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

[Chynah]

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

Cleo, point taken on leads to vs associated with - I had misread your post. Apologies.

"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?"

No intrinsic value for me. But if they are the price to pay in order to get pain relief, and they are safe for the baby, that is a trade off I am willing to make.

This means my starting position is NOT that I don't want syntocinon, CFM, etc. My starting position is that I don't want to labour without pain relief.

You say the system mostly caters to women who want pain relief, however can we agree the system fails a lot of us still? I think on the other thread we said 24% of women are not receiving the pain relief they want? Can we agree this failure rate is much too high?

You say you'd like to hear voices raised to argue for more midwives. I can see the logic in your argument. The problem is that a lot of women here feel they were let down by midwives, so they are unlikely to think that more midwives is the solution to their problem. :)

Would you conversely raise your voice to campaign for midwives to be taught and to tell the truth about epidurals, and to make them more easily available?

I think part of the problem is that midwives are being viewed as a collective. I don't think anyone is denying that there are a few crap midwives out there who should be in a different job or retired. Of course there are, the same as every profession. However that doesn't mean that as a whole midwives are useless and liars and uneducated, which I've got to be honest is the vibe I'm getting from this thread. What we need is more good midwives, midwives who listen and who are able to do their job to the best of their ability in conjunction with the woman. Unfortunately I think some posters have had such terrible experiences they don't believe there are midwives like this out there and thus tar the entire the entire profession with the same brush.

we do tell the truth - we talk about risk factors, however small, we MUST talk about it.
People dont seem to want to hear it though.

amazingly - we are taught about it.

"can we agree the system fails a lot of us still? I think on the other thread we said 24% of women are not receiving the pain relief they want? Can we agree this failure rate is much too high?"

Yes. The system is failing too many of us.

But regarding the 24% of women who don't get the pain relief they requested - I do think it's important to know how much of this is down to pain relief being ineffectual for some women, and also how much of it is down to problems with providing the one to one care necessary for women who've had an epidural with current staffing levels, and how much is down to midwives not honouring women's choices in labour. Many of the voices on this thread are suggesting that the problem of inadequate pain relief is primarily the responsibility of midwives who are manipulating and bullying mothers into having births without analgesia. I personally don't support this view as it doesn't fit with my experience or my knowledge of the way most midwives practice.

"Would you conversely raise your voice to campaign for midwives to be taught and to tell the truth about epidurals"

There will always be a debate about what constitutes 'the truth' when it comes to medical practice. This is particularly true of obstetric practice as labour is so complex and varied. I definitely think midwives have a responsibility to give women up to date, and evidence-based information about pain relief, that focuses on more than just the very narrow range of outcomes we have at the moment. From my POV the best current patient information we have on epidurals is produced by MIDIRS in conjunction with the RCOG - it's fully referenced and includes only good quality, peer reviewed studies.

Here:
InformedChoice

"and to make them more easily available?"

No, I wouldn't campaign to have epidurals made more easily available without a corresponding large increase in the number of midwives working in the NHS. The reason for this is because I believe epidurals can turn a low-risk labour into a high-risk labour (hence the need for CTG and one to one care), and that more high-risk labours in the NHS with current staffing levels would put women and babies in danger.

I found Primafacie dialog with her midwife utterly shocking....
don 't you?

Again - regarding latent stage and epidural
We probably have around 10 or 20 women each day attending the unit in latent stage of labour.
Often we will give them oral analgesia and suggestions for coping, and then go home, sometimes not returning for 2 or 3 days!

If we were to even give half of them epidural - where would people then go to deliver who came in established labour - if our delivery rooms were full with women having an epidural, not established in labour, having one to one care.
People would then end up delivering in the corridors and in hallways, as there would be no room at the inn.
And certainly no midwives to care for them

DrMcDreamy, I do see your point, I really do. If I may -

Yes, the 'few bad apples' argument applies to every single profession, midwifery no more than any other.

However, I think there is another point being made here in some posts, which is what happens when MWs with a very specific birth philosophy and practice is in conflict with what an individual mother feels is best for her.

It's not an easy thing to articulate, and I don't want you to feel personally 'got at' here - but primafacie's post further downthread about her meeting yesterday with a MW illustrates it to some degree.

