OBEM - why are they so anti-epidural?

(151 Posts)
babyblabber Wed 20-Mar-13 21:28:06

Just watching OBEM and I've been wondering every time I watch it, why are the midwives so anti epidurals? Is it the same all over England? There was another episode recently where a girl was practically begging for one and they talked her out of it (at 3cm) & I just don't know why. I know there are risks but they are minimal and thousands of women give birth every day with epidurals but watching that show would make you think they're a last resort.

I'm just curious really. I'm from Ireland where it's more normal for first time mums to have an epidural than not and it's almost presumed you will. Having had two kids I am a big fan of epidurals and secretly think giving birth without one is a bit mental!

(ps don't want to start a big debate, just wondering!)

Shagmundfreud Fri 22-Mar-13 09:31:01

Midwives' whole ethos is to promote normal birth. Epidurals do disrupt the normal physiology of birth and necessitate syntocinon augmentation, and often catheterisation, continuous monitoring, higher rates of episiotomy. Mothers who have one have a radically different postnatal hormonal profile in the hours after birth from women who've had an unmedicated labour. I appreciate that most people don't think that's important, but midwives study the minutae of birth - the finer points of mother and baby interaction in the hours after labour and how these are subtly influenced by hormonal physiology, hence many of them seeing epidurals as a complex intervention.

"Epidurals may slightly increase instrumental deliveries (by about 1 in 20) but they also reduce the risk of tears caused by uncontrollable pushing.@

As for the view that epidurals are not linked with higher rates of c/s, instrumental births etc (except slightly, for first time mothers), which is the advice given in the NICE guidelines, this is based on a meta-analysis of studies almost all of which compare women who are giving birth with epidurals with women who have been sedated with pethidine or other opioids. There are only a TINY number of studies that compare women labouring with epidurals with women having unmedicated labours.

In other words you are comparing outcomes for women having epidurals, with women who are having supine labours, who have been given a drug which is KNOWN to be associated with non-reassuring fetal heart rate traces in labour, and with a group where the majority of women will be having their labours monitored with CTG, something also associated with higher rates of emergency c/s in low risk mothers.

I personally think the evidence from the Place of Birth study is very interesting - that it shows low risk, healthy mums who opt to labour in a setting where epidurals are generally the most accessible (consultant led units) have double the rates of emergency c/s than women who have opted to labour in settings (home or midwife led unit) where an epidural requires transfer and is therefore less accessible.

FWIW I haven't seen the episode of OBEM from the other night. Will watch it this weekend. IMO the conditions women are subjected to in in big, busy consultant led units like the one in the programme generally necessitate epidurals except in the situation where the mothers labour is completely straightforward and quick. Labour is hard enough for most people without syntocinon/being expected to lie on your back/continuous monitoring.

Shagmundfreud Fri 22-Mar-13 09:35:07

here

This is an interesting article.

TheFallenNinja Fri 22-Mar-13 09:41:03

I think the cost gets taken from their wages.

Thurlow Fri 22-Mar-13 12:21:00

Ninja grin

I think the comparisons, like the one you quote shag, are very interesting but there are always a lot of factors involved that are probably very hard to include in such studies. For example, I don't know how other areas are set up, but in my area the MLU and the CLU are in the same building; women are automatically assessed in the MLU, and then can move up to the CLU if they request an epidural or need closer monitoring. So the choice about where to labour is made during labour, not before.

Thus is an area like this, the option of an epidural is available to women wherever they labour. It's an easy transfer from one unit to the other, and I know plenty of women who did it. The MLU, however, is set up like a traditional, separate MLU, all very nice, calming, less medicalised, baths and pools and balls etc, so I imagine it would be the same for a mum labouring in it as it would be if they were in a standalone MLU.

Situations like that skew the figures a little, I imagine, though I appreciate it is very difficult to measure this. It would be interesting to see the rates of epidural, intervention and emcs in this set-up, though.

trustissues75 Fri 22-Mar-13 12:41:01

I think a woman should be informed of all the options and then given the choice - period. These stories of women waiting literally hours and hours for pain relief is appalling. Cascade of intervention be damned - if a woman is made fully away of the possible consequences and still wants one she should be given one as soon as a qualified member of staff is available to give her one - not to be told to wait and see.

