Anyone else 'tricked' out of epidural?

[liznay]

I went over my birth notes today at the 'Birth Reflections' service at my local hospital. (In order to get closure and prepare for No 2!)
To cut a long story short, My previous labour was 27 hours from start to finish although I was only admitted for the last 7 hours.

I asked for an epidural no less than 6 times during this period and was given the excuse that I needed to be 4 cm before I could get one.
Suprise, Suprise, no one would examine me to check how dilated I was and so then it became 'too late' to give me once I had reached 10 cm.
Despite Nice guidelines saying that no woman should be refused an epidural (even in the latent first stage!) apparently the hospital have their own policy.
I am SO ANGRY about this and feel that I was ignored and treated like a small child. Incidentally, the hospital are unapologetic about this and refused to say sorry about the care I received. The most that they would conceed was that they had 'somehow failed me'.
Why is this still happening to us in the 21st century? Anyone else had a similar experience? What can we do about it, and how can we prevent it happening for subsequent births? It's time that midwives stopped deciding for us how much pain relief we need and consult with us regarding how to make our births more comfortable. Not saying that all midwives are like this, but mine was a particular dragon....
I don't want this to turn into a debate on the pro's/cons of epidurals as this has been done to death elsewhere...

Having cared for lots of women with epidurals my personal experience is that epidurals do contribute to higher section rates.
yes dreadingwedding - higher risk women are often encouraged to have an epidural for various reasons, and yes, for various differing reasons they are more likely to have a section

Lots of the side effects noted all contribute - malposition of baby - how can you move baby into a good position if youre unable to mobilise.
Maternal pyrexia - what happens to mum happens to baby too - if mum has a high temp, then baby will, its heart rate will go up and it will become distressed - therefore emergency section.
Dropping blood pressure - seen it once and was very scary - emergency section as baby distressed

Also - needing contractions stimulated - oxytocin drip - baby often becomes distressed. Chance of hyperstimulation, distressing baby and causing a bradycardia (emergency section) or even a ruptured uterus(maternal and baby death potentially)

Epidurals are not a decision to be taken lighlty.
I do also think they are a God-send to those women who need one

Alimat - I have seen such emergencies too. The times where the horror of a dramatic prolonged dangerous dip in babes heartbeat, immediately following an epidural siting, still makes my blood run cold.

Someone on this thread described midwives as lazy-arsed. I can assure whoever that was, that my arse moved not at all lazily, and in fact very quickly, to maintain the safety of those mums and those babes.

""I want an epidural" means "I want and epidural"

Not getting an epidural for someone who says this IS unresponsive and unsymapthetic.

There seems to be a bit of a golf between midwives and some groups of women over this."

If you can find a way that helps midwives to know for sure that women know and understnad the pros and cons of what they are requesting without us having to explain it to them first then yes we'll agree at the first instance of asking a woman should get the epidural they are requesting.

Until then we have to go through all of their options and discuss this with them. It's our jobs on the line if not.

and its also not informed choice.

I fear many people who may have a bad outcome, would then go on to sue the hospital as they werent told that epidurals can cause forceps deliverys and 3rd tears and both faecel and urinary incontinence for the rest of their lives.....

or would they just say - well, I asked for an epidural, i wanted one,its my decision, I didnt want to hear the full facts so its my fault

The monitoring is there because an epidural can have an effect on blood pressure (a positive effect if you have hypertension) and your temperature, but neither condition is considered enough of a complication to indicate against epidurals for the vast majority of women. There is often monitoring of your contractions because the attending nurse can't necessarily tell from your facial expression or other outward signs how your contractions are going, because you're more relaxed and not feeling the worst of the pain. You are at no higher risk for anything than anyone else who has any kind of anesthesia; everyone who is anesthetised is monitored for temp and blood pressure and in the case of an operation, oxygen. All medicines come with some risk, even aspirin, nsaids, cold remedies or acetaminophen. To suggest that an epidural is the riskiest and that increased monitoring proves it is a misstatement of the situation.

The practice for hospitals in years past and for many individual doctors even now is to have women lie on their backs for the whole of labour and undergo monitoring whether they had an epidural or not. It makes access for internal exams and external exams easier. The DVT risk obviously isn't something that concerns the medical profession all that much at all. I think you're far more likely to experience DVT on a long plane trip than during labour.

Monitoring during labour is not in and of itself a bad thing. Some babies experience distress and in order to try to ensure a good outcome for all, monitoring can keep track of how the baby is doing, which can prevent unnecessary cs's. With DD1 I was monitored because there was meconium present when my eaters broke and her heartbeat was fluctuating in response to my contractions (this was hours before the epidural, when I was still in my room) and so I was already being monitored by the time I had the epidural. No harm done.

