Webchat with David Bogod

 

David BogodFollowing a discussion about whether women are denied epidurals, consultant obstetric anaesthetist David Bogod came on Mumsnet to discuss the scientific, political and social aspects of epidural pain relief in labour.

David, who is president-elect of the Obstetric Anaesthetists Association and vice-president of the Association of Anaesthetists of Great Britain and Ireland, has worked at City Hospital, Nottingham, 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%. David has two grown-up boys (one delivered by forceps, one spontaneous delivery, both under epidural).

David Bogod: One of you asked me to set out my position on epidurals at the start of this session. This seems a very sensible idea, so here goes. I have been delighted to have my long-held conviction that epidurals are the most effective form of pain relief in labour recently confirmed by a Cochrane meta-analytic review (the purest form of scientific evidence that the health professional can draw on). 

I think that women giving birth in a civilised society should have free access to this form of pain relief, along with any other methods which have proven benefits. If I were giving birth - an unlikely proposition - I would have an epidural within five minutes of my bum landing on the bed. But, what I think is best is completely irrelevant to you, the woman in labour. My job, and that of your other professional birth attendants, is to provide you with the necessary information to allow you to weigh up the relative risks and benefits and then to make your own choice. If whale music and clary sage aromatherapy do it for you, then whale music and clary sage aromatherapy should be what you get. 

"Women's choice means nothing if they can only 'choose' what their health care attendants think is best for them."

Women's choice means nothing if they can only 'choose' what their health care attendants think is best for them. This kind of paternalism has rightly been condemned in medicine and is, I hope, on the way out. It should go without saying that the same should apply to all caring professions, especially those which claim to advocate for the patient.

Midwives' role caring for women in labour

Letter QThetideishigh: As a consultant obstetric anaesthetist, do you feel, having read the thread about midwives apparently controlling access to epidurals, that there needs to be a much closer liaison/working relationship between anaesthetists and midwives to prevent the incidences of uncontrolled pain during childbirth impacting on the mother's mental health at the start of a challenging time in her life? Dare I say it, could the anaesthetists have more control at an earlier stage in the pain relief situation?

Letter ADavid Bogod: Midwives are fairly protective of their territory, and are the right people to coordinate care in labour. However, it is undoubtedly true that the best and safest units are those in which there is mutual respect between the health care professionals involved in a woman's care, and where communication is good. I'm lucky enough to work in such an environment.

Letter Qjugglingjo: I'd just like to say to my fellow Mumsnetters how impressed I am with the wisdom and thoughtfulness expressed in these posts. I hope you'd agree David? Are there any particular points expressed, perhaps from mothers' experiences of birth here, that you'll be taking away with you from this discussion?

"I can appreciate - but not condone - that some midwives are 'anti-epidural', but trickery and being economical with the truth have absolutely no place in a patient-carer relationship."

Letter ADavid Bogod: I can only agree. I was stimulated to do this by the firmly expressed view that some midwives are 'tricking' women out of epidurals. Frankly, I am appalled that this might be happening. I can appreciate - but not condone - that some midwives are 'anti-epidural', but trickery and being economical with the truth must have absolutely no place in a patient-carer relationship. I hesitate to suggest it (this is your forum after all) but it seems to me that what is needed is a serious conversation at national level between women and midwives.

Letter QUshy: You suggst that women have a conversation at national level with midwives but how? The charities that the government listens to are all natural childbirth ones and their views are exactly the same as midwives. 

Letter ADavid Bogod: Well, this one's down to you guys. However, I do understand that Mumsnet has links with the RCM Heads of Midwifery Advisory Group, so that might be a good place to start. As I understand it, Mumsnet can be a very powerful lobbying group.

Letter Qjmp6: Can you easily tell the difference, in your experience, between midwives who support women's requests for an epidural and midwives who don't?

Letter ADavid Bogod: They don't come with black hats on! The best way is to ask a few searching questions when you first meet the midwife who'll be looking after you during childbirth. You can ask to change to a different midwife if the first is not sympathetic to your requests, but this is rather resource-dependent.

Letter Q

MLWfirsttimemum: 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, eg, a husband) provide monitoring equally well?

Letter ADavid Bogod: Interesting idea! At the moment, a permanent midwifery presence is necessary when an epidural is to be used, but I see no reason why a suitably trained, non-midwife could not provide the necessary extra care needed (I think I would draw the line at a well-meaning partner). Off the top of my head, this could be someone at a nursing auxiliary level.

