Chief midwife tells women that they should endure the pain of natural childbirth

[MissM]

Here.

It's too early in the morning to get my blood pressure up, but my response was off. Have you ever felt like you were going to split in two? No, because you're a man, and you've never bloody given birth!

Tosser.

Only a man could come up with such a comment. As someone said previously better 1-1 midwifery care might help, from what I've heard women fair better if there's a doula involved in the process so maybe the NHS should consider this.

if pain better prepares women for looking after a baby, I'd suggest they go through this pain before conception. Once in labour it's too late to decide you can't cope with being a parent!

Exactly, Mybox! Or adoptive parents.

Get friggin' real!

Is there any other field in which this is even an argument?

No.

That goes to show you how intrinsically misogynistic this presentation is, even worse because he nor his supporters even recognise it as such.

"No one is saying women should not be given epidurals if they want them and/or if they are in serious pain they don't want to deal with in other ways."

Excuse me but that is EXACTLY what this chap is saying. He gets to decide when we have epidurals. Great.

And he's further saying that, if a woman choses an epidural (because she doesn't fancy the pain, of course) she is having less of an experience and will not bond as well with her child.

As IF he would know.

That's what I take exception to.

He put it out there. He made the declarations.

I don't see where it's somehow not fair that women point out the fact that he's making suppositions about something he'll never experience.

Tiktok
You are being very measured and reasonable as always. You are right on many points - it would be better, on the whole, to reduce the numbers of epis given to women who didn't 'need' them and thereby reduce the numbers of very medicalised births. It would be better if women were more supported and empowered to give birth naturally as they would feel less fear about the process and many would find they could have a straightforward natural delivery with quick recovery, rather than an intervention that causes many side effects for recovery.

Buuuuuut

He still said that women who 'don't fancy' the pain are wrong to want an epi. He still said that pain helps to prepare women for motherhood and is an important part of the 'rite of passage' of birth and helps bonding between mother and baby.

here is what causes people to wish horrible torment on him. It really is a valid question - firstly, how can a person who has never experienced this type of pain pronounce on how much of it women should be able to bear? And secondly, if pain helps bonding, prepares a mother for parenthood and is part of the rite of passage of bcoming a parent, why shouldn't men be subjected to similar pain? Facetious - but actually calls out his misogyny on this point, women are expected to suffer in some cases unimaginable pain (not all births are like that, but some are) without pain relief for spurious reasons. Quite infuriating.

Ooh we just made Thought for the Day. Is Rosemary Lane Priestley an MNer??

Have any of you at all actually read what he really did write rather than what the media have spun it as?

The Zepherina Veitch Memorial Lecture June 2009: The Challenge of Normality in an Epidural Culture

Introduction

The following story from a midwife typifies the complexity behind promoting normal birth within an epidural culture. She had taken over from another midwife, looking after a woman, having her second baby who had been in the latent phase of labour but had recently shown signs of her labour accelerating. In the short time it took to get the handover, the woman had become very distressed. The midwife rapidly tried to develop a rapport with her and gave some advice about focusing on breathing during the contractions. This was not enough and she began on entonox within a short period. The contractions were long and intense, with the fetal heart descending on the abdomen. The midwife recognised the familiar manifestation of transition but by then the women was shouting loudly ?to go home?, ?caesarean now? and ?get me an epidural?. Her distress was greater on the bed so the midwife encouraged her to get up, though she was continuously monitored because of meconium-stained liquor. She coped a little better upright or on the floor but still vocalised her distress in no uncertain terms. The midwife was faced with a dilemma. She was sure 2nd stage was imminent but the recourse to the epidural would have calmed the woman and made monitoring the fetal heart easier as she would have been semi-recumbent on the bed. After another 15 minutes, the woman was bearing down strongly and birthed a healthy baby boy.

Later both an anaesthetist and another midwife suggested an epidural was wholly appropriate in this situation and a lively discussion ensued.

