Women should be told that they may not get an epidural before labour?

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A friend of mine recently had her 3rd dc. She had an epidural with her first 2 dc's and had positive birth experiences. Her plan was to have an epidural with this one too.

However, despite hours of contractions, when she got to the hospital she was told she was not in labour (2cm dilated) and so could not yet have an epidural. When her contractions ramped up the midwife told her she was probably now in labour but she could not have an epidural because there were no rooms availible on the consultant unit (she was admitted to the birth centre on the same site).

The midwife then told her she needed 4 things to meet the criteria to get an epidural.
To be in 'active' labour
Have a room availible on labour ward
An anaesthetist availible
A midwife to give you 1 to 1 care

She ended up giving birth without getting an epidural, is quite traumatised and feels very let down and annoyed that no-one ever told her that an epidural may not be an option for her on the day. She was aware she may not get one if she had a speedy delivery but she was in angony for hours . Most women I know have always just been smiled at by midwives and told 'Yeah, you can get an epidural whenever you like!'

Now, I understand the need for all of these things to be in place before getting an epidural but why aren't women informed of this antenatally and just lied to?
I've encouraged her to complain but she say's 'Whats the point, its done now'. I wonder how many other women this has happened to and also don't bother to complain because its over/ they are too traumatised/ to exhaused looking after a new baby.
Is there a conspiracy to withhold the truth so that women won't/can't complain and demand better services?

20 minutes! I waited 2 hours.

Well if we are being compettitive I waited 16 hours from asking. Only got one as I said I couldnt cope with synto (failure to progress despite cluster contractions for the duration) without it as was exhausted.

quite. if we are indeed being competitive then I am still waiting 6.5 years later! I was lied to and like starlight strapped to a bed. Like you madeupme with a synto drip, following three sleepless nights of failed induction.

This isn't care in any way, it is women in pain consistently being misled, outright lied to and disempowered. If they would just say oh we don't want to give you an epidural because the anesthetist is busy / we think it'll slow your labour down / we don't think you're in enough pain then at least we would know why. But I was told that a vital blood test hadn't been done and the lab was shut. With hindsight, utter bollocks.

I didn't mean to be competitive... I'm sure many people suffered more! I was just correcting the 20-minute idea... if all of you would like to join me in correction, good :)

And fishie, I agree entirely. Both my dcs were induced. And I'm not even sure the reasons you cite are valid. I was made to feel bad for having an epidural with ds as I had a long unproductive second stage, said 'bollocks to that' with dd and had a 5 minute second stage with an epidural in place. it's IMHO ALL about the money. They just fuck us over because they can keep the bottom line looking good, and they know if our dcs are born healthy we'll swallow our misery.

And while I know a waterbath isn't always available either, I was at least warned about this, but not about epidural availability.

Yes exactly. I felt very bad telling my pg colleague not to expect much care as the only thing they're interested in is the bottom line ie a healthy baby. But it's true and if we pretend that there'll be lots of brow stroking and kindness in the labour ward we are colluding. Good care and proper information is the exception rather than the norm.

Is it midwives who you think are deliberately withholding epidurals from mothers to save the NHS money?

Why would they do that?

Meant to add, that if a midwife is working on a very busy labour ward the epidural gives her nearly as much rest as the mum once it's set up. Women who've had an epidural don't ask for much from midwives. Why WOULDN'T a midwife want her to have one? I don't believe for one minute they do it to save the NHS money. It doesn't make sense.

Spud, not what I meant, but I think some midwives are perhaps complicit in a policy which is probably the creation of the notorious NHS managers.

As to why midwives don't want epidurals all round, there might be many reasons. The midwives I know are very erm committed to the joys of natural childbirth. The birth system in the UK obviously gives them a lot more authority than the kind offered elsewhere in the Anglophone world. Most women who come here from the US, Canada or Australia are amazed, and tbh horrified, at the power midwives have here over birth. I have heard many stories where that power has been again tbh misused, and the woman has gone away with her fistula and/or her PTSD and shut up about it because her baby was born healthy.

Paulayates - I think that was a chuckaway comment and didn't imply that the midwife was genuinely interested in saving the NHS money by denying pain relief to distressed labouring women.

Sieg - what 'policy' are you referring to? Have you any evidence that there are written or unwritten policies on access to pain relief in place which directly contradict those of NICE (which are that women's requests for pain relief must be responded to and epidurals given if available)?

Re American and Canadian views on our system of care - why would They be amazed at a midwife being the lead professional in a birth? Is it because they think they're underqualified to take that role?

You wouldn't find much support for an obstetric led system of care here. Most people feel midwives are the best people to be lead professional in a low risk labour.

Oh - and on the whole midwifery care is associated with better outcomes overall.

As for the 'joys' of natural childbirth, I think what midwives are usually hoping for is a complication free birth, and in the uk, that seems to be associated with lower use of epidurals. That's not reason for them to obstruct access to epidurals from mothers who've made a clear request for one though, and if there is evidence that this is happening it needs to be acknowledged and addressed.

I have had 7 dc a couple with epidurals and a few without.
My last labour was in 2009 and was a truly terrifying ordeal. I could not handle the pain, dd was in an akward position and back to back I was having full blown ctx from the word go.
I asked and asked and asked for an epidural but the first MW decided that we were going to do it her way she seemed determined I was going to have a quick labour with no pain relief this did not happen and despite asking during every ctx for an epidural she just kept saying "breath".
The next shift arrived and she agreed I should have an epidural but by then all the doctor's were busy or changing shifts.
I gave birth crying and hoping to die.

Since that time I have pushed people away, I have often screamed at DP that he should have stood up for me more, I have flashbacks and feel sick if I see a birth on tv or hear someone screaming.

