Planning for an epidural advice

[Duv]

I'm weighing up my pain relief options for birth and increasingly minded to ask for an epidural as soon as I can have one.

Initially I'd thought maybe I should play it by ear, start out with gas and air/ consider birth pool, but more and more I think, if I'm already quite pro epidural, realistically if I'm in a lot of pain how likely is it I will hold out from requesting one, since so many people who actively plan not to have an epidural end up changing their mind. So I'm thinking if I feel like I will likely end up having an epidural, with all the risks that entails, might as well get the maximum benefit from it as early as possible?

I know my hospital offers mobile epidurals which I think the patient can top up - how easy is it to control the pain relief with this? I would like to be able to move position, and have it wear off a bit to help with pushing (so that I get most of the pain relief for the contractions, pre pushing stage). Is it unrealistic to expect to be able to control the epidural pain relief that much?

Also what about going to the toilet? I know they often insert a catheter for peeing, but what happens about number 2s? If I had an epidural earlier on in the labour isn't it reasonably likely I'd have the epidural for hours and hours and eventually need to go to the toilet, not just for a wee?

Is there a time limit on how long the epidural can be in for? Like if you have one put in and 20 hours later you still aren't at the pushing stage is that a problem? Or can you take your time just as much as if you had no epidural?

And can you eat whilst you have an epidural in?

It may be worth taking a look at the labourpains website if you haven’t already - it has lots of info about pros /cons/ technique etc of epidurals and other pain relief (written by anaesthetists).

Protocols will be slightly different in each unit so perhaps best to ask your own midwife what usually happens where you’re booked in. You need to be in established labour to have a epidural (occasionally they’re used for a long latent phase, but that’s not so common). The epidural tubing can stay in for a few days, but if things aren’t progressing (eg in your example after 20hours) that would be prompting the MW’s/obstetricians to think about what’s holding things up and do they need to do/change something. Where I work there’s no eating once the epidural’s but clear fluids are allowed (there’s a slightly higher chance of ending up in theatre). It’s worth having a think about other techniques even if plan A is an epidural - occasionally it’s not possible to even attempt it, and occasionally (1:8) they don’t always work as well as we hope - there’s a significant amount of witch craft involved! HTH.

I've heard this mentioned before, but why would eating not be permitted? Is there any evidence that epidurals have an increased risk of ending up in a general anesthesic? I would have thought if anything they'd be less likely to, as if there are complications the spinal is already in place which would make getting into theatre quicker? And isn't the risk of having a general anesthesic in labour incredibly low, and even then risks from having a full stomach can be managed? It seems like the risk of eating with an epidural should be something the patient gets to decide not the hospital, given we allow patients to make much more risky decisions about their labour?

I have gestational diabetes so clear fluids as a way of getting calories/energy wouldn't really be a great option, as they'd all be from sugar.

Early epidurals (pre 5cms) are correlated with a higher chance of caesarean birth. The effects tend to be cumulative, so the longer they are in the less sensation is felt making mobilisation even less likely. Women don't tend to move around with an epidural so if you want to and can the motivation has to come from you and if you are tired, that motivation can be hard to muster.

I had an epidural with my first and nothing for subsequent ones. I would advise that if you can avoid it, you do. I'm not saying be a martyr or don't be open to it, just that I believe it's best avoided if you don't need it. I still have back pain from it many years later.

An epidural doesn’t increase the chance of needing a section, but does increase the chance of needing an assisted delivery in theatre. It doesn’t affect any of the other reasons a woman may need to come to theatre (tears/manual removal of placenta etc).

Having a good working epidural can mean that the chance of needing a GA is lower and there are some women for whom we strongly advise an epidural to try and reduce the chance of needing a GA. However, 1:20 epidurals don’t top-up well enough to provide anaesthesia. Depending on how far into the process you get before that becomes obvious then switching to a spinal may be an option, but if it isn’t then a GA is the only alternative. Sometimes in a real emergency there isn’t time to top-up an epidural even if it has been working well and a GA is the usual plan A then. When establishing the epidural or topping up for theatre it can cause complications that need a GA immediately.

