Epidural questions - Why the stigma attached

[horseshoe]

I had one with DD1, G&A with DD2, desperately trying for a home birth for DC3.

I have said to the MW that if I end up going to hospital I am just gonna ask for epidural if I feel I want one to which she replied "Oh you dont want one of those".

With DD1 I did have vontouse delivery but I had epi after 18 hours of labour when I was 8cm dialated and before they realised that baby was back to back and getting stuck in birth canal.

Everyone I speak to especially "angellic "i've had 3 natural no drugs birth sis" appears to look down their noses at this decision.

So can anyone tell me why they are so wrong and what is the best time to have one - nearer birth or early labour. I seem to remeber that they wait until at least 4cm dialated.

Also I have actually really enjoyed this discussion as much as I am aware none of us are going to change their view point.
Personally I think we all want the same basic right, our own choice of how and where we give birth in my case it is with a mobile epi in a calm and supportive atmosphere in other peoples cases it is without any intervention in a calm and supportive atmosphere. This is what needs to be worked towards.

However I am now off to bed.

"for a start they only accept low risk cases which is why I have pointed out it really isn't a fair comparison to compare the safety records of a hospital and a midwife led unit."

Actually the research into impact of place of birth on birth outcomes takes this into account. All the good quality studies try to compare like with like - so they look at outcomes for low risk mums birthing in CLU's/at home/in MLU rather than making undiscriminating comparisons.

"my primary reason, which I also stated, for not going to a midwife led unit is IF there are complications during my labour, of which there is ALWAYS a risk, I want a doctor 30 seconds away"

Fair do's - as long as you're aware that according to current research, as a low risk mum you're about twice as likely to end up having a c-section or an instrumental birth if you book into a CLU than if you birth at home with midwifery care and signficantly more likely to need interventions than if you book into a MLU. But if you're not averse to obstetric input into your labour then that probably won't worry you.

Of course it's all about weighing up risks. Every birth has an element of risk. I was not allowed to deliver in a midwife led unit for my dc3 because I'd had a csection with dc2. A CLU was the only option, unless I'd really stuck my neck out and insisted on a home birth which I wasnt prepared to do because of the small risk of scar rupture. So I went to a CLU and tried to keep the experience as natural as possible, though TBH I found the lack of continuity in care, the doctors rushing around and wanting to intervene rather than allowing me to labour naturally, pretty off putting. I had a natural birth, but the fact that the environment was hugely medicalised was not nice. However, you are still missing the point that unless you are fall into the risky category, midwife led units are exceptionally safe. Having a baby is not an illness. For the vast majority it is a straightforward process. It doesnt need a doctor. The doctors who tried to intervene during my 3rd birth were a hindrance, not a help. IME they were far too ready to offer drugs. In contrast, the midwife who delivered my first baby (big baby, first labour, long and painful) was amazing. As sabire describes beautifully, it is an incredible thing to find within yourself the resources to acheive that.

At the risk of repeating other posts, I would just like to echo the points re MLUs being safe. In our local MLU which has an absolutely fantastic record and reputation you are almost certain to get 1-1 midwife care, quite likely with your own comunity midwife - in hospital this would be very unlikely. The midwives here play it very safe regarding transfer if there are any warning signs. I was transferred to hospital in labour because of a very long second stage (in the end was a natural delivery.)It was a horrid 15 mins in the ambulance but I do not regret it for a second - would much rather have had the majority of my labour in the MLU. Not to mention of course the difference in postnatal support, breastfeeding support etc (available of course to women who've given birth elsewhere.)
FWIW, I have hung on to two things I remember being said while pg last time - sorry, no evidence or references, just what I was told!

• the number of women who would have an emergency requiring a doctor to be literally 30 seconds away is very, very small

-in a MLU, the midwives will be very alert for 'warning signs' throughout labour and transfer women to a CLU in plenty of time

• oh and, obstetricians are experts in 'abnormal' birth, midwives are experts in 'normal' birth - both equally important and neither better or worse choices.

Wanted to add - don't know what Libra's CLU is like, but I can tell her about ours.

