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.

Mibby- it's probably because your waters were gone for so long, so your mw was concerned. Now, how long trusts perceive prolonged rupture of membranes for is variable.

Why didn't you ask your carers at the time out of interest?

The other thing to point out, where mw's are getting the flak, it is often due to management issues that causes a lot of these problems. Mw's are stuck between a rock and a hard place. You lot hate them, and the management overworking them, not giving them breaks, not having support staff available, NOT having enough anaethetists/consultants available. And before anyone says 'its not my problem' IT IS, cos you are the ones (along with the mw) are suffering.

You guys having damage from forceps/ventouse etc is NOT the fault of a midwife, cos a mw can not phsyically do those procedures. Some of you here are completely misplacing your anger and pain. How about we all get angry at the government and campaign for better services for ALL.

Margles

I agree to an extent with what you are saying, however its not just a case of taking BP's, any monkey can do that (you can set the machine to do it automatically). It's in case anyone didn't realise midwives observe and keep an eye on the CTG making sure the baby is ok, not going into fetal distress.

Now CTG interpretation is highly complex and if people are happy to leave the monitoring of this to lowly paid health support workers than that is mental.

But this highlights the lack of knowledge people have about the role and skills of a mw.

flufftastic - I hope you don't think I was criticising midwives - far from it, I am quite angry about the flak they have received on this thread. It does seem though that some women would be happy to go down the route of the American L&D nurse system, as long as they get their epidural, judging by what they have said.

Margles,
I know you weren't sorry didn't phrase quite right. Just trying to point out to the ill informed on here

Flufftastic I did ask, repeatedly but got told a temperature rise meant there was pretty much certain to be an infection and it would be dangerous and irresponsible to go home before my blood test results were back to prove this.

When they came back there was no infection.

It just seemed odd to hear someone so senior at the hospital I gave birth in say that temp rises were normal

Yes, they are with an epidural. HOWEVER, you also had additional risk factors. Would you rather them not investigate for a possible infection?
Now the fact you 'had' to stay in, well yes hospitals can be rather bossy with this, but it is ultimately your choice. You can have self discharged and asked someone to ring you with the results. But I beggar belief at your criticism that they investigated potential infection.

There is new research being carried out at a big teaching hospital in the UK investigating the potential adverse effects of a rise in temp during labour. It is something to be taken seriously.

Alimat -- I thought Mr Bogod's remarks made LessNarkyPuffin's conclusion inevitable and 100% correct.

I don't think a webchat with the RCM would be pointless unless the MWs were to keep their fingers well and truly stuck in their ears.

I believe that the RCM and the anesthetists should sit down and that the RCM could probably learn a lot about epidurals, their risks and benefits, and why pain relief is a good thing.

I was happy to see many of the myths that were advanced as reasons not to give an epidural on the other thread, by MWs, demolished. The 4 cms rule especially.

Margles the system you describe exists and works well in the US, where L&D nurses attend women in labour, including women with epidurals and women being induced (and both in combination). Their training encompasses all the necessary monitoring (and there is plenty of that in the US). The so-called over-medicalised US maternity system seems to make better use of available resources and also delivers more pain relief.

Flufftastic, it might be easier to get something done about inadequate provision of anesthetists if midwives actually believed this was a problem and campaigned alongside patients. What I saw on the other thread was plenty of midwives who really believed pain was a plus for labouring women, made them bond with their babies if they really felt everything they had gone through in order to have them in their arms, blah blah blah. (Plus a lot of nonsense about risks). If there's even one organisation saying pain isn't really an issue in childbirth of course that is the voice that will be heard by the bean counters.

I think we must have been reading a different thread! It is easy to 'cherry pick' info that agrees or diametrically opposes our viewpoint.

I don't know many midwives who whatever their 'ideaology' don't see a place and role of epidurals. However, there is clear argument for this to be an informed process...see other threads on here, women complaining about catheters being inserted when they have epi/elcs such as the like. I mean really???!

