Recently I saw a question on a pregnancy and parenting page asking about being induced at 37 weeks for a “Big Baby” (estimated to be around 9ish pounds/4-4.5kg by 40 weeks). This particular mum-to-be didn’t feel comfortable with being induced then, and did say that, but was seeking advice and support that it was the right thing to do.
I did what I usually do, I advised of the risks, the benefits, that the estimated weight was not “Big” at all and many women birth babies even bigger than that vaginally and after spontaneous labour with no issues at all, and reassured the mum-to-be to follow her heart – in that if it didn’t feel right then tell her doctor that she didn’t want to be induced and would wait until baby decided to arrive on his/her own.

This kind of question is becoming more and more common these days, women being told they are having “Big Babies” estimated to be between 9 and 10pd (which isn’t “big” as such, it is just another variation of normal size) and will be induced between 37 and 38 weeks gestation because of that. These women are apparently not being given any choice in the matter, they are being told it WILL happen, that they NEED to be induced as if they don’t their baby will get stuck (shoulder dystocia) and die because it is too big to be born vaginally.

For the record, this is not evidence based medical practice, this is fear mongering and scare tactics and outright lying by medical professionals in order to get an expectant mother to do what THEY want her to do. A 9-10pd baby is not big, 11+ pounds is “big”. 9-13pd babies are born all around the world all the time without any issues when the mother is able to move around in whatever way she finds comfortable and as a result assist the baby in manoeuvring through the birth canal. In these cases there is no respect for a mother’s decision making, no allowing the woman’s body to do what it was made to do, preventing the natural physiological process of birth from occurring when the time is truly right and making women around the world afraid of a natural body process. To add to this a small baby is just as likely to get stuck as a larger baby if baby’s position and mothers position while birthing are not ideal. There are ways to prevent it and to reduce the chances of it happening, and early induction is not one of them and has a higher chance of shoulder dystocia by preventing the mother from adopting natural birthing positions due to the CTG monitoring and in many cases an epidural as well when the induced contractions become too much for the mother to bare and increasing the chances of baby being malpositioned when artificial rupture of the membranes (amniotic sac) is done as part of the standard practice of induction, traumatic physical and emotional intervention with the use of ventouse (vacuum), episiotomy, forceps and physical pressure on the mothers abdomen, and fetal distress from the induction itself resulting in either the above mentioned interventions or an emergency cesarean occurring.

But what I've mentioned just above is not what prompted this blog post. What prompted this is the lack of up to date knowledge in obstetricians and other mothers who were “fans” of this particular page and answered this particular question.
These “fans” were promoting induction at 37 weeks with no major risk factors or true need, stating that it was “term” and “baby would be fine”. This information is incorrect, not only have the WHO and ACoG, within the last 12 months, updated their guidelines of when “term”, “full term” and “post dates” are, but an induction at 37 weeks for no reason other than an ultrasound weight estimate (proven to be inaccurate in the majority of cases) shows that baby is measuring larger than average. The new guidelines state that “term” is now from 39 weeks to 39+6 weeks after recent research showing that a lot of important brain development occurs in-utero between 37 and 39 weeks and babies who stay in longer have less physical issues than babies born before 39 weeks gestations (eg feeding issues, regulating of body temperature issues etc), “full term” is now from 40 weeks to 42 weeks gestation, and “post dates” is now from 42+1 weeks onwards.

What does this mean for pregnancy and birth and going past 41 weeks gestation? Well frankly it means that every woman should now have a much higher chance of being able to go into labour naturally when their baby and body are really ready without the need to be induced, whether it is at 37 weeks that their baby decides that he or she is ready, or at 43 weeks, AS LONG AS all obstetricians and doctors follow the ACoG and WHO guidelines, which unfortunately for all of us women is not the case. Sadly most obstetricians and doctors do not follow these guidelines, they follow their own guidelines and the hospitals outdated policies on “management” of pregnancy and labour. And “management” it is, they are “managing” us like animals, inducing when they want, cutting us open when they want, giving us medication when they want, telling us what we can and can’t do, scaring us and putting the fear of death into us, only telling us what they want us to know and not what we need to know, essentially taking away our basic human rights and preventing us from making our own truly informed choices and decisions by not providing all of the information and only telling us what they want us to hear.
There are of course exceptions to this, there are some wonderful and truly amazing obstetricians and doctors out there who treat women with respect and dignity that they deserve and do everything that they can to inform women of ALL of the risks and benefits, accept a woman’s choices without trying to change her mind, support her unconditionally in those choices and go out of their way to try and give the woman the birth that she desires. They are few and far between, a dozen or so in every state, a few hundred or so in every country out of a hundred thousand or more obstetricians and doctors around the world that are trained in high risk pregnancy and birth.

