Warning Signs of Preterm* Labor

Warning Signs of Preterm* Labor

(More than 1 month before your due date)

1. Menstrual-Like Cramps

(constant or come-and-go, just above pubic bone)

2. Low, Dull Backache

(constant or come-and-go)

3. Pressure

(feels like the baby is pushing down; feels heavy)

4. Abdominal Cramping

(with or without diarrhea)

5. Increase or Change in Vaginal Discharge

(mucosy, watery, light, or bloody)

6. Fluid Leaking From the Vagina

7. Feeling Bad

8. Uterine Contractions That Are 10 Minutes Apart or Closer

(may be painless)

If you have ANY of these symptoms 1 month before your due date, please call the birthing Center at 607-547-3535

Birth Plan

A birth plan is a way of organizing your thoughts about labor and delivery. As you learn more about yourself and childbirth, your plan may change.

Using this process can be a great opportunity to work through some of your fears about delivery and help put you in touch with your own feelings about birth.

Share your birth plan ideas with your midwife and labor partner(s). Your care provider will review it with you and it will be entered in your hospital chart.

Here are some statements to complete which you can use as a place to start:

Childbirth is…

I expect my labor will be…

I am concerned about…

Before Labor Begins

What is happening…

The baby may drop, called "lightening."
Braxton-Hicks contractions increase.
The character of the baby’s movement may change.
There is an increase in vaginal discharge.
Diarrhea or flu symptoms may occur.

What the mother may be feeling…

Excited that she is close to meeting her baby.
A spurt of energy or "nesting" instinct.
Impatient for labor to begin.
Nervous about her upcoming labor.
Disappointed, if she passes her due date.

What the mother can do…

Prepare the nursery.
Pack a suitcase for her stay at the Birthing Center.
Keep regular appointments with her midwife.
Practice relaxation, mental imagery and breathing techniques.
Continue her regular activities.
Rest, drink, rest, drink.

What the coach can do…

Be available throughout the day.
Prepare for the trip to the hospital.
Practice relaxation, mental imagery and breathing techniques.
Encourage your partner to get plenty of rest and sleep.
Help with household tasks.
Know the signs of labor.
Know the Bassett Birthing Center number – 607-547-3535.

Early Labor

What is happening…

Contractions begin irregularly, then over time establish a regular pattern.
Cervix is thinning out (effacing).
Cervix dilates 0-3 cm.

What the mother may be feeling…

Feels excited and relieved that labor has finally begun.
May be apprehensive about the course of her labor.
Feels very social between contractions.
May be unsure about whether labor has really started.
Contractions often feel like a backache, pelvic pressure, gas or cramps.

What the mother can do…

If day time, continue usual activities. If nighttime, try to sleep.
Remember to eat lightly and drink.
Notify your labor coach.
Pace yourself to conserve your strength for when labor becomes more active.
Rest, drink, rest, drink.

What the coach can do…

Remain calm and be reassuring.
Keep her company if she wants you to.
Encourage her to rest, and eat and drink.
Time contractions from the start of one to the start of the next one.

Active Labor

What is happening…

The quality of contractions changes, becoming stronger, longer and more frequent;
usually 3-5 minutes apart lasting 60-90 seconds.
The cervix dilates to 3-8 cm. Effacement is completed.
A regular labor pattern emerges.

What the mother may be feeling…

Becomes more serious, quiet, preoccupied with her own needs.
May doubt her ability to cope with future contractions.
Working hard.

What the mother can do…

Use relaxation and comfort techniques that work best.
Walk.
Change positions at least every half-hour.
Drink fluids frequently.
Empty her bladder at least every 1-2 hours.
Conserve her energy between contractions.
Rest, drink, rest, drink.

What the coach can do…

Create a safe, calm environment.
Massage the mother’s back, legs and arms.
Minimize distractions.
Remind her to keep up her fluids and breathe evenly.
Reassure her that she is doing well.

