Saturday, December 16, 2017

The Sensations of Labor: Nitrous Oxide

Welcome back to my sensations in labor blog post series! We've made it through the two heavy hitters in terms of both pain relief, and side effects, but we're not through our medical bag of tricks yet.

Nitrous oxide, or laughing gas, or gas and air, can only be given by a doctor or midwife. Depending on state laws, and on individual midwives, it can be available in home births, as well as hospitals and birthing centers. If you've ever received laughing gas at the dentist, you have an idea of how this medication works, though you may have received a higher dose than is given to a laboring person. In labor, nitrous oxide is given 50/50 with oxygen, so the laboring person can't deprive themselves or their baby of oxygen by its use. Some people use nitrous oxide throughout labor. Others use it for particular uncomfortable procedures, like stitches after the birth, or inserting a foley balloon to augment labor. While nitrous oxide has been widely available for a very long time in the UK, it's still fairly new on the scene in the U.S., which means that a lot of pregnant people here aren't familiar with this option, and its pros and cons.

Let's break it down, shall we??

Pros:

Chill out and feel better! Nitrous oxide is a dissociative.  This means it makes you feel sort of separate from your body and whats going on with it. It's really effective for anxiety and fear around a situation or procedure. If you're struggling to cope with labor because you keep getting into your head about how these intense sensations can't possibly be a normal function of your body (even though you know logically that they are), or you can't stop worrying about something going wrong with baby, nitrous oxide can help you feel easy and relaxed about whats going on.

Easy to use! Nitrous oxide is inhaled through a mask. You hold the mask to your face, and inhale and exhale through it. This prevents the nitrous oxide you exhale from being released into the room and exposing your support team, and care provide to it. Any time you want to use it, you pop the mask on and breathe. And it's just as easy to stop using!

Non-committal! Not sure if you'll like how nitrous oxide feels? Not sure if it'll be worth being bed-bound (we'll get to it in the cons, but this is a common policy in hospitals in the U.S.)? Unlike an epidural, you can stop using nitrous oxide anytime just by taking the mask off! In fact, it's recommended to start breathing it as soon as you feel the first sign of a contraction, and take the mask off again as the contraction ebbs away. If it's not working well for you, or you'd rather try something else, it'll be out of your system within a couple of breaths without the mask. It doesn't linger in you or your baby's systems.

Stay yourself! Unlike a morphine rest with its heavy sedative effect, with nitrous oxide, you can spend most of labor (all the time between contractions) completely unmedicated. You won't feel loopy or goofy anymore as soon as you stop breathing the nitrous, so you won't miss out on the experience of your labor, or bonding with your partner as you wait for your baby together.

You're in control, and you're totally safe! Mask on, mask off, it's up to you! But does that make you nervous? How do you know if you've had too much?? Easy! You'll disassociate from your body so much that you'll let go of the mask! It'll fall away from your face, and within a breath or two, you'll be back to normal. This is why no one else can hold the mask for you, no matter what. Over the course of a normal contraction, you won't manage to get to this point, but should you have some strong contractions twin together, you can keep breathing in the nitrous oxide as long as you like, knowing that the failsafe is built into the system.

Cons:

Pain relief isn't exactly the point! So...dissociative, right? Nitrous oxide is great at that! How good is it at relieving pain though? We're talking about something very subjective, and it's going to vary a great deal from person to person depending on how much of their physical discomfort is caused by how their brain is processing the sensations and labeling them as 'scary' and 'bad'. For some people, it's all they need to sail through labor! For other people, it just doesn't seem to do that much!

Mask out? You're in bed! Most hospitals in the U.S. will require you to remain in bed not only while you use nitrous, but for a set amount of time after you breathe from the mask for the last time if you stop, usually about half an hour. This means that if you try nitrous, and and don't like it, you're stuck coping with labor in bed, without access to movement, a tub or shower, birth ball, etc. for comfort. That's a tough spot to be in!

