To feel vindicated by the D of H report, which confirms midwives are withholding epidurals?

[RevolutionofourTime]

www.theguardian.com/lifeandstyle/2020/mar/03/women-in-labour-being-refused-epidurals-official-inquiry-finds

I was denied pain relief during my first labour for no reason whatsoever. When I complained to the head of midwifery, she encouraged me to try a home birth next time. 🤨 I have also witnessed other women in maternity ward being denied pain relief.

Despite this, I have seen it argued here time and again that midwives are not acting as gatekeepers or withholding proper pain relief in labour.

This report confirms what many of us know.

I will be curious to see if this will lead to changes- more specifically, to adherence to the Nice guidelines that it’s never too early and never too late for an epidural in labour.

My overriding impression of British midwives is that they think that birth is a 100% natural occurrence and women need to suck it up and get on with it, we’re basically expected to push out babies like machines that have ‘evolved’ for that purpose. Newsflash, the female body has evolved many things, many of which are counter productive to childbirth making it both dangerous and extremely painful. I will never, under any circumstances subject myself to another British midwife birth again.

Nearly 24 years ago, I eventually got my epidural, and I also asked the anaesthtist to marry me! It all went a bit tits up when the agency midwife (my 4th in a long labour) managed to pull the drip out by falling over the drip stand... then we had about 15 people in the room, and it all suddenly happened after 26 hours.

Second time around I was told 'too late' but then offered pethidine which I gratefully accepted - too late to make much difference to the actual birth, but great for the stitching. No one ever offered me any other painkillers than G&A, epi or pethidine - had no idea diamorphine was an option.

Both mine were born with the cord around their neck, and I do credit the midwives both times for saving their lives, for which I am of course very grateful. But I had some really bad, nasty midwives first time round ("why are you crying? it's only going to get worse you know").

Interesting thread. I too was denied an epidural and any pain relief other than gas and air, despite it being on my birth plan&requested on arrival. Lots of excuses-too early, nobody available to do it, then too late etc.
It was a traumatic birth and this experience coupled with the lack of midwife care given at the time, led to me never wanting to give birth again. In contrast, the ICU staff where we ended up as a result of said birth, were amazing and so wonderfully kind.

My midwife was the one who suggested the epidural. I wasn’t really with it, drifting in and out of sleep, not very coherent and in a lot of pain and she said to me and DH very sweetly, this is very hard for you/your wife, you’re/she’s in a lot of pain, would you like me to get an anaesthetist to give you/her an epidural. She asked DH too because I wasn’t really coherent. It genuinely didn’t occur to me or DH that I could ask for one.

I guess I was lucky based on the experiences here because the epidural was the best thing ever and labour went on for many hours after it was administered. I ended up needed an ECS and the epidural was already done so all good.

I never met one compassionate or kind, never mind caring midwife - I don't know what happened to this profession but imo they were all horrible!

@Sipperskipper

Well, there's a few reasons.

For example, if you're in the pool, I need to get you out, get you into a chair and take you across to delivery unit. The mobilising you will have done forces the baby down the birth canal and if you haven't started pushing when you've just got out of the pool, you can easily have a baby in the corridor en route to the obstetric unit - not good if baby needs oxygen.

If you're already in delivery unit and you're encouraged to sit up, the change in position forces your baby down - think of the perfect position to evacuate your bowels. Being upright helps push a baby out. Women often feel pressure to push at 8/9cm. This pushes the baby onto the cervix and that forces the cervix to open completely. It's really not safe to have a needle in your spine when you suddenly start pushing and if you don't push and the baby just sits there, you could be starving your baby of oxygen. It's not a situation that I would like to be in as a caregiver and an anaesthetist would be terrified if he/she were in such a position because they could irreversibly damage your spinal cord.

Now if it was your first baby and the baby was still high in the birth canal, that's a different story. It's a case by case situation, I guess.

I'm so sorry that so many of you have had such terrible experiences. That breaks my heart. I would never want to think anyone felt that way from my care.

If you are struggling postnatally you have every right to contact your hospital and ask for a meeting with the Head of midwifery or Professional Midwifery Advocate to discuss your case. There may well be some changes that need to be implemented at your unit. If you are scared of having another baby because of your experience you can have a c-section. And if you are pregnant and know you want an epidural please, please tell the triage team before you come in. It used to frustrate me that triage would ask me to take a woman to the MLU and the first thing she would say to me is, "I want an epidural" because that would just delay the woman's care as we'd have to find a delivery unit midwife.

I have scoliosis. To the extent that an anaesthetist can feel that my pelvis is not entirely even (the curve is at the top and my shoulders are different heights). I've had multiple epidurals.

I had one at 8cm with with my 3rd because there was no way I was going to experience a drug free birth again. The pain from it I can conjure up in my mind right now and wince.

They tried fobbing me off. Nope.

Oh, and the 'pressure', it hurt. It was not 'pressure', it was unmitigated, relentless pain that made me feel like I wanted to die.

