Episode 213 - What if I have an epidural
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host, Dr. Melanie Jackson. I'm a clinical and research midwife with my PhD, and each episode, I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth, and postpartum journey. Welcome to today's episode of the Great Birth Rebellion podcast. I'm your host, Dr. Melanie Jackson, and today we are talking about the epidurals.
[0:34] Today's Great Birth Rebellion podcast episode is sponsored by Poppy Child, who's a doula and hypnobirth practitioner. She's the creator of The Birth Box, which has the oxytocin bubble in it, which is a collection of soundtracks that are designed to be used through labor to help you settle your nervous system and navigate your way through labor and birth. In The Birth Box, Poppy has a whole pack of strategies in there that are designed to help you reduce the overwhelm of labor and navigate pain. If you have a look down in the show notes, you see a link directly to purchase the birth box. And if you type the word Melanie in, Poppy's giving us 25% off. Today's episode of the Great Birth Rebellion podcast is all about the use of epidural for labor and birth. And I've used as much evidence that I can find and just some basic information about the process of epidurals, how they work, why women use them and some potential pitfalls to the use of epidurals. The idea of this episode is to prepare you if you are planning on using an epidural or for you to consider whether you want one at all.
[1:49] Now I'm going to take an opportunity here to mention to you that if you're keen to avoid an epidural during your labor and birth, if you do believe that pain is purposeful and important for labor and birth, I want to recommend to you my guide to giving birth without pain medication. Because there's one thing to say to women, don't use an epidural. But if you don't know what else to use in place of the epidural, then we've done you a disservice. The guide to giving birth without pain medication is the alternative to using an epidural for your labor and birth. It has a full list of strategies of what you can do to navigate pain of labor. And it's also got a whole pack of strategies that your support people or your partner can use to help you do the same.
[2:37] I created the Guide to Giving Birth Without Pain Medication based on all of the experience that I've had over the last 18 years attending women who are choosing to give birth at home. And I watched every single strategy that they use to navigate their labor without pain medication because we don't have the option to use that at home. And these are all the strategies that I also used for my own labors, one which was super fast, one which was really slow. Either way, everything that I know about the management of pain during labor is in the Guide to Giving Birth Without Pain Relief. I'll link it in the show notes below for you to access if you're keen to avoid an epidural. All right, let's get into this episode all about epidurals so that you have all the information you need to make the decisions that feel right and best for you.
[3:27] Whatever birth you're planning, knowing about epidurals is a must because there are more reasons and just pain relief to get an epidural. If you're having a cesarean, there's a big chance that you're going to have an epidural. So this information doesn't just apply to you if you're planning a vaginal birth. It is also information for women who may end up with a cesarean section or if you're planning a cesarean section. So knowing about epidurals can prepare you, early to make decisions for or against getting one. And then if you find yourself in the situation where you're considering an epidural in your labor, you know that you're already prepared. You've prepared ahead of time for this possibility.
[4:10] And while an epidural can be an absolute godsend in a long, difficult labor and a necessity for a surgical birth, there are also some significant pitfalls with epidural use and the way that they affect your body. So I'm going to offer some practical tips and also talk all through what an epidural is. And if you do decide to get an epidural, I can offer you some strategies that might help you counteract the downsides that can occur when you do choose to have an epidural. There are always side effects. Although there can be these amazing benefits, there's always going to be a side effect to an intervention in childbirth. So we'll talk about that. So this episode is for you if you are preparing for a birth, if you're supporting somebody who's about to give birth, If you're a doula or a midwife, you can use this episode to share with women so that they can learn more ahead of time before their birth about the choice of epidural.
[5:10] Every woman should be educated about pain management options and epidural is no exception. So regardless of if you plan to have an epidural, vaginal birth, cesarean birth, because, in the moment that you do decide you want one, if circumstances arise during your birth and you've avoided learning about them, then you're getting all of the information in your labor. And so you can't really make a fully informed choice in that scenario. So take the time now to gather all the information that you can so that you can make a fully informed decision and understand what to expect from epidurals. And you may have already decided I am having an epidural. And this episode is just to give you some more information about that choice. And a lot of people think that I'm anti-medical intervention. That's not the truth. I am pro-medical intervention in the suitable circumstances. I just don't like it when medical interventions are overused when they're not necessary. So epidurals aren't bad. Just like cesareans aren't bad, but there are some applicable clinical situations where they can be really, really good, but they are certainly overused, with a downplaying of some of the pitfalls. And I do believe that the way that the current maternity care system is set up.
[6:33] That epidurals can be a symptom of a system that hasn't worked out yet how to adequately support women. And so sometimes epidurals fill that gap. But I'm not saying they're inherently bad. I actually think they're incredible, but they have significant downfalls and consequences that women need to be aware of when they're making a choice about whether or not to have one in labor. So this is a big topic and I'll cover as much as I can and we'll just let's get started so here we go.
[7:06] Epidurals are undoubtedly the most effective option for pain relief during labor none of the other pain management medications or options, even come close to the elimination of pain that an epidural can offer now we'll learn later that they're not always 100% effective, But around 30% of labouring women in the UK, 60% in the USA receive an epidural. And here in Australia, our most recent stats show that four in five women in labour, so this is all in labour stats, so about 80% of labouring women will have some kind of pharmaceutical pain relief, medical pain relief, which that's slowly rising, of course, as every other medical intervention is.
[7:52] But half of those women will have epidurals. So in Australia, about 42% of laboring women end up having an epidural. But let's also remember that epidurals are used during cesarean sections. And here in Australia, we have a 41% cesarean section rate. So the majority of those women, if they're not having a general anesthetic and being put completely to sleep, will be having an epidural type anesthesia for that, for the cesarean section.
[8:19] And so really overall, if you combine the cesarean sections and the laboring women, And about 60% of women who are having their babies, that's a very crude calculation, here in Australia, will have an epidural during their labour and birth. So actually, you are far more likely to have an epidural than a not an epidural for your labour and birth. And that's different, again, if you go to a private hospital, it's up closer to 80%. If you go to a public hospital, we're talking more about 50%. So theoretically, you've got more of a chance of having an epidural than not having one. And really, it's not that that many women medically need one. Often the use of epidural is just a result of social conditioning around birth and the inability of society to properly support women during labour and birth. 60% of women don't have a medical need for an epidural. So just highlight some definite social issues here in the way that we give birth. But it's obvious here that if you want to avoid an epidural, you've got some uphill battling to do.
[9:22] And there are lots of Great Birth Rebellion podcast episodes that can help you labour without an epidural if that's your plan. So you don't have to have an epidural just because that many women do, but be prepared just in case. And I would encourage you to go to the back catalogue of the Great Birth Rebellion podcast because a lot of the purpose of the podcast is about how to work with your physiology and how to work with labour to optimise the function of your body.
