Anyone else 'tricked' out of epidural? (part 2)

[Chynah]

For those that feel the discussion still had some way to go........... please continue.....

gloyw that is correct but I was responding to an earlier post that intimated that with an epidural there is Nothing that crosses the placenta, unlike pethadine. Just double checked, it was your post. I'm not saying in terms of effect on the respiratory system of the neonate pethidine and epidural are on par with each other but neither is an epidural completely without risks in that area either.

Did mr bogod answer any of the questions re the effect of an epidural on oxytocin production? I know he didn't respond to my question about his knowledge of normal birth and the effect an epidural can have on this process.

DrMcDreamy - yes, David Bogod did answer a question about the effects of an epidural on oxytocin production. Here: -

StarlightMcKenzie asked: -

"Could you tell me please anything about the effects of epidural anaesthsia on the birth hormone oxytocin and any implications this may have for the baby or mother post-birth."

David Bogod replied [full answer]: -

"StarlightMcKenzie. Oxytocin levels aren't affected by epidurals. Because of this, epidurals have no effect on the duration of the first stage of labour (although they may prolong the second stage, probably by an impact on the relaxation of the pelvic floor muscles). There is also no evidence at all that they interfere with breast milk production or the ability to breast feed, despite a widely-quoted but truly awful Australian study which suggested otherwise."

Re: epidurals v pethidine - I apologise if I gave the impression that nothing at all from an epidural crosses the placenta. I genuinely don't want to contribute to any more misinformation about epidurals or anything to do with birth. My understanding is (in a rare agreement with cleofartra), and I will use her words - "opioids given intramuscularly will be more harmful to the baby because they go through in much larger amounts."

David Bogod said this in response to a question about the effects of epidural drugs on babies : -

"Yes, epidural doses of fentanyl over 100 micrograms do have an effect on the baby. In practice, doses of this level aren't often used. Even if they are, the effects of pethidine or diamorphine in sedating the baby are many times greater and last considerably longer."

I haven't seen midwives being shot down in flames for lying on this thread. If you are a midwife and you listen to patients and respond to their request for an epidural, then that is fine - as they say, if the shoe doesn't fit, don't wear it. If you have tried to secure an epidural but couldn't because you are understaffed, then you are not at fault - although don't expect women to be impressed with that situation, even though it is not your fault.

But there are also a number of midwives who have posted and said they will not let a woman have an epidural in transition, or when she is ready to push, or more generally who are still scaremongering about the so-called dangers of epidurals. And that is where the issue lies. Why do midwives spread falsities about epidurals? How come they do not know about the actual science and meta analysis? And why do they not try and change the system from the inside to make epidurals more widely available?

This is how my antenatal appointment yesterday went where I tried to discuss my birthplan with a midwife. The chat went like this:

Me: I will want an epidural.

Midwife: Oh, but they lead to more c-sections you know?

Me: No they don't, the Cochrane review is very clear on this.

Midwife: well, they do cause a cascade of complications.

Me: actually no, there is no causal link established, merely a correlation which is not at all the same.

Midwife: well, it will slow down your labour.

Me: that's fine by me, I'd rather have a longer but less painful labour than be in excruciating pain. I would actually prefer to have the epi early on, because my first labour was not very long and I'm concerned otherwise there won't be time.

Midwife: okay, but the NICE guidelines say you cannot get one until you are at least 4 cm dilated.

Me: not true, the NICE guidelines say the exact opposite - that a woman should not be denied an epidural in the latent first stage if her pain is severe.

Midwife: okay then, anyway your baby has no rights until it's born, you can do whatever you want, your body your choice, if you want an epidural then get one.

Me: speechless at the innuendo that having an epidural will actually harm my baby

Midwife: but I should warn you we will not let you in a delivery room until you are at least 4 cm dilated, therefore there is no way you can have an epidural before then.

Me: so when you say it's my choice, it's not much of a choice is it?

Midwife: well you can always go to a different hospital if you're not happy.

Me: funny you should say that, I asked to be transferred to another hospital last time when I was told I couldn't get an epidural as all the delivery bays were full and was told it is against hospital policy to transfer patients.

Midwife: that's correct, we never transfer anyone out on the basis that we are unable to give them pain relief. But you could have walked out on your own.

(So basically I should have started traipsing around London looking for a hospital while contracting every two minutes. How very caring. How very "with woman".)

