Negativity toward epidural in UK?(80 Posts)
Hello, ding a search, I found a discussion on this from 2010, though there might have been others more recently. I'm from Canada, it's much much much more common to have an epidural there, and in fact I only know one person who didn't have one in childbirth, and there was no difference between the labours - I don't know anyone who needed assistance like ventouse or forceps, either.
I understand that statistically there is an increase in the need for assisted delivery, but I'm not convinced it's entirely causally related - a more difficult labour is more likely to cause both the mother to request an epidural and also to cause the need for assistance, and the other risks to mom are so small especially with mobile epidurals, that I can't understand the extreme negativity towards epidurals in this country.
I'm only just shy of 15 weeks, so obviously thinking a ahead at the moment, but I've been thinking about my booking in appt recently, as I have my next appointment next week. After going through all the notes and labelling my as low risk, the midwife asked where I would preliminarily like to give birth. I said a definite no to home birth and no to the midwife led unit, as I wanted to have the option of an epidural if I wanted one.
Her response was to write down that I was told to go with the midwife led unit, with no mention whatsoever that I wanted a hospital birth. She told me also that women who wanted the option of epidurals more often than not got them. Uhh, no shit Sherlock. I've done a fair amount of research into it, I feel quite confident that I'm aware of the risks, and at this point I'm comfortable with them and would be happy to have an epidural in labour, and quite frankly, I'm upset that I've been told I shouldn't have one without being given the data to support the advice. I'm being treated like a child when I am in fact a very well educated and independent woman able to make informed decisions about my care (this pertains to almost all advice given to us while pregnant).
Argh, sorry for long post. I guess my point in posting is to know if anyone else has experienced the same, or what your views are.
I think there is a significant argument that MWs in the UK are not as good as managing labours with epidural as in other countries with higher rates. France has a hysterically high rate of epidural compared to the UK, although a lot are sited with a very low dose and known as a walking epidural. In the UK it's a numb legs and on the bed scenario more often than not and MWs focus on encouraging movement and managing an active labour which if your legs are numbed is more difficult. Once an epidural is sited it seems there's much less support for optimal positioning etc, and an inactive labour increases risk of needing assistance.
A walking epidural is the same as mobile or low-dose, which is available in the UK, and in fact there shouldn't be reason for using the single drug high dose bupivacaine epidural anymore. The epidural will be sited by the anaethetist, but then maintained by the midwife, so there shouldn't be any reason that it isn't used in the UK.
In 1999 24% of maternity wards in the UK offered mobile epidurals (http://onlinelibrary.wiley.com/doi/10.1046/j.1365-2044.1999.00894.x/full), and in 2001 a study suggested that the continued use of traditional epidurals was no longer justified (http://www.ncbi.nlm.nih.gov/pubmed/11454372). Although I haven't yet been able to find the percentage of UK mat wards offering mobile epidurals today, I can't imagine that it hasn't gone up dramatically in the last 15 years, especially considering the number of studies done in the UK on the difference between the two. I did, however, find that 20% of UK hospitals not only administer mobile epidurals, they administer patient-controlled mobile epidurals, meaning the mother has control over when she gets more pain relief, and how much she gets.
I suppose the only way to know for sure what's available to you is to talk to your midwife; however, she may not know, and a conversation with the obstetric anesthetist may be needed to ascertain what exact methods of epidural are offered, whether the traditional full dose epidural, low-dose combined or low-dose infusion. Many hospitals will refuse to call the latter two 'mobile' or 'walking' epidurals, but they are the same thing.
You are starting to seem quite pro-epidural as opposed to pro-choice. If the walling epidural had worked as it should (which they don't always) with my first labour I would have been better off having one. With my second labour though I was better off without. My second labour was an amazing experience, honestly and the contractions were part of it. If you want an epidural you should get one, as should any woman but it doesn't make not having one wrong either.
Yes, I'm pro epidural personally, but still pro choice. More important than that I'm pro educated choice, and I find that the attitude I've seen here in the uk leads health professionals to not fully explain the risks and benefits of anything in pregnancy, not just this. I think that's why I'm try I to find as many statistics as possible. Maybe some midwives are better at fully explaining options than others, definitely possible.