Discussion about epidurals is often linked to the broader discussion of medicalisation of childbirth because epidural typifies the ?cascade of intervention dynamic? that contributes to medicalisation. Public health concern has prompted the Department of Health in the United Kingdom (UK) to measure normal labour and birth outcomes as well as normal birth outcomes (ICCHS, 2008). A working definition has now been agreed as to what constitutes a normal labour and birth and rightly excludes induction of labour, epidural or spinal anaesthetic, forceps or ventouse, caesarean section and episiotomy. The difficultly of reaching agreement across a multi-disciplinary group is reflected in the fact that it can include augmentation of labour, artificial rupture of membranes, entonox, opioids, electronic fetal monitoring and a managed third stage of labour (Werkmeister et al, 2008). The fact that the Consensus Group had to compromise to accommodate the various positions of the stakeholders represented, indicates how certain procedures and drugs are now considered normal in labour. The ubiquity of oxytocin augmentation and epidural is demonstrated in Mead?s (2004) survey of low risk women when she found that rates varied between 14% and 57%. Furthermore, Symon et al (2007) demonstrated the stark contrast in low risk women?s self-reported intervention rates between midwifery-led units and consultant units ? pain agents 25% in the former and 77% in the latter.

The Epidural Epidemic

Epidural rates have doubled in the UK from 17% in 1989 to 33% in 2007-8 (BirthChoiceUK, 2009). There are many reasons for this. The following are possible contributors:

· Elective epidural provision is now a benchmark of good practice in maternity units

· Two generations of women have had access to epidurals so now the mothers of pregnant women are recommending them

· Celeb birth and media portrayals of childbirth often include epidurals

· The professional project of obstetric anaesthetists (e.g. increase in the number of obstetric anaesthetist posts) promotes epidural use

· Over recent decades, there has been a loss of ?rites of passage? meaning to childbirth so that pain and stress are viewed negatively (Leap & Anderson, 2008)

· A techno-rationalist society considers pain as either preventable or treatable (Lauritzen & Sachs 2001)

· The pain relief paradigm is dominant in maternity services (Leap & Anderson, 2008)

· The movement to institutional birth (93% hospital v 7% home and birth centres currently) reinforces medical solutions to clinical symptoms such as pain (Walsh, 2007)

· Fragmented models of care and loss of continuity contributes to greater use of pharmacological agents in labour (Hatem et al, 2007)

· Informed choice as an ethical imperative influences practitioners? response to maternal requests for pain relief in labour (Walsh, 2007)

· The risk discourse predisposes to childbirth intervention including the use of pain-relieving agents (Walsh, 2006b)

Several of these factors work in tandem. Techno-rationalist society (Lauritzen & Sachs 2001) is short hand for a society that equates scientific advances with progress. In relation to pain, technology and drugs have successfully either prevented pain from emerging or treated it effectively when it does. It is counter cultural in such a society to see a purpose to pain, especially physical pain related to biological function which is how traditional and indigenous societies have viewed childbirth over thousands of years. Childbirth is one of life?s great ?rites of passage? transitions within traditional societies (Jordan, 1993). Allied to an antipathy to childbirth pain is a risk discourse that carries within it several paradoxes. In the west, it has never been safer to have a baby yet it appears that women have never been more frightened of the processes and of what might go wrong. Hence another paradox is a high degree of risk aversion, yet a willingness to embrace medical interventions like drugs and surgery that carry risks themselves. Mixed messages coexist like a public health message to avoid any form of drug pre-conceptually and prenatally, but accept an epidemic of drugs during intrapartum care. The risk discourse has foisted on women the relative risk conundrum. How do I make choices against a backdrop of arithmetic possibilities? How do you weigh a 1 in 100 risk of a poor perinatal outcome, compared with say the risks associated with driving a car or living in a smog-filled city. The risk discourse can also overplay theoretical risks and rare negative cases in defining clinical guidelines. Finally, its puts a hierarchy on particular risks at the expense of other risks. The recent change in the NICE Guideline (NICE, 2007) regarding spontaneous rupture of membranes at term is an example of this. The risk of neonatal infection overrides others risks of augmenting women at 24 hours. A number of maternity units are noticing their intervention rates increasing in this group.

Side Effects of Epidurals

When it comes to specific risks associated with a medical procedure, epidurals have many. These have been outlined in the literature in some detail. They can be summarised in bullet format thus:

Side Effects on Labour

· increase length of 1st & 2nd stage of labour

· need for more oxytocin

· increase incidence of malposition

· increase instrumental delivery

· (Anim-Somuah et al, 2008)

· increase 3rd/4th degree tears (Rortveit et al, 2003)

· may increase in C/S if sited early (Klein, 2006)

Side Effects Maternal

· loss of mobility

· loss of bladder control

· hypotension, headache

· pyrexia (Yancey et al, 2001)

· up to 30% of women get partial but not complete relief

· reduces breast-feeding rate on discharge from hospital (Wiklund et al, 2009)