Letter Qemmaelf: There is a direct link between epidural use and assisted delivery (forceps or ventouse). By advocating wider and wider use of epidurals, you are contributing to this birth statistic, with all the consequences of such a delivery on the physical and mental health of the mother and the baby. Do you think that resources would be better spent on providing one-to-one midwife care for all women in labour, thus enabling more of them (again according to research) to achieve normal birth?

"I'm not advocating 'wider and wider use of epidurals'. I'm advocating that labouring women should get whatever pain relief they want, when they want it."

Letter ADavid Bogod: Can I again stress that I am absolutely not advocating 'wider and wider use of epidurals'. I'm advocating that labouring women should get whatever pain relief they want, when they want it. I don't think this is really a very contentious stance (or shouldn't be).

Letter QArtichokes: 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 labours 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?

Letter ADavid Bogod: The two scientifically confirmed effects of epidurals upon the process or labour and delivery are prolongation of the second stage and an increased need for instrumental delivery. Having said that, it is difficult to separate out the reason for a woman wanting an epidural (excessive pain, long labour) from the subsequent effects of the epidural (in other words, it tends to be women with complicated labours who request epidurals). 

The only scientific way to separate cause and effect is by doing a study in which women who request epidurals agree to be divided 50:50 to either receive an epidural or not. These studies are, unsurprisingly, quite difficult to do! However, some such studies have been done, and it is these which have led to our better understanding of the effects of epidurals of childbirth.

Letter QOlivetti: I had an epidural in November. My baby ended up being forceps delivery, due to her heartrate dropping after two hours' pushing. However, I believe this was because my midwives mismanaged the pushing stage, by failing to tell me when contractions came at least four times, so we lost valuable time. I was just one push away from delivering without intervention. Do you agree that this can be the case, and that it is not the epidural itself that necessarily increases the risk of intervention, but a failure to manage the situation?

Letter ADavid Bogod: Sorry to hear about your experience. However, I'm naturally wary about making comments on issues that are really the province of the midwife. You might want to go through your delivery records with one of the senior midwives from the hospital. It's certainly true that epidurals prolong the second stage, so more time needs to be allowed to achieve spontaneous delivery.

Letter QDrMcDreamy: I find it frightening that a fellow professional believes that the monitoring of a high risk women in labour could be carried out by a healthcare assistant. The whole point of continuous monitoring is to identify problems and deviations from the norm. That's why midwives spend three years at university. To insinuate this could be done by someone with no qualifications is pretty insulting.

Letter A

David Bogod: Sorry to offend, but I didn't for a moment suggest that a midwife's role could be devolved to an HCA. I did suggest that a suitably trained non-midwife could assist by fulfilling those specific tasks which involve the care of a woman with an epidural, eg measuring the blood pressure and heart rate, charting the level of block etc.

Letter QFrogGreen: 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?

Letter A

David Bogod: I think it a good idea to make your wishes very clear to your midwife when you arrive on the labour ward; it's far easier to do it then than when contractions are becoming more frequent and intense, by which time you may anyway be under the influence of pethidine or gas and air, and less able to express your desires. NICE recommends that: "Women in labour who desire regional analgesia should not be denied it, including women in severe pain in the latent first stage of labour." This seems pretty clear to me. 

Letter QUshy: I listened on the radio and TV about the Mumsnet thread and was amazed to hear a midwife (who was very senior) arguing that epidurals lead to caesareans! It is a key recommendation of the NICE guidelines that woman are told epidurals do not cause c-sections. So what is going on? What about how risk is presented? I had a midwife tell me about the risks of paralysis. I looked on your website and noticed that it is a risk of one in 250,000 ie you are about 25 times more likely to die in childbirth than be paralysed by the epidural.

Why is the midwifery profession so anti-pain relief? Is this social, historical or what? They claim it is because of the cascade of intervention issue but, in the US, Canada and France, the epidural rate is way higher (double at least) and they have lower instrumental rates. My next-door neighbour, who is a GP, claims that it is because some midwives (along with the natural childbirth lobby groups) are so political and strident that no-one will cross them. Is he right?

Letter A

David Bogod: Firstly, I do agree that some midwives seem to be anti-epidural (while often in favour of other techniques, such as pethidine which has much more profound effects on the baby) but, in my experience, this is a minority of practitioners.