For the past two years I have been a complete weirdo thanks to the shit I went through that day.

My doctor has told me I have PTSD and PND, there is not a day that goes by that I don't think of the labour it has broken me.

The worse thing is sometimes I feel like I am getting back to normal again and then it drops back down again and I spend a week crying and feeling shit.

Doesn't it depend on your definition of 'better outcomes', Spud? What is 'complication-free', too? does it embrace bf rates and postpartum depression and wound healing, or just the immediate safe delivery, because if only the latter then that's what I said.

And yes, they/US/Candadians etc do think midwives are underqualified. Soryr, but they do. If you are used to a consultant, then of course a nurse will look less qualified. Ten/eleven years versus 4/5...

My only evidence of the policy is the number of women refused an epidural (see above, but this bears out my own anecdotage). Do you know of any statistics yourself? And how can you possibly know what support there might be for a different care system?

Isn't MW care associated with better outcomes because doctors are brought in for more difficult cases? Both the economic model and medical outcome model of childbirth are flawed because there are too many factors to take into account - postmenopausal incontinence, women to scared to consider having another child, all sorts of outcomes can't be factored in.

Sieg - substandard care and high levels of intervention are associated with poorer outcome in birth and postnatally.

The real issue here is not midwifery led care per se, but substandard care, which can be found anywhere in the NHS.

No - low risk mothers having obstetric care have higher rates of emcs and assistedbirth apparently. Particularly when compared to outcomes for independent midwives caring for low risk mothers, who have vastly higher continuing bf rates and also much higher rates of intact perinea (much higher than NHS midwives caring for low risk mothers too....)

But when are "low risk" mothers classed as that? Is it on admission for childbirth (or calling out midwives for HB) or during pregnancy? What counts as a low risk mother?

Yes, bretheslowly, you took the words right out of my mouth. I've always thought this; I mean, if it's NHS policy to entrust low-risk deliveries to midwives then of course they are going to look statistically better.

And spud, what is 'substandard care', because I thought we were talking about the provision of anaesthesia... Are you saying the lack of an epidural if requested would be regarded as substandard in the NHS?

The study looking at outcomes associated with different models of care which is on the Cochrane index is a metaanalysis. It included only studies where women were randomised to different models of care.

When they design research on this sort of thing they do generally try to take selection bias into account an control for as many factors as they can. It's a basic requirement in modern health research.

Is it ethical to randomise women into different types of care? At what stage were they randomised? I was low risk until I went quite overdue - would I have already been randomised at this point?

"Is it ethical to randomise women into different types of care?"

Well - I don't imagine they randomised high risk women to midwifery care throughout pregnancy and birth! And I assume there was a mechanism for dealing with situations such as you describe.

"Are you saying the lack of an epidural if requested would be regarded as substandard in the NHS?

NICE recommendations are: "Women in labour who desire regional analgesia should not be denied it, including women in severe pain in the latent first stage of labour"

However - these are recommendations, and hospitals not following them won't necessarily be considered to be providing substandard care.

Actually it's really worth a look at the NICE guidance on intrapartum care because it does say some very interesting things, like:

"Healthcare professionals should consider how their own values and beliefs inform their attitude to coping with pain in labour and ensure their care supports the woman?s choice."

and

"All women in labour should be treated with respect and should be in control of and involved in what is happening to them, and the way in which care is given is key to this. To facilitate this, healthcare professionals and other caregivers should establish a rapport with the labouring woman, asking her about her wants and expectations for labour, being aware of the importance of tone and demeanour, and of the actual words they use. This information should be used to support and guide her through her labour".

When you read this and then consider some of the stories on this board - makes you realise how the care of so many women here falls far short of what it should be.

The thing which makes me sad is that midwives go into the profession usually because they respect women and want to help them. All the midwives I know personally are incredibly compassionate and generous people. But I've been treated poorly by other midwives while pregnant and in labour, and in the course of my work seen some really poor practice.

I wonder what has happened to our system of maternity care to result in some midwives treating women in such a cavalier way and sometimes being downright cruel. It doesn't fit with what I know of the profession generally. But it is happening.

Spidulika,
"I wonder what has happened to our system of maternity care to result in some midwives treating women in such a cavalier way and sometimes being downright cruel. It doesn't fit with what I know of the profession generally. But it is happening."

See, and this is what you avoid completely by going for an ELCS. Even you admit that midwives can be cruel or really bad.

Raluca, this conversation is going in circles but it seems wrong to me to choose to have a cesarean so you can avoid to be under midwife care! It's an operation that carries many risks, and you needn't assume that your body cannot cope with VB.
I used to think that CS would be easier and safer than VB, till my sister nearly died during her second one, because the doctor accidentally ruptured a vessel and all Ida sudden she started bleeding profusely.

She had a medical reason for both her CSs by the way. I'm due in a few weeks and all I aspire to is being open minded and flexible enough to cope with whatever labour brings; remaining calm is the only way to deal with anything unexpected that may indeed include emcs.

If one has tokophobia, a breech baby, a previous traumatic birth, a bad tear or any other factor that would make VB dangerous for either mum or baby, then CS is a great option.

But a fear or aversion of midwives, honestly, that's a bit extreme...

"See, and this is what you avoid completely by going for an ELCS. Even you admit that midwives can be cruel or really bad."

It'll be midwives who'll be caring for you for afterwards......

And there's a difference between a midwife being unkind and lacking in compassion, and being actually incompetent and dangerous.

Most births are OK, and most women are well and happy afterwards. I think the odds are quite good for women trying for a normal birth. For me they've always been good enough to make the alternative option of major surgery really unattractive. And of course there's always the chance of having a really fantastic experience of labour, the psychological benefits of which can last a lifetime. I wouldn't pass that chance up for the greater certainty of a straightforward c/s.