Side Effects Fetal

· tachycardia due to temperature rise

· neonate more likely to be hypoglycaemic

· diminishes breast-seeking and breast-feeding behaviours (Ransjo-Arvidson et al, 2001)

· Requires continuous CTG

Added to these established side-effects are the following psycho-social and midwifery practice factors:

Psycho-Social

· woman becomes a ?patient? in the sense that additional monitoring is required

· choice for epidural is associated with fear of childbirth, giving control over to professionals and passive compliance (Heinze & Sleigh, 2003)

· commonly precipitates cascade of medical intervention

Midwife Practice Effects

· care becomes more technical

· there is a greater need for surveillance

· psychological support needs are less demanding

· midwives are less able to utilise intuitive skills

· the whole package induces obstetric nurse ?feel?

These latter comments reflect some personal reflections of individual midwives that not all midwives would agree with or see a problem with.

All of these negatives have to be balanced with the fact that an epidural is an excellent procedure in the following situations:

· its makes caesarean section safer

· it can make assistant vaginal birth more humane

· it is valuable for protracted, induced or augmented labours

· it is useful for some women with tocophobia or post traumatic stress disorder

Few childbirth professionals would argue against epidural availability and use in these or similar situations. The pivotal point for discussion is its role for normal labour. A related question is to what extent ?informed choice? has become an ethical imperative regardless of context and prior preferences. In the story at the beginning of this article, the scenario of a multiparous woman requesting an epidural in late first stage of labour has been used as an exemplar for the application of informed choice. Many UK midwives would express the tension between responding to a woman?s request in this situation and knowing that this is a transient and challenging part of the labour that will soon pass. Midwives from other countries have expressed surprise when this scenario has been presented in workshops, concluding quite unequivocally that an epidural is not appropriate.

Attitude to Labour Pain

Professionals? attitude to labour pain is a key area to examine. Leap and Anderson have developed and written about the approach of ?working with pain? which addressed this area directly. They contrast ?working with pain? with ?pain relief? (Leap & Anderson, 2008). The following Table summarises the main differences between these two approaches.

Table 1

Pain Relief Approach Working with Pain Approach

• language suggestive of pain - language suggestive of pain as

as a problem normative

• paternalistic, ?we can protect - egalitarian empowerment, ?we

you from unnecessary stress? are alongside you?

• techno/rationalism age, pain is - labour pain timeless component of

preventable/treatable ?rites of passage? transitions

• neutral impact of environment - seminal impact of environment

• clinical expertise of professional - supportive role of birth companions

carers

• special session/focus in antenatal - woven throughout labour

education preparation sessions

• ?menu approach? to options for - supportive strategies for

coping with pain journey of labour

• pain as a ?management issue? for - pain as one dimension of labour

assembly-line birth care in one-to-one, small scale birth settings

• contributes to trend of rising - contributes to trend to less

epidural rates pharmacological analgesia

• risks of pharmacological agents - ?cascade of intervention? dynamic

outweighed by benefits

• first birth special case for ?menu - first birth optimal opportunity for

approach? ?working with pain?

• informed choice means all - informed choice within context of

options must be presented birthing plan and philosophy

(Walsh, 2007)

It is an interesting exercise for midwives to note the number of times the phrase ?pain relief? is used in birth settings over the course of a working week. Though the use of the phrase does not necessarily mean that the user signs up to the whole paradigm, it never-the-less conveys a meaning to all who hear it that pain is a problem.

The ?working with pain? paradigm is predicated on labour physiology that requires pain to be present for the release of endorphins. These naturally occurring pain easing hormones also contribute to the dynamic behind oxytocin release so that it is neither under stimulated nor over stimulated (Buckley, 2004). Endorphins effects are beautifully captured in Hannah?s birth, a short DVD produced by Sheena Byrom, consultant midwife at Blackburn. What the DVD also captures are the empathic responses from Hannah?s birth companions. Moberg (2003)in her captivating book, The Oxytocin Factor, suggests that this hormone is secreted in both men and women, especially during therapeutic touch. She highlights the necessity to bathe a birth setting in love, not fear. When this occurs, the synergy created is more than the sum of individual parts. Hence the centrality of empathic relationships to the birth process, the importance of an optimum environment and of minimising disturbance. All of this takes on an urgency in an institutional birth setting where some of these factors are already compromised.