[9:51] So let's have a look and we'll remember I'm not an anaesthetist, but I have a midwifery understanding and experience of how epidurals work and how the procedure is performed. So the information I'm giving you today is not from the perspective of an anaesthetist. I'd be glad for that because although anaesthetists are incredibly skilled and they are excellent clinicians, they really can only talk about an epidural from their own perspective, the epidural itself. And this is what often happens is that women are being told about the effects and the risks of an epidural from the anesthetist, whose only job really is to deliver that anesthetic and tell you about the risks of the epidural itself. The conversation centers around the procedure, but leaves out all of the flow on risk and.
[10:42] Doesn't involve the anaesthetist. So it's not their job to tell you the downstream risks of an epidural. That's the scope of your midwife or your care provider if you have a doctor caring for you. So the rest of the impact of an epidural are witnessed and managed by midwives, doctors, and pediatricians. So here I'm talking about the secondary risks of the epidural that are not isolated, to the site or insertion of the epidural. And so, you know, we're going to talk about the impact that the epidural has on your body and on your physiology as well. So essentially what's happening when you have an epidural is the removal of pain, and movement from birth and the structures around your pelvis and internal pelvic bowl relax and these should have tone during labor and birth. So this alters the way that your body works when you take away pain, movement, muscle tone, and then also there's an impact on your circulatory system. This has an impact on the way that your body works, but also on how your baby experiences labor and birth. And this is all beyond the initial insertion of the epidural. So we're going to go through both the risks of the epidural itself, but also the downstream risks and consequences of altering your physiology by having an epidural.
[12:05] So let's have a look. What is an epidural and how does it work? So an epidural is a procedure that involves the injection of local anesthetic, into the lining that surrounds your spinal cord. So it's called the epidural space, hence why they call it an epidural. That's where the medication is delivered, not directly into your spinal column, but there's a lining around it.
[12:29] And the epidural space is a potential space containing fat, blood vessels, spinal nerve roots. And so it's not just like this empty, airy, bubbly space where nothing's in the way. There are body parts in there and tissues. And in order to access the space, the anaesthetist needs you to sit upright and hunched over on a pillow. So they put a pillow on your belly and you hunch over it to create a C shape with your back. And that splays out all the bony segments of your spine, your vertebrae. And then when you hunch over, a needle can be passed between the vertebrae in order to access the epidural space. And that's the area around your spinal cord.
[13:13] And so your spinal cord actually ends in your lumbar region around L1, L2 vertebrae. So if you remember high school anatomy, below the site of L1, L2 in your lumbar spine, the nerves splay out a little bit like a horse's tail. So an epidural is inserted below the anatomy of the bulky part of your spinal cord. They position them there to minimize the risk of nerve injury. But there's still nerves down there. But I suppose positioning it below the spinal cord where it sort of mitigates the risk of potential nerve damage but it doesn't completely mitigate the risk of that and we'll talk about that later. So the basic idea is that you have to pass something that becomes a catheter into the epidural space around your spinal cord and it will deliver continuously anesthetic medication for the purpose of, numbing the nerves, to numb the pain that you feel in your uterus, stomach, vulva, pelvic area, and to a degree down to your legs.
[14:20] So although it takes away the pain, it doesn't take away all sensations. So you could still feel pressure and that could change as the baby moves down further into your pelvis. You can feel altering levels of pressure. But if it's working, you shouldn't feel pain. Having said that, epidurals are not guaranteed pain relief, but they are the most effective and most definitive option. So sometimes you can get what we call a window of pain where there's a part of your body where the epidural has no effect on it. It creates patchy pain relief and the epidural only works incompletely. That's also a possibility and that can really disappoint some women who were expecting full pain relief only to be left with a window of pain. Sometimes I'll offer you the opportunity to repeat the entire epidural process or you might just decide that, look, we just have to deal with it.
[15:15] But if it's working properly, the anesthetic medication that gets put into your epidural space numbs the nerves that carry the feelings of pain, allowing theoretical pain relief during labor because your nerves can't send pain messages to your brain anymore. Your body stops talking to your brain about pain. So that's cool if you don't want to feel pain, but pain is also a powerful communication tool for your body and a feedback system. So there are bound to be issues with that, which we're going to talk about when you stop the communication between your body and your brain regarding pain.
[15:52] Now, the medication that's infused into the epidural space is a combination of local anesthetic and an opioid. So they can be called different things in different countries, depending on where you are. The brands are different. It could be bupivacaine or ropivacaine, and the opioid is often fentanyl. Again, the names might be different in each country, but the medicines are the same. And it used to be, even when I was a student about 19 years ago, that if a woman had an epidural, she would be stuck lying on her back. She couldn't feel or move her legs. She was completely immobilized. She had to help her with everything. But epidurals have moved on from being completely numb and immovable women. Some of you may not even realize there was a different type of epidural. It's only just because I've been around for a while in midwifery that I've seen the change of very immobilizing epidurals now to ones that are a little bit less immobilizing. Basically, they use less medication than they used to, and this has created a circumstance. They call them walking epidurals. It's a nickname. It's not really true. You can't really walk around.
[17:02] Some women maybe can, but it's just a nickname, the walking epidural. So they put less medication in than they used to. It has all the same pain-relieving effects, but the woman, you can still move your legs, and often enough that you can actually, move around onto your hands and knees and change positions and sitting upright and you can actually move your legs and feel your legs.
[17:27] So that is a newer development and something that I also considered when I was doing this research because I know that some of the older epidural research is really not applicable to the newer epidural techniques. So I've favoured more recent epidural research knowing that it's more likely that it's studying this lower-dose epidural than the really heavy-dose, high-dose ones.
[17:52] But the modern-day epidurals certainly have allowed for more movement for the woman. And this is significant because it can help women get into more effective pushing positions than being flat on your back. And it also reduces the impact of you sustaining a severe tear.
[18:09] And also, you can protect yourself from a brash, opportunistic episiotomy. And so being upright can also mitigate some of the reasons why you might be offered a forcep or vacuum birth if you've got an epidural. Now, I'm mentioning all of this because epidural practices can vary from hospital to hospital and over the world. So wherever you are listening to this podcast, and they vary from hospital to hospital. So it's worth asking the anaesthetist if you're getting a low-dose epidural or what we might call the walking epidural, or if you're going to be completely numb and immobilized. Are you not going to be able to move your legs at all? So it's worth asking if they can give you, you know, if you have a preference for one or the other, then finding out what is on offer in that hospital. Again, it will depend on the skill level of the anaesthetist, the hospital policy, where you are in the world. They may not be able to diverge from their training, the hospital policy, you know, the usual procedure that happens in that place. But I would just ask the question, what type of epidural am I being given? I can't personally see a downside to getting a low dose epidural. They still have the same pain relieving effects as the classical one that had more medication in it, you just end up having more movement in your body with a low dose or walking epidural.
