Live webchat with David Bogod, president-elect of the Obstetric Anaesthetists Association, Thurs 3 March, 8-9pm

[GeraldineMumsnet]

Following the discussion about epidurals on this thread, David Bogod got in touch because he'd read the thread after seeing it mentioned in the Sunday Times. We're very pleased to welcome him to Mumsnet for a webchat.

David is consultant obstetric anaesthetist at City Hospital, Nottingham, where he's worked for 21 years and carried out more than 2,000 epidural procedures. His unit has around 5,700 deliveries a year, with an epidural rate of around 25%.

He's also president-elect of the Obstetric Anaesthetists Association and vice-pres of the Association of Anaesthetists of Great Britain and Ireland.

David has two grown-up boys (one delivered by forceps, one spontaneous delivery, both under epidural).

If you've got any questions to put to David about the scientific, political or social aspects of epidural pain relief in labour, or any other issues relating to childbirth, then please come and join him on Thursday evening. Failing that, please post your question here as usual.

[3littlefrogs]

When I was working as a midwife (back in the 80s)every patient with an epidural had to be monitored closely by a qualified midwife.

Epidurals reduce blood pressure - often used for that purpose for women with dangerously high BP. Therefore, pulse, BP and Fetal HR have to be monitored closely - by someone who understands what they are doing.

If a woman has an epidural, she cannot feel pain/contractions/full bladder. Therefore close monitoring and regular checks need to be done to ensure that all is progressing normally, and the bladder is emptied regularly.

Symptoms of obstructed labour would be masked by the epidural, so careful observation by a qualified midwife is important.

BTW - I audited a case recently where an emergency section was performed for classic obstructed labour where it was only the fact that the obstetrician popped in to check on the woman, that saved her. Uterine rupture was imminent - so it does still happen.

The increasing use of unqualified staff is dangerous, and If I were still practising, I would be very worried about women with epidurals being inadequately monitored.

HTH

[hotCheeseBURNS]

Can anyone clarify the issue about having to be observed by a midwife once you've had an epidural? Because I, like one or two others who have posted, was left alone with my birth partner to sleep for a few hours after my epidural was administered (I didn't sleep, but I did relax and rest). The midwives didn't return until it was time to push.

If anyone's interested in another personal experience, I had a lovely midwife who called for an anaesthetist as soon as I asked for an epidural. She offered to examine me because she thought I was nearly there but I said no.

I remain traumatised by the pain, combined with the horrible effects of the gas and air, which I experienced before I got the epidural. I'm so grateful that I got my epidural when I did and so angry that other women have been denied pain relief.

[Fenouille]

Thanks WWIB.

[mathanxiety]

When somebody states right of off the bat that they are a professional in the area, it's hard to escape the conclusion that they are speaking in their professional capacity. When what they say about various procedures (and risks thereof) turns out to be flatly contradicted by resources freely available to anyone who can read, they invite whatever conclusions readers may form about them as professionals.

[working9while5]

I don't mean that it has to be like real life, per se. Of course it is different.. but if you are posting as a professional, you should take care when making personal statements such "working had no PND/PTSD and is jumping on the bandwagon" etc without the full facts.

There is a line. Thornykate and WonderingwhyIbother, I don't know how the other thread is going right now as I hid it, but your posts on this thread seem very professional to me (while being different to what you would say to a client in real life). However, there's a difference between arguing a difference of opinion and being accusatory when it comes to individual poster's posting about real life experiences, if that makes sense?

Many women - as should be clear from these threads - feel shaky and vulnerable about their birth experiences. They may very well be sensitive because of this fact and distrustful of the professionals who (rightly or wrongly) they associate with bad experiences. Given that many of these women will want further children, it's probably important that they do not have an unnecessarily adversarial experience with a midwife online. If the midwife is posting an opinion and they are affronted because of projection/being unable to separate their experience from reading what is being said, a midwife can't be reasonably expected to control that. However, sarcasm and dubious comments about someone's experience e.g. "jumping on the bandwagon" and "seems odd" in my case do seem to me to go beyond the bounds of robust public debate and have the potential for harming women who may be quite vulnerable in this context.

Including me!

In terms of reflecting on practice, of course it doesn't have to be in relation to care you have provided for a particular individual. The wiki definition is: ""paying critical attention to the practical values and theories which inform everyday actions, by examining practice reflectively and reflexively. This leads to developmental insight". It depends what you see as "practice", I guess. I would see practice as extending beyond individual client care to encompass anything which involves you thinking/acting/being a nurse/midwive/Allied Health Professional. You can reflect on your role within an organisation, your role in public health promotion following advising your mates at the pub (isn't this why some trusts have mandatory smoking cessation training for all?), on learning you have experienced formally or incidentally, on governmental policy impacting upon your practice etc. In the same way that if you do something weird like put porno pics of yourself up online it is seen to reflect upon your professionalism, sometimes you are thinking as a professional when you are in other contexts entirely. Sometimes I see individuals in my day to day life in my own community (e.g. on the bus, at the checkout register) that make me think about my job and where my clients may "end up" and what their needs as adults will be, and I reflect on this and it informs my work probably as much as experiences I have with my own clients.

