a little concerned I keep having to explain myself when I say I don't want opiates...

[ardenbird]

So I'm starting to get a bit concerned that I seem to have to explain over and over again when discussing my birth plan or even just talking about my wishes (HV, MW, GP) why I don't want the opiate shot. It makes me worried that even though it's in my birthplan, I'll have to have this argument at the time too, and it would be a very bad idea for me to have the shot.

I've already discussed the issue with my consultant, and given my past reaction to opiates he agrees that I should avoid the shot and go straight to an epidural if I can't cope with gas and air. I don't have an actual allergy, so it doesn't trigger any of those flags. But I have very extreme forms of the typical side effects (e.g., uncontrollable, constant vomiting lasting for a few hours followed by several days of severe nausea and vomiting -- really not the best situation for childbirth or caring for a newborn).

It's just about the most important thing to me in my birthplan, aside from taking care regarding my SPD, and I thought that a simple "NO OPIATES" was the best way to go. But just saying that seems to produce cajoling about how painful labour can be and I should consider opiates, and then I have to explain, no, opiates don't mix well with me. Then they tell me about the antinausea shots they can give at the same time. But since I've already discussed this with the consultant and HE didn't suggest this, plus knowing the severity of my reaction, I'm not hugely convinced they would be particularly useful and really not interested in giving it a try during the birth of my first child when epidurals are also an option. (Maybe during another colonoscopy...)

Will the MWs on the labour ward be better? I'm going into the MLU because I want to use a pool, which has been okayed by my consultant, and they'll transfer me to the CLU if I need an epidural (or the weird condition I have him for causes problems).

How can I best present this in my birth plan to avoid arguments? The back-talk I'm getting about this is starting to worry me, and I'd like to make sure I don't have to do this while in pain.

I had "no pethadine" on my birth pan. I didn't want opiates, didn't want sedation, just pain relief.

Was queried once or twice, but I ( and DH ) stuck to "no pethadine", it was about the only bit of the birth that happened as planned. . I went a bit doolally on G&A, then had epidural & ended up with emergency C section ( after 24 hours of failing induction after waters braking with meconium staining and baby not engaged) so was quite handy that epidural was in already :)

DS had enough on his plate that day without starting life sedated.

I am sorry you are having trouble being heard on this subject, ardenbird - I am baffled by what seems to be a widespread acceptance that pethidine is 'normal' and unproblematic. Pethidine injected into a mother in labour has a much greater effect on a newborn baby than epidural anaesthesia (crossing into the placenta in much greater quantities) - I guess the fact that is a lot cheaper than an epidural and can be administered by MWs rather than anaesthetists/consultants is a big factor in its continued use. (I do understand there are many other factors in comparing spinal
anaesthesia to other 'pain relief' options.)

Can you write it on your arm/hand/arse when you go into labour

You need to make doubly sure that if you end up with an epidural that there are no opiates in the mix too (can depend on the hospital/anesthesist)

I am amazed that any HCP would give you drugs or any sort without your consent. Does this really happen?

Pethidine - my MW told me (at an ante-natal appointment, I ahve never had pethidine myself) that if pethidine is given in the earlier stages of labour ie not during the pushing stage, there is much more chance of it not having an effect on the baby than if it was given at the later stages.

This was in the context of me previously having an extrememely long latent phase, and her suggesting that I tried pethidine if the same happened again.

We get a lot of women come in to discuss their birth plan after they've been to an NCT class and it always says 'No pethidine!' I think the reason your HCPs are trying to argue with you is because they don't know you have this terrible reaction, and for some women opiates actually DO give them some relief, so they think they are being helpful in trying to keep your mind open.

I don't buy the argument that opiates are necessarily A Bad Thing (though my lecturers are almost universally anti-pethidine and have basically told us we are never to give it ). It's bad if it's too far along in labour, but I personally wouldn't hesitate to have pethidine in the earlier stages (although anecdotal information seems to suggest that diamorphine is more effective).

And no, no one would ever inject a drug without the woman's consent!

"We get a lot of women come in to discuss their birth plan after they've been to an NCT class and it always says 'No pethidine!' "

Bue - do you think that's because the NCT are giving unbalanced information on pethidine, or do you think that's because women who attend NCT are being given full, evidence based information on pethidine and are making an informed choice not to have it?

