Tuesday, October 20, 2009

Bradley Births and Epidurals

Before I charge into describing my son's delivery, I should probably explain what the Bradley method is. If you are interested or just curious, I highly suggest that you check out the Bradley website. In short, however, the Bradley method involves comprehensive childbirth education, specific nutrition and exercises during pregnancy, discussion and practice of the various pushing positions, and the use of deep breathing and relaxation as a means of having a drug-free labor. An ideal Bradley birth involves as little medical intervention as possible, but Bradley teachers take the time to discuss the various complications which may occur as well as the medical interventions mothers may be offered. Bradley couples come out understanding childbirth and it's various stages in great detail, have a good understanding of what is normal in childbirth, and are well prepared for any difficulties that may arise.

I think Bradley training is so cool, by the way. :)

Bradley births occasionally, but do not always, involve a doula (a paid childbirth coach). In fact, Dr. Bradley, who fostered the Bradley method, probably didn't think doulas were that great. (This is pure speculation, by the way). He referred to his method of birthing as "husband-coached" childbirth. He felt that the coaching experience between a husband and his laboring wife can be a powerful, emotionally intimate bonding experience for both. In his book entitled Husband-Coached Childbirth, he relates a story about when a husband was unavailable during the labor, and Dr. Bradley stepped in as the coach as well as the delivering doctor. While he was happy for how well the mother had done and how well her labor went, he expressed a feeling of almost embarrassment that he'd been playing a role that belonged to the woman's husband.

As a wife who has had two Bradley births, I can attest that having your husband coach you through such a challenging job is a great bonding experience. That's not to say that epidural births aren't great bonding experiences too. A loving husband's support and being able to share in witnessing this wonderful person's arrival can bring couples very close together. But a Bradley mom depends upon her husband's emotional and even physical support, and the husband essentially becomes the woman's "knight in shining armor." Trauma bonding, you might ask? Not really. Just equal involvement.

The biggest reason a woman needs her husband's support so much is because natural childbirth is very difficult to do, especially in this day and age. Even if a woman has done all of the research, taken a class, and goes in prepared to have an unmedicated birth, there is bound to be a point (usually when the woman goes into "transition") when she feels unsure that she can do it anymore. At this point, there is often a nurse ready to offer meds at Mom's request. If, however, the husband has also done all of the research, taken the class with Mom, and prepared and educated himself, he can offer reassurance and moral support through the difficult, and usually brief, period of discouragement. He becomes her advocate in a challenging time.

It might sound insensitive for a husband (who is not in labor) to discourage his wife from getting an epidural when she's in pain. It is very compassionate for a man to not want his wife to suffer needlessly. But epidurals bring with them risks and challenges as well, and when a woman has decided that she wants to avoid those risks and challenges, she needs that kind of positive encouragement. Again, from my own personal experience, once it starts to feel too difficult, the pushing stage is usually only minutes away. I've now had two epidural free labors, one of which was very painful at times, and I've never regretted avoiding the epidural. I am acquainted with a number of women who've also had at least 2 or 3 Bradley births, and they have been grateful each time that they avoided the epidural.

I was thinking to put off an epidural vent for another post, but it feels necessary to explain why I personally feel so strongly about avoiding an epidural. First, I'd like to include links to the American Pregnancy Association and Babycenter on epidural. Both of these articles seem to be pretty objective - neither completely for or against. A third article, which I thoroughly enjoyed as well, is from iVillage. This one is quite good, because it acknowledges the variance between studies and the hot emotions surrounding the debate. Most of all, I appreciate the conclusion it makes that epidurals are an "excellent option for some women." Notice the use of the word "some." Not "most." Not "all."

You see, I want to make it clear that I don't believe that epidurals are evil or something. They just aren't for every woman, and yet so many women who desire to avoid them are mocked by other women when the subject comes up. I am unabashed about sharing my enthusiasm for a mom-to-be who is contemplating unmedicated childbirth. But I have learned that, in a group of women who have epidurals with all of their labors, if you make the mistake of saying that you prefer unmedicated childbirth, the word "crazy" often comes up. So many women who've had epidurals in labor feel the need to defend their choice. I think that's so unfortunate, because I'm going to let you in on a little secret: You don't ever have to defend an epidural to me. I've had three babies - one with epidural and two without - and I get how painful and scary it can be at times. I've just enjoyed my unmedicated births (and recoveries) better than my epidural birth.