It's not side effect free! Nitrous oxide makes some people uncomfortably nauseas. Other people just don't like the feeling of disassociating. Some people feel like they aren't getting enough air because you have to pull pretty hard to get a deep breath out of the mask. You may love it, or you may not!

Could nitrous oxide be a useful tool for your labor? There's only one way to find out! And if you think it might be, you'll want to find out if it's available where you'd like to give birth. It's still not widely available at all hospitals in he U.S.

Have you used nitrous oxide? Did it help you? Why or why not?

Live Omily,
~Emily

Sunday, December 10, 2017

The Sensations of Labor: Morphine Rest

Welcome back to part II of my Sensations of Labor series! Some of you may be wondering why my first two posts are such high-intervention choices for managing the sensations associated with labor. It's a valid question! I strongly believe that when a situation isn't an emergency, a birthing person is best served by starting with the most minimal intervention possible, and escalating from there only as necessary. That said, while our culture certainly has a lot to do with this, and our culture will hopefully continue to change with time, over 90% of people giving birth in America receive an epidural. They've heard of them, and what they've heard is basically that they're magical and fix everything. Giving them the other side of that coin is going to be more helpful than comparing massage, warm water, TENS units, etc. to their magical concept of what an epidural is. I think dispelling the mystique around these medical pain relief options is an important first step to introducing non-medical pain relief techniques as valid alternatives. Also, and this is important, I DON'T THINK EPIDURALS ARE BAD. They are a valid choice for managing labor sensations. Knowing all the pros, and the cons, helps birthing people discern if they're the right choice for their birth, and prevents them from being blindsided by the cons if they choose to use one. Now, onto the 'morphine rest'!

I find that this is a pain relief option that many people aren't familiar with, but it definitely has its place as a tool for birth, so everyone should be aware of it. It can make the difference between getting an epidural (and all that entails), and not getting one in some cases, and can help avoid or resolve labor slowing down or stalling by providing the birthing person with needed rest (hence, the name).

A 'morphine rest' is a term for giving someone a course of iv opioid (or synthetic opioid)-based pain relief drugs (morphine being just one example of what may be given) to someone in labor, generally for the express purpose of giving that one a 'rest' from dealing with labor. The does of opioid given via IV is much higher than what would be given via the epidural, since it's being put into the blood stream, and not directly into the epidural space where it can immediately affect the relevant nerves.

Now I know what you're thinking: why in the world would anyone opt for a HIGHER dose of drugs?? Fair question! But dosage is only part of the picture. A morphine rest is often used for different situations than an epidural would be. Let's look at pros and cons:

Pros:

Sweet sleep! Particularly if you're having a very long and uncomfortable pre-labor or early labor, getting admitted to the hospital, and getting an epidural so early in the game may not be an option at all, or even if it is, you're much more likely to experience a slowing or stopping of labor if you're forced to stop moving so early on in the process. The drug will provide pain relief, and also make you very, very sleepy. A good night's rest can work wonders on speeding things up, and once the drugs wear off, you can be back on your feet, laboring how you choose! Since you'll be better rested later on when things continue to get more intense, you'll be less likely to choose an epidural out of exhaustion.

Stay home! Many doctors will allow you to return home after the drug is delivered via IV providing someone is there with you to take you home and keep an eye on you. This means you can receive significant medical pain relief, without committing to hospital admission, and delay being checked in until things have had a chance to progress to active labor, which doctors, midwives, and doulas all universally recommend!

Keep your options open! A morphine rest is temporary. The drugs wear off, and you're back to normal. You're allowed to be up about again if you're at the hospital, using any other coping mechanisms or position changes you wish. You can opt for an epidural later on if you wish, or switch to non-medical coping strategies. While epidurals can be turned down or off, the numbness persists long enough that most hospitals won't let you out of bed again, and they certainly won't let you go home.

