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.

"What really stops women mobilising is the rest of the childbirth package, including the near-ubiquitous use of continuous fetal monitoring"

So basically the 'cascade of interventions' is caused not by the epidural but by the lack of knowledge of how to care for women with epidurals in place?

@emmaelf

Good evening,

There is a direct link between epidural use and assisted delivery (forceps or ventouse). By advocating wider and wider use of epidurals, you are contributing to this birth statistic, with all the consequences of such a delivery on the physical and mental health of the mother and the baby. Do you think that resources would be better spent on providing one-to-one midwife care for all women in labour, thus enabling more of them (again according to research) to achieve normal birth?

Can I again stress that I am absolutely NOT advocating 'wider and wider use of epidurals'. I'm advocating that labouring women should get whatever pain relief they want, when they want it.

I don't think this is really a very contentious stance (or shouldn't be)

@Artichokes

My midwives held the line that epidurals increased the risk of intervention and thus were a last resort.

Do epidurals really cause more interventions or is it simply that difficult lavours often end in epidurals and intervention but this is correlation not causation?

If there is a causative link can epidurals be managed so as not to increase the chance of intervention? If a woman has a mobile epidural so can keep moving and if that epidural is not topped up towards the end of labour would there be less risk of intervention? If so why is this sort of epidural management not offered as standard?

Artichokes. The two scientifically confirmed effects of epidurals upon the process or labour and delivery are prolongation of the second stage and an increased need for instrumental delivery. Having said that, it is difficult to separate out the reason for a woman wanting an epidural (excessive pain, long labour) from the subsequent effects of the epidural (in other words, it tends to be women with complicated labours who request epidurals).

The only scientific way to separate cause and effect is by doing a study in which women who request epidurals agree to be divided 50:50 to either receive an epidural or not. These studies are, unsurprisingly, quite difficult to do!

However, some such studies have been done, and it is these which have led to our better understanding of the effects of epidurals of childbirth.

david is it not true that most modern epidurals now contain fentanyl which is a opiate? and as such crosses the placenta? Therefore has the potential to affect the baby, eg sedative effects.
This is quoted in the nice guidelines.
Therefore if this is indeed true, it can affect breastfeeding as a sleepy baby will often be relectant to feed.

I Find it frightening that a fellow professional believes that the monitoring of a high risk women in labour could be carried out by a healthcare assistant. The whole point of continuous monitoring is to identify problems and deviations from the norm. That's why midwives spend 3 years at university. To insinuate this could be done by someone with no qualifications is pretty insulting.

Again, thank you so much for coming on here.

So, you disagree with the position that "before 4cm you are not in active labour... this is not evidence based and is against NICE guidelines".

Could you say more on this?
I was one of those women in significant pain in the early stages which went on for 36 hours before I was augmented under epidural, due to malpositioned baby. The fear I experienced and the frustration at being dismissed as not really in labour and therefore not a candidate for epidural, 1:1 support or ANY other pain relief will stay with me forever.

It seemed to be hospital policy not to do ANYTHING under 4 cm.

@Olivetti

Hello
Thank you very much for coming on.
I had an epidural in November. My baby ended up being forceps delivery, due to her heartrate dropping after 2 hours pushing. However, I believe this was because my midwives mismangaged the pushing stage, byt failing to tell me when contractions came at least four times, so we lost valuable time. I was just one push away from delivering without intervention. Do you agree that this can be the case, and that it is not the epidural itself that necessarily increases the risk of intervention, but a failure to manage the situation? I want to have one next time, but intend to be much firmer about ensuring my contractions are tracked properly.

Sorry to hear about your experience. However, I'm naturally wary about making comments on issues that are really the province of the midwife. You might want to go through your delivery records with one of the senior midwives from the hospital.

It's certainly true that epidurals prolong the second stage, so more time needs to be allowed to achieve spontaneous delivery.

Thank you SO much for this answer:

'There are some medical reasons why an epidural might be regarded as unsafe but these are rare. Significant infection in the blood stream or at the site of epidural puncture; abnormal blood clotting; major back surgery; some heart conditions. Epidurals are a reasonable option for the vast majority of labouring women.'

and this too:

'Some midwives do have a tendency to try to artificially limit the range of cervical dilatation over which an epidural can be done (as an extreme example, some might say that before 4 cm you're not in active labour and after 7 cm you're in transition). This is not evidence-based, and goes against NICE guidelines.'

