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Live webchat with David Bogod, president-elect of the Obstetric Anaesthetists Association, Thurs 3 March, 8-9pm(287 Posts)
Following the discussion about epidurals on this thread, David Bogod got in touch because he'd read the thread after seeing it mentioned in the Sunday Times. We're very pleased to welcome him to Mumsnet for a webchat.
David is consultant obstetric anaesthetist at City Hospital, Nottingham, where he's worked for 21 years and carried out more than 2,000 epidural procedures. His unit has around 5,700 deliveries a year, with an epidural rate of around 25%.
He's also president-elect of the Obstetric Anaesthetists Association and vice-pres of the Association of Anaesthetists of Great Britain and Ireland.
David has two grown-up boys (one delivered by forceps, one spontaneous delivery, both under epidural).
If you've got any questions to put to David about the scientific, political or social aspects of epidural pain relief in labour, or any other issues relating to childbirth, then please come and join him on Thursday evening. Failing that, please post your question here as usual.
Should epidurals be available for all birthing women or for those in need of a more medically managed birth?
Who should decide if and when an epidural is ncessary?
I applaud you actually for coming on here and chatting to us.
I hope there isn't too much misdirected ill feeling towards you as in my experience it is not the anaesthetist who says yes or no to an epidural, it's the MW's and Obs.
I would say the vast majority of anaesthetists I have met have been fantastic. They have always given me the time to say what I want and answer any questions I have had, and most importantly they have been very caring. I was petrified of an adverse reaction to the epidural during my section and told the anaesthetist this and he was great with me giving me a commentary on my stats and how everything was ok.
So, my question:
Do you believe it is every womans right (in the UK) to have an epidural if they request one, whether the MW's or Ob's agree or not? Obviously taking into account there isn't any history of adverse reactions to the drugs etc.
Do you think the number if qualified midwives available to monitor and care for labouring women is sufficient to make epidurals available for all a safe policy?
If not, how do you propose addressing this?
(I audit obstetric records as part of my job, and I frequently see entries to the effect that a patient asks for epidural, but staffing levels are unsafe. As an ex midwife, I am aware of the importance of adequate monitoring by a qualified person.)
Number OF qualified midwives....sorry
Had my babies in Nottingham and anaesthesist was lovely
Given your professional experience, and reading the MN thread, of course, I'm sure you are quite familiar with the frustrations some women face when requesting an epidural. It would be great to get another perspective on this.
What are the difficulties you experience with providing epidurals and the management of pain during labour?
This may be a really basic question but can you outline the reasons why someone may be refused an epidural?
why do we have a culture of viewing gas and air as not a powerful anaesthetic in childbirth? People see it as 'just G&A' as though it won't affect the baby like other drugs.
I am still sad now that i had to suffer so badly in the birth of my daughter with no epidural...it was hell. I couldnt go through it again if you paid me all the money in the world.
I would like to know at what point is it 'too late' for an epidural - at 5 cms dilated I was told it was to late for me to have an epidural, it was only when I assertively challenged this that was I able to have an epidural.
I have had both my babies in a very small CLU which does not offer epidurals to any labouring women and advises that women should plan to have their baby elsewhere if they want an epidural. It does say in their leaflet that women who change their mind could be transferred in labour (to a bigger hospital about an hour away).
I wondered if this is a common arrangement because a lot of other Mumsnetters were shocked when they heard that epidurals weren't ever available here. I also wondered if you know how common it is (in general terms - obviously you can't know about individual hospitals) for a woman to have to transfer in labour in order to receive one.
In the event my first was a section so I had a spinal anyway. I would like to state for the record that the anaesthetist who managed to successfully administer a spinal to someone as fat and oedematous as I was is a legend and should get a pay rise
I felt so utterly let down when having DS1 that it took so long for an anaesthetist to be available that fetal distress set in and I was rushed through for an emcs under ga.
