Epidurals

[forgetmenots]

Starting to think worry about the birth, and reading about pain relief. This is (obviously!) DC1! Talk to me about epidurals, please - full or mobile epidurals.

Can you feel crowning, or tears, when you've had one?
Does the needle hurt, does the catheter hurt?
Does having one outweigh the risk of forceps/ventouse (not sure how relatively painful everything is).
Can you actually get some rest when you've had one?

After reading some threads, it sounds like more and more mums are thinking about ELCS and so I'm just trying to weigh it all up... realising that every birth is different and birth plans go out the window but it seems like there aren't many positive experiences out there, so trying to be as realistic as I can :)

TIA

I gave birth in Denmark so my experience was a bit different. I was induced by having my waters broken and went from1.5 with no noticeable contractions to 3cm and strong contractions every 4min. No more progress in the next 2 hours so I went onto the drip, contractions still very strong but no worse than before. I had a walking epidural asap after the drip was connected. It was wonderful. In Denmark they stop the epidural when you reach 9cm. When I reached 9.5cm the epidural was stopped and I just waited for my body to start to push the baby out. It took almost 4hours for my body to start to push and for all that time all I could feel a pressure but not pain. Once I started pushing the pain started to build up again. I felt that I needed gravity to help so moved onto my knees. Gravity helped and the baby was born in the next 20min. The pushing stage was with no pain relief and it did hurt but it was manageable was the pain was in waves. I had 7 stitches again with no pain relief. Before and after the epidural was active I was intermittentlying throwing up from the pain but I would go through the entire again with no changes.

Here you go forgetmenot - this is from the horse's mouth the Cochrane Index, which is the collection of good quality evidence used to form the basis of NHS recommendations on medical treatments and protocols.

here

Worth noting - 33 of the 38 studies included in the trial compare outcomes for women with epidurals with women who are sedated (with opioids, and therefore probably not very mobile or even necessarily upright). Also that the studies weren't able to control for the effect of continuous care which is known to be associated with lower rates of c/s. I suspect rates of continuous care were higher in the epidural arm of the trial.

Anyway, to put a figure on Ushy's statement that the impact of epidurals on rates of assisted birth is very small, the figures in the trial are, (from the abstract conclusion)

"...epidural analgesia was associated with an increased risk of assisted vaginal birth (RR 1.42, 95% CI 1.28 to 1.57, 23 trials, 7935 women), maternal hypotension (RR 18.23, 95% CI 5.09 to 65.35, eight trials, 2789 women), motor-blockade (RR 31.67, 95% CI 4.33 to 231.51, three trials, 322 women), maternal fever (RR 3.34, 95% CI 2.63 to 4.23, six trials, 2741 women), urinary retention (RR 17.05, 95% CI 4.82 to 60.39, three trials, 283 women)"

One of the most interesting findings of this trial is that women's satisfaction with labour doesn't seem to be influenced by the type of analgesia they ended up having!

There is one good sized study quoted in the Cochrane review, which compared outcomes for first time mums having continuous midwifery care with mums who have continuous care plus and epidural. The epidural rates in the two arms of the trial were 43% and 51% respectively, so as Ushy says, not a huge difference. However, I'm very shocked and surprised at the incredibly high rates of assisted delivery in BOTH arms of the trial, and wonder why this is so very much higher than the assisted delivery rates in low risk first time mums recorded in the Place of Birth study, which was published in the UK in 2011. Overall for all mums in the UK the assisted delivery rate is only 12.%!

I can't get my head around different studies either Shagmundfreud. Perhaps outcome is hugely skewed by which hospital you go to - perhaps different hospitals have really very different policies on when to intervene and how much support they give to labouring women?

Shag the impact of epidurals on assisted delivery rates really is small. The Cochrane review you quoted included ancient studies (back in the 80s) and those types of epidural drugs are not now used in those dosages. Cochrane's are only one of the pieces of evidence used in arriving at NICE guidance.

Women who have epidurals will always have higher instrumental delivery rates simply because there are large numbers of mums having second, third or subsequent babies who have them within twenty minutes of arriving at the hospital. These are usually totally uncomplicated births and there is no opportunity for an epidural.

Satisfaction is not improved by epidurals because, sadly, the UK encourages competitive birthing - tut tut if it is not natural and without pain relief. This gives lots of women the feeling that they have failed if they need an epidural.

This is not the case in countries where there is not the stigma attached to pain relief eg France. What you can be absolutely sure of is that if a women wants an epidural and it is denied, there is no way her satisfaction is going to be improved.

Not read the whole thread. But i thought as id just ha one id share :-D

When i was told i couldnt have a waterbirth i knew id need an epidural because the gas and air really wasnt helping me and my contraction pain was my whole hips and pelvis it was horrendous!
I thankfully got it at 6cm it took about 20mins to kick in but it was beautifull! I knew i was contracting because i felt pressure in my bum. I could feel my legs but i wasnt walking or anything.
What surprised me was that i did top ups myself i didnt realise id get top ups. When it came to pushin i chose not to have anymore top ups so i could feel when i needed to push etc it killed burnt like hell but the relief when he came out was great.

