The decision to select or avoid pain medication is a deeply personal one. There are a million seen and unseen forces that go into this decision during labor. You can read more about making this decision in my post Making the Call: If you Ask for Pain Medication during Labor.
If you’re like many women who are on the Sacred Ground of Not Yet Knowing, you wonder how you’ll handle the pain of labor. Perhaps you have done your research and you’re certain what you would prefer. Perhaps you’re more of a take-it-as-it-comes girl. Either way, it is prudent and self-loving to plan for the possibility of utilizing an epidural for childbirth.
Should you choose epidural pain relief in labor, this article can help enhance your medical, emotional and physical experience of it. Print it off, place it in your hospital bag, show it to your support people ahead of time (doula, partner, mom, etc). You can also access a single-page list format (cheat sheet!) of all these tips through my resource library.
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When to get it:
Basically, get it when you want it. Statistically, there is no increased risk of Birth by Cesarean or instrumental delivery (forceps, ventouse) whether a mother receives an epidural in early labor (before 5cm) or active labor (5cm+). There have been MANY studies about that. However, many women still choose to labor without intervention as long as they can. Just moving and being upright through the first stage of labor greatly reduces many interventions, like instrumental deliveries and Cesarean Births. 
Working with contractions and laboring unhindered often gives mothers a sense of control and accomplishment. She will be sure that it’s real labor (as opposed to latent or prodromal), which can minimize the second guessing after her journey is complete.
Several of my past clients kept a pain-relief option (or two) in their back pocket for the moment they first consider an epidural. She may first try laboring in a warm shower or tub, slow-dancing in the dark with her partner or using hot packs – really anything that sounds nice and soothing to her. Giving herself an extra 30 minutes+ of upright, mobile work can greatly increase her satisfaction with her decision for an epidural. Then she can say she truly tried many things. Occasionally, this last–ditch pain-relief will get a woman through the first stage of labor completely, maybe even surprising herself!
If you are planning to receive an epidural, then you can make a couple of choices earlier in labor to expedite go-time. Let the nurse know your plans so s/he can best support it. S/he can also administer IV fluids, which must be completed before an epidural is placed (to minimize the risk of a drop in blood pressure from the medication). She/He can also alert the anesthesiologist to do any preliminary interviewing and examination (they look down your throat. who knew!?), and the mother can sign any paperwork, before the labor is hot and heavy. Some hospitals run through these steps for every patient, anyway.
From decision to relief!
Laboring Woman: Once the decision has been made for an epidural, the laboring woman and her supporters may need to double their efforts to cope as they wait. Knowing that pain relief is coming, but not yet here, sometimes enhances the perception of pain. Again, using her back-pocket coping ideas can help. Even some self-talk can help: “I can do this.”
Anecdotally, A few of my clients have expressed that they were BETTER able to cope when the epidural was on deck. Just knowing that relief was coming helped their experience of the contractions. When the anesthesiologist or nurse anesthetist first arrives, they may have many questions and require some signatures (if this was not done earlier in labor). As much as possible, this will be expedited if mother can manage to answer through contractions or if her partner can answer accurately for her.
Support people: During contractions, stay fully present with the mother to help her get through one contraction at a time. Asking medical staff for a time estimate on the anesthesiologist’s arrival also helps, especially if this is broken down into a number of contractions (if contractions are 3 minutes apart and anesthesia should arrive in 30 minutes, you can frame it to be about 10-12 contractions of work [pro-tip: overstate the number a little just in case]). Remind the mother that every effort she makes is bringing her baby. Reassure her that she is safe and her baby is safe.
In between contractions, when the laboring woman needs less direct support, you can help by clearing the room and tables of any personal items. While staying focused on supporting the mother, be mindful to let the staff arrange the room and make any preparations with the mother (placing a blue surgical hat, getting her into position, etc).
During the Procedure:
Laboring Woman: It is a common protocol in many hospitals to require that non-medical support people leave the room during an epidural placement. This protects mom by eliminating variables (someone passing out, someone inadvertently distracting her or disrupting the procedure, etc).  However, this rule is a surprise to many of my doula clients!