If you have a MW who sees it as her job to get you through labour with minimal anaesthesia, and to discourage you from having an epidural, but what you want is someone who will organise one for you, if YOU decide you need one, then you really do have a problem. Midwives are the gatekeepers to pain control for labouring women. That relationship has got to work.

I appreciate that some posters (MWs and trainee doulas) say that if women were better supported, then they wouldn't need as much anaesthesia - that they would cope better with the pain, etc.

Okay - but there are still women who want to rely on anaesthesia, or know it is easily available if needed. Or who are happy to try breathing, visualisation, positioning, massage etc as part of a birth which also includes more clinical anaesthesia.

I do think too (and it has cropped up on these threads) that women simply aren't being given an accurate picture of the risks and benefits of epidurals by MWs at the moment. Or other pain relief, as it turns out - the stronger effect of pethidine on babies being a good example.

David Bogod on his chat said this: - "I was stimulated to do this by the firmly expressed view that some midwives are 'tricking' women out of epidurals. Frankly, I am appalled that this might be happening. I can appreciate - but not condone - that some midwives are 'anti-epidural', but trickery and being economical with the truth must have absolutely no place in a patient-carer relationship. I hesitate to suggest it - this is your forum after all - but it seems to me that what is needed is a serious conversation at national level between women and midwives."

I wonder how that might happen.

BTW, stumbled across this article on the RCOG site yesterday, v: interesting in light of some of the posts here:

memories

"The more positive the experience, the more women forget how painful labour was. For a small group of women with a negative birth experience, long-term memory of labour pain was as vivid as five years earlier".

I think the problem is, most of the midwives on here agree with what is said.
Most will organise an epidural straight away when it is requested.
Most will document straight away when it is requested
Most will not lie about anaesthetist being busy.

The ones that dont do probably arent on here as they have no passion about what is right for 'their' women

The midwives on here are obviously very upset as it is not their way (it is certainly not mine) of practice, yet most posters on here use the collective term 'midwives' (or other pleasant variants) as if EVERY single midwife behaves in the same way - we ALL seem to be uneducted liars.
That is why some of the respones are so passionate becuase we do not see this in practice (although it obviously happens, unfortunately)

"If you have a MW who sees it as her job to get you through labour with minimal anaesthesia, and to discourage you from having an epidural"

What about the midwife who sees it as her primary responsibility to get you and your baby through birth as safely as possible, and has seen in her day to day work, woman after woman after woman having forceps and ventouse deliveries after the administration of epidural analgesia? Not justifying her not listening to the mother, but trying to point out that the intention is not primarily to avoid pain relief, but to avoid HARM to the mother and baby.

"I do think too (and it has cropped up on these threads) that women simply aren't being given an accurate picture of the risks and benefits of epidurals by MWs at the moment"

Again - can you provide any definition of what counts for 'accurate' information on epidurals? At present, NHS sponsored information on the risks of epidurals (produced by the RCOG as well as by the RCM) states that epidurals are associated with higher rates of assisted delivery, dural tap, episiotomy and running a temperature in labour. This advice is based on a wide range of peer reviewed studies and meta-analysis produced by respectable bodies.

But you and many others here have contested the truth of these assertions.

What do you think mothers SHOULD be told?

cleofartra, in terms of what info should be given to women about epidurals, and other anaesthesia - have a read of David Bogod's chat. He's got most of it covered, IMO.

In terms of what they shouldn't be told - well, have a look at primafacie's post about her meeting with a MW yesterday. Misinformation and bullying.

In your post, I see you talk only about avoiding physical harm (forceps and ventouse) to the mother, in terms of this being the main aim of a MW.

But over and over and over on this thread, we have heard from women with PTDS, PND, with deep and long lasting mental and emotional scars from intolerably painful labours. It's not good enough to measure the success of a labour and birth purely in terms of what physical processes they managed to avoid.

I think you should recognise that while some women might place a very high priority on avoiding at all costs an instrumental delivery, others may risk this in order to get pain relief. Problems will arise when you get a MW with one agenda looking after a woman with a different agenda.

My view is that women should be told the risks and benefits of epidurals. By all means tell them there is an increased association with assisted delivery and episiotomy. If this is a risk they are aware of and prepared to take, in order to get pain relief, then that is an informed decision.

