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.

[Lulumama]

i think wrt to pethidine, it is not that effective as a pain reliever, it makes you feel disconnected and more relaxed (!) and can be beneficial if labour is stalled or slow . Diamporphine is better apparently as a pain reliever. Meptid not really taken off as pain reliever. I think that nothing will stop you feeling the pain except full block epi topped up when wearing off or general. everything else either alters your perception of the pain/ the time between contractions etc or stops you being able to make a fuss.

[lukewarmmama]

David, I had a strange experience with an epidural, and the consultants at my hospital couldn't tell me why this happened...

I was in (induced) labour, had pethidine x2 and then an epidural. All normal until less than 5 mins after the epidural my bp shot up, baby in distress and I had to have a crash c section.

Is it possible for an epidural to have that side effect? Just curious and would be nice to get it straight in my head, not litigious!

Many thanks in advance

[socialhandgrenade]

I was induced with a syntocin drip and the only pain relief option offered was gas and air. I also had a TENS machine and my husband acupunctured me which made it bearable. I ended up having a c-section with a spinal block. The following day I felt very very high, like I was on ecstasy and insisted on hugging the anaesthetist and midwives who had been in the operating theatre. Was this a 'natural' high, or something to do with the drugs?? Also what do you think about acupuncture for pain relief during labour?

[slsp]

Many comments on the thread were generated by a rather binary approach by the respective MWs - seeing pain relief as for the comfort of the mother and therefore in their view not necessary. I was in intense labour with a prem from very early on but nevertheless left the decision regarding pain relief entirely in the hands of my MW on the grounds that I had no idea what was going on and the baby at 33 + 4 was already at a great disadvantage. The bottom line was that I was given pethadine, restarted when labour stalled and then given an epidural. The reasoning I was given was that whilst pain relief is not always good for the baby, neither is the intense pain of the mother. With this in mind my question is:

Is the mother's pain as potentially detrimental to the baby as pain relief? And if so why on earth are some mothers left in such state? Not only is their well-being hugely important, but it would seem the effects on the baby can be argued both ways, leaving the 'suck it up' approach without a leg to stand on.

[ILikeToMoveItMoveIt]

That was why I was asking for clarification Lulu. It is sold to labouring woman as pain relief, but actually, is it?

[GeraldineMumsnet]

Evening everybody,

Thanks very much to everyone who has posted such great questions on this thread. David has been looking through the thread over the past few days.

He'll try to get through as many questions as possible, but he's doing the webchat 'remotely', not at MNHQ, so we can't give quite as much help as usual.

Thanks very much to David for coming on. You're very welcome to Mumsnet.

Over to you...

[DavidBogod]

Hello, and thank you for inviting me onto Mumsnet, where I was first drawn by the Sunday Times article on the thread about midwives and epidurals. Some community you have here!

From the outset, I should say that I am doing this from home on my trusty Mac laptop. I'm not at Mumsnet Towers and don't have anyone to do the typing and posting for me, so please be patient. I will try to answer anything that's relevant and will also be posting responses to the queries and comments made in advance of this session.

One of you (SarahBumBarer I think - where do you get these names?) asked me to set out my position on epidurals at the start of this session. This seems a very sensible idea, so here goes.

I have been delighted to have my long-held conviction that epidurals are the most effective form of pain relief in labour recently confirmed by a Cochrane meta-analytic review (the purest form of scientific evidence that the health professional can draw on). I think that women giving birth in a civilised society should have free access to this form of pain relief, along with any other methods which have proven benefits. If I were giving birth - an unlikely proposition - I would have an epidural within five minutes of my bum landing on the bed.

BUT, what I think is best is completely irrelevant to you, the woman in labour. My job, and that of your other professional birth attendants, is to provide you with the necessary information to allow you to weigh up the relative risks and benefits and then to make your own choice. If whale music and clary sage aromatherapy do it for you, then whale music and clary sage aromatherapy should be what you get. Women's choice means nothing if they can only 'choose' what their health care attendants think is best for them. This kind of paternalism has rightly been condemned in medicine and is, I hope, on the way out. It should go without saying that the same should apply to all caring professions, especially those which claim to advocate for the patient.

OK, that's off my chest. Away we go!

[DavidBogod]

ChocolateBar. Perineal repair is a little outside my comfort zone! However, the obstetrician or midwife carrying out the repair should be able to do so entirely comfortably with correct use of local anaesthesia. If the tear is extensive - particularly 3rd or 4th degree - it should be repaired in theatre with a spinal or epidural anaesthetic.

The rectal route is commonly used for pain-killers, but I would be appalled to think that someone with your history should be bullied into accepting this. All of these drugs can be given orally as well. In my experience, midwives and doctors are much more sensitive to issues of this nature than they were in the past.

Why is it the case that so many women report being given insufficient local anaesthetic for perineal repair work? It happened to me and the doctor just said "It won't be long now". The repair work took 25 minutes! That's a long time to be in pain. I know there are guidelines in place that say that doctors should make sure that women have adequate pain relief before starting to stitch - why are these guidelines not adhered to? Why is it seen as acceptable for women to experience pain of this nature?

