Wednesday, June 20, 2007

Next They'll Be Confiscating Our Paracetamol

My friend is due to give birth in about a week's time.

Today she came in, sat down on the sofa and started crying. This is her first child, her parents are back in Romania, and she is absolutely terrified of giving birth, because she thinks it will be very painful. Which is fair enough, because the received wisdom is that it is rather painful, and can also take quite a long time.

"Never mind," my mother said, "if it gets too much for you you can ask for the epidural and that will make things much easier."

This only made my friend cry even more. It turns out that you have to sign up for the epidural, and she hasn't signed up for it.

She did ask if she could sign up for it. She asked her midwife. She told her midwife that she was afraid of giving birth and afraid of the pain.

Her midwife told her, "You're young and strong and you won't need it," and then moved on to talk about something else. I should think that my friend wasn't terribly forceful about it. Although she speaks very good English, she is a little shy, and still not one hundred per cent confident about speaking English to strangers. But she had clearly said that she wanted an epidural. And you would think that a midwife would understand that she was shy, and nervous, and particularly vulnerable because of her lack of confidence with spoken English - what with all of their woman-centred training and their position as advocate for a woman giving birth and stuff. But I'll come back to that in a minute.

Anyway, it got me thinking. I have never been told by a nurse or a doctor or a chemist that I am young and strong and don't need painkillers for, say, a headache. Or toothache. And I don't know anyone who's been to their doctor or to a nurse to complain about period pains - which are, I understand, very mild womb contractions - and been told that they don't need painkillers or the Pill because they are young and strong and don't need them. When I went to Moorfields Eye Hospital to have the small cyst on my eyelid removed I wasn't told that I was young and strong enough to have it done without anaesthetic. And although when I was very, very young indeed I remember a dentist telling me that I didn't need anaesthetic for a filling, I cannot remember ever being told by a dentist that I didn't need or couldn't have anaesthetic for one in the twenty or so years since then.

So you're not young and strong enough to be able to do without painkillers for a headache or a stomachache or toothache or a filling or an eye operation, but you are young and strong enough to be able to do without the option of an epidural for what is popularly believed to be one of the most painful and physically demanding ordeals that most women will have to go through.

"Young and strong enough." What exactly does that mean? Does it mean that a woman in her early thirties is so young and strong that labour isn't going to hurt? I've never given birth and I'm not a doctor or a nurse, but even I know that's absolute crap. Of course it's going to hurt. It's going to hurt some people less than others and take some people less time than others but I have yet to meet a woman who gave birth without an epidural who didn't describe the labour as excruciating. So it can't mean that.

What it means is that the midwife thinks it is better for you to put up with the pain than not to be in pain. Why?

I know that there are risks with an epidural. Inability to push means that forceps may have to be used. There is a risk of paralysis. There are probably other risks as well. But my friend wasn't told, "Here are the pros, and here are the cons, and here are the possible consequences for the baby, and here are the possible consequences for you, and now it is your decision." Because if she had been told the pros and cons, and then that it was her decision, she would have asked for the epidural. She knew she wanted one. She has always said to us that she wanted one.

Instead she was told, "You're young and strong and you don't need one." In fact, that's what all of my friends who have given birth were told, or if not that particular "reason" then one similar in tone. I have spoken to women who were told that they wouldn't need an epidural because they were young and strong, or because giving birth is "natural", or because in Africa people do it on their knees and go back to work four hours later, or any number of similar variations on the same theme.

Incidentally, every single woman I know who had a baby without an epidural the first time has said that they will ask for an epidural the next time. But that's by the by. This isn't about whether you have an epidural or not. It's about whether you get full, reasoned advice to help you make your decision.

And none of those reasons up there are good reasons not to have an epidural, are they? "You're young and strong and you don't need one." You don't need pills for headaches; lie down in a dark room, drink plenty of water and try to sleep and they'll be gone in a few hours. You don't need pills for period pains; they only last a couple of days at most. And it's not actually a reason not to have an epidural anyway, not in the way that "There is a slight risk of paralysis" might, for some patients, be a good reason not to. But it's a very effective form of emotional blackmail, isn't it? As well as being rather patronising. Who wants to admit to feeling old and weak and actually really needing an epidural quite badly? Who wants to say that they think they do deserve a relatively comfortable birth despite the countless women in less developed countries who can't have one? Who wants to point out that actually "natural" childbirth unadulterated by medical care was the main killer of women of childbearing age right up to the start of the twentieth century? Why should you have a pain free birth? Why are you any better than countless women who don't or can't? When you're only a few months into pregnancy and you aren't actually looking down the barrel of the gun it probably doesn't seem worth making a fuss. And if you're shy and unsure of yourself and it's your first child and you're dependent on your midwife to advise you properly, then you don't want to rock the boat.

Because you're a big girl. Because you're young and strong and you don't need an epidural anyway. Your midwife said so.