I seriously don't know what it is about epidurals, other than it involves a doctor. Some definitions of 'normal childbirth' specifically exclude the use of epidural analgesia (we have lobbied very strongly against this, by the way) but it's not mentioned in the Royal College of Midwives (RCM) definition of normal childbirth, which is "one where a woman commences, continues and completes labour physiologically at term".  

"It is important for a woman to know that her midwife may have an agenda - albeit a perfectly respectable one - which may be slightly at odds with their own wishes."

I think that to understand this attitude, Mumsnetters need to be aware that many midwives regard themselves as the guardians of 'normal' birth. Indeed, the RCM states that midwives should try to "maximise normal birth in the context of maternal choice". That rider about maternal choice is key to the whole Mumsnet thread, of course, and it is often missed out when midwives quote this maxim. It is important for a woman to know that her midwife may have an agenda - albeit a perfectly respectable one - which might be slightly at odds with their own wishes. 

Letter QMargles:  I certainly feel that it would be good to have a midwife to put an alternative viewpoint. When David suggested that other HCPs could look after women with epidurals I began to realise that many women would probably be quite happy with this, given the opinions they have expressed about the midwives attending them. Maybe this system should be put in place to free up midwives for those who appreciate their services? You get this to some extent if you go for a home birth or MLU, but how many women are really offered these options? 

Letter A

David Bogod: I just wanted to make sure there was no confusion about my suggestion regarding using non-midwives to monitor labouring women; my fault for typing too fast and thinking too slow! The point I was trying to make was that the use of an epidural imposes extra burdens on the midwifery staff. If there are not enough midwives on duty to take on that burden, the woman may not get her epidural. As with many other areas of health care, there is an argument for reserving midwives to carry out those special functions for which they are uniquely trained, while 'farming out' other roles to support staff trained in these particular tasks.

Thus, I can envisage a labour ward with its usual quota of midwives, but with two 'epidural-monitoring technicians' to provide the specific care necessary to keep the epidural service safe. The presence of a trained midwife is not only essential in childbirth, it is also - as I understand it - a legal requirement. What we need are staff trained to provide them with assistance.

Letter Qelp34: I had to wait five hours for my epidural even though it was stated in my notes by the midwife that I wanted one and I repeatedly mentioned it. I was lucky and eventually got it, but the stress whilst dealing with labour of whether I would or wouldn't get it was unecessary. Surely hospitals have more than one anaethetist on, as this is the reason I was told I had to wait or may not get it?

Letter A

David Bogod: You may have gathered from my final post that I am not convinced anaesthetists are always informed in a timely manner about all epidural requests. A spot survey which I carried out suggests that the large majority of maternity units have a dedicated obstetric anaesthetist 24 hours per day.

Many, like my own, have two anaesthetists on duty for maternity during daylight hours. They may be held up with a caesarean section, or even two in succession, but even that should not lead to a five-hour delay. There is a national standard relating to response times for epidural requests, which speaks of 30 minutes as the norm and more than one hour only in exceptional circumstances. 

Letter QAtYourCervix: 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 necessary?

Letter ADavid Bogod: Along with most obstetric anaesthetists, I strongly believe that epidural pain relief in labour should be a universally available option. We have to recognise, sadly, that the healthcare budget is limited and this impacts upon a whole lot of services.

However, relief of severe pain should be a basic human right, and I would therefore advocate that epidural services should be prioritised when deciding upon resource allocation. The good news is that it largely is. There are very few maternity units nowadays which do not provide an epidural service and, in the majority of hospitals, this is provided by a dedicated 24/7 obstetric anaesthetist who has no other duties in the hospital (in a snap survey I carried out at a major conference yesterday, this applies to 72% of units).

However, even within these units, an epidural is not always available when a woman wants it. Sometimes, this will be because the anaesthetists are busy in theatre, usually with a Caesarean section, but, more commonly, it is due to there being insufficient midwives to provide the one-to-one care needed. One-to-one care should be every woman's right, and I strongly support any campaign to increase the number of midwives working in the NHS.

Letter Qmathanxiety: Can a nurse monitor a woman after an epidural or does it have to be a midwife? Do you think medical personnel give balanced information to patients (in light of the other thread) or do their biases inform them more than actual statistics when it comes to giving women the information they need in order to make their decision on an epidural? Do you think there are medical professionals who think pain is some sort of magical thing when it occurs in labour, bestowing maternal feelings, 'no pain no gain', and that painful labour is seen by some as a sort of initiation rite that women should go through?

