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...

Oh and just to reiterate I really think a Mumsnet campaign for better staffing in maternity could be very successful and help with a lot of the issues raised in this thread.

There are many ways to cut spending, Viva. Why are labouring women seen as the easy target?

Why doesn't the NHS cut pensions / health visitors / any number of things before limiting pain relief to those in need?

We are going way off the topic here - but cuts are being implemented for other groups also - the elderly, disabled - people whose needs are every bit as important and have even less of a voice.

BiscuitNibbler Pain is sadly one of the first things cut across the board, it seems. My husband (whose conditions leaves him in severe chronic pain) was told last month that pain management groups were being cut across the country -- which is confusing as this course, just locally, has helped so many unemployed people with chronic pain conditions back into work. Sadly these are seen as 'extras' so pain care seem to be going left and right. My MIL, who has MS, is also being kept on a certain level of pain relief as the other options are more expensive. It's sad but as pain is very difficult to prove, and higher pain medication more addictive, it's seen as an easy target for cuts as they can say people are faking/milking the system or raising the bar even higher before it is available.

Dr McDreamy "It (care by a known carer) might be a good thing and most would perceive it as being so but if you get techy about it then it might reveal um something else?"

Yes, there is no doubt having a known carer is better. What we do not know is if some of these known carers ( say a nice but very pro natural birth doula) are influencing women to have less pain relief than they would otherwise have liked. We know that pressure exists - so a reasonable research study should address it.

Why? Because we know that modern epidurals are associated with higher satisfaction.

"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)

That's a huge difference in satisfaction and backs up masses of other research that shows that pain in itself can make childbirth a very traumatic experience for many women.

But then I suppose many posters on this thread will say you don't need research studies to point out the b!!*g obvious!

I think part of the problem is that there isn't a sustained voice from individuals. Pregnant/labouring women are seen as an easy target because health chiefs know that a woman is only going to be in labour once ot trice on average in her life. So they probably think they can get away with it as women will complain but can easily be convinced (most of the time) that it was a one off, things will change, etc, etc.

Wheras someone with a chronic condition or who is in and aout of hospital every month for years will keep on and on at them. Plus women will often think its too late too complain once their labour is over and done with. They're too busy with a new baby, don't think it will benefit them, don't complain.

Plus its a patriarchal society and hospital chiefs are in the main men.

Vivalebeaver Your are so right BUT the crap standards of maternity care are leding to billions (not millions billions) being wasted on litigation. Maternity has the highest rate.

It makes no sense - better care,better training and more staffing of all types - midwives, anaesthestists, consultants - would dramatically cut the bill and not cost anyone a penny.

Yes but the powers that be aren't that long sighted. They just want to see how they can save money that financial year. Plus because of CNST each hospital doesn't pay its own litigation costs - it comes out a national pot/insurance scheme.

That may change though vivalebeaver because the health service is having a big shake up and I understand there are moves afoot to make hospitals more accountable.

Watch that space:)

ushy you make some very valid points - I think the emotional and mental cost of a mother not having pain relief when she desperately wants it are hugely underestimated. That's what happens when mothers are seen not as human beings but simply as baby incubators.

And if we are talking cost and resources - a hospital's relationship with mother and baby tends to stop when they walk out of the door (unless there's litigation, ironically), and that balance sheet is closed - but the costs of a traumatic birth are paid elsewhere. Literally, in terms of post-birth physical and mental care in the NHS, but also in terms of the quality of relationship a new mother has with her baby and partner, and in her quality of LIFE.

And I agree, the general problem is not just staffing, but attitudes and training. I remember the argument about making women pay for epidurals. Again, injured drunks get treated for free, but labouring women in intolerable pain have their pain relief relegated to the category of 'paid-for-luxury?' Insane, vicious, woman-hating nonsense.

Not just litigation. There are other costs like the cost of PND, and the cost of PTSD, and they can be reckoned both in financial terms and in human terms.

Ushy - "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)

Sorry, where does this come from?

