Birth Partner | For Everyone at the Birth

Source: *The Birth Partner* (5th ed.) — Penny Simkin with Katie Rohs

The Context: What Matters About the Decision

About 70% of people giving birth in American hospitals use an epidural. This is neither a failure nor a foregone conclusion. What matters is that the decision is made thoughtfully, in advance, with good information, and is respected.

Four conditions that make unmedicated labor more likely to succeed:

1. The laboring person genuinely wants to avoid medication

2. They know the comfort measures and have practiced them

3. They have continuous skilled emotional support (a partner, doula, or both)

4. Labor is reasonably straightforward

When one or more of these conditions is not in place, unmedicated labor becomes significantly harder. There is no shame in this.

**The birth partner's role:** Support the laboring person's preference, whatever it is. If they want to avoid medication, help them do that. If they want an epidural, support that. Do not impose your preferences on their body and their experience.

Discuss the preferences before labor. Agree on a code word — a specific word or phrase that means "I am ready for an epidural and I mean it." This protects the laboring person from being pushed into medication when they are just venting, and protects them from being denied relief when they genuinely want it.

Key Terminology

**Analgesia:** Reduces pain without eliminating sensation. The person remains conscious and aware.

**Anesthesia:** Eliminates sensation entirely in an area or induces unconsciousness. Regional anesthesia is the term for epidurals and spinals.

**Systemic:** Affects the entire body via the bloodstream (narcotics, sedatives, tranquilizers).

**Neuraxial / Regional:** Targets the spinal cord and nerve roots (epidural, spinal, combined spinal-epidural). The most effective route with the fewest systemic effects on the baby.

**Local:** Affects a small, specific area (the local anesthetic injected before an episiotomy repair).

**Block:** A medication that interrupts the transmission of pain impulses along a nerve pathway.

Systemic Medications

Narcotics (Opioids)

Given by IV or IM injection. Provide pain relief and sedation but do not eliminate pain. Onset: 20 to 30 minutes. Duration: 2 to 4 hours.

**Common drugs:** Meperidine (Demerol), fentanyl, butorphanol (Stadol), nalbuphine (Nubain), remifentanil.

**How they help:** They reduce the emotional reaction to pain as much as the sensation itself. The laboring person dozes between contractions, which provides rest.

**How they complicate:** The transition from doze to contraction peak is abrupt. Without warning, the laboring person is suddenly at the strongest point of the contraction. This can feel out of control and harder to manage than a contraction that builds from the beginning.

**Birth partner role with narcotics:** Stay awake. Watch the laboring person's face and body for behavioral signs that a contraction is starting. Before the peak hits: "Okay, here comes one. Open your eyes. Breathe with me." Get them into rhythm before the contraction peaks. Do not look away.

**Effects on the baby:** All narcotics cross the placenta. Timing matters — narcotics are typically not given close to anticipated birth because they can suppress the newborn's breathing. If they were recently given, Naloxone (Narcan) can be administered to the newborn to reverse the effect.

Sedatives and Tranquilizers

Rarely used as primary pain relief. Occasionally given early in labor to allow rest during a prolonged prelabor phase. Cause drowsiness. Do not reduce pain directly.

Nitrous Oxide (Laughing Gas)

An inhaled gas (50% nitrous oxide, 50% oxygen) breathed through a mask held by the laboring person during contractions.

**How it works:** Reduces anxiety, takes the edge off pain, and creates a sense of dissociation. Does not eliminate pain. Effects begin within about 30 seconds and wear off within about a minute of stopping.

**Advantages:** Immediate effect, wears off immediately, not metabolized by the baby, can be used and stopped freely.

**Disadvantages:** Does not provide complete pain relief; requires holding the mask and breathing in a specific pattern; can cause nausea, dizziness, or a floating feeling some people dislike.

**Availability:** Not universally available in the US but becoming more common. Ask the facility whether they offer it.

Regional (Neuraxial) Analgesia: Epidurals and Spinals

Regional analgesia is the most effective form of pain relief in labor. It provides the greatest relief with the least effect on the baby's mental state and the birthing person's consciousness.

The Epidural Space vs. the Dural Space

The spinal cord is surrounded by a membrane called the dura mater. Between the dura and the bony vertebrae is the epidural space.

