epidurals, forceps, episiotomies,slowing down labour.

[jasper]

I have read and heard that having an epidural increases the chance of a forceps delivery,episiotomy, and may slow down labour.
While I don't think this is a reason not to have an epidural, I am interested to know if

a)this is in fact true
b)why this should be the case.
Is it partly because labours requiring epidurals when taken as a group, will not be the same type of labours as those not requiring epidurals?
i.e. if epidurals are needed it is more likely to be because there are minor complications anyway and it is the complications, not the epidurals which may lead to increased use of forceps/episiotomies?
I suppose it is one of those areas that can never be researched , but I would be interested to hear everyone's views on this.
Incidentally do we have any midwives or obstetricians who contribute to the discussions?
Thanks.

Message withdrawn

jasper

bloss is absolutely right about the "cascade of interventions".

in my case, when i eventually had the epidural(s), they slowed the labour down to a snail's pace, i couldn't move, my "pushing" was really weedy and guess what? i ended up with a ventouse delivery and within a hair's breadth of a forceps or c section.

i kept an open mind about all this prior to my labour but next time would try to avoid an epi if at all possible.

to your point re complications, my baby was in the OP position, so i don't know if that makes me a normal labour or part of "complications" subgroup.

i see the insomnia is no better! not long to go now eh?!

all the best.

Jasper - I had all 3 of mine without epidurals, so I have no personal experience of them. However, I do have friends who had them and went on to have unassisted deliveries. Also, I've heard alot of good things about mobile epidurals - my sister had one for her 2nd, and was able to 'pop' the little one out on all fours (her, not the baby!). Also, I know of friends who had forceps/ventouse deliveries without having an epidural, so I think alot of what happens (regarding delivery) depends on baby's position, size etc, which you can't do much about. Have heard that epidurals are excellent pain relief though. GOOD LUCK - keep us posted and let us know how you are doing!

jasper - your point that some labours 'require epidurals' is interesting - though it may be true in a minority of cases (not being an expert I don't know why) surely mostly it is the mothers who 'require' the epidural as a method of pain relief, not the labour itself?

Also - Bloss - I think it is fairly normal to expect those with private healthcare to have more interventions of all kinds. Apart from real medical need, there are those who are 'too posh to push' and require a planned c section (extremely common in my part of London amongst the notting hill mums!). There is also the fact that many private hospitals have no emergency rooms, so are more likely to intervene if any signs of abornormality occur. And don't forget that in a culture where you are charged for every asprin swallowed, private hospitals have a lot more to gain from expensive procedures whereas an overstretched NHS hospital may delay intervention until they are absolutely sure someone needs it for staffing or cost reasons.

For the record - I had a ventouse (I can never spell it!) without either epidural or episiotomy, and found it extremely helpful. In fact, I requested it after 3.5hrs pushing. Also - the thing about being mobile is that it really helps the baby to come down. However, in my case, when the baby was crowning but unable to make it out of the final bit, I found stirrups (where you have to be on the bed) helpful too, as they seemed to widen the pelvis to it's maximum position. All I can say is, I was really grateful for being allowed to try for so long(32hrs) to have the baby 'naturally', grateful for the enlightened surgeon who told me that I didn't necessarily need a episiotomy for a ventouse as they were 'very old fashioned' and very very grateful for the ventouse itself!

Manna, interesting point about private versus NHS.

One of the things my (NHS) GP told me when I was pregnant was to bear in mind that Obstetricians (sp?)have the highest insurance of any medical professional (she may not be right, but she was a GP and obstetrician). Her point was that some consultants prefer early intervention because they're terrified of anything going wrong. (I had a consultant who wanted me hooked up to a foetal monitor, I didn't want one because I wanted a home birth etc).

I got my home birth with no drugs in the end, but swore afterwards that I'd have an epidural next time! Interested to know for future reference what a mobile epidural is like, since that's what I'd be tempted to go for.

Jaspar, there was a meta-analysis (a combined analysis of all the good published trials available) of epidural analgesia. Epidurals gave better pain relief, but were associated with longer first and second stages of labour, an increased incidence of fetal malposition, and increased use of oxytocin and instrumental vaginal deliveries. There was no significant effect on caesarean section rates.

I think you are right in questioning cause and effect here, if you have a quick uncomplicated delivery than you're much less likely to end up with an epidural. I haven't done any obstetrics for years but my memory is that plenty of women deliver without intervention after an epidural so the the "cascade of intervention" is not always inevitable. On the other hand, that is exactly what happened to me unfortunately.

I had any epidural because the consultant had decided to use forceps as dd was distressed.

Second time round was gas and air only.

Slightly changing the subject but I, literally, thank God that I had an emergency CS - my son had a very unusual medical condition which could not have been detected before birth, had I had a 'natural' birth, we probably would have both died. The CS was performed 'at the last minute' due to DS being very distressed.

BTW - anyone read in today's papers about the baby who died due to the strength that had to be used during a forceps delivery?

