’t do it so readily. Honest, doctors are extremely cautious to a fault for avoiding anything too risky.”

Either he's an idiot or he's lying. Ask him if he knows the meaning of "iatrogenic complication". Ask him if he knows how many illnesses and injuries are the result of medical care. Ask him if he really believes that there is no risk to injecting narcotics into the bloodstream, especially that close to the spine. Ask him why, if epidurals are so safe, you have to sign a consent form specifically for the epidural, detailing that you understand the risks and take responsibility for making the choice. This page might be helpful: http://www.healing-arts.org/mehl-madrona/mmepidural.htm

I said, “Natural labor is easier because women release endorphins that aid with the process. I would deny myself that with epi.” He said, “Who says? Your body will still release that stuff.”

I don't have resources to refute that (I'll have to see if I can find something... I'm thinking Sarah Buckley's book might be helpful here,) but I'd like to hear his scientific explanation for why he thinks that is.

Other considerations: because the mother is on her back with little movement and directed pushing, she's more likely to tear or receive an episiotomy. (What is his rate? I'd like to know what he considers "rare".) She's more likely also to have a forceps delivery and damage to the vagina. The hard forced pushing without an urge is also likely to result in a prolonged second stage which can be hard on the baby. To be fair, he has probably never seen a normal natural birth and so doesn't know what his patients are missing.

And what if the epidural doesn't take on one side? Then you're having to deal with the pain without being able to move around.

What about epidural-induced maternal low blood pressure and how that affects the baby? What about side effects from the IV fluids? What about epidural fever which would involve separation from your babies and an unpleasant septic workup on them? Does he really feel that all these things are totally benign?

Read Henci Goer again. Look up some of those studies she refers to and read them for yourself. Ask your husband to consider that maybe just maybe your doctor doesn't know as much as he thinks he does. Have your husband do the research with you.

[miriam]

“Natural labor is easier because women release endorphins that aid with the process. I would deny myself that with epi.”

From my early midwifery classes eons ago, I can recall that the body will shut down its own production of endorphins if you get artificial pain relief.

I know for certain that drug addicts and alcoholics have low production if at all of endorphins because they have been self-medicating for a while.

Nature knows what to do since it made you.

I think you should look into a good doula or a home birth or a midwife.

[FreeThinkinMama]

I wouldn't make a decision to get an epi until you're actually in labor. How does the doctor figure that you can handle the first baby coming out but you can't handle the pain of him putting his arm inside to turn the baby? I don't think you can really tell how much pain you'll be able to tolerate until you're actually faced with it.

Some other risks of epi's that I don't think were mentioned are maternal convulsions, respitory paralysis, and cardiac arrest. (from http://www.geocities.com/skettimamma/interventions.html )Also if you're planning on bf'ing it can have an impact on the babies in that area.

I think the domino effect of interventions is real. Not that having one of these interventions like an epi will guarantee that you'll need another but studies show it increases your chances. In my experience it was the other way around. I had the induction which led to an amniotomy, which led to the epi which led to fetal distress and oxygen masks/cont. external & internal fetal monitoring, laboring flat on my back, purple pushing and a 2nd degree tear. I can easily see it happening the other way around with an epi at the beginning causing other things. That said, if you do decide to get the epi when you're in labor, having it done at the end after you're dialated 5+cm is less likely to cause problems then if you have it done in the beginning as far as c-section rates from what I've read.

[3-StarSystem]

Ugh, I actually consented to have the epi line in because of the Dr. using the "I'm going to have to stick my arm up into you up to my elbow if baby B turns." argument : I was so scared because twin B was significantly bigger than twin A (By about two pounds and a MUCH bigger head.) and they were monochorionic so I knew that if I took a while trying to get B out I was at an increased risk of placental detachment and all that stupid rot.

Lucky thing though, I had a failed epidural the whole time tee-hee. Never had any reduction in any sensation or lack of motion when they turned it on or up and they tried about 5 times to get the damn thing "in" so I think that has something to do with the fact that a) it didn't work and b) I've displayed every symptom of site damage and long term damage associated with epidurals when it comes to my back.