I don't really have an axe to grind with midwives, per se. I think it's perfectly possible to represent a particular opinion online that may not chime with the experiences of potential service users as long as there is due care taken not to cause harm and the tone remains more or less professional (with maybe a bit more discussion and debate than you would expect in a clinical situation). Discussion and debate is not a problem, I don't think. Casual extrapolations from a few posts online, the use of perjorative or potentially controversial language or showing personal affront, no. That doesn't mean tolerating name calling - but it's entirely possible to say something like "I don't accept what you say and think your language is abusive" without reverting to sarcasm and rolling eye emoticons as some have done.

Again, who knows if the person I took issue with is even a midwife? None of us can. This is why, when dealing with a sensitive and emotive topic, it would be great to have official representation from the RCM on this matter to avoid some of the more ill-advised comments.

[MummyBerryJuice]

Can you really not see that when you engage with strangers on a public forum as a midwife you become a representative of your profession?

It is very different to having a conversation with your friends. Not only do they know you well and have a shared history with you. They van see you, hear your tone and read your body language. It is a totally different encounter

[WonderingWhyIBother]

I don't know how I feel about the implication that midwives posting on mumsnet should consider their posts as interactions with clients. I posted on the other thread, I am a midwife, and I certainly do not consider that post to be on par with the communication I have with women when I am working. I view my posts on here to be more similar to discussions I would have with friends/in social situations, than to discussions I would have with women in my care.

Similarly as someone else has pointed out, the name calling and aggression on these threads would not be acceptable towards staff within the NHS, and I dare say the majority of posters involved would recognise this and not act in such a way in real life.

In answer to the question about VEs, I offer VEs and I explain my rationale. For example, 'I think a VE is indicated because....', or 'our policy says I should offer a VE now because....' and follow this up with, 'how do you feel about that?' Or 'is that okay with you?' Somethimes I discuss the implications of declining as I'm offering the VE, other times only if the woman expresses that she might decline. I have certainly had women decline VEs, the implications of this completely depends on the situation, if it was someone in labour, where everything else was normal and the pattern of the contractions indicated labour was established/progressing then it would not be a massive issue, however is it was someone who was in hospital for indication then obviously that would pose a problem. I would never coerce a woman to have a VE, however it would be my role to ensure she was fully aware of any implication of declining, while supporting her in her right to do so. Sometimes there might be something I could do to make it more acceptable for a woman and I might ask this or offer any options I think of - common example, use of entonox for examination.

[thornykate]

I honestly don't agree that the MWs who contributed on MN recently have berated women or suggested that women shouldn't voice an opinion although I appreciate that every poster involved has a right to percieve other posters statements in a there own way.

I posted because regardless of someones job that doesn't mean that they are immune to the effects of name calling & slants upon their own professionalism. Personally I think that most of us wouldn't like to have such things thrown at us & it isn't helpful when we are then criticised for being hurt by it & then expressing the same. We rarely get the best out of one another when judging.

On the other side of the fence are the women who feel hurt & let down so are carrying their own feelings, I do feel it is important for these women to be individually acknowledged & for reflective practice to take place by their own practitioners.

There are women posting on here who deserve answers from the people directly involved in their care. But any MW posting on here or MWs union cannot give these women direct answers, they can only speculate as to reasons why & why things didnt happen & that's not enough when you are still suffering the effects. The practitioners involved need to be able to show why they made their decisions & the more women that approach their care team & ask for this the better. Eventually this may become more of a standard practice & easier to access? I do worry though that if people only vent on here they still leave the discussion without the answers & closure that they need & deserve so it may not help them in the long term?

I am only familiar with models of reflective practice that are used when the practitioner has actually been involved in giving the care so my perception is not that MWs who have posted on here do not practice active reflection, sorry if I misunderstood your point there?

I feel now is the time for me to bow out as I have a lot of work to get through.

[Fenouille]

I hesitate to post this because this thread (like the other two) seems to be rapidly going downhill despite some very eloquent and thought provoking posts.

Someone mentioned that for many women childbirth its their first experience of hospitalisation. This was my case. I should probably also say that this hospital was in France, not the UK, so there are certainly differences of procedure.

I wanted to pick up on the right to refuse a VE (our any procedure I suppose). Even though my permission is requested before such examinations it would never occur to me to refuse as the requester is the professional, the expert.