Its the latest study on epidural analgesia and satisfaction undertaken. pubmed: PMID: 17548909
Good points gloyw and mathanxiety

And this is the Australian study -sorry can't find the pubmed on this at the mo but here is the news report:

"Having an epidural during labour may protect key muscles and therefore cut the risk of incontinence in later life, a study of nearly 400 women suggests.
Research in the BJOG, the leading obstetrics journal, found more than one in ten women who had vaginal births suffered damage to the "levator" muscles which hold up internal organs.
A third of those who had a forceps delivery suffered some muscle trauma.
But overall women who had the spinal analgesia ran a lower risk of damage.
"

Mistyvalley quote" But forums such as these are also valid and reach a wide audience.

I'm never going to join a group to become a 'user representative', for several reasons.

1. "Firstly, I don't even live in the area any more."

Valid point, but you could write a letter to the service explaining good points and highlighting areas that you feel need improving. You should get a letter back as they will need to investigate any complaint. CHECK

1. "Straight after the birth I was just grateful to have a baby at all, I wasn't interested in complaining about how she got here."

And that is how many women feel, glad to have survived and grateful that they have a healthy baby. However, if you don't let the service know that ley are letting women down, they will continue to do things in the same way for other women who are engaging in or coming in to the service.

1. Thirdly, I knew remarkably little about the politics and procedures of childbirth, and thought my experience, though horrendous in parts, was pretty normal (which, sadly, it probably is).

If you begin to bring your concerns to the table, then you will learn the politics and procedures of how the system works. ; ) Going to MLSC meetings is a starting point. The MSLC is there to hear women's views as service users and get a feel for what women want.

To DrD et al, who keep mentioning that the 'NHS is not a bottomless pit' - well true, and indeed spending on the NHS as a proportion of GDP is indeed rather less than in the country where I now reside (and, like France, where epis are the norm and gas and air seen as medieval). But why then, can the NHS afford to pay its doctors far more than all these other European countries? Why does the NHS offer third world maternity and childbirth care whilst having doctors' salaries second only to the USA (where medicine is a graduate degree - ie you already need to have paid for a first degree)? I'm sure that, if they paid average EU level doctors salaries they could afford a rather better level of pain relief, and spare you from the effort of dictating deciding who 'safely' gets pain relief. thank god I'm in a country with more patient choice.

Ushy - So 85% who have an epidural are satisfied compared with the 26% who don't. That looks like overwheming satisfaction. I have looked this reference up and it's not quite so cut and dried as you would make out.

Quoting directly from the source you give:
^RESULTS: A total of 2109 and 2851 patients completed the antenatal and postnatal survey, respectively. The former revealed that only 47% of patients had been exposed to the concept of epidural analgesia in labour, and only 13% opted for such analgesia. In the postnatal cohort, the overall epidural analgesia rate was 10%, although 19% had actually requested it. 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%) [P

Margles as long as the sample size was adequate for the study design, the results still hold. The "p value" is extremely good showing that this finding is robust. That said, I have not read the study (and have not time to do so), so do not know whether the sample size is adequate and whether the stats used were appropriate.

cardamomginger the 'p' value is significant. But you can't judge the whole study on the basis of that value alone. The 'p' value doesn't indicate the importance of the effect under observation, and it cannot be judged as evidence against the null hypothesis. It must be seen in the context of all the other evidence gathered.

A sample size of 2851, as quoted above, sounds good. But what is the confidence interval? What was the control? Were confounding factors identified? Was there a control arm?

agreed! and as I said I haven't read it!

"That's a huge difference in satisfaction and backs up masses of other research that shows that pain in itself can make childbirth a very traumatic experience for many women."

How do we reconcile this with the fact that women are more likely to say that they had a good birth experience if they book to give birth in settings where epidurals are not available? (ie, home and birth centre).

Actually as a group women who book to give birth at home have the best psychological outcomes than women who give birth in hospital, where ever they eventually have their babies, despite the fact that the only pain relief they generally have access to is entonox.

