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.

[domesticslattern]

Thank you very much for answering my question.

[Fenouille]

Probably too late for a follow up, so thanks for answering my question. I agree it's seen as no bad thing here generally (although it is changing slowly) but I felt it was almost seen as too much of a good thing as when I met the anaesthetist before my labour my questions about side effects were dismissed with the comment, "you have been reading a lot haven't you?"! I was very interested therefore to see your 60-70% statistic.

[doricpatter]

Great webchat, thank you :)

[GeraldineMumsnet]

Thanks David, enjoy your wee dram and thanks for coming on.

I'll post the rest of the answers that David did before the webchat shortly. As David says, he'll be looking in after this, so if you have any burning questions, once you've seen the rest of his replies, post 'em here.

[expatinscotland]

Thank you for coming, Mr Bogod.

[gaelicsheep]

Thank you very much to David for answering my hastily typed and garbled question. (If my internet connection hadn't packed up for 10 mins I could have thanked him while he was here.) I'm just glad I was finally brave enough to do it again and have the chance to know what a normal labour is like.

[GrumpyFish]

Thank you very much for your answer, really useful webchat.

[Alimat1]

David - if you get a chance to come on again, can I ask you Re;latent stage

how long would you be happy for a women to have an epidural sited for?

Latent stage can last for several days.
as a midwife I have never seem a woman have an epidural for latent stage.
Would giving it end up in induction and the cascade of intervention involved with that?

I have seen several sited prior to induction, when women are not in labour at all but obviously wanting pain relief prior to it all starting.

[dizietsma]

Very interesting webchat, thanks David. I was in back to back labour at a planned home birth with my daughter for 27 hours and was refused gas and air because I "wasn't far enough along". I suspected it wasn't right, good to know for future reference that they can't refuse me pain relief based on the stage of labour.

[GeraldineMumsnet]

Ok, here are some more answers:

moosemama: I have always wondered why walking epidurals aren't more freely available. Surely they are preferably to a full epidural as in most cases, staying upright and mobile during labour helps move things along.

DavidBogod: Moosemama, see my response to LeninGrad.


ohanotherone: Are epidurals more likely (or less likely/no difference) to lead to intervention which in turn may require forceps etc. and lead to damage to pelvic floor muscles/perineum? I really want a precis of the actual clinical evidence as opposed to your initial thoughts on the matter.

DavidBogod: ohanotherones, see my previous answers. For the scientific evidence, I can do not better than point you to the Cochrane review on the subject. A useful lay summary and link to the full document can be found at onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD000331/pdf_abstract_fs.html

Lulumama: Do mobile epidurals really exist? how mobile can you be? or is it simply 'mobile' in as much as you can move around the bed rather than get up and stand?

DavidBogod: see my response to LeninGrad.

Margles: I have heard of saline injections being used in Scandinavia instead of epidurals. Do they work, and if so, are they ever used here?

DavidBogod: Margles. Yes - a very odd business, the saline injection into the skin overlying the back of the hip-bone, and almost exclusively practised, as you say, in Scandinavia. Studies have shown that it has no useful effect and probably only works as glorified distraction therapy (apparently it stings a lot!). I think even the Swedes are dropping it now.

missedith01: I had an elective caesarian for a footling breech that wouldn't be turned. The team tried tilting the operating table to no effect, and then the anaesthetist gave me some wonderful drug that simply Made It Go Away. It was lovely, like being a normal person again.

My question is: if there is another pregnancy, is there any reason not to take the wonder-drug all the way through?

DavidBogod: missedith01, it sounds like you had a spinal anaesthetic for your Caesarean section. Sadly, a bit too strong for labour, plus it only lasts about two hours. The closest you'll get, assuming you're not opting for another section, is an epidural.

mathanxiety: Sort of asked before, but can a nurse monitor a woman after an epidural or does it have to be a midwife?Do you think medical personnel give balanced information to patients (in light of the other thread) or do their biases inform them more than actual statistics when it comes to giving women the information they need in order to make their decision on an epidural?

Do you think there are medical professionals who think pain is some sort of magical thing when it occurs in labour, bestowing maternal feelings, etc. 'no pain no gain' and that painful labour is seen by some as a sort of initiation rite that women should go through?

DavidBogod: Mathanxiety. At the moment, it has to be a midwife, but I'm interested in the possibility of other heath professionals carrying out this role.

As to your other point, there is certainly a very vocal lobby who believe that labour 'should' be painful, as exemplified by the hapless male academic midwife who voiced this view a couple of years back, and received a lot of flack for it (rightly so, to my mind).