I was aiming for a home waterbirth but had to go in for induction and then arm. Doing this without having someone free to give me an epidural was just appalling. Labour was fast and furious and it all spiralled out of control very quickly. And I did do all the prep, I just happened to not be able to cope with the pain of cxs at all. Same with second labour which started naturally but they were quicker to take me straight through for a CS so I could at least be awake.
In fact, I find it extraordinary that we haven't done more on all this as a society, we need walking epidurals and similar options.
Also, it's not just about epidurals on demand, CSs should be on demand too. I had to fight for one second time around after I was told that there was no guarantee of getting an epidural if I wanted one that time either. It's an utter disgrace.
Maternity services are woefully under-resourced. We need one midwife per mother, good birthing units and more support for home births. In any event we should not be restricting access to pain relief and CSs under any circumstances, it is inhumane.
My question(s) - why aren't walking epidurals offered commonly and what innovations are on the horizon for pain relief in labour and childbirth?
I had an epidural during the birth of my DD1 and as a result feel very positive about the entire birth experience, so to speak.
However, I had no dedicated midwife during the 10 hours leading up to having the epidural (despite having fetal monitoring) but as soon as the epidural was in I had to be monitored at all times by a midwife. This felt (to a layman) like the wrong use of resource.
My question is; is it actually absolutely necessary to be under dedicated observation by a qualified midwife when given an epidural or could a less qualified (or non-qualified person e.g. a husband)provide monitoring equally well?
My midwives held the line that epidurals increased the risk of intervention and thus were a last resort.
Do epidurals really cause more interventions or is it simply that difficult lavours often end in epidurals and intervention but this is correlation not causation?
If there is a causative link can epidurals be managed so as not to increase the chance of intervention? If a woman has a mobile epidural so can keep moving and if that epidural is not topped up towards the end of labour would there be less risk of intervention? If so why is this sort of epidural management not offered as standard?
Thank you for coming to Mumsnet.
I had an uncomplicated birth with no instruments and only G&A but one thing still bothers me. Why did they take the gas and air away when it was time for me to push? I was shocked but in no position to argue! Is this a general policy and if so why did no-one tell me about it before?
Thanks for coming Mr Bogod,
My experience is polar opposite to many on the original thread, as my consultant talked me into having an epidural at the same time as beginning my induction on a synt drip. The delivery ended horribly with keilland forceps, resulting in minor injuries to DD1 and major injuries to myself. I then suffered from PTSD.
Following counselling, I have gone on to have 3 further children (including another induction) with no epidurals. I would rather go through the pain during the birth, and not have the increased risk of another instrument delivery and resulting pain and further surgery.
I suspect that witnessing experiences like mine is the reason that some midwives don't like epidurals. Is there anything that can be done to minimise the likelihood of needing an instrument delivery for women who really want an epidural?
From a slightly different viewpoint -
Following NCT antenatal classes I was keen to have as natural a birth as possible with DC1.
I was fortunate enough to be able to have this, with the opportunity to use the birthing pool at Tooting Hospital. Although a fairly long first labour, in active labour all morning in the hospital pool, I was able to have DD1 with no other pain relief, and able to say it was a positive experience.
DC2 arrived more quickly, no pool option available on the day at Peterborough Hospital. Laboured at home in the bath through most of first stage. Made a fairly late transfer to nearby hospital, and was pretty much into pushing stage on arrival. Made quite heavy use of gas and air for a short period (5 mins) Baby arrived fairly quickly and again as smoothly as these things go !
My question is really how do you feel about women's different preparation, expectations, and hopes for the birth of their babies. How helpful do you feel birth plans are for example ?
I'd say the preparation I had, and the birth plans I wrote, helped me to engage with the whole process in a positive way, and contributed to good outcomes for each birth. But I'm aware too that everyone is different, and that I was also very fortunate.
How can we enable the best birth possible for every woman, taking some account of their different experiences and expectations going into labour ?
Thank you for being brave enough to come on and answer all our questions.
Mine is similar to another poster's question really in that I have always wondered why walking epidurals aren't more freely available. Surely they are preferably to a full epidural as in most cases, staying upright and mobile during labour helps move things along.
