OBEM - why are they so anti-epidural?

[babyblabber]

Just watching OBEM and I've been wondering every time I watch it, why are the midwives so anti epidurals? Is it the same all over England? There was another episode recently where a girl was practically begging for one and they talked her out of it (at 3cm) & I just don't know why. I know there are risks but they are minimal and thousands of women give birth every day with epidurals but watching that show would make you think they're a last resort.

I'm just curious really. I'm from Ireland where it's more normal for first time mums to have an epidural than not and it's almost presumed you will. Having had two kids I am a big fan of epidurals and secretly think giving birth without one is a bit mental!

(ps don't want to start a big debate, just wondering!)

"To the extent that a long augmented labour ending in a vaginal birth with a baby hauled out with forceps is not seen as 'abnormal""

I think you'll find most people don't categorise a forceps delivery involving syntocinon as a 'normal' birth. Midwives certainly don't.

"yes - respecting a woman's request when she asks for pain relief has to be the default setting in any humane society".

As someone who is an advocate for natural birth of many years standing, who mixes with A LOT of midwives, I have never heard anyone support the view that women should not be listened to and that they should be routinely denied pain relief if it is available and safe to administer.

"And yet these zealous UK MWs are sticking in needles freely at the same time as frowning on epidurals"

Most midwives don't 'frown' on epidurals. All the midwives I know see them as a valuable and important tool for childbirth. They do worry about epidural use becoming routine in childbirth, as it has done in other countries which have obstetric led maternity care. Most midwives have concerns about the use of opioids in labour. I know a good number of midwives who see pethidine as a useless drug, who are happy to communicate this view to their clients. Some hospitals (for example St Thomas's) have stopped offering it to labouring mothers.

"I don't see why a lot of natural birth advocates talk about hormones and interrupting the natural flow while ignoring the fact that women are basically being drugged into artifical 'highs' "

I think you'll find they don't ignore this. They are also VERY concerned about the widespread use of opioids in labour.

"From a mental health pov, not to mention the effect on newborns of opiates, I find that a bit disturbing."

I'm not aware that there is any research flagging up concerns about women's mental health following a childbirth involving sedation with opioids, which you'd expect there to be if there was anything to worry about in relation to this given that they've been used in birth for centuries. All 'natural birth' advocates I know worry about the impact of pethidine on newborns.

Point being made: it is false to assume that midwives are generally 'anti epidural' and 'pro pethidine'. They value epidurals for women who can't cope with labour pain, and for complicated labours; most midwives do have concerns about the use of pethidine.

It seems very very odd to me that there is no research into the effect on women's mental health relating to the use of opioids during labour. And that because there is no research, that must mean everything's fine!

For a start, Twilight Sleep had a pretty serious effect on a lot of women. And there have been plenty of posts here from women who took pethidine and loathed it, feeling alienated and dissociated from the whole process of birth.

How strange none of that is a concern, but epidurals are. I guess it comes
down to money. Or a lack of concern about mental and emotional well being.

Actually, this is interesting (10 seconds on Google threw this up) -

www.macllp.com/child_birth_anesthesia/opioids.cfm

Just info from a hospital in the US about childbirth anaesthesia. It points out that opiods sedate both mother and baby - and "higher doses are accompanied by the dulling of all senses, leading to altered consciousness, and a reduced urge to breath. In worst cases these drugs can dangerously impair breathing in the mother and, more commonly, in her newborn."

I'll take the epidural/spinal, thanks. If anyone thinks that giving birth in a state of drug induced altered consciousness ain't a problem - well, that's their choice, I guess.

banana87 I've been induced twice and didn't have an epidural and didn't feel the need for one, even with my first where I had a very long second stage. Interestingly when I spoke to the MW who had been with me early in labour after the birth she said 'oh, maybe you should have had an epidural' whereas although it took forevre I'd say I felt exhausted rather than in insufferable pain. So I certainly wasn't discouraged from having one by the MWs. In comparison my third was a classic short sharp induced birth and although it was intense and I only had about two puffs of G&A due to how quickly it ramped up I never felt like I couldn't cope with the pain. I work in the pharm industry and don't have any issues with using pain relief but personally I didn't need it. I would have had a worse experience if I had been forced to have an epidural, choice works both ways and it is as bad to insist on one as it is to refuse one.

FWIW the cascade of intervention is bullshit as well, a moments thought shows that if mothers are offered a series of interventions then obvious all the ones who would have ended up up having a CS will have had all of the others. It does not follow that the intervening interventions caused the CS. I for one avoided a CS thanks to the lesser interventions I had with DS.