Endorphin effects are masked and undermined by epidurals, opioids and syntocinon. If caring for a woman with an epidural is more instrumental and task orientated than intuitive and empathic, one senses a vicious cycle of oxytocin antagonism being set up. Is it any wonder that labours become dysfunctional?

The Transforming Power of Labour

One of the key questions for childbirth professionals in the 21st century is what will happen to the narratives of transformation and growth in childbirth if normal labour is effectively anaesthetised by the epidural epidemic. These are the countless number of personal testimonies that women share about an experience of growth and empowerment through childbirth. The vast majority of these are characterised by drug-free or low intervention labours, though not all (Thompson, 2004). The most moving ones are from vulnerable women who lives prior to birth had been blighted by abuse or disempowerment. Phrase like ?my greatest achievement? (Esposito, 1999), ?I can do anything now? (Spitzer, 1995) and ?I feel so strong? (Walsh, 2006a) litter these stories and pose a profound challenge to the ?pain relief? paradigm. It is difficult to debate the topic because it implies criticism of women who chose or needed intervention, almost suggesting they could be poorer mothers because of it. Emerging evidence that normal labour and birth primes the bonding areas of a mother?s brain better that caesarean or pain-free birth adds to this perception (Swain et al, 2008). In recognition that caesarean birth may undermine birth physiology, obstetricians have been researching the so-called ?natural caesarean? to see if normal physiology can be harnessed in this situation (Smith et al, 2008). The advent of the ?mobile epidural? illustrates how obstetric anaesthetists are trying to engage with labour physiology around movement and upright posture to recruit those benefits for women with epidurals.

All these attempts to engage with childbirth physiology in the context of medical procedures that undermine them serves to highlight how science struggles to mimic precisely what is natural. The complexities behind oxytocin secretion remind biomedicine that altering one variable (skin to skin in caesarean and movement in epidural) will never reproduce the conditions for maximising physiology. That requires a whole systems approach (Downe & McCourt, 2008), examining environment, attitudes and beliefs, practices, relationships etc. If pain plays an integral role in optimising labour physiology and priming the woman for motherhood, then it is hard to see how an epidural can fit into this whole systems approach.

Elective Epidural Service

In the light of this discussion so far, a rationale certainly exists for questioning the appropriateness of an elective, ?on-demand? epidural service, especially if there is public health commitment to increasing the rate of normal labour and birth in the UK. However, given its embeddedness in UK maternity service provision, it would be a brave person who would take up such a position. This paper?s intent is to simply encourage debate about these issues. If the present course is pursued so that in another 30 years epidural rates are 60%, it cannot be predicted what that may mean for women, babies and families. It is unlikely that Zepherina Veitch, the founder of the Royal College of Midwives would have welcomed such a future. She was more concerned with social reform and public health and would probably have resisted the advent of drugs in normal labour.

An anecdote is told of an anaesthetist who used to refer to epidurals as ?happidurals?. In the context of a fragmented model of care with no continuity, in a clinical environment with little resemblance to home, where women are kept on beds while continuously monitored, it is understandable that epidurals are a welcome relief. But it is important not to confuse system failure with woman?s preference. In fact all over the UK in different birth settings, women are birthing entirely drug-free, even with their first baby. This latter group can be found in midwifery-led units, birth centres and at home. First birth mothers stories of drug-free labours tend to remain hidden in small scale birth settings because they are seldom told beyond these settings. Their testimonies are so important for labour ward midwives and obstetricians to hear because they are routinely exposed to the opposite. Case reviews in maternity hospitals tend of the negative variety. Like the following anecdote from a student midwife, midwives may be losing skills. She feared qualifying because she was not sure she could be alongside women in pain without her own discomfort manifesting. She was also not sure she could spot natural endorphin effect because she had seen so few natural labours.

Conclusion

The evidence is incontrovertible that epidurals undermine childbirth physiology. That rates are now double what they were 20 years ago says much more about the context of childbirth and childbirth professionals? attitudes than it does about the current generation of women?s ability to adjust to labour pain. In fact there is considerable anecdotal evidence that women adapt their expectations to the service provision so the rare consultant unit that does not have an elective epidural service has not seen a fall in bookings. Similarly, co-located and free-standing birth centres remain very popular. However with these, along with homebirth, representing around 7% of UK total births, the vast majority of women enter a large hospital model where epidural provision is electively available. In this context, the impact on normal birth intervention rates is profound. Addressing this context requires a rethinking of pain paradigms, attention to birth environment, and a move to more relational models of care. Finally, there needs to be a robust debate about whether epidurals really serve society and families best by being an elective choice, especially in relation to normal labour and birth.