My first labour was extremely long and very painful due to a determinedly back-to-back baby. Eventually I was all but ordered to have an epidural and hormone drip and told that it was the best thing, as without the epidural my muscles wouldn't relax enough for me to give birth naturally. Could this have been right? Because I was (and still am almost 9 years later) very dubious about it and believe that if I had instead been encouraged to stay upright and mobile I may not have gone on to need an instrumental delivery.
Obviously having the epidural meant that I was then immobile and stuck on my back on the bed strapped to a ctg monitor. I've always wondered if they hadn't done the epidural, or I had at least been able to have a mobile epidural and stayed upright and mobile, would ds have managed to turn and not required a ventouse delivery.
I have since had two further children. My second son was also back to back, but I stayed mobile throughout the labour, did lots of walking and he turned before delivery. I only needed a bit of gas and air right at the end with his delivery.
Dd was breech and turned by ECV then induced, but again I stayed upright, did A LOT of walking and kept mobile and she was born with no pain relief within and hour and half of the first contraction.
Going on my last two labours, I can't help wondering whether, if I had been more confident and assertive about not wanting to have an epidural - or perhaps if a walking epidural had been available - during my first labour, things would have gone more smoothly.
This is something I often wonder about, as the midwife topped up the epidural too late without checking to see if I was fully dilated first (I was) and ds's heart rate dropped through the floor almost immediately afterwards - cue panic stations and about 15 different people rushing into the room, stirrups, ventouse etc etc. I have since read research suggesting a significantly reduced heart rate in labour can be an indicator for autism and my ds1 does indeed have ASD, so I will always wonder whether things would be different for him, if I had just stuck to my guns and said no to the epidural.
Thank you David, for coming on to answer our questions.
My question is: Would you advise mothers to ask for an epidural at the very start of proceedings, if they think they want one, or wait and see how their labour progresses? Is there some point of no return after which an epidural can't be administered?
Are epidurals more likely (or less likely/no difference) to lead to intervention which in turn may require forceps etc. and lead to damage to pelvic floor muscles/perineum? I really want a precis of the actual clinical evidence as opposed to your initial thoughts on the matter. Many Thanks
Ps. Last time I had a pain free hypnobirth but I'm four months pregnant now and want to know as someone posted on another thread that actually there was evidence to say that epidurals lead to less pelvic floor damage and who knows what will happen this time around.
Is there a time in labour before which an epidural is too early from a medical point of view (as opposed to the need to avoid having a midwife and room taken up)?
Had my first baby last year and had to labour at home for 8 hours before I was even allowed to go into hospital (MWs on the phone kept saying if I could be on the phone then I was clearly not suffering enough- little do they know that I am a very quiet person who never shouts/swears etc). When I was finally allowed to go to hospital the MWs were changing shifts and even had to ask 3-4 times just to get G&A. Then tried the pool but by then it was too far (had been in too much pain far too long) and so asked for epidural. Anaesthetist was brilliant and the relief enormous but 13 months down the the line I keep wondering why I had to suffer in pain for the preceding 11 hours rather than be allowed to go to hospital and have pain relief sooner.
So, is there a good medical reason for delaying epidurals until one is in agony or is it a matter of resources? And if it is a matter of resources, is there any other area of medicine where anaestesia for pain of the magnitude of labour pain is considered optional or delayed until the patient is screaming in agony?
Secondly: is it possible to retain epidural access to manage postoperative pain, e.g. after an instrumental birth/caesarian? I think I read about this somewhere but when I asked at the antenatal course the MW laughed and said something along the lines of "labour and birth, and the aftermath, are painful."
Thirdly: why not get anaesthetists/anaesthetic nurses to give a lesson about pain relief in antenatal classes? The MWs at both of my courses were obviously biassed against epidurals (oddly seemed to think G&A and pethidine were more "natural") and I did not think the information they gave was balanced, at all.
do mobile epidurals really exist? how mobile can you be? or is it simply 'mobile' in as much as you can move around the bed rather than get up and stand? The unit I am familiar with does not offer them but says they give a fairly low dose epidural ...thank you very much.
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