Doulas and Epidurals

Ah, the question of having a doula when you’re planning an epidural. Today, many, many women plan on an epidural when the time comes to deliver their baby. They either plan to walk in to the hospital and request one right away, so they “don’t have to feel anything” or they have stated that they want to try it natural but aren’t opposed to getting one, depending on how it goes. And some dont’ plan on one at all but need it anyway.

If you’re considering hiring a doula, you might look at that and go, “hmm, well, what’s the point of having a doula if I am going to not need the comfort and support they can provide? With an epidural, my labour isn’t going to hurt, so I don’t need a doula.”

You know what? You may be right. Maybe you have this great plan to get an epidural, not feel any pain, maybe have a nap then wake up and have yourself a baby. And maybe that is exactly what will happen.

But then again, maybe not. So, why WOULD you get a doula when you’re considering an epidural, if it sounds like this magical, painless experience? You don’t need extra support when you’re not going to be in pain, do you?

At the time of writing this, I had just returned from an 18 hour birth. This birth was a long haul. And from the beginning, this mother was planning on an epidural. Since it was her second baby, she knew that she would need extra support, however, even if she got the epidural that she planned, especially due to the process of birth with her first child (which, by the way, she had planned to do naturally but wasn’t opposed to medications, and ended up needing an epidural that first time too). As a doula, my role is not to force anyone into having the birth I think they should have, or to belittle their choices. So I planned to support her to my best ability, as well. I fully admit that I have had two unmedicated vaginal deliveries myself. But my labours are over relatively quickly, and I have pain tolerances that differ from those of other people. So while I can say all day that “if I can do it, so can you!” the reality is simply that that is not true. Maybe if everyone had my experiences, they could also do it that way, but maybe they can’t. And maybe I couldn’t have done it if I had some of the experiences I’ve been witness to. Nor is birth a competition where the “winner” is the one who has the “most natural” birth, or whatever. My experiences are just that – my own – and I cannot, and try very hard not to put them onto someone else. I don’t have expectations of clients – but I do want to be sure I am supporting them in what they need for their birth. I want to be sure I am doing what they need, and not encouraging them to push through the pain for longer than they feel that they can handle it. They don’t have to handle it if they don’t want to. As a doula, (or a partner!) it can be challenging to figure out where exactly a person has reached their limit. Whether they are saying “gimme all the drugs!” because that’s how they are coping with the pain (but they really don’t want them), or whether they are saying “give me the drugs” because they have reached the place where they need the unique pain-relief that it offers? That’s the trick. Either way, its not my place to make that decision for them.

I’ve had clients look at me and say “Can I have an epidural?” (To which, by the way, my response is always ‘You don’t need my permission! This is your birth. You can have an epidural. You’re doing amazing, and if that is what you want, that is perfectly fine!’) then continue on WITHOUT one and birth babies with nothing but strength and determination. Or those that say "can I have an epidural?" and then choose TO get the epidural, before birthing their babies with strength and determination and a little extra help. I’ve also had clients who say “I really don’t want an epidural but I’m so tired and only 4cm and I can’t keep on without something to help me” (response here: if you really don’t want an epidural then I will support you, let’s see if this alternative provides you some relief, and here are your other options). Or those that say, “I’m so tired, nothing is working, what can I do?” Sometimes its appropriate to let people know an epidural is a valid option. Providing options for people and letting them choose how best to proceed for themselves and for their babies is always, always the way forward. An epidural is a tool. It is a very effective method of pain relief when it works. It comes with certain downsides, but what doesn’t? Even birthing naturally has downsides – such as, it fucking hurts. If a client wants an epidural, then my job, as her doula, is to support her needs, support her desires, and continue supporting her birth however she needs me to.

Once that epidural is in, the role of the doula may change in some ways. The main function, providing support, doesn’t change. But the path forward certainly does. And this is where people may think theres no need for a doula with an epidural. And this is where I would say there is absolutely space to include a doula in a birth that includes an epidural, whether it was the “plan” or not.

At our hospital, when a birthing person has an epidural in place, several things occur. After the anesthetist is finished and everything is taped in place, the birthing person is placed on continuous external fetal monitoring. Her levels are checked (this is done by taking a frozen ice pack, and having the birthing person tell them if it feels as cold against her face as it does on other parts of her body, that she shouldn’t be feeling the ice pack at all – upper legs, belly, near the breast – and on both sides.) These levels tell the staff if she is feeling anything where she shouldn’t be, and lets them know how well the epidural is working. A catheter is placed. Her temperature and blood pressure is checked, as well, and then she is able to get comfortable in her bed, and usually able to rest and possibly sleep. These levels, temp, blood pressure are checked regularly, and here, the birthing person is encouraged to switch which side she is lying on about every half hour to hour or so.