"It seems very very odd to me that there is no research into the effect on women's mental health relating to the use of opioids during labour"

Or indeed of the effect on women's mental health of the use of epidurals in labour, as these profoundly impact on the normal hormonal physiology of both labour and the immediate postnatal period.

As for there being a lack of concern about the emotional wellbeing of mothers and babies among health professionals - all I can say rain is that you should go and have a look at the main stream midwifery journals in the UK, Practising Midwife, British Journal of Midwifery - as these have articles and research papers about these subjects in every single issue. Midwives do care about these things.

"I'll take the epidural/spinal, thanks"

That's fair enough, but can I just point out that epidurals contain opioids too? Fentanyl usually, which is a very, very strong opioid. That's why some women experience pruritis after the administration of an epidural.

"If anyone thinks that giving birth in a state of drug induced altered consciousness ain't a problem"

But if you have an epidural you are also in a drug induced state of altered consciousness, compared to what you would experience if you weren't taking a powerful drug! Without an epidural you'd have extremely high levels of endorphin and oxytocin in your body, which have a profound impact on feelings and sensations.

You have a lot to learn about epidural anaesthesia. A good place to start might be mumsnet's own webchat with David Bogod, here - www.mumsnet.com/onlinechats/david-bogod

Among many other things.... "... epidural doses of fentanyl over 100mcg do have an effect on the baby. In practice, doses of this level aren't often used. Even if they are, the effects of pethidine or diamorphine in sedating the baby are many times greater and last considerably longer."

And "oxytocin levels aren't affected by epidurals." (this specifically in response to a question: 'Could you tell me anything about the effects of of epidural anaesthesia on the birth hormone oxytocin and any implications this may have for the baby or mother post-birth?')

This webchat with an obstetric anaesthetist would actually be really useful for a lot of women on this thread. It is science based myth busting, and concerned with actual evidence rather than woo. Very useful.

It's not true to say that midwives don't like epidurals as it means more work for them.

Generally the opposite is true. If the woman I'm looking after has an epidural then I can't be given anyone else to look after no matter how busy the ward gets. If I already have two women I'm looking after then someone else will have to take my second woman so I can stay with the one having an epidural.

So from my point of view a woman having an epidural is a good thing as far as my work load is concerned. It's easier to look after one person with an epidural rather than two women without epidurals and a postnatal woman!

To be honest there's an argument that care of a woman with an epidural is easier full stop, there may be more obs to do and another chart to fill out but there is generally less encouragement, etc needed as the pain is gone.

I don't watch obem but where I work its unlikely anyone would get an epidural at 3cm.......women are meant to be in established labour so 4cm. At 3cm its possible that labour stops and doesn't start again for a few days. If there's an epidural on board then you'd either need to stop it in such a case and send the woman home. Or more likely the dr would decide to induce as "we're now committed" and break the waters.

I wonder if my epi slowed down my first birth, but tbh, the pain was so bad I was out of my skull. She was face up, with her right hand up cupping her head above the ear. I was in agony for hours, all night, begging. She wound up an H-F forceps delivery and I have no regrets. Cons got in and first thing she said was, 'Oh, little one, your wee handie shouldn't be up there!' and then, 'Oh, wee one is looking at the stars!' The pain was so bad before the epi I truly wanted to die.

I def should have had epi first time, the pain was too much, I was strangly calm going into labour after years of fear of CB, irrationally thinking about it too much, I felt strangly calm and safe, I had a nice easy build up of two days of contractions before establised labour.
I got terrific support but I asked for an epidural when i felt I could not cope anymore, I had done my research into it all, and yet I was steered towards pethadine, as someone said up thread, you feel the pain but you care a bit less.

Pain is pain though.

i just cant see dentists advising people to breath through a tooth absess, my mother used to say that tooth ache - and child birth were on a par, she had four DC in the 60's/70's. Including an emergency cs.

The thing is - mother hood is a life long thing, and when your at the starting gate you can loose site of that and you get all caught up in how you have to have a natural birth and shouldnt need pain relief because the body can do it, and you shouldnt give in, but if you do need pain relief - you have " given in", and then the BF and its all a big package all along with companies flogging first timers huge travel systems they spend 600 quid plus on, they want to start so well , be soo good.

its hard to be soo good two years down the line when your toddler is pushing every single boundary and you have been up all night with them, and have them alone all day, they wont eat, they are too thin, etcetc or your ten year old is playing up and wont play ball and your so scared about them and how to handle them or your teenager seems to be falling in with the wrong crowd or seems to be getting too fat or too thin... etc etc etc.

