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

[Chynah]

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

The one-woman, one-midwife system can be done, because that's how they set it up in Canada from the get-go in the 1990s. Midwives work in small groups, they each care for 40 women a year from antenatal through delivery and postnatal, and they are on-call for their clients. Women generally love their midwives and are happy with their care - and that's purely down to the system being set up in the interests of women, not because the midwives are better or more caring. The current NHS system drags down midwives and mothers.

I can't see how it can ever be done here, though. The maternity care system is too entrenched and it would be such a massive shake-up. Being an on-call caseload midwife is also a lifestyle choice and you couldn't possibly convince tens of thousands of midwives to embrace that model, even though many would probably prefer it. You'd lose too many midwives. Might be a way of clearing out some of the dead wood, though...

Gloyw,

It's not 'semantics' when you've distorted my comments (partly by misquoting me and partly by omission) to imply that I'm unsympathetic and insensitive.

"You used to do this a lot when you posted as tittybangbang, I remember.

This thread deserves better".

And now implying that my contributions to this thread are - what? Pointless? Stupid?

As for my ignoring comments - isn't that exactly what you've done in response to my posts?

As for 'extreme statements' - where?

Bue - you say that it couldn't be done here - but it used to be done here until the mid 1970s when the Local Authority midwives were taken into the NHS.

It would require a big shake-up:

There was a big push to get women into hospital from the 1960s onwards - that was a big shake up. If it's been done once why can't it be done again?

A big shake up is coming in the NHS anyway, so how about seizing the opportunity?

I can't see why a revised system could not be put in place. It's been done in some areas - it could be extended nationally if the will was there.

Lots of midwives would leave: I don't doubt that some would, but lots of midwives are leaving already because they don't feel they can provide the service they want to under the current system.

Margles, now that you mention it of course I realise that you're absolutely right. I've read plenty about midwifery practice in the 50s and as you say, much of it was caseload/community based.

I suppose I agree that it could be done. But I fear that it won't be done, that the political will just wouldn't be there. But this is a Mumsnet campaign I could get behind...

cleofartra....

Just read the thread. And the original 'tricked out of epidural' thread. Really, just read it. I respectfully quote exactly what you have said - EXACTLY - as I have no desire at all to distort what anyone says... and you get angry. I haven't distorted what you've said. I've simply repeated it to you.

Moving on.

Re: MWs - in my PCT, last year they changed the system so that MWs had to choose between being a community MW, and being a MW attending birth. So they now do either ante-natal, post-natal or labour/delivery care.

I made the point to my local MW team that I could see problems there - just one being, how does a post-natal care MW meeting a new mum for the 1st time know what she was like before the birth? It must make it harder for them to pick up signs of PND, for example. Everything gets done through notes and handover.

They told me that so many women had complained they saw a different MW each time, the system had been changed - it was felt that MWs on call to deal with labour and delivery missed too many routine ante-natal care appts. They called it a lack of continuity.

I said I thought this didn't solve the problem of lack of continuity in care - rather, it formalised it.

I got the impressions the MWs weren't happy either - apart from anything else, having seen a mother through pregnancy, they weren't going to meet the baby, which seemed sad.

careers.bmj.com/careers/advice/view-article.html?id=1224

For those who are under the impression that midwives are not qualified enough to manage labour

I am a practising midwife and I find it sad reading through these threads. Am I guilty of 'refusing' a woman an epidural? Yes I am. Why? Because I could tell that every time, by the time IV access has been sited, an anaesthestist in attendance all scrubbed up, there would be a baby being born as labour was progressing rapidly. Therefore I concentrated my efforts on supporting the woman getting through transition and birthing her baby safely. I indeed did that recently where I offered a pool instead of an epidural and the birth occured only 40 minutes after the lady got in - an epidural would never have been sited and working effectively in this time. Why did I offer the pool? Because the lady in question had had a bad experience with an epidural last time and I didn't want her to have the same experience which was quite probable that it would happen again. She had a waterbirth, being the first to touch her baby, bring her little one to the surface, both going home well 6 hours later. Happy with her care.

