"you can't have G&A yet cos you're only 5cm"

[glovesoflove]

That's bollocks isn't it? Any midwives be able to explain if it is true?

I have had 3 births all with Gas and Air and TENS.

First turned into an emergency shoulder dystocia due to mis-management by a seriously out of depth midwife. After waiting in the day unit for 40 mins and being told by duty mw that "there is no way you are in labour as you are easily able to talk and walk" - was examined and found to be 5cm. No issues with G and A after that once got to room so although birth was a nightmare (6/7 hours later, to be fair) did at least have some good pain relief.

By far the most painful one was the second one, the only one where she was giving it the old crap about "you might be hours", "it will be ages", "save the gas and air for when you really need it" at 4cm shortly after arrival. At that point she disapeared for a "tea-break" leaving me alone with DP and absolutely no pain relief and the next we saw of her was when he pushed the emergency button 45 mins later as the head was emerging
and I realised I had inadvertently given birth in excruciating agony, screaming for the epidural I was adamant I would never have, literally begging DP to knock me out and stop the pain (baby back to back) with absolutely no bloody pain relief whatsoever despite being cm's away from a bloody G and A machine that was not switched on!!

Third time i had a lovely, caring midwife who actually let me drive the progress and took me seriously when I said it was kicking off and gave me the gas and air as soon as I arrived despite only being 2/3 cm at the time. She left it up to me as to when I started to use it, which I did when I needed to, starting slowly and building up gradually so that by the time I got to transition and crowning, I had such a good rhythm going with the gas and air and breathing and was timing it so well to peak with contraction peaks that it was actually pain free at the end - I couldn't believe it. I could feel the most violent, bone-shaking contractions as per other labours but no pain.

All of which leads me to believe that the best midwives are the ones that have the time and patience to spend with women in labour and actually listen to what they are saying about what their own bodies are telling them. They have the experience (hopefully) I know, but I think it is dangerous to make assumptions about how dilated, how long it's going to take etc. I appreciate they must encounter some women screaming at 1cm that probably need immediate epidurals but most women can be trusted to use pain relief as and when they feel the need I think.

An aside: I was actually admitted at 1cm dilated - my contractions were painful and 4 minutes apart however, and had been that way for hours.

The midwife could have gone all 'hospital policy' and sent me home until I was 4cm. But she took into account that I was already 41 weeks, my waters were bulging, baby was moving less - and that I could either continue to labour painfully at home, with no pain relief, or to do it where they could help me.

Good call: baby's CTG was bad, the two sweeps didn't work, and when they broke my waters there was meconium. Turned out the cord was wrapped around baby's neck, and had they not induced when they did, he might have been in trouble.

I wonder how often apparently disproportionate pain in early labour is an indication of things going wrong.

I had a very deep sense of unease that if I did not get effective analgesia my labour would not progress. As it turned out the epidural resulted in my contractions becoming much more coordinated and regular. I think my pain (and my associated terror) was actually inhibiting my contractions.

I was thinking that too toffeemum- for me, personally, g&a at 2cm would have been all wrong as it took another full day and then some before Dd was born- I started the g&a about 7hrs before she was born and had to ditch it for the final hour or so as it was really slowing things down. But my pain as I said was manageable with tens and baths etc etc and everything that followed was pretty textbook.

This isn't a "midwife bashing" thread - have already said that I have plenty of respect for MWs as an occupational group, I just want to know if there is ANY reason why someone at 5cm cannot have G&A. It would seem there isn't.

My contractions "changed", they stopped feeling like something that hurt but was constructive and started feeling like the bottom of my pelvis was being hit with an axe. I didn't tell the MW that because she only came into my cubicle to tell me to be quiet. It was only when a different MW (the nice one who gave me the diamorphine!) came in saying "what's all that noise?" in a friendly way and actually paid attention to how I was behaving that they discovered I was fully dilated and miraculously found me a bed on the delivery suite.

I totally appreciate that staffing levels are crap, etc, but I cannot see why I couldn't have G&A at 5cm, when I was already totally unable to walk and could only tolerate being in one or two positions. I had planned an active labour but I was in so much pain I couldn't move.

Am going to look into having my notes reviewed.

All I wanted was to be in a room with DP, no monitor, some gas and air and a reassuring midwife. That was too much to ask, it seems.