I know this is going a bit off-topic for you, but as Ushy has replied, I would like to ask her about this 2007 study which investigates epidural rates in low-risk women. Fig. 1 shows that when low-risk first-timers opt for an epidural, the chances of c-section jumps to about 30% i.e. nearly a third of women who opt for an epidural have a c-section, when they don't, the rates are near 0%!!! This is incredible. I've scratched and scratched my head over this. It is based in Australia. Don't know if their intervention policies are very different from the UK (I had thought not). Any ideas?

Obviously, all women traditionally at risk from intervention: diabetic, high bp etc were all excluded. Only women considered low risk were used. One assumes that complications would develop in both groups at the same rate? They seperated primi- and multiparous women in the study too and found the trends were more marked in first-timers. Annoyingly, I'm sure I could read the full version when I found it a few months ago and now I can't.

Ushy -
"Women who have epidurals will always have higher instrumental delivery rates simply because there are large numbers of mums having second, third or subsequent babies who have them within twenty minutes of arriving at the hospital. These are usually totally uncomplicated births and there is no opportunity for an epidural.

Yes - it is hard to design research which controls for this, and in all of the studies there are very big cross-overs between the 'non-epidural' and 'epidural' arm. Which is why I think it's interesting to look at the outcomes of the Place of Birth study. This study looked at outcomes for women who are giving place in settings (homebirth and free-standing midwifery units) where epidurals simply aren't available, and opting for one requires transfer, usually by ambulance. That reduces the risk of confounding surely? Can you think of anything else, other than epidural use that would account for the 14.9% assisted delivery rate for healthy mothers who have opted to deliver in obstetric led units (where 30% have an epidural) as opposed to the 4.1% assisted delivery rate among healthy mothers who opt for a home birth, where there is a transfer for epidural rate of only 8.3%? Or even the 5.6% assisted delivery rate for free-standing midwife led units? Still practically only a third of that seen in obstetric led units.

Because there would be similar rates of malpresentation and failure to progress (the main reason for assisted delivery, and the main reason for opting for an epidural other than if a mother has planned in advance to have one) among low risk mothers who plan to give birth in either settings surely?

TBH - if a woman asks a midwife for advice on how to avoid having an assisted delivery, the midwife is still probably right to say either - planned c-section, or plan to have your baby in a setting where epidurals aren't available!

"Satisfaction is not improved by epidurals because, sadly, the UK encourages competitive birthing - tut tut if it is not natural and without pain relief."

"This gives lots of women the feeling that they have failed if they need an epidural."

Well, I think that's a matter of opinion. ;-)

On a personal note, having had an epidural with one birth and not with two, I know what I prefer. I think you have to respect the feelings of individual women on this one. If someone tells you they had a more satisfying birth without an epidural then it's a bit disrespectful to assume that the source of their satisfaction is simply smugness arising from a misplaced sense of competition about coping with pain don't you think?

Just wanted to come back and say thanks to everyone who has posted, I'm reading through the information now so that whatever happens I've at least done my homework and understand the pros and cons. Really appreciate it.

I had an epidural with DS and intend to have one again if I have a similar labour this time (I'm 32 weeks). I was supposed to go to the MLU to give birth, but I had an awful four day hesitant labour - contractions at 4 mins apart, but not dilating for most of that time. When I was eventually admitted to hospital the midwives in the MLU advised me to go to the labour ward to get decent pain relief instead of trying to cope - I was so exhausted they thought I wouldn't be able to push.

I was lucky that it was a quiet night on the ward - got there, had gas and air (which was bliss at first, after nothing but paracetamol at home) and quickly requested an epidural. Id request one early as it sometimes takes time. The midwife didn't bat an eyelid (I've heard of women being talked out of it) and the lovely, lovely anaethsetist arrived about 30 mins later. I hunched over on the bed while they sited the needle. Didn't feel the needle or anything other than the contractions. It worked v quickly and gave blissful pain relief and I got some rest, then got ready to deliver. Contractions continued as normal and I dilated well - it certainly didnt slow my labour.

It was topped up once and by the time DS was delivered a few hours later I could feel a lot, although I'm sure the residual drug in my system dulled the pain somewhat - i could certainly feel contractions, pain and when to push.

No tears, no stitches, no other interventions and DS was born weighing 8lbs 10 (I'm 5'1"). I felt very well afterwards. I walked around and had a shower about an hour later. Midwife was super.

Overall, a very good experience, although there are risks such as the headache and I was v nervous of anything being inserted into my spinal column. I think, if I'd had a quick-ish labour, I might well have got through it on gas 'n' air in a birthing pool, but i felt it was necessary with such a drawn our labour.