Transition

What is happening…

Contractions are stronger, come closer together and last longer;
contractions every 2-3 minutes, lasting 90 seconds.
This is the most intense stage of labor, but it is also usually the shortest.

What the mother may be feeling…

Overwhelmed with the intensity of contractions.
The urge to push at the peak of contractions.
Tendency to doze between contractions.
You may experience: tremors, nausea, vomiting, irritability.

What the mother can do…

Use whatever coping mechanism works to manage your contractions.
Relax between contractions.
Change positions.

What the coach can do…

Continue to offer comfort measures.
Be patient and understanding even if she is irritable.
Let her know she is doing a good job & that the end is near.
Encourage relaxation between contractions.
Stay with her.

Pushing

What is happening…

Contractions change in character: strong, but further apart;
every 3-5 minutes, lasting 60 seconds.
Baby moves gradually through the birth canal.
More of the baby’s head or hair is seen as delivery comes closer.
Shoulders are born one at a time.
The baby’s body slips out easily after the birth of the shoulders.

What the mother may be feeling…

An uncontrollable urge to push.
Relieved that she can finally push.
Burst of energy.
Pressure and stretching in the vagina.
Excitement as the baby’s head becomes visible.

What the mother can do…

Tell the nurse or midwife that you have to push.
Position yourself to promote more effective pushing.
Work with the pushing effort of your uterus.
Rest between contractions.

What the coach can do…

Assist the mother into a comfortable pushing position.
Offer ice chips between contractions.
Inform mother of her progress.

The 1st Hour of Life

What is happening…

Your uterus is shrinking to the size of a softball.
The baby’s urge to suckle peaks at 20-30 minutes.
Your baby is quiet (usually) and alert.

What the mother may be feeling…

Exhilarated at her success.
Cramping from the uterus as it gets smaller.
Involuntary trembling of limbs.
Warm blankets are provided for mother and baby.

What the mother can do…

Hold her baby close: skin-to-skin
Breastfeed (if that is her feeding method of choice).
Eat if you are hungry.

What the coach can do…

Enjoy the fruits of your coaching.
Take at least one photograph (optional).
Help the mother with positioning as necessary.
Eat if you are hungry.

Labor Recommendations

	P	Position: (change position frequently) Pillows, blankets, walking, sitting, leaning on coach during contractions, squatting, all fours, left-right side-lying, toilet, birthing stool
	U	Urinate: (at least every 1-2 hours) An empty bladder allows more room in the pelvis for the baby.
	R	Relaxation: Shower, Jacuzzi, music, massage, imagery, visualization, progressive relaxation, counter-pressure, warm/cool compresses, any activity you find relaxing.
	R	Respiration: Use normal even breathing to avoid hyperventilating. Some couples find specialized breathing techniques to be helpful during labor.
	H	Hydration: Drink clear fluids throughout your labor; juice, ice chips, lollipops, water, Jell-O, broth, ice pops. Ask your midwife or nurse if there is any reason you cannot eat as you would like.

Comfort in Labor: Breathing Techniques

ACH LABOR IS UNIQUE AND WOMEN EXPERIENCE THE FORCE OF LABOR DIFFERENTLY. Some women find a structured breathing pattern helps them through their contractions and keeps them in touch with their labor partners.

Focal Point

Purpose: To enhance concentration in labor.

Choose any object at or slightly below eye level to focus on while practicing breathing patterns. You can bring this same object with you to the Birthing Center and Childbirth Education Classes. Many women also find using an internal focal point effective; i.e., close your eyes.

Cleansing Breath

Purpose: To increase the flow of oxygen to mother and baby.
To signal the beginning or end of contraction.
To encourage relaxation.

1. Take a deep breath.

2. Breathe in through nose or mouth, out through mouth.

Slow Chest Breathing

Purpose: To manage contractions during early to active labor.
To deliver adequate oxygen to mother and baby.

1. Keep your face relaxed!

2. Rhythmic breathing in through nose/mouth, out through mouth.

Modified Slow Chest Breathing

Purpose: To manage contractions during active labor.