Maybe things would have been different if that had happened - instead I was woozy from diamorphine, on a public ward with people remarking loudly about the noise I was making.

From then on it was the classic cascade of intervention and an emcs. Gave birth to very ill baby, special care, the lot. I have had two more cs since.

GlovesofLove - you say the nice m/w found you to be fully and found you a bed on delivery suite? So you weren't taken to delivery suite at 5cm, that's not good? Did they say why you weren't moved - did they have no beds?

At 5cm you're in labour and should be on a partogram, so fetal heart checked every 15mins.

Where I work women on the antenatal ward should be moved to delivery once 4cm.

I agree. As i said I was "just 4 cm" with my second and he was born 45 mins later.

And when I told the mw might not be a good time to go on a tea break, is my second, this baby is coming soon trust me, she just ignored me. Should listen to what the women are saying their bodies telling them more IMO

I honestly thought the midwife on my labour ward was taking the piss when she offered a paracetamol. She wasn't of course.

I had just gone into very painful and fast labour following induction, but wasn't believed for a while as apparently I didn't 'look' like I was in labour In retrospect I think I was just too shocked by the pain to express it in a vehement enough way to be taken seriously.

But I did get G&A (and pethidine) almost straight away when taken to the delivery room at 5-6cm.

Viva I have no idea why I didn't go to delivery suite earlier. Lack of beds I assume, DP says the nice MW did apologise to him a couple of times saying I shouldn't be on the assessment ward.

When I finally did get G&A it helped a bit, but not enough hence demanding diamorphine. I was about 8cm by the time I got it I think.

Slow progression was not an issue as my waters had broken a few hours earlier, I was progressing and the local policy is that you have to deliver within a certain time.

I was just treated like I was "making a fuss" which is totally wrong IMO. I used to have a job where I hurt people, basically, and they got pain relief when they were struggling and it wasn't two paracetamol and a TENS that had ceased to help ages before!

You should absolutely be able to have gas and air at 5 cm, to deny women this is inexcusable.

I work on a ward and sometimes delivery suite is too busy to accept women who need G&A and time and again I am told to offer a bath, meptid, or 'bring her down slowly'!!

In these cases, I go to delivery suite myself and haul up the portable G&A cylinder to use on the ward.

I would also say that sometimes women having really strong, painful contractions at 2 cm are often those who will labour quickly. Their labour just seems to start off quite intense and thus goes quickly, but obviously they have to get through the 1,2,3,cm stages first. The 4cm rule is too rigid imho.

I will also say that having had 4 children myself I know that contractions are usually more intense at 8-9 cm so someone who is in agony at 2cm will invariable need an epidural somewhere along the line. And also G&A before 4cm.

Poppyella - that is interesting about the fast labour. That was my experience absolutely with a 5 hour (induced) labour from first contraction to delivery.

Once they kicked in properly (which took about an hour max from first grumblings) they were honestly as bad at the beginning as they were at the end.

I wish you had been on my ward! I got fobbed off for what seemed like ages with 'go and make yourself a nice cup of tea', then 'go and have a nice bath'. All while in active labour, as it turned out. I couldn't even stay in my hospital bed as my groans would have kept the other patients awake (it was about midnight). Utterly terrifying to be in that much pain in the face of total nonchalance and offers of bloody paracetamol. I wasn't examined (and found to be 5-6cm) until I was nearly hysterical (and I am SO not prone to hysteria).

It's a good job they didn't suggest a bath, I might have screamed the place down. I'd already had a bath at home but contractions in the bath were much more painful than on dry land.
I used up the cylinder they brought me while waiting to go to delivery suite. That meant I was left without any G&A AGAIN for ages.

There is no way on god's green earth that I will agree to a VBAC if I conceive again. DP agrees. We actually coped well at the time I think but with hindsight we were both terrified. I was convinced I and the baby would die, it was horrible.

And they checked baby's heartrate twice in six hours so not sure what good me being there did!