Now I shall flip this round. I cared for another lady recently who requested an epidural, I bleeped the anaesthetist - the anaesthetist was unable to attend due to an emergency on ITU. And yet I was blamed by the lady for lying to her about bleeping him. As a midwife, it is sometimes extremely difficult to convey this and please all parties. Please ladies, understand that anaesthetists may well be busy with another lady/emergency and may not be able to attend, it is not the midwives fault. The NHS is extremely strapped for resources and will be further stretched in the coming years with probable redundancies from nursing/midwifery and possible doctor staff. We do our best with what we have. Whilst in an ideal world, an anaesthetist would just be sat on labour ward waiting for your arrival, this is never going to happen.

Reading the anti-midwife and midwife bashing comments on this thread has saddened and shocked me so much. It makes me actually want to give my career up (and I love my job to bits) as I would hate to be thought of badly - I do the absolute best for all of my women and promote normal active childbirth wherever possible whilst supporting women in their decisions. And if that decision is an epidural, fine!!! Nothing wrong with this!! I will do my best to get you one!

And as for the DrMcDreamy link to the bmj as above - spot on! Should be given out at all doctors inductions.

Scarfqueen I do see where you are coming from and I know you must work incredibly hard doing a job I could never do. However, can you see the other side?

Is it ever right to refuse an epidural? Ever? No-one can be exactly certain when a baby will arrive -it may look like it will arrive in 5 minutes but it could be five hours. Even if it is only an hour later or half an hour, if the woman has lost control that memory can stay with her for a lifetime.

You say too, that you support normal active birth but do you have a right to decide what is normal? Some women would say that in a society where women generally have equality there is nothing normal about being left in mind crushing pain because some elements of society consider it normal.

I know midwives argue that many women are 'grateful' to have been 'supported' to avoid an epidural. There may be some but between 91-98% of women who have modern epidurals would have one again.

What about this small group who are grateful. Why? Because of the risks? But what were they told about the risks? David Bogod, the obstetric anaesthetist, has just finished a web chat on MN. The difference between some of the risks touted by some health care professionals and the truth is staggering.

Perhaps some of this small group of women who are 'grateful' for being refused an epidural are actually women who wanted natural childbirth and 'lost it'. But let?s have a think about this. If woman says no to sex and a man ignores her he is guilty of rape. It is not a defence for a man to say she just likes rough sex and want her shouts of 'no' to be ignored. The law respects the word. I want an epidural has to mean I want an epidural. It does not mean I want an epidural but I want you to ignore me.

I totally accept your point that a lot of the problems are lack of anaesthetists but I have NEVER heard a midwife argue for more anaesthetists. I HAVE heard them argue that, as a previous poster said, epidurals should be charged for, or 'pain is a right of passage'. Why is the midwifery profession not acting as advocates for women and drawing attention to the inadequate pain rleief services?

This really isn't midwife bashing - it is just hugely sad. There is something fundamentally wrong with midwifery training that is leaving so many women distressed, angry and alienated. You cannot run a service ONLY for women who want natural childbirth. You have to run a service for all women.

Women have changed, society has changed. Midwifery has to change. I am sure you really want to do your best for women and I can tell you are a really thoughtful reflective person. Please stay as a midwive and fight for change from within.

David Bogod, the obstetric anaesthetist, has just finished a web chat on MN. The difference between some of the risks touted by some health care professionals and the truth is staggering

why , when SEVERAL other professionals discuss risks is it classed as lies when ONE other professional, who does a web chat, discounts them?

Who do you believe?
The choice is yours eh?

The webchat is very interesting reading, and I would recommend anyone browsing this thread to go and have a look. So much that is discussed here is covered there.

I just want to repost this paragraph (Ushy, I hope that's OK, it's an answer in response to a question from you). I think David Bogood gives a measured response to something that has cropped up on these 2 epidural threads a fair bit.