1. This technique begins as Slow Chest Breathing then the pace is gradually increased until the peak of the contraction. After the peak subsides the breathing pattern gradually returns to Slow Chest Breathing.

"Hee Hoo" Breathing

Purpose: To manage active to transitional labor contractions.

1. Inhale through your mouth, producing the "A" sound.

2. Exhale through your mouth producing either the "Hee" or "Hoo."

3. Use these techniques in a rhythmic pattern:
3:1 A-Hee A-Hee A-Hee A-Hoo
2:1 A-Hee A-Hee A-Hoo
1:1 A-Hee A-Hoo

Blowing

Purpose: To assist the controlled delivery of the infant’s head or shoulders.

1. Quick inhalation through the mouth.

2. Forced blows on expiration.

Tips for Using Breathing Patterns

Practice breathing techniques daily with your coach, mimicking 60-second contractions. Remember to always begin and end each contraction with a cleansing breath.

It is the coach’s role to help the laboring woman:
–relax between contractions
–help her concentrate on the breathing technique in use
–suggest another technique if the present one is ineffective.

Comfort in Labor: Positioning

HANGING POSITIONS FREQUENTLY CAN
IMPROVE THE PROGRESS OF YOUR LABOR
AND MAKE YOU MORE COMFORTABLE.

Positions for Pushing

Good positioning is particularly important when it is time to push. This means choosing a position which:

Makes use of gravity,
opens the pelvis wide, and
offers no resistance against the perineum.

The diagram above illustrates several different positions which will
complement your pushing efforts effectively.

Comfort in Labor: Massage

HE USE OF MASSAGE IS UNIVERSAL AMONG LABORING WOMEN. Any time we use "touch" to soothe or reassure a laboring woman we are using massage. Listed below are several easy-to-use techniques which can help ease the pain of labor.

Counter-pressure is a technique used to relieve the discomfort of "back labor." Many women experience lower back pain during contractions.

To do counter-pressure, the coach applies firm pressure at the base of the mother’s spine during contractions with heel of his/her hand. Moving the heel of the hand in a small circular motion while applying pressure can give additional relief.

Warm and cold compresses can also be used to provide relief during labor.

Perineal massage is a technique used to increase the possibility of delivering a baby without a tear or an episiotomy.

Instructions for Perineal Massage

The massage should be done daily for at least 5 minutes, beginning about 6 weeks before your due date.
Either you or your coach can do the massage.
Wheat germ oil, available at health food stores, is recommended by some people, but other vegetable oils can be substituted.
Make yourself comfortable, lying in a semi-seated position against some pillows.
The first few times you do this, take a mirror and look at your perineum so you will know what you are doing.
Dip your fingers into the oil and rub it into the perineum and lower vaginal wall.
Doing the massage: If you are doing the massage yourself, it is probably easiest to use your thumbs. Your partner can use his/her index fingers. Put your fingers 3 inches into the vagina and press downward (toward the rectum). Maintaining steady pressure, slide your fingers upwards along the sides of the vagina, moving them in a rhythmic U or sling-type movement. This movement will stretch the vaginal tissue, the muscles surrounding the vagina and the skin of the perineum. In the beginning you will feel tight, but with time and practice, the tissue will relax and stretch. Concentrate on relaxing your muscles as you apply pressure.

Comfort in Labor: Relaxation and Imagery

ELAXATION AND IMAGERY ARE TOOLS YOU CAN DRAW UPON TO HELP YOU COPE WITH YOUR LABOR. They require some practice, but can be mastered easily. Practice these exercises alone or with your coach(es). Like massage, breathing techniques and positioning, relaxation and imagery exercises can be used for more than just your labor. They are skills you’ll carry with you throughout your life.

Progressive relaxation is simply a way to relax your whole body by alternately tightening and relaxing your muscles from head to toe. This is how it’s done:

STEP 1: As with any type of relaxation, music helps. Put on whatever kind of music you like – just be sure it’s soothing. Use the same recording during your practice sessions at home and bring it with you to the Birthing Center for your labor. (Each room, including the Jacuzzi, has a cassette tape player.)