[19:26] All right, so that's a bit of an intro into epidurals and how do they put this thing in. Let's have a look. The process of how an epidural is inserted. We're going to go through that now. And this will give you an idea of the process, but also the additional add-ons that are included when you opt for an epidural. So it's not just an epidural that you'll be getting. There are risks and benefits to the epidural itself that you'll be receiving, but there is a whole bundle of other elements that go along with having an epidural. It's the epidural bundle and then we start to introduce new interventions, that come along with the epidural but these individual interventions also come along with their own risks and benefits and the anaesthetists will not tell you about those. Their job is to talk to you about the epidural itself but all of the other elements in the epidural bundle it's the job of your other care providers to tell you about the risks and benefits of those. But I very rarely have seen a thorough and complete information process conducted with a woman when she's electing to have a epidural during labor. The only real information I've seen given is from the anaesthetist and all of the other elements of the bundle are not really talked about. But we are going to talk about them today because we go there on the Great Birth Rebellion podcast.
[20:50] So the anaesthetist won't tell you because their job is to inform you of the risks and benefits itself, not all the rest of the stuff that goes with it. And all of this education is often given while you're in labour. So you're in a circumstance where you've already made the decision that you either want or need an epidural. Your mind is already made up, often before women even understand the process of an epidural. So at that point, you're willing to accept an epidural and the informed consent process becomes procedural rather than educational. It's kind of like, I've already decided I'm happy epidural and an anesthetist as well, I'm required to tell you all the risks and benefits. And then you sign the form to say, yes, you agree. But in fact, the decision's probably already been made before you had all the information. So that's what we're going to do today. Get all the information so that when it comes to the juncture where you might want to choose or need to choose an epidural, you can make a fully informed decision about the whole package. You know what you're getting yourself in for.
[21:50] So here we go. What's the process of getting an epidural? So firstly, there is not an anaesthetist waiting outside your door or even potentially in the birth unit just ready to give you an epidural. If you decide you want to have one, there is a period of time between your decision, and actual effective pain relief. Of course, the time frames vary widely depending on the circumstance, but hospitals sometimes, depending on the size of the unit, have to call their anaesthetist in. Smaller hospitals might not have them on site at nighttime, for example, if there's no surgery happening. But in busier hospitals, anaesthetists will be dividing their time between the operating theater, birth unit. And so if they're with another woman, then you'll have to wait. So they might be putting an epidural in for another woman. They might be attending a cesarean section. And so you'll have to wait. You go in the queue for an epidural. So if we think about the timeframe between making the decision to have an epidural, and you laying pain-free in your labour bed, a realistic timeframe is an hour to an hour and a half. So have that expectation in your mind that when you decide to have an epidural, it's not going to be instantaneous. There's going to be a waiting time.
[23:07] And so you make your decision, your care provider may offer you some education and the anaesthetist is called and they prepare themselves or finish what they're doing and then they come to you then there's this consent process and you fill in the form they let you know the risks and benefits and they explain the procedure and obviously you are also still in labor, going through all this so you're possibly having a hard go of it that might be why you've chosen to have your epidural and so all of these conversations preparations and education is happening in the gaps between your contractions. So you're still labouring but you're also making a complex medical decision.
[23:45] And after all that, if you agree, you sign the form, you're ready for it, the midwife will set up for the procedure. And this requires a clean and systematic process. It's a sterile technique. Obviously, they're putting something very close to your spinal cord. So there's a lot of positioning and preparation and cleaning and setting up that happens before the first single even goes in. And the process of putting in the epidural, putting it in place can take 10 to 20 minutes and it takes around 30 minutes to take full effect. So you can see what I mean with the one to one and a half hour lead time between decision and actual pain relief. And this can be really hard for women because you've already made the decision that you want it or that you need it, yet you still have to continue working through the pain of labor in the interim. And that waiting time can really require a lot more mental energy and mental strength from you. But also, this is the time that requires your support people and your care team to really give lots of extra care and encouragement and support, knowing that you're feeling like you've got no more capacity, and perhaps that's why you chose an epidural, you're going to need your team to really muster and help you with your mental energy and hold out until your epidural gets there.
[25:04] Okay, so back to the process. So if you aren't already in one, they'll ask you to put on a hospital gown because it opens at the back. Obviously, very convenient if you're having an epidural. So if you're wearing your own clothes, they'll ask you to take those off, time to wear a hospital gown.
[25:21] And I feel like this almost, it's kind of symbolic, draws a line that you're really moving from an autonomous, free-moving woman with control over what your body is doing. You can wee on your own. You can do all these things on your own. You're going through a physiological process of labor, but now you're moving into a type of labor that requires medical input for the remainder of your labor and birth. It symbolizes the commencement of a medical procedure and henceforth a medically managed labor and birth. So that kind of feels like that donning of the hospital gown kind of draws the line. You are now requiring medical management for the rest of your labor and birth.
[26:07] So next, your care team may take an updated blood sample or a blood test. And this is sometimes just part of the policy and procedure of an epidural. And you'll also have a cannula sighted somewhere in your hand, wrist, elbow, somewhere along one of your arms, sighted in your vein for IV or intravenous access for fluids. And depending on where you are, some facilities will start running fluid through that right away. And this cannula that they're using for IV fluids can also become a port to administer any other medications or anything if you need. So now, in your plan to have an epidural, you also have an IV cannula and IV tube attached to your arm for the rest of the labor. And this will have an IV pole and a pump, and that sits by your bedside. So these IV pumps will deliver fluid at a steady rate, but they also tend to beep for everything. So you are tethered to this machine and the alarm goes off for various things, and it's just so typical of hospital birth machines, they beep and alarm so often. I think if you do think you're going to have an epidural, you know, even just in general, take some ear-cancelling headphones or something that can block out the sound because the minute birth becomes medicalised and machines get involved, there's just so much beeping and it makes it really hard to rest if that was your plan.
[27:31] So if not already applied, you will have, throughout the whole time of having an epidural, a continuous fetal monitor, continuous fetal heart rate monitoring. Here in Australia, we call it CTG. And we've spoken about CTGs multiple times on the podcast, and I'll put those episodes in the show notes if you want to know more about them. They come with their own inherent risks and benefits. Some people think what risks could there be to actually listening to the baby's heart rate in labour, but we know there are many, many. In fact, we've had multiple episodes about CTGs just so we can cover them all. But a CTG will give a constant heart rate check on the baby and it prints out, the running tally of the baby's heart rate. So these two discs of the CTG are strapped onto your belly and they're attached to a larger CTG machine that sits again beside your bed and it makes heart beating and beeping noises all through the labor as well. So you can hear this constant kind of sound of the baby's heartbeat and if it detects anything unusual, it'll start beeping. But often these things beep unnecessarily. So now you're also tethered to a second machine by some cords or sometimes they're Bluetooth, they're CTGs. But again, in themselves, they have a reputation for limiting women's movement. And, you know, it just adds the immobilization of the epidural.
