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.

Never. Low on the priority list I would have thought.

I had an epidural with my DS2 and it only worked on my left hand side, a/tist was at a lost to know why, he had been doing them for 20 years.

When I pushed out DS, it felt like I was pushing him out all wonky!

Love Anna Conda!

Carocaro - you said it would be low priority but why should we accept this? Labour pain can be horrific and more women end up with PTSD from childbirth than from being in the armed forces at the mo! (interesting stat I saw in some article the other day!),

So why should we accept being treated like crap?

Big difference between being treated like crap and and the current epidural system. Not everyone whoose had an epidural in the UK has been treated like crap. And the failure of on epidural does not automaticall mean a traumatic birth resulting in PTSD.

There are many new techniques for many diseases, illnesses and conditions and not all get implemented straight away across the country.

Especially now, with the new cuts. Every department is fighting for £. Any new option for a better way to do something is definately worth looking at, but with most things in the NHS it's down to £ and a new thing is probably a no no at this time.

Did you have a bad time with a birth?

My understanding is that 80 to 90% of women who have an epidural during labour say they have 'very good' or 'complete' relief of pain, (Midirs Informed Choice leaflet on Epidural analgesia). Can't see in that case how this new technology will improve things much.

And TBH it's only a minority of women in the UK who opt for an epidural as it is. IMO the vast majority of women who have horrible experiences and unmanageable pain in labour would be better served by having more midwives, and more midwives who are relaxed and unstressed.

Can't see it as a good use of public money to spend money on analgesic technology when women and babies are being damaged by a lack of one to one care in labour

Cleofartra - are you a ;midwife? Agree one to one midwivery would be good but midwives are not analgesics. I actually had an utterly horrible birth with lovely midwife who was convinced that 'I could do it' - what she failed to understand was that I did not want to do it - I do not think suffering brain drilling agonising pain is even remotely 'empowering' - to expect women to put up with that kind of agony in the 21s century if they choose not to is crap. The NHS should treat men and women equally. Is there any equivalent where men would be left in such severe pain? I don't think so.

Incidentally, my second DS was with epidural - bliss:)

Part of the reason not that many women get epidurals is, as Gailforce says, because thousands of women don't get the pain relief they want.

"but midwives are not analgesics".

Not sure that's true. Research suggests that women who have one to one care from a midwife are less likely to request pain relief! To me that suggests having a midwife by your side throughout labour can sometimes make pain easier to deal with.

"what she failed to understand was that I did not want to do it - I do not think suffering brain drilling agonising pain is even remotely 'empowering'"

No - did you request and epidural? If you were in a hospital where epidural analgesia is available for labouring women, if you clearly requested one and didn't get it for any reasons other than clinical ones, then you are right to feel hard done by. The midwife should have listened to you.

"part of the reason not that many women get epidurals is, as Gailforce says, because thousands of women don't get the pain relief they want"

Agree that sometimes it's because of a shortage of anaesthetists and midwives, which needs to be addressed.

Most women I know though want to get through labour without using opioids or having an epidural and the things that would enable them to do so - more midwives, better birth environments, less routine monitoring and induction of labour, better access to water birth - are not always in place.

So yes - more access to pain relief for those who want/need it. And better access to those things that make the use of opioids and epidurals unnecessary for those who don't.

Sorry - should read "And better access to those things that make the use of opioids and epidurals less necessary for those who don't.

Yup, like many women I requested an epidural but the lovely midwife said "try to manage a bit longer" and when I said I couldn't she said it was too late. I have never been so angry with anyone in my life! I felt completely betrayed and the birth was a nightmare.