Temporary relief for temporary discomfort! Are you experience terrible back labor, and are hoping the baby will turn given time and position changes? Does the doctor want to use a foley balloon to dilate you those first few centimeters and get things moving? Why opt for long-term pain relief for a short term procedure or situation?

Cons:

Drugged birthing person, drugged baby! Yes, your baby will experience the effects of this drug as well. These drugs are this dosage are not shown to cause any long term effects or issues, but many people are still not comfortable with their baby receiving this dose of these drugs. This option will not be offered if there's reason to think you'll have your baby in six hours or less, because it isn't safe for a newborn, who needs to be highly alert and stimulated to transition to breathing on their own etc., to be under the influence of opioids. If you have any reason to think this labor could go unusually fast, it likely won't be recommended to you, and it's a riskier choice. At the end of the day, this is always a calculated risk, as even a seemingly very slow labor can suddenly speed up and resolve very quickly.

Itchy Pukey! Itchiness, and nausea/vomiting are common side effects with opioids. Not everyone experiences them, but the higher the dose, the more likely they are, which is why you're much more likely to experience these side effects with a morphine rest than with an epidural.

Incomplete Pain Relief! IV opioids are less effective at reducing pain than the epidural. Depending on the severity of your discomfort, you may still experience significant pain. For labor contractions, this can mean not noticing the beginning or end of the contraction, but suddenly being struck by the peak. The element of surprise, and the lack of time to prepare and get into a breathing pattern can make contractions difficult to deal with, especially if you're sleeping, and are woken up by the intense sensations. If you're dealing with this, it's helpful to have a partner who notices how your breathing pattern or how you hold your body changes when a contraction starts, who can wake you up and get you into coping mode before the contraction peaks, and let you drift back off as the contraction ebbs away.

As you can see, this option is clearly not right for every birthing person, or every situation. It's one choice among many that can be beneficial in the right circumstances. Wouldn't it be cool if we thought of all birth interventions that way?? :-D See you next week for a discuss of nitrous oxide, aka, gas and air, or laughing gas!

Live Omily,
~Emily

Sunday, December 3, 2017

The Sensations of Labor: Epidurals! (part 1 in a series)

With the launch of The Flying Doula (my doula business, and my new website! Check it out!!!), I wanted to share a post about a topic that every pregnant person has on their minds: the sensations of labor! I soon realized that this is a huuuuge topic, so this is going to be a series! Yaaaay!!! Today we'll have a little overview, and we'll focus on a topic that could probably be a series in and of itself: the epidural!

When discussing the experience of labor with my clients, I favor words like, 'sensations', 'intensity', and 'power' because they leave room for your subjective experience of labor to be whatever it is! But let's be frank: the majority of people who have given birth in our culture (and there's a whooooooole conversations to be had about how our culture contributes to this) describe at least parts of it as being significantly painful, even extremely painful, to the point of being the most pain they've ever experienced in their lives.

And that's SCARY! How could it not be?? I don't like to talk about that much because if you're expecting something to be painful, if you're fearing something will be painful, if you're tensed up and closed off to something, there's just no question that your experience will be the worse for that negative anticipation, bodily tension, and catecholamines (fight or fight hormones). Catecholamines also work antagonistically with the primary hormone of labor: oxytocin. When they go up, oxytocin goes down, which can easily slow or even stall labor. (This is a survival adaption. If you're in danger, you need to get the hell out of there, not drop a vulnerable baby!)

AND, not everyone experiences labor that way! For some people, it may feel intense, and uncomfortable, but pain just isn't the word they would use to describe it. A small percentage of people orgasm at some point during labor and birth (don't look so surprised! All the same hormones, and body parts are at play here, and vaginas can accommodate very big things when warmed up and stretched adequately. Some people are into fisting!) For some people, it just never feels worse than mild cramping, and they're shocked to find out their baby is well on its way when someone finally decides they'd better get checked, just in case.

But of course, that can be scary in its own way! No one wants to be the subject of the headline: " BABY BORN ON BROOKLYN BRIDGE!!!"