Re epidural info, here is what David Bogod posted in response to my suggestion that women should be provided with a simple leaflet so they can assess the information for themselves:

"That basic flyer is available for all at www.oaaformothers.info (conflict alert - my own organisation). You will find a bullet-pointed epidural information card there. Feel free to distribute the web version freely or to ask your local midwives to make it available."

PDF of epidural leaflet from Obstetric Anaesthetists' Association

Their other leaflets re pain relief can be downloaded from this page (the links are in the cells of the buff coloured table on the right)

"have a read of David Bogod's chat. He's got most of it covered, IMO".

Are you suggesting that David Bogod should write the patient information re: epidurals for the NHS? Or that only his opinion should be reflected?

I see you talk only about avoiding physical harm (forceps and ventouse) to the mother, in terms of this being the main aim of a MW.

"It's not good enough to measure the success of a labour and birth purely in terms of what physical processes they managed to avoid".

No - I'm not discounting the importance of psychological outcomes at all.

"I think you should recognise that while some women might place a very high priority on avoiding at all costs an instrumental delivery, others may risk this in order to get pain relief".

I do recognise this.

"Problems will arise when you get a MW with one agenda looking after a woman with a different agenda".

Most midwives have a 'holistic' agenda - which is to end up with a happy and healthy mother and baby.

And they know that this is most likely following a straightforward delivery where the mother has been listened to and given optimal care. I'd suggest that this is what most midwives are trying to achieve.

MistyValley - do like the brevity of that leaflet you link to.

But 'the comment' "In general epidurals do not affect your baby" would be a bit more helpful if it said something that gave some idea of what indicators they're referring to.

There's fairly good evidence that babies born after the administration of epidurals don't have lower APGAR scores and are no more likely to be admitted to SCBU than babies born after the administration of opioids.

But that doesn't mean they aren't affected by epidurals in more subtle ways. (from Dr Sarah Buckley: "Epidural research, much of it conducted by the anaesthetists who administer epidurals, has unfortunately focussed more on the pro's and con's of different drug combinations than on possible serious side-effects (34). There have been, for example, no rigorous studies showing whether epidurals affect the successful establishment of breastfeeding (35).

Several studies have found subtle but definite changes in the behaviour of newborn babies after epidural (36, 37, 38) with one study showing that behavioural abnormalities persisted for at least six weeks (39). Other studies have shown that, after an epidural, mothers spent less time with their newborn babies (40), and described their babies at one month as more difficult to care for (41).)"

I'm not arguing that these findings should be reported to parents - I'm not sure about the quality of this research. What I'm saying is that it's wrong to imply that no evidence of harm is evidence of lack of harm.

Parents need to know what questions doctors are answering to get a better picture of what the issues are for them

Cleo you said "Most midwives have a 'holistic' agenda - which is to end up with a happy and healthy mother and baby. They know that this is most likely following a straightforward delivery where the mother has been listened to and given optimal care. I'd suggest that this is what most midwives are trying to achieve."

SO TRUE Cleo. But have a reread of some of these posts and see how many of the clearly intelligent women who have posted on this thread cannot get health care professionals to listen to what they are saying or even understand their perspective. How much more difficult would it be if they were in the middle of labour?

"and see how many of the clearly intelligent women who have posted on this thread cannot get health care professionals to listen to what they are saying or even understand their perspective"

What posts were you thinking of particularly?

cleofartra -

You refer to several studes (which ones?) where you yourself say you aren't sure of the quality of research, and say you aren't arguing that these 'findings' should be passed on to parents (well, no, indeed, and it's not entirely clear why you are raising this) -

Where what you say is that babies born to mothers who have epidurals might be affected in 'more subtle ways' than the ones where it's clear epidurals DON'T have a negative effect on babies, and mention 'behavioural abnormalities.'

Is this just mothers who have had epidurals, in an otherwise straightforward birth? Might they be spending "less time" with their newborn babies [than whom? I wonder?] SOLELY because they had an epidural, and not for other reasons? traumatic birth, baby in SCBU, etc etc?

Vague, alarmist scaremongering again, Cleofartra - shame on you.