The midwives on our CLU are flying by the seat of their pants the whole time, caring for several women at once. If you go on to the CLU as a low risk mum you are ignored for most of your labour because staff are too busy attending to the higher risk mothers who need their attention.

If, once you come into this busy, stressfull environment your labour stalls (as it so often does - most c-sections in labour are due to 'failure to progress') then you will seen by a bleary eyed registrar with stains down their coat - probably one who doens't speak English very well, who doesn't look you in the eye or address you by name. If things go seriously pear shaped they'll call in a consultant, but they tend to have to go VERY pear shaped first.

The ward is often quite dirty and chaotic. Staff come in and out borrowing bits of equipment. You only get one pillow. You have almost no furniture in the room apart from a bed (which you're expected to lie on most of the time) and a plastic chair for partners. There is nowhere to buy food, but anyway they discourage you from eating in active labour (so you better deliver fast before you run out of energy to push your baby out).

After you give birth you are transferred up onto a dirty, crowded postnatal ward and your partner has to go home.

The MLU on the other hand guarantees one to one care. The midwives who work there are the cream of the crop because competition for jobs in low tech units tends to be fierce. The rooms are quiet, clean and well equipped. There's a kitchen where you can warm up food and prepare hot drinks. Most of the rooms have pools and mood lighting. After you give birth you and your partner can stay together until you're discharged.

The only low risk mums I know locally who opt for the CLU over the MLU are those who want an epidural from the word go.

Purple - I agree with you.

When I was "allowed" a HB, the MW assured me that at the first sign of trouble they would have me in an ambulance on the way to hospital. In hospital they tend to moniter you for a bit before making decisions on what to do.

Also for alot of Emergency CS, it takes so long to set up the epi anyway and so while I was being transferred they would be getting it all ready. Luckily I live Very near a hospital.....not sure if I would of considered it if I was farther away.

I have searched for MLU, but I have no local ones

horseshoe - i'm with you 100%. if you want an epidural go for it. i had a very long and painful first labour and requested an epi part way through. (it took 8 hours to get one - but that's another story). I was left traumatized by my birth experience and during my second pregnancy i was very anxious about birth.

i found the mws i met during my pregnancy to be largely dismissive of my wishes which made my anxiety worse as I didn't feel i could trust them as they didn't take my fears seriously. My brother is a consultant anaesthetist and i discussed the issues with him at length. i believe i am well informed and able to make a rational decision about what's best for me and my baby - but time after time mws would be very negative about epidurals and prefer to recommend pethidine etc.

As for why this happens - personally I put some of this down to professional control - if you have an epi then it's a doctor (anaethetist) not the mw who's in charge. I suppose also some mothers take birth very seriously and for them it's part of their self-esteem and identity and they are proud of not needing medical intervention. But there are equally some mothers - and i count myself among them - who just want a birth that is safe and as painless as possible.

I am more than happy for people to have homebirths, do hypno-birthing etc etc it's not what i want but it's up to them - but personally i found labour very painful and scarey and wanted to have an epidural. I don't think this makes me a bad person but there have been many times when midwives have made me feel like this and that makes me very angry.

I wish people would let others make their own choices and not 'look down' on other people's choices about birth. I have 2 kids and IMO i think the important bit is how you look after your kids - not the (hopefully!) short bit when you're squeezing them out!!!

Good luck to you Horseshoe - do whatever feels right for you. (And BTW you need to be 4cm dilated to get an epi - but ask for one asap and make sure it's in your birth plan. Most hospitals have a standard protocol about their provision of epidurals and you can ask them for it if you have any questions or the mw is not taking you seriously.) My mw suggested explaining clearly to any mw treating you why you want an epi if you have strong views as the assumption tends to be 2nd and 3rd time mums won't 'need' one (their words not mine).

"But there are equally some mothers - and i count myself among them - who just want a birth that is safe ....as possible."

Have to say - that part of what most mothers I know who choose a homebirth, particularly those who choose a homebirth after having had a birth in a CLU, is their belief that staying at home is actually healthier and safer for themselves and their babies. It's not all about having an 'empowering' experience.