Second question (if I may) re being given diclofenac after the repair work. As a victim of sexual assault I had real issues with being given drugs rectally. The doctor and midwife basically bullied me into having it (not sure why it was so important to give pain relief after stitching but not during ). I realise that they probably thought they were doing the right thing, but it's caused lots of problems for me on an emotional level since. Why is there so little awareness among HCPs about the fact that victims of sexual assault might have strong feelings about this sort of thing and why do HCPs not listen to women and respect their views? [/quote]

[DavidBogod]

Alimat1. See my previous answers. I have put more epidurals in in the latent phase than I would care to remember!

What are your feelings of epidurals being given in the latent stage of labour as per NICE guidlines?

Have you ever given one in latent stage ie not established labour and not due for induction?[/quote]

[DavidBogod]

SarahBumBarer. See my introductory post. I'm not comfortable commenting on specific care in my own hospital on a public forum, as you might imagine.

David - welcome and thank you.

I was just wondering if you could set out your position on epidurals at the start of the discussion - I'm assuming from your profession that you are "pro" epidurals but is that in all cases? ie would you say that epidurals should be routine?

Specifically, how do you feel about Notts City Hospital then as I found my ante-natal care in Nottingham included a reasonably evident anti-epidural/pro natural birth message? (I have almost nothing but good memories of my birth experience at City Hospital by the way)

I'd also be very interested in your answer to DomesticSlattern's question about the removal of gas and air at the pushing stage since this was also a feature of my care at City Hospital yet is clearly not a national practice (thinking of One Born Every Minute here) and is my one minor gripe with City. Would I be able to insist on keeping the G&A next time?[/quote]

[DavidBogod]

Thetideishigh. Midwives are fairly protective of their territory, and are the right people to coordinate care in labour. However, it is undoubtedly true that the best and safest units are those in which there is mutual respect between the health care professionals involved in a woman's care, and where communication is good. I'm lucky enough to work in such an environment.

Hi David,

As a consultant obstetric anesthetist do you feel, having read the thread about midwives apparently controlling access to epidurals, that there needs to be much closer liaison/working relationship between anesthetists and midwives to prevent the incidences of uncontrolled pain during childbirth impacting on the mother's mental health at the start of a challenging time in her life. Dare I say it, could the anaesthetists have more control at an earlier stage in the pain relief situation.

I won't post my birth story as it might make me identifiable but if I had been given the confidence in pain-relief availability and choices, it could have been quite different.

Tip for midwifery departments - if you want people to have confidence in the service you are running don't run shambolic ante-natal clinics/lose notes/neglect to refer to notes at all/lose test results/talk patronisingly to educated and intelligent women/deny that there is any such thing as a mobile epidural. [/quote]

[Lulumama]

hello David


yes, i see what you mean ILTMI

[DavidBogod]

Fimbo - Rathlin. Dural puncture occurs in around 1 in 100 epidurals, is listed as a complication in all the relevant literature, and should be explained to you by the anaesthetist who attends to do your epidural. The resultant headache can be very severe indeed and can last up to two weeks (in very rare cases it can last much longer and become very difficult to treat). Blood patch is a very effective treatment, but a second patch is needed in around 15-20% of cases. Long-term consequences are very rare, and are usually limited to the chronic headache described above.

@rathlin

Hello, are there any long term effects from a lumbar puncture during the siting of an epidural for a c-section resulting in two blood patches (1st one failed) to cure a post dural puncture headache? Thanks in advance.

[ILikeToMoveItMoveIt]

Hello David

I did at 'Perineal repair is a little outside my comfort zone', isn't it everyones? - ouch!

[jugglingjo]

Though I welcome many of your introductory comments, I do feel that you are slightly in favour of epidurals over say water birth, which I personally found very helpful in both my labours (DD1 born in pool at Tooting Hospital)

I thought your comments on "whale music and clary sage aromatherapy" were possibly slightly less than fully respectful of the water birth option, which many women have found a fabulous option - but is not always available. Indeed no pool offered for second birth, even following my use of one for very smooth first labour. ( Made use of water again by labouring in bath at home throughout first stage ! )

[DavidBogod]

Sfxmum - Iliketomoveitmoveit. Pethidine is an opiate, related to morphine. As such, it has pain-relieving properties with sedation as a side effect, along with nausea and vomiting. It has been used for donkey's years by midwives and certainly has a place, especially in the early stages of labour when a bit of sedation can be a good thing. However, its ability to relieve labour pain is not good - some studies have suggested it doesn't relieve pain at all - and it does cross the placenta whenever it's given in labour, sometimes resulting in a baby that is measurable more drowsy during the first 24 hours after birth. Some units have dropped pethidine in favour of diamorphine, a more powerful drug but with the same side-effects.

