What gives a midwife the right to say

[finallypregnant]

You are doing fine without an Epidural?

I don't mean that in a horrible way but it appears that my hospital are not really that responsive when you ask for an epidural.

When my time comes, I'd rather not have one but I have read threads on here where the girls have been turned down an epidural because the midwife says they are doing fine!

Surely, it is not the midwife who makes that call but the mum screaming in agony when TENS, G&S and Pethidine are not working?

Obviously if you are at 8-9 cm and they say it is too late then fair enough.

"I think you are missing the point entirely Sabire. I am not disputing that there are higher rates of intervention associated with epidural, I am disputing that it is causative."

I didn't miss the point at all. my initial comment was about the lack of research which compares a group who've had ELECTIVE epidurals (ie - those women who are not choosing an epidural in response to the events of labour), with a group of women who choose to try to cope WITHOUT an epidural (a proportion of whom will go to to opt for an epidural in response to events in labour).

"Women with complicated, not progressing well, difficult labours are more likely to be offered and accept epidurals. They would have likely required intervention anyway, even if they had gamely turned the epidural down....It wasn't their epidural that led to the intervention, it was there atypical labour...."

Not necessarily. I say this because of the differences in intervention rates among women who birth at home. Those low risk women who opt to birth at home have much lower intervention rates as a group than low risk women who birth in hospital.

A low risk woman who opts to labour at home has just the same likelyhood of malpresentation (the main reason for instrumental births) as a low risk woman who opts to birth in a hospital setting, yet has half the risk of instrumental birth.

You've also ignored my comment about how an epidural disrupts the basic physiological process of labour and how it is therefore logical that it would be associated with higher rates of intervention.

"It's rather simplistic to conclude that epidurals are the cause of labours with interventions. It's not a level playing field"

No - it's not, and that's why it's so difficult to design ethical research to identify how epidural anaesthesia impacts on outcomes. However - most midwives I've met are convinced that there is a causal relationship between epidural anaesthesia and higher rates of instrumental birth.

Sabire - I'd like to counter each of those points in turn and I'm not ignoring you. Perhaps I'll return to this thread later when I have more time...(i really should be getting on with what I am supposed to be doing)

i really should be getting on with what I am supposed to be doing)

Oh me too!

But seriously handle - how can something which a) reduces the amount of oxytocin in a labouring woman's body b) relaxes her pelvic floor c) generally results in the woman being in a recumbent position for birth and d) reduces her ability to push spontaneously NOT impact on the progress of the second stage of labour in a way which is unhelpful to normal birth?

Apparently in Belgium, (where I now live) epidural is the ONLY form of pain relief made available in hospitals I'm sticking with the 1 dd I think! Though it is standard to have a physiotherapist at the birth!

Tried googling to see if there were any statistics but only managed to find one study - done purely on low risk births (no breech, no low/high weights etc) The average number of CSs in total was about 15% (11% for women 25/29 but 20% for women over 40). Nothing to say how many had had epidurals - but if there's no other choice....?

A bit off topic but interesting enough there was a correlation between the day of the week of admission and the no. of CSs: 15% on a Monday and only 7% on a Saturday. Less surgeons and anaethetists working at the weekend? A bit sad maybe that looking up this stuff is more interesting than what I'm supposed to be doing (at work) - though it is Friday pm and there is chardonnay chilling...

Apparently in Belgium, (where I now live) epidural is the ONLY form of pain relief made available in hospitals I'm sticking with the 1 dd I think! Though it is standard to have a physiotherapist at the birth!

Tried googling to see if there were any statistics but only managed to find one study - done purely on low risk births (no breech, no low/high weights etc) The average number of CSs in total was about 15% (11% for women 25/29 but 20% for women over 40). Nothing to say how many had had epidurals - but if there's no other choice....?

A bit off topic but interesting enough there was a correlation between the day of the week of admission and the no. of CSs: 15% on a Monday and only 7% on a Saturday. Less surgeons and anaethetists working at the weekend? A bit sad maybe that looking up this stuff is more interesting than what I'm supposed to be doing (at work) - though it is Friday pm and there is chardonnay chilling...

I'm just wondering about conducting an experiment in which people are made to pass oranges through their nostrils and the procedure takes some hours. When they yell for the most effective pain relief we'll just tell them they're doing really well.

I had a 'low-dose' epidural when i was about 8cm dilated- it just affected my back, i had been in agony in my lower back but it went all warm and the pain disappeared.
I could feel everything and pushed the baby out fine- he had huge shoulders tho and took 45 mins of pushing.
i was able to walk as soon as i'd delivered the placenta and fed him.
Defo considering walking onto the labour ward this time and saying
'check me, if i'm 5cm gimme the epi!'