**Epidural:** Catheter placed into the epidural space, just outside the dura. Medication bathes the nerve roots as they exit the spinal cord. Takes 15 to 30 minutes to achieve full effect.
**Spinal:** Single injection through the dura into the subarachnoid space (which contains spinal fluid). Very fast onset (2 to 5 minutes). Usually for cesareans or very late labor.
**Combined spinal-epidural (CSE):** Two-step: the spinal provides fast-acting relief for early active labor; the epidural catheter is placed and used to add or continue analgesia as labor progresses.

The Epidural Procedure

1. IV fluids are given first to reduce the risk of blood pressure drop.

2. The laboring person sits curled forward (or lies on their side in a fetal position) so the vertebrae separate and the target space opens.

3. The skin on the lower back is scrubbed and numbed with a local anesthetic.

4. The epidural needle is inserted between vertebrae into the epidural space.

5. A thin plastic catheter is threaded through the needle. The needle is removed. The catheter stays.

6. Initial dose is given. Effect begins within 15 to 30 minutes.

7. Continuous infusion keeps the epidural working throughout labor. Patient-controlled epidural analgesia (PCEA) allows the laboring person to press a button for an extra dose within safe limits.

**Adjusting the epidural:** Some laboring people experience "patchy" relief — a spot that is not covered, or relief that is stronger on one side. Repositioning, adjusting the dose, or adding medication can address most of these problems.

Caine Drugs (Local Anesthetics for Neuraxial Use)

Bupivacaine and ropivacaine are the most common. They block nerve impulses. Combined with neuraxial narcotics (fentanyl, sufentanil), a low dose of each achieves good pain relief with better ability to move the legs ("walking epidural") compared to older, higher-dose techniques.

Neuraxial Narcotics

Fentanyl and sufentanil provide rapid onset and cross to the baby more than morphine does. Effects on the baby: possible temperature dysregulation, impaired suckling for up to 2 days. At low doses, these effects are modest. At higher doses, they are more significant.

Epidural morphine (brand name Duramorph) is commonly given after cesarean delivery for up to 24 hours of post-surgical pain relief.

What an Epidural Feels Like

Within 15 to 30 minutes of the first dose, the laboring person typically feels a warm, heavy sensation spreading through the lower body. Pain diminishes from sharp and consuming to manageable pressure. Most people can still feel contractions as pressure waves but not as pain.

Some people feel nothing at all. Some retain some sensation on one side or in patches.

**Common side effects:**

Blood pressure drop (hypotension): treated with IV fluids and repositioning
Itching from the narcotics: treated with a low dose of Benadryl or Naloxone
Shivering: common, not dangerous
Difficulty urinating: a urinary catheter is typically placed after an epidural is working
Fever: epidurals are associated with intrapartum fever, which can lead to sepsis workup for the newborn even when there is no infection
Slower labor progress: may result in Pitocin augmentation
Reduced ability to push effectively: the second stage may be longer; a peanut ball can help with positioning

**Birth partner role during epidural:** The birth partner may feel less urgently needed once the epidural is working. This is normal. Stay present. There is still emotional support to provide, position changes to facilitate (peanut ball, side-to-side rotation every hour), and the labor to track. When it is time to push, the birth partner becomes active again.

The Pain Medications Preference Scale (PMPS)

A planning tool developed by Simkin that helps the laboring person articulate their preferences before labor.

Scale from 1 to 10:

**1 to 3:** Strong preference to avoid all medication; has prepared extensively; willing to accept a difficult labor experience in exchange for no medication
**4 to 6:** Prefers to avoid medication but is open to it if labor is very hard or prolonged; wants to try comfort measures first; values flexibility
**7 to 10:** Plans to use an epidural; prefers to have it early; pain avoidance is a priority

Whatever the number, it is not a judgment. Knowing the number helps the birth partner know how hard to advocate for comfort measures vs. when to start moving toward asking for medication.

General (Systemic) Anesthesia

Used for emergency cesarean when there is no time to place a regional block, or when regional anesthesia has failed.

The laboring person is unconscious for the birth. The birth partner is not present in the operating room during the surgery.

**Risks:** Aspiration of stomach contents is the primary danger, which is why a nurse anesthetist may hold the neck during intubation. Nausea and grogginess are common on waking. The experience of not being present for the birth may be processed as a loss.

