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.

Also, thanks to the amazing ladies on here I knew that epidurals were hard to come by so I prepared mentally for not being able to have one. So I knew the baby head test would be painful at a couple of cms dilated when they asked me if I wanted to have an epidural and I said I wasn’t sure as I was scared and the anaesthetist turned up two minutes later literally ready to go! Must have made it quite high up the chart!

I’ve been a midwife for over 10 years and have always tried to do for my patients what they have asked. I’ve set up for epidurals on ladies who are having their second + children and are rapidly progressing through their labours and I’ve caught those babies when the epidural still couldn’t be sited in time. I’ve consoled women desperately awaiting an anaesthetist to come and site an epidural but due to them being more urgently required in theatre having to to wait. It’s awful not just for the woman but for the midwife as well as our role is to be ‘with women’ and advocate for her but sometimes ‘you need to wait for your epidural’ really isn’t a stalling technique it’s reality. A woman or fetus in a life threatening situation will always have to take precedent over a request for analgesia. Unfortunately a labour ward anaesthetist has to be a senior doctor as pregnant women by their unusual physiology during pregnancy are complicated - they need to consider that they are effectively managing 2 sometimes more patients in the same body and that requires a huge amount of skill. Siting an epidural is a blind procedure - it’s difficult and having a patient who is unable to keep still whilst the needle is being pushed in between the vertebrae very near the spinal cord carries a lot of risk. Obviously there is not an endless supply of senior anaesthetists available at all times. This is why most women are not offered an epidural when they begin involuntary pushing - it’s not feasible to try and stop a woman doing what her body is instinctively making her do. As to the discussion on placing an epidural in the early stages of labour prior to it being established- generally it’s not done because the research shows it can slow labour or even stop it which then brings a cascade of interventions that make the labour riskier for both mum and her baby. It’s what happens in the USA (where they get paid much more for extra interventions and emergency LSCS - watch Ricky Lake’s documentary “The Business of Being Born” it really strips it down to the greed of private healthcare). Obviously in some situations it is warranted- if the lady is having an induction of labour anyway an epidural before starting the syntocinon drip is a sensible decision if that is her choice as she will be able to get into the position to best site an epidural safely and it is much more likely to work. Epidurals have shown in research to increase the chance of needing help to deliver either instrumentally with forceps or ventouse or needing a LSCS. An LSCS affects your future birth choices for subsequent children and makes you slightly higher risk the next time you are pregnant. Multiple LSCS impact on the risks of major complications at delivery. I recommend all women to read as much as they can and attend positive birth groups - have your birth your way - epidural as soon as possible or drug free - but do it fully informed so you know exactly what you’re agreeing to.

Before being induced I was really quite worried from hearing other women’s stories that I’d be declined pain relief or that my midwife would try to discourage it. My actual experience couldn’t be further from those worries.
If anything, she encouraged me to try different pain relief options and discussed them all with me. When I’d agreed to diamorphine she went off immediately to draw it up, and it worked wonders to keep me from losing control.
I was also very anti epidural but really struggled with the rate of how fast my contractions were coming. She was actually the one who suggested thinking about an epidural when she could see that I was clearly struggling. I toyed with the idea for quite a while, but again, as soon as I said I wanted one, I swear the anaesthetist was in the room within about 30 seconds so I really couldn’t fault her at all.

I wasn't allowed any and I had the syntocin drip.

Pure hell.

I hope this signals the end of the dominance of the "natural birth at all costs" mentality. I gave birth 10 and 8 years ago and looking back I am so angry about the message I received that pain relief would lead to problems with delivery. During my pregnancies the message I got throughout from midwives and NCT (not to mention MN - incredible prevalence of anti-epidural threads) was that having an epidural would create problems during the birth. Guess what, I didn't manage to get an epidural through either of my labours and ended up with medicalised deliveries with both anyway.

First birth I had specified on my birth plan that I didn't want to be dissuaded from an epidural if I wanted one. "No anaesthetist available". Luckily they became available after an hour of pushing when they realised the baby was in a difficult position and I needed an EMCS.

As my first baby was surprisingly hefty (and I was very slight) I was told throughout second pregnancy that this baby would likely be big and I should try to stay as mobile through birth as possible so should avoid an epidural. I had gas and air and a tens machine, was in so much pain (back labour) that I couldn't move anyway and was so exhausted by a 3 hour pushing stage that I ended up delivering flat on my back with stirrups and a ventouse. They took away the gas and air for the last hour as well because apparently I was "relying on it too much" .

Ironically, I ended up having a spinal anyway as I had a 3rd degree tear and had to be stitched up in theatre. Bloody wish I'd had it before the tear!