“So what?” You might say, “They are trained in pregnancy and birth, they know what they are doing.” Yes, they are trained, in “HIGH RISK” pregnancy and birth, the types of pregnancies that might be dangerous for mum and/or baby. They are NOT trained in natural physiological childbirth, they are not trained in the kind of birth that does not need drugs to make it start, that does not need intervention or constant monitoring, that does not result in a mother on her back in a bed unable or "not allowed" to get up and move around and physically help her baby to get into a better position for birth, they are not trained in allowing a woman’s body to do what it was made to do and treat every woman the same as if they have the same risks as every other woman. Every woman, every body and every baby are different with different risks and different needs, we do not all fit into same mold (eg not everyone has a 12 hour or less labour just as not every woman has a very long 55+ hour labour), but obstetricians and doctors are trained to fit everyone into the same mold with the same risks regardless our own individual risk factors, body shapes, histories, abilities and needs.

How can we change this? How can we make pregnancy and birth an individual thing again? How can we make obstetricians treat us with the respect and dignity that we deserve? How can we make them respect our decisions and choices without trying to scare us or bully us into what they want us to do? The answer is that every woman and every man must make the decision to stand up for themselves and their partner, to say NO, to make obstetricians and doctors understand that it is NOT a medical professionals or hospitals decision to make on when a baby comes into the world, to make obstetricians and doctors stop scaring women with generalised risks and outright lies, to make the maternity system in whatever country you live in stop and listen and change its policies for the benefit of ALL women, to make pregnancy and birth about the woman once again and not about the medical side of things. Women everywhere need to take their bodies back, to make sure that everyone knows that SHE makes the decisions regarding HER body and HER baby, and that hospitals, obstetricians and doctors are NOT the ones to make the decisions. Even in a life or death situation the mother has the right to decide what is to be done and should be given the chance to do so, even if there is only a minute available for her to make that decision that will affect her and her family for the rest of their lives, she should be the one to decide, not someone else who doesn’t have to live with the consequences.

So there you have it. We live in a medicalised world that is slowly trying to remove all natural bodily autonomy from women, that is trying to stop women from being able to choose if she has an induction or cesarean or waits until her baby and body decide that it is the right time, a world where women are being scared and bullied into inductions and cesareans instead of being given the right information and support to make a truly informed decision over their bodies and method of birth, a world where women are ridiculed for their decisions, denied good care, denied the right support that they need and are traumatised on a regular basis when they are in the most vulnerable state and position.

Can you imagine a world where women are supported personally in a way that fits their individual needs and wants and are empowered in the process? Can you see a world where a woman is able to choose whenever she wants if she has a home birth, an unassisted birth, a hospital birth, an induction or a cesarean without being judged, ridiculed or traumatised in the process? Where she is truly informed about the risks and benefits of every procedure instead of only informed that  the medical professional feels is all she needs to know? Where she can birth however she wants without being lied to or scared by medical professionals? Where she can trust those who are caring for her and supporting her to give her the power to make her own decisions regardless of where she lives, her body shape, her previous history, or what she looks like? I can, I can see that world, our world can become that world. If we all worked together to make changes, if we all supported one another in our individual decisions regardless of what they are, we can create that world and make it ours.

Jenna Edgley
Student Birth Doula
Placenta Encapsulator
FOOTPRINTS & RAINBOWS

By Jenna Edgley, Student Doula, FOOTPRINTS & RAINBOWS

A big thank you to Janelle Durham for compiling the results of so many studies in one place.

How many of you know all about epidurals? Do you know all of the possible side effects? Do you know what good things that they can do? Do you know what can happen when things do go bad? And do you know the medical interventions that they can cause? Do you know when they are truly needed or when they aren’t actually needed and can be detrimental to your labour?

In this blog post I will be addressing all of these questions and more and supplying the most current (at the time of writing this) risk percentages in easy to understand explanations without all of the medical jargon (apart from the actual name of things like artificial rupture of membranes, where I also supply an explanation in layman’s terms).