Ushy Fri 22-Mar-13 12:58:29

I would love to see the actual evidence for a cascade of intervention with epidurals.

They have done a number of studies where they looked at interventions in births in hospitals before an 'on request' epidural service was introduced and then after.

These so called 'impact studies' found no difference and they are the best evidence that the 'cascade of intervention' is a myth.

What they did discover was that women who requested epidurals were in more pain because they were the ones experiencing the more difficult labours. Those women who strolled into hospital and popped the baby in five minutes with no complications obviously didn't ask for epidurals.

Thurlow Fri 22-Mar-13 13:12:08

That's a good point, ushy, and what I've wanted to say. No two women's labours or pain are comparable. A lot of women will be in more pain, or suffering more (however you want to put it) because there is naturally something going on with their body and their labour that is causing that. There's a high chance that reason would have caused an intervention anyway. There's no real way of knowing, that's not something that I imagine can be scientifically measured.

There is absolutely nothing wrong with encouraging a woman to have an epidural free labour. There is nothing wrong with offering pain relief on a slow and sliding scale and seeing how the woman manages in water, then with G&A etc.

But it's the push back - the "oh, really, are you sure? But you can manage it, it would be so disappointing if you did have an epidural" - that is frankly insulting to a woman in pain.

trustissues75 Fri 22-Mar-13 13:12:23

Ushey - from an anectodal POV - I can tell you that my epidural given to me after being at 3cm for around 12 hours and still at that stage 2 hours after ARM did indeed not lead to a cascade of interventions. I went from 3 - 10 in less than 15 minutes and DS was out shortly after.

LeBFG Fri 22-Mar-13 13:18:52

Epidurals are not all bad. As you found trustissues75, they can enable women to relax and dilate. As Thurlow says, women feel these things differently and every labour a women experiences will be felt differently - dependant on stress, baby's positioning etc. What I object to is too much pushing an agenda - whether that be pro-epi or anti-epi. Stick to the facts. Give women a real choice. My experience (abroad) is a pro-epi culture. Perhaps the UK MWs have swung too much to the opposite extreme?

VodkaJelly Fri 22-Mar-13 17:43:08

I have always been anti epidural, partly because I have a massive needle phobia. My 3 DC's were all born with G+A and pethidin. I had drips with DC1 and DC3.

However, DD was born 11 weeks ago. After being in labour for 24 hours - 6 of them in the labour suite, DD got stuck, and the contractions slowed down. I then BEGGED for an epidural, the pain was unbearable, I was literally losing my mind with the pain. I was transferred to the high dependency unit and lucky the consultant who saw me said that I needed an epidural.

I ended up with forceps and being cut and stitched up and didnt feel a thing. I was so grateful for the epidural as I couldnt cope with the pain. The relief was immense.

I have no idea if the midwifes did cats bum mouths as I delirious with the pain.

Shagmundfreud Fri 22-Mar-13 18:02:38

Thurlow - the research I referred to allocated the low risk mother s to each arm of the trial BEFORE the start of labour, and then excluded those who presented at hospital with any risk issues.

This would minimise the likelihood that women in the CLU arm were there because their labours were more challenging to start with.

Shagmundfreud Fri 22-Mar-13 18:39:53

Ushy - the problem with the study you mention is that there would have been no 'control group' of women having long and challenging labours who didn't have an epidural. I think when a baby is presenting in an optimal position the epidural probably doesn't make much of a difference to the outcome. It's when the baby is presenting poorly, which would lead to a longer and often much more painful labour, that being fully mobile might make a difference to a spontaneous birth or one involving forceps or c/s. However - the common response in uk hospitals to long and challenging labours is to offer epidural.

In fact in midwifery circles midwives discuss this issue - that they are losing their skills in caring for mothers having challenging unmedicated labours because women who opt for this are as rare as hens teeth these days.

rainrainandmorerain Fri 22-Mar-13 19:42:52

As an aside - I think there is a huge danger in using 'normal' or 'natural' birth to just mean 'do it without pain relief.'