Questions --
Do you think it is time midwives sat down with anesthetists and had a chat? Topics could include real risks associated with epidurals as opposed to remote risks, and what exactly the NICE guidelines translate into when it comes to practice.

@me23

david is it not true that most modern epidurals now contain fentanyl which is a opiate? and as such crosses the placenta? Therefore has the potential to affect the baby, eg sedative effects.
This is quoted in the nice guidelines.
Therefore if this is indeed true, it can affect breastfeeding as a sleepy baby will often be relectant to feed.

Yes, epidural doses of fentanyl over 100 micrograms do have an effect on the baby. In practice, doses of this level aren't often used. Even if they are, the effects of pethidine or diamorphine in sedating the baby are many times greater and last considerably longer.

I am considering a VBAC for DC2 (1st birth was an EMCS), due in April. From reading the RCOG guidelines on ERCS, it appears to my untrained eye that an epidural may increase the likelihood of a successful VBAC. Is this the case? Would this just refer to a mobile epidural (to allow change of position etc) or any epidural? (I will probably be deilvering at a comparatively low volume hospital where mobile epidural won't be available).

Thank you

@DrMcDreamy

I Find it frightening that a fellow professional believes that the monitoring of a high risk women in labour could be carried out by a healthcare assistant. The whole point of continuous monitoring is to identify problems and deviations from the norm. That's why midwives spend 3 years at university. To insinuate this could be done by someone with no qualifications is pretty insulting.

Sorry to offend, but I didn't for a moment suggest that a midwife's role could be devolved to an HCA. I did suggest that a suitably trained non-midwife could assist by fulfilling those specific tasks which involve the care of a woman with an epidural, e.g measuring the blood pressure and heart rate, charting the level of block etc.

@Checkmate

Thanks for coming Mr Bogod,
My experience is polar opposite to many on the original thread, as my consultant talked me into having an epidural at the same time as beginning my induction on a synt drip. The delivery ended horribly with keilland forceps, resulting in minor injuries to DD1 and major injuries to myself. I then suffered from PTSD.

Following counselling, I have gone on to have 3 further children (including another induction) with no epidurals. I would rather go through the pain during the birth, and not have the increased risk of another instrument delivery and resulting pain and further surgery.

I suspect that witnessing experiences like mine is the reason that some midwives don't like epidurals. Is there anything that can be done to minimise the likelihood of needing an instrument delivery for women who really want an epidural?

Checkmate. The evidence suggests that keeping mobile is the best way to achieve a spontaneous delivery. Your midwife should be able to help you with this. In addition, a 'passive hour' of not pushing when you enter second stage is proven to help.

A syntocinon drip is often used in the second stage with an epidural to speed matters up. Turning the epidural off in the second stage of labour, a common practice, does not have any measurable impact upon normal delivery rates and, according to NICE, should not be happening.

I was another like beakysmum who was in horrendous pain in early labour (turned out baby was back to back) which was totally dismissed. I wanted to avoid opiates and an epidural for various reasons, fear of side effects mostly, but I asked for gas and air which was refused as it was "too early". The pain was truly horrific and not only did it make me totally panic at what was to come (which was nothing anyt worse actually) it stayed with me for years afterwards. Is this common to refuse gas and air to a woman in horrendous pain? I suspect they thought I was just makiung a huge fuss. Having now had a normal labour I know my pain level in labour 1 was extreme.

@beakysmum

Again, thank you so much for coming on here.

So, you disagree with the position that "before 4cm you are not in active labour... this is not evidence based and is against NICE guidelines".

Could you say more on this?
I was one of those women in significant pain in the early stages which went on for 36 hours before I was augmented under epidural, due to malpositioned baby. The fear I experienced and the frustration at being dismissed as not really in labour and therefore not a candidate for epidural, 1:1 support or ANY other pain relief will stay with me forever.

It seemed to be hospital policy not to do ANYTHING under 4 cm.

The issue which you so graphically illustrate is that every labour if different. Putting arbitrary limits on certain pain-relieving interventions, while easy to do, does not really imho, represent woman-centred care

Sorry for typos. Trying to get in there before 9 (but suspect I didn't quite make it)

@FrogGreen

Thank you David, for coming on to answer our questions.

