Failed Epidurals - new technology

[gailforce1]

Article in Daily Mail Health section from Tuesday 23 November 2010 - still available to read on internet. (Yes, I know, Daily Mail!!)
A new high-resolution ultra-sound has been researched in Canada which showed a successfull insertion rate of 91.8%. The first hospital in GB to use it is Ninewells Medical school in Dundee.
Apparently the failure of an epidural is a one of the factors leading to an increase in the number of women requesting a CS for their second birth. According to the Birth Trauma Assoc around 150,000 (a quarter of new Mothers) don't get the pain relief they need during labour (I find this a shocking statistic).
One reason given for the failure of epidurals is the lack of expetise of the anaesthetist. In many NHS hosspitals it is a junior anaethetist rather than a specialist obstetric anaesthetist doing the epidurals - the specialists are working in the theatres.
It is also difficult to insert an epidural if the patient is obese (15% of women are obese at their first antenatal appt).
However, even the most experienced anaesthetist can have problems if the women cannot keep still having left it too long to have an epidural or have been encouraged not to have one in case it slows labour.

So, given the cuts how long will it be before this new technology is available at all maternity units? Surely this should be a huge financial saving if it leads to a reduction in C Sections but more importantly that women get the pain relief they need.

[violethill]

Agree - I wouldn't have wanted to give birth either lying flat or sitting - neither seem the optimum position. Also, if you want to be in water, that's ruled out if you go for an epidural

[Cleofartra]

Wanted to add, I can understand how you can have good birth outcomes with an epidural when a baby is well positioned and where the labour is driven along by syntocinon.

What I'd like to see is a comparison of outcomes for births when labour is difficult. I suspect the vast majority of women having long, difficult labours in this country eventually have epidurals. It'd be hard to design a study which compares outcomes for mothers having 24+ hours in active labour both with and without an epidural because most labours in the UK aren't 'allowed' to continue that long without augmentation and usually epidural. It's like trying to look at outcomes for prolonged pregnancy when 99% of the population accept induction before 42 weeks, and those that don't are a very unique, self-selecting group.

[Cleofartra]

"Cleofartra - it is only the old style epidurals that meant you have to give birth on your back"

Even if you're sitting up you're still pushing a baby uphill, which isn't helpful sometimes. In reality most women in my local hospital (which offers low dose epidural)give birth in a semi-supine or supine position, epidural or no epidural. In fact 11% give birth lying completely flat and 19% give birth in stirrups. And that's at a London teaching hospital. . Over 50% give birth semi-supine - ie, sitting on their tail bone. In standing, squatting and kneeling positions the pelvis can open up much more.


And having to be continuously monitored as you are with an epidural doesn't really allow for true mobility in labour.

I can see what you're saying about how amazing it must be to see your baby emerge with a clear head. Personally though I found that the two unmedicated births I had were followed by much more intense and long lasting euphoria than when I gave birth with an epidural - the result of having normal postpartum hormone levels I assume, which you don't get with an epidural.

[HelenLG]

Ushy,

I wish my experience of epidural was of clarity, but unfortunately I was on gas and air as well as a full dose epidural during my labour, so it's not so much clarity as a horrific confused blur.

My labour was the most horrible and painful thing I've ever gone through, and was the complete polar opposite of what I wanted to happen. That said, I wouldn't consider have CS for my next one (yes, I am considering another one!!), as although the birth was traumatic, I was fully mobile and recovering by the next day, which I wouldn't have been with CS.

[Ushy]

Cleofartra - it is only the old style epidurals that meant you have to give birth on your back. You can sit bolt upright with a modern epidural - it only imobilises you if you have had it in place for a very long time which probably suggests you have got other problems anyway.

It is quite interesting because you can actually see the baby open his/her eyes for the first time but with a clear head and not in pain. (That was my experience anyway when I eventually got an epi with DS). I am not big into emotional moments but that was quite memorable!

[violethill]

I agree that it can be an interesting experience actually. I had one with my second birth, which was by CS. I found it fascinating that I could be absolutely wide awake, feel pressure, tugging, pulling, but no pain. Seeing as for major abdomininal surgery,it's either general anaesthetic (more risky) or epidural/spinal anesthetic, I had very little choice. It's not, however, something I would choose when there is no medical need.

Whether the causal link is established, there is enough of an associated risk of instrumental delivery for many women to avoid epidurals.

"Long traumatic deliveries give rise to more epidural requests "- again, yes, it's easy to establish a link; but these things are such a grey area. What one woman may describe as 'long and traumatic', another woman might just accept as a 'normal, painful birth'. A lot depends on your expectations, access to accurate info prior to the birth etc. I often think that the most useful piece of advice I was given before I had my babies was from a new mother who was quite honest and said 'You'll feel pain like you've never felt before and which you wouldn't believe possible'. I'm not saying women necessarily expect labour to be pain free, but I do think there's a large variation in what women expect/anticipate/tolerate.