Obviously fear surrounding labor is strongly tied to anticipating the sensations of labor, and also to the unknown. You just can't know how your brain will interpret the sensations of labor, or how fast, slow, intensely or gently, your body will go through labor. Some clients dilate several centimeters before they're even in labor. Others labor HARD for hours and hours just to achieve enough effacement to begin dilation! There is such a wide range of normal, and a really important aspect of labor preparation is working on getting comfortable with this not knowing, with taking your birth one moment at a time, as it comes. That shit is HARD, and it's one of the reasons why meditation work is part of the Flying Doula umbrella (and def the subject of another post in this series)

But, another important part of labor prep that can help you feel perhaps just a bit more ready for this adventure is to research your pain relief options in advance! So we'll be dealing with those options one post at a time in this series, and today's topic is...

The Epidural

The mystical, magical epidural if you're approaching birth from the point of view of our current birth culture, or perhaps the EVIL, INTERFERING, BIRTH-RUINING epidural if you've spent some time on natural birth message boards.

Well surprise-surprise: the truth is somewhere in the middle. Like every medical treatment ever, the epidural has pros and cons, and for some people and some labors, the pros will outweigh the cons, and for others, the cons will outweigh the pros. So lets talk a bit about what's entailed in getting an epidural, and what some of those pros and cons are.

An epidural is a tiny flexible tube that stays in your epidural space, allowing small amounts of a 'caine' pain reliever (think novocaine at the dentist), and an opiate/synthetic opiate-based pain reliever to be injected into this space, providing generally very effective pain relief and numbness to the entire lower body. It's put in place via a large needle, but the area is numbed via injections of a 'caine' pain reliever before hand, because that needle needs to be placed very slowly and carefully for the epidural to be safe, and effective. 

Different anesthesiologists will position you differently, but the common thread is that you'll be asked to curl forward to make your lumber spine, and the space between your vertebrae where the doctor will be aiming, as big and accessible as possible. Every doctor, and every situation is different, so sometimes the epidural can be placed very quickly, and sometimes it takes some time. It's critical that you stay still while the process is going on, even if you have contractions. If you can't, the doctor will stop and wait for you to be able to stay still again, which of course makes the process longer. Once it's all set up, in most cases, you'll have a button you can press to get another dose of medication in your epidural so you're in control of how much pain relief you get. You'll be locked out from overdosing yourself, so no worries there.

Along with the epidural, you'll receive an iv so that meds to raise your blood pressure, or fluids to bolus your blood pressure, can be quickly administered, as the epidural sometimes causes a drop in blood pressure. You'll also have your blood pressure taken regularly, usually via an automatic cuff that stays on your arm, your blood oxygen level monitored via a clip on your finger, and two sensors held on your belly via stretchy belts to monitor your baby's heart rate, and your contractions. Since you can't get out of bed or walk because of the numbness, you'll have a catheter inserted into your bladder. Some or all of these interventions may have already been in place before the epidural, depending on your labor, your risk status, your choices, your hospital, and your doctor...but that's a whole other blog post!

Other potential side effects include a bad headache, and very, very, very rarely, pain that persists for weeks or longer. In a tiny, tiny percentage of women, the epidural is totally ineffective. Just does not work. We don't know why! Again, this is exceedingly rare, but it is a real thing to be aware of, especially if the epidural is the only pain relief/comfort measure you're considering. More commonly, the epidural can leave a 'window' of sensation where you can still feel the discomfort of contractions. There are ways of dealing with this though, and often it can be resolved.

This might sound scary, and obviously you should take all possibilities into account when considering your pain relief options, but statistically, the epidural is very safe, and very effective. So, lets talk pros and cons.

Pros:

Pain relief! Obviously. But this isn't a matter of taking something for your headache or toughing it out. This isn't just about making the experience of labor and birth less unpleasant, though that is a very real and valid benefit of the epidural for some people. Because, you know what comes along with pain? Tension! And you know what makes it hard for a baby to descend and put good, even pressure on a cervix so it can dilate? Tension!

