Why is my midwife trying to talk me out of epidural

[Melvin2021]

Hi I'm 38.5 weeks and I've been pretty certain from the off that I would like an epidural when in labor obviously if everything goes to plan. Mt midwife said I don't want one and to see how I get on? Has this happened to anyone else?

We're all different. I had pethidine and it allowed me to sleep when I'd been awake for 36 hours, I didn't feel sick and it didn't slow the birth down.

Ditto. Allowed me to get some much needed sleep. And labour was 13.5 hours from first twinge to delivery.

Midwives are zeslots for natural birth. Ignore, ignore, ignore.

*zealots

The way I see it, every birth is different and you can't know how you'll manage until your mid way through labour. I'd certainly put in your birth plan that you'd like one.
In my case I had a crash C section for cord prolapse under General anaesthetic for DS1
I wanted to be " present" during DS2's birth As it happened his birth has to be sped up with the drip so I had an epidural in place anyway and we went home the next day
DS3 was entirely natural with not even paracetamol!
Definitely push(!) for an epidural as there may be a wait for an anaesthetist
Good luck

1. to manage expectations, if there's no anaesthetist available you can't have one.
2. cascade of intervention. I'd rather suffer labour pain ten times over than have an episiotomy and forceps which are so much more likely with an epidural.
3. long term impact, epidural can fuck up your spine permanently.

If it's what you want be very firm and advocate for yourself because some midwives think they are the gatekeeper of pain relief. There's lots of other stuff though like a tens machine, gas and air, paracetamol, oromorph etc

I’d be seriously pissed if a midwife told me what I did/didn’t want in my labour.
I had an epidural and it could not have gone any better. I had no complications and no assistance in having my son. If you want one, you should have one (obviously assuming an anaesthesiologist is available).

Correlation does not equal causation. It isn’t clear whether women having epidurals are having them due to higher levels of pain or prolonged deliveries due to complications which would require intervention with or without epidural.’

The above had been repeated a couple of times, and worth repeating again.

A review of the literature suggests that the correlation between epidural and intervention isn't evident post 2005, when improvements to epidurals were made.

I’d be seriously pissed if a midwife told me what I did/didn’t want in my labour.
I don't think anyone advocates getting drunk during labour.

@MissM2912

I am bowing out- OP- good luck with your birth. It really makes no odds to me whether you have a section if you think that is for the best.

A section is not the worst thing that can happen. I did a lot of reading before DD was born. I concluded that in a perfect world I wanted a vaginal delivery with no interventions and no epidural (I was very worried about the possibility of a spinal headache as I had crippling migraines when I was younger). After that the order of preference went ELCS, EMCS, and right at the bottom of the list was an assisted delivery. I was quite keen on being continent after giving birth. I don't think the relative long-term risks of section and assisted delivery are properly presented by HCPs to pregnant women, and it really is infantilising. My birth plan basically said that if there was any reason at all to suppose I was going to have trouble, I wanted to go straight to a section without trying anything else. (I was very lucky, I had a really straightforward delivery with only gas and air.)

I find the best way to be guaranteed an epidural is note the time your diamorphine will wear off entirely, vomit over your midwife due to unrelenting pain levels shortly prior and then demand one. Worked for me after being on the maxed out hormone drip for seven hours.

Mine was described as 'patchy' and I've heard of a few others who've had the same thing happen. I wasn't aware it might not work pre-birth so that was a huge disappointment. I ended up with an EMCS but that was due to sky rocketing blood pressure (due to the pain!) and DD's poor position rather than the epidural. I also have a history of back pain/sciatica but the frequency and severity of episodes is unchanged from pre-pregnancy, which is backed up by the NICE guidelines.

I think though OP it might be worth thinking about how you respond to pain normally. I curl up in a ball and want to be left alone so the concept of the wires and monitoring didn't bother me, but others pace/change positions to cope. If you're in the latter group then perhaps waiting and seeing might not be a bad idea.

This is geared to a US audience but has good summaries of research and Cochrane reviews on epidurals: evidencebasedbirth.com/epidural-during-labor-pain-management/

Note that although there is an increased risk of forceps/vacuum intervention, this link wasn't found when looking at more recent data which may suggest more recent epidural techniques lower the risk.

Medical professionals should inform you of the risks and benefits, but it's up to you to decide. If you want an epidural, your decision shouldn't be second-guessed.

FWIW, I had an epidural due to back labour and was very happy with my decision. My labour was 8 hours total, I didn't need any augmentation with pitocin, nor any assistance, although I did have a second-degree tear. I was out hiking 2 weeks after delivery.