My question is: Would you advise mothers to ask for an epidural at the very start of proceedings, if they think they want one, or wait and see how their labour progresses? Is there some point of no return after which an epidural can't be administered?

FrogGreen. See my previous answers. I think it a good idea to make your wishes very clear to your midwife when you arrive on the labour ward; it's far easier to do it then than when contractions are becoming more frequent and intense, by which time you may anyway be under the influence of pethidine or gas and air, and less able to express your desires. NICE recommends that ?Women in labour who desire regional analgesia should not be denied it, including women in severe pain in the latent first stage of labour.?; this seems pretty clear to me.

@GrumpyFish

I am considering a VBAC for DC2 (1st birth was an EMCS), due in April. From reading the RCOG guidelines on ERCS, it appears to my untrained eye that an epidural may increase the likelihood of a successful VBAC. Is this the case? Would this just refer to a mobile epidural (to allow change of position etc) or any epidural? (I will probably be deilvering at a comparatively low volume hospital where mobile epidural won't be available).

Thank you

Mobile epidurals are the norm nowadays (or at least the mixture is; the philosophy sometimes gets lost). An epidural probably won't increase your chances of a successful VBAC but - and this is really quite important - it's a valuable safety feature for any woman with an increased chance of needing an emergency section, a category that you would come into. If you have an epidural in place, it is relatively easy to top it up safely; if you don't, you may need a general anaesthetic, which is not so safe.

Dear Mr Bogod,

I gave birth in France where an epidural was the only pain relief on offer. I did end up having one which only acted on one side unfortunately. The anaesthetist gave me a second big dose after I asked her if it was possible to resite it. I wasn't very happy with the additional dose as I lost all feeling completely in one side, but she told me that the high dose was to get things moving.

I've only read on here about epidurals slowing things down. So do they slow things down or do they speed things up?

@SuiGeneris

Is there a time in labour before which an epidural is too early from a medical point of view (as opposed to the need to avoid having a midwife and room taken up)?

Had my first baby last year and had to labour at home for 8 hours before I was even allowed to go into hospital (MWs on the phone kept saying if I could be on the phone then I was clearly not suffering enough- little do they know that I am a very quiet person who never shouts/swears etc). When I was finally allowed to go to hospital the MWs were changing shifts and even had to ask 3-4 times just to get G&A. Then tried the pool but by then it was too far (had been in too much pain far too long) and so asked for epidural. Anaesthetist was brilliant and the relief enormous but 13 months down the the line I keep wondering why I had to suffer in pain for the preceding 11 hours rather than be allowed to go to hospital and have pain relief sooner.

So, is there a good medical reason for delaying epidurals until one is in agony or is it a matter of resources? And if it is a matter of resources, is there any other area of medicine where anaestesia for pain of the magnitude of labour pain is considered optional or delayed until the patient is screaming in agony?

Secondly: is it possible to retain epidural access to manage postoperative pain, e.g. after an instrumental birth/caesarian? I think I read about this somewhere but when I asked at the antenatal course the MW laughed and said something along the lines of "labour and birth, and the aftermath, are painful."

Thirdly: why not get anaesthetists/anaesthetic nurses to give a lesson about pain relief in antenatal classes? The MWs at both of my courses were obviously biassed against epidurals (oddly seemed to think G&A and pethidine were more "natural") and I did not think the information they gave was balanced, at all.

SuiGeneris. So many questions! There is no reason why an epidural should be delayed until you are 'in established labour'; the NICE guidelines state: "?Women in labour who desire regional analgesia should not be denied it, including women in severe pain in the latent first stage of labour.? When this happens, it is usually a matter of resources, as you say. My thoughts on this are fairly unprintable but, along with midwifery and obstetric colleagues, anaesthetists are ensuring that adequate resourcing of maternity services is kept very high on the health agenda.

To your second question, epidurals are often used outside the maternity suite for post-operative pain relief (after, for example, hip replacement or bowel surgery). Some centres use them post-Caesarean section and those that don't have other tricks up their sleeves, including spinal opiates and local anaesthetic nerve blocks to keep patients comfortable after section. Post-operative pain, while a 'normal' response, is never desirable, can be harmful, and should be treated seriously.