For a lot (most?) of women, there is very little that is 'natural' about their birth anyway. From being in a hospital environment, having to go through early labour on a brightly lit ward surrounded by other women, to being moved to a 'delivery suite' to repeated vaginal examinations to a whole host of interventions from ARM to sweeps to induction....

But no - what gets focused on, obsessively, as a barrier to 'normal' or 'natural' birth is epidural anaesthesia.

Btw, I come at this as someone who has/is having planned CS's by choice. But even I, from the 'outside' can see the damage in reducing the whole debate about natural birth to the availability of epidurals. I think there are often other agendas at work which people aren't open about - whether it is women having to bear children in pain and sorrow etc or a kind of 'if I had to go through awful pain to have my baby then you should too' attitude.

All that aside, I totally agree with the previous poster who suggests there is nothing wrong with offering a 'sliding scale' of pain relief, and helping women to make informed choices etc (both of which involve more than a simple 'ok' when a woman asks for an epidural) -

But face pulling and an 'oh gosh, how very DISAPPOINTING you are' attitude are wholly out of place in a care giver dealing with a vulnerable woman. Any MWs dealing out that sort of attitude should be ashamed of themselves.

Ushy Fri 22-Mar-13 23:26:07

rain good point but the sliding scale idea has a downside.

Epidurals are more effective when administered early - it is the late epidurals that are more associated with instrumental deliveries and failure to work. Also, working through gas and air, the pool, pethidine and everything else leaves you totally spaced out, sick and out of it.

It is perfectly reasonable for a rational woman to say no, I don't want anything else - just an epidural. You are vulnerable in labour and it isn't fair to expect women to have a pain relief debate or 'prove' they know the risks and benefits of epidurals before they have one. NICE says if a women requests an epidural she should get one.

I say here here to thatsmile

MyDarlingClementine Fri 22-Mar-13 23:56:02

I have heard people mention but I am not o fey with this - that there are a few different types of epidurals you can get which mean you can be mobile, not as mobile as without one but certainly some sort of movement.

op i didnt watch that particular episode, I have noticed though some women in such pain, writhing round, get an epidural and suddenly they are sat up, back to normal its amazing to see.

CouthySaysEatChoccyEggs Sat 23-Mar-13 01:41:41

I've had syntocin 4 times, and never had an epidural. After the syntocin drip was started I managed with G&A (Autocorrect wanted to change that to G&T, probably the best thing for labouring mums...wink ), and pethidine.

I went longer without syntocin in my fourth labour, (was induced with first 3, but went into labour naturally with DS3, but labour stalled) and found it such a breeze compared to having the syntocin straight away, so I can see how some people could think that labour without an epidural when syntocin is used might be 'cruel', but I found that to be 'normal' labour for me, and the first 20 hours with DS3 were actually really mild.

Yet most people can have a colposcopy and LLETZ under local anaesthetic, and I had to be knocked out under GA or I might have kicked the Consultants teeth out from writhing round in pain...

CouthySaysEatChoccyEggs Sat 23-Mar-13 01:50:13

I did find that I was treated as something of a rarity in my local hospital - 24 hour induced labour with a back to back baby as a 16yo who refused an epidural (though by the end I was begging for a C-section).

72 hour induced labour (contractions every 2 minutes or closer for the entirety) refusing epidural with a back to back baby.

I found DS2's 8 hour induced labour a breeze by comparison!

DS3 I had a 24 hour labour.

But all the MW were incredulous that I was turning down an epidural.

Twattybollocks Sat 23-Mar-13 06:24:29

I think the woman should have an informed choice. Interestingly in my local hospital this time round they said I could have an epidural whenever because new research had shown it didn't slow labours down at all. Anecdotally, it sped up my first labour considerably, I'd been at 2-3cm for 2 days and went from 3 to 10 in 4 hours, apparently I was fighting the pain and once I relaxed things went faster. I did need a ventouse, due to an unusual presentation, but I think I would have needed one anyway as he was well and truly stuck. Second time around I needed no help and got her out in 2 pushes with no tearing, That was with a perfect
Epidural and I literally didn't feel a thing. Third time I tore as I was on the drip and the epi didn't work so i was still in agony and couldn't control my pushing at all. It was still only one or two pushes but the result was a lot different in terms of recovery and pain afterwards.