Historically, of course, this was the position held by the church and establishment (universally male) up until the mid-19th century or later ("In sorrow thou shalt bring forth children" - Genesis) and it was only the persistence and bravery of men like James Young Simpson and John Snow - who gave Queen Victoria chloroform at the birth of Prince Leopold - that started the ball rolling towards pain relief in labour.

Ironically, the 'pain in labour is good' lobby is now largely made up of women who claim to be empowering other women. What they should be fighting for - imho - is a properly funded maternity service, with one-to-one midwifery care, which puts maternal choice at its very heart. But don't get me started!

sakura: So I suppose my question is, why did you decide to become an obsetric anaesthetist?

DavidBogod: Sakura, I have the best job in the world. I walk into a room to find a frightened woman screaming with pain, and walk out again 30 minutes later with her back in control, comfortable and enjoying the process of giving birth.

Our job's not just confined to epidurals, of course, and I have the regular privilege of helping women through childbirth by caring for them during Caesarean sections, as well as dealing with the more fraught situations of haemorrhage, eclampsia and many other acute clinical emergencies.

I must also say that I find that working with my midwifery and obstetric colleagues to provide a good and safe environment for childbirth to be a very fulfilling and rewarding experience. Sometimes it's quite fun too!

Ushy: I listened radio and TV about the Mumsnet thread and was amazed to hear a midwife (who was very senior) arguing that epidurals lead to caesareans!!!! It is a key recommendation of the NICE guidelines that woman are told epidurals do NOT cause c/s. So what is going on?What about how risk is presented? I had a midwife tell me about the risks of paralysis!! I looked on your website and noticed that it is a risk of 1 in 250,000!!! i.e. you are about 25 times more likely to die in childbirth than be paralysed by the epidural!!

Why is the midwifery profession so anti pain relief? Is this social, historical or what? They claim it is because of the cascade of intervention issue but, in the US, Canada and France, the epidural rate is way higher (double at least) and they have lower instrumental rates.

It is actually scandalous .... my next door neighbour who is a GP claims that it is because some midwives (along with the natural childbirth lobby groups) are so political and strident that no-one will cross them. Is he right?

DavidBogod: Ushy, you ask "Why is the midwifery profession so anti pain relief?". Firstly, I do agree that some midwives seem to be anti-epidural (while often in favour of other techniques, such as pethidine which has much more profound effects on the baby) but in my experience this is a minority of practitioners. I seriously don't know what it is about epidurals, other than it involves a doctor. Some definitions of 'normal childbirth' specifically exclude the use of epidural analgesia (we have lobbied very strongly against this, by the way) but it's not mentioned in the Royal College of Midwives (RCM) definition of normal childbirth which is "?one where a woman commences, continues and completes labour physiologically at term.?

I think that to understand this attitude, Mumsnetters need to be aware that many midwives regard themselves as the guardians of 'normal' birth. Indeed the RCM states that midwives should try to 'maximise normal birth in the context of maternal choice'. That rider about maternal choice is key to the whole Mumsnet thread, of course, and it is often missed out when midwives quote this maxim. It is important for a woman to know that her midwife may have an agenda - albeit a perfectly respectable one - which might be slightly at odds with their own wishes.

breatheslowly: Is it more likely that it will only work on one side if you can't stay very still for the epidural?

Is there any reason why I shouldn't have had the epidural before the drip - is there any benefit in waiting?

DavidBogod: Breatheslowly. No, some epidurals are unilateral (one-sided) but it's not more likely if you move during insertion. See my earlier comments about the NICE guidelines on when epidurals should be inserted.

urbanproserpine: Are you aware that you are often the representative for all the Meds when in these situations? You are right by the persons head, closer than their partner on one of the most significant moments of their lives, and they will remember you forever? I have to say in my case positively, and I couldn't tell you what the many other people in theatre during my section said to me.

Just wondered if you were aware of this, and if you consider it's an important part of your responsibilities?

DavidBogod: Urbanproserpine. Thank you! With more and more of our patients being awake for surgery (not just in the obstetric field), this role of the anaesthetist is becoming even more important. It used to be said that young doctors went into anaesthesia because they didn't like talking to people - not any more!

[gaelicsheep]

MR Bogod obviously really loves his job and is so enthusiastic about his subject. So refreshing and such an informative chat.

More of this kind of thing please. And please give a wide berth to any more politicians who come on here to promote themselves and fob us off.