In the context of the mention of uterine rupture (a very, very rare event and not one usually associated with epidurals), monitoring is always done for a VBAC, which is the main condition associated with uterine rupture. Other circumstances associated with uterine rupture are very difficult forceps deliveries or difficult manual removal of the placenta, external cephalic version or some other issue like a car accident. The overall risk of uterine rupture is miniscule however.

90% of uterine ruptures occur at the site of a previous SC scar or a scar from any other uterine surgery. Even at this high association with presence of scars, if you're a good candidate for a VBAC, your risk of a rupture is about 1%. Again, the monitoring is there to ensure prompt action can be taken if indications are that the baby is in distress. Uterine rupture occurs in 1 out of 15,000 pregnancies. I am gobsmacked to see it referred to as some sort of routine risk associated with epidurals. It is a very, very rare occurrence even among women at high risk (and the risk factors do not include epidurals). at the scaremongering here.

'Chance of hyperstimulation, distressing baby and causing a bradycardia (emergency section) or even a ruptured uterus(maternal and baby death potentially)'
Please do not say "chance" without also stating that this "chance" is very, very slight indeed.

SC = CS'
eaters = waters

I think Alimat was referring to use of syntocinon when talking about ruptured uteruses. So perhaps more a risk of using syntocinon to augment labour because of a potential slowing of things due to the epidural rather than a direct risk related to the epidural itself.

I would think that too.

Labour frequently slows down with an epidural, hence more likely to need syntocinon and all the accompanying risks.

Yes it is hard to give all pros and cons for ANYTHING. Some aneasthetists require a consent form for an epidural. I don't blame them because of potential complaints afterwards of "I never knew it would XYZ" (trauma as detailed by above posts).

erm.....did i say it was routine...can you highlight the bit where I stated it was routine please?
Do you not want to be told of it...put your head in the sand...lalalalalalala - cant hear youuuuu.
Also - can you highlight the bit where I said an epidural was the riskiest???

When you sign your consent form for a section or any operation you are told of EVERY potential risk - generally none of which i have seen thank God. Why not for an epidural

As far as DVT risk - you are wrong - more and more women are prescribed a low molecular weight heparin following labour to prevent this. If you have read the causes for maternal death in the CEMACH report then you will already know this is the highest reason for maternal death. It is a BIG concern for the health service otherwise they wouldnt prescribe it - its very expensive and we all know the NHS wouldnt waste money on something that wasnt a 'concern'
where I work, if youre a smoker and your labour is longer than 12 hours - then youre prescribed it - its thats big a cause for concern!!!

Also thank God we are a bit more educated than just looking at the grimace on a womans face to tell how much pain she is in. bloody hell - if only it were than easy. CTG is crap at telling you about contractions - its tells us if youre having one or not - palpation of the abdomin tells us far more.
The monitoring of the contractions is for us to know what the fetal heart is doing in relation to contractions - does it decelerate during or after - how long - is it a reassuring decel or non-reassuring.
CTGs are not used lightly as they pick up ominous signs that may or may not be a cause for concern - more often than not, they are of no concern, but the only way to tell is by taking a fetal blood sample - not pleasant in labour and very worrying for parents.
There are lots of reasons why women are monitored - not just for epidural, but if possible we try not to.
Again there is lots of reseach saying how many false positives there are with CTG - ie - saying there is a problem when there is not

Im takling you are of American origin when you talk about doctors preferring you to lie on your back.
Midwives dont want you to lie on your back and be subservient. We can examine women in all sorts of positions!!

She's Irish, Alimat. Is it okay for Irish to disagree with you?

'Do you not want to be told of it...put your head in the sand..'

I already knew of it because I'm an educated, intelligent person who really doesn't need harridan healthcare providers on a power trip deciding what is best for me and my body at a time when I feel I'm in great enough pain to need epidural pain relief, which was the entire point of the OP - that women are not listened to by midwives all too often.

And your rants are pretty much proving her point.

'Midwives dont want you to lie on your back and be subservient. '

I wanted to lie on my back and have epidural pain relief. I couldn't care less if that's not what the midwife wanted, it's not about what she wants.

Is it that hard to understand, not all women experience pain the same way and some want regional pain relief?

but mathanxiety is proving she isnt educated saying things like monitoring is fine and no problem. And midwives use the 'grimace' technique to work out strenth of contractions.

..and flying on a plane is a bigger risk for DVT.

Ive just worked out what it costs the NHS to prescribe the course of heparin injections for someone who requires it for 6 weeks (alot of women) £995 per/ person. That is not done lightly

At no point ANYWHERE have i said I would refuse to get anyone an epidural if they asked me. As I said - I always phone up and if there is a problem i inform the woman.