I am also reminded of my midwife at my first birth, who told me afterwards that my labour had been very long and difficult (baby wasn't in a good position, she was big, and it was my first labour). The midwife told me that had I been in a hospital, she was 99% sure I'd have been encouraged to have interventions, both for the pain and to speed things up. If that had been the case, no doubt I would have totally believed afterwards that those interventions were inevitable. So, it's not as though every labour only ever has one outcome from the outset. Some labours will never go smoothly, and some babies need to be born by CS, right from the word go. However, there are many more births which could go in any direction, from totally natural, to fairly medicalised, to highly medicalised.

[Cleofartra]

Amazing really that there aren't more profound effects with epidurals, given that they profoundly disrupt the hormonal cascade involved in labour and result in most mothers being immobile and having supine deliveries - both physiologically absolutely abnormal.

I had an epi with my first and found it a very interesting experience. Wouldn't have done it again though - don't like people fiddling with my body or feeling physically disabled.

[Ushy]

Yes, of course women who have epidurals are more likely to have assisted deliveries -there is an association - what isn't clear is that modern light (not heavy dose)epidurals are causal. Long traumatic deliveries give rise to more epidural requests - those births are heading for problems anyway.

The US anaesthetists think there is no proven causality - the UK anaesthetists think there is causality only with high doses for protracted periods.

[Cleofartra]

"ramping up and exaggerating the risks of pain relief and making women feel guilty and a failure if they don't 'achieve' natural drug free birth).


The majority of first time mothers in the UK - will have a birth which involves:

syntocinon
opioids
instruments
episiotomy
continuous monitoring

Most will give birth in a supine position.

Most will have access to epidural analgesia and opioids.

Most women will express disappointment with their experience of childbirth.

Many will have severe problems with breastfeeding linked with morbidity from childbirth.

I say all power to those organisations which are informing women about their choices.

If there are concerns about the quality of the evidence they are using then fine - this should be flagged up. All these organisations have a responsibility to provide information based on up to date, peer reviewed and good quality evidence.

But as far as I'm aware the NCT, the Royal College of Midwives, the NHS, and the Royal College of Obstetricians and Gynaecologists all support the view that women who have epidurals are more likely to require an assisted delivery. My understanding is that their advice is reviewed regularly and that newly published research is taken into account when guidelines and advice is redrafted every couple of years or so. I don't accept that any of these organisations have a 'vested interest' in exaggerating the risks of epidural analgesia.

As for France having lower c/s rates and assisted delivery rates than the UK - well yes, but then they are also much thinner and healthier than us, and maternal age on first birth is lower than ours. Both these things have a profound impact on operative birth rates. They also have very low rates of breastfeeding.

[japhrimel]

births not borths, obviously

[japhrimel]

The jump made is that failed epidurals leading to requests for ELCS next time round is a significant part of a rise in CS rates.

Also, the quote above doesn't actually say that people who have had failed epidurals are more likely to then have an ELCS. Having an impact on the decision is not the same as causing a different decision - and it may not be any different to women who ask for an epidural and can't get one because of a lack of doctors at the time, or women who have traumatic borths for other reasons.

It's a real Daily Mail issue with anything medical/science related to put two things together and assume causation.

[gailforce1]

Japhrimel the article quotes Sue McDonald of the RCM "but there is little doubt that if a woman doesn't have a successful epidural, it can impact on whether she chooses a CS in subsequent pregnancies".
I think with this issue no research/statistics are yet available since the trend has only just been noticed eg one unit noted a request for cs increase by 40% in the past year.
A good reaserch project for a student midwife perhaps?

[Ushy]

Cleofartra You are absolutely right - in hospitals with a restrictive epidural policy the majority of women who have an epidural will have a caesarean or need an instrumental delivery - that's because the only ones who get epidurals are the ones heading for complications any way.

There have been a couple of studies where whole hospitals have moved from having a restrictive to a high epidural rate and it has had no impact on the overall rate of assisted delivery.

Moreover France has a huge epidural rate (60-70%) and LOWER assisted delivery rate than UK.

There seems to be a really big anti pain relief misinformation machine out there. (I don't mean mners - I mean organisations with a vested interest in selling 'natural childbirth' amd ramping up and exaggerating the risks of pain relief and making women feel guilty and a failure if they don't 'achieve' natural drug free birth).

That said, good luck to women who CHOOSE natural childbirth themselves - I don't have an issue with that all.

Think I will get some T-shirts printed with 'I achieved an epidural' :)

[Cleofartra]

Ushy - there are major problems with the research on outcomes associated with epidural use.

And it's really important for women to know that the issues with epidural may be very different for first time mums than for multiparous women.

fwiw, meta-analysis I have seen of a range of studies over the past five year finds a higher rate of assisted delivery in first time mums following epidural. In some hospitals the MAJORITY of primiparous mums having an epidural will go on to have a ventouse delivery. And really, that can't be right, or good for mothers or babies.

[violethill]

Whether an epidural increases the risk of forceps / csection or not, the indisputable fact is that as a major medical procedure, it carries SOME risk. It also means the mother is less mobile, cannot move into the optimum birthing position and at worst there is the risk of long term effects.