[29:00] The next thing that may happen is you'll be offered a vaginal examination prior to the insertion of the epidural. So some hospitals have a criteria for when you qualify for an epidural. It might depend on their resources.
[29:13] Also, though, if you request an epidural and then a vaginal examination is done, maybe you're actually really close to giving birth. You might be 8, 9, 10 centimetres, and maybe that would impact upon your decision to have an epidural. So often you'll be offered a vaginal examination prior to insertion of the epidural. It gives a little bit more information about whether or not you still want one, or you may be subject to a sort of selection criteria by the hospital as who qualifies for one and who doesn't. But your midwife will then check your basic observations before proceeding, blood pressure, temperature. And these things will all be done more frequently for the rest of your labor, as will the vaginal examinations. They'll be checking frequently and routinely, as will your observations. Again, the function of your body is going to change when you have an epidural. And so now it's the responsibility of your care providers to monitor and check, that it hasn't altered too far that we've actually created some pathology by introducing the epidural. And because an epidural can affect both your blood pressure and temperature adversely, your care team's aware of that and they'll check more often. Now, for the first hour or so, the blood pressure cuff may stay on because there's going to be a lot more frequent checks of your blood pressure early on to see that your blood pressure doesn't drop too far. So then we add to the epidural bundle the CTG.
[30:38] For heart rate monitoring, the IV for fluid administration, the BP cuff, the blood pressure cuff, and they're all attached to their associated machines around your bed by cords. So you're a little bit tethered at this point. Now, if all that checks out, the anaesthetist will come and give you some education about the risks of the epidural and ask for your consent to perform one. And you can ask as many questions as you like before you do that. And then off they'll go, they'll get an epidural trolley, The midwife will help you get into position while the anaesthetist sets up the trolley. And this is usually you'll sit on the side of the bed and your legs will be hanging over. They'll hopefully put something to support the bottom of your feet. Pillow will go on your belly and you'll be invited to hunch over the pillow and create a C shape with your back. And the anaesthetist will then be behind you on the other side of the bed setting up for the procedure. So the midwife will be with you, ideally, supporting you through the process and giving you some instruction with that.
[31:39] Now, don't forget, even though I'm just discussing this procedurally, you are still in labor. You're still getting contractions and potentially you chose an epidural because the contractions are big. So you'll have to navigate a number of contractions in this hunched over sort of C-shaped position. And the anesthetist and the midwife will communicate with you about which times it's okay to move and there will be times where you need to stay completely still and that could be through a contraction. They do work really hard to do things in between contractions but there are part of the epidural siding procedure that require you not to move. So if a contraction comes then that's going to take some self-control and the support of your care team to help you navigate that full sensation while also being hunched over a pillow in a c-shape.
[32:31] So you're in this hunched over position in a hospital gown which is open at the back, ivory fluids attached and the anaesthetist will tape some sterile drapes to your back which have a window cut out of it at the back and that represents the space where the anaesthetist will concentrate on for their procedure. Now they'll lather your back in some antiseptic to clean the area. This can be quite cold and some women can feel it trickling down their back and into their bum crack. It's just another one of those sensations that no one really talks about, but all that stuff can trickle down and wet your bum whole. It's a little bit unnerving. I've heard women talk about it and complain about it before. So just so you know.
[33:12] So now the insertion process can begin.
[33:16] So they'll usually wait until after a contraction, so they've got the most time between contractions, after which you've got to stay still and in the position that the anaesthetists guide you into because there's needle parts coming. So firstly, they'll inject a local anaesthetic around the area into the skin. That will be a few needles with local anaesthetic to numb the area so you don't feel the big epidural needle going in. So it's not your spine yet. It's just around the area where the epidural needle goes in. Obviously, it hurts because it's a needle with local anesthetic in it. But after that, you shouldn't be able to feel the pain of the procedure. But still pressure. You'll still feel some sensation, but not pain.
[34:03] So once that takes effect, they'll ask you to assume that C-shape hunch position for real now. There's a lot of little trial and trial goes as they find the right spot to put the needle in, but now it's for real. This is where it counts because a thick, firm, hollow needle is going to be passed through your skin, past your vertebrae in between the gap that your vertebrae will have when you're hunched over because they're splayed open. And the needle is it's a hollow tube and it creates a tunnel into the epidural space and through that they're going to pass a small flexible tube through the needle so you can imagine it's a hollow it's a hollow needle and it's got to be a lot bigger than the usual needle because they're going to pass a catheter or a little hollow tube through that, flexible tube and that's going to be what sits inside your epidural space. That big needle that they put in is just the, it shows the direction for where, the little flexible catheter needs to go. It's just an administration tool, I suppose. So once the metal needle is in place and they've found the right spot, there's some little tests and fancy things they can do to check that, yes, they're definitely in the right area. They will pass the flexible tubing through that needle and remove the metal needle. And then they will take the tubing in place.
[35:30] It will cover the whole entry site, this very big patch of sticky material. And then they'll stick it all the way up your back. So it's well and truly stuck to your back because they don't want that moving. So the metal needle is not really in for very long, maybe two to five minutes, depending on how easy the procedure is. They just get it in the right place. They make sure it's in the right place so they can pass the tubing through. Obviously, that will depend on the efficiency of the anaesthetist and your individual anatomy. I mean, some women, it's harder to find the epidural space than others. And, you know, some women report having multiple attempts at that. Okay, so now the plastic flexible catheter is inserted into your epidural space. It's all heavily taped up to your back and up to your shoulder. And the medication is put through that catheter that's in your back that's going to stay there the whole time because the medication gets continuously pumped through into the catheter. So think about how the fluid enters into an IV catheter. This is a continuous delivery of medication through that tubing, which stays in your back the whole time. And that.
[36:47] Tubing is attached to another port, which is attached to another cord that leads to your epidural pump. And that's the pump that delivers the medication continuously through your labor. So now we have the epidural tubing attached to its pump that's coming from your back. The CTG is applied to your belly with two discs and two straps. That's got its own machine. Then the IV tubing, which is delivering fluid to your veins, that's got its own pump and IV pole. And then because of the medication and its effect in your body, your midwife is going to be checking your blood pressure more frequently. So for the first little while, you might have also a blood pressure cuff attached that will be checking your blood pressure. So we've got the epidural package thus far. And your epidural pump can work in a number of ways. So that pump is going to have a medication bag attached to it and be delivering the epidural medication either continuously, just on a regular drip rate, or what we call little bolus injections. So it'll be, again, set to automatically deliver the medication at certain points, or there can be a way that you can control the dosage yourself. Obviously, there'll be a cutoff point. They won't let you overdose, but you just tap for more medicine when you feel like you need it.