I think the problem is that midwives and NCT people put very high value on the experience of vaginal birth and don't understand people who don't. I personally couldn't care less how my baby is born as long as it is safe and I am not traumatised. I think midwives, doulas and NCT teachers are a self selecting group - I could never be a midwife however I do admire people who are - the thought of touching placenta makes me cringe - aargh.... but I am sure the job has lots of highs:)

"I think the problem is that midwives and NCT people put very high value on the experience of vaginal birth and don't understand people who don't. I personally couldn't care less how my baby is born as long as it is safe and I am not traumatised"

I think midwives and birth professionals put a high value on women having a happy and healthy birth and postnatal recovery period. They feel strongly that having major abdominal surgery on the day that you assume care of a newborn can put you under additional stress at a time when you're already extremely tired and vulnerable, and is not something to take lightly. We know that many, maybe even most, mothers could avoid having c/s and still get through birth with a healthy baby if they had optimal care. Midwives are health professionals after all - their primary concern is to safeguard your health and that of your baby. Reducing the need for assisted and instrumental births is part of their role. I don't know one mother who'd choose a ventouse or forceps delivery over a spontaneous vaginal birth if they could come away from either with a healthy baby.

That said - it's also their role to listen to the mother and to meet her wishes for the birth if it's possible to do so. Actually that's their primary role. But women have to make their wishes known - that's why I'm quite enthusiastic about birth plans!

But the evidence that epidurals cause instrumental dleiveries is far from clear alhtough at NCT classes you get told it as absolute indisputable fact! This is what SOAP (The US anaesthesia professional body) says based on its analysis of the latest research evidcence: "The relationship between epidural analgesia and forceps deliveries is complex. Some studies have shown more forceps deliveries in patients with epidurals while others have not. This may be highly dependent on practice style and preferences of your own obstetrician."

So would seem sense for obstetricians and midwives to brush up their skills rather than deny women who want it efective pain relief.

Being denied an epidural when it's a good clinical choice is a completely different issue to ineffective epidurals.

And not being able to get an epidural - e.g. because of a lack of anaesthetists - when one is asked for at an appropriate time is a different scenario to a woman asking for one at, say transition, when it may not be an appropriate choice.

Agree Japhrimal but we made a complaint to the hospital which was upheld.

I had asked for an epidural at 6cm when it was quite appropriate - the midwife then kept saying 'just a bit longer' and when I finally said I really need it NOW, she said it was too late.

In the letter of complaint resolution it said that the hospital had an on request policy at ANY stage of labour and it was regrettable that staff had not responded appopriately etc etc....

The obstetric anaesthetist spoke to us afterwards and said he 'knew a lot of this goes on and it is not acceptable'.

There are LOADS of posts on other mumsnet threads about women not getting pain relief they ask for so I know ours was not an isolated case.

In my case it was not lack of anaesthetists -it was the midwfe believing it was somehow 'better' to give birth without pain relief. I don't know whether a lot of midwives come into midwifery after being NCT teachers or what it is but it certainly does not result in more women being - as Cleofarra says - happy and healthy.

It actually results in more traumatised women begging for a C/S next time!

ushy what reason was given by the midwife for not organising the epidural? As your complaint was upheld were the trust going to ensure that she received suitable training so that she would not repeat this with other patients?

gailforce I haven't actually got the letter here because I am at work but it said something like 'the Trust will learn lessons from your experience and endeavour to prevent a recurrence'

I assumed they were going to talk to the midwife- the anaesthetist was certainly going to because he was definitely cross about it. He seemed to agree about the whole anti pain relief thing.

Ushy - as a group low risk mothers who have their babies at home, or who have their babies in birth centres, where they don't have immediate access to epidural analgesia seem to have better psychological outcomes following childbirth than low risk mothers delivering in consultant led units with epidurals available 24 hours. How do you account for this, if easy access to epidural analgesia is crucial for populations of women to increase the likelihood of a happy birth?

"at NCT classes you get told it as absolute indisputable fact!"

Not at my classes you don't! You get told that the relationship is complex and that there is not a clear cause and effect relationship between epidurals and assisted birth. However, I also point out that at present it does seem that there is a very strong association between epidural use and assisted birth in first time mums, and also that the research tends to rely on mothers who've had opioids as the control group, who like mums who've had epidurals, may well spend a great deal of their labour on the bed in a supine position.