This is when I gave up and asked to have an appointment with the head of midwifery. Not that I have much faith it will get me anywhere - I've pretty much made my peace with the fact that I will be denied pain relief again because the anti-epidural sentiment is institutional and sadly, that is not something I can change on my own. But it does make me angry, and scared, and I can't see how this will help me or anyone about to give birth.

By the by, I would quite like to see some evidence that epidurals make it more difficult to bond with your baby, as I think was suggested by Cleofartra (?). Is it actually your thinking that Italian, French, Canadian mothers have less of a bond with their babies because they have access to pain relief? I would highly question that.

"Also no one of the people I know that had an epidural in other countries had issues like slowing labor or increasing the chances of assisted delivery (also because forceps are only left in UK, the rest of the civilized world has banned them!)."

What in heavens' name are you talking about? It completely untrue that forceps are only used in the UK. And just because your friends didn't have instrumental deliveries doesn't mean there is no link between epidural and increased need for ventouse of forceps. This is the most widely acknowledged downside to epidurals!

Primafacie - I think your post absolutely sums up the problem. Yes in theory we have a choice, but in reality, we are lucky if we get what we want, and are often bullied and made to feel bad for wanting it.

You know, if that midwife were asked to report that conversation back, she could (rightly) have said 'well the mother wanted an epidural, and I she could have one (after 4cm, of course)'. Which would be a very different account to yours...

Another part of the problem is that if you haven't had a baby before, you don't feel you are in much of a position to insist on what you want, and tend to believe the midwife as she is the professional. With hindsight I wouldn't have been so accepting of 'the system' (not that it would necessarily have been easy to do otherwise).

"Oxytocin levels aren't affected by epidurals"

So why do most women who have epidurals also have syntocinon then?

"Entirely agree but that is why we have meta-analysis - summaries of multiple studies to give a consensus view".

Yes, this is true. Hence this meta analysis from the respected Cochrane Index on the outcomes associated with epidurals will be interesting to many people.

"Epidurals for pain relief in labour
Epidurals are widely used for pain relief in labour. There are various types, but all involve an injection into the lower back. The review of trials showed that epidurals relieve pain better than other types of pain medication, but they can lead to more use of instruments to assist with the birth. There was no difference in caesarean delivery rates, long-term backache, or effects on the baby soon after birth. However, women who used epidurals were more likely to have a longer second stage of labour, need their labour contractions stimulated, experience very low blood pressure, be unable to move for a period of time after the birth, have problems passing urine, and suffer fever. Further research on reducing the adverse outcomes with epidurals would be helpful".

Worth noting:

"all but one study compared epidural analgesia with opiates"

"I really enjoyed the web chat. I'm italian originally and no one of my friends who had a natural birth in Italy have done so without epidural.... "

Or an episiotomy I should imagine, given that the rate over there is 4 times what it is in the UK.

j"you actually get the anaesthetist AND you care for the women in a way that does not lead to complications that fulfill your beliefs. i.e. do not use constant electronic monitoring"

Do you think it's SAFE to provide an epidural and not continuously monitor the mother?

"There are other women for whom managing or avoiding intense pain is what makes their birth a satisfactory experience.

And that's FINE too. Surely"

Err, yes!

Have I said anything to suggest I DON'T think that different women have different needs and priorities in labour?

Because you keep flogging this point every time you respond to my posts, despite the fact that I've not said anything to imply that I think all women's needs and desires in labour are the same.

(though I appreciate it's much easier to construct a vigorous argument in support of your point if you put up 'straw-man' arguments to suggest that the other person is being completely unreasonable.... )

Cleofartra - your posts do seem to indicate though that you think epidurals are a Bad Thing, and as such they should be argued against wherever possible? Or have I misunderstood you?

Cleo You have quoted the Cochrane Review and it is absolutely true that more women who have epidurals will have instrumental deliveries. That does not mean instrumental deliveries are the cause - women in more pain with longer labours tend to have more complicated labours.