Can you still apply this purity and severity and strictness then,this total selflessness all for the baby.

Are these people still carrying through I would love to know.

Was all for a natural birth pre DD1, like so many. The books had me well convinced, a needle in my back was unthinkable, hypnobirthing all the way etc. But you just can't legislate for everything in labour, can you? My waters broke and labour was just so explosive from the start. I was trying to communicate to my midwife that I really felt DC was coming NOW but because I 'looked' quite calm and because my birth plan was all 'don't give me loads of VEs', she suggested, at the very point where I felt I just couldn't go on, that she 'check me again in 4 hours'. I broke and got DP to organise the epi. Midwife (this was in Ireland) was a bit are you sure? (trying to be supportive of my birth plan, I think) but organised it straight away. It was the worst pain ever sitting up on that bed getting the needle in my back. BUT it was so wonderful to get a relief from the pain and I dilated fully within minutes and went on to have a great birth.

Still would really like to try to avoid epi if there's ever a DC2, just because of the risks and because at least I know now what is happening during labour. But I've totally given up on this fetishing of natural birth stuff. I really see the big picture now.

Great post elizaregina

Interesting hearing opinions from MWs - reading a lot on MN about birth it's easy to assume MWs are using pethidine a lot. Certainly was the case for my sisters....but no idea how widespread this is.

Interesting reading about workload too. When I gave birth first time around there were three women (including me) giving birth at the same time - one MW on duty. She was able to do this because we all had the epidural and all hooked up to the monitor so she could do 'remote' monitoring of our progress. With my second birth I was advised by the OB to hire a private MW as I didn't want an epi or continual monitoring and thus would need a MW with me at all times and the OB couldn't guarantee I would have access to this.

But I've totally given up on this fetishing of natural birth stuff. Good for you. I feel we should be viewing births and birth pain as just 'normal' birth. No fetishising. Acceptance that pain is part and parcel of the birth process, intricately linked to the release of hormones etc. I would like less fear to be associated with birthing - there is a common perception of overwhelming pain associated with childbirth which isn't (always) true. When we get rid of the fetishisation, we (as a group of women) will also be happier with the epidural - accepting it if required.

Eliza - labour is over for most people in 24 hours (or 36 in my case) no matter how painful it is. Struggling as I am now with an autistic child and an aggressive and unhappy teenager I look back on my very long, painful and unmedicated labours as a breeze - at least those are two things I managed to do in the way I wanted and the sense of achievement I felt at the time is still with me.

If I came on to this thread and rubbished and trivialised women's reasons for wanting an epidural, characterised them as 'weakness' or 'cowardice' I'd quite rightly draw a huge amount of flak.

So why is it acceptable to characterise the motives of women wanting a drug free labour as pointless perfectionism or competitiveness? Can people not accept that some women feel very strongly that having an unmedicated labour is important to them, and that its disrespectful to trivialise their beliefs and feelings as silly and without value?

Also wanted to add that the view that it's unrealistic and perfectionist to want or expect to labour without an epidural - according to the POB study only one healthy woman in ten needed to transfer to hospital for an epidural from out of hospital birth settings. If you excluded first time mothers from that sample it would go down to 2 in a 100.

"there is a common perception of overwhelming pain associated with childbirth which isn't (always) true."

And more to the point, overwhelming pain in labour isn't necessarily intrinsically pathological, traumatizing or impossible to get through without an epidural.

It's an absolute myth that the only women who cope well without epidurals are women who have straightforward, short or 'easy' labours.

Acceptance that pain is part and parcel of the birth process, intricately linked to the release of hormones etc

Yeah. I agree. Because I had been led to believe by all of the natural birth hypno stuff (and I read LOADS of it) that if you weren't afraid, labour would progress smoothly and that the pain would be minimal/manageable. I wasn't afraid when I went into labour. I was pissed off (because DP woke up when my waters broke) and wanted to be alone in a dark cave. The pain was huge, unreal, but as long as I felt it was going somewhere it was just about manageable. I went into hospital when my contractions were 3 mins apart and still wasn't afraid, was psyched, ready to do it. But fuck me, don't tell me that it didn't hurt. I got afraid when I thought that my own feelings (that the birth would be happening SOON and I could start pushing SOON) were apparently at odds with what was happening down below (only at 4-5cm, midwife saying she'd see how I was getting on in 4 hours). That scared me beyond belief, when I thought I had got it so wrong.