I did have to have the internal version when twin B was born and I don't blame them very much because he kind of slooshed off to being transverse from vertex and I did NOT want a c-section unless everything was tried. You know what?
I held still during the whole dang thing when theoretically I wasn't receiving any relief. I was fully dilated, the Dr. had small-ish hands. It hurt like a sonofa and I won't lie about that, but I don't think that having an epi line in JUST because they don't think you can handle it is reason enough for an epi. I wouldn't have accepted anything to start with if my babes weren't having such problems (They had twin-to-twin transfusion syndrome and baby A was NOT doing well.) and there wasn't such a significant weight difference which did end up making the birthing time of baby B much different than you would typically expect. (He came about an hour and a half later.)

Go with your gut. I hate to say it, but if they legitimately need to turn that baby they can whether or not you need the epi. They can also try externally. Plus, they have NO WAY of knowing how you can handle it. I'm one of those people that can hold still through pretty much anything and I was in a hypnotic state for most of the birth so I was for the most part very calm and still no matter what was being done to me.

[Jude Rose]

Originally Posted by Spark

I just linked a twin mama with similar experience to your thread. hopefully she'll have two hands to chime in.

Just reading your post, it sounds like you're feeling unsupported right now. I want to tell you that I support you. I believe it is not only possible but probable that you can have the healthy happy twin vaginal birth that you're dreaming of.

Do you want us to find you a WI MW who attends twin homebirths? Is that your first choice still?

Thank you for the support You were right.
No, I'm not in the frame of mind of have a homebirth anymore. I know too much now about twin births to be able to be calm about it. Thanks.
I keep having fanntasies that I can be an advocate and teach these people to stop underestimating women. (even though liek I said, they're much better than most)


As for other commetns, his last episiotomy was a mom who was crowning for over half and hour and begged for relief. He literally rarely does them.
He whole group is known for being out of the norm because they do deliver naturally and believe in being patient.....except apparently with a breech twin. :

You all have given me the counter-bracing I needed to deal with this blow. I especially appreciate hearing from the PP about her TTTS birth. Wow.
I am strong and can't imagine any pain that would overcome me. There's too many people trying to 'protect' me and I really appreciate the stats and opinions you all listed.

[SlingWearin'Mama]

Going into the pg I was sure I didn't want an epi. My daughter was born without one why would I have one this time. My OB sounds similar to yours, he went over the cons of not having one but ultimately said it was my choice. Some of the arguments I found reasonably valid, such as not having general for an emergency, I REALLY didn't want general. So who knows maybe that speech in the back of my mind played a part in my decision for an epi when I went into labor. I started off my labor at 11:30 at night absoloutely exhausted from a long day of just living life carrying around an extra 75 LBs and keeping up with my 2.5 y.o. (this is a perfect time to remind you to take a nap every day in the last few weeks!) I just couldn't imagine going through labor this tired. Also do NOT go into the hospital until you are ready to pop out a baby unless an epi is what you want. They insisted I lie on my back for monitoring which is something I was unable to do prior epi... I had the epi, slept for many hours, woke up completely dilated and off to deliver I went. Now the difference between pushing out my daughter and pushing out my boys was huge! I definitely lost the urge to push and much of my effectiveness of pushing. My first I pushed her out in 20 minutes it took a long time like 1 1/2-2 hours to push out baby A and Baby B was delivered an hour and 11 minutes later. However a lot of that was internal/external version time. They believed baby B was a lot bigger so ruled out a breech delivery for him (he turned out to be the exact same size) at this point the epi was wearing off and the version was no picnic I can tell you but many people get through these just fine.

So I dont have a lot of help for you. I have gone over the what would I do if I could do it over again. And other than taking a long nap that day I dont know. Had I not gotten an epi who knows how things would have or would have not changed. I still would have needed the version and for that part I was happy to have one in place but think I could have managed without, a big baby just went through there a hand isnt that different.

Good luck in your decision I know what a complicated one it is. I agree with an above poster, there is no real need to decide now. You can stick with I dont plan on one and you can always change your mind if you want to.

Easy labor vibes to you!
Jenn

[sapphire_chan]

What was that experiment where injecting water provided just as much pain relief?

Anyway, in a twin birth, I'd think you'd want to be even more certain of not having an epidural so that you can get into different positions to allow baby B plenty of room to get into a optimal position and also so if baby B is breech you have the best chance of him/her being birthed with no problems.

[momto l&a]

Having personally know woman who where temporarily paralyzed after and epi and couldn't hold the newborn baby for HOURS after birth I would never have one.