Letter A

David Bogod: At the moment, it has to be a midwife, but I'm interested in the possibility of other health professionals carrying out this role. 

As to your other point, there is certainly a very vocal lobby who believe that labour 'should' be painful, as exemplified by the hapless male academic midwife who voiced this view a couple of years back, and received a lot of flak for it (rightly so, to my mind). Historically, of course, this was the position held by the church and establishment (universally male) up until the mid-19th century or later ("In sorrow thou shalt bring forth children" - Genesis) and it was only the persistence and bravery of men like James Young Simpson and John Snow (who gave Queen Victoria chloroform at the birth of Prince Leopold) that started the ball rolling towards pain relief in labour. 

Ironically, the 'pain in labour is good' lobby is now largely made up of women who claim to be empowering other women. What they should be fighting for, in my opinion, is a properly funded maternity service, with one-to-one midwifery care, which puts maternal choice at its very heart. But don't get me started.

Epidurals and pain relief during labour

Letter Q ChocolateBar: Why is it the case that so many women report being given insufficient local anaesthetic for perineal repair work? It happened to me and the doctor just said, "It won't be long now." The repair work took 25 minutes! I know there are guidelines in place that say that doctors should make sure that women have adequate pain relief before starting to stitch - why are these guidelines not adhered to? Why is it seen as acceptable for women to experience pain of this nature? 

I'd also like to ask about being given diclofenac after the repair work. As a victim of sexual assault, I had real issues with being given drugs rectally. The doctor and midwife basically bullied me into having it (not sure why it was so important to give pain relief after stitching but not during). I realise that they probably thought they were doing the right thing, but it's caused lots of problems for me on an emotional level since. Why is there so little awareness among HCPs about the fact that victims of sexual assault might have strong feelings about this sort of thing, and why do HCPs not listen to women and respect their views?

Letter ADavid Bogod: Perineal repair is a little outside my comfort zone! However, the obstetrician or midwife carrying out the repair should be able to do so entirely comfortably with correct use of local anaesthesia.

If the tear is extensive - particularly 3rd or 4th degree - it should be repaired in theatre with a spinal or epidural anaesthetic. The rectal route is commonly used for painkillers, but I would be appalled to think that someone with your history should be bullied into accepting this. All of these drugs can be given orally as well. In my experience, midwives and doctors are much more sensitive to issues of this nature than they were in the past.

Letter Qrathlin: Are there any long-term effects from a lumbar puncture during the siting of an epidural for a c-section resulting in two blood patches (first one failed) to cure a post-dural puncture headache?  

Letter ADavid Bogod: Dural puncture occurs in around one in 100 epidurals, is listed as a complication in all the relevant literature, and should be explained to you by the anaesthetist who attends to do your epidural. The resultant headache can be very severe indeed and can last up to two weeks (in very rare cases it can last much longer and become very difficult to treat). Blood patch is a very effective treatment, but a second patch is needed in around 15-20% of cases. Long-term consequences are very rare, and are usually limited to the chronic headache described above.

Letter Qsfxmum: My question is regarding pethidine. I was given this halfway through a very long labour and it was possibly one of the worst experiences I have ever been through: it felt like being buried alive while still feeling quite a bit of discomfort. So is it common for this drug not to actually work very well and have such adverse reactions?

"Pethidine's ability to relieve labour pain is not good and it does cross the placenta whenever it's given during labour."

Letter ADavid Bogod : Pethidine is an opiate, related to morphine. As such, it has pain-relieving properties with sedation as a side-effect, along with nausea and vomiting. It has been used for donkey's years by midwives and certainly has a place, especially in the early stages of labour when a bit of sedation can be a good thing.

However, its ability to relieve labour pain is not good - some studies have suggested it doesn't relieve pain at all - and it does cross the placenta whenever it's given in labour, sometimes resulting in a baby that is measurably more drowsy during the first 24 hours after birth. Some units have dropped pethidine in favour of diamorphine, a more powerful drug but with the same side-effects.

Letter QOoid: Why can a bit of sedation be a good thing in the early stages of labour? Yes if you want a quiet, passive woman (who would arguably be better off labouring actively).

Letter ADavid Bogod: Labour can be a long and pretty tiring business. It's been likened to running a marathon, and good hydration and nutrition, coupled with a rest in early stages if possible, often help later on.

Letter Qstrandednomore: This may be a really basic question but can you outline the reasons why someone may be refused an epidural?
 