@flowerfairy6004

Epidurals do not cause a cascade of intervention. That is an outdated view and not supported by up to date research.

@FelicisNox

I don't think YABU but I do think many are missing a valid point: no, it's not too late to have an epidural unless you hit 10cm but epidurals impact on your ability to give birth safely. Not true

Epidurals impede the mother's ability to push increasing the need for medical intervention (forceps, venteuse, emergency C section) Not true

they have a negative effect on the baby, effectively knocking it out for hours on end and interferes with feeding. Not true

It also makes mothers more prone to tearing, are known to cause the worst headache of your life and can give you long term back pain. Not true

To the lovely poster suggesting we just ‘use gravity’, it is perfectly possible to have a mobile epidural and to give birth on all four. I’ve done it myself. Having an epidural doesn’t mean you’re lying flat with your legs in stirrups.

Please read the Cochrane reviews on epidurals during labour, which debunk all the pseudo science you are reciting.

Also consider this: Canada has an NHS-like system (free healthcare on tap), under provincial jurisdiction. In the province of Quebec, 70% of births are under epidural - that’s more than twice the UK rate. Yet the rate of both CS and AD, are well below the UK rate.

The main difference between the two systems is that 98% of births are doctor-led. Only 2% are midwife-led.

To all those saying it’s because the NHS is cash strapped, the cost of providing negligent maternity care is by far what costs the NHS the most.

*In 2018/19, NHS Resolution received 10,678 new clinical negligence claims, compared with 10,673 in 2017/18, an increase of just five claims (0.08%).

Some 10% of claims related to poor maternity care but data shows they are the most costly to the NHS.

The report said: “Overwhelmingly, the cost of clinical negligence is driven by maternity claims, which represent 10% of the number of clinical claims we received in 2018/19, but half of the value of claims received and 70% of the £83 billion provision reported as at 31 March 2019.”*

(www.shropshirestar.com/news/uk-news/2019/07/12/rise-in-nhs-compensation-bill/)

Here are the WHO conclusions, based on a comprehensive review of the evidence:

“Maternal outcomes

Pain relief: It is uncertain whether epidural analgesia compared with no analgesia reduces pain scores, pain intensity or the need for additional analgesia during labour because the certainty of the evidence for all of these outcomes is very low.

Mode of birth: Moderate-certainty evidence suggests that epidural analgesia probably leads to fewer women undergoing caesarean birth compared with no analgesia (5 trials, 578 women, RR 0.46, 95% CI 0.23–0.90). It is uncertain whether epidural has an effect on instrumental births because the certainty of this evidence is very low.

Duration of labour: It is not clear whether epidural analgesia makes any difference to the length of the first or second stages of labour compared with placebo, as the certainty of the evidence is very low.

Augmentation of labour: Low-certainty evidence suggests that epidural analgesia may make little or no difference to whether or not women receive oxytocin for labour augmentation (3 trials, 415 women, RR 0.89, 95% CI 0.63–1.24).

Birth experience: Low-certainty evidence from a single trial suggests that epidural may increase the proportion of women reporting they were satisfied or very satisfied with pain relief in labour (70 women, RR 1.32, 95% CI 1.05–1.65). Compared with no analgesia, it is uncertain whether epidural affects women’s perceived feelings of poor control in childbirth because the certainty of this evidence is very low.

Side-effects: Review evidence on the relative effect of epidural compared with placebo or no intervention on hypotension, vomiting, fever, drowsiness or urinary retention is very uncertain.

Fetal and neonatal outcomes

Perinatal hypoxia-ischaemia: It is uncertain whether epidural analgesia has an effect on the number of babies born with Apgar scores of less than 7 at 5 minutes because the certainty of this evidence is very low.

Long-term outcomes: These were not reported in the included studies. Mother–baby interaction and breastfeeding: These were not reported in any of the included trials.”

extranet.who.int/rhl/topics/preconception-pregnancy-childbirth-and-postpartum-care/care-during-childbirth/care-during-labour-1st-stage/who-recommendation-epidural-analgesia-pain-relief-during-labour

Pain relief: It is uncertain whether epidural analgesia compared with no analgesia reduces pain scores, pain intensity or the need for additional analgesia during labour because the certainty of the evidence for all of these outcomes is very low.

Sorry, but am I reading this wrong as it makes no sense to me! Are they saying that there’s no evidence an epidural compared to a placebo reduces pain score??!

