If You Have an Epidural - You Need Epidural Birth Preferences
Over the last 2 years lots of birth prep classes are also including cesarean birth preferences. So in the event a cesarean became necessary you’ll have thought through some of the aspects that are important to you such as lowering the screen, immediate skin to skin etc). Yet hardly any classes or specialist birth preparation programs include epidural birth preferences (download your free template at the end of this article).
In my part of the world around 80-90% of moms are having epidurals. That’s a lot MORE epidurals than unplanned cesareans. So doesn’t it make sense that you understand a bit more about epidurals and ways you can optimise this option while reducing some of the potential tradeoffs?
So whether your plan is to get the epidural on arrival (or as soon as possible) or you’re not planning on using medication consider writing some epidural birth preferences that you can keep tucked away in your labor bag. I’ve added some extra notes for clarity but feel free to reach out if you have any questions.
Please feel free to adapt to your individual circumstances.
Epidural Preferences
Thank you for your support on this special day and your help in avoiding potential nerve/pelvic organ/pelvic floor injury from common practices used with an epidural.
My partner (and doula) will remain with me in the room while the epidural is being administered for emotional support.
Some hospitals only ‘allow’ one person to be with mom during the epidural placement for infection reasons. I’ve been to births where there was 4 other family members in the room or just myself and the partner. But as with all of these policies they are negotiable).
I will be using the GentleBirth App during and after the administration of the epidural to help me remain calm and focused during the procedure.
There’s 2 tracks in the app to help you stay calmer (and more still) during the procedure and an ‘after epidural’ recording to help reduce shakes, itchiness and keep you connected with your baby.
Labor
Please provide me with a peanut ball and allow for frequent position changes during the first stage of labor.
Some new research suggests that using a peanut ball with an epidural can shorten the pushing stage. It’s a great tool to help open the pelvis so your baby can rotate through the pelvis easier. Being left lying on your back closes your baby’s exit by about 30%.
I may request that the epidural infusion is turned down to allow for more effective pushing.
Sometimes this can help you feel more pressure and go with those sensations - but as the epidural may have reduced your natural pain relievers you may find it painful to reduce the epi.
If my baby and I are well I prefer to labor down and not start pushing until my baby is at zero to +2 station to reduce exhaustion.
As long as you and baby are well would you rather start pushing close to the finish line +2 station in the pelvis - or way back at the starting line when baby is still descending - which option do you think will conserve the most energy for you and your baby.
I prefer a mother led non coached 2nd stage if I can feel the urge to push.
If you’re still feeling sensations and pressure - let your body do as much of the work as possible and it’s ok if you want some direction too. No hurry here - 3-4 hours of a second stage with an epidural is not associated with complications. 3-4 hours of holding your breath and turning off the oxygen to you uterus and pelvis - well you can see how that can be a problem.
If I have adequate control of my legs I would like to try various positions including hands and knees. My partner and doula will assist. If available please provide a squat bar to assist in my pushing efforts in an upright position to avoid lithotomy.
I just love getting moms up on their hands and knees with an epidural - they feel so much more empowered and productive working with gravity. It’s not always possible but it’s always worth asking if you have good sensation in your legs. Walking epidurals are not common in the US and most of Europe but there’s almost always more productive positions to move into with an epidural than what you tend to see on TV (and in most hospitals).
**To create more space for my baby my ankles need to be further apart than my knees for internal rotation of my femur bones. If my knees are further apart than my knees the space at the pelvic outlet is reduced.
**In the event stirrups are necessary please move my legs simultaneously with another staff member or my partner when lifting in and out of stirrups.Please keep in mind the position of my ankles to create more space.
You have options! Talk to your careprovider about avoiding this position if you and baby are well.
In the event stirrups are necessary please move my legs simultaneously with another staff member or my partner when lifting in and out of stirrups.
(You most likely won’t be able to feel your legs - so we want to avoid damaging your hips/legs/back)
To reduce the risk of back/pelvic injury please to not direct me to pull my legs back or for my partner to push my head forward.
Avoiding the position above may help to reduce unnecessary back/pelvis injury.
I prefer no vaginal stretching or massaging of the perineum in labor. Please do not use mineral oil to lubricate my perineum as it can interfere with the seeding of my baby’s microbiome.
Your vagina does not need any additional lubrication during labor and birth - no coconut oil, mineral oil, warm soapy water, Johnsons Baby Shampoo (yep I’ve seen that too). Not only does introducing these unnecessary lubricants impact your vaginal microbiome it can cause the cells in the vaginal walls to be compromised making infection more likely. You’ll be busy focusing on your labor so ask your partner to remind staff when they start getting the oil out. The pressure I’ve seen careproviders apply with their hands inside a mom’s vagina can be very unsettling. Again - talk to your OB/midwife about their routine practice.
When my baby’s head is partly visible please apply a warm compress to my perineum to reduce the risk of severe perineal trauma. I am aware that I will be unable to gauge the temperature of the compress so please test it on my arm first.
An epidural is associated with more perineal injury - but this very simple intervention has been shown to reduce severe perineal injury (3rd and 4th degree tears). Your partner or doula can do it - or your nurse/midwife but she may be limited to charting as well as other clinical tasks. Ideally only apply the warm compress when baby’s head if visible so we don’t cause the tissues to swell.
I would appreciate your expert guidance to focus as my baby’s head crowns.
Your careprovider will guide you to stop any intentional pushing you may be doing at that point - but your body is still nudging baby down. It would be like me telling you right now to stop digesting that snack you ate 10 minutes ago it’s out of your control.
Please do not pull on my baby’s head as he is being born.
This is quite common and can result in tearing or even a shoulder dystocia (baby’s shoulders get caught in the pelvis). You have to wonder how did the human race survive until we started pulling babies out of vaginas….think of that mom who unexpectedly birthed her baby in the car or had an unplanned homebirth - I guarantee you she was SUCKING that baby back in to try and not give birth in the car.
Please do not suction my baby on the perineum routinely.
Thankfully I don’t see this too often but one side effect of this intervention is that it can cause baby’s heartrate to drop suddenly and may impact baby’s breathing and breastfeeding for several hours later.
Assisted Birth (use of instruments)
If instruments are required to assist my baby and a vacuum is being considered I understand an episiotomy is unlikely to be necessary.
Thankfully with a vacuum episiotomies are unlikely nowadays but ask your careprovider at your next prenatal. Find out how often they feel it’s necessary to do an episiotomy.
If a forceps is advised I would like the most senior Obstetrician to perform the procedure.
Forceps seem to go in and out of fashion when hospitals are trying to reduce their cesarean rate but they can come with potential increased chances of injury for you and your baby. It is a procedure requiring a skilled careprovider. This is definitely worth discussing with your careprovider ahead of time as some moms may choose a cesarean if there is time.
Suturing/Stitching
Please ensure I have adequate analgesia for any suturing that may be needed.
Yes sometimes even with an epidural you may need additional local numbing. If stitching is painful ask your careprovider to stop until you have adequate pain relief.
Please only place my legs in stirrups right before suturing is about to begin to avoid the risk of a DVT.
Moms can be left in stirrups for hours during pushing and then for more time during suturing.
Thank you for your support on this special day.
I hope this was helpful! What questions do you have?
Download a template of epidural birth preferences here.