Shagmundfreud Sat 23-Mar-13 07:46:13

Couthy - I transferred in from a homebirth with my third for syntocinon and didn't have an epidural. Honestly it was hard but it was doable because I had my independent midwife with me who was outstanding and gave me such amazing support.

I think the problem is that a woman having an unmedicated labour which is anything other than straightforward needs VERY skilled, intensive and intimate support from a midwife she has a strong relationship of trust with. I think it's very difficult to get this on the NHS in most obstetric settings because of the way midwives have to work, and the institutional pressures they are subject to. And given this - epidurals are the answer to lack of really outstanding midwifery care.

Shagmundfreud Sat 23-Mar-13 07:51:12

"I think there is a huge danger in using 'normal' or 'natural' birth to just mean 'do it without pain relief."

If the form of pain relief you use disrupts the normal hormonal physiology of birth to the point that you need synthetic hormones to be administered through a drip throughout the labour in order to achieve delivery of your baby then it means you are not having a 'natural' or 'normal' birth. Doesn't mean that your labour isn't enjoyable, safe or what you want. And it's important to draw attention to the fact that there is no moral weight attached to whether you have a 'normal' or 'natural' labour or not.

Shagmundfreud Sat 23-Mar-13 07:55:05

Is anyone here in agreement that when women are informed (antenatally) about pain relief it ought to be made clear that the meta analysis of epidurals on which NHS recommendations regarding pain relief are made doesn't compare outcomes of unmedicated with medicated births, but the outcomes of epidurals with opioids (usually pethidine)? Because I think most women are in no way aware of this and IMO it's a MASSIVE oversight.

spiritedaway Sat 23-Mar-13 08:03:20

Certainly typical attitude at LGI. . My last baby- , i was basically told to shut up and get on with it. I had no birth partner and my wishes were ignored. Could have punched the bitch to be honest, but am over it now smile

RedToothBrush Sat 23-Mar-13 08:06:44

And it's important to draw attention to the fact that there is no moral weight attached to whether you have a 'normal' or 'natural' labour or not.

Isn't there?
I think its worth pointing out the number of women who report comments made by midwives to the contrary on a regular basis on MN. Or report comments made by friends and family that judge them in a negative way, if they don't have a normal or natural labour.

Do you remember the thread with the link to the midwife forum that was publicly viewable - until MN picked up on all the horrendous moralising and judgements that practising midwives were posting - which then suddenly became member viewing only.

I think you need to start changing the attitudes of the medical establishment on that one, before you post comments like that, which bare no resemblance to what women seem to experiencing and can see with their own eyes.

And thats before you deal with the press view on this subject, which helps to shape public perceptions to a huge degree.

rainrainandmorerain Sat 23-Mar-13 08:47:19

Oh, there is a LOT of moral judgement attached to the idea of 'normal' or 'natural' birth! On these boards and elsewhere (god, I remember that HORRIBLE midwives board thread....I would be terrified of being in the care of one of those bullying people).

Time and again you see pain relief, or lack of of, being held up as the biggest marker of natural or normal birth. To the extent that a long augmented labour ending in a vaginal birth with a baby hauled out with forceps is not seen as 'abnormal" - but having pain relief is.

It's all very anti-woman in my view. And Ushy, yes - respecting a woman's request when she asks for pain relief has to be the default setting in any humane society.

LeBFG Sat 23-Mar-13 08:49:29

Shag, I'm with you about the studies. I'm also personally a bit surprised that women routinely say they've had natural birth to mean a non-epidural birth with opiate pain relief. It's now of no shock to me that France have banned opiates during labour. And yet these zealous UK MWs are sticking in needles freely at the same time as frowning on epidurals. Need some joined up thinking me thinks.

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