[38:10] And now this can take time to take effect. Maybe think in your mind about 30 minutes to properly take effect. And while that's happening, while they're waiting for the epidural to take effect, it doesn't just happen instantly, it happens over time, your midwife will also place a urinary catheter through your urethra, which is where your urine comes out. And they'll pass the catheter into your bladder and insert and inflate a balloon. And that will remain there for the rest of your labor and birth. And this tube is attached to a bag where your urine will collect and the midwife will periodically empty that. So taking stock. Yes, you've got your epidural in. That comes with CTG monitoring for the baby, IV fluids, urinary catheter, more frequent observations. And so all of those individual additional items have, obviously there's a reason that they're there. They're there to mitigate some of the pitfalls of epidurals, but they also come with their own risks and benefits in addition to those of the epidural itself. So it's the epidural package, and each of these attaches you to a new cord, some new tubing, and a new machine.
[39:23] So, I mean, now this really does, there's no way around it. This represents a medicalized birth, and I'm not saying it to be judgmental in any way. But everything about this scenario is now medical and not physiological. You are having a baby. It's amazing. It's a beautiful moment. You're having a baby, but it's not physiological. It's just what happens when you have an epidural.
[39:51] So it's not saying that your physiology won't function. It's not like you're not going to have a vaginal birth. You absolutely can. But the chances are reduced in this scenario. And of course, it could be a vaginal birth, but it's not going to be a physiological one. And as I said, this is no judgment. It's just stating a point and something for you to consider if you're thinking about having an epidural. Thinking about having an epidural, you're also signing up for a medicalized birth scenario.
[40:22] So then what are some of the reasons that you might choose or be offered an epidural? There has to be a good reason. I mean, women wouldn't go through that process that I just explained for funsies. It's not just for fun. There's a reason why you'll choose an epidural. So let's have a look at some of those. All right. So you might just choose one because it's your choice. You might just want one. Maybe you don't want to feel the pain of labor. Maybe labor has been going for ages and you just really need to sleep and that's certainly the main reason that I see my clients choosing one they're they're fine with pain management, but with really long labors where they get just exhausted the purpose is to stop feeling the sensation of labor so that the woman can sleep and recuperate, so that she can push her baby out And there might be psychological and emotional reasons for why you need to dissociate from labor in this way. Maybe you have a clinical fear of labor pain. There are lots of reasons why women feel like they need to have an epidural, but certainly maternal request is one reason for epidural. You would want one, and there's lots of different reasons for that.
[41:37] The next reason that you might be offered one, it can be the medical solution to two particular issues. Some women will get an early urge to push so their cervix isn't fully dilated, but they really feel like pushing and they can't resist it. That can be for a number of reasons. We don't have time to talk about why that would happen at the moment, but a medical solution for that is sometimes to offer you an epidural. The other one is a swollen cervix. Again, not going to go through the details of this, but if you're experiencing a swollen cervix or an early urge to push, one of the medical solutions to this is an epidural. Now I've seen swollen cervix and an early urge to push happen at home. There's lots of other options for you to choose if that's what you're experiencing, but certainly in hospital, an epidural is one option that you'll be offered. The next one is, is if you're having an induction of labor. There's no mistake about it. There's been research on women's experiences. Induction of labour is far more painful than physiological birth. And so women may elect to have an epidural in the instance of induction of labour because of the difference in sensation.
[42:51] The other reason why a clinician may recommend one is if you're having a breach or twin vaginal birth, if that's what you're planning. Many practitioners, and I'm not saying this is right, I'm just telling you what it is. Many practitioners believe that for women planning a breach or twin vaginal birth, that an epidural should be in place. And this is for the sole reason that the practitioner believes that if the birth doesn't go well and that they need to intervene with internal manoeuvres, then it's easier to do that, it's quicker, and it's less traumatic for the woman if, she already has an epidural, it's more comfortable. Ironically, citing an epidural in these circumstances is likely to increase the chances of babies needing assistance to be born.
[43:42] But the other reason is that they're offered here is that you can quickly convert from a planned vaginal birth to a cesarean birth if that's required without needing to do a full general anesthetic. Again, not saying it's right, just saying that's one of the reasons why you might be offered it. If you have high blood pressure that develops through labor or can't be controlled by oral medications or IV medications, an epidural is offered as an option. So sometimes this happens with preeclampsia or gestational hypertension. One of the side effects of an epidural is that it can really drop your blood pressure. So some clinicians will take advantage of this side effect in this particular circumstance is to drop a woman's blood pressure.
[44:27] Obviously, if your blood pressure is already low, it can create a pathological circumstance. But in the presence of pathology, like a really high blood pressure that can't be managed any other way or with preeclampsia, then an epidural can have the effect of dropping your blood pressure. There are also some women with serious heart conditions or complex health conditions, who want to have a vaginal birth, but they're sometimes offered an epidural as a way of reducing physical and emotional stress on the body, if their body is already under stress, for example, with a serious heart condition. So labor is certainly physical and mental hard work and some women have health conditions that won't allow this. An epidural can be an option to help have a vaginal birth or experience labor but with an epidural in place. Now this is one that I absolutely hate. I think it's completely stupid but some clinicians will recommend that women who have bigger bodies that they should have an epidural to give birth for women who are larger. It doesn't make any sense. I think it's completely ridiculous but there you go. If you're a bigger woman you may be confronted with a clinician who recommends it purely on your size. I don't think that you need to, by the way.
[45:50] Now, the other reason that you might have an epidural, might be inspired to have an epidural is to relieve the pain and anxiety, of the people in the room, of your care provider, of your support people, of your partner, if it's the father of the baby or the other parent of the baby, who are just too emotionally immature to be able to help you manage, your labor and birth without letting their own experience impact upon you. And so they might want you to have an epidural to take away the pain so that you can manage the pain that they're experiencing by supporting you through a hard thing. Did I make myself clear with that? It's that some women have an epidural to relieve the pain discomfort experienced by the people around them who are unable to provide the woman with the support she needs because they're so upset by seeing the woman in discomfort that they can't see past their own needs.
[46:51] So they want you to be out of pain so that they can be out of pain because they don't know how to fully support you. They would like for you to not be in pain so that they can tap out of supporting you in that way. Now, this is not just the case with your support team. You might have a really rubbish support team who just wants you to have the epidural so that their workload is eased so that they can feel more comfortable in the birth space. But this can be the same for some, not all, definitely not all. Some midwives and doctors would simply rather that you become quiet, compliant, and immobilized, because they are more comfortable with medicalized management of birth and they don't have the skill or will or intention to support you through the process of labor. I know that all sounds really shady. There's actually no shade or judgment from me. It's just the truth of how some midwives work and how some people support other women in labour. Again, no judgement, just statement of facts.