My 'rants' are because there is so much ill-informed info on this thread that i couldnt hold back anymore.
An ill-informed woman in labour is terrible - you need all the facts - not fiction.
(Someone much higher up the thread mentioned getting an episiotomy without anaesthetic and with scissors - shock horror, not with a scalpel. Can you imagine the devastation caused by a scalpel cutting through a perineum straight onto a baby's head - that why we use scissors. And EVERY one I have done or seen , is performed with local)

If people hate midwives so much, then i suggest they look into freebirthing

I guessed she was american by using the the phrase 'individual doctors' - who deliver in USA - its midwives who examine and deliver in the UK
Also the use of acetaminophen - again an american term, im guessing she means paracetamol

and I expected her to disagree with me

Well then, it's probably best not to make such assumptions then. Canadians also use such terms.

And the poster is Irish.

'And EVERY one I have done or seen , is performed with local'

Loads of posters on here over the years who've had episiotomies with G&A only, no local.

Alimat, the risk of uterine rupture is 1 in 15,000. You are far more likely to be run over by a bus. By a bus with a specific number.

I am not running around saying lalala with my fingers in my ears. a 1 in 15,000 risk is a tiny risk.

'I fear many people who may have a bad outcome, would then go on to sue the hospital as they werent told that epidurals can cause forceps deliverys and 3rd tears and both faecel and urinary incontinence for the rest of their lives.....'

Epidurals and forceps deliveries -- likelihood please, compared to forceps deliveries without epidurals?

Forceps deliveries that cause lifelong incontinence and 3rd degree tears -- likelihood please, compared to forceps deliveries that do not have these consequences?

You are making giant leaps, huge assumptions, and conflating unrelated risks. The risks you have outlined are incredibly small and not directly related to epidural use.

and its fine if you want to lie flat on your back with an epidural - as long as you know it increases your risk of long labour, malposition, DVT and instrumental delivery.
After we have 'fully informed' you as is in our job description - you can do what you want.
If we dont do that - we would be stuck off and lose our jobs

Sometimes there just isn't the time to infiltrate with local anaesthetic and wait for it to take effect sometimes that babies heartrate is a deafening thud of less than 60bpm, sometimes we're terrified that the episiotomy isn't going to do the trick and we're going to have a dead baby on our hands. Other times midwives just get it wrong. Midwives are human. Yes we listen to our clients but sometimes it is helpful if that is a two way street.

As for lying flat on your back, great, that is what you want to do, we're trained to recognise though that particular position can impair not only the normal birthing process but venous return, leaving you feeling faint and not quite right. We have to tell you this stuff and recommend something else. If you choose not to take this advice, fine but we have to tell you. not to do so would be negligent.

then if women really have have has episiotomies without a local anaesthetic - they should complain. That is against guidelines and policies.
As i said - I have never seen one, and have never heard of one either. I do know that women are in second stage and very distressed and scared. The routine is - one contraction - use lignocaine. Next contraction cut and baby out.

Can you show me the evidence that states epidural use does not cause higher instrumental rates?

Alimat 1 - you quoted from the Cochrane review but that study was looking at epidurals as far back as the 1980s!!!!

You can't even remotely compare the lighter epidurals of today with them.

Here are some recent studies:

"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." Swedish study 2006

"Our study demonstrated no increase in the rate of operative deliveries in a population that suddenly received access to on-request labor epidurals." (Jacksonville - US)

More importantly this:

"Patients who received epidural analgesia in labour were more likely to consider their experience as favourable (85%) compared to those who went through labour without such analgesia (26%) (2007)

The basic problem I think that women attracted to midwifery as a profession tend to have very passionate views about intervention free childbirth and it means midwives being being unable to understand people like expat.

Loved your last post expat So short but so true!

this is the list of refernces used for the cochrane review

www.ncbi.nlm.nih.gov/pubmed?Db=pubmed&DbFrom=pubmed&Cmd=Link&LinkName=pubmed_pubmed&IdsFromResult=10796196

how dare anyone judge me as to what views I have on what labour 'I think women should have'
You do not know me, my history or my practice.
I said if expat wanted to lie on her back - thats fine by me. Do you not expect me to inform people of risks and benefits - just keep them in the dark?

The OP asks why she didnt get an epidural - it has been mentioned several times that anaesthetists are often busy in theatre with an emergency, yet it has turned into a 'lets hate and judge all midwives' thread

It's also worth noting that not all units use the newer 'mobile' epidurals. I know of none in my region. We still use a much heavier denser block. I guess our anaesthetists are sticking to what they know. When I hear of women walking to the toilet etc with an epidural in situ I'm amazed. In a good way. I'm sure those epidurals do have less impact on instrumental/section rates. Unfortunately as I said they are not necessarily used widely and until they are the risks that arise from epidural use will continue to be those quoted above in the cochrane review.

Monitoring is fine. What are the risks of monitoring vs. not monitoring? How many babies and mothers died before the age of monitoring, from conditions that would be detected by monitors and saved if doctors or midwives could have 'seen' what was happening and taken action in time? My great grandmother for one, and her second child.