**Birth partner role:** Go to the baby. If the baby is well, hold the baby skin-to-skin until the birthing person is in recovery and can hold them. Photograph the baby from birth so the birthing person can see it as soon as they are conscious.

Local Anesthesia

A local injection of an anesthetic agent (lidocaine or similar) into a specific area. Used for perineal repair after birth (stitching tears or episiotomy). Also used to numb the area before placing an IV or during minor procedures.

Discomfort from the initial injection is brief. The anesthesia takes effect within a few minutes and lasts 1 to 2 hours.

The Epidural Domino Effect

Source: *The Birth Book* — William and Martha Sears

Understanding how interventions can cascade is important for informed decision-making, not to discourage the epidural, but to understand the full chain of effects before consenting.

When an epidural is placed, several things happen in sequence. The laboring person loses the ability to feel the urge to push efficiently. Pitocin is often added to compensate for slowed contractions. Pitocin-induced contractions are stronger and more frequent than natural contractions, which makes the epidural feel more necessary than it might have otherwise. The fetal monitor shows the baby's heart rate responding to the stronger contractions, which can prompt concern. At each stage, the management of one intervention creates the indication for the next.

None of this is inevitable. An epidural placed at the right time, in an otherwise normally progressing labor, with a supportive team, does not always trigger this cascade. But it is more likely to do so in the following conditions: epidural placed before 5 cm; baby in a posterior position; labor that was already slow; facilities or practices that move quickly to augmentation.

**What to think about before placing the epidural:**

Has the laboring person tried the full range of comfort measures, including water immersion? Have positions been changed recently? Is exhaustion the driver, and if so, would a short-acting narcotic for rest serve better? These are worth discussing with the care team, not as a way to avoid the epidural, but as a way to make the timing deliberate.

**The other side of this:** Sometimes an epidural interrupts a cascade rather than starts one. A laboring person rigid with fear and tension who gets an epidural may suddenly relax enough for the cervix to dilate and labor to proceed. The intervention is not inherently good or bad. It is a tool. The question is whether it is the right tool at this moment.

What the Epidural Takes Away (and Gives Back)

Source: *The Birth Book* — William and Martha Sears

At the end of the first stage of labor and through the pushing stage, the body produces a surge of oxytocin called the Ferguson reflex. This reflex is triggered by the baby's head pressing against the pelvic floor and is the body's own mechanism for strengthening contractions and assisting descent during pushing. In unmedicated labors, oxytocin levels are measurably higher in the pushing stage than at any other point.

Epidurals reduce endorphin levels and blunt the Ferguson reflex. When the natural surge does not occur, Pitocin is often added to compensate, which drives a harder, less physiologic contraction pattern. The laboring person also loses the instinctive sense of when and how hard to push, requiring external coaching from the care team rather than her own body's signals.

This does not make epidurals wrong. It explains why pushing with an epidural takes longer on average, and why allowing the epidural to lighten or wear off during the pushing stage, if the laboring person is willing and able, often results in more efficient pushing, faster descent, and lower rates of forceps or vacuum assistance.

If an epidural is in place and the pushing stage is not progressing, ask the anesthesiologist about reducing the dose. Regaining some sensation is enough to restore the urge. Not all facilities or providers will offer this, but it is worth asking.

Narcotic Timing: What Matters at the End

Source: *The Birth Book* — William and Martha Sears

Narcotics cross the placenta within 30 seconds of IV administration. The peak effect on the baby's nervous and respiratory systems occurs approximately two hours after the dose. This is what drives the timing guidance for narcotics in labor: if birth is likely within two to three hours, a narcotic given now will peak in the baby at the moment of delivery, when the baby needs to breathe independently.

This is why most caregivers will not give a narcotic once the laboring person is in late active labor or transition, or once strong pushing has begun. If a narcotic was given earlier and birth happens sooner than expected, Naloxone (Narcan) can be given to the newborn to reverse the respiratory depression.

The practical implication for birth partners: if the laboring person is asking for pain relief in late active labor or transition, the first response is to assess where things are before bringing in a narcotic. Transition is short. If she is likely within an hour of pushing, a narcotic at this point will not help her through the hardest part and could affect the baby at birth. An epidural, on the other hand, has no peak effect in the baby because the medication stays in the epidural space and only a very small amount reaches the bloodstream. Timing guidance for the epidural is different: placement at any point in active labor is generally safe, though placement before 4 to 5 cm may slow early labor.