[47:58] The other reason is that epidurals can replace one-to-one care. So research shows that where women have adequate support in labor by a tapped-in support team, a doula or a midwife, they require fewer epidurals and fewer pharmaceutical pain relief because their needs for support are adequately met. So sometimes a woman feels like she needs to have an epidural because the people around her cannot meet her needs or support her through labor. So she almost feels defeated. And needs to have an epidural. Okay, those are some of the reasons why women have epidurals or why they might be recommended them.
[48:35] Now let's have a look at how the epidural and the other interventions in the epidural package might affect your body. So let's start with the epidural itself and the medications that go through it. So there are first the risks to the actual procedure and the mechanical element of having an epidural sighted. So the fact that a needle and a catheter are in your epidural space near your spinal cord poses certain risks. And then there are risks associated with the medicine that goes in there. And then there are risks of what happens to you and your baby when you can't feel the pain of labor and the physiological function of your body is no longer optimal. So there's kind of compounding risks, both primary and secondary.
[49:19] And an epidural does also impact on the baby, both during the labor and afterwards. So we know that having epidural not only has a postnatal effect on you, but it also has a postnatal effect on the baby. And I've heard midwives and anesthetists tell women that the medicine doesn't impact the baby because it stays in the area, in the epidural area where it was inserted. But that's not true. And I'll show you some of the evidence as we go. Actually, the medication does leave your spinal cord. It enters your bloodstream and it reaches your baby. It can pass through the placenta and it does pass through the placenta. So that's the truth of it. Okay, now, so the risks of the epidural itself, and this is the information that you'll get from the anaesthetist when they come to count to you on the epidural. They have a well-rehearsed script that they rattle off. They remember all the stats so that they remember to tell all women the same. And then they'll ask you if you have any questions. and that they will only give you the risks of the epidural, their responsible part of this. That's their part and role is to give you the epidural. They don't give you information about the flow-on risks or secondary risks of the epidural.
[50:31] So here's what your anaesthetist will likely tell you and this is from the Australian Society of Anaesthetists and this information is what they have publicly on their website but also what I've heard say to women during the process of having an epidural. So, okay, they start with saying an epidural can be started at any stage of labor. It is very safe and can be used for both vaginal births and cesarean sections as it allows the mother to stay awake and alert during the baby's birth. So before we go any further, I'd also like to suggest here that safety is in the eye of the beholder. So calling something very safe is an opinion and a conclusion. It's not information. So what is considered safe and risky to one person is not considered safe or risky to another. So here's the information that they'll give you. You decide for yourself if this feels safe or risky.
[51:30] So if you have an epidural, there is a one in eight chance that you will need additional pain relief that's required on top of the epidural because your epidural wasn't completely effective for pain relief. So one in eight women will require additional pain relief on top of the epidural. There's a one in 20 chance that your epidural will not be functioning well enough for a cesarean birth, which means that if you move from planning a vaginal birth with an epidural and you're required to go into surgery, the epidural may need to be redone. You might require a spinal anaesthetic or a general anaesthetic. That's one in 20.
[52:13] 1 in 50 women will experience a significant drop in blood pressure and I'll tell you why that's important later and potentially dangerous later, 1 in 50. 1 in 100 women will have a severe headache. 1 in 1000 will have temporary nerve damage which could include things like a patch of numbness on your leg or weakness in your leg after the epidural or suit after. 1 in 13,000 will have permanent nerve damage. That's not expected to heal.
[52:45] One in 50,000 can have an epidural abscess or infection or meningitis. So that's an infection in your spinal cord that can affect your meninges. Serious scenario, but one in 50,000. One in 100,000 will have an epidural hematoma. So that's a blood clot in the epidural space around your spinal column. Also a one in 100,000 chance of unexpected affected anesthetic spread. Now, why is that important? Is that if you numb every nerve to your body and it spreads higher than the intended place, it can affect things like your breathing. So it's kind of serious, but it's very rare. One in 100,000. And then one in 250,000 women will have what is called a severe injury, which includes being paralyzed. So if a million women had an epidural, four of them would be paralyzed or have a severe injury as a result. I would assume this is lifelong.
[53:49] So those are the direct risks of actually having an epidural sighted in your back, the risks of the actual procedure. But then there are some flow-on possibilities and very few women actually get counseled about these. And I do know that some hospitals will have things like birth classes. So perhaps maybe in there they're talking about epidurals, But it would depend on who's running those and what kind of information they're delivering.
[54:13] Okay, so in no particular order, here are the other things that might happen to you when you choose an epidural. Obviously, one amazing thing is that you might actually get the pain relief that you were hoping for or it has the effect that you were hoping for. That's entirely possible. But one definite, without a doubt, thing that will happen, we can say that 100% of the time after having an epidural that you will fundamentally change the physiology and function of your body. And you can't rely on your body's natural birthing ability to work as it should. 100% of the time that you have an epidural, you have interrupted the physiology, of your birth, the way that your body would normally work.
[54:54] So when you remove the pain of labor and birth, you also alter the function of your hormones. And labor is so hormonally driven and so hormonally governed. It's a hormonal feedback mechanism and the feelings and the hormones rely on each other. So pain is an important part of physiology of labor and when that's gone your body doesn't function properly to give birth to your baby. Not saying it's going to not function at all but it's not optimally functioning. It may still work but not as it's supposed to. So don't expect physiology to remain intact. It's a bit delusional to think that when you take away the pain of labor you're not going to impact on any of the rest of the processes. Now when you interrupt physiology This means that you also increase the chance that you're going to need other interventions to fill in for the functions that your body would have normally provided. Because you've interrupted physiology, it's not working the way it's supposed to. So for example, a common thing that midwives see, and actually less so with these newer epidurals, is that once the epidural starts, the frequency and power of the contractions reduces. Which makes sense because we've interrupted the hormonal flow.
[56:06] And labor is often hormonally governed. It is hormonally governed. And when you reduce pain and interrupt hormonal flow, you change the efficiency of the contractions. And so if this happens, your care provider may offer you artificial oxytocin, so augmentation, via a drip to help you counteract this issue. And I remember when I was a student, this was in 2008, midwifery student. The hospital I was working at was considering routinely starting oxytocin for every woman who had an epidural because of the impact of this. I don't think it ever actually took off or became a thing, but there was certainly discussion and observation that when the women had an epidural, their labor contractions reduced or stopped in frequency or strength, and they needed to boost the function of the body by adding oxytocin.
[57:03] Now, the next thing is, is because of the impact of the epidural, there are changes to the shape and function of your pelvic floor and the pelvic bowl and the structures that are in there. And there is a purpose to your pelvic floor and pelvic bowl having adequate tone. They're important to help with optimal positioning of your baby in your pelvis. So when these are no longer functioning as they should, and then paired with reduced movement of your own body because of the impact of the epidural, there's an increased chance of the baby being in a suboptimal position to be born. So more chance that the baby's going to be in a posterior position and not as easily able to navigate your pelvis as it normally would. So this can lead to issues of malposition for the baby and then this requires further intervention. So either minor ones like you could change your position if your care providers are helping you change position or maybe some more major ones. So manual rotation where the practitioner puts their hand inside your vagina to access the baby's head and they can manually rotate the baby using their hand.