NICE acknowledges this: "epidurals are associated with a longer second stage of labour and an increase in instrumental birth although this affect could be due to the package of care currently practised"

NICE acknowledged this because numerous international studies do not show any link between instrumental deliveries but the UK ones do. Why? As David Bogod said, women are told to stay on the bed, are constantly monitored with EFM (electronic fetal monitoring) and both these are independent risk factors for instrumental delivery. Midwives also encourage women to delay epidurals - to see if they can 'cope'. This again increases the risk of instrumental delivery. Moreover it is drummed into women that they are MUCH more likely to have an instrumental and of course this has a psychological effect. In countries where none of this happens there is no difference in instrumental rates.

I think Primafacie's post is such a revealing one - this is exactly the sort of thing we are complaining about.

Clearly there are some midwives who are not going to change their view. We are all entitled to hold different opinions. The difficulty is that midwives are in a position of power and when they impose THEIR views on those who do not share them they are not supporting women they are abusing them.

OOps - mant epdiurals are the cause

Aargh - meant epidurals are the cause! Third time lucky

"your posts do seem to indicate though that you think epidurals are a Bad Thing"

Not at all!

I think epidurals are a blessing to women because there is now vastly less reason to fear a really difficult labour.

"I think epidurals are a blessing to women because there is now vastly less reason to fear a really difficult labour."

As long as you actually get one, that is, and are not flatly denied one, fobbed off, or bullied out of one, etc, etc,

True.

Sigh. cleofartra...

I'm sure if people read this thread, and the other (if they have the strength), they will be able to see where I, and others, have taken issue with what you've said.

Again, I do recommend people read the David Bogod chat.

"That does not mean instrumental deliveries are the cause - women in more pain with longer labours tend to have more complicated labours."

I've acknowledged this elsewhere on mumsnet on more than one occasion.

It also means that there is no proof that there ISN'T a cause and effect relationship between epidural and assisted delivery. The research comparing outcomes for uncomplicated deliveries with and without epidurals is pretty much impossible to produce.

But we don't worry too much about these things so much when it comes to other risk issues. We don't know what causes SIDS but we know there's a strong association with prone sleeping. Therefore most mothers sleep their newborn babies on their backs.

We don't understand know HOW or IF epidurals cause problems in the second stage of labour, but we do know there is a very high likelihood (for first time mums anyway) that if you have one you'll also have an assisted delivery.

Which is why most women don't want one!

Would also like to add - we also know that if you put low risk first time mums in a setting for birth where access to epidurals is problematic (ie, at home) they're vastly more likely to have a normal delivery than similar women labouring in environments where epidurals are easier to access. And that's factoring in all the women who book a homebirth but end up transferring because of complications. (ie including the transfers in the outcomes for the homebirth arm of these trials).

To me that suggests that opting for a low technology environment is more likely to result in a healthy, spontaneous birth for low risk women as a group.

Cleo, what do you call a "very high likelihood" that epis lead to an assisted delivery? I would like to see the figures for that.

And when you say that this is "why most women don't want one!", what is this based on?

Clearly for you, there is intrinsic value in not being tinkered with - not having CFM, not having an episiotomy, not having labour augmentation, not having a catheter, not having forceps/ventouse. Because of that, you think a low tech environment (i.e. home birth) is more likely to deliver a good result. That is all fine if that's what you want. Other women, however, do not see the stuff listed above as major issues. I am one of them. I don't have a problem with the medicalisation of birth. I have a problem with excessive pain. I think the health system should cater for me too. Do you agree?

Primafacie good post - exactly what we are all trying to say. We're all different and want different things so what is so hugely difficult about understanding that

Cleo you said ?we also know that if you put low risk first time mums in a setting for birth where access to epidurals is problematic (ie, at home) they're vastly more likely to have a normal delivery than similar women labouring in environments where epidurals are easier to access.?

Women are not usually ?put? in low risk settings ? they choose to go. And they tend to have different attitudes to birth compared with women who go to consultant units. Birth centre women,for instance, value low interventions and natural birth, consultant unit women value things like epidurals and not having to transfer. Have a read of this study by Longworth ?Investigating women's preferences for intrapartum care: home versus hospital births.

The problem with birth centres is that the summation of all the research data shows more babies die and in the only study looking at serious morbidity, that was also much higher. That is why a huge national study was commissioned as a matter of urgency ? it still has not reported.

I do agree about homebirth but ONLY for women who want it. Like epidurals - ONLY for women who want them. Doh...can't we just agree on that Cleo

Ushy: I don't agree that all women choose a CLU. The government was supposed putting the option to have a home birth/MLU/CLU birth in place by the end of 2009. Guess what? It didn't happen, so many women go to the CLU because they are not aware that there is an alternative.