And the mobile/'light' epi sorted me right out: when the pain went the fear went and I jumped to 10cm in minutes, pushed out my baby with no tearing or episiostomy, was flooded with amazement and delight to see her, breastfed within minutes. So...I am all for a frank acknowledgement that intense pain is part and parcel of MANY if not MOST labours. Have only had one so cannot compare. My mother has had 5 labours and a couple were straightforward, quick and 'easy'. Her first and her last were intensely painful and traumatic.

So why is it acceptable to characterise the motives of women wanting a drug free labour as pointless perfectionism or competitiveness? Can people not accept that some women feel very strongly that having an unmedicated labour is important to them, and that its disrespectful to trivialise their beliefs and feelings as silly and without value?

It isn't. I accept that. I'd absolutely love to have an unmedicated labour. I'd never trivialise that wish, because I share it. Can absolutely understand why your births represent moments in your life you return to and cherish at difficult times. However, I am personally very wary of adopting absolute attitudes - either NO DRUGS EVER or ALWAYS DRUGS HIDEOUS PAIN - about any of this stuff. I feel that there are always shades of grey.

"This webchat with an obstetric anaesthetist would actually be really useful for a lot of women on this thread. It is science based myth busting, and concerned with actual evidence rather than woo. Very useful."

Also useful to look at the information on the website of the Society of Obstetric Anaesthetists, here and the Cochrane Index reviews, http://www.thecochranelibrary.com/details/browseReviews/579369/Pharmacological-methods.html here which rain I think you'll agree are not 'woo'. Especially the latter which are systematic reviews of a very wide range of evidence.

From the patient information leaflet on the Obstetric Anaesthetists' website:

• With an epidural, the chance of the obstetrician having

to use a ventouse or forceps to deliver your baby is 14%. Without an epidural it is 7%.

• With an epidural, the second stage of labour (when your cervix is fully dilated) is longer and you are more likely to need medication (oxytocin) to make contractions stronger.

• You may develop a fever, which may be associated with

distress to your baby.

• If you have higher doses of opioid through an epidural,

your newborn baby may be more likely to need help with breathing (see reference 12 on page 15) and you may have less chance of breastfeeding successfully (see reference 13 on page 15).

But you know, I made no comment about babies being affected by the opioids in epidurals, only acknowledged that fentanyl is usually used in epidurals.

Re: oxytocin and syntocinon - I find it interesting that an obstetric anaesthetist talks about these two things as though they are identical. Syntocinon is NOT oxytocin. It's a synthetic version of it and they don't necessarily work on the human brain in the same way. In any case, it's utterly bizarre to suggest that oxytocin levels aren't affected by epidurals. If this was the case then why on earth would they have to give most women with epidurals syntocinon? If they still had optimal oxytocin levels after the administration of the epidural they wouldn't need it!

"However, I am personally very wary of adopting absolute attitudes - either NO DRUGS EVER or ALWAYS DRUGS HIDEOUS PAIN - about any of this stuff. I feel that there are always shades of grey."

You know - I don't think ANYONE on this thread or anywhere else has said or implied 'no drugs ever' or 'always drugs'. I don't know any midwives or natural birth advocates who don't believe that epidural has an important role to play in modern obstetrics. I think it's not helpful to suggest that this sort of absolutist thinking is common.

here

Cochrane

I think the reason why some women have very strong feelings about pain relief and whether they don't want to have it, or feel that they did something 'wrong' by having is comes down to the attitude of some people and tutors - "if you weren't afraid, labour would progress smoothly and that the pain would be minimal/manageable" (not picking on you, curtsey, I completely agree with your post, it was just as well written phrase).

I fully believe that every woman should aim for and hopefully be facilitated to have the birth experience that they want. So if they want a home birth, or a water birth, or a pain relief birth, they should be encouraged to do that. Equally if they are of the mindset that they would like an epidural as early as possible, that should be allowed (workloads allowing etc).

However when women embrace the concept that accepting the pain and embracing the process will result in a relatively pain-free, or manageable labour, and then they find the pain overwhelming, or their labour lasts a long time and they are exhausted, and they then opt for pain relief - that is when some women struggle afterwards and feel that they failed somehow. People who are then militant that it was their own acceptable of labour pain allowed them to have a pain-free birth don't help the situation. Sometimes labours just are slow, or the baby is back-to-back, or other reasons which are completely out of the woman's control in terms of managing their pain and exhaustion.