[58:09] Or they might choose to use forceps or a vacuum. And if none of that works and the baby remains in a malpositioned position and potentially becomes stuck or lodged in there, then they might solve this with use of a cesarean section. So you can see why I have a problem with epidurals being called safe. There appears to be a higher risk of an epidural triggering a cascade of intervention where one intervention leads to the next and then the next and as the risks and the impact, of the previous intervention compound they need to be mitigated and solved by the use of another intervention and then the cascade continues and so one study I looked at which had 500 women in it I know that doesn't sound big but for the purpose of epidural it's not a bad size and for the purpose of this study it's a suitable size, but they had 500 women and half of them had epidurals and half of them had none. And the rate of posterior positioned babies occurred four times more frequently in the epidural group. So if you had an epidural, the baby was in a posterior position 8.8% of the time. And if you didn't have an epidural, it was 2.2%.
[59:23] And now the positioning issue and the changes in the pelvic floor and potentially the changes in the power of the contractions and the woman's position can also lead to a more lengthy and difficult pushing phase. And this may motivate your clinician to intervene to speed up the pushing phase by offering things like an episiotomy or vacuum of forceps. And these interventions are commonly offered in response to a lengthy pushing phase anyway, regardless of if you're having an epidural or not. And so it makes sense that they would be offered in response to this even if you had an epidural or possibly even more readily if you do have an epidural and we know that the rates are increased of episiotomy forcep vacuum.
[1:00:13] But possibly they're offered more readily because there's fewer barriers. The woman can already not feel her vulva and it becomes easier to perform episiotomies because, you know, you're often on your back if you've had an epidural and it's all access area. And so it's kind of easier to do an instrumental birth or an episiotomy if you know a woman can't feel it and things are taking a little bit of time.
[1:00:37] Now, the next risk is that of maternal thermoregulation. So when you've had an epidural, your body is less able to thermoregulate to maintain a normal temperature. And there's multiple reasons for this. It's been studied, but we do know that it has an effect on your blood vessels, and that's possibly the reason why your thermoregulation is altered. It's the same mechanism by why your blood pressure would drop. So women who have an epidural are also more likely to have a fever during labor. But then you don't know if the fever is because of the epidural or if maybe there is an actual infection that's happening. And so what happens is it leads to more tests and more monitoring to find out, is there an infection or is this just the effect of the epidural? And so it starts a cascade of more testing and more screening and then possibly a decision to start antibiotics as a just-in-case scenario. So again, we're witnessing the cascade here. Epidural, change in thermoregulation, there's a fever. What do we do? Let's check if it's an infection or not. Well, it's a bit hard to tell. Why don't we just give antibiotics just in case? Now, the next thing is that the medication that does go into the epidural has a side effect of itself.
[1:01:56] I saw one study that said 60% to 100% of women, that was a combination of multiple studies. But the medication that goes into the epidural can cause women to feel really itchy all over. It's actually a really common side effect. So one of the articles, yes, said it ranged in the research from 60% to 100% of women experienced itching as a result of the epidural. And because of this, additional medications are given to counteract it. So it could be an antihistamine or if it's more severe, they can give you some stronger medication. So it's just another example of the cascade where one medication has a side effect. So let's just give another one to counteract the side effect of the previous medication.
[1:02:38] And another effect that women might experience, and this is particularly if an epidural is topped up for higher doses for more effective pain relief in things like a cesarean section, for example. And again, there's a few suggested mechanisms for this, but it's probably due to a change in blood flow and circulation that occurs when you have an epidural. The impact it has on your blood pressure and the effect on your thermoregulation, can cause uncontrollable shaking or shivering. And it's very pronounced, like women's bodies are shaking, also paired with the possible itching that you're getting and beeping machines and extra observations of blood pressure and things, it can make it really hard for a woman to rest if that was the intention of her epidural with all this other stuff going on.
[1:03:28] You know, they can help mitigate this with things like lots of warm blankets and comfort and wrapping you up to see if they can get you warm. But it's thought to be a shivering response.
[1:03:39] Okay, so we spoke about the drop in blood pressure that can result from an epidural. And sometimes this is a desired effect. If your blood pressure is really high and it dropped it, that's great. But if your blood pressure is normal and it further reduces this, it can create a pathological drop in your blood pressure. And one of the functions of blood pressure is to perfuse your own body with blood, oxygen, and nutrients. But when you're pregnant, your blood pressure also sends blood around your body to perfuse the placenta and therefore your baby with adequate amounts of blood, oxygen, and nutrients. And when you reduce your blood pressure, you also reduce the efficiency of your body to deliver blood oxygen and nutrients through your placenta and to your baby.
[1:04:28] And this is one proposed reason why a change in heart rate for the baby is noted on a CTG for babies whose mothers have had an epidural. So the reduced blood pressure means reduced blood flow and this means reduced oxygenation and an increase in the likelihood that your baby will have some challenges to their well-being. So it reduces the capacity of your baby to cope with the stress of labor, and it can be a reason that there's a non-reassuring condition for your baby and this might result in you requiring further interventions like a cesarean section. So there has been some research on this about the use of cesarean section as a result of presumed fetal compromise.
[1:05:13] So this particular study that I'm talking about, it asked how many women required a cesarean section during labor because their care provider thought that their baby was compromised and therefore needed to be born quicker. And so this study is called Effect of Intrapartum Epidural Analgesia on the Rate of Emergency Delivery for Presumed Freedal Compromise. And it's a nationwide registry-based cohort study. It was done in 2023 so likely with the more modern versions of epidurals so they wanted to know, how many women got cesarean sections after having an epidural because their clinician thought that their baby was now compromised, and they had a comparison group so they could also check how many women who didn't have an epidural had a cesarean section because their care provider thought their baby was compromised. Equal groups, equal types of women. So we can't say, oh, the women who had the epidurals, maybe they had more risk factors. Nope, they were equal groups. So in this study, among the women who received an epidural, and these are big numbers, I'll talk about the numbers later, but among the women who received an epidural, 13.2% of those women underwent an emergency caesarean section for presumed fetal compromise, so presumed compromise of the baby.
[1:06:38] That was compared to 4.1% of the women who had no analgesia, no pain relief at all. But then they also had a look at the women who received alternative pain medication, so not an epidural, but they did choose to have some medicine to reduce pain. And they had a cesarean section for presumed fetal compromise, 7%. So epidural, 13.2%. No pain relief at all, 4.1%. And if you had some other type of medical pain relief, it was 7%.