STEP 2: Get into a comfortable position. If your coach is with you have him/her read the following steps to you.

STEP 3: Lightly close your eyes and breathe slowly. Feel your chest rise and fall. Listen to the rhythm of your breath as you inhale and exhale quietly – with no more effort than a whisper.

STEP 4: Now begin to close your eyes tightly. Hold your eyelids down so that your upper face and brow are squeezed. Breathe slowly. Little by little release your eyes.

STEP 5: Clench your jaw. You can feel the tension travel across your face to your ears. The muscles in your neck are tight. Continue to breathe quietly through the tightening. Gradually release your jaw.

STEP 6: Pull your shoulders back and up toward your ears and hold this position. Breathe in and gently let the breath out. Slowly lower your shoulders. Let them fall back to their natural position. Breathe deeply. Notice how smooth your brow and face are. Your eyes are lightly resting closed. Your jaw is free. The strong muscles of your neck are comfortably settled.

STEP 7: Clench your right hand. Tighten your fist so that you can feel the tension run from your fingertips through the joints of your hand through your wrist and into the muscles of your lower arm and elbow. Breathe slowly. Now relax your fist by uncurling your fingers. Feel the release radiate through your hand, wrist, lower arm, and past your elbow. Shake your arm slightly and let it rest. (Repeat for the left hand.)

STEP 8: Tense your abdomen. Feel the stomach muscles pulling in. Breathe easily while you squeeze your abdomen. As you exhale let the tightening go. With each breath your stomach is rising, finding a comfortable place, in line with your chest. Let your upper body sink back.

STEP 9: Tighten your buttocks. Your entire lower torso raises up as you do this. Let your breath drift in and out. Let go of the buttock muscles. Release.

STEP 10: Stretch your right leg and flex your foot up. The back of your leg and calf are rigid. Your knee is locked. Breathe gently in, let your exhalation whisper out. Lower your foot slowly, releasing the muscles in your leg. (Repeat for the left leg.)

Breathe easily, without effort. Your face, eyes, jaw and neck are resting. Your shoulders are comfortable. Your arms are lying at your side. Your chest rises and falls to the rhythm of your breath. Your lower body melts into the floor. This is how it feels to be relaxed.

Responding to Your Labor – Relaxation

Objective – let go of tension which drains energy and resists progress of labor.

The setting for labor is important.
Atmosphere needs to be quiet, calm, somewhat darkened room.
Mother needs plenty of pillows for support.
Learn to observe and release tension in your body.

Touch of Relaxation

release tension to partner’s
touch and massage

Progressive Relaxation

release every muscle of your body progressively from head to toe.

Conscious Release

isolate a muscle group, tense and release it.

Mental Imagery

visualize the inside of your body giving way to your baby
mentally float with the contraction
stay completely relaxed as you concentrate on what is happening to your uterus, cervix and vagina.

Mental imagery or visualization uses your imagination to help you "walk through" your labor and delivery. It is a natural extension of the progressive relaxation exercise described above, because it works best when you are relaxed. This technique builds positive birth images which are yours alone – because they come from you. Mental imagery also increases your ability to concentrate and daily practice (with or without your coach) will give you a time to focus on your pregnancy and rest. So put on your labor music and imagine…

Your breath rises and falls like waves sliding over sand on a beach.
Your baby is listening to your breath flow in and out, the beat of your heart, the roll of your stomach.
Your uterus is holding your baby, wrapping him or her in its warmth.
The baby is moving, exploring, waiting.
You are riding along with your uterus as it tightens and relaxes, letting your body do the work.
As your labor passes in whispers, you are letting go a little more with each breath.
Your cervix is relaxed and softening with the rhythm of your labor.
Moving along with your body, you climb to the very peak of each contraction and then follow it down the other side… one contraction at a time… up, over, rest.
Each contraction is leading you away, opening your cervix, hugging your baby.
Your baby is finding its way down.
You are stretching, opening, working along with your body.
The strength of your uterus is overpowering, pushing, moving the baby out past the burning and through the pain.
You can feel your baby’s head, it’s there, reach down and touch it.
The force of your uterus rises again and your baby is born.
You are holding your baby for the first time.