My birth plan was to avoid pain relief of all forms (long story why which I won't go into). Due to my induced labor not progressing as they hoped the consultant on call wanted me to have an epidural + c section. I was adamant not to however after 38 hrs of labor agreed to a partial epidural so they could top me up should a c section become medically necessary. I felt very bullied into doing this but was fortunate to have a very supportive mid-wife who fought my corner. I retained sensation and could still walk etc but had one 'numb patch' on my back. What I will say is having done 90% of my induced labour with no pain relief at all, I found the way I thought about pain made all the difference.

DD was born naturally a few hours after the partial epidural, when my mid-wife broke my waters but not without my ripping and needing a further episiotomy. I wholly blame the epidural & agree with the other poster who said they'd take labour pain over the episiotomy.

Moral of the tale? trust your instincts and craft your birth plan accordingly.

@DappledThings

I’d be seriously pissed if a midwife told me what I did/didn’t want in my labour. I don't think anyone advocates getting drunk during labour.

Oh I don’t know

@HandScreen

Midwives are zeslots for natural birth. Ignore, ignore, ignore.

We're really not. We should be (and I am) a zealot for women centred care and informed choice.

I'm a lecturer and impress on all my students that we should not be giving loaded information or trying to persuade anyone to do anything. But give evidence based information in a timely manner and then support decisions.

Ok, I've only read about the first approx 50 posts so I don't know if this has been covered but here is my tuppence. I'm an experienced labour ward midwife.

Midwives couldn't give a stuff about the price of epidurals. This is not a factor in anything.

Research shows that epidurals DO NOT cause an increase in caesarean section rates. They DO however cause an increase in instrumental births and episiotomies. This is partly due to the fact that they relax your pelvic floor causing the baby to adopt a suboptimal position in your pelvis. It is also caused by the fact that you are generally just sat in bed which compunds the impact of your pelvic floor being relaxed. This is part of the cascade of intervention. Suboptimal positions can lead to raised maternal temps and the use of antibiotics etc.

You have to have IV fluids and ideally a catheter with an epi so you are more restricted in movement. Most trusts also insist on continuous monitoring so there may be more cables with that making it even harder to move. Some trusts are allowing a degree of intermittent monitoring though which is something to ask about.

Research has shown that they don't increase the first stage duration (getting to fully dilated) but they do prolong the pushing stage....partly as you can't feel to push as well and partly due to the position of baby.

They are pretty safe and the risks of nerve damage etc is tiny.

There is a significant amount of research which shows that women labour best when left alone and with as little intervention as possible. However, this isn't what a lot of women want so as long as you understand the potential implications then you should be able to have whatever pain relief you choose. I would just say, see how you go and ask for one when you feel like you actually need one, not just in case.

@Willthewashingeverend

Ok, I've only read about the first approx 50 posts so I don't know if this has been covered but here is my tuppence. I'm an experienced labour ward midwife.

Midwives couldn't give a stuff about the price of epidurals. This is not a factor in anything.

Research shows that epidurals DO NOT cause an increase in caesarean section rates. They DO however cause an increase in instrumental births and episiotomies. This is partly due to the fact that they relax your pelvic floor causing the baby to adopt a suboptimal position in your pelvis. It is also caused by the fact that you are generally just sat in bed which compunds the impact of your pelvic floor being relaxed. This is part of the cascade of intervention. Suboptimal positions can lead to raised maternal temps and the use of antibiotics etc.

You have to have IV fluids and ideally a catheter with an epi so you are more restricted in movement. Most trusts also insist on continuous monitoring so there may be more cables with that making it even harder to move. Some trusts are allowing a degree of intermittent monitoring though which is something to ask about.

Research has shown that they don't increase the first stage duration (getting to fully dilated) but they do prolong the pushing stage....partly as you can't feel to push as well and partly due to the position of baby.

They are pretty safe and the risks of nerve damage etc is tiny.

There is a significant amount of research which shows that women labour best when left alone and with as little intervention as possible. However, this isn't what a lot of women want so as long as you understand the potential implications then you should be able to have whatever pain relief you choose. I would just say, see how you go and ask for one when you feel like you actually need one, not just in case.

Would you say though that some labours are not going to progress normally, due to position of the baby for example, and the epidural won't make a substantial difference to this?

Or could you get a difficult labour to progress more easily without epidural?

I had two very similar back to back labours, had epidural with both and interventions with both, forceps and ventouse.
My third turned herself in labour, I believe because she was slightly smaller and I didn't need an epidural and had a pretty normal delivery.