References

Anim-Somuah, Smyth R, Howell C Epidural versus non-epidural or no analgesia in labour. The Cochrane Database of Systematic Reviews 2008, Issue 1

BirthChoiceUK (2009) NHS Maternity Care Statistics 2007-8. Available from: www.birthchoiceuk.com/maternitystatistics07-08.pdf [Accessed June, 2009]

Buckley S (2004) Undisturbed birth ? nature?s hormonal blueprint for safety, ease and ecstasy. Midirs 14(2):203-209

Downe S, McCourt C (2008) From being to becoming: reconstructing childbirth knowledges. In S Downe (ed.) Normal Childbirth; Evidence & Debate. London: Churchill Livingstone

Esposito N (1999) Marginalised women?s comparisons of their hospital and free-standing birth centre experience: a contract of inner city birthing centres. Health Care for Women International 20(2):111-26

Hatem M, Sandall J, Devane D, Soltani H, Gates S. Midwife-led versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2007, Issue 4.

Heinze S & Sleigh M (2003) Epidural or no epidural anaesthesia: relationships between beliefs about childbirth and pain control choices. Journal of Reproductive & Infant Psychology, 21(4):323-334

Information Centre, Community Health Statistics (2008) NHS Maternity Statistics, England: 2006-07

Jordan, B., 1993. Birth in four cultures: a cross-cultural investigation of childbirth in Yucatan, Holland, Sweden and the United States. Prospect Heights: Waveland Press.

Klein M (2006) In the literature: epidural analgesia: Does it or doesn?t it? Birth, 33(1):74-76

Lauritzen S, Sachs L 2001 Normality, risk and the future: implicit communication of threat in health surveillance. Sociology of Health & Illness 23(4): 497-516

Leap N, Anderson P (2008) The role of pain in normal birth and the empowerment of women. In S Downe (ed.) Normal Childbirth; Evidence & Debate. London: Churchill Livingstone

Moberg K(2004) The Oxytocin Factor. New York: Perseus Books

Mead M (2004) Midwives? perspectives in a 11 UK maternity units. In S Downe (ed.) Normal childbirth: evidence and debate. London: Churchill Livingstone

NICE (2008) Induction of Labour. London: RCOG. Available from: guidance.nice.org.uk/CG70/Guidance/pdf/English [Accessed June 2009]

Ransjo-Arvidson A, Matthiesen A, Lilja G, et al (2001) Maternal analgesia during labour disturbs newborn behaviour: effects on breastfeeding, temperature and crying. Birth 23(3):136-143

Rortveit G, Daltveit A, Hannestad Y, Hunskaar S (2003) Vaginal delivery parameters and urinary incontinence: the Norwegian EPINCONT study. American Journal of Obstetrics & Gynaecology, 189:1268-74

Smith J. Plaat F, Fisk N (2008) The natural caesarean: a woman-centred technique. BJOG, 115(8): 1037?1042

Spitzer M. (1995) Birth Centres: Economy, Safety and Empowerment Journal of Nurse-Midwifery Vol. 40, No. 4 July/August pp371-375

Swain J, Tasgin E, Mayes L, Feldman R, Constable R, Leckman J (2008) Maternal brain response to own baby cry is affected by caesarean section deliviery. Child Psychology and Psychiatry, 49(10):1042-1052

Symon A, Paul J, Butchart M (2007) Self-rated ?No? and ?Low? risk pregnancy: a comparison of outcomes for women in obstetric-led and midwife-led units in England. Birth, 34(4):323-330

Thomson, G. (2007) A Hero's Tale of Childbirth: An Interpretive Phenomenological Study of Traumatic and Positive Childbirth. Unpublished PhD Thesis, University of Central Lancashire

Walsh, D. (2006a) Improving Maternity Service. Small is Beautiful: Lessons for Maternity Services from a Birth Centre. Oxford: Radcliffe Publishing

Walsh, D. (2007) Evidence-Based Care for Normal Labour & Birth: A Guide for Midwives. London: Routledge

Walsh D (2006b) Risk and Normality in Maternity Care. In A Symon (ed.) Risk and Choice in Childbirth. London: Elsevier Science

Werkmeister G, Jokinen M, Mahmood T, Newburn M (2008) Making normal labour and birth a reality?developing a multi disciplinary consensus. Midwifery, 24, 256?259