You will review these techniques with your instructor in childbirth education class, but it’s a good idea to practice them regularly with your labor coach at home. The more you repeat these relaxation sessions during your pregnancy, the more effective they will be during your labor. Practice sessions at home also help your coach learn how to relax and how to be relaxing!

Comfort in Labor: Hydrotherapy

YDROTHERAPY MEANS USING WATER AS A WAY TO REDUCE THE DISCOMFORTS OF LABOR. It is both safe and effective. There are two options for hydrotherapy at the Birthing Center: taking a shower or using the Jacuzzi.

Showering gives you a gentle massage that can reduce the pain of labor by allowing your muscles to relax. Sitting on a shower chair and targeting the spray on your lower back provides relief for back labor. There are private showers in four of the LDRP rooms.

The Jacuzzi room is located in the Birthing Center. There are many advantages to using the Jacuzzi, see the chart below. Its primary uses are for enhancing relaxation in labor and the promotion/stimulation of labor. It may be used in almost any phase of labor and sometimes it is recommended for relieving discomfort in the postpartum period. Many women report feeling that the labor pains are "cut in half" or that "it made labor easier so I could handle it better."

It is safe to use the Jacuzzi whether or not your bag of waters is broken. This is because water cannot pass beyond the first third of the vagina.

Your nurse or midwife will check the water temperature – 98.6 works best for babies. If the water temperature is too warm the fetus could develop a rapid heartbeat. Although this circumstance is rare, your nurse will check the baby’s heartbeat periodically while you are in the Jacuzzi.

Between uses the Jacuzzi is sanitized. Both the tub and jets are cleaned with a Clorox solution and a disinfectant, then they are rinsed with water. This regimen has proven successful and is followed after each use.

Breathing techniques, position changes, relaxation and mental imagery are all easy to do in the tub where you can focus your effort without distractions. The Jacuzzi room has a tape player, so be sure to bring an audio cassette with you during labor. Coaches may hop in if it’s helpful to the mother-to-be. Also, be sure to take a drink, such as apple juice, with you to keep yourself well hydrated.

Advantages

Disadvantages

Safe

Effective non-medicinal method of pain control

Enhances the quality of labor contractions
without medication

Does not depress body systems in either
mother or fetus

Improves mother’s self-control

Provides a private, secure space to labor in

Promotes a focused labor effort

Reduces anxiety

May decrease Blood Pressure

Does not prohibit maternal movement or repositioning

Reduces back discomfort

Increases flexibility of muscles and tissue

Enhances perineal stretching

May intensify labor

Does not provide complete pain relief

May slow early labor (rare)

Analgesia for Labor and Delivery

L. Michael Newman, Ph.D., M.D.
Department of Anesthesiology
Bassett Healthcare, Cooperstown, NY

General Information

Epidural, spinal, or combined epidural anesthesia may be employed to relieve either labor pain or provide the anesthetic for a cesarean delivery. The techniques are safe for mother and baby. The anesthetic is usually administered by an anesthesiologist (M.D.), but may be administered by a CRNA (nurse anesthetist) under the direction of an M.D.

What is an Epidural, a Spinal, or a Combined Spinal Epidural?

All three techniques are similar in that they involve the placement of a needle in the lower part of the back. With the patient either sitting or lying on her side (usually the left side), the back is cleaned with an antiseptic solution and covered with sterile drapes. The skin and deeper tissues are then anesthetized with a small amount of local anesthetic using a very fine needle. The needle is now inserted to the proper depth and the anesthetic administered.