I was given G&A when I had my 1st internal to see how dilated I was, and it gave me instant relief from the excrutiating pain I was in at the time (can't even remember how long I'd been there by then but it was a good number of hours). I was then told not to use the G&A. I ignored that, and used it whenever I had a contraction. I was told about 3 more times to stop using it, and then the midwife dismantled the mouthpiece to stop me using it anymore. There was no discussion as to why I had to stop using it, nor was I asked how much pain I was in at the time (i had stomach problems caused by the vomitting I'd done over the previous 9 months as I had the extreme sickness - my problems extended beyond birth but it became clear that was why I was in such pain during labour). I had a total meltdown at this point, and was still left alone before the woman bringing food to the ward found me in so much distress she ran to get the midwife at that point (DP had gone for a pizza )

It always bothered me why they would refuse to let me use the G&A when it clearly helped with pain relief. I was ignored and patronised by the MW, and to then have her dismantle the mouthpiece was just cruel given the level of pain I was in at the time.

Viva - What happens if a patient has requested no VE and so you can't establish whether she's 4cm or not? Would you refuse G&A unless she consented to an exam?

Can I ask a practical question? How do they know how many cm you are? Is there a ruler on their fingers?

(too posh to push here)

Panzee - its practice. On l/w we have a wooden block that a midwife's DH made for us with all different size holes drilled in to it. As a student I spent a lot of time with my fingers in that block. But it is a bit subjective. One persons 5cm will be anothers 4cm.

Tweetinat - I've only personally known one person refuse a VE. She was either being induced or in early labour (can't remember) o nthe antenatal ward. First baby, she'd had a VE before and found it painful. She was contracting (mild to palpate) and in a lot of pain, wanted to go up to l/w, wanted drugs (can't rememebr what). Refused a VE. So I rang l/w and tried to get her there. They point blank refused to accept her unless she had a VE. I really did try and argue her case but sister on the l/w wouldn't budge. Its shit really and I know it sounds shit, we're meant to be advocates for women and come up against walls like this.

Anyway we had a compromise, she had G&A for the VE. I honestly can't remember if she was 4cm and went to l/w or if she wasn't and had to stay on antenatal.

When a multip comes in I don't always VE them, if you spend time with them (if you can) you know they're in labour and get a feeling if they're going to crack on or not. Primps are harder to assess without a VE. If someone really stuck to their guns and insisted on no Ve we'd have to give gas and air. But I would think there would be quite a bit of pressure on them to have the VE. People would mutter about possibility of obstructed labour or lack of progress that needs synto not being picked up on. Staff would honestly believe its all in the best interests of the woman but I totally get what you say about women not being "allowed" to make decisions which is wrong.

Thanks Viva! The slight difference in perception of 3 or 4 cm is the issue I have with an exact cm guideline before you can move wards/have an epidural etc.

I understand that there are lots of signs that show the woman's progress, but I guess it comes down to staffing. A quick feel will be quicker than spending time one on one.

Viva - very interesting, thanks. My hospital were very respectful of my wishes to have no VE. (No real reason other than I wanted a very 'hands off' and natural labour. I was not required to have one upon admission and was given G&A as soon as I asked for it (probably about 1hr after arrival) and DS was born about 2hrs later. I was on the ML unit though - I wonder how different and respectful they would have been if I'd have stayed on the delivery unit...

One thing to consider as well is that midwifery is a culture with widescale bullying. And I don't mean from the midwife to the woman but from midwife to midwife. Especially senior midwife to junior midwife. Its something I've seen (a lot) where I work, its something I've been on the receiving end of. Its something that's a recognised problem country wide and our unit did try a while ago to sort it out but failed (I think).

Its hard for a junior (by junior I mean authority wise not expereince wise) to go against the shift co-ordinator or really at times to argue your point to much. If you do and you piss the co-ordinator off the chances are they will also be a supervisor of midwives. Next thing you know you're on supervised practise for very suprious (sp?) reasons, then you fail your supervised practice, off to an NMC hearing where the senior midwives at your hospital gang up against you and you're struck off. I've seen it happen.

So I think when you work in a culture where there is a certain amount of fear of the power that some people can wield it is conducive to people doing what they're told for an easy life which may not be in the best interest of the women. There is also the risk that the bullying goes down the chain - more experienced midwives bully the younger ones, everyone bullies the newly qualifieds, students are shat on and the women are caught up in it.

VivaLeBeaver - I wish that were not the case about bullying, but, having worked as a doctor on ob/gyn wards, it makes sense.

The profession really needs to get it's house in order if is to prevent burnout in experienced and compassionate midwives.

Hiding behind protocols may improve the stats but it depersonalises care for women and risks problems in atypical labours being missed.