When is it too late for an epidural? And why? - Mothering Forums

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#1 of 25 Old 05-08-2008, 01:32 AM - Thread Starter
 
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I've been hearing about women having epidurals around the time of their Transition phase. But I thought there was a certain point in labor when hospitals deem it "too late" to get an epidural. When and why is it too late to get an epi?

* * *

BTW...I'm a believer in natural childbirth but asking these questions to continue learning.

Thanks,
Lydia
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#2 of 25 Old 05-08-2008, 01:34 AM
 
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I got mine at 8 cm, it didn't even kick in by the time I delivered.

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#3 of 25 Old 05-08-2008, 02:58 AM
 
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but take a moment to think about it.

When a woman decides she wants an epidural several things need to happen:

1. Anesthesiologist is called, who needs to "pull" the drugs for the epidural and set up the cart, review the chart etc
1A. Also, there may be other women "ahead" of her, or in the OR doing a section, and another anesth. may not be available.

2. Mom needs to get a "bolus" (large amount) of IV fluid prior to the procedure, if she has not had an IV already running (I have seen anything from 500-1000cc required, half to full liter) This can take 15 minutes or so, the IV may need to be placed and started, with the fluid running wide open

3. Benefits and Risks are explained, consent given

4. Procedure started, usually completed within 15 minutes

5. Test dose given, checking for no reaction from mom or baby

6. Medication administered, slowly starts to take effect in another 15 minutes, full coverage 30-40 minutes.

So...you are looking at a minimum of about an hour before mom starts to feel good relief, from the moment she requests the epidural. If the baby is going to be born before that time is up, then all mom ends up with is a really numb immediate postpartum period.

An epidural can certainly be administered at any time during labor or pushing! I have had a client push non-medicated for two hours, decide she wanted an epdural, get one, and then go on to push her baby out after that!

So,it's never "too late," it just may not provide adequate relief before the baby is born.

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#4 of 25 Old 05-08-2008, 03:22 AM
 
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Sometimes dialation is occuring very rapidly and the mama feels really out of control and requests an epidural. The nurse is good and checks her, but she's a 3. They call the doc, mama gets her epidural, and then as a baby 10 minutes late. Time elapsed: 1 hour. She wanted pain relief b/c it was going soooo fast. But they didn't know. So she got an epidural, with the side effects of epidural (Rare, but there), but not the good stuff (the pain relief).

No doc wants to give an epidural and risk side effects with the mama not getting the benefits. It's a guessing game or a judgment call for "too late".

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#5 of 25 Old 05-08-2008, 11:57 AM
 
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I had my first at 10 cm (homebirth transfer) and my 2nd at around 4 cm. With both the baby was born in less than an hour after getting the epi and I had complete pain relief with both.
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#6 of 25 Old 05-08-2008, 12:18 PM
 
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I don't think there is a window that you miss medically, but like the PPs have said, it can take awhile to get the epidural in place and working. So in that sense it can be 'too late'. I've had a client or two receive an epidural after they had been pushing for some time to get some rest and see if that changed anything. Another client received an epidural after 3 hours of pushing to prep for a forceps birth. But often mamas who ask for them late in their labor don't actually have the time to get one.

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#7 of 25 Old 05-08-2008, 12:34 PM
 
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Around here hospitals will give epidurals even at 10 cm. Of course, given that late it likely wouldn't even take effect until after the birth.... Basically, if a woman asks for one, they get it for her as quickly as they possibly can. The epidural rate here is somewhere around 95%.

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#8 of 25 Old 05-08-2008, 12:48 PM - Thread Starter
 
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Thank you to all that have responded so far. Without firsthand experience myself, I just don't know how the whole epidural procedure unfolds.