Re. food, the normal physiology of pregnancy means that the risk of having a full stomach even just with clear fluids is significantly higher than in non-pregnant women. That risk is high enough that we have to do a ‘full stomach’ anaesthetic for any woman needing a GA after about 20 weeks gestation. Vomiting is common in labour and particularly in theatre and vomiting solid food whilst flat on your back (in theatre) is at best unpleasant. The real risk of solid food comes with GA though, with the combined effects of pregnancy on stomach emptying and the increased risk of having a ‘difficult’ airway (the chance of failed intubation at term is 1:250 so 10x higher than when non-pregnant) and the much higher rate of oxygen consumption can combine with disastrous consequences. Solid food in the lungs is more dangerous than clear fluid as it can block off bigger airways, causes more inflammation and is harder to get out.

So, while the risk of needing a GA is still relatively low, the risks associated with having a GA are high and have of a stomach full of food may increase the risk of a catastrophic event. It may be that anaesthetists are able to reassure on an individual basis that it is ok to take some food depending on any other patient specific stuff (eg how well labour’s progressing, any other anaesthetic risk factors, other medical problems), but it is most common for the starting point to be no food once the epidural’s in. Hope that helps.

I had an epidural with my first and second pregnancies and I’m planning to have one for my third. First pregnancy was all fine just had the pain relief as gas and air did absolutely nothing. Second pregnancy I started with gas and air which did help and made me feel woozy but quickly ended up begging them for an epidural (I was induced with this pregnancy so more painful anyway). They also got the needle stuck in my back and we’re about to rush me down to theatre to remove it when they finally managed to get it out. Sounds gross and was stressful but there was no pain. I find it’s hit an miss though with how effective the epidural is. The top up button lights up whenever it’s been long enough for you to have another dose. I have heard people say they have had an epidural and still managed to give birth on all 4s rather then laying down but I don’t know if this is true/safe.

I would still opt to have one this time round though

Hey OP. If you're set on having one, then do look up how to stay active with it as keeping your body moving and still using gravity can help birth go smoother

So look up positions, especially with a peanut ball and get your birth partner(s) involved in educating themselves on birth positions they can assist you with.

Basically you want to stay off your back to allow your sacrum to still be able to open and if you can get supported to get onto your knees that's great too.

Best of luck!

Just be aware they can only be offered if the anaesthetists are available to provide them. It was made very clear to me before I'd even asked in labour ward they were unavailable that shift.

You genuinely might not need one.

I was willing to have an epidural if I needed it but in the end I just didn't find childbirth anywhere near as painful as I was expecting. Didn't need anything stronger than a paracetamol. Obviously everyone's experience is different and every birth is different, but my experience does make me think that playing things by ear is sometimes the best way forward.

what happens about number 2s

It will come out with baby

I mean if you're really compacted and they think it will affect baby's descent you can be given an enema.

It's all part of a midwife's job though so they will be discreet 😊

I had an early epidural - couldn’t see the point of any pain or discomfort. It was brilliant - slept most of the day and watched Wimbledon. Highly recommended.

This (assuming NHS)

Midwives will often tell you to delay having an epidural under the belief that it will slow your labour. Anaesthetists are often difficult to get hold of or unavailable.

R.e eating/pooing. In all my labours, I cleared my bowels completely quite soon after contractions started. Maybe due to the contractions or nerves!

I also didn’t feel like eating at all during labour. A bit like how you lose your appetite when exercising.

I think it’s great to have a birth plan but be prepared for it go completely differently than planned x

Not sure how long ago that was, but there are nationally agreed guidelines re. the provision of epidural and the acceptable timescale for an anaesthetist to respond. There are also national guidelines for escalation if it's not possible to respond in that time. Super small units may not be able to provide a 24hr epidural service, but that should be made clear before 'the day'. One of the reasons the anaesthetist 'isn't available' is that the midwife hasn't actually asked them to attend - so it is always worth asking if that conversation's really happened (less common i think these days, but still definitely a thing).

I’m 39 + 5 and could have written this myself op! We are lucky to have a couple of friends who are anaesthetists (and have worked on Labour wards) and I’ve now written that I want an epidural as part of my birth plan.

A lot of people want a more natural birth and to see if they can cope before the pain gets to a certain level. Great if that works for them, but from that point, if you choose to then have an epidural you are relying on availability and up to 30 mins for it to fully kick in. No thanks from me. I can’t think of many (any) other medical scenarios where we are encouraged not to take pain relief.

For me, I trust in it as a form of pain relief. I don’t want a painful birth and I think the apprehension of pain will make me anxious and could fire up my adrenaline and slow down the birth.

In my own journey to think about what pain relief options are available and what I want, I’ve found a sense of shame from some people on me jumping straight to the epidural choice. If it’s right for you, just remember it’s your birth and your rules! Good luck