Relaxation! Some people in some labors are able to keep breathing and softening their bodies, and labor along just fine without an epidural. Others reach a point where that is just not possible anymore. They're unable to get back into a place where they can just let labor happen and not fight it. This is a miserable place to be. No one should ever feel like they have to continue at this point just because they technically could. But aside from that, their tension could slow dilation and/or descent of the baby, and their distress could trigger the catecholamines that slow labor. In instances like this, an epidural could speed up labor, and prevent the need for other interventions!

Sleep! This is no small potatoes, people. I always tell my clients who can't believe I'm sitting up all night with them, when this is all over, I go home and go to bed! You're going to have a newborn to care for! And even before that, you'll need to push this baby out. The pushing stage is a lot of work for most people, and if you've had a very long, hard labor, and are too exhausted to think straight, you may struggle to push your baby out. Nature helps us out here of course, by giving a burst of those catecholamines right when you need that surge of energy, and of course, if you don't have the epidural, you'll be able to move freely to find positions to help baby descend more easily...but we'll talk about that in the cons section. Sometimes rest is whats needed so refuel the uterus and get it back to a more consistent or effective contraction pattern as well. If you haven't been able to eat, sleep, or take in much fluids over the course of your labor due to your discomfort, an epidural could be a tool that would allow you to refuel your body, so your uterus can continue the hard work of opening, and expelling your baby.

Awareness! The intensity of labor will take you to some interesting places. You'll connect to your mammalian brain in a way you probably never have before. You'll find yourself rocking, tapping, chanting, grabbing, moaning, anything to help you ride these incredibly powerful waves! This can be a beautiful experience for many people, but for others, it's just scary, and not how they want to welcome their child. They want to be fully human, full themselves, talking to their partner, co-parent, and/or support person, waiting excitedly for their baby to arrive! The epidural can let you do that.

Cons:

So many tubes! The epidural itself, and the different monitoring protocols it comes with, means you'll suddenly be tethered by many different tubes and machines. Few people would call this a comfortable situation. Of course, if all you want to do is lie still and sleep anyway, it may not seem like much of a sacrifice.

Stuck in bed! No sitting and hula-ing on your birth ball, no blessedly hot shower, no 'dancing your baby down'. You're grounded, missy/mister/mixter! If you had pictured yourself being an active participant in your labor, the epidural can be a bit of a let-down. You can still carefully change positions in bed with help, and in fact regularly switching sides will not only help promote descent and dilation, but can make your epidural more effective (see, 'window' of sensation), but a lot of options aren't available anymore, and that can be a bummer.

Slowing down labor! This potential side-effect of the epidural is much more likely to be an issue when the epidural is administered before labor is well-established. By blocking the sensations of labor, a kink gets thrown into the hormonal chain that keeps labor progressing. But as I like to say, at a certain point, there is just no stopping this train! If you've made it to a strong, active-labor contraction pattern, odds are good things aren't going to slow back down, but it is a possibility to be aware of, especially if you're less than three centimeters, and/or not meeting that 411 rule, or your labor has stalled out in the past.

You give me fever! (insert song clip here) A fever is a potential side effect of an epidural, particularly one that has been in place a long time. The fever itself isn't high enough to be dangerous to you and baby, the problem is, there's no way for your medical team to know if your high temperature is just a side effect of your epidural, or if it's a sign of infection that could be putting you and your baby at risk. They have to assume the latter, and that means wanting your baby born sooner rather than later, which can mean more interventions, and possibly even a c-section, possibly starting iv antibiotics immediately, and a potential work-up in the NICU, including a spinal tap, for your newborn. Not everyone who gets an epidural, even if they have it in place for a long time, will get a fever! And of course, getting or not getting the epidural does not change your likelihood of getting a fever caused by an infection (well, sometimes a catheter leads to a bladder infection, and without the epidural, you don't need one of those...but that's getting tangental.)