Wiklund I, Norman M, Moberg K, Ransjo-Arvidson A, Andolf E (2009) Epidural analgesia: breast feeding success and related factors. Midwifery, 25(2):e31-e38

Yancey M, Zhang J, Schwarz J et al (2001) Labour epidural analgesia and intrapartum maternal hyperthermia. Obstetrics & Gynaecology 98(5):763-70

No. of words (excludes refs and abstract) 3000

Abstract

With epidural rates doubling in the United Kingdom over the past 20 years, the impact on normal labour and birth in profound. Rates if labour and birth interventions have risen inexorably over that time. Changes have also occurred in wider birthing milieu such as the rise of a risk discourse, the diminishing of a ?rites of passage? meaning to birth, the growth of obstetric anaesthetic services and the advent informed choice in maternity care policy. This paper discussed the impact of these changes on normal birth, and, in particular on the attitude to pain in labour. An elective epidural service is critiqued and a call made for an urgent debate on how maternity services and ultimately society should respond to these profound changes.

Key words: epidural, normal birth, risk, pain

Author:

Dr Denis Walsh, Associate Professor in Midwifery, Nottingham University, UK

Email: [email protected]

Address:

Dr Denis Walsh

Associate Professor in Midwifery

University of Nottingham

Post Graduate Centre

City Hospital Nottingham

Hucknall Rd

Nottingham NG5 1PB

Tel: 0115 8231926

Kat - I dont know where Walsh said 'women who don't fancy pain are wrong to want an epidural' and of course that is far too simplistic and judgemental.

The paper (which I had read, and it's good it is posted here so people can appreciate the nuances of the debate rather than media paraphrasing) includes this challenging, but I think, important statement : "... it is important not to confuse system failure with woman?s preference. In fact all over the UK in different birth settings, women are birthing entirely drug-free, even with their first baby [....] stories of drug-free labours tend to remain hidden in small scale birth settings because they are seldom told beyond these settings. Their testimonies are so important for labour ward midwives and obstetricians to hear because they are routinely exposed to the opposite."

Nothing in the paper states that women whose labours are prolonged, out-of-the-ordinary, obstructed or similar should be prevented from having an epidural. The debate is around normal labour, and the role of 'epidurals on demand' and whether this de-skills midwives and removes something important from the culture of giving birth and supporting women who are giving birth. If the right support, the right systems, the right environment enable women to have less need for epidurals, then this could be a good thing.

It is no use saying 'we will not allow women to have epidurals unless [insert some sort of obstetric challenge here]' and leaving mothers 'un-midwifed' in hostile, inflexible, rule-beset labour rooms.

To decide, as we can do, that the 'epidural epidemic' is not wholly a good thing, means looking at training, staffing, antenatal preparation, and new ways of working with women and their partners. It also means acknowledging that for all the gains in pain relief, we may also have lost something.

The anecdote with which he starts the paper exemplifies the attitude that I object to:

"Later both an anaesthetist and another midwife suggested an epidural was wholly appropriate in this situation and a lively discussion ensued."

No mention of what the mother thought. Never occurred to anyone to ask her.

In any case he's setting up a straw man: by the time women are in transition they aren't given epidurals.

Agreed, LeninGrad. The paper, and the debate, is not directed at individual women, still less judging individual women for their pain relief choices.

In the words of the conclusion to the paper: "That rates are now double what they were 20 years ago says much more about the context of childbirth and childbirth professionals? attitudes than it does about the current generation of women?s ability to adjust to labour pain."

I repeat - it is juvenile to invent tortuous punishments for Walsh for raising the issue, and unproductive to reduce this debate to one of 'yahboo, he's a man, what does he know about our pain?'

From personal experience, epidurals give you 18 months unremitting back pain and certainly don't prevent post natal depression. I had my 2nd at home without anaesthetic, and in my experience, giving birth is less painful than a frozen shoulder and vastly more comfortable than appendicitis. I think the professor makes a good point.

In 'New Life', Janet Balaskas says that if the mother is knowledgeable, confident, etc, the birth will be less painful.

Obviously if there are complications you need medical assistance.

This paper, however carefully worded (and in many places well-intentioned) is about taking choice away from women.

Eg:

"a rationale certainly exists for questioning the appropriateness of an elective, ?on-demand? epidural service"

"Finally, there needs to be a robust debate about whether epidurals really serve society and families best by being an elective choice, especially in relation to normal labour and birth."