Spinal:
As can be seen in the figure, the spinal needle is passed between the bones through the skin, ligaments, epidural space and dura into the spinal fluid. Once in the spinal fluid, the medication is injected where it mixes with the fluid and blocks the pain receptors in the nerves and spinal cord. It should be noted that the needle is placed one to two inches below where the spinal cord ends so there is no injection into the spinal cord, but only into the fluid surrounding the spinal nerves and cord. The onset of spinally administered medications is rapid and usually their initial effect can be felt within minutes as warmth and tingling in the feet.

Epidural:
As can be seen in the figure, the needle is positioned in the epidural space that is next to the dura. Similar to the spinal anesthetic, the epidural is placed one to two inches below where the spinal cord ends. Once the needle is placed into the epidural space an epidural catheter (a very thin, flexible plastic tube) is placed through the needle into the epidural space. The needle is removed and the catheter is taped to the back. The patient can lie on her back with no problem after the epidural catheter is fixed in place. The advantage of this technique is that it allows for continuous and long-term administration of medications. For example, if the epidural is placed early in labor the anesthetic may be redosed as the labor progresses or if she should require a cesarean delivery a stronger medication may be administered through the catheter to provide anesthesia for the surgery. The onset of epidurally administered medications is slower than spinally administered medications and may take fifteen minutes for their initial effects to be felt.

Combined Spinal Epidural:
In this procedure, an epidural needle is placed as described above. A spinal needle is passed through the epidural needle and the appropriate medication is injected into the spinal fluid. An epidural catheter is then placed into the epidural space and the needle discarded. This technique allows for the rapidity of onset of a spinal anesthetic as well as for the long-term management with an epidural catheter. It is especially useful for the "walking" epidural used in some places for laboring patients as well as for the post cesarean delivery management of pain.

Walking Epidural:
This term denotes the use of very dilute solutions of medication via the epidural catheter, with opiates and/or local anesthetics (see drugs used below) given spinally or epidurally prior to the start of the epidural medication. The result is minimal to no numbness of the patient’s legs and no motor block (the patient can move her legs). The patient may be allowed to walk about the labor floor, get up and go to the bathroom (avoid using a bedpan), and/or sit in a chair and walk about the room as she desires. This will of course depend on her condition and needs the permission of her obstetrician as well as the proper choice of medications by the anesthesia team. The doses used in the "walking" epidural are appropriate for all labors. Only when the monitoring of the baby and the patient’s medical or labor condition permit, as well as the patient desiring to walk, is ambulation considered.

What Drugs are Used in Spinals and Epidurals?

Local Anesthetics:
The "caines" such as lidocaine, bupivicaine, ropivicaine, chloroprocaine and tetracaine are the local anesthetics commonly used in obstetric anesthesia. The choice of the drug will be dictated by whether it is given spinally or epidurally. Other factors such as speed of onset, length of action, procedure (labor vs. cesarean), and maternal health considerations go into the selection of the drug. The same drug may be used by the same route but in different concentrations for pain relief in labor or anesthesia for cesarean. There is no evidence that these drugs have any short- or long-term adverse effects on the baby, including the ability to nurse. Should you have a cesarean delivery, you will be unable to move your legs for up to a couple hours after the surgery. This is a normal effect of the concentration and amount of local anesthetic necessary to provide the anesthesia for the procedure.

Opiates (Narcotics):
Morphine, fentanyl (100 times as potent as morphine) and sufentanil (10 times potent as fentanyl) are the commonly used opiates in obstetric anesthesia. They are most often combined with local anesthetics and given in very low doses. Like the local anesthetics, there is no evidence that these drugs have any short- or long-term adverse effects on the baby, including the ability to nurse. These drugs may also be employed to provide postoperative pain relief after a cesarean delivery or an especially difficult vaginal delivery.

Epinephrine:
Epinephrine is sometimes added to opiates and/or local anesthetics to intensify and prolong their actions. Like opiates and local anesthetics, in the doses employed it has no adverse effect on the fetus or the mother.

What are the complications?