I really do wish that some women wouldn't knock others for taking pain relief early, and others wouldn't mock a desire for a natural birth.

Oh - and for those of you who are interested, this is what the Cochrane review of 38 trials (of which all but 5 compared epidurals with opioids) involving 9658 women overall found:

"Epidurals relieved labour pain better than other types of pain medication but led to more use of instruments to assist with the birth. Caesarean delivery rates did not differ overall and nor were there effects of the epidural on the baby soon after birth; fewer babies needed a drug (naloxone) to counter opiate use by the mother for pain relief. The risk of caesarean section for fetal distress was increased. Women who used epidurals were more likely to have a longer delivery (second stage of labour), needed their labour contractions stimulated with oxytocin, experienced very low blood pressure, were unable to move for a period of time after the birth (motor blockage), had problems passing urine (fluid retention) and suffered fever. Long-term backache was no different. Further research on reducing the adverse outcomes with epidurals would be helpful."

"I really do wish that some women wouldn't knock others for taking pain relief early"

Yes, me too.

However, I have rarely heard anyone doing this on mumsnet or in r/.

Big needle near my spinal cord didn't appeal.

No one suggested it and I would have said no if they had.

Pethidine sent me to sleep for a few minutes, otherwise pretty useless.

Best pain killer by far was DH rubbing the top of my legs because DD1 had squashed my sciatic nerve. Contractions were a minor annoyance compared with the pain in my legs.

DD2 was born at home so I could keep walking about and wandering up and down stairs thus preventing her wedging herself on said nerve.

I get way more frighteningly painful constipation than either of themselves contractions.

The knocking or the taking pain relief early?

The only person I know of who had an 'issue' free birth was, weirdly, an American (but over here in the UK) who had an epi at 4cm and actually had an easy birth, no tearing etc. Not saying that as anything like proof epidurals are fine, just thought it was interesting.

I do pick up a bit of militancy sometimes on the MN boards about embracing the pain and there's a sense of looking down on women who don't 'embrace the pain'. And very weirdly I had a night out with my NCT group when our babies with about a year old and one of them rehashed our births and was basically working through everyone's reasons for having and epidural or an emcs! It was very odd. Two of the group had emcs's because their baby was pretty much stuck; she seemed to judge that as them failing! I had one because my baby was found to be ill, she deemed that an acceptable reason Though she seemed disappointed in me for only getting to 4cm in 36 hours!

I was induced for both my DCs. I had an epi with my first and it was the best thing since sliced bread! Had my second 3 years later with just G&A. All pregnancies and births are different. I don't regret my epi but found my second birth easier to deal with so didn't need one. There are no medals on offer for a drug free birth!

First off; I think every woman, once made aware of the risks, should be able to request and have one.

That said, I can see the midwives point. Fear can drive you rather than the actual pain. The assurance that it can be done or (in my case) the absnece of the option can push you through.

I had done hypnobirth training and laboured on a packed commuter train before getting home to do the 45 min drive. When we got through the doors I asked for an epi, the fear of it getting worse drove me. In hindsight I was in transition. Midwife wasn't convinced I was in labour, waters went 5 minutes later and I was ready to go, DD was born 90 mins later. I got off of the bed within 1/2 hour of having 3 little stitches. There was no way I needed it. BUT had I of been at home, I would have gone in earlier and got one, I do think this would have slowed down the birth and if nothing else led to a less enjoyable, bed bound experience for me.

However when women embrace the concept that accepting the pain and embracing the process will result in a relatively pain-free, or manageable labour, and then they find the pain overwhelming, or their labour lasts a long time and they are exhausted, and they then opt for pain relief - that is when some women struggle afterwards and feel that they failed somehow.

Yep, exactly, Thurlow. I'm a bit of a people-pleaser and interested in health generally and I like doing things according to how the experts say it should ideally be done. I think I did want a medal, actually - and I felt so annoyed with about myself for not having been 'tough' enough. Even though the actual pushing part and bonding experience with the baby went really well.

I've witnessed lots of absolutist thinking re. childbirth, I think it is fairly common! Perhaps more so in RL and on other forums than here on MN. Both the kind of person who deconstructs your birth to see where you went wrong, and also the kind of person who will tell anyone who's listening to 'never make a birth plan, as soon as you go into hospital it goes out the window, take every drug on offer'.

But ultimately, even though I had a great experience with the epi, I do not want to have another one if I ever have another dc. If it works out that way so be it, but the risks are undoubtedly there.