[rempy]

Alimat, on the general surgical side of things we run epidurals for 72 hours usually as a maximum, then try to remove them, as the risk of infection increases with the length of time they are in place. Very occasionally we run them for 4 or 5 days, often in intensive care patients who we fear will need to be artificially ventilated if we switch to opiate based pain relief. In paediatrics I have seen them tunnelled under the skin, and used for longer - for very specific indications - leg lengthening surgery etc. In each of these scenarios it is a risk vs benefit decision, taken on an individual patient basis. Epidural infection is extremely rare, but potentially catastrophic. I fear it greatly as a complication. I would be devastated if my actions as a doctor, however well intentioned, led to a mother being paralysed, or in chronic pain.

In the unit I am in at present, we site epidurals early mostly on the understanding that there is a clear commitment to delivery - which does then often involve augmentation etc but in some cases can mean only rupture of membranes in women on their second or subsequent deliveries.

[dizietsma]

urbanprosepine is right, I still remember the name of the lovely man who eventually Took The Pain Away with an epidural (Juan). One of my friends said she fell violently and inappropriately in love with her anaesthetist when he gave her the epidural!

[Fenouille]

gaelicsheep hear hear

[mathanxiety]

Thank you for your answer about nurses or others attending patients as opposed to MWs.

My own experience of one labour with an epidural and four without in the US was that L&D nurses monitored me the whole time, (except for the last birth when I was attended by midwives from a midwifery practice and the third when I barely made it to the hospital). The policy in both hospitals I experienced was to have an L&D nurse present with a patient throughout labour (not a MW unless you were a MW's patient for your ante natal care).

[Alimat1]

Thanks Rempy

[ZuzuBailey]

Very informative webchat - thank you.

For years I have wondered why neither G&A nor pethidine provided effective pain relief for me.

I now understand why. There's such a conspiracy of silence surrounding labour & birth and it's great to hear an honest straightforward explanation.

[DrMcDreamy]

I am thinking of approaching the RCM to see if they would be intrerested in offering to do a similar webchat to give the other side of the coin so to speak. Would anyone be interested in this or would it be pointless?

[LessNarkyPuffin]

Other side of the coin??? From what some posters have been told by midwives and what Mr Bodgod said about the NICE guidelines, a lot of midwives have been flat out lying to their patients.

[TondelayoSchwarzkopf]

I didn't participate in this chat but have just read it - really interesting well informed discussion with some helpful links. Thanks for bringing David Bogod in.

[Alimat1]

after replies like that from LessNarkyPuffin - pointless DrMcDreamy

[MummyBerryJuice]

Thank you David. This was a truly informative (and affirming) web-chat. You clearly enjoy your work and are passionate about a woman's right to choose.

I agree wholeheartedly that a paternalistic attitude (whether coming from a male or female) when caring for a labouring woman is both outdated and unacceptable. Thank you for giving us ideas on how to empower ourselves to affect the type of labour we desire.

[thornykate]

Sometimes it is easier for people to demonise an individual or profession than to accept the complexities of the situation that is going on around them. I would be interested to hear what the RCM said though.

[Mibby]

Gutted I missed this, DD flatly refused to go to sleep :(

A question if you (Dr Bogod) have chance to return. I gave birth in Nov 2010 in Nottingham City Hospital and had an epidural for a forceps delivery, eventually getting DD out 36 hours after my waters broke.
The care up to the point of birth was fabulous but went rapidly downhill after that.
I ended up being kept in for several days, despite my strong and repeated protests and one of the reasons given for this was that my temperature had risen after the epidural, which meant I 'almost certainly' had an infection, according to my MW. Now considering your reply to Antidote ("We know that body temperature tends to rise when an epidural is in place") this makes no sense

[Margles]

DrMcDreamy & Alimat1. I certainly feel that it would be good to have a midwife to put an alternative viewpoint.

When David suggested that other HCPs could look after women with epidurals I began to realise that many women would probably be quite happy with this, given the opinions they have expressed about the midwives attending them. Maybe this system should be put in place to free up midwives for those who appreciate their services? You get this to some extent if you go for a home birth or MLU, but how many women are really offered these options?

The argument against making use of other HCPs is of course that it would just be used as a way of cheapening maternity services - why bother to employ a midwife trained for three + years when you can get someone who has done a short course on measuring blood pressure? This has already happened to an extent with post-natal care, which generally seems to leave much to be desired.

I personally would like to see a system where we could book directly with an individual or small group of midwives - like independent midwives but on the NHS. Then you could choose one who was in sympathy with your own outlook instead of having to take pot luck.