I'm also not sure I agree with you 100% that midwives are negative about epidurals because they don't want to lose control of the mother's care (though I suspect this may be true in some cases). Many midwives are very concerned by the rapid decline over the past few years in the number of low risk, healthy mothers having normal births (by normal in this context I mean births without the use of forceps, ventouse and c-section). There's a real preoccupation with this issue in midwifery education and debate. Most midwives see increasing rates of epidural use as part of the problem and feel that normal birth rates would increase if epidural rates went down. That doesn't excuse the way they've spoken to you on this issue though - primarily their job is to empower you to achieve the birth you want, not the birth they feel would be healthier for you and your baby.

Re: your midwife's suggesting that you should explain to the midwives providing your care in labour why you want an epidural - I personally don't think you should have to justify your choice to your caregivers or use any sort of persuasion. It's really not right that you should have to do this in labour - it puts too much stress on you. I would suggest the 'broken record' technique as described by Nicky Wesson (I used it with my consultant when I was trying to book a homebirth). Goes something like this: "I would like an epidural now: please can you send for the anaesthetist" Midwife: "Are you sure you need one? You're making really good progress and it could slow your labour down". Mum, "I appreciate your concern but I want an epidural now: please can you send for the anaesthetist." Repeat as necessary. Don't explain and don't justify. That's their job, not yours!

Aarrgh - bad grammar and typos!

Have to say - most mothers I know who choose a homebirth, particularly those who choose a homebirth after having had a birth in a CLU, do so in the belief that staying at home is actually healthier and safer for themselves and their babies. It's not all about having an 'empowering' experience.

"If, once you come into this busy, stressfull environment your labour stalls (as it so often does - most c-sections in labour are due to 'failure to progress') then you will seen by a bleary eyed registrar with stains down their coat - probably one who doens't speak English very well, who doesn't look you in the eye or address you by name."

I actually find this quite offensive knowing a lot of registrars, if I turned round and said I thought all midwives were jumped up non-medics who think they knew more than they do which can cause outcomes much worse than what would have happened under proper medical care you would quite rightly jump down my throat about it. There are bad doctors and bad midwives, there are good doctors and good midwives.

I am sure not every CLU is like yours just like I am sure not every MLU is like yours. I just wish we could have a happy medium where there is access to all medical intervention needed but ALSO enough midwifes and a clean and secure environment for what you call a natural birth. I am seriously bemused why we can't have the best of all worlds on this occasion seeing as the resources are in place for either/or.

sabire - i don't want to generalise about midwives, i'm sure you're right about some of the reasons why they are anti-epi. there's many factors i'm sure. but sadly i met quite a few who were ill-informed and dismissive.

we all clearly have different opinions about what is best for us and our babies - and can cite evidence pro and against most things! my point is that you should be allowed to choose for yourself and your informed decisions should be respected - not derided - by those caring for you.

Don't know where you live Libra. I'm in London. Most large CLU's around where I am are like my local hospital - very, very busy and understaffed, with high c-section rates and low rates of normal births. There are three MLU's within travelling distance of where I live. They all offer one to one midwifery care, the option of waterbirth and the chance for families to stay together after the birth.

And yes - I shouldn't have generalised in that offensive way about registrars.

I'm only reflecting on my experience and the experience of many of the others I know. And of course being grubby, knackered and not speaking good English doesn't make you a bad doctor.

By the way - I'm sure I didn't say anything about 'natural' birth. I've been talking about 'normal' births - ie, births without interventions.

Unfortunately the money DOESN'T seem to be there to provide the sort of care that women want and need. Perhaps if one in four women didn't end up needing major abdominal surgery to give birth there wouldn't be such pressure on NHS finances.... but reducing the rates of c-section would require increasing staffing levels..... and we can't afford to do that while shelling out for so much surgery..... it's a vicious cycle......

But the money is there, as you say yourself the MLU you know have well-staffed, comfortable surroundings why this can't be provided in a hospital or at least hospital grounds so the doctors are on-hand if neccessary I don't understand, surely the MLU money must come from the NHS budget.