I can easily see why a woman similar to me - first time mother, low risk pregnancy, etc - would look at these same statistics and choose to not have one. The postdural headache risk, for one, is a great reason to turn one down. Or the threat of constant monitoring (which may happen, but not always). What doesn't make sense is the pervasive belief that epidurals are harmful to baby, prevent good bonding, delay lactation, cause paralysis in mom, and mean you have to labour and give birth flat on your back. Some of these were never true, some of them are no longer true but they are still bandied about as reasons to not get an epidural.
It's the misinformation and lack of communication from health professionals I can't abide.
Just because it's available doesn't mean the uptake is high, though, and just because it's available doesn't mean MWs are any better at managing the dosage to enable active labour because the birth culture is very different. People in the UK don't ask for epidurals as a matter of course. They are generally encouraged to go up the scale of pain relief and epidural comes last before a GA! Therefore when an epidural is administered the intention is to block the pain out and it is the numb legs scenario, unlike other countries where an epidural in itself is seen as a gradually progressive form of pain relief in it's own right. IME it's just another cultural difference. Also a consultation with an obstetric anaesthetist isn't routine, unlike countries with a higher epidural rate where the choices are described in quite some detail. Personally I'm quite pro that consultation having benefited from it in my first pregnancy in France and finding out my spine is pretty unsuitable for any kind of epidural or spinal so I get to skip from pethidine to a GA, but I'd have been pissed to discover in the UK on D-Day that it wasn't an option once I'd asked for one.
wispa I found two studies you may find interesting. They are recent too. The second one references comparative statistics that you were asking for (ie. relative risk etc), the detail of which are in the results section. I hope it helps. Ultimately your choice, of course!
Pain management for women in labour: an overview of systematic reviews:
Epidural versus non-epidural or no analgesia in labour.
wisp but you seem to basing this assumption (that the UK is a thoroughly anti-epidural nation) on your interaction with ONE health care professional. That's like meeting a midwife who says the opposite and deciding that the UK must be completely anti-natural birth! I repeat, over 50% of first time mothers have an epidural. If the entire NHS were systematically trying to prevent women from accessing pain relief in labour, that simply wouldn't be the case.
Nom I think you are right that a lot of midwives do a bad job of managing epidural births, however we do usually use low dose and some movement is possible unless it has been topped up for hours and hours. I had one mentor who was very skilled at facilitating an active pushing stage, so I love a kneeling birth with an epidural if the woman has the strength in her legs. That doesn't happen with most midwives! However, in other countries with much higher rates, there would be no choice at all, it would be legs up in lithotomy, so I don't think they do a better job of managing labour in other countries, necessarily. My friend in France was genuinely surprised when I mentioned something about a woman choosing what position to push in. She didn't know there were options!
Personally I wouldn't have wanted to have any sort of intervention unless needed and I include epidural in that. I certainly wouldn't have planned to have had one before seeing how the labour progressed.
Given the way DS got stuck (and what I was told by the staff afterwards) I think an epidural would have massively increased my chances of needing a C-Section anyway.
Everyone will make the choice of which pain relief they feel is best for them. I dont think epidurals not being the first choice for most people is a bad thing
and I find that the attitude I've seen here in the uk leads health professionals to not fully explain the risks and benefits of anything in pregnancy,
When I went to be induced an anesthetist spent a good 20-30 minutes talking to me about epidurals, he was very matter of fact giving the pros and cons, discussing the benefits and the possible issues. That was what made me decide even more that it wasn't for me unless I really felt it was needed.
Fair enough, I'm probably more annoyed at that midwife than anything though I also found my sonographer equally uncommunicative, and I was annoyed to find out on my own time that I didn't really need to have cut down on coffee or cut wine out entirely, so it's more than just advice about labour. I'm sure elsewhere in the world it's no better. Is it wrong to think it should be better, though?
I was induced and found the midwives looking after me were actually quite pro-epidural. As it happened I decided to wait and see and did eventually have a "patient-controlled" epidural which was great. I could still feel to push and was up and about almost immediately after giving birth. Despite it only being a few hours since the epidural was sited.