Quote:
Originally Posted by SalmonBayDoula View Post
Mom needs to get a "bolus" (large amount) of IV fluid prior to the procedure, if she has not had an IV already running (I have seen anything from 500-1000cc required, half to full liter) This can take 15 minutes or so, the IV may need to be placed and started, with the fluid running wide open

3. Benefits and Risks are explained, consent given

So...you are looking at a minimum of about an hour before mom starts to feel good relief, from the moment she requests the epidural.
Thank you for this detailed description. I have more questions.
  • Why is the bolus needed?
  • How are the benefits and risks explained? I've always wondered about this part. Does it actually say stuff like risk of paralysis, chronic headaches, non-effective pain relief, etc.? Or is more generic? Of course, the mom must sign a piece of paper, but are the risks and benefits verbally explained at all, or must she read it in its entirety?
  • An entire hour, huh? I had no idea. This time lag could work both ways, I guess. Meaning the mom could actually give birth before an epidural has time to be administered. Or the mom could feel even more desperate as she waits for the drugs.
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#9 of 25 Old 05-08-2008, 01:21 PM
 
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Why is the bolus needed?

A dangerous drop in blood pressure is a risk of epidurals, so women get IV fluids to artificially raise the blood pressure and hopefully avoid the crash.

How are the benefits and risks explained? I've always wondered about this part. Does it actually say stuff like risk of paralysis, chronic headaches, non-effective pain relief, etc.? Or is more generic? Of course, the mom must sign a piece of paper, but are the risks and benefits verbally explained at all, or must she read it in its entirety?

In my personal experience and as a doula, the woman is given a form which she does not read (who stops to read something thoroughly when they're in pain?). There's generally no discussion of the risks. As a doula I read the consent form once and it was laughable how little they disclosed about the risks of epidurals.

An entire hour, huh? I had no idea. This time lag could work both ways, I guess. Meaning the mom could actually give birth before an epidural has time to be administered. Or the mom could feel even more desperate as she waits for the drugs.

If a woman already has IV fluids it can be more like 20 minutes if the anesthesiologist is readily available. When a combined spinal/epidural is given some moms will feel relief around 5 minutes after it's inserted.

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#10 of 25 Old 05-08-2008, 01:35 PM
 
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Jumping in here...

I have birthed three babes in hospitals, and have had epidurals with all three. My second labor was induced and intensely painful. I was not educated about the effects of pitocin at the time, and foolishly thought I could do it without pain relief. By the time I asked for an epidural, I already felt pressure "down there". I didn't dare tell anyone about this, because the pain was so great. I got an epidural, but it never kicked in, not even postpartum. I'm not sure if the reason was that it wasn't placed well, or if I received it too late. With zero pain relief, I eventually lost consciousness, which was the best thing that could have happened to me, lol. I simply could not go on, and this gave me a break. My Dr. let me be, and after a while, brought me back around with more pitocin. The entire labor was excruciating beyond belief, I wouldn't wish it on my worst enemy.
With babies 1 and 3, I received an epidural earlier on in labor, and I had no trouble with them.
I'm expecting baby #4, and planning a homebirth this time, so no more epidurals for me!

Mom of 4
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#11 of 25 Old 05-08-2008, 02:23 PM
 
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Quote:
Originally Posted by SalmonBayDoula View Post
So...you are looking at a minimum of about an hour before mom starts to feel good relief, from the moment she requests the epidural. If the baby is going to be born before that time is up, then all mom ends up with is a really numb immediate postpartum period.
And even if there is plenty of time, the epidural might not work. So even women who go in thinking"I'm going to get an epi as soon as I can" should know about other ways to manage pain.
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#12 of 25 Old 05-08-2008, 03:03 PM
 
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I had a client get one at 10 centimeters. She was unable to push without being manically out of control, probably due to a past history of abuse.
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#13 of 25 Old 05-08-2008, 03:18 PM
 
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Originally Posted by sapphire_chan View Post
And even if there is plenty of time, the epidural might not work. So even women who go in thinking"I'm going to get an epi as soon as I can" should know about other ways to manage pain.
Good point. I begged for my epidural after the OB broke my water (think I'll start by declining that little procedure next time) and I swear it took about a year before they gave it to me (for the reasons above, they were doing the iv). Yeah, some other pain management techniques would have been handy!