And to be fair, you dont see the flip side of this, where a woman gets the epidural she wanted and then complains that she didn't know that X would happen or Y would happen. So midwives get it from all angles, can't do right for doing wrong.

There is physiological argument to the role of the hormonal interplay during labour and there are risks of epidurals (Dr explained them quite well i.e. only 60-70% epidurals work effectively- I'd thought it was higher than tbh).

But fundamentally what I have read on here, is that women are unhappy with the service, and midwives are unhappy with the service that they are able to provide. We need to start working together to make changes and not spend so much time bitching at each other. For all of you that want epidurals, there are the same again who want waterbirths, or homebirths etc. If more women who wanted to low tech interventions like WB/HB got it, I am sure there would be more money in the NHS to fund those who want epidurals.

mathanxiety - you are happy with the system in the US; some people here would agree with you. I don't, and I have American friends who don't. I would hope that we could all agree that we would like to see maternity services improved. How we do that is a matter for debate. Personally I think it requires much more than epidurals on demand.

I ask you all this. Would you really be happy to be monitored by somebody who did not have any training other than to know some numbers equal bad and others equal good? No training to interpret a ctg trace? No training to measure things manually if the machines fuck it up? No training to explain why in some circumstances something that might normally mean bad can mean ok because xyz is also occurring? someone who can't explain anything to you further because they don't know the physiology behind the 'bad' numbers? And before you say, train them to know that stuff, we do, it takes 3 years and they're called midwives.

Yes, I actually would! I did not have a dedicated midwife in the room with me when I had my epidural. Yes, someone came in at regular intervals to do my vitals but most of the time it was just me, DH and my mum in the delivery suite.

Also I would rather have had a trained midwife helping and guiding me through the process of labour before I felt I had lost control of the pain (and thereby perhaps have prevented the need for the epi?) n

As long as the person monitoring is trained to raise alarm when any red-flags occur I cannot see why they shouldn't be used and that trained midwives could then be free to help where they would be more effective.

I am slightly concerned about the attitude displayed by some (not all) midwives. The assumption than labouring women aren't able to make decisions regarding their own care, the idea that they, the mw, knows better than the mother. It is an attitude society has long sought to remove from doctors (and judging by David's answers, are slowly succeeding) that it is particularly disheartening to see it so frequently from the people who are meant to be the mothers' champions!

MummyBerryJuice ''Also I would rather have had a trained midwife helping and guiding me through the process of labour before I felt I had lost control of the pain (and thereby perhaps have prevented the need for the epi?)''

This is precisely what midwives are fighting for too.............PRECISELY, to be able to offer such care. Complain to the management that there weren't enough mw's to support you during labour.

Let's work TOGETHER.

Mummyberryjuice on one band you're happy for any old tom dick or Harry to be with you so long as they've had ten minutes training and the next you'd want a midwife in there. I'm a little confused.

I think that you wilfully misunderstand McDreamy. At no point did I say that 'any Tom, Dick or Harry with ten minutes training' would be appropriate. What I did say was that mws may be better utilised supporting women from the outset and thereby decrease stress levels in labour and perhaps enablingpre women to cope without an epi.

Great webchat, very interesting, thank you.

Just wanted to add my two penn'orth as I contributed to the 'tricked' thread.

• if it is a problem that so many women go into childbirth ignorant about what happens during an epidural (shocked by having to have a catheter etc) - why is it happening? Just a basic flyer with a series of bullet points could explain the procedure, and outline the risks and benefits. This could be given to women during pregnancy. God knows you get enough leaflets and other gubbins thrown at you, surely something like this would actually be USEFUL? And a similar leaflet explaining what will happen if you have to have emergency CS or other interventions.

• in my experience the possibility of things 'going wrong' (eg needing extra pain relief, interventions or CS) are just brushed under the carpet at midwife appts from booking onwards. Yes this may be due to lack of time, but I would say it contributes to a lot of the stress and shock women experience when reality hits them.