Bue, correct! forceps is not used in italy, France and Germany, it is only restricted to some life and death cases where specially the life of the mother is at risk. Most hospital these days' don't even have one.

I am pretty sure there is no slow down of labor because having spent half of my pregnancy in italy, I have asked my doctor there and he said that that was not the case. Also my cousin is an anesthetist in Italy and she confirms that.

Again, as my UK NHS OB GYN and David B in the web chat confirmed, the correlation between epidurals and assisted delivery and/or c section rates appears to be mostly due to the UK NHS medical protocols which allows epidurals only for already difficult cases of labor.

It makes a lot of sense that in other countries where epidurals are commonly administered to everyone, this correlation is not significant.

c section rate in Italy is much higher than in UK, hence I assume that's how they deal with difficult cases.
I would have a c section 1000 times over a forceps delivery (having had a family member brain damaged by this in the 70s when it was still widely used)... which I find an extremely barbarian (and sadly cost saving) practice.

"Cleo, what do you call a "very high likelihood" that epis lead to an assisted delivery?"

No - not 'lead to'.

'Associated with'.

"there is intrinsic value in not being tinkered with - not having CFM, not having an episiotomy, not having labour augmentation, not having a catheter, not having forceps/ventouse"

Well I'd argue that for ALL women the ONLY value of having CFM, episiotomy, syntocinon, a catheter, or forceps/ventouse would be to improve the likelihood of a safe birth for you and your baby surely?

What other value might they have?

"you think a low tech environment (i.e. home birth) is more likely to deliver a good result"

Well - in the sense of delivering a healthy baby with a good apgar score, and a mother with her abdomen and her perineum intact, and with very low rates of PND and PTSD - yes. Homebirth is associated iwth 'good' results.

"I don't have a problem with the medicalisation of birth. I have a problem with excessive pain. I think the health system should cater for me too. Do you agree?"

I agree. And luckily for you it (mostly) does cater for women who prioritise pain relief over having an intact perineum.

Sadly, it caters far less well for women who want births without a lot of interference, who tend to need one to one care in order to achieve this.

The way we things are now, the only way to guarantee one to one care is to pay for an independent midwife, book with a case-loading practice, or have an epidural. Shame really.

Re: assisted delivery rate for primips with an epidural - will hunt the study down. It was in MIDIRS journal last year. Big, big Australian study.

(other interesting thing in this study - found a 70% c/s rate in primiparous women having induced labours with an epidural......)

"We're all different and want different things so what is so hugely difficult about understanding that"

Nothing difficult. We all understand that.

And it'd be nice to hear voices raised in support of changes in maternity care which would help the majority of mums who at present DON'T want an epidural to achieve the birth that THEY want too. An increase in the number of midwives and the availability of continuous care and case loading would (from what we know) have a positive impact on EVERYONE's experience of birth. Fewer women would opt for epidurals (because we know that one to one care and care from a known midwife is associated with fewer requests for epidurals), and fewer women would end up needing c/s. That would mean that women who do request an epidural would be more likely to get one, because the over all need for medical care in labour would be reduced, freeing up anaesthetists to provide pain relief for labouring mothers.

And I've found this thread very frustrating in that IMO there's not been much acknowledgement that there's anything more than individual factors involved in mothers' need for pain relief. My case is that institutional factors make a HUGE difference to women's experience of labour and their ability to cope with pain. That's totally relevent in this country where the majority of mothers choose an epidural in response to the events of labour, rather than planning elective epidurals.

Re: the safety of out of hospital birth settings - I'm happy to take my advice on this from the RCOG and the RCM. There is no consistent, good quality research showing that birth away from hospital is less safe for babies, and plenty of research showing it to be safer for mothers.

www.bbc.co.uk/news/health-11071881

quoting studies that found epidurals have actually a positive impact on labor

"...But overall, those who had opted for an epidural, the spinal analgesia which blocks out some or all of the pain of contractions, had a lower risk of [pelvic floor] damage than those who had none.

Two-thirds of the women who suffered damage had no epidural.

The researchers, led by Dr Clara Shek, speculated there may be two reasons for this. Firstly, women who have epidurals tend to be told when to push as they can no longer feel contractions This means the potential damage from premature or over-pushing is reduced."