(during an epidural catheter supply shortage)
Are you considering an epidural for your birth? How did you come to that decision? Have you thought about other options or alternatives? Here are some things to consider that can help you feel more informed:
Epidurals
are the most effective and commonly used method of pain relief during labour. About 60% of people giving birth in Canada use an epidural to receive effective and continuous pain relief by blocking sensation to the lower parts of the body. Epidurals can provide pain relief while the birthing person remains awake and alert, but also allow them to rest or sleep if they are exhausted from a long or overnight labour.
In a 2018 Cochrane review, that included 40 randomized controlled trials and over 11,000 participants, epidural analgesia resulted to be the most effective method of pain relief and best maternal satisfaction when compared to injectable opioids and using no analgesia. They also proved to be safer than injectable opioids with less risk of nausea and vomiting or breathing problems. However, epidurals also showed to increase the risk of severe perineal tears, low blood pressure, fevers, urinary retention, longer first and second stages of labour, more need for Pitocin and increased risk of Cesareans for fetal distress.
Epidurals also come with a bundle of interventions and contribute to the medicalization of birth. Low blood pressure caused by epidurals, often requires frequent blood pressure monitoring and IV fluids. The loss of sensation of the lower body does not allow the labouring person to walk and move about in labour, but instead they must remain lying down in bed for hours. This may further slow the progress of labour, requiring pitocin for augmentation but will also require catheterization of the urinary bladder. Epidural medications can cross the placenta and can impact baby’s suckling and breastfeeding. These are all important factors to consider when making a decision to use an epidural and should be used only when the benefits outweigh the risks.
I am absolutely not anti- epidurals, in fact, I think epidurals can feel life-saving at times, but do think they are grossly overused and most birthing parents that used them are probably not aware of the associated risks and have chosen to use one without full informed consent. And what about this current world wide shortage of epidural catheter supplies??
So, I think it’s time to start thinking about other comfort measures that are good to start with regardless of your choice for an epidural, since a lot of them can be used together AND MAYBE you won’t need an epidural at all (OR in case epidural supplies are not available). Here are my a few of my favourites:
Nitrous gas,
otherwise known as laughing gas is a great option for those who don’t want to use an epidural, and although it does not provide the same amount of pain relief as an epidural, it does have similar level of pain relief than injectable opioids with fewer side effects to the birthing person or baby. It can be used at the hospital by your OB or your midwives, it is simple to use, can be used during any part of labour, works instantaneously and has the benefit of giving the birthing person control as they choose when they take their next ‘hit’. Some of the disadvantages include that it must be taken repeatedly as needed and can cause a sense of detachment, a feeling of claustrophobia from the mask, as well as nausea, dizziness or vomiting in some cases. It can also cause adverse effects on people with a B12 deficiency.
Hiring a doula
or having continuous labour support can help families who chose a home or hospital birth or any type of pain management tools. Doulas have been found to increase birth satisfaction for the birthing person and their partner by providing physical support such as massage, positioning, breathing, as well as emotional support with encouragement and words of affirmation. Doulas can also support the family through education and advocacy. RCTs have found that continuous labour support is linked to a reduced rate of pain medication, shorter labours, reduced risk of having a Ceasarean birth as well as babies with better APGAR scores AND they are risk-free! The only disadvantage is that not everyone can afford to hire a professional doula. However, if that is the case, I encourage you to ask someone that you trust like a friend or family member to help provide an extra set of supportive hands.
Water immersion
is another great option that can be used during labour or birth, at home or at some hospitals as an alternative to pain medications. It is not as effective as an epidural but more effective than injectable opioids. RCTs have shown that water immersion lowers pain scores and the use of pain medications during labour, but also reduces maternal anxiety and increases birth satisfaction and privacy. Water immersion can take a bit of set up and managing during the labour, but for most is an enjoyable and exciting part of setting up your environment for a homebirth. The only disadvantage is that it is not available in all birth settings or potentially the cost of buying or renting the pool for a homebirth.
Hypnosis and mind set
are great free, non-invasive, and accessible methods that should be used by everyone, epidural or not. Hypnosis might involve different techniques such as relaxation, deepening, breathing, imagery and visualization with the ultimate goal of changing the mindset before giving birth. This can help the birthing person to feel more confident and trust their bodies and birthing instincts as well as release fears about birth. In studies, people assigned to hypnosis groups are less likely to use pain medication than those in the control group. Really, the only drawback is that these methods need practice and consistency to be used effectively.
Breathing and Relaxation Techniques
are simple, non-invasive and accessible methods to help cope with labour that can be used alone, but are best used in combination with other methods. Conscious breathing has shown to lower pain scores in several trials, when combined with other non-drug approaches such as labour support, massage, muscle relaxation and labour support. In one trial, relaxation techniques lowered pain intensity by 1.3 points in early labour. Also, learning these techniques can have positive benefits far beyond labour and birth, such as extending to breastfeeding, parenting and work.
Childbirth Education
has shown to reduce the rate of epidural use, lower the rate Cesarean births, shorten the second stage of labour and less perineal trauma. CBE may also benefit parents by reducing the fear and anxiety as parents are better prepared when they learn about expectations of labour as well as effective coping strategies.
It is important to remember that maternal satisfaction during labour doesn’t all come from the method of pain management that was used or how effective it was, but rather on how mom was supported and made feel during this time. I hope that this information is useful in helping you to make a decision about pain management strategies that you might use during your labour. If you would like more information on any of the above interventions or techniques I encourage you to check out our Evidence Based Birth Childbirth Class or another class in your community.
References
Hodnett et al. (2002). Am J Obstet Gynecol, 186(5 Suppl Nature), S160-172
Anim-Somuah M, Smyth RM, Cyna AM, Cuthbert A. Epidural versus non-epidural or no analgesia for pain management in labour. Cochrane Database Syst Rev. 2018
Collins, S., Fiore, A. T, Boudreau, J. A., et al. (2018). Nitrous Oxide for the Management of Labor Analgesia. AANA Journal. Vol. 86(1):72-80.
Hellams, A., Sprague, T., Saldanha, C., et al. (2018). Nitrous oxide for labor analgesia. JAAPA. 2018 Jan;31(1):41-44.
Bohren, M.A., Hofmeyr, G., Sakala, C., et al. (2017). “Continuous support for women during childbirth.” Cochrane Database of Systematic Reviews 2017, Issue 7.Art. No.: CD003766.
Vanderlaan et al. (2017). Neonatal Outcomes with Water Birth: A Systematic Review and Meta-analysis, Midwifery. Manuscript accepted, article in press.
Chaillet, N., Belaid, L., Crochetière, C., et al. (2014). Nonpharmacologic approaches for pain management during labor compared with usual care: a meta-analysis. Birth, 41(2), 122-137.
Uçar, T. and Golbasi, Z. (2019). Effect of an educational program based on cognitive behavioral techniques on fear of childbirth and the birth process. J Psychosom Obstet Gynaecol. 2019 Jun;40(2):146-155