• again, another one I have banged on about before, but women suffer a lot of unnecessary stress by being ignored and belittled in the first stages of labour - until they reach the 'magic 5cm dilated' and actually start to receive some proper midwife care. Stress is not a good thing physiologically or psychologically - it doesn't take a genius to work that out. It can also remove control and choice from the woman, but maybe that just suits the system a bit too nicely, hence the lack of will to address it?

I fully support the choice of women to have a water birth with minimal outside involvement. Why can't some of the people on here accept that women in labour who want effective pain relief are entitled to it - they shouldn't have to argue for hours to get it because of the midwife's opinion that they don't really need it.

Can you imagine someone in a hospital screaming for pain relief and being fobbed off? If it wasn't a birthing mother it would be all over the papers. How we would react if it were a male dominated profession telling women how they should be handling childbirth and insisting they knew what's best for the mother.

The pain of labour used to be considered women's punishment for the sins of Eve. It was considered necessary that women should suffer to give birth. It was bollocks coming from collared men and it's still bollocks coming from (mostly) women.

Hi David,

I had to wait 5 hours for my epidural even though it was stated in my notes by the MW that i wanted one and i repeatedly mentioned it. I was lucky (which i felt in the end) and eventually got it but the stress whilst dealing with labour in whether i will or won't get it was unecessary. Surely hospitals have more than 1 anaethetist on, as this is the reason i was told i had to wait or may not get it?

@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.

David here. I just wanted to make sure there was no confusion about my suggestion regarding using non-midwives to monitor labouring women; my fault for typing too fast and thinking too slow!

The point I was trying to make was that the use of an epidural imposes extra burdens on the midwifery staff. If there are not enough midwives on duty to take on that burden, the woman may not get her epidural. As with many other areas of health care, there is an argument for reserving midwives to carry out those special functions for which they are uniquely trained, while 'farming out' other roles to supportl staff trained in these particular tasks. Thus, I can envisage a labour ward with its usual quota of midwives, but with two 'epidural monitoring technicians' to provide the specific care necessary to keep the epidural service safe.

The presence of a trained midwife is not only essential in childbirth, it is also - as I understand it - a legal requirement. What we need are staff trained to provide them with assistance.

@elp34

Hi David,

I had to wait 5 hours for my epidural even though it was stated in my notes by the MW that i wanted one and i repeatedly mentioned it. I was lucky (which i felt in the end) and eventually got it but the stress whilst dealing with labour in whether i will or won't get it was unecessary. Surely hospitals have more than 1 anaethetist on, as this is the reason i was told i had to wait or may not get it?

You may have gathered from my final post yesterday that I am not convinced that anaesthetists are always informed in a timely manner about all epidural requests. A spot survey which I carried out on Wednesday suggests that the large majority of maternity units have a dedicated obstetric anaesthetist 24 hours per day. Many, like my own, have two anaesthetists on duty for maternity during daylight hours. They may be held up with a Caesarean section, or even two in succession, but even that should not lead to a five-hour delay. There is a national standard relating to response times for epidural requests (see that final post again) which speaks of 30 minutes as the norm and more than one hour only in exceptional circumstances.

@MistyValley

Great webchat, very interesting, thank you.

Just wanted to add my two penn'orth as I contributed to the 'tricked' thread.

• if it is a problem that so many women go into childbirth ignorant about what happens during an epidural (shocked by having to have a catheter etc) - why is it happening? Just a basic flyer with a series of bullet points could explain the procedure, and outline the risks and benefits. This could be given to women during pregnancy. God knows you get enough leaflets and other gubbins thrown at you, surely something like this would actually be USEFUL? And a similar leaflet explaining what will happen if you have to have emergency CS or other interventions.

• in my experience the possibility of things 'going wrong' (eg needing extra pain relief, interventions or CS) are just brushed under the carpet at midwife appts from booking onwards. Yes this may be due to lack of time, but I would say it contributes to a lot of the stress and shock women experience when reality hits them.