Also, the consent form was a joke, I couldn't even sign my name, much less read the form (I had educated myself ahead of time, at least.) Heaven knows what I signed though.

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#14 of 25 Old 05-08-2008, 03:28 PM
 
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Consent varies from hospital to hospital, some places, a woman needs to sign a consent for an epidural and some places not. Sometimes the anesth. will explain the risks (headache, soreness, patchy pain relief, fever, slow down labor, paralysis etc) and sometimes not, sometimes the I hear them say "did you take childbirth classes? okay, remember what you learned about the epidural, good, do you have any questions?"and that constitutes consent.

Sometimes the mom can receive a combined epi/spinal and get quicker relief (spinal is much faster after the meds go in) but those are not done around here (not sure why!)

And I agree, even if a woman is sure that she wants an epidural at some point in her labor, she should learn and plan on some non-pharm. coping techniques, so that she can have some relief until she gets the epi, or on the chance that it doesn't work or has windows of pain.

Sharon

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#15 of 25 Old 05-08-2008, 04:33 PM
 
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I got one after dilating to 10, waiting for the urge to push, then pushing for an hour. DS was malpositioned and not descending so the midwife suggested it to let me rest (because of his position pushing was excruciating) and let him labor down. I hadn't had any IV fluids and it took 30 minutes for them to run in enough for the anesthesiologist to do the epidural, and at least another 30 minutes for it to take effect. Longest hour of my life. After it took effect I rested for about 2 hours then pushed for another hour before DS was born. There's another thing you don't see too often - my second stage lasted over 5 hours and the only thing anyone said about a c-section was that I didn't need one, I only needed some more time.
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#16 of 25 Old 05-08-2008, 04:43 PM
 
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I got one at ten.

They had decided to do a c-section. Dd was stuck due to her cord but they didn't know why it wasn't happening at the time.

They did an epi because the surgeon on call was already in surgery and it would take a bit for him to get to me.

It still didn't take fast enough for the surgery, he gave me a local in my abdomen before cutting me

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#17 of 25 Old 05-08-2008, 08:06 PM
 
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Quote:
Originally Posted by ldsapmom View Post
I had a client get one at 10 centimeters. She was unable to push without being manically out of control, probably due to a past history of abuse.
How sad.

I had a client get an epidural at 7-8 cm.

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#18 of 25 Old 05-09-2008, 12:39 AM
 
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I've nevr had one but when I was having Beverly, they induced me with pitocin. I was very clear to them that I didn't care for drugs but it seems like they came in every 10 minutes trying to get me to have an epidural. When I was 9 cm they were trying to give me one. After I had her, they gushed about how great it was that I didn't have to have the epidural. I remember thinking later that I hope some woman who got one didn't hear that because I was afraid it would make them feel bad. I think over the years of having kids, my pain tolerance has soared way up there.
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#19 of 25 Old 05-09-2008, 12:47 AM
 
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Quote:
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the only thing anyone said about a c-section was that I didn't need one, I only needed some more time.
That's impressive. You gave birth in a hospital? (Guessing since an epidural was available.) It is so nice to read about medical people (besides the ones here at MDC, I already expect you folks to be perfect ) being patient.
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#20 of 25 Old 05-09-2008, 08:28 AM
 
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A woman can get one during transition if she can lay still for the IV and the epidural injection. But I personally find that is hard to do during transition.
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#21 of 25 Old 05-09-2008, 12:09 PM
 
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That's impressive. You gave birth in a hospital? (Guessing since an epidural was available.) It is so nice to read about medical people (besides the ones here at MDC, I already expect you folks to be perfect ) being patient.
Yep, Sibley Hospital in D.C. Sadly, my midwife practice has since disbanded, I heard because they weren't bringing in enough money to offset the malpractice costs.
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#22 of 25 Old 05-14-2008, 07:46 PM
 
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Quote:
Originally Posted by UrbanCrunchyMama View Post
I've been hearing about women having epidurals around the time of their Transition phase. But I thought there was a certain point in labor when hospitals deem it "too late" to get an epidural. When and why is it too late to get an epi?