Second I have had 3 natural births and haven't seen the need for one personally.

Granted I have never had twins so I have no idea what thats like.

[lifescholar]

An epi was my last choice for pain meds, but after 49 hours of labour, with no sleep, I was too exhausted to go on, and I knew there was no way I could push. AND, I was still only at 4 cm.

So, I had an epi, and gave birth to my son 5 hours later. Neither my son nor myself had ANY of the possible side effects, during labour or after.

I'm absolutely in no hurry to have one again, specifically because of the risks, but it CAN happen that you have a totally healthy birth with an epidural.

But, if you really don't want one, then don't get one! There are other options, and like you said, everything could go very smoothly anyways! I never gave up on myself, even after HOURS and HOURS of labour and nothing happening. I would go in believing that everything will be fine. If something DOES happen, they have everything necessary at their disposal to fix it.

No point in going in anticipating problems that might not even happen!

Best of luck to you!

[anniegirl]

I have a close friend who had twins and her OB told her the EXACT same thing...that she really ought to have an epidural because if the OB had to reach up in her and turn twin B it would be too painful without one. It was my friends first birth as well.

Well, she labored to 7cm just fine and the OB was pretty insistent about the epi, so she got one even though she wasn't feeling the need for one. It was classic: as soon as she had it and was confined to bed one of the baby's heartrate started dropping because his cord was compressed. They did a c-section. Had she not had the epi, she would have been moving around and either the cord would never have gotten compressed, or if it had she could have moved into another position and it probably would have taken care of it.

My friend is an amazing woman and handled the whole thing with grace, but she does regret letting the OB tell her what to do (getting the epidural) when it didn't feel right in her gut.

Your OB sounds very patronizing. Preferring to labor naturally should be reason enough for him, you don't owe him an explanation, nor should you have to pass some kind of debate test with him. But if you feel like giving him another reason an excellent one is that if the baby starts to sound distressed you can move to another position (hands and knees etc.) which gives you another line of prevention for a c-section.

[Arwyn]

Originally Posted by fourlittlebirds

What about epidural-induced maternal low blood pressure and how that affects the baby? What about side effects from the IV fluids? What about epidural fever which would involve separation from your babies and an unpleasant septic workup on them? Does he really feel that all these things are totally benign?

Ok, this is a bit OT, but I've thought about this question a lot, and my conclusion is doctors dismiss or minimize the risks of these kinds of side effects because they're well within their ability to "handle" medically. To them, maternal fever and a septic workup of the newborn IS "no big deal". They just order the workup, prescribe prophylactic antibiotics, and congratulate themselves on a job well done - easy peasy. The baby is away from mom for a little while, gets jabbed in the back, cries a lot? Well, better safe then sorry, right? And they never get a chance to see the long-term emotional or physical consequences that can have for the mom, the baby, the motherbaby unit, the breastfeeding relationship, the rates of PPD, the agony of thrush, etc - but even if they were made aware of it, they would once again minimize or discount those risks because either they can "handle" the problems medically, or, they don't need to be handled medically, so there's nothing really wrong.

We don't need to worry about medication A causing side effect X because we can always give you medication B and if side effect Y pops up, there's always procedure Q. That's the kind of logic they're using - that's the kind of logic they're trained to use.

[pigpokey]

Originally Posted by Jude Rose

ge/pain.”

I said, “There have been even worse results from an epi. It’s dangerous. It affects the babies”
He said, “Listen to common sense. Do you realize how litigious this country is? If epidural were that dangerous, we wouldn’t do it so readily. Honest, doctors are extremely cautious to a fault for avoiding anything too risky.”

This is the one I find easiest to speak to. It's simply not the way they (doctors) analize litigation risk. Litigation risk is based mainly on standard of care. Standard of care is not 100% based on evidence (risk analysis). It often evolves independently of good evidence. It sometimes takes quite a while for good evidence to change standard of care.

Risk analysis and deciding what is "dangerous" vs. acceptable is a decision for the patient to make. He should not be poo-pooing your risk analysis. He will not have to face the consequences of an epidural -- you and your family do. It's well within the standard of care, so what is his risk?

[stacyann21]

I would say because you don't need it and there's a real chance it can harm your labor outcome. You can do it. Yes, it's painful but it's manageable. Your doctor scares the crap outta me though :