• again, another one I have banged on about before, but women suffer a lot of unnecessary stress by being ignored and belittled in the first stages of labour - until they reach the 'magic 5cm dilated' and actually start to receive some proper midwife care. Stress is not a good thing physiologically or psychologically - it doesn't take a genius to work that out. It can also remove control and choice from the woman, but maybe that just suits the system a bit too nicely, hence the lack of will to address it?

That basic flyer is available for all at www.oaaformothers.info (conflict alert - my own organisation). You will find a bullet-pointed epidural information card there. Feel free to distribute the web version freely or to ask your local midwives to make it available.

Thank you again, this one of the best threads I have been on recently. Off to read the Cochrane review and saving both that and this thread for when it is time to give birth to no.2 . For what's worth, the emotional response to this thread was "I want to go and give birth in your hospital and under your care". So thank you!

MN: a similar chat with the president of midwives would be very good. On the other hand, speaking to the person at the top of the profession does not necessarily mean the MW one then gets in labour delivers (no pun intended) on the promises of the leader of his/her profession. The NCT keeps saying how they support choice by women and are no longer the "natural" childbirth trust, but the NCT teacher we had was VERY anti-epidural and VERY pro-alternative medicine. Now, if someone else can give birth and get by just by swallowing sugar pills and smelling nice smells, I am delighted for her (and envious). I can't. I knew that before it happened. It would have been nice if the person giving the course had given scientifically accurate information rather than her own ill-informed (ignorant) opinions. But that's another thread entirely.

Hi David
Thanks for your response re the leaflet, it looks very useful. I have linked to it on the 'tricked' thread.

If I can be picky (this is MN, after all) I'd say it would be even better with a diagram and/or explanation that the needle goes in between the bones in the spine. It might sound too obvious, but I reckon it's always best to spell things out.

And maybe the fact that you will have to have a catheter tube put in as you won't have control over your bladder while the epidural is working might be good too, as this was mentioned by a midwife here as being one of the things that mothers are surprised by.

Thank you for replying to my post its nice to be listened to. Being a health professional myself i definately had a fear of not being heard whilst in labour and i have to say it partly was true although i cannot fault the MW. Next time round i will be more informed and hopefully i won't have to feel like i am being the pt from hell!

I didn't take part in this webchat, and I also missed the furore over the original "trickery" thread. However, I have been catching up with both avidly, and would like to say a huge thank you to Dr Bogod for taking part in this. It is so refreshing to hear things from an anaesthtist's point of view and not just that of the midwives I came into contact with during my preganncy, who although on the most part lovely and supportive I found very biased towards natural birth and breastfeeding with very little info to offer if that wasn't the route you wanted.
I did have an epidural after a slow but painful labour that turned into fast and excrutiating after 20 some hours. I had a brief but productive argument over whether or not to have one with the midwife I was eventually handed to, after being left with only my husband for company up to the point they realised I really was in labour. I wasn't offered any constructive advice around the epidural, only that I wouldn't "be able to feel my baby come out" which, quite frankly, only supported my desire for one!
The reason for me posting (for first time) is that I had no continuous monitoring after my epidural. I had no idea I was supposed to and I don't feel it had any adverse effect on me. I was left to sleep for a good 4 or 5 hours with someone popping in occasionally to check everything was ok. Suited me fine at the time I must add, I thought it was a terribly civilised way to finish off my labour and couldn't understand why no one had mentioned how fabulous it was!
My second point echoes a few on hear about just how important the role of the anaesthetist has become. My labour culminated in an emergency cs as dd had turned and was well and truely stuck. My experience once I was handed to the surgical team was phenomenally positive. My lovely anaesthetist talked me through the shakes and teeth chattering when he topped me up so I could stay still enough for them to operate. He reassured me constantly, talked me through what was happening at the business end, and he was even the one who told me my beautiful dd had arrived safely into the world. I will be eternally grateful to him for turning what could have been a very traumatic experience into such a positive one, so much so that I will be requesting an elective cs for no2.