I would love to see research comparing outcomes for low risk women having epidurals, when the control group consists of low risk mothers who are encouraged to mobilise, have access to a birth pool, and who one to one care from a midwife experienced in physiological birth. Sadly this research doesn't exist at present as far as I'm aware (though I'm quite happy to be corrected if anyone knows of any!).

"The US anaesthesia professional body"

Personally I have difficulty reconciling American medical opinion about childbirth with what I see here in the UK. Almost all births over there are obstetric led, are induced or accelerated, aggressively monitored, and supine. And really, if that's the case, no wonder women who don't have epidurals often end up seriously traumatised and with poor birth outcomes!

I think that in making a complaint about the NHS the important outcome is that they will endeavour to prevent a recurrence as what has been done to you cannot be undone.
Perhaps there is an important lesson to be learned from what happened to you - if you ask for an epidural and the midwife says no that you then ask to speak to the anaesthetist and make sure you birth partner also backs up up/stands up for you.

A personal question ushy will you be requesting a cs next time?

"the anaesthetist was certainly going to because he was definitely cross about it. He seemed to agree about the whole anti pain relief thing"

Doesn't mean he knows best! Anaesthetists only ever see women who are at the end of their tether and in extreme distress in labour.

What they don't see are all the mothers who come in in transition, asking for an epidural, saying they can't go on, who don't have one for one reason for another and go on to have a straightforward birth. The ones who turn around and say 'God that was awful, but I'm SO glad I didn't have an epidural!'. They do exist you know. Midwives see them all the time.

Personally though the bottom line for me is 'mother's choice' - if she requests an epidural then the anaesthetist should be sent for. If it's safe to site an epi when he or she arrives, then it should be done. Don't like the idea of doctors or midwives telling people what they need when it comes to making birth bearable.

I had 2 failed epdidurals. I am a healthy size 12 and have had no back surgery. The first was quite traumatic as they didn't believe me and started cutting into me for an emcs. So I screamed the place down and they knocked me out. They made me feel that I was a stupid over hormonal pregnant lady that over exagerated the pain.
So...with number 2 I ended up having a vbac. Midwife lovely and said that I should have an epidural as I wasn't coping very well with the pain at all (I had 4 of them trying to calm me down). So anyway. It didn't work again even after three attempts and I had this enforced natural labour and stitching without anaesthetic 4 hours after the birth which was also pretty traumatic.

So anyway, with number 3 i wasn't taking any chances and I insisted on a c-section. i had a spinal and it was pure relief. Bliss. The best birth experience ever.

I really do think that women shouldn't have to endure a natural birth without pain relief if they don't want to. I am no good with pain. Number 3 was an accident and I requested to be sterilised after number 3 as there is no way I can put myself through the whole birth experience again. I would love to have more children but I can't bear the thought of going through it all again.

Maybe that technology would have helped me ? They still can't tell me why the previous epidurals failed. They don't know. Posting on mumsnet when I was preg with number 3 opened my eyes - failed epidurals and sutuiring without pain relief is So COMMON !!!

I agree with Cleofartra

Many women reach the point in labour where the pain is agonising and they feel they can't go on, but they don't have an epidural (meybe through the encouragement of the midwife urging them that they can manage it) and they are really pleased afterwards that they have given birth without heavy duty analgesics.
I was certainly one of those women. I was grateful for my midwife who had faith in me that I could deliver naturally, and who supported me wonderfully.

The thing is, everyone is individual, and what one person would say is a midwife bulldozing them into opting out of pain relief, another person would say is a midwife who has been hugely encouraging and supportive.

Whatever the exact stats about epidurals leading to further interventions, the fact is, an epidural is a major medical procedure which carries some risk. That's a fact. And many women do not want to have a birth which is hugely medicalised like that.