Letter ADavid Bogod: There are some medical reasons why an epidural might be regarded as unsafe but these are rare. Significant infection in the blood stream or at the site of epidural puncture; abnormal blood clotting; major back surgery; some heart conditions. Epidurals are a reasonable option for the vast majority of labouring women.

Letter Qohmeohmy: 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.

"Gas and air is pretty benign. It provides mild pain relief with some sedation. Studies show no measurable effect on the baby at all."

Letter ADavid Bogod: The active drug in gas and air is nitrous oxide ('laughing gas'), delivered 50:50 with oxygen. Gas and air is really pretty benign. It provides mild pain relief with some sedation and, because it is self-administered, it is really very safe indeed. Studies show no measurable effect on the baby at all.

Letter Qapple0211: I would like to know at what point is it 'too late' for an epidural? At 5cm 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.

Letter ADavid Bogod: Once an anaesthetist is in attendance, you have to expect to wait at least 30 minutes to elapse before the pain goes away. There is therefore, and understandably, a reluctance to start the epidural procedure when birth is regarded as imminent. I have often stopped halfway through doing an epidural to help deliver the baby!

However, predictions regarding the expected time of delivery are notoriously inaccurate, so the default position should be to proceed to an epidural unless 10cm dilated and actively pushing. We often insert epidurals at full dilatation during the early part of the second stage before pushing starts. Some midwives do have a tendency to try to artificially limit the range of cervical dilatation over which an epidural can be done (as an extreme example, some might say that before 4cm you're not in active labour and after 7cm you're in transition). This is not evidence-based, and goes against NICE guidelines.

Letter QAntidote: My epidural was topped up prior to having an emergency section, and I got really bad shivering and chattering teeth as if I was freezing cold. I think that the lovely anaesthetist told me it was normal, and may have explained why but I can't remember! Do lots of people experience this, and if so why? 

Letter ADavid Bogod: It's not uncommon, although rarely as violently as you describe. We know that body temperature tends to rise when an epidural is in place, and this is probably due to 'inappropriate' shivering like you describe. It is probably due to the cold epidural solution making the temperature of the spinal cord and brain fall, which tricks the body into thinking that it is cold. Warming the epidural drugs does have some protective effect.

Letter QLeninGrad: Why aren't walking epidurals offered commonly and what innovations are on the horizon for pain relief in labour and childbirth?
 

Letter ADavid Bogod: There are quite a lot of misconceptions about mobile epidurals (as they have come to be known), so thanks for this question. In fact, pretty well every epidural performed in the UK now uses the dilute drug mixtures which are the key to maximising mobility. There are some fine 'tweaks' which can still be done, for example by minimising the concentration of local anaesthetic in the first epidural 'dose' and by using 'top-ups' delivered by the midwife (or, even better, by the woman herself) instead of a continuous infusion, or by using a combined spinal-epidural (CSE) approach.

"What really stops women mobilising is the rest of the childbirth package, including the near-ubiquitous use of continuous fetal monitoring, the drip and the reluctance of carers to let women out of bed (and the reluctance of many women in established labour to get out of bed."

What really stops women mobilising is the rest of the childbirth package, including the near-ubiquitous use of continuous fetal monitoring, the drip and the reluctance of carers to let women out of bed (and, it must be said, the reluctance of many women in established labour to get out of bed). 

As for innovations, probably the biggest is the use of a very short-acting pethidine-like drug called remifentanil, administered by the woman using an intravenous patient-controlled analgesia (PCA) system. It's not as effective as an epidural, but better than any of the other alternatives. There are still only a small number of hospitals offering this, however.

Letter QStarlightMcKenzie: Could you tell me anything about the effects of epidural anaesthsia on the birth hormone oxytocin and any implications this may have for the baby or mother post-birth? 

Letter ADavid Bogod: Oxytocin levels aren't affected by epidurals. Because of this, epidurals have no effect on the duration of the first stage of labour (although they may prolong the second stage, probably by an impact on the relaxation of the pelvic floor muscles).

There is also no evidence at all that they interfere with breast milk production or the ability to breast feed, despite a widely quoted but truly awful Australian study which suggested otherwise.

Letter Qme23: Is it not true that most modern epidurals now contain fentanyl which is an opiate? And, as such, crosses the placenta and therefore has the potential to affect the baby, eg sedative effects. This is quoted in the NICE guidelines. If this is, indeed, true, it can affect breastfeeding, as a sleepy baby will often be relectant to feed.