Handle and Sabire

You both have good points and I think the actual truth is somewhere in the middle of what you are both saying.

Epidurals definately result in an increase in instrumental births. But there is a big difference between having an epi at 2 cms and having it running for 12 hours and having one at 8cm and having it running for a couple of hours.

I really doubt there is a big difference to the instrumental rate in having a late epi - it just gives pain relief in transition and helps with pain relief in pushing. However if someone has hours and hours of epi, and cant feel a thing, they are much more likely to have instrumental birth, and also very much more likely to need synto to restart or speed up labour.

This is true mostly of primips, I really dont believe it makes a huge difference in multips, although it will slow labour significantly and result in an increased use of synto.

But Handles point of some women needing intervention at the end irrespective of having an epi is also very true, and women who have a baby in an OP or asynclitic position are likely to want to have an epi due to higher levels of pain, but they are still at high risk of an instrumental birth anyway! Likewise, when I do a VE and find that someone has a prominent pubic arch or slightly small pelvic outlet, where I think she is not going to push the baby out herself, I would encourage an epi, knowing that this woman will probaby have an instrumental birth anyway, however active they are.

Also there is a big difference in the mindset and the outlook of women who choose a homebirth and the general hospital population having babies. In the unit I work in, most women dont really care about being active and the kind of things we talk about on mn, such as this. They want you to get the baby out for them and do it as quickly and painlessly as possible. Maybe as little as 20% have any real preferences or desire for a natural childbirth experience - which is sad really. Its a rare Indian, African or Eastern European woman who will get off the bed in labour without major coaxing

Maybe thats just in my hospital!

As to the Australian study - I am very surprised at that as I have until recently worked in Queensland for many years and the c/s rate overall in my unit (admittedly a big tertiary unit) was over 40%, thats for inductions, spontaneous etc. For any primips to achieve c/s rates of 1.7% rising to 31% just because they had an epi, I would have to be very sceptical about - in fact I just dont believe either figure actually - these figures must have been spun somehow. Logically they just dont add up.

Im not disputing your quoting of the study, but I am very disbelievingsceptical of the results. Do you have a reference or link for that study please Sabire? I may have to eat my words again!

Sorry this has turned into an essay again ladies!

Because an epidural is the first step to a whole load of interventions that make it more likely that you will need ventouse, c-section etc.

Saying "You are coping" could be seen as encouragement? I didn't have an epidural with DD because it was too late. It was very painful. I got through it.

With DS I had an epidural, giving birth wasn't nearly as painful, but I pushed for 2 hours, almost needed an emergency c-section and had an episiotomy which meant I couldn't sit down for 2 weeks.

I do agree that at the end of the day the choice is down to the mother. However, midwifes know that in a birth without complications, less intervention will make the process of birth more straightforward, if also more painful.

I suppose, at the end of the day the midwife needs to be able to read how the birth is going, and sometimes she may get that wrong. That is why its good to have somebody in there who knows you well and will fight your corner. However, I don't think midwives are trying to withhold epidurals because they are mean.

Don't apologise for the 'essay' Mintpurple: I'm sure there are lots of us who are grateful for your informed input!

The study appeared in the last copy of MIDIRS (march 2008)

"Birth outcomes associated with interventions in labour amongst low risk women; a population based study"
SK Tracy, E Sullivan, YA Wang, D Black, M Tracy
Women and Birth: the Journal of the Australian College of Midwives, vol 20, no 2, June 2007, pp 41-48

I wasn't disagreeing with Handle that malpresentations etc are more likely to lead to a need for epidural anaesthesia AND a higher likelyhood of instrumental delivery unconnected to the epidural. I just don't think this explains away ALL the increase in intervention rates after epidural.

LOL at your comments on getting mums off the bed.

Makes me think of a feature in this month's M&B magazine. Mum is having a tiring, longish labour. Registrar comes in, tells her her baby feels 'quite large'. On hearing this she "decided to have an epidural". Ends up with a ventouse birth (second baby).

I just wonder if the registrar went through the additional possible cons of having an epidural if you're carrying a suspected large baby......

I have mixed feelings about epidurals. I think often, if you are given the opportunity and correct support - it is possible to labour without ending up in total agony...but because of the way hospitals operate women often do end up in agony and needing an epidural.

I had an epidural when my first baby was born and it made everything longer and escalated the need for further intervention which traumatised me among other things. The second time I took a different approach, but I had a midwife who specialised in home births.

Thanks for that Sabire - Ill see if I can find a copy at work tonight!

Message withdrawn

When you are spending a long time in hospital listening to women day and night in labour all you can do is laugh or you will end up terrified of giving birth. I was in for 1/4 of my pregnancy and have seen some horror stories, if I didn't keep my sense of humour I'd not have managed to get through.