@Strandiv - you had a good midwife and that's how they should be. I have on several occasions said the same to women. Being an MLU midwife I often come across women who insist on a "natural birth". It's very hard for them when a midwife suggests they have an epidural.

@vivaLaBeaver - I appreciate what you're saying, but I don't work on a delivery unit. It's a distance away.The women I meet spontaneously labour and generally labour well. By the time I'd get them to DU for an epidural they'd be pushing it out in the corridor - unless it's a primp. And of course we're not supposed to be leaving our women to get an anaesthetist in case she delivers alone. There was never enough staff to get a doctor on my behalf on the labour ward.

With a busy labour ward in most hospitals, why is there not an anaesthetist assigned to the ward?
This has been going on for years. The word of the mother has been ignored. Numerous women have suffered PTSD and mental health issues because of their birthing experiences. Anger, disappointment and upset has fallen on deaf ears. I am pleased this is out in the open now. Perhaps something will be done.

*It's important to know that it takes a good 20 minutes to set up and administer an epidural and that's only if:

• there is an anaesthetist and ODP available
• the woman can stay very still
• she has a normal BMI so her spine can be palpated easily
• she has a normal shaped spine ie. not scoliosis
• the anaesthetist is very experienced
• you have a midwife who is qualified to care for someone who has an epidural in situ
• blood results have already checked ie platelets and full blood count*

I had an epidural, but mot in the UK, and I really believe that it was done in under ten minutes (although it took about 20 minutes before I started feeling the effect). The anasthetist looked in his twenties, so not super experienced and my bmi at the time was 42 or 43, so morbidly obese.

I really don't recognise what you wrote here.

@Oscaree

I question many of these statements... any actual anaesthetists about?

• there is an anaesthetist and ODP available well that’s obvious but also indications from the article are they are readily available
• the woman can stay very still I was not very still, most women in labour aren’t
• she has a normal BMI so her spine can be palpated easily not sure I completely believe this, even in bariatric patients the spine is still palpable due to where normal fat

distribution occurs surely

• she has a normal shaped spine ie. not scoliosis again not convinced
• the anaesthetist is very experienced no just no
• you have a midwife who is qualified to care for someone who has an epidural in situ don’t know about that, but surely all

Midwives should be trained as standard

• blood results have already checked ie platelets and full blood count I had none of this and was still administered an epidural

I had no idea that you were supposed to pause till the baby turns so pushed him out in one.

@JoJothesquirrel how do you mean, pause until the baby turns? My first is due soon and I’ve never heard of that before!

I got told I couldn’t have an epidural as there was no time, baby was coming now. DD was born 4 hours later in theatre with forceps and a spinal block. My SIL had the same - ‘no time’ yet theatre and CSection hours later.

Ah yes - the "pressure". Utter, utter bollocks. It's unrelenting, agonising, skin tearing, bone crushing agony.

@Oscaree very true, I’ve only worked in a consultant led unit so never had that added factor of having to move room/down the corridor.

We’re really lucky that the midwives station is central to all the rooms....I know I can stick my head out the door and ask anyone at the station to bleep the anaesthetist for me. Worst case I’m a ten second walk from my room to the desk and will quickly bleep them myself.

@Oscaree

I am a midwife. Yes, it can be too late to give someone an epidural when they're 8/9cm dilated.

I’m a midwife too. This is total bollocks.

It could be unsafe to offer a woman who has had children before an epidural at 8ish cm.

No, no it couldn’t.

Sorry, but you’re just a bad midwife. As evidenced by statements such as if you don't push and the baby just sits there, you could be starving your baby of oxygen

@Strandiv

I've attended many epidurals that have taken up to an hour because the woman was unable to stay still and some that have had to be abandoned completely.

• I've had the awful experience several times at work where the anaesthetist has introduced themselves to the woman, had their pager bleep and had to leave to perform an emergency c-section on someone else. I totally sympathise with the woman in pain and it's truly horrible to have to wait when you've made a decision like this and you need to be pain free.

-No, you cannot always palpate the spine of an obese woman. Anaesthetists have scanning equipment they can use if this is the case, but of course that involves another member of staff being able to operate the machinery for the anaesthetist as they are already sterile. -Scoliosis again - yes some patient's spines need to be scanned to avoid damage to the spinal cord. Usually anyone with spinal conditions have a meeting with the anaesthetist to discuss appropriate pain relief antenatally, just in case they can't have an epi.

• Junior practitioners of course take longer than a very experienced one. We see that in every job.
• Not all midwives are qualified in epidural care, I'm afraid. Or their competencies may be out of date if they haven't been on their annual update.

-Re blood results, your full blood count at 28 weeks will have been enough, they should have that result already, but if the docs suspected any infection or problems along the way, the anaesthetist wouldn't want to perform an epidural without an up to date full blood count, white cell count and platelet count. I have had women who have been denied epidurals until I've taken their blood on the request of the anaesthetist.