@sfxmum

hello thank you for coming

my question is regarding Pethidine, I was given this half way through a very long labour and it was possibly one of the worst experiences I have ever been through, it felt like being buried alive while still feeling quite a bit of discomfort
(apology for the dramatic language but it really felt awful)

so is common for this drug not to actually work very well and have such adverse reactions?
TIA

[DavidBogod]

Jugglinjo. I can only agree. I was stimulated to do this by the firmly expressed view that some midwives are 'tricking' women out of epidurals. Frankly, I am appalled that this might be happening. I can appreciate - but not condone - that some midwives are 'anti-epidural', but trickery and being economical with the truth must have absolutely no place in a patient-carer relationship.

I hesitate to suggest it - this is your forum after all - but it seems to me that what is needed is a serious conversation at national level between women and midwives.

@jugglingjo

I don't know what David feels, but before he kicks off tackling some answers to these points and questions I'd just like to say to my fellow Mumsnetters how impressed I am with the wisdom and thoughtfulness expressed in these posts.

I hope you'd agree David ?
Are there any particular points expressed, perhaps from mothers experiences of birth here, that you'll be taking away with you from this discussion ?

[Ooid]

Why can a bit of sedation be a good thing in the early stages of labour? Yes if you want a quiet, passive woman (who would arguably be better off labouring actively).

[DavidBogod]

I'm grateful to Geraldine at Mumsnet Towers, who is cutting and pasting a number of answers which I prepared earlier to the advance queries which have come in over the last few days. They should pop up over the next hour.

[DavidBogod]

Labour can be a long and pretty tiring business. It's been likened to running a marathon, and good hydration and nutrition, coupled with a rest in early stages if possible, often help later on.

@Ooid

Why can a bit of sedation be a good thing in the early stages of labour? Yes if you want a quiet, passive woman (who would arguably be better off labouring actively).

[jugglingjo]

Yes, I'm sure that truly respectful patient-carer relationships are a key factor in providing good care to women in labour.

I'd say improved funding is also a crucial area. I feel this area of health care is woefully under-resourced at present, especially in failing to provide one to one support by a midwife known to the woman during labour.

Many options including home birth and water birth as well as epidurals should be much more readily available.

[Ooid]

I think that is arguable, isn't it?
Lots of things 'hold up' the normal development of labour, many of them iatrogenic.

Surely far, FAR more beneficial is good one-to-one care from an involved caregiver. Shame it costs so much.

I know there is undoubtedly a place for analgesia but to begin it so early in many cases (especially with a painkiller which can cause so many psychologically undermining side-effects) seems fairly cruel.

[Ushy]

Hello David, thanks for coming You suggst that women have a conversation at national level with midwives but HOW? The charities that the government listens to are ALL natural childbirth ones and their views are exactly the same as midwives.

[expatinscotland]

Thank you for coming, Mr Bogod.

I was one of the more vociferous posters on the original thread so am interested in your comments.

I had two births under epidural - one back to back labour with a baby who also turned out to have her hand up cupping her ear. I waited 4 hours for an epidural in that case. Ended in delivery by H-F forceps with no negative effect.

Another birth, like doricpatter, it was a case of transferring to a CLU (Paisley) to get one. This was a 1.5 hour ambulance journey, they knew I was coming and why I was transferring, yet I still waited hours again for an epidural, repeating my request (the reason why I came there to give birth, anyway) for hours as I was left alone (no birth partner, either). Had diamorphine. It just made me stoned.

My son was over 2lbs. heavier than either of his sisters, had cord was wrapped round his neck and was delivered by ventouse - no episiotomy, although I did sustain a 2nd degree tear which healed well.

My concern is that, as more and more hospitals are closed, this will be a more common scenario.

Basically, particularly in Scotland, the option to have epidural pain relief is becoming less and less of an option at all.

[DavidBogod]

@AtYourCervix

Should epidurals be available for all birthing women or for those in need of a more medically managed birth?

Who should decide if and when an epidural is necessary?

AtYourCervix, ILikeToMoveItMoveIt, 3littlefrogs: Along with most obstetric anaesthetists, I strongly believe that epidural pain relief in labour should be a universally available option. We have to recognise, sadly, that the healthcare budget is limited and this impacts upon a whole lot of services. However, relief of severe pain should be a basic human right, and I would therefore advocate that epidural services should be prioritised when deciding upon resource allocation.

The good news is that it largely is. There are very few maternity units nowadays which do not provide an epidural service and, in the majority of hospitals, this is provided by a dedicated 24/7 obstetric anaesthetist who has no other duties in the hospital (in a snap survey I carried out at a major conference yesterday, this applies to 72% of units). However, even within these units, an epidural is not always available when a woman wants it. Sometimes, this will be because the anaesthetists are busy in theatre, usually with a Caesarean section, but more commonly it is due to there being insufficient midwives to provide the one-to-one care needed. One-to-one care should be every woman's right, and I strongly support any campaign to increase the number of midwives working in the NHS.