Death or paralysis occurs on the order of 1:500,000. This is an extremely rare event, and you are more likely to be hit by lightening or killed by pigs in Iowa or Indiana. There is a myth that if you move during the insertion of a spinal or epidural you will become paralyzed. This false statement is an attempt by a few practitioners to scare patients into holding still. Movement on the part of the patient makes the insertion of the spinal or epidural difficult and in some cases impossible, but does not result in paralysis.

Nerve damage occurs with a frequency of 1:10,000 to 1:20,000 and is rarely associated with the anesthesia. The most frequent cause of these obstetric nerve palsies is the position of the patient during, and the length of, the second stage of labor.

Headache does occur and the "spinal" headache associated with epidural or spinal anesthesia occurs in less than one percent of the cases. In most cases it is mild, self-limiting, and easily treated with pain relievers such as Tylenol™. A few cases require other measures, but whatever approach is taken a spinal headache is something that the anesthesiologist can easily treat.

Backache is common in pregnant women in both the pre-delivery and post-delivery phases. During the later part of the pregnancy there is a hormone secreted named relaxin. Its purpose is to relax the ligaments of the pelvis so the bones can move to allow the baby to exit via the vagina. The hormone also relaxes the ligaments along the spine and this, in combination with the added weight of the pregnancy, leads to the backache associated with pregnancy. In the postpartum stage the mother spends time bending over, picking up the baby, diapering the baby, etc. This also adds to the back strain. A number of studies have found no relationship between the use of spinal or epidural for labor or cesarean delivery and the postpartum occurrence of long- or short-term backache. It should be noted that after an epidural there may be a point of tenderness on the lower back where the needle was inserted. This is much like a bruised shin and should go away in a few days like any other bruise.

What are the Effects of Spinal or Epidural on Labor?

As previously stated, there are no unfavorable effects from the drugs on the fetus, newborn, or mother. There are some studies that have suggested epidurals during labor will increase placental blood flow. This should improve the nutrition and oxygenation of the fetus.

The length of labor is longer in those patients who request epidurals. A few well-done studies seem to suggest that women who opt for epidurals have more difficult labors than those who don’t. Additionally, current studies document that epidural usage increases the length of labor when compared to other modes of analgesia such as combined spinal epidural and, by extension, spinal opiates.

Cesarean section rate is not affected by the use of dilute epidural analgesia during labor, although three is an association between the use of epidurals and the incidence of cesarean sections. Many well-done studies have exonerated epidural analgesia as the culprit in the current cesarean delivery rate in the United States. The high rate of cesarean sections is multifactorial and beyond the scope of the present discussion.

Instrument delivery, i.e., forceps, is associated with but not caused by epidural analgesia during labor if current dilute solutions are employed.

Ability to push will not be affected by a properly managed epidural or spinal opiate during labor. If the labor should be a long one and the patient’s is numb and can’t tell "where to focus to push" then the epidural infusion ought to be turned off for 30-60 minutes and turned back on at a lower infusion rate. It is cruel and inhumane to turn of an epidural during the second stage of delivery. In fact, studies support that this is unnecessary and withdrawal of pain relief is inappropriate.

An increase in the mother’s temperature has been observed in some women having epidurals (0.5° to 1° C per 7 hours) and no negative effects have been observed in mother or baby.

Finally, as a result of the decrease in maternal pain, there is an alteration in the maternal levels of the stress hormones. This can lead to a decrease in the neonatal heart rate. It occurs in a small percent of the cases, is transient and without serious effect.

Summary:

Spinal, epidural, or combined spinal-epidural analgesia or anesthesia is a safe, rapid way to provide pain relief in obstetrics. It is safe for mother and baby and may be used for either labor or cesarean delivery. The complications are rare and relatively benign. Other than increase the length of labor, the use of this form of labor pain relief has little effect on obstetric outcome. You should not hesitate to opt for this mode of analgesia; there is no extra credit for pain during labor, and this author considers "natural childbirth" to be that accomplished without lipstick and eye shadow but with appropriate analgesia.