@Dropyoursword

Wow! Thanks for that. A woman's baby died at my hospital because she had an epidural sited at her request. The epidural took a long time to site. When she was assisted back on the bed the baby's head was visible and the baby was delivered dead.

As for my comments, I did clarify that it needs to be considered case by case and if she's a multip who is obviously transitioning and about to push, yes it would be unsafe to get her up and get her an epidural.

@Oscaree
Thanks for responding... your clarification statements do debunk most of your original statements though. So actually it is all possible. Might take longer, might require further equipment, you already have all the blood tests you need,

Ahhh posted too soon.
Seems like non of the statements rule out an epidural. And if an anaesthetist is called early early enough could easily administer, if they’re called away for an emergency, again if called early enough they could come back and administer. Or another anaesthetist found.

Like I said I had an excellent midwife and got an epidural. An overall good experience.

But @Oscaree I am slightly worried that the statements you put on here are widely believed by many midwives and and as such the default position from them maybe to deny the patients wishes for an epidural because they’re making all these assumptions of the complexity of it or the inconvenience of it.

My midwife was a german lady who hadn't done many births before mine. She persuaded ke to do a water birth and I went with it. She never offered any pain meds at all, not even gas and air and I didn't think to ask because I tend to be very submissive with medical people. A doctor poked his head round the door once and she told him to go away without even looking at me.

The pain was so bad I ended up pushing at 8cm just in hopes of ending it. I had a 4th degree tear and felt every moment of those 40 minutes of ripping myself apart. Then I had an epidural and several hours of stitches. It was the worst experience of my life and I wished she had offered meds rather than making me think I would be a failure if I didn't do it drug free.

Anaesthetist with interest in obstetrics here.

@Rosspoldarkssaddle in most hospitals (unless pretty small) there will be an anaesthetist "assigned" to labour ward 24/7. In the daytime there may well be more than one, but after ~6pm and at the weekend it will often only be one. If there's an EmCS or an instrumental delivery that's us in theatre for at least 45 minutes, can easily be up to 2 hrs. A straightforward epidural takes me ~40 minutes from walking in the door to leaving with it set up - so if more than one woman asks at a similar time, one of them will be in for a longish wait. I work in a very busy labour ward in a huge hospital, and we just don't have enough anaesthetists to provide two on LW out of hours. Sometimes I can call a colleague over from one of the theatre suites if they aren't busy, or call the consultant in from home in an emergency, but the former is no guarantee and the latter still takes time.

It's not just a matter of sticking a needle in the back. You have to get a brief history from the patient to make sure there aren't any medical reasons that an epidural wouldn't be safe, explain the procedure and the risks, set up sterile kit, scrub up, get the patient sat/lying in the right position, clean the back, allow the skin to dry and drape it. That's about 20 minutes before I can put a needle anywhere near - can be sped up a little if I have an experienced assistant but I often have to do it all myself. The actual insertion of the epidural catheter only takes a couple of minutes if it's easy, but it isn't always! Then you have to put on dressings, reposition the woman back into bed, give a test dose, programme and attach the pump (again, can be helped by an assistant but I have to check it), and write all my notes and prescription.

@Strandliv all of those statements are relevant, but not all essential.

- there is an anaesthetist and ODP available See above re. availability. We never hear about the ones where the MW doesn't get as far as asking us.

- the woman can stay very still - lots of women do move a lot if in a lot of pain, but they MUST stay still for at least a couple of minutes while the needle is in. I've never actually had to abandon one because someone couldn't sit still, but I have had to be very blunt on occasion.
- she has a normal BMI so her spine can be palpated easily - helpful but not essential. Overall, a higher BMI tends to make it more difficult but it's variable both ways.

- she has a normal shaped spine ie. not scoliosis - makes it easier but again not impossible
- the anaesthetist is very experienced - not really. There is a basic level of competency we must achieve to be able to cover labour ward on our own, but I wouldn't say it's VERY experienced. However, you do tend to get slicker the more you do!
- you have a midwife who is qualified to care for someone who has an epidural in situ Most labour ward midwives are, but if a woman has e.g. transferred in from a MLU, or a midwife has been called in from community duties due to the unit being super busy, there are some who aren't able to care for women with an epidural. Usually the LW co-ordinator would change midwives around to facilitate this though.
- blood results have already checked ie platelets and full blood count If a woman is low risk and has normal 28 week bloods, repeat samples are not needed. But if there are any complications like pre-eclampsia, we need very up to date blood samples, usually taken within the last 6 hours. If we miss a low platelet count or clotting abnormalities the complications could be severe.

Hope that helps!

I wanted on, it was on my birth plan and it was the first thing I said when I arrived to hospital. My midwife said ‘oh you don’t need that, you’ll be fine’ and gave me 2 paracetamol. I was 10cm dilated for 5 hours before I eventually got one followed by a forceps delivery. Bloody barbaric. It’s put me off having more children.