Btw, it's the first time I've seen anyone mention that pethidine has greater and more harmful side effects on a baby than epidurals (pethidine is a sedative narcotic that crosses the placenta, unlike an epidural, and can lead to floppy, unresponsive babies, with all the follow up care/difficulty feeding etc that that can lead to).

As far as I can see, pethidine is used because it's cheaper and MWs can inject it so there's no need for a doctor/anaesthetist. Even though it's more damaging to babies. I can see some women might want to try it before an epidural to stay mobile, but really, I can see far more reason to be critical of pethidine in terms of baby and mother wellbeing than epidurals.

Anyway, here is the para: -

DavidBogod: Ushy, you ask "Why is the midwifery profession so anti pain relief?". Firstly, I do agree that some midwives seem to be anti-epidural (while often in favour of other techniques, such as pethidine which has much more profound effects on the baby) but in my experience this is a minority of practitioners. I seriously don't know what it is about epidurals, other than it involves a doctor. Some definitions of 'normal childbirth' specifically exclude the use of epidural analgesia (we have lobbied very strongly against this, by the way) but it's not mentioned in the Royal College of Midwives (RCM) definition of normal childbirth which is "?one where a woman commences, continues and completes labour physiologically at term.?

I think that to understand this attitude, Mumsnetters need to be aware that many midwives regard themselves as the guardians of 'normal' birth. Indeed the RCM states that midwives should try to 'maximise normal birth in the context of maternal choice'. That rider about maternal choice is key to the whole Mumsnet thread, of course, and it is often missed out when midwives quote this maxim. It is important for a woman to know that her midwife may have an agenda - albeit a perfectly respectable one - which might be slightly at odds with their own wishes."

Alimat You said "why , when SEVERAL other professionals discuss risks is it classed as lies when ONE other professional, who does a web chat, discounts them?"

Because in my day job I have to look up medical research data to identify whether there are possible grounds for clinical negligence claims. I go on to the medical databases to check good quality peer reviewed evidence and current UK best practice medical guidance.

I started checking out what midwives were telling me during my maternity leave ( what a saddo - couldn't stop doing the day job) and I just couldn't believe how different it was from what up to date research said.

The reason I believe David Bogod is that his comments match the data - not because I am anti midwife - I am absolutely not!

I think gloyws point is the important one - we need to try to understand how this divide has happened and what is at the root of it.

Epidurals also contain the use of an Opiod that does cross the placenta that has a similar effect to that of pethidine on the baby.

Well i suppose as he has 'helped' deliver countless babies we should believe him then

Again - where are these anaesthatists/ which hospital - oh, to have help from a hallowed anaesthetist delivering a baby

Also Ushy -
There are several midwives on here who have said they will happily sort out an epidural for women when they ask, but STILL repeatedly get shot down in flames for lying.
I have said several times, if someone asks for an epidural I get it sorted.
Funnily enough, the other anaesthatist who said the complete opposite to David - as in she had NEVER had an epidural refused due to lack of one-to-one care has not even been acknowledged.
Funny eh? So who is telling the truth there?

Alimat, I think people forget that midwives are the only people involved in providing intrapartum care who engage with the mother throughout the entire process, from conception through to the postnatal period, in all contexts - from straightforward, normal deliveries, right through to high risk, operative births. Wonder where the idea comes from then that midwives have a uniquely skewed perspective on birth, compared to other health professionals who deal with intrapartum care?

"Some definitions of 'normal childbirth' specifically exclude the use of epidural analgesia (we have lobbied very strongly against this, by the way) but it's not mentioned in the Royal College of Midwives (RCM) definition of normal childbirth which is "?one where a woman commences, continues and completes labour physiologically at term.?

Might have something to do with the fact that epidurals profoundly disrupt the normal hormonal physiology of birth.

And of course that most epidurals involve syntocinon, the use of which is not included in the RCM's definition of 'normal birth'.

