I am a l&D nurse with a very natural bent. I am seeking peoples advise on how to help women through transition when they ask for a epidural. Usually these are women who are trying to go natural, but aren't completely dedicated like you have to be usually. So, they'll get to the transition point and of course being fighting there fears that they can't do this anymore. I am horrible at working with them through this point. I'm just curious, what has helped anyone out there to make it through this point? I'm hoping to get some good ideas. Also, it's kind of a tricky point because some women really would rather have the epidural and get mad if they don't get it while others just need encouragement. Just looking for advice in this area. Thanks.

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That is a really great question. As a childbirth educator, one thing I teach my class about is the "Take-Charge Routine" (sounds aggressive but it isn't). Essentially it is getting close to the woman (perhaps holding her shoulders or hands if she is alright with it), making eye contact with her and saying, "look at me...breathe with me" while helping her re-gain her rhythm in breathing. As you know, transition is generally the most intense part of labor and usually the shortest part. Reminding the mother of that and how far she has already come can be helpful. For most women, by the time they reach 7-8 cm, the contractions are usually as painful as they will get, although they will be closer together. Also, reminding her that she and her baby are alright (assuming that is the case) and to voice her feelings can be helpful. It is totally normal to be scared, desperate, trembling, nauseas, etc and giving her re-assurance that everything is going well can be helpful in getting her through. When she says, "I can't do it" you can gently remind her that she IS doing it. How far she has come and how close she is to holding her baby in her arms. Every single contraction is one she will never have to experience again, but each one has gotten her closer to meeting her baby.

Having her change positions can be a wonderful help. A wise mama once said, "when you hit a wall, make a change." Using upright positions (which is obviously more likely if she's not medicated) can really be of benefit in completing the dilation process more quickly. Also, remind her that vocalizing can be empowering. If she wants to moan, yell, or chant, encourage her to do so.

You could ask her if she would like to try to hold off on the epidural for 10 mins while trying some of these things and if she is still wanting medication then by all means, her request should be honored. Hopefully this will give both of you an opportunity to determine if she just needs more support or really wants the meds.

Best wishes,
~Amy
Hi Rachel,

If only there were more nurses like you!

As a doula and student midwife I find that having a code word for when mom definitely wants an epidural is very helpful. I have a chat with the mom right at the beginning and go through her birth options with her. If mom doesn't have strong feelings about whether she has an epidural or not and is very distressed I will of course help her have the best birth possible which for some moms is an epidural.

If mom is really committed to a natural birth emotional encouragement at this point is crucial as you know....do the 'take charge' routine...get her to focus.....remind her to slow her breathing.......tell her how wonderful she's doing....'stay with your baby'......'you ARE doing it'......'you are amazing'.......but if she uses the code word I would accept that she has reached her limit and respect her choice.

Any mom would be lucky to have you.