The woman was screaming, howling, being abusive and we were all expecting her to be near the end so it just seemed odd to hear a MW say "but you're only 2cm". Especially to those of us who'd given birth and knew "worse" was to come.

mrsbick are you me?

mintpurple very informative thankyou

Even Dr Sears (natural childbirth and co-sleeping guru) thinks that there is such a thing as a good epidural that enables women to have good birth experiences that would be impossible without one.

For the record, I would be one of the women who had an epidural and then an instrumental delivery with episiotomy. But the decision to have an intervension-stuffed delivery was made first and then I insisted that they had better give me an epidural before they strapped me into the stirrups (with an OP presentation) and hooked up the drip. I had already coped for 14 hours first stage and 2 hours second stage without.

With my first labour, things progressed very quickly and like most first time mums, I had written a very specific birth plan, which clearly said no epidural on it. As it turned out, the whole labour lasted 8 hours and I managed on gas and air and a shot of pethidine, which tbh, I felt was given too late in the day as I was in agony during the pushing stage and then started to feel a bit numb once DD was born.

However, my second labour lasted for 25 hours, with about 11/12hours stuck at 7cm. The gas and air wasn't touching the sides and the pethidine again, I don't feel as though it had any affect. DS shoulders were also in an awkward position and in the end, I was begging for an epidural. When it was given, I was warned that it might not work (it half worked, giving pain relief down the right side of my body only) and ended up with searing, burning pain added to my contractions caused by the shoulder problem. When the epidural was in, I was able to move, feel my body (both sides, even the side free from pain) and could feel the urge to push when it briefly came.

The failure of my body to dilate meant that I was exhausted, at one point delirious. DS was not in any way engaged and it was getting to the point where I was literally screaming the delivery suite down.

In the end DS was delivered by forceps anyway, but I don't believe this was necessarily down to the epidural. I think it was mainly because he was not in any way engaged and pushing was a pointless exercise. The epidural was actually removed at one point and I was given a spinal which was given when the decision to deliver DS by forceps was made.

In total, I went for over 20 hours without major pain relief. Had I experienced this birth first, there is no way I would consider having another child.

The MW at the time didn't want me to have the epidural and was quite vocal about it, telling me that things would progress very quickly - they didnt.

starlight, I "got" that from a consultant anaesthetist

stripeyknickersetc - am absolutely flabbergasted you have never seen a woman walk with an epidural

Starlight - because at 2cm you're not in labour. I'm not disagreeing that the pain can be awful but you can be at 2cm and contracting for days. Where I work you wouldn't even be "allowed" on the labour ward never mind be "allowed" an epidural. There just isn't the staffing to have someone in the latent phase of labour, potentially there for days at 2cm with an epidural - for one thing the risk of the woman having a dvt if she was tehre for days with an epidural would be significant.

If I was looking after a woman and she was 2cm and in that much pain I'd offer her diamorphine. Most people at 2cm I send home.

Some people will crack on quickly and once they're 3-4cm they will be deemed suitable for an epidural. But no way would anyone where I work get one at 2cm, even if I tried to convince the shift coordinator to let a woman have one I'd be laughed off the ward!

I'm sorry you had such a rough time.

That must mean I was in labour for less than an hour. I was checked and found to be 2cm, given drugs to slow contractions and first dose of steroids. Checked again in an hour, was fully dilated and delivering a foot. Having never gone through it all knowing that's what's happening I feel like I don't know much about what happens when a baby is born, other than what I felt like.

I remember watching the print out because at first we weren't sure it was contractions (already been sent home with "BH", "SPD pain" really small possibility of early labour) and the numbers being almost disappearing between contractions, going up to six during. Then it was 10 dropping to 6, 12 to 6 and all of a sudden it made a straight line upwards till it stopped at mid-40s between and 60s during a contraction. I looked at it and thought "I thought it hurt at 6!" When it shot up there was a sudden increase in pressure that took me off the bed, but when it got where it was going I was OK. I have no idea what it all means or what happened when it shot up like that. I think I'm doing a tired ramble!

As far as I'm concerned, if you are contracting and effacing/dilating then you're in labour.

Hospital protocols are there to allow hospitals to run efficiently. The hospital doesn't admit women in the latent stage of labour because space doesn't allow, and because coming in early makes it more likely that women will end up having interventions.

I think it's wrong for hospitals to tell women in the latent stages of labour that 'they're not in labour'. It's demoralising and disrespectful. It'd be better to explain that they are in the early stages of labour: that their contractions may tail off or pick up, and that they should go home, rest, eat and start looking forward to meeting their babies!