I tend to agree that it's sound advice to try to keep out of a CLU unless there's medical need, or you want an epidural to give birth. There are much better and equally safe places to give birth IMO when the pregnancy is low risk - which is the majority of cases

[japhrimel]

TBH It's a typical Daily Mail article where they've taken a few quotes and facts and made their own interpretations from them. The information given does not make it clear that failed epidurals are responsible in any way for the rise in CS rates or birth trauma rates - its what the Mail is implying, but not what the evidence is saying, reading between the lines of the article.

There's also no evidence it would seem that the money would be best spent on new equipment, rather than more staff, more training or better patient education.

Cleofartra - I have OC, so avoiding the CLU isn't an option for me and although my OC has been so well managed I'm going to term, I'll be induced at 40+3 if I don't go into labour naturally by then. Although I am very against having an epidural (because I don't think it will work, so I'll end up with the issues but not the benefits), I'm not anti-drugs though.

And FWIW, my NCT classes haven't been anti-drugs. Pretty balanced in fact, with good info on what options are good when, including when it is too late to ask for an epidural!

[VivaLeBeaver]

Ushy - yes I totaally agree that a woman may not make it clear in her actions. However it seems to me you made it clear in your words and should have been taken seriously. I said earlier I've seen women ask for epidurals who appear to be coping but at the end of the day they are the only ones who know how bad it is.

[Ushy]

Sorry but people keep saying that epidurals increase instrumental deiveries - the evidence with "modern" epidurals is conflicting - lots of studies do not show this at all.

2006 Review of 18 studies:

Women receiving early epidural (NA) for pain relief are not at increased risk of operative delivery, whereas those receiving early parenteral opioid and late epidural analgesia present a higher risk of instrumental vaginal delivery for nonreassuring fetal status, worse indices of neonatal wellness, and a lower quality of maternal analgesia.


This is a Swedish study of over 94000
"This investigation shows no clear association between epidural use and caesarean section or instrumental delivery, indicating that there is no reason to restrict the epidural rate to improve obstetric outcome."

A 2005 Polish study:
There were no statistically significant differences in the rates of instrumental vaginal deliveries, 1 and 5-minute Apgar scores, length of third stage of labor and perinatal blood loss in patients with and without epidural analgesia.

[gailforce1]

Regretably I don't thinkg the cost of a relatively small piece of equipment which can be used extensively over years after it's purchase, is going compare to the salary of a professional.
Given that junior anaesthetists are often giving the epidurals I would have thought it would make sense to give them every assistance! You must also remeber the terrible dural tap headache that women go on to suffer if the epidural has not been properly administered.
Dr McLeod from Ninewells Hosp says "why do this blind when there is equipment available to make pain control 91.8% effective". Clearly he does not think that the rate of succesful epidurals without this equipment is good enough and I am sure if you were one of the women for whom it failed you would agree!

[Cleofartra]

I tell women that if they want a drug free birth and it's important to them, then they want to try to avoid being induced and FGS, to try and stay away from the labour ward if they can possibly help it.

Send a woman into an environment which hampers her chance of having a normal birth (which I'm sorry to say is true of many CLU's) then there's a good chance she'll end up having an epidural or pethidine, no matter what her feelings when she's writing her birth plan.

Women who have really strong feelings about not wanting an epidural shouldn't expose themselves to a medicalised birth environment if at all possible. It's like taking someone on a vegetarian wholefood diet into MacDonalds and saying - go on, have anything you like!

[gailforce1]

The article quotes the Birth Trauma Assoc saying "each year around 150,000 women -one quarter of new mothers- dont't get the pain relief they need during labour" and often this is linked to a failed epidural.
i would be interested to know if there was any reseach into the %of induced labours needing epidurals as compared to spontaneous labours.

[pirateparty]

X-posted with the last sentence of your latest post cleofartra.

[pirateparty]

What no-one has mentioned is the risk of an epidural failing without the ultrasound. Which is about 10%... About the same as with the ultrasound then...

Yet another case of the daily wail getting everyone's knickers in a twist to sell newspapers.

Another one here for spending money on more midwives and also more anaesthetic cover for labour ward rather than emporer's new clothes equipment.

[Ushy]

Vivalebeaver you said 'generally when a woman really does want one she makes it clear'

I must come back to you on this because this was exactly what my complaint hinged on.

The midwife insisted that I was not unduly distressed because I was not rolling round or screaming. I am not a highly strung or emotional person so I wasn't climbing the wall or hysterical. I had asked, calmly but firmly, twice for an epidural and said I was in unendurable pain. I used those precise words so I thought I was making it very very clear. I remember feeling totally desperate that there was no response to the words. I didn't know she wanted the words back up with some drama.

The consequences for me were awful - I had full blown PTSD, dropped to six stone in weight and was off work for over a year. It was the worst experience of my life.

So words matter - some people only use words and words should be listened to.

[japhrimel]

One thing I really would question is that of these women who requested a CS second time round, how many actually had a failed epidural that would've been helped by an expensive technique to site one better?

Not getting the pain relief they wanted is not the same as asking for an epidural at an appropriate time, getting one and it failing. It could be that they didn't ask for one until it was too late or that they couldn't get one because of a lack of staff...or that the birth was traumatic for completely different reasons (e.g. bad tear with a forceps delivery, which may actually be a more likely scenario with epidural).