This recent birth I was at – the mother had had a busy day, and had not been sleeping well for a couple of weeks. She was past her due date, and had been ready to have this baby for a couple of weeks. Lots of prodromal labour and discomfort had contributed to a person who was just done with being pregnant. When her labour finally did start, spontaneously, that afternoon, she was more than ready for it. When she and her partner chose to go to the hospital, I offered to meet them there and they agreed that was a good idea. She was feeling a lot of intensity. She was admitted, and intensity increased, and the contractions, while short, were coming regularly fairly close together. She laboured exceptionally well (to my eyes – her experience of it was different than how I perceived it). She was willing to try many different techniques looking for comfort, and eventually just wanted to lie down. About 5 hours after being admitted, exhaustion had set in, and she started asking about getting an epidural. We had a discussion on the point of pushing through the pain without one, versus getting one right away. And ultimately, she asked to wait an hour but with further thought and gentle suggestion, she said the time was good to call in the anesthetist. Once the epidural was in, she attempted to rest, and her body was able to relax. In an effort to let her rest and relax, I followed her lead with her desires. I conversed with her when she wanted, I trusted her to choose how she would be most comfortable, and I offered her food and drink regularly. When the doctor arrived in the morning, she felt much better. The decision was made to have her water broken, and dilation quickly progressed to a certain point. With a peanut ball between her legs, to help keep the pelvis open, we continued talking, laughing, eating and drinking. Three and a half hours later, however, there had been no cervical change, contractions had spaced out, the baby was having odd variables – not super concerning, but they were there - and her doctor recommended a consult with an OB. The OB did her own assessment, and suggested that since the birthing person did not want a caesarean, that she could continue trying maneuvers, but that oxytocin had to be started and if baby didn’t tolerate the oxytocin a caesarean would be required.

This wasn’t news any of us wanted to hear, even if it wasn’t a surprise to any of us. So what else could we do?

The answer is, whatever the client wanted us to do. This particular person needed some things. She needed a visual of what movements the baby needed to be making through the pelvis. She needed some space to process and speak to her spouse. She needed to cry. She needed good energy being sent her way. And she needed someone to suggest different positions to try in order to help the baby move how it needed to move, in order to be born safely.

The nursing staff in our hospital has taken Spinning Babies workshops, as have I. These are techniques and tools that we can use that MIGHT encourage a baby to move. Some babies simply need to be born surgically. Some babies can be give all the encouragement in the world, and still won’t move, and then there are some babies that just need a bit of encouragement and space to move where they need to be for an easier birthing. There is no guarantee that trying ANY of these will be what works – and yet over and over they help. Several positions were suggested, that are safe to use with an epidural. And since I was the person most familiar with Spinning Babies in that particular room at that time, I and the nurses helped and encouraged this woman to try them out. On suggestion from another nurse, we tried Exaggerated Runners position. After that, we did a Side-lying release, and because she could feel and move her legs, a Forward-Leaning Inversion and Shake the Apples on the bed with the bed at a slight Trendelenburg to encourage the baby to back up and flex their head. When those were done, and because the birther was still willing to attempt another position, flying cowgirl with the peanut ball for half an hour on each side. For each of these, alongside her supportive partner, I helped this mama get into the correct position. I supported her physically through them, and encouraged her to continue visualizing her baby moving down. She did her own work mentally as well – energy work, visualizing, her cortices and her bars, with the help of her partner. And once we had done these, she continued to rest. When her doctor returned, she had progressed to a 10, and her baby had flexed its neck. She was fully dilated, about 3 hours after the OB had recommended thinking about a caesarean birth. And just over half an hour after that, this amazing person pushed her baby out.

So, what did the doula (me) do to support this birth? We all knew going into it that an epidural was the medication of choice, and likely to happen. Once it was in, I couldn’t suggest a shower or bath, I couldn’t help her walk the halls, or get into other gravity fed positions. All the techniques and tricks I know for physical movement went out the window. But what could I do. How could I try and give this mother the best support I am capable of providing, and increase her comfort?

This is what I have studied to do. This is my job – to do and suggest what is helpful to birthing people, what works and is right for them and their situation. For an epidural – physical comfort is managed by the medication. It is mental and emotional comfort that I can provide. I helped her environment stay calm and relaxing by turning off the hospital lights and putting out fairy lights (so the nursing staff didn’t need to put on a spotlight). Calm, dim lighting – very relaxing. I ensured she ate if she was hungry, and drank water. I talked with her if she wanted to talk, and sat quietly when she didn’t. I suggested some things to help open the pelvis, but when she chose not to do that yet, I respected her wishes. And when the time came for further action, and more effort to be put into helping the baby go where they needed to go, I made suggestions and facilitated moving her body into positions that encouraged that to occur. It’s why I have attended additional body work workshops. By me being there, we were able to do these maneuvers for the recommended times. No nursing staff were tied up by helping her. The benefits of having me there were endorsed by the nursing staff, because I was able to focus solely on helping my client do these things without having to be anywhere else. I was constant support for what she wanted to do. Doing something may not be better than doing nothing, but in this particular case – my knowledge, and my skills may have played a role in helping this little baby come into the world. And in this case – trying all the things is what she wanted to do. Had she not, she still wanted and needed my support. And had all I done was just to sit by her side, with her partner, and send her love and strength, and if that is what she needed, then that would have been okay, too. This was a case where having a doula was beneficial, because of the knowledge and skills I have acquired. But any doula would have been a help here, as long as the birthing person wanted one there. A doula isn't magic. Sometimes, just being there is enough. Sometimes gentle encouragement. Other times, making suggestions and helping facilitate them. And even with an epidural, a doula can help.

So can you epi-doula? Can you doula someone with an epidural? Can you make a difference for that person, when they are not feeling any pain? Is a doula “worth it” when you plan to have an epidural, or are planning on other medical pain relief?

The answer, is unmistakably....

Yes.