While it's a good thing that epidurals are as reliable as possible for the women who choose them, I can't see how this latest thing is going to be massively high on the list of priorities, given all the other demands on resources.

Where I work I don't see a problem with non-effective epidurals. The odd one or two which are obviously significant for those individuals but not enough to warrant spending a lot of money on new technology.

What I do see a lot of is women been told they can't have an epidural as the ward is too busy/not enough midwives. So I think any money would be better spent increasing m/w numbers.

Some women I have had to say to them sorry you can't have an epidural as the ward is too busy. The majority of them have been happy afterwards to have managed without.

However if a woman asks for one and its safe for her to have one I'll ring the Dr to get one. Sometimes I think I should spend more time encouraging the women that they can manage a bit longer, etc. But to be honest I practise defensively these days. I figure someone can't make a complaint against me for getting them an epidural they've asked for but if afterwards they're annoyed they didn't get one then they can complain. Sometimes I get a woman one and to me it looks like she's doing fine but she's the only one who knows how close to the edge she is. If at 6cm she's asking for one then transition will tip her over the edge and it is too late then. I will ask a woman if she's sure and if she says yes then off I go.

There are midwives who when they see you ringing for an epidural or getting diamporhine out the cupboard suck their teeth and say stuff like "have you offered her a bath/tried to be more supportive/etc" I just give them the stare and tell them that the woman wants xyz and thats what I'm getting her, then stick 2 fingers up behind their backs.

Violethill you said "The thing is, everyone is individual, and what one person would say is a midwife bulldozing them into opting out of pain relief, another person would say is a midwife who has been hugely encouraging and supportive."

It is absolutely clear from what you write that having a natural birth mattered a lot to you. A thirty second conversation with you could have established that - a thirty second chat with me would have established the exact opposite.

You are right we are all different but to be honest it is not rocket science to work out how people feel about these things.

May be then, antenatally, women who want to avoid pain relief should tell the midwife that if they ask for an epidural they want to be supported to manage without. Failing that, the rest of us mean what we say.

Isn't that the solution?

Sorry - doesn't even need to be antenatally - you could communicate that when you arrive.

I don't see why either way it couldn't be in your birth plan - and discussed with birth partners so that they know when to back you up and when to help convince you that you can cope without.

I actually have it my birth plan that I do not want any health professionals to offer me an epidural. But that's because I'm at higher risk of it possibly not working because, due to a genetic hypermobility issue, local anaesthetics are ineffective for pain in me. My DH knows though that if I really can't cope and we're past the point where pethidine or diamorphine is suitable, then if I ask for remifentanil (alternative to epidural for women who are not suitable for epidural at my hospital), he is to back me up. But if I ask for an epidural, he's to ask me why as a failed epidural would be worse than nothing IME.

Ushy you obviously had a bad experience, but a more accurate way of placing epidurals wouldn't have helped one bit in your situation.

Ushy - they thing is I've seen a lot of women with very pro no drugs birth plans. They come to hospital with a 3 page birth plan using a TENS machine and asking about the pool. Its on their birth plan that they don't want an epidural, they don't want diamorphine or a managed third stage or an instrumental.

The contractions get stronger and they're struggling. I'm doing my job of being supportive and encouraging.

She says she can't do it any more (and 99.9% of women say that in labour). Goes on to say she wants an epidural.

Do I say; ok if you're sure thats what you want and you understand you'll have to be monitored and it may increase the chances of an instrumental then I'll get that sorted.

Or do I say. You're doing great you really are, you can do it, you are doing it, etc, etc.

In an idea world if I said the second it would help the woman and be the encouragement she needs. She carries on and is happy that she did it without an epidural.

In reality I'd worry that she'd manage it a bit longer, get to fully, feel distressed with the pushing and blame me. Make a complaint and sue.

I think a lot of women would be in the former group but I'm more likely to want to avoid the chances of the second scenario so I sort an epidural out. Am I doing a large proportion of women a diservice by not trying to encorage them more?