I think if docs and midwives stopped seeing each other as the enemy that might help as well. (A generalisation but as you said we can only go on personal experiences and the docs I know aren't usually very complimentary about midwives in general)

I think we both want the same thing we are just coming at it from different directions

I have to say that although it's anecdotal, my experiences have been similar to sabire's. The MLU where I delivered had fantastic one-to-one care. The CLU was chaotic, understaffed and not a conducive atmosphere to having a natural birth. The Csection rate was over 20% - it's hard to believe that all those csections are a medical necessity. I wonder how many are a result of the cascade of interventions .I think Libra makes an interesting point: in some respects, I think doctors and midwives maybe feel threatened by eachother's roles. As I see it, a midwife should be the specialist for any normal, straightforward delivery. A normal birth does NOT need a doctor or surgeon! When I had my dc1 at the MLU, I had some interesting chats with the midwives. They all saw working in a MLU as the 'top' job - many of them had moved from big hospitals because they were fed up of feeling that they were playing second fiddle to the doctors or being there to monitor women with epidurals rather than being able to actively support a woman in achieving a drug free or near drug free birth. They definitely got greater satisfaction out of the MLU role.
The fact is, there are never going to be unlimited resources. There will always be a pot which has to be divided among many different things.
Ultimately yes, it's a woman's choice. But I think the reality is that MLUs are always going to provide a more homely, natural atmosphere, because once you start having doctors there, you are by definition creating a medicalised atmosphere which will have an impact on how the mother feels.

sabire you also make a very good point about money. If csection rates didn't run at 20/25% in many hospitals, there would be more money to go around. Epidurals too are expensive, though not in the same league as the costs of major surgery. it IS a vicious circle - those costs won't be reduced until proper staffing enables more women to give birth without so many interventions. But the staffing won't be there while all the interventions are going on!
I'm NOT saying women shouldnt have epidurals to save the NHS money. I accept that there are some women who cannot contemplate giving birth without an epidural, though in this country they are a minority. I'm talking about women who have the potential to achieve a natural birth, but who because of all the issues and pressures surrounding medicalised births, end up having all kinds of costly and unnecessary interventions.

Libra1975, our MLU is in the main hospital, 20 yards away from the CLU on the same corridor - yet I still meet the occasional low risk mum who opts for the CLU over the MLU because they think it'll be 'safer'. I usually point out to them that in the MLU they're actually about 15 feet closer to the operativing theatres than the rooms at the end of the CLU and that they won't see a doctor on the CLU unless their labour becomes problematic.

I understand people's anxiety about free standing MLUs and homebirths. But I think it's important to keep a clear head and look at the evidence on their safety.

If a country like the Netherlands can have almost 30% of babies born at home under the care of midwives and have better infant and maternal mortality than the USA, where almost all babies are born in hospital under the care of doctors then I think one needs to ask some pretty searching questions about what constitutes 'safe' care in labour.

If birth a short trip away from obstetric care was as risky as so many people assume it to be surely you'd expect to see some evidence of significantly increased rates of neonatal deaths linked to homebirth/births in freestanding MLUs?

"it's hard to believe that all those csections are a medical necessity." - I have asked myself questions about this so many times. I just can't bring myself to believe that doctors or midwives would stand by and allow a woman to be taken to theatre if they felt she could safely achieve a vaginal birth. People who work in the NHS tend to have strong principles about these things: they believe that the interventions are necessary to safeguard the health of mother and baby, and it's hard to argue that they're not, in individual cases. You simply can't know, even with hindsight. That's why I've started to feel that there is something about the care that women get in hospital that actually puts them and their babies at risk: they're not having 'unnecessary' interventions - women have problematic births because of the environments they birth in and because of the way their labours are managed. And then of course they need the doctors to sort out the problems that being in hospital has created.

.... I know what I'm trying to say but I think Tricia Anderson explains it better!

messageboards.ivillage.co.uk/n/mb/message.asp?webtag=iv-ukpbhomebir&msg=2962.2

I do wonder about the high perinatal mortality in the US being used as evidence for the relatively safety of different types of birth. Does it take into account the other factors such as the many women in the US who don't get proper antenatal care? Just wondering who it is who is dying in the US - the middle class women who get the unnecessary sections or the poor (usually black) women who don't get proper care through the pregnancy?