These sentences mean: perhaps epidurals shouldn't be an elective choice. That is, perhaps women shouldn't be able to choose them.

Walsh doesn't think women are best able to judge for themselves what care and what (if any) pain relief they need during labour. He is suggesting that more women should have to give birth in settings where epidurals (in particular) are simply not available to them.

Thank you maternaltouch, I'd just spent 10 futile minutes trying to find out what was actually written.

FWIW, I have had 2 births, one with epidural, one totally drug-free.

FOr me, the fear of pain, the fear of birth was the worst part. My first baby, I received NO psycholigical support or 'caring' from the midwives, and was frightened, disempowered and in great distress. An epidural was welcome relief.

My second birth (at home) I had 1:1 care from a kind and supportive midwife. And found that I could give birth without the fog of fear and distress that had poleaxed me the first time.

Yes, it's hard to debate, but my second experience, where my pain was managed with support, care and encouragement was a bloody sight better than my first experience where it was managed with strong drugs and where I was left with an overwhelming sense that I was less of a nuisance to the system when strapped passively to a monitor than when upset and in pain.

Dr Walsh appears to be arguing that experiences like my second birth are to be encouraged. I agree.

In the paper Walsh gives a list of possible reasons for the rise in epidural rates.

Several of these are insulting to mothers eg "Celeb birth and media portrayals of childbirth often include epidurals".

He does not include any of the ways in which birthing women are let down by midwives. For example, no mention of:

• frightened birthing women sharing midwives 1:7 and being left to labour by themselves for hours on end (as I was)

• labouring women being repeatedly sent home and making distressing journeys to and from hospitals

• most women still being expected to birth in front of complete strangers, since almost none of us have any continuity of care or have met our birth midwives in advance

A high epidural rate is a symptom of poor support for birthing women. It's not the cause.

"...The Oxytocin Factor, suggests that this hormone is secreted in both men and women, especially during therapeutic touch. She highlights the necessity to bathe a birth setting in love, not fear. When this occurs, the synergy created is more than the sum of individual parts. Hence the centrality of empathic relationships to the birth process, the importance of an optimum environment and of minimising disturbance...

Wouldn't it be better if this was where the focus should be? Optimum environment for giving birth. All the other things that have been mentioned in this thread, such as one-to-one care, named midwife throughout etc.
Without these things in place then the uptake of pain-relief is surely going to be higher. With these things in place then it's possible that requests for pain relief might drop.

My last birth was disrupted by seemingly over-anxious midwives. I was in a room on the antenatal ward after being induced. As nothing had been happening I was left alone for the night. Labour started and progressed quite quickly but I was okay so carried on rocking on birthing ball and reading my book. Only small lamp on to read by so subdued lighting. I was quite happy. Began to feel pressure underneath so got excited and buzzed a m/w (more to share than anything else). She was a different m/w to the one attending me all through the day, who had got to know me and understood my need to stay off the bed, off my back. M/w insisted she examine me on the bed....but then I could get back off she assured me. She lied. I was close to giving birth and she told me to stay on the bed, barking orders at me when I objected, switched the main lights on, buzzed for assistance, 2 more m/ws rushed in and me, the bed were bundled into the lift to go up to delivery (because I couldn't deliver one floor down could I). Up on delivery I was transferred to the care of a different m/w, onto a different bed and laid down to deliver. By this point I was disoriented, in excruciating pain(as I knew I would be if laid on my back, which the day m/w knew all about but these new ones didn't) and ended up pushing for dear life just to get it over with. Baby born within 25 mins of arrival on delivery unit.
It has always puzzled me why I couldn't have been left in my quiet, subdued lit room, rocking on my ball, quietly excited feeling my baby descend, to just have my baby. Rather than calling the m/w I wish I'd locked the door. It would have saved the 'Casualty' scenario and might have saved my pelvic floor.

Sorry, that was a bit longer than I intended and probably a bit off the point.

Hmmm should I post this? Oh why not.

umf - in the paper, this is one of the reasons for the rise in epidurals:

"Fragmented models of care and loss of continuity contributes to greater use of pharmacological agents in labour"

To me, this is a criticism of the way labouring women are cared for - I think it would be adding to the debate to spell it out, though, as you have done, and to add the detail you have done.

tiktok - true, but I think it really does need to be spelt out: a lot of women are still experiencing deeply distressing neglect during labour, and any any exploration of a high epidural rate needs to put these problems at the forefront.