I do know several people who have given
birth in the same hospital who were told that the anaesthetist was unavailable/they couldn't transfer from MLU as "too busy" on delivery suite.
bue really?! Both hospitals I've been at in France have given out leaflets about labouring positions and birthing positions that specifically avoided litho, and been quite happy to facilitate that in practice. Lying on your side and kneeling supported on the bed for the birth were also specifically mentioned as possible with an epidural in my antenatal classes. Unfortunately a lot of French women insist on an OB being present though
heaven knows why and then it can all go downhill because they like that position. But if a woman is badly positioned during the first stage of labour it increases the chances of malpresentation for the second stage, and even if you end up in litho during the second stage as long as the first has been managed well you have better chances of avoiding needing assistance. Good MW management can make all the difference and this is anecdotal rather than evidence based but it seems UK MWs are fab at managing non-epidural labours but less good with. French MWs OTOH are pretty crap at helping with non-epidural labours despite the fact that the same techniques can be applied. It also very much depends on the hospital/clinic. With DS I went further afield because the nearest clinic had a 97% epidural rate and the chain of events was very much 'you arrive, we put in a drip and epidural, you lie down, we monitor you continuously, you dilate at 1cm per hour and we examine you every hour, you push, if baby doesn't come out we go and get it'. I didn't hang around long enough to find out whether they were giving out the nice little leaflet but I imagine they had to at least pay lip service to it.
Squatting gets funny looks, tis true....
Ultimately it's down to expectation. People expect an epidural to take the feeling away rather than take the edge off and if they get the MW to turn it up to that level then there isn't a lot you can do.
I was completely against epidurals before ds because I am against intervention the reason being that I feel ANY unnecessary intervention has risks which I would not like to take.
I tried for a home birth with ds but after a 40 hour labour I ended up with an epidural, ventouse, episiotomy, the works.
When you get an epidural they read out all the risks to you which sound pretty horrific.
I ended up with dangerously low blood pressure because of it and baby was affected too.
I also let the epidural wear off for pushing stage because not feeling where to push is not nice and makes things harder. This is where I disagree with your point about causation. ..not being able to feel where to push and having to be laid down because of the epidural is more likely the cause of the cascade of intervention rather tgan a long or hard initial labour IME.
I think a healthy amount of information is useful, but honestly you can tie yourself in knots trying to analyse every piece of research, much of which will be conflicting, or will have been carried out on groups of women which may not be directly relevant to you anyway. Statistics don't tell the whole story!
I think it's a lot simpler than that: many women simply choose a non medicalised approach. That's not making a moral or medical judgement; it's simply a preference. I had my babies in a midwife unit where there was no epidural available. My first labour was particularly long and tough, but I had made a choice that the benefits of the MLU environment outweighed other factors. I didn't spend weeks reading up all the research: I looked at the more basic facts and decided that I really wanted to try to have my babies naturally, I wasnt keen on any drugs I might not need and I didn't want to be continuously monitored. For other women, a hospital birth or home birth might be their preferred choice
I think there's a danger of over thinking it. Opt for a hospital if you're more comfortable, and epidural if you wish. But the culture in the UK is different from some other parts of the world and there is a strong desire for low tech births as well as hospital ones, some women prefer to labour with just a midwife and not an anaesthetist in sight, and that's equally valid to a medicalised birth
Nom that's really interesting! I know my friend had a private OB so perhaps that is the issue. She has had all three of her babies there and genuinely didn't know you could give birth in a position other than on your back! OTOH I have worked with a French midwife over here who was fabulous at facilitating active birth. I am pleased to know the picture there is rosier than I thought!
wispaxmas I think unfortunately you've just hit on the fact that midwife appointments are not long enough to give information on all the topics required MWs tend to give out a lot of leaflets and expect you to get info from those. I am not convinced you'd find it all that different in Canada - part from my friends who have had midwives there (as they have long appts and talk about everything) prenatal visits with a doctor tend to be very short. It seems to be a fairly universal problem and it's a shame.
not read the thread I do not think they are against it - just can they provide it, the cost, the one anethetist who may or may not be busy,. the no of women on the ward and the more waiting in the wings wanting a bed, kwoing an epi may slow you down!
wispa don't forget you are looking at an NHS in massive crisis, midwives pleading for more numbers and help, massive un precented birth rates, on an already fatally dangerous system...
With the greatest respect, make sure your hospital isn't known for turning away women in labour like mine were. getting into ours in the first place was an issue, let alone getting an epi.
bue - totally right. Having had dd in the UK and the dtwins in Canada I can confirm the UK midwife and Canadian ob appointments were perfunctory and short. My mw appointments in Canada though, ah they were amazing...I could sit for hours boring them about all my pregnancy woes. And I knew plenty of people who didn't have epidurals, I didn't.