You say 'no evidence of harm' isn't evidence of lack of harm. No, for sure. But it's better than EVIDENCE OF HARM, which we have in terms of side effects for pethidine, for example.

Again, I'd rather trust a professional - David Bogod clearly says of epidurals: - "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."

I'm sure you can respond, Cleofartra, 'ah, but there isn't any evidence that they don't interfere with breastfeeding? eh?'

PS cleofartra, the 'argument from ignorance' is what I was trying to draw out from your post.

This explains it well - en.wikipedia.org/wiki/Argument_from_ignorance

"Vague, alarmist scaremongering again, Cleofartra - shame on you"

'Scaremongering'?

Gloyw - please stop with all the cat's bum faced moralising and false outrage at my comments. It's very unnattractive.

These studies have been reported in respectable midwifery journals and it's not unreasonable to discuss them in the context of this discussion.

"Again, I'd rather trust a professional"

1. I very much doubt that a consultant anaesthetist is an authority on breastfeeding, therefore I'd be unwilling to take his assertions as the very last word on the subject.

1. He mentions one study, which he describes as 'god awful'. Actually there have been a number of studies which have raised this issue. When he says 'there is also no evidence at all that they interfere with breastmilk production or the ability to breastfeed' what he doesn't mean is 'there have been good quality studies which have examined this issue and have concluded that breastfeeding isn't affected'.

It's not scaremongering to suggest that a form of labour analgesia which is linked to high rates of instrumental birth and in which opiates are usually used might have an impact on breastfeeding. We know babies who have had assisted deliveries are more likely to be jaundiced and to have cephalhaemotoma and general bruising.

Isn't it fair to suggest that these things might interfere with the establishment of breastfeeding, which involves such delicate mechanisms and is so easily disturbed in the first week of life?

Re: Argumentfromignorance:

~"This represents a type of false dichotomy in that it excludes a third option, which is: there is insufficient investigation and therefore insufficient information to "prove" the proposition to be either true or false".

But you are arguing surely that there is sufficient evidence to prove epidurals are safe and have no deleterious affect on babies?

I was just pointing out that a leaflet which insists that 'epidurals do not affect your baby' is subtly misleading, because it does not set out the parameters of the research on which the assertion is based.

Cleo There's research on breastfeeding that shows epis IMPROVE breastfeeding.

Usually when you get such conflicting results either there is no link or it is just study design and poor matching. The consensus is it makes no difference.

Chang 2005

CONCLUSIONS: Continuous epidural anesthesia and postpartum analgesia are effective and safe with little side effects in pain relief, improving the mental state, and promoting breast feeding. Obvious analgesic effect reduces catecholamine level, promotes prolactin secretion, and benefits the breast feeding.

Chang 2006
There was no significant difference between the epidural analgesia and no-analgesia groups in breastfeeding effectiveness or infant neurobehavioral status at 8 to 12 hours or in the proportion of mothers continuing to breastfeed at 4 weeks

Interesting,Ushy.

Cleofartra, I wish it was false outrage on my part.

It's not. (I am amused by the idea I should be interested in whether you find my posts 'attractive' or not. I wasn't aware I was in a beauty contest!)

You say - "It's not scaremongering to suggest that a form of labour analgesia which is linked to high rates of instrumental birth and in which opiates are usually used might have an impact on breastfeeding."

As long as you are absolutely clear that this is pure conjecture on your part, and not based on any evidence, and isn't part of a discussion about evidence based advice - fine. It's as valid as any other guesswork.

And as long as we overlook the fact that opiates affecting newborns is a MUCH greater risk with pethidine than epidurals. As discussed earlier on this thread. And as you yourself said "opioids given intramuscularly will be more harmful to the baby because they go through in much larger amounts."

On a different note, in light of another of your posts, where you say that in terms of birth, you are not "discounting the importance of psychological outcomes at all", I remembered a particularly dismissive comment you made earlier. About a piece by Emily Woof in the Guardian, where she describes her traumatic births, and mentions how her independent MW abandoned her when her births needed emergency intervention.

You simply dismissed her experience - here, for anyone who wants to read it - www.guardian.co.uk/lifeandstyle/2010/mar/13/natural-childbirth-caesarean-emily-woof - by saying, 'Ah well, she's a journalist with an axe to grind...'