"That rider about maternal choice is key to the whole Mumsnet thread, of course, and it is often missed out when midwives quote this maxim."

It's possibly goes without saying because midwives believe it's blindingly obvious that that listening to a mother and respecting her wishes is one of the central tenets of good practice.

"Btw, it's the first time I've seen anyone mention that pethidine has greater and more harmful side effects on a baby than epidurals (pethidine is a sedative narcotic that crosses the placenta, unlike an epidural, and can lead to floppy, unresponsive babies, with all the follow up care/difficulty feeding etc that that can lead to)"

Although interestingly enough, almost all the research which compares the outcomes for epidural births with non-epidural births (and which, as you say, finds minimal disadvantages and risks associated with epidurals) uses as the control group mothers who have had opioids in labour, rather than comparing mothers who've had unmedicated deliveries.

It's human nature to cherry pick the arguments that support your own philosophy, it's just sad that the other point of view can not be acknowledged and understood, even if not agreed with.

DrMcDreamy, it is my understanding that an epidural 'mix' can vary - basically bipuvicaine, which is used largely because it has a very low negative effect in terms of transfer to placenta - then fentanyl or opium. Amounts can vary.

ALL NHS info I've read tells me that pethidine has a stronger, WORSE effect on the baby because there is greater placental transfer.

You are a midwife - polite question here on a heated thread - is that not what your info and understanding is? When David Bogood says pethidine has 'much more profound effects' on the baby, is he wrong?

Perhaps technokitten is still around to help with technical questions.

"What about this small group who are grateful. Why?"

Possibly because they appreciate being back home with their babies within a few hours of birth instead of spending a night on a postnatal ward with a catheter in situ waiting to regain the feeling in their legs.

"When David Bogood says pethidine has 'much more profound effects' on the baby, is he wrong?"

David Bogood is right - opioids given intramuscularly will be more harmful to the baby because they go through in much larger amounts.

But then there is the separate issue of assisted delivery and how that affects babies.

cleofartra, I can understand why that might be very important for some women (a quick recovery, and early trip home, if that is the result of their individual birth - likely to be other factors there though than simply refusing an epidural, surely)-

And that's FINE. If that's their choice and it works for them, then GREAT. Really.

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.

Btw, latecomers to this thread, David Bogood's webchat can be found here -
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

Important I think that people read and form their own opinions.

It's human nature to cherry pick the arguments that support your own philosophy, it's just sad that the other point of view can not be acknowledged and understood, even if not agreed with.

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

I think very few midwives actually lie - a few perhaps but that would be the same in any profession. I think they genuinely believe what they say is right. So it is training that is the problem.

You are never going to agree whatever we say but it does not really matter as long as when you meet women in labour who request epidurals 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, make her lie flat on the bed., tail off the epidural at the end of labour etc.

Can we agree on that?

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.... unless there where issues of timing and resources which were openly admitted as such by their healthcare providers.

This is a UK-only political / ideological debate that no one from the outside world can really understand, unless it is only a way of masking an understaffed and under resourced NHS.

My cousin is an anesthetist and had 2 kids with an epidural, she would never recommend otherwise. She is aware that risks are minimal and the upside is great.

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!). My doctor here said that's probably due to the fact that in UK women who are given epidurals are the ones who are already in a difficult labor situation (something also confirmed by David B in the web chat)

I was talking about this with a midwife who was running me through all the risks of epidurals and I also said I saw a study that says that there is a benefit to having an epidural, it sometimes can make labor faster cause taking away the pain women are more likely to push in the right way.
She categorically denied that study had any validity but all the others she was quoting about horror stories obvsiouly were valid.

No one wants to be ungrateful to midwives , they do a great job, but they are biased towards what is commonly known as "natural birth"... which to me is just a matter of semantics... because i think i've heard somebody on this forum referring to her labor as "natural" after she had G&A, forceps intervention, pethidin, and episiothomy. I really don't know what's natural about this... I think a c section is probably less intrusive than what she had to her.... but she was proud not to have used any epidural or c section