"By tiktok on Tue 14-Jul-09 09:53:44
...The paper, and the debate, is not directed at individual women, still less judging individual women for their pain relief choices..."

Unfortunately, Walsh has chosen to frame the debate in a way that does judge women for their "discomfort" relief choices. In his interview with the Observer he stated that:
"A large number of women want to avoid pain. Some just don't fancy the pain [of childbirth]. More women should be prepared to withstand pain. Pain in labour is a purposeful, useful thing, which has quite a number of benefits, such as preparing a mother for the responsibility of nurturing a newborn baby."

He is a pratt. I agree with you Tiktok, and wish that Walsh was not such an idiot, since it allows his valid points to be brushed aside. In effect, he has created a strawman, with his misogynistic attitude and his belief that epidurals should not be an elective choice.

I have rarely in my life felt as angry as I do about this pronouncements of this wicked, stupid man.
He presumes his 'ideal' of childbirth, painful, 'spiritual', a 'transformative' 'journey' where we depend upon midwives for 'support' is what we all want and if we don't want it, we should be forced into it by the withdrawal of pain relief (esp epidurals) - and yes, he does favour this as umf's posts make clear. He thinks it should be up to midwives to decide how much pain or distress a woman is in and decide if that pain deserves relief or not. This is paternalistic and is completely against all trends in pain relief which is to hand over the power to the person who is actually enduring the pain. He also comes from a position where he makes the assumption that pain relief is bad, that a 60per cent epidural rate would be a bad thing, and that of course everyone agrees with this. He is begging the question - big time. I happen to think that the rise in epidural rates has a huge amount to do with women being listened to at last, that the old idea of labour pain being the curse of Eve and that all women should endure it to become proper mothers being recognised as misogynistic and outdated, and that modern epidural anaesthesia is now seen to be safe and appropriate to be given 'on demand' - though sadly, as this thread shows, all too often it is still being withheld by midwives. I think it is a GOOD thing, not a bad thing, and if 60 per cent of women WANT epidurals, then who is he to say they shouldn't have them? Women having babies are by definition adults, and they have a right to decide if they want the pain taken away or not. We don't need to be infantilised, patronised or have choices removed from us.

Personally, I have no desire whatsoever for a 'transformative journey' with pain. And I don't believe in hooey like spirituallty, and deeply resent that and old hippy is allowed to talk about stuff like this in a medical context. By all means enjoy your crystals and mumbo-jumbo lifestyle but don't try to force it upon other people who simply do not share it. It is not objectively better, as Walsh seems to be saying, merely his subjective preference.

Well I had epidurals with both of mine, and I have to say both births, once the epidurals were fitted, made me feel calm, in control, and focussed. I was completely aware of all that was happening, able to smile and chat all the way through the pushing stage and when my two beautiful dds were born I had absolutely no problem 'bonding' ( hat that expression) with them.

The responsibility of motherhood was a complete shock to me but I have NO reason to believe it was because I didn't scream, moan and go through agonising pain to get my dds out.

I recently spoke to two friends who told me that their natural births made them feel frightened, out of control, and traumatised afterwards.

FFS I didn't really see childbirth as anything else other than a means of getting babies out of my body. All this evangelising about rights of passage etc is pure bull.

msled - totally agree with your "Women having babies are by definition adults, and they have a right to decide if they want the pain taken away or not. We don't need to be infantilised, patronised or have choices removed from us."

Elsewhere in medicine the emphasis is on giving patients more control over pain relief. It's now recognized that patients who can press a button for morphine, for example, don't actually overdose - they regulate it rather sensibly.

But where childbirth is concerned, the idea that women might be making rational, considered choices is out of the window.

i have epidurals both times. it was great - i read a magazine and watched telly

i have the lowest pain threshold of any human being on the planet. so much so infact that i am ashamed to admiot it as a northerner

good for you if you can do it naturally - have a medal, go eat cake with gaia - who gives a shit. whoop de do. does that make you a better person than i am? lets say yes it does - lets say when it comes to childbirth - your better at it than i am if you did it naturally - you can have it - keep it - the adolation is yours good for you.

now ask me if i would change anything?

errr no

in fact if i found out that a miricle had happened and i was going to give biorth to twins again tomorrow - i would probably ask to have a c-section - and i would want to be asleep during it.

when i woke up - i would then pay someone to look after the babies whilst i slept for a week.

"FFS I didn't really see childbirth as anything else other than a means of getting babies out of my body"

And that's a good thing for everyone ??? And more people should feel that way????