I pointed out she wasn't a journalist, and felt that was a really unpleasant way to dismiss someone else's birth trauma.

I wonder if your reluctance to hear someone else's bad experience is because it doesn't fit your own ideology. If someone had suffered at the hands of an obstetrician, in a medicalised environment, you would have been open to them. As it was, Emily Woof was someone who feels NCT, an anti-epidural anti-intervention approach and an independent MW let them down. But you just don't want to hear that, do you?

I find it extraordinary, and it does disturb me, actually, that someone who describes themselves as an ante-natal teacher and a trainee doula simply - doesn't - listen enough.

As far as the risks of epidurals go - where there are clear known risks, women should be informed. If they aren't, their decisions and choices are compromised. Where there are no known risks, they should not be offered vague, alarmist scaremongering misinformation.

Gloyw will respond to your post later. On phone now so don't want to write too much other than to say it's not 'pure conjecture'that epidural has been linked to more difficult breastfeeding. There have been quite a few studies (albeit of varying quality) in the past decade which have suggested this to be the case.

Ushy - were you aware that nearly half of the non-epidural control arm of the Chang study had used pethidine in labour? A drug which has a clear and well documented impact on women's chances of succeeding with breastfeeding.

And that the study didn't control for social class. For me this is relevant - higher social class is strongly associated with both epidural use AND with longer duration of breastfeeding (and lower rates of supplementation).

I really think that any research into bf outcomes need to control for these things to be considered truly reliable.

cleofartra, I'm not sure why you are prepared to consider various studies of 'varying quality' about the effects of epidurals on BF-ing when you've made it clear in previous posts that you won't consider any research about birth from the USA - no matter how superlative the quality! - because their maternal care system is so different to the UK.

(I noticed you were happy elsewhere to accept studies that involved Canadian research, even though they have a very different obs/gynae approach too. But then it was something you were sympathetic to, not opposed to...).

As a committed EBF-er, I know there are SO many factors that influence successful BF-ing, from access to support, to culture, to family... leaving aside physical problems.

I was aware, and grateful, that after my planned CS that I found BF-ing so much easier to establish than friends who had been through days of painful labour. I wasn't exhausted or in pain to start with, so was much better able to cope with it all.

So, after a night's reflection, I've realised that actually, for me, the debate stopped with the admirable webchat with David Bogod. And I really do urge others to read it.

www.mumsnet.com/Talk/mumsnet_live_events/1160539-Live-webchat-with-David-Bogod-president-elect-of-the-Obstetric-Anaesthetists-Association-Thurs-3-March-8-9pm

So many of the scaremongering about epidurals on these threads cleared up - so clear about the risks, too, which is JUST as important if women are to be informed.

Fellow of the Royal College of Anaesthetists, President Elect of the Obstetric Anaesthetists Assocation - I'm happy that he is someone well informed.

There will always be people who don't want to believe something because it conflicts so strongly with their existing beliefs - but goodness knows there is nothing you can say to them. They'll ask for evidence, then find ways of discounting it if it contradicts what they think, then believe the flimsiest, unscientific publication if it backs up what they already think. It's only human, it's called cognitive bias, but it doesn't half make debate a waste of time.

Bottom line for me - epidurals should not be denied or withheld from women who ask for them. Whether in advance, or during labour (which is unpredictable, and plenty of women change their mind about pain relief options when confronted with the reality of it all). I feel the same about other birth choices, btw - home births, which also need one to one MW care, should be available to those who want them.

And yes, an increase in the number of MWs. But only in properly trained, well informed staff (i.e not those who refuse to accept that a Fellow of the Royal College of Anaesthetists doesn't know what he's talking about!) - who see it as their job to support all women, not just those who share the same ideology as them, work with other medical professionals when necessary, and not protect their own professional territory so fiercely that women get less than optimal treatment.

More of them - marvellous.

i.e not those who refuse to accept that a Fellow of the Royal College of Anaesthetists doesn't know what he's talking about!

That only makes him an expert on anaesthetics, and that was valuable input.

It doesn't make him an expert in other fields. Once he strayed outside his area of expertise his arguments weren't as well thought through as he admitted himself i.e. whether other HCPs should sit with women who have had epidurals.