I am educated enough to know the difference between a very tiny risk and a realistic risk, something you seem incapable of. There are risks and there are risks. On the whole, labouring on your back is not going to kill you or your baby or cause even small problems for either one of you. On the whole, walking around during labour is not going to kill you or cause problems for you or the baby. One the whole, having an epidural is not going to kill you or cause even small problems for you or your baby. On the whole, not having an epidural during labour is not going to kill you or cause harm to your baby. (It may leave you shaken to the core and at higher risk of PND later though)

It simply is not that much of a terrible, risky thing to have an epidural.

The grimace technique is something that belongs in the middle ages. My mum's cousin was a community midwife in rural Ireland many decades ago and delivered thousands of babies at home in the little farmhouses in her district. Some women were conditioned to make light of labour pains back in her day, and they may still be in certain cultures. Some women she encountered were completely unaware of what labour would be like and were hysterical when she tried monitoring them. Pain is highly subjective and physical responses to it are also highly individual. Mum's cousin 'lost' babies that could have been saved if there had been more objective monitoring, and she was a good MW, well trained, state of the art for her day. The use of objective monitoring is far more effective.

I am Irish, and delivered my babies in the US. Of the women I know who have had babies in Ireland and the UK, about half were attended by doctors for various reasons. I was attended by a MW for one delivery, actually the one with the most potential for complication due to my age at the time and gestational diabetes.

Heparin is used before general surgery for many patients who are at risk for blood clots and also for certain heart, blood vessel and lung conditions, not just for women after delivery. It's also used in NICUs to prevent clotting in IV tubes. Do you begrudge the other patients that £££ course of Heparin or whatever they need their conditions or for clot prevention? (The idea that the cost of medicine should be taken into account when deciding best practices is actually quite horrible). And how often is Heparin used after delivery, for six weeks? In half of patients? Two or three out of 10,000?

Only 1 - 2 out of every 1000 women will develop a venous thromboembolism, and the number of women who have a pulmonary embolism as a result of VTE is smaller still. Here are the risk factors for VTE during pregnancy:

• you have had a previous VTE
• you are very overweight
• you are over 35 years old
• you are immobile for long periods of time, for example after an operation
• you have pre-eclampsia
• you are recovering from a caesarean delivery
• you have another medical condition that predisposes you to thrombosis, such as active inflammatory bowel disease or some chronic kidney problems.

During pregnancy itself, blood flow to the legs is markedly reduced from about 16 weeks, with the minimum blood flow occurring at term. Pregnancy itself therefore, and not epidurals or lying on your back during labour for the sake of monitoring, often necessitates heparin use. And again, it is a very, very small proportion of the already small number of women women with VTE who will suffer a pulmonary embolism. It is a very rare occurrence therefore and not the huge problem that is bankrupting the NHS that you seem to suggest it is.

WRT uterine rupture 'can you highlight the bit where I stated it was routine please?'

You neglected to mention that the risk of uterine rupture is 1 in 15,000. You stated there was a 'chance', but didn't say what that chance was. You stated there was a 'chance' in the same sentence where other risks were casually mentioned (again without any statistics)... 'Also - needing contractions stimulated - oxytocin drip - baby often becomes distressed. Chance of hyperstimulation, distressing baby and causing a bradycardia (emergency section) or even a ruptured uterus( maternal and baby death potentially)' If you are going to mention a whole bunch of possible complications all in the one breath you need to mention the real life likelihood of all these potential risks, preferably vs. the risks of no intervention at all, and you need to mention the statistics.

Well,
I was forced to lie on my back and had my feet put in stirrups against my wishes.
I wanted to give birth kneeling upright on the bed, but this did not suit the midwife.

The reason that this has turned into a midwife bashing thread is that invidual posters have had bad experiences during THEIR births.

No one is saying that all midwives are uncaring and deeply unsympathetic to labouring womens' pains. This said though, some of the things I have read on this thread lead me to believe that my initial assumptions were right. Some Midwives are against epidurals and will do everything they can to prevent them. It's interesting that it's mainly been the midwives on this thread that have felt the need to scaremonger about epidurals, when most of us are already well aware of the (small) risks involved.

Alimat - I don't think anyone is judging you at all.

There is a real communication problem here - if grown, intelligent women posting on mw cannot get there message across how much more difficult is it going to be for people in labour?

There is a gulf between midwives and many of the general public. There was some male midwife claiming women didn't need epidurals and the internet nearly crashed with women screaming to rip his balls off:) Quite a lot of midwives were agreeing with him. (I'm not saying you would have done). There is a real problem with the midwifery profession not being on the same wave length as a lot of the women they care for. I think it is certainly in tune with the natural birth types but not everyone buys into that.

Isn't MW a good place to see if we can build some bridges and understand why that gulf exists?