Third, well some anaesthetists do. And, sadly, in some centres (not my own) anaesthetists are kept away from the antenatal class for fear of 'medicalisation' of childbirth. The best evidence-based antenatal information on childbirth in labour (conflict alert - I am about to become President of this organisation) can be found at the website of the Obstetric Anaesthetists Association (www.oaa-anaes.ac.uk), with a 'pain relief in labour' leaflet available in over 30 languages.

@gaelicsheep

Sorry for typos. Trying to get in there before 9 (but suspect I didn't quite make it)

You made. It sounds like a ghastly experience. Frankly, I can't see any reason for refusing gas and air to a woman at whatever stage of labour she's at. If she's not in labour but still has severe pain, that this needs (a) investigating and (b) treating.

@RancerDoo

How often do epidurals not work (partially or wholly)?

Is it common for an anaesthetist to be unable to site the epidural? (This happened to me during the pushing stage of labour - he got the needle in but wasn't sure if he'd hit the right space - and made for a very unpleasant hour (rocking contractions every 3 mins) followed by a general anaesthetic. Am I an oddity or is this quite common?)

RancerDoo. I think many anaesthetists tend to overstate the efficacy of epidurals. They probably only provide the level of pain relief which the woman wants in about 60-70% of cases, The others sometimes need stronger solutions or even the epidural resited. They are still far more effective than any other form of pain relief, however.

It's unusual, but certainly not unknown, for an anaesthetist to have difficulty in getting an epidural in. It's a delicate business, with the possibility of severe headache if he/she overshoots (and a very rare incidence of nerve damage).

There's only a small gap between the bones of the back, and the insertion site can be difficult to locate if the woman is moving (not at all uncommon in the throes of labour), or if she is overweight.

@Fenouille

Dear Mr Bogod,

I gave birth in France where an epidural was the only pain relief on offer. I did end up having one which only acted on one side unfortunately. The anaesthetist gave me a second big dose after I asked her if it was possible to resite it. I wasn't very happy with the additional dose as I lost all feeling completely in one side, but she told me that the high dose was to get things moving.

I've only read on here about epidurals slowing things down. So do they slow things down or do they speed things up?

Bonjour Fenouille. They slow down the second stage and have no effect on the first.

They do things differently in France! The epidural rate is indeed very high in most French cities, but what's important is that there's no negativity associated with this.

I once read a copy of Paris Match magazine in which French cities were rated according to their 'woman-friendliness'. The epidural rate was one of the factors used in the scoring system, with a high rate being good! A UK magazine doing the same analysis would regard a low epidural rate as good. Go figure!

Please please can you answer the question about why they took the gas and air away when it was time to push?

@domesticslattern

Please please can you answer the question about why they took the gas and air away when it was time to push?

Domesticslattern. There is no reason to withdraw any form of pain relief, whether it be gas and air or epidural, when you are ready to push (unless, I suppose, it was sending you so loopy that you weren't able to listen to what the midwife was telling you!)

I don't want to outstay my invitation, so am about to shut up shop for the evening. Thank you all for being gentle with me - I hope that my replies have addressed most - if not all - of your queries. I'll probably check in from time to time to see if there are any burning questions.

I'd like to close, if I may, with some advice for those of you who will be utilising maternity services in the future and want an epidural.

Get informed. The OAA leaflet at www.oaa-anaes.ac.uk has evidence relating to different methods of pain relief in labour.

Make it clear on your birthplan that you are fully informed of the risks and benefits of epidural pain relief and would like to take advantage of it at a time in labour when you feel that you need it.

Tell your midwife of your plan as soon as you are admitted in labour or for induction. Ask her if she has any problem with you having an epidural when you want one. Be aware of the NICE guidelines mentioned which stipulate that you should be able to have your epidural when you want it, even in the latent first stage of labour.

When the time comes, tell your midwife and ensure that she contacts the duty anaesthetist and informs him/her of your request, even if busy in theatre. Ask her to make a note of this request in your records.

If more than 30 minutes elapses before the arrival of the anaesthetist, ask again and keep asking. There is a national standard which states: "Where a 24-hour epidural service is offered, the time from the anaesthetist being informed about an epidural until being able to attend the mother should not normally exceed 30 minutes, and must be within one hour except in exceptional circumstances.? (www.aagbi.org/publications/guidelines/docs/obstetric05.pdf)

There's a bottle of Glenmorangie calling to me, so good luck to you all and goodnight.