The problem I have with the epidural is how much they are encouraged in the medical community with very little discussion about the risks and challenges that often come with an epidural. I thought of including a link to Web MD about epidurals, but the one minute video of a MALE doctor arguing that MOST women have a more satisfactory experience with epidural just bugged me too much. :) Who is he to argue how satisfactory a woman's birth experience is? What is a woman, who has just brought a baby she already loves into the world (possibly in a very miserable way), going to do when she sees her little bundle of joy? Yell at the doctor because she tore badly or because she came down with a fever?! (Imagine incredulous look on my mysterious face) Doctors don't know exactly what is going through a woman's mind or how well a woman is going to recover after he leaves the hospital. I remind you of my labor with my daughter. When it was over, I felt euphoric - that is until the recovery stage began. Then I felt awful. So, this man's "testimonial of the epidural in labor" (which he has never actually received) means nothing to me.

Okay, I'm backing off a little now and am going to try and be objective. For the record, I'm laughing and smiling, and I hope you are too. :)

Epidurals bring risks. Not everyone reacts the same to an epidural. Not every anesthesiologist is the same. Compared to how much pain medication was once used during labor, epidurals use much less; but it's still medication in labor, and some studies indicate that babies might not latch on as well if they were born in an epidural labor. Other studies disagree. My daughter was a sleepy little slug and latched terribly from day two (because she wouldn't latch on during day one). But who knows why that was. I personally think it might have had something to do with the epidural (and the fact that I was in too poor condition to hold her during the first hour of her life).

One thing that I believe it is completely irresponsible to deny is that pushing is more difficult with an epidural. Pushing out a baby is tough work. It requires a lot of strength, and the better the pushing position, the easier and more doable it is. The best positions require you to pull your knees all the way up to your armpits - no joke. This is not easy when your legs are warm, numb blobs of flesh. It is tough.

You also cannot feel the muscles that you are pushing with very well (or maybe not at all). Don't worry, the baby still comes out with an epidural, especially if he/she is in a good position, isn't too big, and if the body is pushing some great, heavy duty contractions behind that baby. BUT, you may end up needing an episiotomy if that baby is crowning long enough to worry the doctor, and you don't want to get me started on episiotomy.

But I must get started on episiotomy, so my apologies. Episiotomies are not a bad thing. You can even find an article on website as recent as 2007 which argues that episiotomies "prevent tearing." I didn't include this link either, because I again found it annoying. When we took our Bradley class in 2004, I did extensive research on episiotomies and was amazed and impressed to find that the current consensus (and again, this was back in 2004) was that episiotomies are best saved for babies in distress. If you read the above babycenter link (on "episiotomy") you'll find the same kind of information.

Episiotomies involve cutting the perineum, and muscle which separates the vagina and the anus, to enlarge the vaginal opening and ease the birth of a baby. It used to be routine, especially when many moms were knocked out at birth and babies were routinely delivered by forcep extraction. In recent decades, they have still been used fairly routinely because doctors have wanted to prevent Mom from tearing. Now doctors are realizing that, unless we have a baby in distress who needs to be born NOW, it's better to give Mom some more time. For one thing, she just might not tear. For another thing, if she tears, it is not any worse, and it's usually better, than if she has an episiotomy. When a woman tears naturally, it might be a pain for a doctor to sew up (to which I respond, "I'm paying you big bucks to catch a baby. Shut up, and sew me." Too intense?). In a naturally occurring tear, however, less tissue tends to tear, and Mom usually recovers a little better than if she had an episiotomy. Believe it or not, it's true.

But here's the worst thing about elective (and when I say elective, I mean "no baby in distress") episiotomy: There is always a chance that Mom will tear beyond the episiotomy. These are ugly tears, either to the anus or the even the rectum. Ouch!! (Believe me, I know.) You do not want to have to deal with a 3rd (anal) or 4th (rectal) degree tear unless it's in the name of saving your sweet baby. So, as you can tell, it KILLS me that most of my friends have episiotomies with ALL of their labors. I've wondered at this weird phenomenon. Why would all of these doctors keep cutting their patients, thereby guaranteeing that they'll HAVE to have stitches when there is a chance that they might not tear or that their tearing would be minimal and easier to recover from? I pondered this allowed to my husband the other night. I had an epiphany.

Well, actually I had two epiphanies. First, I think doctors in my area might not be keeping up with the times on episiotomy. I live in Utah where tons of babies are born every year, and doctors out here are very busy and probably have little time to consistently spare for medical journals (or bossy moms). In some ways, it's fabulous to have such experienced doctors. In other ways, it stinks, because they're SO busy. I don't want to be conspiratorial, but I think that a lot of doctors (and some midwives) are a little impatient with how quickly a baby should be born. I guess you could argue that getting them here quicker to avoid fetal distress is better than waiting for the fetal distress, but I still think Mom should be taken into consideration on this. I also think that some busy doctors might be rationalizing cutting for their own convenience and schedule. And finally, with so many patients and having delivered hundreds of babies already, some doctors are just used to cutting their patients in labor. Unfortunately, the only ones who have to suffer for it are the patients.

