I am a midwife, and I find this thread and the previous one so disheartening. The general opinion of midwives seems to be so poor, when most of us work very hard to help women acheive a birth they are happy with.
My preference is for normal, natural childbirth, I think it is generally the best to start to life for a baby and the best start to motherhood for a woman; however I recognise that there are always exceptions to this and for whatever reason - expectations/experience/personality some women will not find natural childbirth empowering, and I have the same respect for and obligation to these women. And then there are those who are not experiencing natural childbirth because we have already interfered e.g. induction (we as in the health care professionals working within maternity, which imo as a whole accepts such interventions far to readily :( ). I still want these women to find their labour and a birth a positive start to motherhood, or at least not a negative one.
My approach to pain relief is to discuss the options fairly early on in labour/induction where possible. Make sure women are aware of the pros and cons for each options, and then tell them they are free to ask me more about any of these options at any time but they are the best judge of how they are coping so I will wait for them to ask (I've never like the approach of offering an epidural/diamorphine persistently, I feel it gives the impression the midwife thinks the woman is not coping, when that might not be how the woman herself feels, and cause her to question herself and her ability to cope).
My list of cons for epidurals goes something like - they don't always take away all of the pain (an ineffective epidural is one of the most difficult things to deal with ime, especially if a woman has held off, feels she can't possibly cope any longer, and then still has to); You often won't be able to move/control your legs on the bed without assistance and you can't stand up; They can make labour longer, because you aren't mobile you don't have the benefit of gravity, in conjuntion with this they relax the pelvic floor muscles and can make it more difficult for the baby to move into a good position. This can result in intervention such as artificial rupture of membranes and augmentation of labour, which also carry risks; They can make pushing more difficult and longer because you often don't have the urge to push, and its harder without it (as well as the baby might not be in an optimal position, and you don't have the aid of gravity) which can increase the likelehood of an assisted delivery, and also of perineal trauma; We need to monitor the baby's heartrate constantly, continuous monitoring is linked with increased interventions such as fetal blood sampling and operative birth; You probably won't be aware of the sensation of needing to pass urine meaning a catheter would be required as its important to keep your bladder empty; You need a drip up, because epidurals can lower the blood pressure, which in turn can cause a drop in the baby's heartrate, so we try to counteract this with intravenous fluids, but sometimes it still happens; We also keep a closer eye on your blood pressure; It takes a while afterwards to get the feeling back in legs and be able to get up and about; Our policy is for clear fluids only for women with epidurals; A small amount of the drug used in the epidural crosses the placenta and this might make the baby sleepy and feeding, especially breastfeeding, a bit more difficult at first; You need to sit very very still for a short period of the process, and maintain the same general position for most of it, which can be uncomfotable when you are having contractions, it can be as quick as 15 minutes to get the epidural in place, but can also be quite a bit longer. I let the anaesthetist talk about the technical risks such as headaches etc. These are the risks and realities of an epidural, not me trying to trick a woman out of having one.
(I don't mention the possible effects on the hormonal process of labour, and how this might affect bonding/attatchment/breastfeeding/emotional and mental health, because this is an area still requiring a lot of study - but I certainly believe epidurals can impact on this)
The pros are, if they work well you will be pain free, and for some women this outweighs all of the risks (including the unmentioned hormonal stuff), only you can make that decision.
If a woman decides she wants an epidural I go and bleep the anaesthetist, generally they attend quite quickly. If they can't I always try and give the woman an indication as to why they can't come straight away (while maintaining confidentiality) and try and give an ETA, and continue to support her until he/she (or occasionally her baby!) arrives.
If a woman is in a panic and swinging bewteen wanting an epidural and not, or her partner/mum/sister is trying to convince her to have one, I tell her I think she is coping very well, and that I believe she will continue to cope without an epidural and we will all support her to do that if that's what she wants, but she is the only one who knows how she feels. I would never tell a woman I thought she needed an epidural.
We don't offer epidurals during the latent phase. And the anaesthetists where I work would be very reluctant to do one during the second stage. That is not a midwife decision, although it is one I support.
I try to offer the birthing pool as an alternative to an epidural where appropriate and available.
If women are being induced or augmented with syntocinon I always explain that these are different to natural contractions as we are forcing them, therefore the body doesn't have as much time to build up endorphins which can make the pain more difficult to deal with. For this reason we should offer epidurals to all women undergoing induction/augmentation, however if you want to see how you cope with the contractions before making a decision, or are keen to avoid an epidural I will do everything I can to support you.
I am not some evil woman who loves to watch other women suffer. I would not lie to or coerce a woman to stop her from getting an epidural. I am also not lazy, I work my arse off for every minute I am at work, I support every woman to the best of my ability and I believe all of these things are true of the majority of midwives. But I am definitely not perfect, and neither is the system. Midwives are often under a lot of pressure, looking after more than one labouring woman which dilutes the care they get, 13 hours shifts without a break etc, we're also human, and humans get stuff wrong sometimes.
A few years ago I cared for a woman who was being induced, when I transferred her from the antenatal ward to break her waters and proceed with the induction she was having irregular contractions, she told me she wanted an epidural for pain relief. I discussed the benefit of mobilising for a couple of hours following having her waters broken to allow the contractions to hopefully establish and avoid the syntocinon drip and asked her if she would be happy to do this, explaining if the drip was required she could have an epidural before it started. When I broke her waters her cervix was posterior, uneffaced and 2cms dilated, we agreed a plan to reassess in 2 hours and I hoped by that time her contractions would be more regular, there would be changes to her cervix and the drip wouldn't be required. Over the next hour and a half she mobilised, the contractions became more regular, and she asked for an epidural. But at this point she seemed to be involuntary pushing, so I asked if I could examine her before I rang the anaesthetist, she agreed and she was fully dilated, her baby was born less than 30 minutes later. I hope she doesn't think of me as a horrible midwife who denied her an epidural, and I really hope she isn't traumatised by the experience. I acted with her best intentions in mind, her progress in labour was unusually and unexpectedly fast, even the best and most experienced midwives (never mind just normal ones like me) are surprised sometimes, because nature is unpredictable. So maybe some of the women on here weren't cared for by evil lazy midwives, but just by normal human midwives, working in an overstretched system, who would be pretty devastated to learn they in anyway contributed to a woman being traumatised by her labour and birth.
Sorry its such a long post.