LeBFG I think the reason the study you cited showed an apparently huge association between epidurals and caesareans is that it is a population study and although the women might have been low risk at the start of labour many would not have remained so. The ones that developed complications would be the ones who needed c/s, epidurals, instrumental deliveries. It is chicken and egg.

Several researchers therefore looked at what happened to instrumental and caesarean rates in hospitals when they went from having no epidural to having an on demand one.
They found that neither increase as did a recent randomised trial.

www.ncbi.nlm.nih.gov/pubmed/18044297

And most of the new studies are showing no association:

www.ncbi.nlm.nih.gov/pubmed/22931627
www.ncbi.nlm.nih.gov/pubmed?term=The%20influence%20of%20patient-controlled%20epidural%20analgesia%20on%20labor%20progress%20and%20neonatal%20outcome%5D.

NICE has looked at the research on this as has the National Institute of Health in the US and both concluded there is no causal link between epidurals and caesarean section. Definitely none. There may be an increase in assisted deliveries but it is small.

So I guess the message is - go with what you feel is best. If you want epi, go for it, if you don't, don't. Good luck anyway.

Ok this was my experience.
Had a full one with ds2 and LOVED it. The only negative was getting it in. I have bad posture so didn't make it easy for them. They had to keep stopping and starting after my contractions as I could not keep still. It didn't hurt being put in one bit. Took about 30 mins to kick in and I was completely numb. Sat chatting to dh we read the paper did crossword. It was so calm and surreal but wonderful. I had to work with the midwife when it came to pushing as I literally could not feel anything. After 4 pushes and no intervention he was there. I did sustain a 2nd degree tear but obviously didn't feel a thing.
Was completely paralysed for 8 hours but didn't bother me did make it a bit awkward to shuffle round in bed. A tiny bit of back ache the next day. And I did have scabs on my back for a while where they had failed attempts at getting it in.
No side effects for me.
Ds3 due in 6 weeks and the epidrural is MOST certainly on my birth plan. I will be requesting it as soon as I step foot onto delivery suite :-D

Ushy - that first study you provide the link to comes from a system of maternity care where all women in hospital have HIGHLY medicalised care, involving continuous monitoring in labour.

You are not comparing women having active, physiological births with one to one support from midwives skilled in physiological birth, with women having epidurals.

The argument about how epidurals disrupt the normal mechanism of birth mainly revolves around the fact that they restrict a woman's normal movement in labour (even mobile epidurals).

The other studies you link to have heavily sedated and supine women (and also those being continuously monitored - something we KNOW increases the rates of emergency c/s in low risk women without improving outcomes) as the control group. These women have high rates of c/s (as do women in the epidural). Well - no shit, Sherlock!

OP - the bottom line is that healthy women who give birth in environments where epidurals are easily accessed have MUCH higher levels of emergency c/s, and instrumental births than similar women giving birth in environments (home and free standing midwife led units) where epidurals require transfer, usually by ambulance.

OK Ushy. Thanks for the reply. I want to first deal with your three links. THe abstracts are Saudi, Chinese and Polish respectively. In two of the three studies, the epidural group was being compared to opiod pain relief (in one of these it was opiods or gas). In the Chinese study, they don't define the control group in the abstract - but in this paper I find the results very puzzling: there was no difference in oxytocin use between the groups. I find this amazing impossible to believe. It might just represent the reluctance of chinese practitioners to intervene if labour slows down, perhaps they are just more patient? In the Saudi study, although c-section rates were no different, forcep/suction interventions were higher in the epidural groups (more than twice for first-timers and more than 6 times for repeaters!!!).

I would very much like to see these sorts of studies done in the UK or a similar country. Choice of intervention (be it c-section or forceps) is very clearly a judgement call on behalf of the presiding OB. There will be country/county/hospital guidelines for this I would assume?

Epidurals do slow down labour and hasty OBs or guidelines that recommend intervention after x interval will procure different results from places that are more hands-off.

As for my paper, I agree with you. This was my inital thought. But when I read it in full I remember them addressing these issues (perhaps I've misremembered - either way, so annoying we can't now access the full version). So, the only study we can meaningfully discuss is Shagmund's Place of Birth study - where in patients that develop birth complications would be shunted off to hospital. And here, there is a difference. I find this evidence quite strong and convincing.

LeBFG - the problem is that pretty much ALL the research into outcomes associated with epidurals is done in settings where ALL women are having highly medicalised births, where CTG is being used, and where rates of assisted delivery and c/s may be very high (China has a 49% c/s rate I think).

That's not helpful to a mother who's got to make choices about epidural that also involve choices about where she's going to give birth.

I don't think it's unreasonable to say to someone, that there's evidence to suggest they're probably no more likely to have a complicated labour if they opt for an epidural, than if they go to the labour ward, opt for pethidine and spend most of their labour on the bed thereafter. Because both epidural and pethidine are associated with higher rates of abnormal fetal heart rate patterns in labour, and women who've had pethidine may be more likely to end up having CTG (which is associated with higher rates of CS).