Tracy
Hi Tracy,
I like your suggestion of a code word. Like Rachel I am a labor/delivery nurse. I have assisted at home births but currently work in a hospital. At home we used many of the techniques that Amy suggested. Positive affirmation of progress and change of position are a part of labor care in the home and hospital. Vocalization is helpful--keeping the voice low, moaning instead of screams. Massage and counter pressure help some women. In the home setting some women grabbed my hand and asked me to pray as they moved to the position that they preferred. At the outset these women laboring at home were committed to laboring naturally. The environment did not suggest intervention.
I have all this experience behind me but struggle with transition in the hospital. If I know a couple well, and their desires it is easier to help them cope. The code word is a helpful idea.
The hands-and-knees or kneeling and leaning forward on back of the bed position is the one most women prefer during transition. Or else you can use any of the standing positions and movements and have her lean forward onto another person so that she can rest completely supported in the short breaks between contractions. Many women find it helpful to sit on the toilet in transition. Some women need to groan and moan and make a lot of noise at this stage of the labor to help relieve pain, whereas others need to be very quiet. It is vitally imperative that she not be disturbed or distracted unnecessarily. To help her gain control of her breathing, you should first stand up. Touch her face or wrists with your hands. Gently call her name, bring your face close to hers, and do the breathing with her. Generally, when the contractions become unbearable, transition is almost over and she may only have a few more contractions left. Be sure to tell her this...
You should totally b get certified as a doula. Not to actually be one, but to learn all of the awesome tricks and things they do to help woman through labor! It would be perfect for you!!!
If a woman is asking for it, that is a sign that she is out of her head and in transition. I did it once, and yet had the head about me to ask the nurse if the medication she was suggesting was safe. She lied to me, and said it was completely safe. So I took it, against my birthing plan, and my better judgment. I was so mad afterwards when I realized how I was tricked in my weakest moment, and my husband didn't even stand up for my wishes. (He would never do that again now mind you) The worst thing was, they didn't see that call for help as a sign that I was about to give birth. I could have been so encouraged and renewed in energy had I have been told, "The baby's almost here, you're in transition now." From more recent experiences at home, I can say that all a woman needs at transition is to be focused on, and encouraged that it's almost over. Instead of living with regret with what you did to yourself and your baby (my baby had bad side effects, and was given a drug to offset them, that I was told only afterwards, could cause deafness.)
Angela, I agree completely. I've heard stories of women who asked for the medication and their support team told them "one more contraction", "one more minute", and kept telling them that until it was time to push. I don't think I've ever heard a woman say she wished she had had medication after having a natural birth. I know how it is to be in transition and feel like you can't do it, can't go on. The best thing my doula did for me was to tell me "you ARE doing it, and you're almost done!" That encouragement was what I needed to get me through it. So many women get medication during transition, which is actually silly when you think about how close they are to pushing the baby out. If you get narcotics during transition then they can cause problems with the baby (floppy baby, breathing trouble, lethargic, not wanting to breastfeed), and if you get an epidural that late in labor you could be stuck with the numbness for hours after the birth (I've experienced that, even when I got the epidural at about 5-6cm). I think the absolute best thing you can do for a woman in transition is to focus on her, encourage her, tell her how great she is doing and that she's so close to seeing her baby, and she CAN do it. The take-charge routine by Penny Simkin is excellent for this. It involves getting right in the mother's line of sight, getting her to focus on you as you talk directly to her. Coach her with each breath and breathe with her, and encourage her the whole time. It works wonders.
When I reached transition (or at least when I assumed I did because they only checked me when I got there and at 9.5) I was on the seat in the shower, which was so helpful. I was lucky because when I got my hospital, the nurses I had were soooo supportive and wonderful. I told them that I didn't want an epidural and so they suggested things that I could do to avoid it, in a very nice way, not too pushy but honest. One said, I know it's hard to get up and move around, but if you DON'T want drugs then lets try this, and I tried the shower as there wasn't a birthing tub available. It's really hard when you are at a hospital and the drugs are right down the hall! When I was in transition, I kept thinking that it was going to take sooo long and my water hadn't broken so it was going to get worse. So at that point I started doubting. If only I verbalized why maybe they could have rationalized my thinking! But anyhoo, because I expressed my feelings earlier and I was doing well, the nurses stalled, which I didn't realize at the time, but now I can't thank them enough. I went back in the room for the intermittent monitoring, had the blood work done, etc and by the time that was all over I was 9.5cm.
So as for your question, I would definitely ask questions to the mom and keep her engaged if at all possible. I also found that keeping things light and humorous (if that's possible, haha!) is great. When the contractions started to get really intense, let her do whatever makes her most comfortable (positions, rocking, lying on her back, whatever). Talking to her, and engaging her to make the time somewhat go quicker, because at that point every contraction can seem like ETERNITY. Maybe also reminding women that if they get an epidural, that it **may** slow things down, and ask them if they's rather try to go without so that they can get it over quicker? That may have deterred me from thinking about getting one!
Transition is the time in my labors where I refuse to believe what anyone is telling me. That's the point that I'm convinced my labor is going to last forever, where I want to escape and run away. In my last labor, my baby was posterior and it was far, far, worse going through transition than with my first labor. I wanted to leave my home, go to the hospital and demand a C-section. I didn't want drugs, I wanted to be done.
What helped me the most was having people right with me, perfectly available. My husband was at my side and I wrung his arm. My friend was at my back pushing against my sacrum, and my midwife was down by my feet helping me focus on not tensing up.
Its funny though, reading books that tell you, "transition is really intense, it makes you think you can't do it anymore." But reading that, and then going through it, are two completely different things. I really really thought I couldn't do it anymore. In my head I was thinking, "no, no you are all lying to me, this isn't transition, I really can't do anymore. I'm going to loose it if there's another one like that." But the amazing thing is, if somebody is there to keep telling you, "focus on this contraction, then let it go, don't think about the next one", then you can keep going.
Remember that the mom can hear everything you say, even if she can't respond. I found that I would listen to conversations around me, chuckling inside myself if they were funny, or joining them in my mind if they were interesting. I can't tell you how much that helped me stay part of something outside myself. Some women might find it distracting, but I loved it as long as it didn't feel like people were actually talking about me or what I was doing. One of my best friends would save up weird facts to repeat at random moments during my labor, just to lighten the mood. At one birth she said suddenly, "Peter the Great died of a cold." It was perfect.
This onversation is really really interesting!!

I remember just saying oer and over (when asked if I wanted drugs) "I don't know, I don't know". Its all I could spit out and what i WANTED was to know how much farther, or be encouraged through just a few more. My twin sis ended up saying that I didnt want an epidural and how about I get checked and then maybe something minor for pain depending, and it was like a weight was lifted off, having someone be able to answer for me. I was concentrating darn it! :-)

Anyways, this time (our third) will have DH filling that role and he knows that encourageing me to breathe slower, and handle one at a time and not look to how many more, just to focus on this one contraction should be far more helpful. Its what I needed to make it through when what I was offered was Nitrous.
This is just me personally, I'm not a healthcare professional, just a mom of one, but for me what helped was always, always knowing that the pain was a means to an end, and the end would mean holding my baby. Even through the worst of it I envisioned the end. I think your mentality goes a long way during labor. I don't know if that will help with your patients, but if you are with them early on to remind them, then it might.
I'm not a CBE or Doula, but what helped me was reminders of how far I had come, how close the proverbial finish line was, suggestions of alternate methods and essentially no talk of epidurals (which I had specified in my birth plan). If something had to be changed, the suggestions offered were different positions, walking, massage. And of course, the lovely and all-wonderful hospital shower which I firmly believe made all the difference. Even though I didn't ultimately birth in water, it got me through the hardest stages of labor before I moved back to the bed and I would recommend it to any woman. Even if you have an IV (as I did), it's possible. I just had my arm wrapped in a plastic bag and slung the IV cord over / through the door and had the post right outside the door.

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