If there are any midwives left on this thread I would be interested in hearing whether when you ask for permission to carry out a VE you really expect someone to refuse, and how do you react if they do actually refuse? Do you try to explain the reason for the exam, especially if there is no other way to find out what you are trying to check for, our do you just say, "OK, your choice"? This really is an innocent question because it could have implications on the continuing care of the patient and I wonder how you get around that if there is a refusal.

FWIW I ended up with a forceps delivery under epi, but my midwife was marvelous. I was more cheesed off with the anaesthetist who gave me a second large dose of epi without my permission after I asked her to come back and re site it due to it being effective only on one side.

[MummyBerryJuice]

9while5 has quite eloquently put it but to me it seems that some of the mws on the thread have forgotten hat hey are talking to patients not colleagues.

Certain frustrations (patients changing their minds for example) and experiences (difficult patients), while perfectly normal and acceptable to discuss with colleagues are not appropriate when engaging with the public. Likewise, musings about the rejection of offspring by sheep and mice after epidural anaesthesia may be interesing when examined academically but when thrown into the mix of an already highly charged emotional discussion is highly inappropriate.

[DrMcDreamy]

Mistyvalley, you misunderstand me, My postings have absolutely nothing to do with my personal beliefs re pain relief - you must have missed the post where I had an epidural for my 2nd delivery. I genuinely think women should get the pain relief that they want, I just don't think it is always practical or possible and because I have a bit of knowledge on the subject I'm joining in, the majority of things I have posted have been within the spirit of debating and discussing the subject at hand. The thing I posted about epidurals and animals was a genuine musing whilst thinking on this subject and a quick google search shows it to be a genuine phenomena, rats and ewes if you're interested. I thought we were having a reasonably lively discussion and perhaps that is my fault fault for misreading things. I have tried to keep everything to an evidence based background and keep opinion out of it as far as possible.

[working9while5]

Also, "professionalism" is so narrowly defined sometimes in our culture. It is supposed to imply a certain type of character, method and spirit: surely professionalism, in the context of this discussion, is better represented by advocating for open dialogue between clients and those who care for them and discussing the need for trust and confidence between patient and professional vs picking on the phraseology of one minor point (which, in itself, was as much a rhetorical device as a serious point to argue).

I think it's interesting that the core point I have made ad infinitum has been ignored: do you think that my overriding contention - that it is most important to maintain core standards with reference to dealing with potential service users (empathy and compassion/listening skills/prioritisation of the patient experience/transmission of appropriate evidence base/advocacy for clients) - is nullified by one phrase which you disagree with? You honestly believe that using one phrase "in the vernacular" is more unprofessional than arguing with women about their experiences and berating them for saying general (not specific) negative things about midwifery vs engaging with them to enhance their understanding of their care?

I think some midwives have tried to do that - but not all. And again, who knows if Alimat is even a midwife? We need a proper representative to engage in a proper debate who can inform people who want to know, people who are patients (like me, actually!) what's what right now in maternity services.

[working9while5]

thornykate, I follow similar thinking when posting as a professional in my own field. However, here I am both professional and patient. I wouldn't write about my delivery in a report either. It changes things.

In terms of what you are querying re: my professionalism, you seem to be taking issue with this line:

"Certainly, if there was a bit more evidence of reflective practice vs "it's not our fault, women just don't get it the ungrateful cows, no one loves us", it might help with the shoe swapping"

This was a response to a post saying we should all walk a mile in eachother's shoes. It should be fairly clear from the context of the whole discusison am not inferring in the least that midwives (e.g. the whole profession) think in this way. It should also be clear that the portion in inverted commas is an interpretation of a number of posts which focused on the midwive vs the patient experience.

I think it's a little bit disingenuous to take issue with one line when I have written quite a lot on this thread about the need not to extrapolate from the views of anonymous posters representing themselves as midwives about the whole profession - indeed, I have been clear that I am not even convinced that the particular poster with whom I take most issue (who, after all, took issue with me as a patient "jumping on the bandwagon) is even a midwife.

Your issue is with one phrase. One phrase in numerous posts. You have not responded to the more general point about engaging in positive vs negative ways in public fora with patients/prospective patients.

In that errant phrase - to be clear, just in case there is confusion - I was saying that I have inferred e.g. deduced logically from my reading of words by both (supposed) midwives and patients that some posters were suggesting that women were ungrateful. This conclusion is based on the words I have read e.g. it has been inferred based on my understanding of the text (which, although it will be coloured implicitly by my experience, was inferred in good faith). There seem to be a number of posters who share the same reading, which suggests there must be some evidence for my thinking.

In this instance - as again, I should think is clear - I have laid my cards on the table. Yes, I have some professional knowledge of the NHS which informs my thinking on this issue and in particular, informs my understanding of how health professionals should interact with the public and serviced users. This is inevitable. But I came to this thread with the perspectives of a patient. I fear you are creating a strawman here and trying to discredit a pretty straightforward and uncontentious position that healthcare professionals would do best to listen to patient experience and be sensitive to that experience even on an online forum.