I too was denied pain relief, the midwife didnt even look in my notes at my birthing plan which clearly stated what I wanted. I was 18years old and scared. I was only given gas and air, but after the birth, I had a retained placenta which wouldnt deliver, so they gave me an epidural to remove it! I felt cheated after I’d already been through all that pain giving birth then got an epidural anyway!

@RevolutionofourTime

A Cochrane review in 2018 which looked at over 11,000 women showed that labour stages were longer in the group with epidurals and also that they had an increased use of syntocinon (hormone) drip to speed up their labours. www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000331.pub4/abstract
Therefore that is a cascade of intervention - woman came in labouring on her own and she ends up needing to be assisted to carry on labouring! Also there’s evidence of more women retaining urine - which means the woman would need to be catheterised for longer and may need to deal with having to care for the newborn whilst also dealing with having a catheter in until the bladder regains the correct sensations in order to empty properly. I’m not demonising epidurals - they are an excellent form of pain relief and they should be available if wanted to everyone however like all medical procedures they come with risks - dismissing all the risks and saying that it’s rubbish isn’t informed consent - women should be proactive prior to labour and read the risks and benefits of all of the pain relief options and likely medical procedures they may undergo in labour - that way they can truly have an informed consent. Knowledge is power and I’ve found that women who have done this always seem to have much better birth experiences regardless of whether they opted for a medicalised birth or a more natural one. The trauma comes when decisions are made quickly and without the woman and her partner really understanding what they’re agreeing to and then having to deal with possible consequences they weren’t expecting. That’s why debriefing is so important.

@DropYourSword it’s because statistically it couldn’t be proved. Basically most medical trials use statistical analysis to show whether something without a doubt will happen every time it’s repeated. In the case of epidural analgesia you’re always going to find some women who it didn’t work for or who it only worked partially for - again this is due to it being a blind procedure and unless the catheter is inserted into exactly the right place in the epidural space it may not work as the drug won’t get to the right place and may not work at all or only work on certain areas of her body. So for those unfortunate women their perception of pain is going to skew the statistical data as they will report that their pain was no better or worse

My birth plan said I wanted an epidural asap. I asked for one and then there was a changeover where the new midwive said the previous midwife "forgot" to get me it. My husband had to stand up to the midwives to get me one and they were annoyed when I asked if they were trying to stop me from having one because the midwife at my NHS antenatal group was so against epidurals. It was too busy so 7 hours later a student under supervision did it and it didn't work properly. I had said in my birth plan I only wanted student midwife in the room.

@flowerfairy6004 I don't think anyone is denying the risks, they are, quite reasonably stating then even though we are only women we are capable of balancing our understanding of the risks with the want of an epidural. The study is basically saying epidurals don't always work, which is true, but I don't really see that as an argument for taking away a woman's choice.

@flowerfairy, this only states a correlation, not a causative effect. It’s hardly surprising that women with longer labour are more likely to ask for/receive an epidural, if only because they have more time to ask for one. That doesn’t mean that the epidural caused their labour to be longer.

Ditto with oxytocin.

I find the “knowledge is power” line rather patronising. I was very well informed about the risks and benefits of an epidural, and I was crystal clear that I wanted one, but was still denied it.

Unfortunately in my experience, what stands between pregnant women and knowledge, is the misinformation they receive from their midwives during pregnancy appointments. Not everyone enjoys, or has the capacity to undertake, reading medical journals.

See also how a Bristol hospital was advising patients, as recently as last month, to “try to avoid epidurals” and have a home birth instead.

www.independent.co.uk/news/health/nhs-maternity-safety-bristol-normal-birth-babies-a9331766.html

The trauma comes when decisions are made quickly and without the woman and her partner really understanding what they’re agreeing to and then having to deal with possible consequences they weren’t expecting. NO. The trauma comes from being manipulated and overruled by someone with little or no understanding of MY decision making powers or experience. I was NOT ill informed nor was I inarticulate, I was however vulnerable, in pain and scared. That would be because I was being cared for by ridiculously unreasonable midwives with their own plan for what I should/could/would be doing. Neither birth had to be like that at all.

As an example, here’s how my own conversation with a midwife at an antenatal appointment for DC2 went. I actually wrote it down at the time as it was so shocking:

“Me: I will want an epidural.

Midwife: Oh, but they lead to more c-sections you know?

Me: No they don't, the Cochrane review is very clear on this.

Midwife: well, they do cause a cascade of complications.

Me: actually no, there is no causal link established, merely a correlation which is not at all the same.

Midwife: well, it will slow down your labour.

Me: that's fine by me, I'd rather have a longer but less painful labour than be in excruciating pain. I would actually prefer to have the epi early on, because my first labour was not very long and I'm concerned otherwise there won't be time.

