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.

Sorry, I can spell. Keyboard is crap.

I wonder how many women look back and regret having an epidural - most say they were so grateful for it they would have married the person administering it!
The article states that "midwives revealed that expectant mothers are increasingly demanding a surgical birth second time around because their first birth was so traumatic they have been left afraid to give birth naturally". Some units have seen the requests for c sections rising by 40% in the last year alone. Some Mothers are so traumatised that they put off or abandon plans to have more children.
Surely investing in an ultrasound to guide the anaesthetist must be a sound financial decision weighed against the cost of the inceasing number of c sections? Let alone the number of women so distressed by their births that they require psyclogical help afterwards (how much does that cost?)which also affects their bonding with their baby.

VivaLeeBeaver that's a good question! My thoughts:

Firstly, for women like me - there's no problem because I didn't want to avoid an epidural so why some midwives try to talk those of us who know exactly what they want out of our choice is a mystery. I know you're not one of them but as you said - they are out there :)

For women who do want to avoid an epidural and genuinely change their mind, isn't there an issue about the quality of antenatal information they are getting about how painful labour is? So shouldn't they be told exactly what you said in your post and be asked what they want you to do if they genuinely change their mind? And then record it in the notes to cover yourself if it leads to a complaint.

I can see the problem but people have to take responsibility for the decisions they make.

I don't think, though, the default position can ever be that you ignore the requests women make.

I think its difficult to accuratly describe/get over how painful labour is. And of course its so different for so many people. One of my friends says she doesn't know what the fuss is about - likens childbirth to having a big poo!

There are women who genuinely have changed their minds and want an epidural and those who as a way of getting through it/coping with it are nearly chanting "I can't do it, I can't do it, I want an epidural, I can't do it". But they don't mean it. I like to think I can tell the difference. Generally when a woman really does want one she makes it clear.

I would rather that after the birth a woman think "I wish I hadn't asked for an epidural, I wonder if I could have managed without". Not ideal but better than been traumatised because a m/w didn't take her seriosly and get one.

And I do know what you mean about midwives who want to talk a woman out of epidurals or pethidine. I think they think they have the woman's best interest at heart but midwives should remember that what the research says is statistically likely to give the "best" outcome is not always the best for that individual. For some/many women an epidural and a foceps/ventouse is a better option than a gas and air non-instrumental birth.

You're right, women do have to take responsibility for their decisions. Its my job to make sure they're informed decisions and support women in their decisions.

Gailforce sorry - posts crossed - did not mean to ignore you!

I totally agree with you.

viva you give the impression that by avoiding an epidural a woman will be guarenteed to avoid an instrumental delivery - is that true?
I seem to recall on MN women having to have a forceps delivery without any pain relief?

Sorry, don't mean to give that impression at all and its not true. However there is research that shows having an epidural increases your risk of having an instrumental.

"I wonder how many women look back and regret having an epidural"

I've seen research which says that women tend to be very loyal to their birth choices - whatever they are.....

But there are people on here who had an epidural who feel substandard or unsympathetic care in labour contributed to their decision to have one - they felt cornered into it. Not in the sense that it was forcefully suggested or that they were coerced into it, but that emotional or physical support to help them cope with a challenging labour was lacking. I'd certainly put myself in that category with my first baby.

"The article states that "midwives revealed that expectant mothers are increasingly demanding a surgical birth second time around because their first birth was so traumatic they have been left afraid to give birth naturally".

But you could also argue that promoting home births, increasing number of beds in midwife led units, having more provision for waterbirths, having more midwives on duty, more caseloading, and reducing the number of inductions would achieve the same thing - a reduction in both the number of c-sections and the number of women dissatisfied and traumatised by their labours.

"Surely investing in an ultrasound to guide the anaesthetist must be a sound financial decision weighed against the cost of the inceasing number of c sections?"

But if 8 or 9 women out of every ten who have an epidural already get very good or total pain relief, how much of a difference is it going to make?

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).

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.

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.

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

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.

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!

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!

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.

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.

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!

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

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.

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' :)

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?

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.

births not borths, obviously

"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.