Epidural Contract

Natural Attachment Labor Support Epidural Contract

This Epidural Contract is designed to help you make an informed decision concerning the risks, side effects and after-effects of an epidural.  For more information about epidurals, check the epidural information from Compleat Mother Magazine.

My doula agrees to:

  • Support my choice of an epidural at my birth.
  • Suggest an epidural if it seems to be the best course of action.
  • Remind me to change positions often to allow the epidural anesthesia to reach all parts of my lower body.

I agree to:

  • Discuss the epidural with my doula or my partner FIRST, before asking my nurse or doctor/midwife.
  • Try three (3) more contractions before asking the nurse or doctor/midwife for the epidural.
  • Consider getting the epidural when I physically can't handle my contractions any longer and not when I fear that it's going to get worse or that I might ‘lose control’.

I understand that the epidural:

  • Will require an I.V. to be inserted prior to receiving the epidural.
  • May increase the possibility of a cesarean surgery instead of a vaginal birth.
  • May increase the possibility of a urinary catheter because I may not be able to urinate with the epidural. I also understand that the catheter may increase my risk of a bladder or urinary track infection, requiring antibiotics, which may, in turn, cause me to have a yeast infection and cause my baby to have thrush.
  • May increase the possibility of a vacuum or forceps delivery because I may not be able to push the baby out.
  • May increase the possibility of an episiotomy because the I.V. may cause my perineum to be engorged and therefore not able to stretch to allow the baby to be delivered easily.
  • May lower my blood pressure possibly requiring additional medical intervention.
  • May slow down my contractions, usually requiring additional medical intervention (Pitocin).
  • Will severely restrict my mobility and ability to change positions during labor.
  • May cause itching, requiring additional medical intervention which, in turn, may cause additional discomforts. May provide uneven, incomplete or no pain relief.
  • May cause spinal headaches or spinal fluid leaks, requiring additional medical intervention after the birth.
  • May reduce the natural production of endorphins which, in turn, will reduce endorphin response associated with pleasure and joy.
  • May cause disturbances of the fetal heart rate requiring additional medical intervention for my baby.
  • May cause my baby to have drowsiness at birth and poor sucking reflex, requiring additional medical intervention and additional lactation support.
  • May cause maternal fever which can lead to hypethermia and require additional medical intervention, including neonatal NICU workup, such as a spinal tap.
  • May cause decreased muscle strength and tone in the first hours of my baby's life.
  • May cause decreased maternal/infant bonding.

If I ask for an epidural, I want my doula to: (check all that apply)

 Talk me out of it, no matter what I say.

 Remind me that I really don't want it, unless I use the release word _________.

 Ask me to try ______ more contractions and then, if I still want it, I will ask again.

 Remind me that I want to try to wait until my cervix is ______ cm dilated.

 Help me get the epidural when my cervix is ______ cm dilated.

 Help me get the epidural as soon as I ask for it


Client name


_____________________________________________                  _____________________

Client signature                                                                                    Date signed


____________________________________________                    _____________________

Doula signature                                                                                    Date signed


Additional Epidural Information

For nearly all women, they obliterate the sensations of labor and delivery. Occasionally the block is incomplete.

Continuous electronic fetal monitoring is almost always used.

An IV must be used.

The woman must stay in bed, losing her ability to be active and limiting the positions she may assume.

Pitocin is frequently given at the same time for slowed labors.

They can lower the woman's blood pressure and put the woman and infant at risk.

The relaxation of the woman's pelvic muscles via epidurals may prevent those muscles from assisting in the usual rotation of the fetus as it moves to a normal birth position.

The urge and ability to push may be reduced or extinguished.

They more than double the use of instrument delivery and more than triple the use of forceps delivery because the baby has not rotated normally or the mother cannot push. (Kaminski, et al, "Obstetrics and Gynecology 69:770 [1987])

They increase the cesarean likelihood due to "failure to progress" in women giving birth for the first time at least two to threefold; cesareans are at least 6 times more common for failure to progress in women giving birth for the 1st time if the epidural is given before 5 cm of dilation and the woman's dilation is slower than average (Thorp, et al, presentation at 1989 "Birth" journal conference).

Failure to progress is the most common reason for a 1st-time cesarean.

Persistent, chronic backache is significantly greater among women who have epidurals during labor (MacArthur et al, "British Medical Journal" 301:9-12 [1990]).

Serious, nonfatal complications (cardiac arrest, spinal damage, toxic reactions, and prolonged severe headache) associated with epidural anesthesia occur in the range of 1 per 10,000 deliveries (Scott and Hibbard, "British Journal of Anesthesiology 64:537-41[1990]).

Narcotics are now being given at the same time to strengthen its effect.

Narcotics are known to cause breathing problems in infants when given within several hours of birth.

All drugs cross the placenta and affect the baby.

When the cord is cut, the infant is left with trace amounts of any drugs that were being given to the mother at the time of birth.

The infant's immature organs must detoxify the drugs.

The infant's immature brain can be affected by his mother's drug use during labor and delivery.


Download this form here, print and sign, then contact Michele to set up your consultation.

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