Mom can seek support and help from her nurse, doctor or midwife who remains with her. She can even state directly how they can help her – giving her encouragement, direct eye contact, breathing with her or holding her hands firmly. Women often use a coping tool through an epidural that was useful through contractions.
Supporters: Before the woman’s partner or support people leave, they can create a quick special moment as they part: kissing her cheek, reminding her of how strong she is (or some meaningful phrase). Supporters can ask the medical staff how they will know when to return, or if they should inquire at the front desk. Support team should grab their phone, wallet and coat as they leave! During this 20-30 minute procedure, partners and support people can also take care of their own needs. I encourage a walk outside in the fresh air or some stretches, a small meal or snack and a connection with someone they love. This is a great time to update family and friends, especially sharing the high points of the journey so far. (Go ahead, brag about how amazing she is.)
If the hospital does allow the support team to remain in the room through the epidural placement, each person can run a quick self-assessment of their comfort level and physical state. “Have I eaten lately? How long have I been awake? Am I squeemish?” To be reeeally safe, support people can place chairs behind their butts in case they feel light headed. Using long, relaxed breaths can help calm a stressed body and be a firm support to the laboring mother.
Laboring Woman: As the epidural takes effect, mothers often feel relief in just a few contractions. 80-85% of epidurals work fully. If she experiences “break through pain” or incomplete relief, the anesthesiologist will continue to work for a more effective block.
Once the pain subsides, the mind begins to assess and reflect. Sometimes women are grateful or thrilled with their choice, while others are disappointed or grieving. She may feel some of each, which is normal. Humans are complex and can feel many emotions at once. Just now I was really happy I had fried fish for dinner, but I’m also experiencing a stomach ache.
Supporters: It can be a little exciting, maybe a little nerve-wracking to come back into the labor room. The laboring mother will have a few more tubes and beeping machines around her body. Still, women often feel more like their normal selves when the pain is eased. She may not have looked up at anyone for hours while she was coping with contractions! She may be able to engage in a conversation or even smile. This reunion can be a huge relief for everyone when the procedure goes smoothly.
However! This transition requires some intention. The laboring woman may want to chat and process her experience, or she may need some comfort and reassurance. I am always careful not to tell the mother how she should feel or project judgment on her decision. No “Aren’t you glad you got the epidural?” or “You made the right choice.” The subtle judgment behind statements like these may shame or quiet her personal thoughts about it. I only validate her wisdom in making the choice for herself, then let her fill in the story as she is experiencing it.
Because she will be unable to roll from side to side, support people can bring a chair up by her bed so she can see them. She can feel more connection if her people are nearby, at least initially. For my doula clients, I offer a foot massage after an epidural is placed. This can root her firmly in her body, and keeps the labor hormones going. I also bring the adjustable table by the bed and place things she might need close by (chapstick, her phone, teddy bear, ice chips or water, etc). Once everyone gets used to the new normal, many moms will take the opportunity to sleep.
Laboring woman: Hospitals are noisy, beepy places. Even the medical care women receive from their nurses can disrupt rest. So to increase the chances of sleeping, mothers can bring earplugs and eye-masks with them. Even a towel or sweater placed over her face can block out lights from computers and machines. Obviously turning the lights down in the room will help. If a machine beeps, she can call the nurse right away (machines typically don't stop on their own).
Once the laboring woman decides to sleep, family and friends can be notified via text that she will be turning her phone off. Airplane mode is great here. I’ve seen many women unable to rest because her phone keeps going off. Or maybe she was on Tinder – not totally sure. Mom can also ask the nurse to minimize any disruptions or cluster all her tasks together (temperature, blood pressure, etc).
Support people: Sleeping in a hospital is seriously challenging. Hopefully during a tour, partner was able to see what accommodations are available. It’s often a fold out chair or couch. I always suggest a few extra pillows from home. These can be kept in the car until needed. If it seems helpful, extra support people like doulas or family members can find somewhere else to rest. I’ve slept in the back of my car many times over the years, but a waiting room works, too. Reducing the number of people in the room can also help the laboring mother sleep. (of course, keep your phone close and LOUD)
Coping with Side Effects:
Itching (pruritis): It’s a common side effect to experience an itching sensation with an epidural. If it is severe, the laboring woman can try cold compresses or cold washcloths. There are also medications available; they can make her drowsy.
