Why those planning for an epidural still need a doula

Doulas are most commonly associated with those planning unmedicated deliveries, sometimes referred to as “natural births” (a term I don’t really love, but that’s another story).  This has led to a curious belief that doulas and epidurals are an “either/or” proposition: if you want one, you don’t plan on getting the other.   Or, if you’re a doula, that once your client gets an epidural, you no longer have much to offer.  To me, this is a gross oversimplification of a complex issue.  Yes, doulas are an important option for pain relief that in many cases, can render an epidural completely unnecessary.  But like many things, it is not a black-and-white issue.

For starters, the core principles of doula work are emotional, informational and physical support for the birthing family.  Even those without pain can benefit from someone to keep them informed and tended to during labor!   Furthermore:

I would argue that doulas are just as important (and maybe more) for those who want an epidural.  Here’s why.

Epidurals have downsides — in particular, they have downsides that doulas are proven to compensate for. 

Epidurals are a Godsend for many women, who simply would not have a positive birth experience without pain relief.  And for folks experiencing abnormally difficult labor, it may turn out that the epidural is the last and only thing standing between them and a cesarean.  For still others, epidurals can be used to manage true medical complications, such as dangerously high blood pressure.  There are many reasons to be thankful for this wonderful advancement in modern medicine.  However, it is important to understand:

There is no free lunch when it comes to an epidural.

In addition to a litany of risks like fever, itching, nerve damage, spinal puncture/headache and a sepsis workup for the baby (including spinal tap), there is an increased chance of instrumental delivery and a potentially increased chance of cesarean delivery.  This is because epidurals are associated with stalled labor — the heavy dose of narcotic (e.g., fentanyl) tends to slow previously adequate contractions, and so relax the pelvic floor that the baby is unable to complete the “cardinal movements of labor” — engagement and descent followed by the flexing and rotating manuevers necessary to be born.  Epidurals can also decrease your ability to push effectively — another thing making instrumental delivery more likely.  Additionally, those connected to epidural anesthesia are confined to bed, which not only eliminates freedom of movement (a key way to promote labor progress), but also constricts the otherwise flexible pelvis, further decreasing the chances baby will be able to engage and navigate out.  Further still, epidurals can cause fetal distress, whether due to lowered maternal blood pressure or a slowed labor requiring heavy use of pitocin.

Happily, these risks are exactly those that research shows having a doula can reduce.  

Evidence is clear that having a doula substantially reduces the risk of cesarean section, instrumental delivery, the length of labor and the chance of a distressed newborn — four of the major risks of getting an epidural.

So how exactly does a doula help someone planning an epidural?  Exactly the same way she helps someone without:

By keeping her moving.

That’s right.  Just like an unmedicated client, doulas have a lot of value to add by bringing movement to the equation for clients who either are planning to get an epidural, or already have one.

Since those with epidurals are confined to bed by the spinal catheter and associated co-interventions (wires and tubes connecting you to an electronic fetal monitor, IV fluids, urinary catheter and pitocin), you may be wondering how its possible to get a patient with an epidural moving.  First, I would point out that, even if you’re planning for an epidural, a doula can help you last as long as possible before calling for pain relief.   In general, the longer you can make it before calling the anesthesiologist, the more likely your labor will have progressed, and the more likely your baby will have engaged before you introduce factors that tend to impede engagement and progress.  A doula can help you maximize this pre-epidural time with strategies to promote optimal fetal positioning.  And this is achieved by movement — keeping you walking, rocking, bouncing, sitting in the shower and so forth, until you feel ready for your epidural.

Once the epidural is administered, your doula can maximize your remaining potential for beneficial movement by making sure you are being moved from side-to-side every half hour or so.

Switching positions frequently reduces the chances your baby will become distressed or that labor will stall. 

Unfortunately, nurses are very busy with things like charting, checking on other patients, watching vital signs and similar, leaving little time to focus on such luxuries as when and how you are being repositioned.  A doula can help fill this gap.

Secondly, a doula can make skilled use of a peanut ball to open the portion of your pelvis that most needs to be opened (either the inlet or the outlet), depending on what station your baby is at.   This is important; although peanut balls have gained in popularity among labor and delivery wards, there is no guarantee you will be offered one, and even when offered, lack of understanding among labor and delivery staff about the physiology of the pelvis means that peanut balls are commonly positioned in a way that actually decreases the available space for baby.  A doula trained in Spinning Babies® can correctly position the peanut ball to promote an internal rotation of the femur, which is necessary to widen the isichial tuberosities enough for a physiologic birth.

A doula trained in Spinning Babies® can also ensure that, before and after nurses roll you from one side to another, you have completed a Sidelying Release, in order to diffuse tension around your pelvis, sacrum and related ligaments that may be preventing your baby from descending.  With some creative use of pillows and positioning of the labor bed, it is also possible to move a mother with an epidural into a modified hands and knees (called “knees/chest” position), which is wonderful for promoting progress and relaxation.  No matter what position you are in, a doula can apply massage, counterpressure, rebozo work, heat and other modalities to help promote normal labor progress.

Who knew that it was possible to do so much for someone with an epidural?

The good news is: it is.  And it is my hope that doulas will raise the bar for women with epidurals, so they no longer have to lie in bed like a beached whale with few options for participating in the birth of their own baby.  Instead, if you hire an appropriately trained doula for your epidural-assisted birth, you can expect to engage in active, strategic rest designed to preserve the chance of a normal delivery.

Finally, it is important to note that epidurals don’t always work.  A not insubstantial portion of epidurals “don’t take” — meaning the patient does not experience relief, or only experiences uneven relief, leaving them not only in pain, but also in a state of panic and limited mobility — both of which serve to further increase pain while decreasing ability to cope.  Even if the problem is later corrected and pain relief ultimately becomes adequate, this can be extremely traumatic for someone who has relied upon the idea of prompt pain relief followed by a restful, comfortable labor.  This is especially true if the individual is completely unprepared for pain because they believed childbirth education classes were unnecessary for someone planning an epidural.  Additionally, even adequate epidurals don’t mean a discomfort-free birth.  Pushing with an epidural still involves some sensation, in particular rectal pressure, which can be nerve-wracking.  Women on epidurals can also experience discomfort during vaginal exams and other internal procedures.  Having someone there to keep you calm during pushing or interventions can go a long way toward a positive, informed birth experience.

In the event you are the unfortunate soul whose desired epidural is in some way ineffective, you are going to need another option for interim pain relief.  The doula can assist in keeping you calm and apply tricks from her toolbag while the anesthesiologist works to correct placement.  Or, if you really find the medical management of birth and the sensations of descent to be overwhelming despite the epidural, the doula can help buffer some of that by helping you feel informed and in control.  A win-win!