What is an epidural and what does it do?

Epidural anaesthesia is a form of anaesthesia that blocks pain in a particular region of the body. The goal of an epidural is to provide pain relief rather than anaesthesia which leads to total lack of feeling, however many epidurals end up being quite strong and take all feeling away. Epidurals block the nerve impulses from the lower spinal segments which results in a decreased or completely numbed sensation in the lower half of the body. Epidural medications fall into a class of drugs called local anaesthetics. They are often delivered in combination with opioids or narcotics in order to decrease the required dose of local anaesthetic. This produces pain relief with minimal effects. These medications may be used in combination with other drugs to prolong the epidural’s effect or to stabilize the mother’s blood pressure. There are two types of epidural – the “numbing” epidural that numbs the lower half of your body, and the “walking” epidural, where after the initial dose only 1 of the drugs used in an epidural is administered, which reduces the amount of sensation to the lower half of the body while still allowing movement and the ability to feel contractions (in effect it takes the edge off the pain so that you can manage it successfully).

Will an epidural affect my baby?

Yes it will. The drugs used in an epidural travel through the blood stream, go through the placenta and go into your baby’s blood stream. In some cases the drugs used in the epidural can make the baby very sleepy after birth which can impact latching and sucking (if you are breastfeeding) and affect how much of the bottle the baby drinks and how well it sucks (if you are formula feeding). Sometimes the epidural drugs can make your babies heart rate go up really high (180 beats per minute or higher) or really low (under 90 beats per minute), this is classed as distress and in the majority of cases a cesarean is needed quite quickly to get the baby out safely.

What are the side effects of having an epidural and how common are they?

An epidural can lower your blood pressure which in turn can reduce your baby’s heart rate and reduce the amount of oxygen that baby gets. You are approximately 74.2 times more likely to have this happen than someone who does not have an epidural (depending on which study you read you have up to a 50% risk of this happening with an epidural).

An epidural can cause you to develop a fever (raised temperature above 38 degrees Celsius). You are 5.6 times more likely to develop a fever than someone who doesn’t have an epidural (depending on which study you read you have a 4%-24% risk of this happening with an epidural, some studies showed that 95% of those with epidurals developed a fever).

An epidural may cause uncontrollable itching, especially when an opioid (a drug made from opiates and their derivatives for example anything with morphine or codeine in it) was included in the medication. An average of 62% of women with an epidural with opioid medication included experienced itching of various intensities. Without the opioid only up to 4% of women experienced itching with most cases appearing to be mild and very few mums requesting treatment for the itching.

An epidural can cause sedation or drowsiness. The Mayberry study showed that an average of 21% of women with an epidural experienced this.

You may need augmentation with pitocin or similar induction drugs if you have an epidural. The Mayberry study showed that women with an epidural were 2.8 times more likely to need augmentation of their labours if they had an epidural.

If you have an epidural you will be more likely to need an assisted delivery (ventouse/vacuum or forceps delivery). In the Lieberman compilation of 16 individual studies it showed that an average of over 50% of women with an epidural were unable to push their babies out without the assistance of the ventouse (vacuum extraction) or forceps.

According to Thorp’s study of 93 women (only 1 woman in the non-epidural control group opted for an epidural) you are 11 times more likely to end up with a caesarean section with an epidural than a woman without an epidural. Lieberman et al (1996), found that there was a 17% risk of caesarean from an epidural.

An epidural may increase your risk of having a post partum haemorrhage, the Lieberman study showed that women who had an epidural where twice as likely to have a post partum haemorrhage than women who didn’t have an epidural (10% with epidural compared to only 5% without an epidural).

You may experience a severe headache after birth. These can last for as little as 8 weeks, or as long as 8 years after birth. This is caused by a small leak of spinal fluid into your blood (also called a dural puncture) and can be fixed with a blood patch where a small amount of your own blood is injected into the epidural space and can relieve the headache.

You may develop a back ache on the first day after your epidural is removed. The few studies on this have shown no noticeable percentages in further abnormal headaches at 1 week and 7 weeks post partum, but there could always be exceptions.

What is good about having an epidural?

An epidural can block or reduce the pain from contractions.

An epidural can help you to rest and recover your energy during a long labour or a very painful labour (an induced labour involving pitocin or similar inducing drugs can be more painful than a “natural” labour so an epidural can be helpful in inductions).