Elevated temperature: With an epidural, the body is not as efficient at regulating temperature. Many women feel hot while everyone else in the room has sweaters on! Use simple tricks like removing layers and blankets can help, as well as cool washcloths on her forehead or neck. Ice chips or popsicles feel fantastic, too.
Shaking: Shivering and shaking can happen with an epidural, but are also common side effects in unmedicated births. The hormonal surges and fluctuations of birth often show up in this physical way. Most mothers find some relief by allowing or not fighting the shaking.
Vomiting/nausea: Remember that table we pulled up next to the mother, so she can have everything she needs in arm’s reach? This is a great place to keep a puke receptacle. Better just to have it out, even if the woman isn’t feeling nauseous. That can change quickly!
Labor progress: Even though the laboring woman has pain relief, her body is still in labor. Arranging the environment to foster some loooove hormone (oxytocin) may help. Keep the lights dim, limit people in the room, bring familiar smells, etc. The nurse may come in every 30-60 minutes to have the mother rotate from one side to the other. Epidurals work by gravity, so changing the woman’s position keeps one side from getting too numb. This rotation can also help the baby to navigate the pelvis, and the cervix to dilate evenly.
The hospital may be up on the newest research, which is showing a DRAMATIC reduction in Cesarean Births with this cheap little intervention. I believe the medical term is “peanut ball”. The mother can rest with the peanut ball between her knees, which helps to open her pelvis in a very specific way. Some doulas carry peanut balls with them, or I’ve had clients also purchase their own. If one is not available, a stack of blankets and pillows can serve. The goal is to get the knees far away from each other, like a frog’s legs. Bonus points if you take a picture.
Laboring Woman: If an epidural is strong enough, the mother may not feel the urge to push. Once she has finished dilating, there are a couple of options. The staff may encourage a few contractions of “practice pushes” to see if she is able to move the baby down with each contraction. If this isn’t effective, they often will leave her to rest until her uterus has passively moved the baby down without her pushing effort. This is called “laboring down”. Some hospital staff prefers this as a standard protocol.
While allowing the mom to labor down usually makes the second stage longer, it shortens the amount of time she has to actively engage in pushing (which is hard work!) Laboring down also has an added benefit of reducing the odds of instrumental delivery. While she rests, she may feel pressure in her butt, poetically referred to as “rectal pressure”. This is a sign that her baby is moving down, and can help to guide her as she pushes.
Statistically, it doesn’t change much if the epidural medication is reduced or allowed to “wear off”. There is no significant decrease in the need for Birth by Cesarean or instrumental deliveries.  However, some women like to feel the contractions again in order to work with the sensations. She may also find that she can control her legs more if the medication is turned down. This is an option available, and can be left up to mother’s preference.
As for pushing positions, the research is pretty mixed. In my experience, I see the options depending more on mother’s mobility (which can vary with the amount of medication in the epidural) and the philosophy of the doctor or midwife. It’s a great question for pregnant women to ask at a prenatal appointment, “What positions do your patients use for pushing if they have an epidural?”
If the laboring woman doesn’t have a lot of mobility or strength, semi-reclined and side-lying seem to be the most workable. However, I have had clients push on hands and knees, using the squat bar and kneeling against the back of the hospital bed, even with epidurals! Women may try several different positions through the 2-3 hours of pushing to make the most progress.
If the laboring mother can’t feel the pressure changing as she moves her baby down, she can get feedback from some external sources. A doc or midwife may place gloved fingers in her vagina during pushing to feel the effectiveness of each push and position. Some will use their fingers to press into the part of the pelvis where mother can direct her energy (some laboring mothers appreciate this. Some find it uncomfortable or invasive. She can let her Care Provider know her preference.) Often a standing mirror is available on the Labor and Delivery floor, which can be brought if mother would like to see the effort she is making. Once baby has reached a low position, some care providers will ask if the laboring mother would like to feel her baby’s head. Although she may be deep inside of her own mind and hesitant to move much, I notice that women are fantastically motivated when they do try this.