(Am not advocating a US-style system at all, btw, just wondering if there is more to those stats than meets the eye.)

I have a colleague who worked in an Australian hospital a few years ago where one Christmas all of the consultants were away except one (don't think it was supposed to happen tho!). That meant that only 'true' emergency sections could be done. Their rate went from 30% to 3%! Interesting.

Also interesting to hear so many mw's advocating pethidine. I'm not a fan of epi's but pethidine is even lower on my list.

Do mw's advocate pethidine? My midwife was a big fan of gas and air, and so was I by second stage but I wouldn't have wanted pethidine for the same reasons as epidural - potential side effects/knock on effects on the baby.

I sense a stigma. I had an epidural and it was integral to managing a complicated labour and birth. Yet childbirth is supposed to be natural, so when a woman endures the pain of childbirth, and it all goes to plan, I think she feels more of a woman: I can see in my friends who've all had "natural" second births after epidural firsts, that it boosts their self-esteem no end.

However, every mother's pain threshold is different, and different babies' positions present different levels of pain and different complications.

Years ago, of course many more babies and mothers died in childbirth. I sometimes wonder if DS and I would have become one of these statistics, if it weren't for modern intervention. However, modern intervention - ventouse, forceps, hormone drips to speed up and intensify contractions - can heighten pain to such an extent that an epidural is essential to not becoming completely overwhelmed/traumatised by it.

So I think it's worth remembering that in many cases, epidurals are a valuable part of the modern intervention that keeps many more babies and mothers alive and healthy through childbirth these days.

It's also interesting how there's no stigma attached to being anaesthetised for a c-section, but there is for having an epidural to manage a difficult birth - with much prodding and poking about with forceps and the like - which hasn't quite reached that stage of intervention.

Just wanted to add, epidural was great for me, first time. I was in labout for three days, though (posterior presentation) didn't get it til the last eight hours.

Begged for one the second time, didn't get it because the anaesthetist was bizzy doing a C-section.

So, don't just say "oooh yes I'm going to have an epidural next time" and rely on it happening... that's all I wanted to warn folk about.

I knew I wanted an epidural with my first child and had to ask my midwife three times to be moved to shared care - they were very dismissive of my request. I know that childbirth is 'natural' and therefore the pain is too but I wanted pain relief. (No guarantee of being able to have an epidual in MLU) I wouldn't have a tooth out without pain relief so why the hell would I want to push out an eight pound baby with just gas and air? I waited 24 hours in labour until I was 4cm and practically crying with the pain and then went in for the last six hours and had the epidual straight away - it was wonderful!! Even though my son was back to back I didn't need any intervention and I pushed him out in 15 minutes. No question I am having an epidural next time.

Interesting that someone mentioned Northwick Park. I gave birth there - went into labour three days too early to go to the MLU I'd planned to.

It's a horrendous, scary shithole but I was lucky to be there just after they had been put into special measures and I had very good MW care. I see from the papers, however, that three more women have died there since I gave birth there.

Let me try and explain what I mean about 'positive experiences' now I've calmed down a bit.

The problem with the 'positive attitude' thing is this: your labour, really, has nothing to do with your attitude.

You could have the most positive attitude in the world, ever, and you still might have to have intervention to save your life and that of your baby's.

What happens in your labour is down to sheer, blind luck. But many women are not told this. They are told that if they have a positive attitude, they'll get through it fine. They vaguely know about interventions, but hey, that won't happen to them - they have a positive attitude.

Hence, when they are faced with the realities of birth, they are utterly terrified. If they go for intervention - even when it's necessary - they still feel that they've failed.

Here is some interesting research about women's expectations of birth. Women saying they had no idea about the type of pain, how long the pain would last, what they could do about the pain.
www.biomedcentral.com/1741-7015/6/8

If I had to tell women to have any kind of attitude about birth, I would recommend 'prepared' rather than 'positive'.