Epidural Agreement

This agreement is provided to ensure that you have made an informed decision concerning the risks and side effects of an epidural for you and your baby during labor and postpartum. Please put a check mark next to those issues which you would like to be reminded of if you ask for an epidural during your labor.


These are the things that would bother me the most:


___Will require an I.V. bag of fluids to be given prior to receiving the epidural.

___Will require the blood pressure cuff to tighten on your arm every 15 minutes or less.

___Will require a urinary catheter because you may not be able to urinate with the epidural.

___The catheter may increase my risk of a bladder or urinary tract infection, requiring

antibiotics, which may cause you to have a yeast infection and cause your baby to have


___Will severely restrict your mobility during labor.

___Will severely limit the positions in which you can push (no squatting to increase pelvis size).

___May increase the possibility of a vacuum or forceps delivery if you are unable to

effectively push the baby out.

___May increase the possibility of an episiotomy because the I.V. may cause your perineum to become engorged and therefore not able to stretch to allow the baby to be delivered easily.

___May increase the possibility of a cesarean surgery instead of a vaginal birth.

___May increase the incidence of chronic backache.

___If done too high may cause you to feel as if you’re not able to breathe.

___May lower your blood pressure, possibly requiring additional medical intervention.

___May slow down or stall your contractions, especially if given before 5 cm dilation,

thereby requiring additional medical intervention (usually Pitocin).

___May add an hour or more to the pushing stage.

___May provide uneven or incomplete pain relief.

___May cause extreme itching, requiring additional medical intervention, which in turn, may cause nausea and dizziness.

___May cause or increase nausea, vomiting and shivering.

___May increase your risk of infection (at site of application and from the subsequent and frequent vaginal exams).

___May cause an allergic reaction.

___May cause spinal headaches or spinal fluid leaks, requiring additional medical

interventions after the birth.

___Will deprive you of the natural production of endorphins which, in turn, may reduce

endorphin response associated with pleasure and joy.

___Will deprive you of the sense of mastery over labor and feeling of accomplishment.


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___Will deprive your baby of your natural production of endorphins which help your baby cope with the pain of the contractions.

___May cause disturbances of the fetal heart rate requiring additional medical intervention for you and/or for your baby.

___May cause your baby to be drowsy at birth and have a poor sucking reflex, requiring

additional medical intervention.

___May cause maternal fever (called “epidural fever”) which may 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 your baby's life.

___May cause decreased maternal/infant bonding.

___May cause increased breastfeeding difficulties.


If I ask for an epidural (most women do), I want my doula to (pick one):


___ Encourage me to keep going, no matter what I say.

___ Talk me out of it, unless I use the release word: _______________________

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

___Ask me to wait for ______ more minutes and then, if I still want it, I will ask again.

___Remind me to try to wait until my cervix is ______ cm dilated.

___Help me get an epidural when my cervix is ______ cm dilated.

___Help me get an epidural as soon as I ask for it.