Support person: A woman with an epidural will often need physical support during pushing. Depending on the position she chooses, support people can help with holding a leg or hoisting her body toward the squat bar. A contraction comes and everyone moves into place. Between contractions, she can stay where she is or move back to a more restful position. Partners can help with cooling her hard-working body with some cold washcloths, offering her sips of water and encouraging every effort.
Because of the excitement, adrenaline and exertion of pushing, it’s a GREAT idea for support people to grab a small snack at the beginning of pushing. Sneaking a few bites of granola can stave off any dramatic movie scenes of fainting when the baby is born.
After the Birth:
Epidural use is associated with some breastfeeding challenges. If she plans to breastfeed, a mother can prepare more proactively when she takes a great breastfeeding class, goes to a breastfeeding support group (prenatally!) and gets connected with a lactation consultant ahead of time. Partner and community support is one of the biggest influencing factors that can determine breastfeeding success. So partners can go with her to her class and meet the lactation consultant, as well.
Emotional processing – Women go through several different incarnations of their birth story over the first year. Her perceptions of her choices and the meaning she ascribes them will shift as she processes. This is a normal part of digesting a very big life event! If any decision or event in labor seems to plague mom’s thoughts, or if she would like some fresh perspective, I highly recommend seeking out a trained Birthing From Within mentor with special education and experience in Birth Story Listening. You can find a listing here.
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Babes, I know how RIFE with contention and opinion your lives are (and the internet is). But what that been helpful in your plan for pain medication? What has given you pause? What has given you reassurance?
Research (Science, bitch!):
 Sng, Ban Leong, Wan Ling Leong, Yanzhi Zeng, Fahad Javaid Siddiqui, Pryseley N. Assam, Yvonne Lim, Edwin S. Y. Chan, and Alex T. Sia. “Early versus Late Initiation of Epidural Analgesia for Labour.” The Cochrane Database of Systematic Reviews 10 (2014): CD007238. doi:10.1002/14651858.CD007238.pub2.
 Chen, Ying-Ling, Yi Chang, and Yu-Ling Yeh. “Timing of Epidural Analgesia Intervention for Labor Pain in Nulliparous Women in Taiwan: A Retrospective Study.” Acta Anaesthesiologica Taiwanica: Official Journal of the Taiwan Society of Anesthesiologists 51, no. 3 (September 2013): 112–15. doi:10.1016/j.aat.2013.09.001.
 Lee, Hui-Ling, Liang-Ming Lo, Chung-Chuan Chou, Tzu-Yi Chiang, and Eng-Chye Chuah. “Timing of Initiating Epidural Analgesia and Mode of Delivery in Nulliparas: A Retrospective Experience Using Ropivacaine.” Chang Gung Medical Journal 31, no. 4 (August 2008): 395–401.
 Lawrence, Annemarie, Lucy Lewis, G. Justus Hofmeyr, and Cathy Styles. “Maternal Positions and Mobility during First Stage Labour.” The Cochrane Database of Systematic Reviews 10 (2013): CD003934. doi:10.1002/14651858.CD003934.pub4.
 Orbach-Zinger, Sharon, Yehuda Ginosar, Julia Sverdlik, Claudio Treitel, Kiri MacKersey, Ron Bardin, Dan Peleg, and Leonid A. Eidelman. “Partner’s Presence during Initiation of Epidural Labor Analgesia Does Not Decrease Maternal Stress: A Prospective Randomized Controlled Trial.” Anesthesia and Analgesia 114, no. 3 (March 2012): 654–60. doi:10.1213/ANE.0b013e318241f4f3.
 Tussey, Christina Marie, Emily Botsios, Richard D. Gerkin, Lesly A. Kelly, Juana Gamez, and Jennifer Mensik. “Reducing Length of Labor and Cesarean Surgery Rate Using a Peanut Ball for Women Laboring With an Epidural.” The Journal of Perinatal Education 24, no. 1 (2015): 16–24. doi:10.1891/1058-1243.24.1.16.