Very good post Geppa. The phenomenon you describe isn't universal, but it certainly exists. I encountered it myself. It is a horrifying truth that about 10% of the roughly 750,000 women giving birth in the UK annually are unhappy with the pain relief received. We are often brushed under the carpet, and we are not well researched. Given that women who have epidurals are often able to get some rest, i would like to know whether those of us who were refused are more likely to end up with instrumental deliveries, tearing etc. I suspect my experience in this respect was not unrepresentative...
OP, it is very true that a lot of people discussing the subject in Britain are unaware of the distinction between causation and correlation. Although having seen some US literature and forums, I don't think that's limited to us! It is true though that it is impossible to ascertain how much of the slightly lengthier average labour time is down to women who request epidural being more tired and in more pain than those who don't. As for your own birth plan, it is really poor that you said you didn't want to go to the MLU and the midwife wrote that down anyway, totally aside from the question of pain relief. I'd complain, and of course insist on it being changed.
Almost all the research into epidurals around the world uses as the control group, women who have had pethidine or another strong opioids. And yes - compared to heavily sedated women having mostly supine labours (ie, women who have had pethidine), epidurals don't look so bad.
However, the Place of Birth study 2011 flagged up that healthy, low risk women who opt to try to give birth in setting where opting for an epidural requires a transfer to a different setting (ie birth centres and home births) appear to have rates of emergency c-section half of that of identical women who opt to labour in settings where epidurals are readily available. I think this is very telling. I haven't met a midwife who doesn't feel that epidurals sometimes create a situation in labour which can only be resolved with surgery. It's because of the link between epidurals and higher rates of fetal distress, which the latest Cochrane review found clear evidence for. Opioids are also associated with higher rates of fetal distress.
I'm not anti epidural btw. Think they can be very useful. But I think we've got the balance right in the UK mostly.
Chunderella - 1 in 8 epidurals doesn't work at all, or gives incomplete pain relief. I'm sure women who experience epidural failure are unsatisfied with their pain relief. Ditto the 40% of women who find pethidine useless. It's not always about pain relief being denied. Sometimes it's about pain relief simply not working very well. Not all pain is controllable, even with the wonders of modern pharmacology!
I had my babies at UCH in London. I don't know anyone who had their babies there, requested an epidural, and didn't get it if they still wanted it. The anaesthetist told me their rate was c.95% within 15 mins of request (although i forget the exact figures).
I thought I wanted one with my first and went to the labour ward for that reason. They examined me and said I was too late. I said "but you always say that" based on what the NCT etc had told me. The midwife said she'd call the anaesthetist. To cut a short story short my baby was born about 2 minutes later. The anaesthetist came a few minutes after that and apologised for not having come sooner - the midwife said to him "you'd have been too late even if you'd been here immediately."
Wispa - I am not sure that the availability of mobile epidural has increased massively in the UK actually? I was due to give birth at one of the big London teaching hospitals and they weren't available there (a year ago). In the event I moved before the birth and got one privately - it worked well for me, I could shuffle around with DH holding my hand and felt the urge to push etc (though it had mostly worn off then!)
I think like a lot of things NHS related availability of the mobile version is still a bit of a location lottery...
None of what you have posted amounts to actual evidence that the slightly lengthier labours are caused by epidurals rather than associated with them minifingers. We all know about the links between the two. Unfortunately, there seems to be much less research on eg rates of foetal distress in women who were denied epidural (which happened to me). We would need a lot more of this before we could say with any confidence that it was the epidural rather than the circumstances leading it to be requested that were the problem.
And yes, of course they don't always work and I suspect women who have had failed epidurals might well have worse outcomes than average. Could be wrong but it sounds plausible doesn't it? Although an incomplete epidural will frequently leave a woman with much more relief of pain than any of the other, less efficient but cheaper options that we are too often forced unwillingly to settle for. So those two outcomes really need to be considered separately. As for mostly having got the balance right in the UK, matter of opinion of course, but while there are 75,000 of us annually who remain dissatisfied with our pain relief, I find that at best a too-positive slant on things. It should really require more than the number of women who have the confidence to say they are dissatisfied being a minority.
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