Midwife: okay, but the NICE guidelines say you cannot get one until you are at least 4 cm dilated.

Me: not true, the NICE guidelines say the exact opposite - that a woman should not be denied an epidural in the latent first stage if her pain is severe.

Midwife: okay then, anyway your baby has no rights until it's born, you can do whatever you want, your body your choice, if you want an epidural then get one.

Me: speechless at the innuendo that having an epidural will actually harm my baby

Midwife: but I should warn you we will not let you in a delivery room until you are at least 4 cm dilated, therefore there is no way you can have an epidural before then.

Me: so when you say it's my choice, it's not much of a choice is it?

Midwife: well you can always go to a different hospital if you're not happy.

Me: funny you should say that, I asked to be transferred to another hospital last time when I was told I couldn't get an epidural as all the delivery bays were full. I was told it is against hospital policy to transfer patients.

Midwife: that's correct, we never transfer anyone out on the basis that we are unable to give them pain relief. But you could have walked out on your own.

(So basically I should have started traipsing around London looking for a hospital while contracting every two minutes.)”

So much guilt tripping and misinformation.

@MrsRobert it won't have been a "student" that put your epidural in. It may have been a more junior anaesthetist under supervision, but for them to be working in obstetrics that still means they've been a qualified doctor at least 3 years. I can't imagine anyone letting an actual medical student do an epidural! So your "no students" on your birth plan wouldn't have included them. It's still your right to request not to have a junior trainee to do it, but it sounds like it wasn't fully explained to you.

Hi @flowerfairy6004 - I can’t believe that ineffective epidurals would be SO frequent as to completely skew data like that. It genuinely doesn’t make sense to me. There is no question an epidural provides better pain relief than a placebo. I just can’t wrap my head around this!!

@5zeds and @RevolutionofourTime I’m not denying that there are healthcare providers who aren’t providing the remit of advocating for their patients and it is horrifying the amount of stories on here of women who have felt that their feelings were disregarded and disrespected - unfortunately like any job there are people who shouldn’t really be doing the job. Also from your conservation @RevolutionofourTime it’s obvious the midwife was caught on the back foot and should’ve got someone who was more up to date with the research to come and discuss with you - however I do understand that we as a health service do not have the capacity to admit all women in the latent stage of labour for epidurals - you have to have one to one care on an epidural and there isn’t the resources to facilitate that. Unfortunately there is nothing that can be currently done about that unless the system is completely overhauled. It may be different if the NHS becomes privatised and more money is available to build bigger hospitals and employ more staff but it will also mean that healthcare will be a matter of who can pay for it rather than free for all

@dropyoursword, I am not sure either, but perhaps this is due to the difficulty in comparing pain relief Vs no pain relief when births are all different, epidurals can be given at various stages and so on? In other words, you can’t have double blind studies, and women can’t be asked to have the same birth twice, once and epidural and once without, and compare their pain levels.

Anyway, the WHO acknowledged this and added “ The GDG agreed that while there is limited evidence on the impact of epidural analgesia compared with no epidural analgesia for pain relief during labour, epidural analgesia is a proven method for relieving pain related to surgery, including abdominal surgery, and chose to recommend it as a pain relief option.“

You can’t give women in labour a placebo. That won’t be done. It wouldn’t be against a placebo, it would be against another effective form of pain relief. And efficacy of pain relief is dependant entirely on patient reporting, very difficult where each labour is different. I suspect this is why there’s insufficient clear data.

Would you be happy being told you’re being given pain relief and being given a placebo in labour?

People are only given a placebo as part of a clinical trial they consent to.

FUCK NO I wouldn’t be happy with a placebo. So I would not consent to being part of a trial that potentially gave me one.

I will need to find this study and read further!

@flowerfairy6004, the issue isn’t my convo with the midwife - I knew she was not well informed and I just ignored her. The issue is all the other women that she sees, and to whom she dispenses this bad advice.

It shouldn’t be expectant mothers having to inform midwives about the risks and benefits of epidurals, or NICE guidelines.

FUCK NO I wouldn’t be happy with a placebo. So I would not consent to being part of a trial that potentially gave me one.

It would be unethical to use a placebo in this circumstance just as it’s unethical to use placebos in the treatment of cancer etc. In these cases it’s usually a case of comparing one type of treatment to the current gold standard treatment, to see if there’s an improvement in efficacy or outcomes. Very difficult to judge this when it comes to pain relief because of the many variables.

instantly forgotten?”
Utter bollocks, my Dd is 15 now and I still get flashbacks