It can lower your blood pressure (this doesn’t happen to everyone and is extended upon in another answer below).

It can help you to relax if you are “tensed up”.

Some women have a more positive birth experience with an epidural.

If I have an epidural what are the most common interventions that can occur as a result?

The most common interventions are:

1 – Artificial rupture of membranes (if they haven’t already broken) where the Midwife/Nurse/ObGyn breaks the amniotic sac.

2 – Pitocin/Syntocinon, an artificial oxytocin drug that is used to induce or augment labour and is used by many obstetricians to make labours go faster than they would normally may be started if the epidural causes your labour to slow down or stop. Pitocin/Syntocinon has its own risks that could be detrimental to labour and babies health as well.

3 – A caesarean section (c-sec) where the baby is cut out of your uterus. This is major abdominal surgery and in the average woman who has no complications as a result of the surgery is not fully healed until around 6 months after it occurs.

4 – Consistent Electro- Foetal Monitoring (CFM), where special pads are placed against the mothers skin to pick up the babies heart rate and another pad that picks up the contractions, these are often held in place by stretchy straps (that appear similar to seat belts), or in some hospitals this is done with the use of sticky pads similar to what is used to monitor your heart in an echocardiogram or a it can be done with a clip that is placed on the baby’s skull. This can be very uncomfortable for many mums and usually means that the mum has to remain on her back on the bed as movement can make the baby move away from the pad picking up the baby’s heart beat.

5 – A urinary catheter. Basically when you have a run of the mill (or full) epidural, and even quite often with a walking epidural, you can no longer feel when you need to do a wee. A urinary catheter is placed, with a small medical balloon attached to the end of it which is inside your bladder which is inflated to hold the catheter in place, and has a collection bag attached to it to collect the urine so that the urine doesn’t build up in the bladder. The side effects of this are discomfort for a few weeks afterwards, urinary tract infections (these don’t always happen but have been reported as a common occurrence by many mums) and the possibility of receiving a diagnosis of “obstructed labour” if the urine starts to get a rose coloured tint to it (this can sometimes be caused by baby’s head pressing on the bladder as he/she descends into the birth canal and the balloon from the catheter can cause baby to get stuck and not descend any further – in this instance deflating the balloon and repositioning it further into the bladder can help a lot – rather than being a genuinely obstructed – read stuck – baby), and incontinence. A not very common complication of having a urinary catheter is scarring and bladder damage.

When is an epidural really needed?

There are several things that could suggest that you may need an epidural.

The most common of these is exhaustion, when you are extremely tired and have been labouring for over 24 hours without sleep an epidural can be placed to allow you to “have a break” from the contractions and enable you to get some decent sleep before the big show starts.

Another time an epidural may be needed is if your blood pressure is steadily rising during labour and is getting close to dangerously high levels. One of the side effects of an epidural is lowered blood pressure, and in this instance an epidural can be very helpful. This doesn’t always work for everyone however, and in some cases it can do the opposite and make a woman’s blood pressure go even higher. No one can predict who this will work for, and sometimes it can work for one labour and not for the next labour and vice versa, so it really is a “see as you go” scenario.

Epidurals can also be easily turned into spinal blocks, so if you are attempting to have a “Natural Caesarean with trial of labour beforehand” then an epidural can work really well in helping you to avoid the pain caused by contractions to begin and making it easier for you to get a spinal block when you do go to theatre. The down side of this is that labour can stop shortly after an epidural is placed which may mean that your body doesn’t get the full effects of natural oxytocins, or it can drop your blood pressure so low that you don’t get to experience your “Natural Caesarean” in the way that you wanted to.

If you are “tensed up” from the pain then that can slow your labour down and make it last longer than it normally would. In this instance there is around a 50/50 chance that having an epidural placed can allow you to relax enough to dilate quicker than you previously were and enable your baby to be born sooner.