Do you practice evidence based midwifery? Where is the evidence base for pethidine being an effective analgesic?

"And no, no one would ever inject a drug without the woman's consent!"

I think it's very difficult for women to give informed consent in labour when they're exhausted and vulnerable, for a drug which many know nothing about.

I think lots of women are coerced - subtly and not so subtly - into having pethidine in labour. I was. I've seen it happen to other labouring women.

I appreciate it can be useful. But I sometimes wonder whether it's more useful for midwives than it is for mothers.

"if pethidine is given in the earlier stages of labour ie not during the pushing stage, there is much more chance of it not having an effect on the baby"

It WILL have an effect on the baby.

If you have pethidine your baby will be heavily sedated. If you have it early enough in labour there are unlikely to be obvious signs of sedation when your baby is born (like depressed breathing and obviously depressed reflexes). But your baby will still have traces of opioids in their system for many hours following the birth.

From the Australian Prescriber

"Early studies reporting that pethidine had good analgesic effects in labour were unfortunately flawed because efficacy was evaluated by an independent observer rather than the patient. If the patients were interviewed it was 24 hours post-delivery.3

A double-blind randomised controlled trial compared intravenous pethidine with placebo in 84 women during labour. Pethidine provided effective pain relief in only 23.8% of patients compared to 7% of those given placebo. Although this difference is significant (p < 0.05), there was no difference between the median or mean visual analogue pain scores in the pethidine and placebo groups. Pethidine significantly increased the sedation scores, dizziness, nausea and vomiting.4

Comparison with other analgesics
In a randomised controlled trial involving 20 patients in labour, pethidine (up to 1.5 mg/kg) and morphine (up to 0.15 mg/kg) given intravenously produced no significant change in pain scores over time with three doses. Following treatment with opioids 15 of the patients requested an epidural. Nausea was more common with pethidine (6/10) than with morphine (1/10). Patients receiving pethidine were calmer and more euphoric, but both drugs caused similar significant sedation (mean sedation scores 8/10 after three doses). The patients were therefore all significantly sedated and fell asleep during labour, but were awakened by pain during contractions. The researchers concluded that labour pain was not sensitive to systemically administered pethidine or morphine and that it was unethical to treat requests for pain relief by giving sedation.5"

Friend of mine wrote that she had an intolerance to opiates. The mw assumed she was or had been an addict!

Can you put something about not wanting any risk of opiates in your baby and are therefore withdrawing consent to them in any form, direct or through epidural?

I have a severe adverse reaction to a different drug (I'm not allergic, had a nice doctor define that very clearly for me! :) ) My midwife took it very seriously and wrote it all over my notes. I had to wear a nice red wrist band too. I didn't have anyone question it during or after the labour.

If you don't already, perhaps having an explanation in your notes would help? At least that way you can throw you hand up and say "read the notes!" (neck snaking optional)

Mango makes a good point. I have an intolerance (not allergy) to ibuprofen & was given a red wristband to this effect everytime I was admitted to hospital. Can you ask the hospital if they are likely to issue a wristband in this situation. This would solve your problem as they are taken very seriously

It was many years ago when I had my children. There were no epidurals, birth plans etc. My first labour was back to back, two days of active labour contractions at very short intervals so they gave me pethidine (nobody asked you or consulted you in those days!) in the last 12 hours before she was born. Made me sick. They took her away to be 'cot nursed' as they called it for 12 hours and she was so sleepy she would not breastfeed which was incredibly frustrating. The whole thing turned into a vicious circle of wouldn't feed, frustration for me and distress for my daughter. Result one 'difficult' baby, one depressed mother who gave up even trying to breast feed after three weeks.

I refused all drugs second time around and I certainly would not choose pethidine were I having babies today.

The consultant wrote stuff in my notes about my reaction, so it's in there.

I just visited the MLU today (incidentally, taking advantage of an unexpected afternoon in the hospital that turned out to be nothing serious) and gave a dry-run to getting in and out of the pool (I'm in crutches for SPD, so it was a question). I mentioned not using opiates to the ward sister and she was very understanding and also said they don't allow them in the pool anyway! So hopefully it won't even be an issue if i'm in the pool. And it was nice that she listened to me :)