Great answers, and no fighting!
Manna, my use of the term "requiring epeidurals "was indeed clumsy, and I should have oput it better - labours where epidurals were given.
Yes, bossykate, insomnia still bad with three weeks to go.
I had an epidural with my first and was delighted to be given it - did not work brilliantly but certainly enough to make the pain go from torture to bearable. Eventualy also had episiotomy and forceps and have nothing but praise and admiration for the care I received all the way through, ie I don't think in my case I was unnecessarily medically managed, but who knows? Maybe this has something to do with my disposition!
Mine was not a mobile epi, but I did lie on my side and not my back, which my midwife tells me is a good position for pushing.Presume it can't be as good as standing .
Incidentally second time around ( gas and air and a big bath of water) despite having the option of moving around/ going on all fours, I had NO inclination to move at all and wanted to be lying down the whole time. This I suppose from a lifetime of lying down when in pain .

Dear Jasper, really hope you get a good nights sleep soon! Haven't really contributed to these pages before, but you asked if any midwives contribute - i am, so i will!
Epidurals do have a tendency to slow labour, for the main reason that, as mentioned, women tend to be immobile. With little help from gravity and an upward climb so to speak, labour is hindered. Lying on your left side however opens your pelvis, and is a great position to adopt (epidural or not).
If labour slows down, a syntometrine infusion is often given to advance labour. thos in turn can occasionally lead to fetal distress, hence the need for a quicker delivery - c/s or ventouse/forceps if fully dilated.
Those who reach full dilatation with an epidural sometimes find that 'urge to push' which is so overwhelming without an epidural, is lacking. Having to be taught to push with little sensation is difficult for any woman!!
Better go, baby crying - and by the way, i had epidural, synto and ventouse!!

Jasper - also note that midwives (Leese please confirm) recommend to go up and down the stairs (not for hours - I only did 8 stairs 3 times) to accelerate... I had just been examined and told I was 3 cm dilated (second labour)... so I said "what can I do to accelerate the blxxxx thing" as one does in these lovely circumstances... she said go up and down your stairs... I didn't want to but I was also not prepared to be in agony for another 7 hours... so I immediately went up the stairs. As soon as I finished this exercise - which I managed to do quite quickly - I was having urges to push.... 30 minutes later I was in the water - delivered 40 minutes later - Needless to say I wish I had done this during my first labour which went ON and ON and ON !
BTW neither labour had any epidural (used homeopathy and water for painrelief) - I would have begged for one (I am not bravour than anyone else) but to my own amazement I did manage it without it.

leese many thanks for stepping out of the closet...now we know you have found you wew won't let you go!
Yes, it was my left side I was advised to lie on for both deliveries.
O
At one point during the first stage ( pre-epidural) my midwife encouraged me to go for a wee walk along the corridor trailing my entonox cylinders as I went, to a sort of day room for labouring women , with a TV, facilities for making snacks etc. She suggested I try squatting on this big bouncy ball thingy, like a spacehopper without horns. "Esther" was on TV...it was all very surreal.
Pupuce did you have gas and air available for your homebirhs?

Jasper, I used a birthing ball as well but that was in the early stages.
There was gas and air for the first home birth but I hated it... so I told them not bother bringing it for the second one.... so I don't know if they did but I wasn't interested.

Jasper, all the research I have ever read suggests that epidurals slow down contractions & this was certainly the case in my own labouring experience. As I understand it, it is the slowing down bit & the being on your back bit which then means that you are more likely to have obstetric intervention.

I had a mobile epidural because after 36 hours of labour I was fully dilated but my contractions were dying away so I had to have the syntocin drip too. I was too tired and too much of a chicken not to have an epidural, as the "artificial" contractions caused by the drug are supposed to be more painful than " natural" contractions. From the time I had the drip to the time my son was born was about 45 minutes, without intervention, and I sat up in bed (the bed was adjusted to become like a seat) so had the benefit of gravity. I would do the same next time, as pushing even with an epidural isn't totally pain-free so I can't imagine what it's like without one!

Hubby is an anaesthetist so my knowledge is a little 2nd hand. But I've heard the "lecture" often enough!!
The density of the epidural depends on the amount and type of anaesthetic used. I had an epidural during my first labour and it could either be topped up to increase pain relief or slowed down to lighten the effect. I could still move my legs, kneel, go on all 4s, but was a little too wobbly to stand and walk around (I could holding onto hubby and bed, but wasn't encouraged as staff were concerned I might hurt myself!)Apart from a retained placenta, needing to be removed in theatre (D+C type of thing) there was no other intervention.

Most women seem to have epidurals because of being

1. knackered and in pain, with no idea of how much longer they have yet to go on for,
2. because of other interventions, ie induction where prostaglandins used often increase the speed and intensity of labour making it more difficult to deal with,
3. poorly postioned baby making labour much more unbearable ie back labours where the baby's back faces your back, thus perhaps pre-disposing the need for further intervention later.

Looking at our local Obstetric hospital stats for uptake of epidurals in 1st labours (45%)and then subsequent ones(only 7%)with intervention rates making similar reading, it certainly backs up no1 above. 2nd time around, you know what to expect and are prepared to go on a little longer before asking for help. Labours are generally quicker too, as the uterus already has a rough idea of what to do, with both faster 1st and 2nd stages.