 Lemos, Andrea, Melania M. R. Amorim, Armele Dornelas de Andrade, Ariani I. de Souza, José Eulálio Cabral Filho, and Jailson B. Correia. “Pushing/bearing down Methods for the Second Stage of Labour.” The Cochrane Database of Systematic Reviews 10 (2015): CD009124. doi:10.1002/14651858.CD009124.pub2.
 Kelly, Mary, Eileen Johnson, Vickie Lee, Liz Massey, Debbie Purser, Karen Ring, Stephanye Sanderson, Juanita Styles, and Deb Wood. “Delayed versus Immediate Pushing in Second Stage of Labor.” MCN. The American Journal of Maternal Child Nursing 35, no. 2 (April 2010): 81–88. doi:10.1097/NMC.0b013e3181cae7ad.
 Schmitz, T., and E. Meunier. “[Interventions during labor for reducing instrumental deliveries].” Journal De Gynécologie, Obstétrique Et Biologie De La Reproduction 37 Suppl 8 (December 2008): S179–87. doi:10.1016/S0368-2315(08)74756-2.
Torvaldsen, S., C. L. Roberts, J. C. Bell, and C. H. Raynes-Greenow. “Discontinuation of Epidural Analgesia Late in Labour for Reducing the Adverse Delivery Outcomes Associated with Epidural Analgesia.” The Cochrane Database of Systematic Reviews, no. 4 (2004): CD004457. doi:10.1002/14651858.CD004457.pub2.
 Kemp, Emily, Claire J. Kingswood, Marion Kibuka, and Jim G. Thornton. “Position in the Second Stage of Labour for Women with Epidural Anaesthesia.” The Cochrane Database of Systematic Reviews 1 (2013): CD008070. doi:10.1002/14651858.CD008070.pub2.
 Roberts, Christine L., Charles S. Algert, Carolyn A. Cameron, and Siranda Torvaldsen. “A Meta-Analysis of Upright Positions in the Second Stage to Reduce Instrumental Deliveries in Women with Epidural Analgesia.” Acta Obstetricia Et Gynecologica Scandinavica 84, no. 8 (August 2005): 794–98. doi:10.1111/j.0001-6349.2005.00786.x.
 Kemp, Emily, Claire J Kingswood, Marion Kibuka, and Jim G Thornton. “Position in the Second Stage of Labour for Women with Epidural Anaesthesia.” In Cochrane Database of Systematic Reviews, edited by The Cochrane Collaboration. Chichester, UK: John Wiley & Sons, Ltd, 2013. http://doi.wiley.com/10.1002/14651858.CD008070.pub2.
 Downe, Soo, David Gerrett, and Mary J. Renfrew. “A Prospective Randomised Trial on the Effect of Position in the Passive Second Stage of Labour on Birth Outcome in Nulliparous Women Using Epidural Analgesia.” Midwifery 20, no. 2 (June 2004): 157–68. doi:10.1016/S0266-6138(03)00052-4.
 Wiklund, Ingela, Margareta Norman, Kerstin Uvnäs-Moberg, Anna-Berit Ransjö-Arvidson, and Ellika Andolf. “Epidural Analgesia: Breast-Feeding Success and Related Factors.” Midwifery 25, no. 2 (April 2009): e31–38. doi:10.1016/j.midw.2007.07.005.
 Brimdyr, Kajsa, Karin Cadwell, Ann-Marie Widström, Kristin Svensson, Monica Neumann, Elaine A. Hart, Sarah Harrington, and Raylene Phillips. “The Association Between Common Labor Drugs and Suckling When Skin-to-Skin During the First Hour After Birth.” Birth (Berkeley, Calif.) 42, no. 4 (December 2015): 319–28. doi:10.1111/birt.12186.
 Persad, Malini D., and Janell L. Mensinger. “Maternal Breastfeeding Attitudes: Association with Breastfeeding Intent and Socio-Demographics among Urban Primiparas.” Journal of Community Health 33, no. 2 (April 2008): 53–60. doi:10.1007/s10900-007-9068-2.