Letter A

David Bogod: Yes, epidural doses of fentanyl over 100mcg do have an effect on the baby. In practice, doses of this level aren't often used. Even if they are, the effects of pethidine or diamorphine in sedating the baby are many times greater and last considerably longer.

Letter QCheckmate: 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 syntocin drip. The delivery ended horribly with kielland forceps, resulting in minor injuries to my first daughter and major injuries to myself. Is there anything that can be done to minimise the likelihood of needing an instrument delivery for women who really want an epidural?

Letter A

David Bogod: The evidence suggests that keeping mobile is the best way to achieve a spontaneous delivery. Your midwife should be able to help you with this. In addition, a 'passive hour' of not pushing when you enter second stage is proven to help. A syntocinon drip is often used in the second stage with an epidural to speed matters up. Turning the epidural off in the second stage of labour, a common practice, does not have any measurable impact upon normal delivery rates and, according to NICE, should not be happening.

Letter Qbeakysmum: So, you disagree with the position that "before 4cm you are not in active labour... this is not evidence-based and is against NICE guidelines". Could you say more on this? I was one of those women in significant pain in the early stages, which went on for 36 hours before I was augmented under epidural, due to malpositioned baby. The fear I experienced and the frustration at being dismissed as not really in labour and therefore not a candidate for epidural, one-on-one support or any other pain relief will stay with me forever. It seemed to be hospital policy not to do anything under 4cm.

Letter A

David Bogod: The issue which you so graphically illustrate is that every labour is different. Putting arbitrary limits on certain pain-relieving interventions, while easy to do, does not really, in my honest opinion, represent woman-centred care.

Letter QGrumpyFish: I am considering a vaginal birth after caesarean for my second child (1st birth was an emergency caesarean), due in April. From reading the RCOG guidelines on elective repeat caesarean section, it appears to my untrained eye that an epidural may increase the likelihood of a successful vaginal birth after caesarean. Is this the case? Would this just refer to a mobile epidural (to allow change of position etc) or any epidural? (I will probably be delivering at a comparatively low volume hospital where mobile epidural won't be available.)

Letter A

David Bogod: Mobile epidurals are the norm nowadays (or at least the mixture is; the philosophy sometimes gets lost). An epidural probably won't increase your chances of a successful vaginal birth after caesarean but, and this is really quite important, it's a valuable safety feature for any woman with an increased chance of needing an emergency section, a category that you would come into. If you have an epidural in place, it is relatively easy to top it up safely; if you don't, you may need a general anaesthetic, which is not so safe.

Letter QRancerDoo: How often do epidurals not work (partially or wholly)? Is it common for an anaesthetist to be unable to site the epidural? This happened to me during the pushing stage of labour - he got the needle in but wasn't sure if he'd hit the right space, and made for a very unpleasant hour (rocking contractions every three mins) followed by a general anaesthetic. Am I an oddity or is this quite common?

"Epidurals probably only provide the level of pain relief which the woman wants in about 60-70% of cases. They are still far more effective than any other form of pain relief, however."

Letter A

David Bogod: I think many anaesthetists tend to overstate the efficacy of epidurals. They probably only provide the level of pain relief which the woman wants in about 60-70% of cases. The others sometimes need stronger solutions or even the epidural resited. They are still far more effective than any other form of pain relief, however. 

It's unusual, but certainly not unknown, for an anaesthetist to have difficulty in getting an epidural in. It's a delicate business, with the possibility of severe headache if he/she overshoots (and a very rare incidence of nerve damage). There's only a small gap between the bones of the back, and the insertion site can be difficult to locate if the woman is moving (not at all uncommon in the throes of labour), or if she is overweight.

Letter QFenouille: I gave birth in France where an epidural was the only pain relief on offer. I did end up having one which only acted on one side, unfortunately. The anaesthetist gave me a second big dose after I asked her if it was possible to resite it. I wasn't very happy with the additional dose as I lost all feeling completely in one side, but she told me that the high dose was to get things moving. I've only read on here about epidurals slowing things down. So do they slow things down or do they speed things up?

Letter A

David Bogod: They slow down the second stage and have no effect on the first. They do things differently in France! The epidural rate is indeed very high in most French cities, but what's important is that there's no negativity associated with this. I once read a copy of Paris Match magazine in which French cities were rated according to their 'woman-friendliness'. The epidural rate was one of the factors used in the scoring system, with a high rate being good! A UK magazine doing the same analysis would regard a low epidural rate as good. Go figure!