I know it helps enormously to have a hubby who can take charge of your epidural personally, and that once in situ, the anaesthetist seems to vanish in a puff of smoke, but my tip if you head down the epidural path is to tell your anaesthetist what you want from it. He/she can then set the infusion running to give you the pain relief you need. (Pain free often results in no mobility and thus perhaps a greater chance for intervention later, a lighter effect allows greater mobility but you may not be pain free)

Pupuce - yep, stairs are definitely a good idea, 'specially at home deliveries where you can bomb up and down your own stairs with no odd looks from visiting relatives!! If not stairs, just any mobility is a good thing. However, there have been times i've said - "why don't you go for a little walk", knowing the last six hrs have been spent on the bed, only to be looked at in such a way, that i'm well aware had any object been to hand, i would've been clobbered with it. The knackered woman and exercise don't always mix well, so you have my neverending admiration Pupuce for managing eight stairs three times!!!
Another quick note re: epidurals - not all units offer mobile epidurals, so it's worth checking this out beforehand. Although, as far as I'm aware, all the epidurals are administered in the same way initially (i.e cannula in the back), different hospitals have different policies as to the administration thereafter. Some give bolus 'top - up' doses as req'd via the cannula - this means the effects of the epidural wear off, you feel more and more sensation, and ask for further top ups as needed - i suppose this has the benefit of letting the drug wear off so pushing may be easier to get to grips with. Other units run a continuous infusion of the epidural drug via the cannula. It is set at an initial start rate by the anaesthetist, then the rate altered as necessary. Midwives check how effective the 'block' is every hr or so, by spraying a very cold solution onto your body to see when you can feel it - too high, the rate is lowered, not high enough it may be raised - does all this make sense? - I do have a tendency to ramble when i get the chance!! Of course, you could ask for the rate to be lowered so you could feel a little more sensation to push, but i must be honest, i've yet to meet the woman whom, after having 'her' epidural, is happy for me to reduce the rate!!

Jasper,

I had an epidural with my ds, only as pain relief as I had him in Spain (with the spanish nhs) and it is the only form of pain relief they have.

I dont know whether the dosage would be different over here, but I could still move around and could still feel enough to push. The whole labour lasted 6 hours, so not particularly slow and no intervention was needed.
I did have oxygen though, as apparently the baby receives less oxygen with the anaesthetic, so I suppose in some cases this might lead to problems.

Jasper

I took a birthing class that specialized in "drug free" methods of labor and delivery, putting baby to breast immediately, etc.

After 24 hours labor, no dilation, and being put on a pitocin drip, I said "no more!" and asked for the epidural (with doc's encouragement). Up to then, had been walking, used birthing ball, bath etc. I went on my back and 6 hrs. later had a c-section. Maybe the c-section wouldn't have been necessary had I been able to let gravity continue to work for me, but I will never know. I feel bad about that - especially since I didn't get to hold dd for another 6 hours. Pain relief was amazing, however!

Incidentally, all couples in the class except one had c-sections (various reasons) - at the same hospital. The couple that birthed naturally (and were the last ones to deliver) switched out of the hospital two weeks before delivery and went with a midwife at a birthing center. I think they didn't like the track record!

If I had to do again (and hopefully will!) I would try to do a walking epidural, so I could continue to squat, all fours, etc.

Honeybunny, can you really specify what you want your epidural to be like? I can't imagine they would do that in our jolly, but slightly backward, local hospital. Are you sure it isnt just cos your husband is an anethetist (sp??)?

I posted a message a few weeks ago regarding the prospect of a 4th c/section and my fears etc. No-one else out there experienced this? Oh dear!

Sorry I didn't experience that... Are you pregnant for the 4th time and worried that you'll have a fourth c-section ?

A planned 4th section I'm afraid, due to complications during the birth of my first child - undetected placental abruption with tragic results. Obstetrician will not allow me to go into labour in case of reoccurrence therefore the repeat sections. Each one seems harder to recover from than the last and I just wanted to know if this is typical. Hardly a common experience I know but just my luck.

I had an epidural both times. First time round, I did end up with forceps delivery. Second time round it did not work (i.e the pain remained the same) but I ended up giving birth without intervention. It didn't seem to delay things (in fact I speeded up when the lovely midwife told me she'd have to leave soon because of shift changes - that gave me the oomph I needed and I gave birth a few minutes later!).
The absolute worst thing about epidurals is having to have a catheter (sp?) inserted. You don't notice at the time but BOY did I notice afterwards. It's horrible having this 'thing' attached when you want to move around and I didn't exactly enjoy having it removed.

Epidurals have my vote. I had twins in Nov 2001 in a Germany hospital where c/sections are not elective and they have no gas/air available. I was induced at 10 am, asked for my epidural at 12.30 pm, just as I could start to feel the contractions. Had a nice afternoon nap. It began to wear off around 5 pm which I found helpful because you can just feel the contraction which helps you when you want to push. I still didn't have any pain. Twin 1 was born at 5.49 pm and twin 2 12 mins later. No intervention and no episiotomy, the whole experience was wonderful. I personally felt that I could take in everything that was going on in a calm manner without having to worry about pain.