[1:07:13] So this one was actually a big one, great big numbers. It was a nationwide study of over 600,000 singleton births, so not twins or anything. All the babies were full term. This is a Dutch study, and they looked at birth between 2014 and 2018. And they had 120,000 women who had had an epidural, about 85,000 that had alternative analgesia, and over 400,000 that had no analgesia or pain relief during labour. And all risk factors were removed that would maybe have led to compromise of the baby. So if they had a chromosomal or congenital abnormality or malformation, if already the baby was in distress, if the woman had already planned a cesarean birth, if the baby was breech, and if they had used multiple forms of analgesia, they were excluded. So they tried to make the groups as evenly matched as possible so they could see if the epidural had an effect. And so the primary outcome, the number one thing that they were looking for is how many women who had an epidural had an emergency caesarean because they thought maybe the baby was compromised.
[1:08:26] So this study showed that your baby is at least three times more likely to require a cesarean section due to suspected compromise, if you've had an epidural versus if you've had nothing and twice as likely to need a cesarean section if you used other types of methods of pain relief. So this indicates that at the very least, if you have an epidural.
[1:08:53] Your baby will be more likely to show signs of distress that warrant cesarean section. In fact, three times more likely to show signs of compromise so much that your care provider will recommend a cesarean section as the solution. Now, the next question is, were these babies actually compromised or did they just appear to be? So then we have a look at the studies about low APGAR scores, the requiring of resuscitation and if the babies ended up needing to stay in a special care unit or neonatal intensive care unit. So one study, again, you'll find all these research papers in the resource folder for the podcast. So this next study was written in 2021. Again, it's a Danish study and it's called Epidural Analgesia During Birth and Adverse Neonatal Outcomes Population-Based Cohort Study. And this one was done on low-risk women, and it was comparing newborn outcomes for women who had an epidural versus the ones who didn't. So they looked at APGAR scores. They wanted to know how many babies had a low APGAR score, and an APGAR score is the score that your baby gets one in five minutes and ten minutes after birth. It kind of gives them a rank of how well they transitioned to extra uterine life. They also looked at hypoxia, so deoxygenization, but I'm not sure how they measured that fetal hypoxia.
[1:10:21] But anyway, and then they also measured how many babies needed to go to neonatal intensive care. So they matched the study groups and found that for women who had an epidural, their baby had a 0.6% chance of a low APCA versus 0.3% with no epidural. So that's double the chance that your baby could have a low up gut if you have an epidural. The fetal hypoxia rates, the low oxygen rates were the same, 0.6. But if you had an epidural as a low risk woman, in this particular study, there was a 10% chance. So a one in 10 chance that your baby would require admission to an intensive care unit. And that's compared to 5.6% if you had no epidural. So again, approximately double the chance of needing neonatal intensive care for women who've had an epidural. And another paper, which you can find in the resource folder again, it's called Epidural Analgesia in Labor, a narrative review, states that both local anesthetics and opioids, so the two types of medications that go into an epidural.
[1:11:26] Cross the placenta and can be detected not only in the umbilical vein of the baby, but also in the urine of the baby after birth. Which confirms that the epidural medication does not stay in the epidural space. It enters the woman's bloodstream and crosses the placenta, and the medications of an epidural do reach the baby. So the article states that these drugs may accumulate in a baby's body.
[1:11:51] Which leads to depression of the baby's normal bodily functions, including feeding latch and potentially breathing and transitioning. And this can also hang around. So the impact is long lasting because the baby has an impaired clearance capacity because their liver is immature. So liver enzymes that normally break down medications and clear them from our bodies are not as robust in a baby's body. It's an immature system, which means that the baby can't quickly break down and excrete the medicines after birth so that the impacts linger.
[1:12:28] Now, the article also explains that epidural is associated with a reduction in uterine artery blood flow through contractions. So even when using low doses of local anesthetic, which we use now in modern epidurals, there's still an impact on blood flow to the baby during a contraction, which is on top of the reduced blood flow that would already happen during a normally contraction anyway.
[1:12:52] So this information, it adds to the idea that with an epidural, there is thought to be an associated reduction in blood flow to the baby, both at rest and during contractions. Now, there's heaps of papers on the impact of breastfeeding establishment and the ability of the baby to breastfeed. It's a massive topic and I can't go through it. But the point is that, yes, there are papers that clearly indicate that use of epidurals impact on the baby's ability to feed soon after birth and potentially in the first week. Again, there's a lot of research on maternal satisfaction with epidurals. It's an entire research field in itself. And unfortunately, I can't go into it all today except to say that there is definitely a category of women who believe that an epidural enhanced their experience of birth. And so that's one positive effect is that you want an epidural, you had an epidural, it was a great experience, you're happy with the outcomes and you're glad you did it. That's one possibility.
[1:13:59] But there is also a category of women who felt profoundly disappointed with their birth and the result or the impact that the epidural had. There's so much to say to this. And hopefully by understanding what I've spoken about today, perhaps if your decision is informed, then you can feel more confident and more satisfied in your decision if you choose or don't choose to have an epidural. At least maybe with this level of preparation, it might impact on your experience of the epidural.
[1:14:30] Now, the next thing that can happen with an epidural is that it can be harder to push your baby out. And I've already spoken in detail about the strategies that you can use to push your baby out if you have an epidural. I covered it in detail, multiple, multiple options of how to mitigate that. In episode 167 of the Great Birth Rebellion podcast, I'll link it in the show notes below, I gave five suggestions on how to mitigate the fact that it's harder to push your baby out when you have an epidural. So if you go back and listen to episode 167 of the Great Birth Rebellion podcast, I'll link it in the show notes below, you'll get some really clear strategies and tips on how to push your baby out if you do choose to have an epidural. There are five things that you can do to make it easier and reduce your chance of needing a cesarean section, episiotomy, vacuum, or force at birth. Now.
[1:15:25] As we've learned, unfortunately, when you have an epidural, you can't rely on your body to function physiologically because you've turned off a lot of the necessary elements that allow physiological birth to function and unfold. So you have to rely on the involvement of your care providers to assist, coach, monitor and manage your labor and birth if you've chosen to have an epidural. It's just the reality of it. You've moved from physiological birth into a medicalised birth, and that requires a different type of management. Okay, that is what I have for you today. That is a broad sweep look at some of the benefits and pitfalls of epidural analgesia. I'm your host, Dr. Melanie Jackson, and I will see you in the next episode of the Great Birth Rebellion podcast. To get access to the resources for each podcast episode, join the mailing list at melaniethemidwife.com and to support the work of this podcast wear the rebellion in the form of clothing and other merch at thegreatbirthrebellion.com follow me, mel @melaniethemidwife on socials and the show @thegreatbirthrebellion, all the details are in the show notes.
This transcript was produced by ai technology and may contain errors.
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