* * *

BTW...I'm a believer in natural childbirth but asking these questions to continue learning.

Thanks,
Lydia
I was told that some doctors are not allowed to let the woman have an epidural in transition. This was true with a friend's mom...

If this is so, I am even more upset that no one told me I was in transition. I think if the midwife had checked me and seen I was almost to pushing, she would not have let me get that, and I would have applauded her for not letting me...

After the fact, anyway...maybe not at the time

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#23 of 25 Old 05-14-2008, 08:57 PM
 
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I am pretty against vaginal exams in hospitals, but I always talk to my clients about vaginal exams when it comes to epidurals. Sometimes, it is the very thought of relief (especially with a LONG drawn out labor) that gets the mother to do the dilating she needed to do...so I suggest that when she makes the decision to get an epidural, the mother get a vaginal exam. SOmetimes, by the time that hour or so is past and they are ready to actually have the epidural placed, if she were to get another vaginal, the information found could actually be quite useful...like she is a nine or a ten, and by the time the drugs took effect, the baby would likely be born.

It is important for women to know that about 90% of the time, when a woman is asking for pain relief outside of the physical and emotional support she is receiving from her family/friends, she is in transition...and transition is the shortest part of labor--on average lasting 45 mins to an hour...just about the same amount of time it takes to get stuff together for the epidural.

I agree with salmonbaydoula, I have seen different status quo, depending on the doc, the nursing staff, and the hospital. I HAVE seen docs actually (albiet as if they were debaters in the contest of a lifetime, at triple speed...) go through the actual dangers of epidural. However, by that time, the woman is just not in a place to actually process what is being said. Luckily, in the case of my clients, we have gone over and over the risks and benefits of interventions that are likely to be offered, so they ARE able to make truely informed consent, regardless, because they have thought about it ahead of time. Unfortunately, not every woman has a doula! I, too, have seen docs give the worst possible side effect as being a spinal headache (which I have experienced and is truely awful, terrible, horrible, debilitating and excruciating...but NOT the worst thing that can happen from an epidural!), and that rather breezily, with "and we can FIX that, too!" tacked on to the end. It all depends, though on who is there and what the protocol for that place entails.

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#24 of 25 Old 05-14-2008, 11:45 PM
 
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I didn't get my epi late in labor (long into labor....24 hrs or so...but only 5cm). Just having had one I can say that I can NOT imagine being that still during serious contractions close together which I imagine is part of the reason they aren't done later in labor.


And I will say that although I do NOT remember all the pieces of the "disclaimer" they give you beforehand, and I wasn't in the best position to process it, I do remember that they read it outloud to me both a) before I signed and b) before actually administering the epidural. That part = good. The tone of voice of the anaesthesiologist....a little on the breezy side for my liking.

And although I did not get the dreaded headache, I did get this wierd horrible pain that would randomly shoot through my spine off and on for about 24 hours a few (maybe 4 or so) days after the birth.

But in the end....I would have been under general and unconscious when my son was delivered if I hadn't had the epidural so I guess I'm glad I had it.
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#25 of 25 Old 05-20-2008, 12:59 AM
 
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I have a friend who I believe arrived at the hospital in transition. She called me when her ctx started and could barely talk through them.

The main entrance to the hospital was closed so she had to go to the ER entrance. She and her Dh were greeted by staff there and the OB wanted to check her while she was still in the car. She checked her from behind while she was on her knees facing away bc my friend told her no way jose was she laying down on the backseat with back labor. The OB said she was 6.5cm.

She was admitted to labor and delivery. She asked for an epidural a few minutes of being there and the OB checked her and said she was almost 9 but said ok the epidural and the anesthesiologist (wow, the little red spell check line didn't show....amazed myself...) came and numbed her up.

I wasn't in the room at the time or I would've said something to her about waiting a few more minutes. She was ready to push about 10 minutes later...

I remember asking for one after a long 22 hour back labor in which my daughter refused to turn no matter what but was told it was too late. I think I was 6ishcm at the time.
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