Pushing options get limited! So, pushing a baby out is hard work, and being able to listen to your instincts and move around, from all-fours, to squatting, or lying on your side, to sitting on the toilet, to walking around the room, can really help baby descend and save you some effort. But with an epidural in place, you need to stay in bed, and you can't support your weight on your legs. In theory, you can still push while lying on your side, but in practice, you'll almost certainly be advised (told) to lie on your back, grab onto your thighs, pull them toward you while you crunch around your baby, and hold your breath for a slow-count of ten while you push for all you're worth. Go on, pop a blood vessel! Now, this kind of pushing absolutely has its place. This position helps baby duck under your pubic bone, and if you pull your legs up enough, you'll even make space for your sacrum to move as necessary. It's not a bad position to push in! And sometimes it really takes three loooooong pushes per contraction to get baby moving...but that shit is HARD, and it will leave you out of breath and panting after every contraction. If you're out of breath, guess who else is, too? Yep! Baby! Between contractions you'll be advised to 'breathe for baby!' 'take long, slow, deep breaths!', and possibly even offered an oxygen mask to pump up your blood oxygen faster. If you had the freedom to push in whatever position you wanted, you'd be more likely to be able to follow your own body and push for as long as feels right with your contractions, and you'd almost certainly pause for a breathe before that ETERNAL ten count. With gravity helping, the pushing phase would likely go faster, so no one would be stressing about watching the clock, and needing your pushes to be more effective faster. 

If you can't feel whats happening, its hard to call the shots! Relating to that previous point, if you don't have an epidural, or your epidural is turned down enough that you have some sensations, your care provider will likely wait to advise you on pushing until you...START PUSHING! Like, on your own, because your body's telling you to! Some doctors will tell you to let them know when you feel 'rectal pressure'. They mean to tell them when you feel like you need to poop. But if you just aren't feeling much of anything with your wonderfully effective epidural, what often happens is, your doctor checks, finds you fully dilated, and tells you to go ahead and push. Has your baby descended enough for you to be able to push effectively? Has your uterus built up the fundus enough to successfully eject the baby? Without knowing if your body would instinctively be pushing on its own, we can't know that. And now the clock is started. What clock? Well, most hospitals in the U.S. aren't going to let you push for more than two or three hours, even if baby is doing well, because despite little evidence to support this cultural idea, more than that is just too long to push. Time to give up, and roll on to c-section. And...

If you can't feel, it's tough to push effectively! Think about how weird it is to talk and eat after getting novocain at the dentist. Your motor control is a little wonky because you aren't getting sensory feedback from that part of your body. Without that feedback, pushing, and figuring out how to push effectively, takes longer, and if it takes too long, you could be looking at a c-section.

Now, I listed more cons than pros to the epidural, but I want to be really clear here: those pros are all really important and valid ones, and lot of those cons are interconnected enough that a different person may have combined them. Counting isn't going to tell you much. Your own values and wishes for your birth will tell you more, and at the end of the day, you just won't know until you get there. I've had clients who were certain they did not want an epidural wind up getting one, and having an excellent birth experience because of it. I've had clients who were having a very challenging labor, and they didn't get an epidural, and looking back, they're proud that they stuck to their guns, but wondering if it was really worth it. I've had clients not get one, and have an awe-inspiring, beautiful, 'natural' birth experience that they'll be drawing on for inspiration and confidence for the rest of their lives, and I've had clients who got an epidural, and then wondered if it was necessary/helpful. I have yet to have a client who wants one and ends up not getting one, but it absolutely happens!

So, whats my final say on the epidural? It reminds me of that old joke...how many doulas does it take to change a light bulb? Answer: we don't change the lightbulb! We help you decide how you want to that lightbulb changed, and we support you through the process. I think the epidural is a tool. Sometimes its the right tool for the job, and sometimes its not. It's as simple as that.


Live Omily,
~Emily