Letter Qohanotherone: Are epidurals more likely 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.

Letter A

David Bogod: Have a look at my earlier answers on this subject. For the scientific evidence, I can do not better than point you to the Cochrane review on the subject. This is a useful lay summary

Letter QMargles: I have heard of saline injections being used in Scandinavia, instead of epidurals. Do they work and, if so, are they ever used here?
 

Letter A

David Bogod: Yes - a very odd business, the saline injection into the skin overlying the back of the hip-bone, and almost exclusively practised, as you say, in Scandinavia. Studies have shown that it has no useful effect and probably only works as glorified distraction therapy (apparently it stings a lot!). I think even the Swedes are dropping it now. 

Letter Qmissedith01: I had an elective caesarian for a footling breech that wouldn't be turned. The team tried tilting the operating table to no effect, and then the anaesthetist gave me some wonderful drug that simply Made It Go Away. It was lovely, like being a normal person again. My question is, if there is another pregnancy, is there any reason not to take the wonder-drug all the way through?

Letter A

David Bogod: it sounds like you had a spinal anaesthetic for your caesarean section. Sadly, a bit too strong for labour, plus it only lasts about two hours. The closest you'll get, assuming you're not opting for another section, is an epidural. 

Letter Qsakura: So I suppose my question is, why did you decide to become an obsetric anaesthetist?
 

Letter A

David Bogod: I have the best job in the world. I walk into a room to find a frightened woman screaming with pain, and walk out again 30 minutes later with her back in control, comfortable and enjoying the process of giving birth. Our job's not just confined to epidurals, of course, and I have the regular privilege of helping women through childbirth by caring for them during caesarean sections, as well as dealing with the more fraught situations of haemorrhage, eclampsia and many other acute clinical emergencies.

 I must also say that I find that working with my midwifery and obstetric colleagues to provide a good and safe environment for childbirth to be a very fulfilling and rewarding experience. Sometimes it's quite fun too!

Letter Qbreatheslowly: Is it more likely that an epidural will only work on one side if you can't stay very still for the epidural? Is there any reason why I shouldn't have had the epidural before the drip? Is there any benefit in waiting?

Letter A

David Bogod: No, some epidurals are unilateral (one-sided) but it's not more likely if you move during insertion. See my earlier comments about the NICE guidelines on when epidurals should be inserted.

Letter QMistyValley: If it is a problem that so many women go into childbirth ignorant about what happens during an epidural (shocked by having to have a catheter etc), why is it happening? Just a basic flyer with a series of bullet points could explain the procedure, and outline the risks and benefits. This could be given to women during pregnancy. God knows you get enough leaflets and other gubbins thrown at you, surely something like this would actually be useful? And a similar leaflet explaining what will happen if you have to have emergency caesarean or other interventions.

Letter A

David Bogod: That basic flyer is available for all at www.oaaformothers.info (conflict alert - my own organisation). You will find a bullet-pointed epidural information card there. Feel free to distribute the web version freely or to ask your local midwives to make it available.

Letter QOompaLumpa: I am expecting my first child in June. I have been advised by my consultant that due to my medical history (severe asthma with a couple of ventilations) that I should either have a c-section or at the very least an 'early' epidural to help me. I am worried that on the day these options might not actually be available to me due to resourcing. Do you have any hints or tips on how to make sure I get the care I am told I need?

Letter ADavid Bogod: You need to make sure you see an anaesthetist in the antenatal period. The advice you've been given sounds very sensible, although most asthma improves during pregnancy as long as you keep taking your medication. I am quite certain that, having flagged you up in this way, you will receive all the help you need. We always prioritise those patients who have a medical indication for an epidural.

Letter Q

doricpatter: 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. 

Letter ADavid Bogod: It's only a small percentage of women who deliver in midwifery-led units without any epidural service, and of course they are told in advance that they can't have an epidural unless they move to the big hospital down the road, so at least they know where they stand. Transfer rates vary, and those units which are located in the same building as the consultant-led service tend, unsurprisingly, to have transfer rates which are higher than isolated units. Figures vary from 10-30% of women transferred in labour, the higher figure tending to occur in those units which are open to first-time mothers (not all are). Of course, not all of these transfers are for pain relief.

Letter QSuiGeneris: 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 anaesthesia for pain of the magnitude of labour pain is considered optional or delayed until the patient is screaming in agony? 