The other epiphany was this: It's pretty hard to push out a baby with an epidural. Maybe that's why most of my friends get episiotomies every time. Between their busy, slightly routined doctors and the slow progress that comes with an epidural, it might just seem necessary to cut the mom most of the time. It still makes me a little sad. I have a few friends who go naturally like me, and they sometimes don't tear a bit. Imagine not tearing during childbirth!!! What a wonderful thought!

I daydream about not tearing, but I'm afraid that once you've had a 4th degree laceration in labor, you have lots of scar tissue where you once might have stretched. The chances of not tearing are pretty slim. BUT, I still have an agreement with my midwives that if the baby has some time to spare, please let me get him/her out without cutting. I'll probably tear, but it's nothing to a 3rd or 4th degree (which practically never happens without an episiotomy). In fact, in my last delivery (baby #3), the baby did start to struggle while he was crowning. My wonderful midwife, who realized that I was tired and needed a second wind, gently asserted, "If he doesn't come out on this next contraction, we'll have to do an episiotomy." I was exhausted and wanted to make it clear that I would comply if needed. Then I heard the OB in the room ask her, "Why wait?" Her answer: "She's had a 4th degree laceration." It snapped me out of fatigue and back into reality. He was struggling. We could lose him. I doubled my effort. When he didn't come out on the contraction, I kept pushing, and a few seconds later he slid out in all his glory. I tore, but only - get this - 1st degree (less than/equal to an episiotomy). Cutting me would not have changed his condition, but it would have changed mine. And, I know that sounds selfish, but a healthier recovery blesses both the mom and the baby.

So before I return to epidurals and finish my little rant there, I just want to encourage you to discuss episiotomy with your doctor and see if they'll hold off on the scissors unless it's really necessary. And do a lot of kegels.

So though I haven't discussed the obvious benefits of epidural (do I need to?), I can say with confidence that it is not without it's risks and challenges, and not every woman loves her epidural birth. (You hear me, Mr. WebMD?) So it's possible that epidurals might not be the answer for everyone.

Now do I think that moms should suffer in anguish and agony in order to bring their babies into the world? Not if it can be avoided! Sometimes I meet women (typically older than myself) who had at least one or two babies without medication because they had been made to feel guilty about considering an epidural. This makes me just as sad for them as for one who is bullied into having an epidural and then has a bad experience. It should be a woman's choice when possible. They are the ones having the babies, and they are the ones having to recover. Their choice should be respected.

Of course, there is always a slight possibility that Mom's labor will fly by so fast that she'll have a car birth or the anesthesiologist won't get to her on time. That happens, and it honestly sounds pretty scary. Considering that possibility, I think it would be wise for ALL moms to do some deep relaxation exercises just in case. (I mean, you really never know how fast your labor will progress).

If a woman truly desires to go unmedicated, however, with proper education, training, preparation, and relaxation, childbirth does not have to feel like anguish. It doesn't have to be scary. It will always be work - very focused, challenging work - but it doesn't have to feel like pain. A majority of contractions, under deep relaxation, will feel more like pressure in your abdomen and possibly some burning back pain. It's not an easy feeling, but it doesn't have to "hurt". Of course, especially during transition, when the baby exits the uterus and/or when the contractions come so strong and fast that it's hard to relax, there will be minutes of pain, even fear possibly (and maybe even some swearing). But they pass sooner than you know, and when you feel the urge to push your baby and have all of the power and control of your muscles behind those pushes, it is AMAZING. I can't tell you how amazing.

Okay, I'm getting ethereal here. Now I'd be a liar if I said that it never hurts from that point on. Actually, when a baby is crowning, it's pretty stingy and ouchy. Gotta fess up there. But it's also short-lived when you have good control and good coaching. And then it's over, and your little guy/gal is laying there all slimy being checked out and placed on your belly. (Or, in my cases, being checked out, laid on your chest for 30 seconds, and then whisked away to the NICU for an IV or something... yeah, another post, my friend). Then, sometime in there you deliver your placenta and get stitched up (if needed), and while baby is having a bath (or an IV), your nurse starts cleaning your room, and you get up, walk into the bathroom unassisted, sit down, and pee... now that, my friends, is cooler than you can believe. Just saying...

So, if you love your epidurals but have a friend who has a genuine desire (or even remote interest) in going unmedicated, can I make a request? Don't tease them. Don't defend your decision to have an epidural. (It needs no defense.) Don't say something like "They're not handing out trophies or anything." (Please please don't.) And please don't reassure them that they should never feel bad if they decide to change their mind. There are plenty of people, their doctors included, who can give them that reassurance.

When a woman is hoping to go unmedicated, she has enough self-doubt of her own to deal with, especially if it is her first pregnancy. Instead, encourage her and wish her the very best and, if it seems appropriate, let her know that you've heard that a good Bradley class or a Hypnobirthing class can make all of the difference. It's a just a little food for thought from someone who has been where she is...

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