When isn’t an epidural needed?
1 - An epidural isn’t needed as soon as you arrive at the hospital if you and baby are happy and you are not exhausted.
2 - An epidural isn’t needed before you reach 4cm dilated.
3 - An epidural shouldn’t be placed after you reach 8-9cm dilated.
4 - An epidural should not be placed if your blood pressure is already lower than normal. It may make it drop even lower which will not be good for you and can negatively affect your baby.
5 - If you are in transition and start demanding an epidural (which happens more often than you would think even in mums who are labouring drug and intervention free by their own choice) an epidural should not be given. Not only will it most likely not start to work on time, but if there is enough time for it to work it can make pushing very hard and even make your pushing not be effective enough to get the baby out.
6 - If you use blood thinners then you should not have an epidural.
7 - If your platelet counts are low then you should not have an epidural.
8 - If you are hemoraghing or in shock you should not have an epidural.
9 - If you have an infection in your back then you should not have an epidural.
10 - If you have a blood infection then you shouldn’t have an epidural.
11 - An epidural should not be done if the epidural space cannot be located by the anaesthetist.
12 - If labour is progressing too fast and there is not enough time to administer the drug (mentioned in #'s 3 and 5 of this section).

Why do some doctors insist on epidurals as soon as a woman gets to hospital while in labour?

Training, hospital policy and personal beliefs. Many older doctors were trained when epidurals were considered to be “the next best thing to chloroform” (chloroform, amongst other drugs that are now not used, was used extensively in the 50’s and 60’s to effectively “knock women out” so that they wouldn’t have to be in pain or make a sound during labour and birth) and they see it as an “aid for labouring women” in a misguided belief that no woman should go through that kind of “pain”. Many also feel that women should not make a sound during labour or pushing and a full epidural is the best way to achieve that in lieu of performing a caesarean section. Newer doctors are trained differently but their personal beliefs and desire to prevent what they see as “unnecessary pain” can make them think that epidurals should be given to everyone.

I must point out that not all doctors are like this, there are many who prefer to avoid the use of an epidural if they can, and many who prefer for the woman to decide if she has one or not rather than forcing it on her.

Some hospitals have a policy of making every woman who arrives in labour between 4cm and 8cm have an epidural placed. This is not evidence based and can be detrimental to a woman’s labour and birthing experience. Hospital policy is not law however, and you always have the right to refuse if you wish to. If anyone tells you otherwise then they are not supportive of you and you can request someone else to look after you.

What can I do to reduce my risks of further intervention or any damage to my spine if I choose to get an epidural?

Have a very experienced anaesthetist administer your epidural, and ensure that the cords are placed somewhere where they won’t be underfoot. Also if you already have spine issues (bulging/compressed disks and spine damage) then it might be best to avoid an epidural altogether.

To avoid further intervention get a “walking” epidural, which only has one of the 2 epidural drugs administered to you. This way you can stay active and “feel” the contractions without feeling all of the “pain” as well. This kind of epidural is beneficial for pushing as you can still feel the surges and the pressure and can push more effectively.



Study Sources:
Lieberman E, O’Donoghue C. Unintended effects of epidural anaesthesia during labor: A systematic review. Am J Obstet Gynecol 2002; 186:S31-68. A total of 1900 articles were examined, and evaluated for inclusion in the review based on the authors’ criteria. They limited their review to original reports in English, in peer review journals since 1980; they included both randomized trials and observational studies; they excluded studies with no control group, studies that evaluate specific drug regimens, studies that examine epidurals for anaesthesia during cesareans, studies conducted exclusively on high-risk populations, studies where population selection renders results uninformative, studies with analytic choices that make results impossible to interpret, and studies that examine outcomes only for the overall population of delivering women.

Mayberry LJ, Clemmens D, De A. Epidural analgesia side effects, co-interventions, and care of women during childbirth: A systematic review. Am J Obstet Gynecol 2002; 186:S81-93. More than 700 publications were identified; they narrowed that down to 150 studies that addressed one or more of the common side effects and co-interventions, plus 75 articles addressing relevant clinical or nursing care information related to unintended effects of epidurals. They only included prospective, randomized, controlled trials published between 1990 and 2000. These studies were then further limited by pre-established criteria: evidence of little or no crossover effect, minimal loss of subjects after random allocation to comparison groups, and satisfactory description of the randomization procedures. In the final review, they included 19 studies, with a total sample size of 2708 women.

Thorp JA, Hu DH, Albin RM, McNitt J, Meyer BA, Cohen GR, et al. The effect of intrapartum epidural analgesia on nulliparous labor: a randomized, controlled, prospective trial. Am J Obstet Gynecol 1993; 851-8.

Other Sources
http://americanpregnancy.org/labornbirth/ (under the section on Epidurals)