I think she's trying to say you need to be flexible, sometimes it's too late for one, they also can slow down labour and increase likelihood of interventions. See how you feel is good advice I labour is different for different people, for me it wasn't painful so I didn't have any drugs or air even

@Greybeardy isn’t Fentanyl just a stronger form of morphine? I looked into it after I had a ELCS for my last child as I was surprised at how out of it I was. I was expecting to find the experience terrifying and had done loads of breathing exercises beforehand as I was terrified of the thought of lying there awake and being sliced open. Within a couple of minutes after having it I was chilled as anything and felt just like I had when I’d been on opiates after an operation in the past. Or is the one done for ELCS different/ stronger than if the woman is expected to carry on labouring?

Malpositioned babies make up a huge number of those requiring birth using forceps/vacuum and a lot (not all) of these are caused by the epidural and the position of the woman post epidural. Lying semireclined in bed is one of the best ways to get a back-to-back baby which is how the majority of women are with an epidural. So if there was no epidural to start with, the likelihood of the malposition is reduced and it doesn't become a difficult labour to begin with.

If you have a malpositioned baby to begin with, it can be compounded by the epidural. However, have also seen women stall in labour at a certain dilation due to malposition. They have then had an epi and then been able to rest and relax and they progress well following. Women with back labours are more likely to need an epidural because it is notoriously more painful.

Im very much in the camp of going in to labour with no fixed ideas and just seeing how you go. If you need a epi though, get one!

@Willthewashingeverend

Malpositioned babies make up a huge number of those requiring birth using forceps/vacuum and a lot (not all) of these are caused by the epidural and the position of the woman post epidural. Lying semireclined in bed is one of the best ways to get a back-to-back baby which is how the majority of women are with an epidural. So if there was no epidural to start with, the likelihood of the malposition is reduced and it doesn't become a difficult labour to begin with.

If you have a malpositioned baby to begin with, it can be compounded by the epidural. However, have also seen women stall in labour at a certain dilation due to malposition. They have then had an epi and then been able to rest and relax and they progress well following. Women with back labours are more likely to need an epidural because it is notoriously more painful.

Im very much in the camp of going in to labour with no fixed ideas and just seeing how you go. If you need a epi though, get one!

Thank you, that was really helpful.

One midwife did suggest it was the shape of my pelvis that made my babies tend towards back to back.

[quote TrenchArse]@Greybeardy isn’t Fentanyl just a stronger form of morphine? I looked into it after I had a ELCS for my last child as I was surprised at how out of it I was. I was expecting to find the experience terrifying and had done loads of breathing exercises beforehand as I was terrified of the thought of lying there awake and being sliced open. Within a couple of minutes after having it I was chilled as anything and felt just like I had when I’d been on opiates after an operation in the past. Or is the one done for ELCS different/ stronger than if the woman is expected to carry on labouring?[/quote]
Fentanyl isn't morphine--it's a semi-synthetic opioid, about 100x stronger than morphine (and stronger than heroin; in North America, heroin being cut with fentanyl is a huge problem).

It really really isn't. At no point in my training or subsequent 11 years as a senior midwife providing labour care have I ever been told to dissuade/deny a woman an epidural due to the cost. I've worked in multiple hospitals across 2 countries (public and private) and cost is never a factor.

In fact years ago I worked at a hospital which didn’t do epidurals after midnight as there was only one anaesthetist for the hospital after that time. So I used to say to women at about 9/10pm that if they thought there was any chance they might want an epidural to say now.

I hated that, as women would panic and have one even if at that point they were ok. But better that than having to tell a woman at 1am that she couldn’t have one.

@Hospedia

but statistically a high number, something like 50% end up needing an assisted delivery or section

If you're going to thrown stats around then you need to cite your sources. Where did you get this 50% figure?

This paper that investigated that very phenomena shows that deliveries where there is the use of epidurals result in a far greater incidence of assisted delivery or Caesarean sections. The first column is the total of all deliveries, the second column is those where an epidural was used, the third where no epidural was used. Almost 46% of women who had n epidural ended up having an instrumental vaginal or Caesarian delivery in comparison with women who did not have an epidural, where only 26% of deliveries ended up with an instrumental or Caesarian delivery.

Route of birth        
 Normal vaginal delivery 646 (61.8%) 118 (36.1%) 528 (73.5%)
 Instrumental vaginal delivery 242 (23.1%) 124 (37.9%) 118 (16.4%)
 Caesarean section delivery 158 (15.1%) 85 (26%) 73 (10.1%)

www.ncbi.nlm.nih.gov/pmc/articles/PMC5136389/