[thornykate]

I suppose we could accept personal insults that don't place us in physical danger but I do feel that in a culture where NHS staff are subjected to a lot of abuse it should be challenged whenever possible wherever it occurs no matter what form it takes. Hopefully that way the culture can change in time.

No 9-5 I am not suggesting NHS professionals band together against the public I am referring to NHS official guidance on verbal aggression in the workplace & I'm pretty sure that isn't suggesting we band together against the public either.

Yes you can infer words however you wish but IMO it was unfair and not professional language. That may be my own rule of thumb though- if I wouldnt want to write it in a report I dont say it out loud!

Starlight that is good advice for people on either side of the fence on how to deal with problems in healthcare.

[ReggaeMudda]

Starlight, debrief is something that is being well promoted within the maternity services at present, allowing women to meet with the people responsible for their care and discuss what happened and why in order for them to gain insight and highlight areas for improvement by the maternity team.

[working9while5]

(Incidentally, I am far from convinced that the posts I am referring to are from a registered health professional).

[ReggaeMudda]

9-5, you would make a good midwife.

[working9while5]

Incidentally, "inference" is not wrong. It's a perspective. You "can't" be wrong in inferring something. Inferring is "reading" something a certain way based on a combination of the words and individual experiences.

I certainly never said that midwives were "lying cows". I said that some posts seemed to me to be implying that women were ungrateful and that midwives' experiences needed to be heard by service users. There was a specific post where a supposed midwife said that she had served many women who were unpleasant and difficult to please. That's unprofessional.

You seem to be saying that NHS professionals have a duty to band together against the public? Really? I am also a member of the public and a service user - each of us is.

[working9while5]

I wouldn't accept aggression at work for the reasons you mention, but it is different online - no? You don't need to participate and you are not in any danger.

At work, I assume you are told to tell the person that you will not engage with them (if you feel you are safe enough to do so). Don't we all have conflict resolution training to ensure we don't inflame the situation by telling people that their feelings are wrong? We state we will not tolerate the behaviour. We apologise if necessary. We try to listen and resolve in the first instance. That's not what's been happening here.. what's been happening is a lot of hand-wringing about how awful it is for midwives which is exactly what you are told not to get into with service user's sharing their negative experiences, isn't it?

But am fine to agree to disagree, too! .

[thornykate]

We may have to agree to disagree as I still believe you were wrong to infer that MWs believe women to be lying cows & that sort of inference from a fellow NHS professional is potentially more damning to NHS professionalism as any other statement you have cited from other posters.

Frontline NHS workers are at substantial risk of aggression & violence from members of the public. It is never OK to shout at NHS (or any) staff even when we are upset, ill, in pain etc & I suggest you get support if you are expected to tolerate this. Thats not just my opinion it's the official party line from The NHS security management service.

If we accept name calling & shouting what else must we accept?

Sorry to digress from the thread I just feel strongly that it is important not to minimise name calling or accept it without challenge.

[working9while5]

Cross posted with you Margles. This is the situation we all face, isn't it? This is why it is important NOW more than EVER to ensure that we are listening and open vs defensive and closed. As with the recent universities bill, the government will make decisions based on public consultation vs consultation based on evidence. As professionals we need to get the message out there about the impact of proposals like Margles has mentioned vs engaging in divisive debate that might make a service user feel midwives were less necessary than evidence says they are.

It has to be about matching evidence with client experience in an empathetic fashion. Sod the names. They don't matter. What matters is maintaining quality of care and campaigning for better in an uncertain time.

[working9while5]

The mistake is to reject best evidence because it doesn't fit with current resources. In my field, therapy is indicated three times a week for one client population who nationally are "lucky" to receive 45 minutes of therapy once a half-term. There are huge variations in service delivery across postcode areas based on resourcing constraints that have nothing to do with evidence and everything to do with budgets.

If we tell our patients that they don't require x therapy or x dosage because we can't provide it, we prop up a failing system. Service users deserve the right to campaign for better and/or seek private services (if they are in any position to obtain it, which is an issue for another day).

If we get cross because they are outraged at being told that they didn't need x to find out, when their grief/pain/shock subsides that actually, they needed it three times a week, then we are failing them - and ourselves.

We have to advocate for our clients. We have to question our own professional practice and be honest with ourselves: how much of what we believe is based on evidence and how much on what we know is available in the current system?

We might need to do that in our departmental meetings or locally behind closed doors. We don't necessarily need a placard.

We do need to be open and listen to what our clients tell us without feeling affronted, even if what they say is not palatable and even if we don't agree. We still need to listen, and listen hard.

That's the only way..