Second, is it possible to retain epidural access to manage postoperative pain, eg after an instrumental birth/caesarian? I think I read about this somewhere but when I asked at the antenatal course the midwife laughed and said something along the lines of "labour and birth, and the aftermath, are painful".

Third, why not get anaesthetists/anaesthetic nurses to give a lesson about pain relief in antenatal classes? The midwives at both my courses were obviously biased against epidurals (oddly seemed to think gas and air and pethidine were more "natural") and I did not think the information they gave was balanced, at all.

Letter A

David Bogod: So many questions! There is no reason why an epidural should be delayed until you are 'in established labour'; the NICE guidelines state: "Women in labour who desire regional analgesia should not be denied it, including women in severe pain in the latent first stage of labour." When this happens, it is usually a matter of resources, as you say. My thoughts on this are fairly unprintable but, along with midwifery and obstetric colleagues, anaesthetists are ensuring that adequate resourcing of maternity services is kept very high on the health agenda.

To your second question, epidurals are often used outside the maternity suite for post-operative pain relief (after, for example, hip replacement or bowel surgery). Some centres use them post-caesarean section and those that don't have other tricks up their sleeves, including spinal opiates and local anaesthetic nerve blocks to keep patients comfortable after section. Post-operative pain, while a 'normal' response, is never desirable, can be harmful, and should be treated seriously. 

Third, well some anaesthetists do. And, sadly, in some centres (not my own) anaesthetists are kept away from the antenatal class for fear of 'medicalisation' of childbirth. The best evidence-based antenatal information on childbirth in labour (conflict alert - I am about to become president of this organisation) can be found at the website of the Obstetric Anaesthetists Association (www.oaa-anaes.ac.uk), with a 'pain relief in labour' leaflet available in over 30 languages.

Letter Qgaelicsheep: I wanted to avoid opiates and an epidural for various reasons, fear of side effects mostly, but I asked for gas and air, which was refused as it was "too early". It stayed with me for years afterwards. Is this common to refuse gas and air to a woman in horrendous pain? 

Letter A

David Bogod: It sounds like a ghastly experience. Frankly, I can't see any reason for refusing gas and air to a woman at whatever stage of labour she's at. If she's not in labour but still has severe pain, that this needs (a) investigating and (b) treating.

Letter Qdomesticslattern: I had an uncomplicated birth with no instruments and only gas and air, 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?

Letter A

David Bogod: There is no reason to withdraw any form of pain relief, whether it be gas and air or epidural, when you are ready to push (unless, I suppose, it was sending you so loopy that you weren't able to listen to what the midwife was telling you).

Letter Qurbanproserpine: Are you aware that you are often the representative for all the doctors when in these situations? You are right by the person's head, closer than their partner on one of the most significant moments of their lives, and they will remember you forever? I have to say in my case positively, and I couldn't tell you what the many other people in theatre during my section said to me. Just wondered if you were aware of this, and if you consider it's an important part of your responsibilities?

Letter A

David Bogod: Thank you! With more and more of our patients being awake for surgery (not just in the obstetric field), this role of the anaesthetist is becoming even more important. It used to be said that young doctors went into anaesthesia because they didn't like talking to people - not any more!  

David Bogod: I'd like to close, if I may, with some advice for those of you who will be using maternity services in the future and want an epidural. 

  • Get informed. The OAA leaflet at www.oaa-anaes.ac.uk has evidence relating to different methods of pain relief in labour. 
  • Make it clear on your birthplan that you are fully informed of the risks and benefits of epidural pain relief and would like to take advantage of it at a time in labour when you feel that you need it. 
  • Tell your midwife of your plan as soon as you are admitted in labour or for induction. Ask her if she has any problem with you having an epidural when you want one.
  • Be aware of the NICE guidelines mentioned which stipulate that you should be able to have your epidural when you want it, even in the latent first stage of labour. 
  • When the time comes, tell your midwife and ensure that she contacts the duty anaesthetist and informs him/her of your request, even if busy in theatre. Ask her to make a note of this request in your records. 
  • If more than 30 minutes elapses before the arrival of the anaesthetist, ask again and keep asking. There is a national standard which states: "Where a 24-hour epidural service is offered, the time from the anaesthetist being informed about an epidural until being able to attend the mother should not normally exceed 30 minutes, and must be within one hour except in exceptional circumstances." 

Last updated: 15-Mar-2011 at 1:00 PM