Would also want to say that if women give birth under circumstances that make normal coping strategies (and normal labour) difficult- ie, where there are high rates of induction, high rates of augmentation, high rates of CEFM and high rates of intervention, then you are BOUND to find that many will find epidurals will improve the quality of their birth experience.

The real test would be to compare satisfaction rates for low risk women labouring with elective epidurals, with satisfaction rates for women labouring under optimal conditions - ie, with one to one care from a named midwife, freedom of movement, a good birth environment and access to a birth pool.

A sample size of 2851, as quoted above, sounds good. But what is the confidence interval? What was the control? Were confounding factors identified? Was there a control arm?"

And more to the point - what do any of us know about the maternity services in Hong Kong as this is the most important consideration when trying to work out how the findings of this study would apply to UK mothers.

Here's a link to some new findings from research in the USA into Electronic Fetal Monitoring.

www.biosciencetechnology.com/News/Feeds/2011/02/products-chemicals-and-reagents-study-finds-that-electronic-fetal-heart-rate-monit/

So (I'm very much paraphrasing now, but this is based on the most recent Cochrane reviews, and is the best evidence we have) what we know to date is that EFM is not a good idea for low risk women - it is directly attributable to an increase in c/section rates. EFM is useful in high risk women, and is associated with a reduction in neonatal seizures.

What the evidence from this study would suggest is that EFM is associated with significantly improved fetal outcomes for all the study group, and states " The study demonstrates that the use of EFM decreased early neonatal mortality by 53%."
Without having access to the whole published study it's impossible to critique it fully, but this is revolutionary stuff - it certainly goes against current obstetric and midwifery thinking. I'd be sad to see continuous EFM being adopted because it represents significant medicalisation of childbirth, but I'd also be the first to accept changes to recommended practice if they can demonstrably improve outcomes.

(Having said that, a decrease of 53% seems really unlikely! EFM has been commonplace for so long now without demonstrating anything like that kind of effect, so the study's authors will need to have some kind of robust, because their findings will be scrutinised by far greater minds than mine, that's for sure)

I'm trying to make a point that I'll accept any evidence if it's robust. Obstetric and midwifery knowledge is a fluid and evolving process, and its practitioners need to be equally flexible.

I'm really sorry that some people on this thread have had such bad experiences. I'm sorry that so many have such a negative view of midwives. I hope that those who want change in service provision find a way to get the change that they want - but I also fear that such change could result in a far more paternalistic and less woman-centred form of maternity care than exists at present.

What we have is obviously not working for a significant number of people. I hope that ye can find a coherent vision of what would work.

Cleo You asked an important question regarding how can it be that women who have epidurals such high satisfaction rates if women who give birth at home or birth centres appear to have such high satisfaction rates when there is no epidurals available?

Well, surprise surprise that's been looked at as well! (The following is a conflation of about eight different studies)

Firstly, home birth does have high satisfaction rates. Birth centres only have high satisfaction IF the woman succeeds in giving birth there. Those that have to transfer in labour have the lowest satisfaction of any group.

Women who choose home birth are very motivated to give birth with minimum interventions and they see birth as a huge personal achievement. If you like, they have a different beliefs system to women who choose to go to hospitals who tend to be more safety focused. (You'll find many midwives and natural birth antenatal teachers hold this belief system). When homebirth women succeed, they have huge personal satisfaction but the downside is they are much more traumatised if they need a caesarean or instrumental delivery.

The key conclusion is this: women have best outcomes when you respect their personal choices

Once again, extensive academic research concludes the blindingly obvious

Sorry, missed something!

The overwhelming majority of women - given a free choice - will choose to give birth in a hospital where there are doctors on hand if things go wrong and theoretically available epidurals. They are a bigger group than the homebirth and birth centre groups.

Consequesntly, pain relief is something they want to be available. When it is they are pleased and when it's not - as you can see from this thread - they are quite rightly very angry because their expectation and needs were not met.