When I wrote my post about midwives and insurance (which sadly did not quite manage to scoop the Most Unintentionally Hilarious Post Ever prize - sorry, midwives) I remember quite a lot of people telling us all about Woman Centred Care and Patient Choice and how midwives act as an Advocate for Women in hospitals, particularly vulnerable women. Well, one of our prime motivations as human beings is to avoid unnecessary pain. By "unnecessary" I mean "pain that we do not need to feel because it can be controlled". And one of the most impressive advances in medical science over the twentieth and twenty-first centuries has been that human beings can now choose to avoid pain in a large variety of situations, one of which is labour.* Some of these painkillers come with side effects and some of them can cause other forms of harm. But in all cases it is up to the patient, isn't it? You read the booklet, you listen to the doctor, you weigh up all the circumstances and sometimes you take them and sometimes you do without.

Yet midwives continue to shame, rush, cajole and bully women into forgoing an epidural. Why? Why do they expect women to put up with that sort of pain and discomfort throughout a process that can take as long as two days, when they'd be the first to hand over two paracetamol if you had a headache or period cramps? And why should my friend now be dreading giving birth and feel that there is no one that she can talk to about it apart from us? Aren't midwives supposed to make sure that women don't feel like that?

If midwives really believe in Patient Choice and Woman Centred Care, why don't they just lay out the clinical pros and cons of having an epidural, and let the woman decide, and support her in her choice?

I don't know. But I am sure that if we hang around for a while some commenters will come along and tell us. Let's see if I'm right.

(My previous post on midwives and insurance here. Mr Kitchen on midwives and professional negligence here.)

(*This paragraph has been edited since original posting to remove what might have read as a suggestion that there are no circumstances in which pain cannot be controlled.)

59 comments:

Mark Wadsworth said...

I dunno, don't they routinely offer epidurals?

My only first hand experience is when my Mrs said "I'd like an epidural please" and they explained the risks and she repeated "No, I want an epidural" and they went "Oh fine" and hooked her up.

OK, she's had mild backache ever since, that's life.

Katy Newton said...

Who was it who explained the risks to her?

Mike said...

Hardly surprising really - last year the RCM wanted women to PAY for an epidural. It can lead to a longer labour though. I guess they want to get home in time for Corrie.

Jeremy Jacobs said...

another manifestation of the nanny state

Anonymous said...

Sue MacDonald (Royal College of Midwives) thinks that women ought to pay for epidurals and that heaven forbid: "Sometimes women think 'I just want to get rid of the pain, how fantastic'"

I don't know if Ms Macdonald has ever had a baby - I have and it was like shitting a bowling ball very slowly over several hours while simultaneously being punched in the belly every minute, throughout day and night, so yes, it was indeed FANTASTIC not to attempt to carry on bearing the unbearable.

Women can choose to experience pain, sure. But I don't see why they should have to; we are a civilised country with easy medical methods to prevent this - and there's plenty of evidence to show it to be virtually risk-free. I don't see why the 'signing' up has to be in advance either. As you say, if 'choice' is to mean anything, it is to be able to have it at the appropriate time.

Roger Thornhill said...

What is this "didn't sign up for it" nonsense? As if you know in advance if you are going to need it? Arrogant bullies.

My sis needed it on her first. Her second practically rebounded off the wall she came out so fast.

thescotster19 said...

DK this guy is clearly a loon, or it's some part of an elaborate prank. PS all that stuff about cookies was mine, sort of an indirect reference to Katy's blog, to try and infuriate the beast still further by assuming his identity.

Anyway, good post about the epidural. (or was that Katy?) I think I'm losing it.

Devil's Kitchen said...

Katy wrote the post.

I have disabled Anonymous comments for a while (for the first-time ever).

DK

Machiavelli's Understudy said...

Oh boy! A real life fruitcake!

I've never come across one on a blog before (ConservativeHome aside. They make it look so easy.).

Do you think this one might be your FJL, DK?

MatGB said...

Wow! DK and Katy are really the same person? And DK runs a cookery blog from Memphis?

Suddenly it all makes sense. Um, wait, no it doesn't. I@VE met the ugly bastard and there@s no way he@s been writing everything is electroc for the last few years

Loons everywhere< innit great?

Katy Newton said...

I have deleted the spammage on the basis that it was (a) fucking ridiculous and (b) made the thread completely unreadable...

flashgordonnz said...

I think you have to "sign up" to ensure that an annie-thezy-oly-jist is available to administer the epi. Otherwise you'll find them all at home watching House / ER / Holby / Greys Anatomy / ChicagoHope, et al.

Boo hoo, I want to read what the nasty man said. Can you turn it into a post?

(ps can you choose the length of yr wrd verification? I grew old trying to type it in. Twice!)

Mark said...

I'm an anaesthetist and I don't understand:
1) why the midwife should explain anything about the risks, in my experience they are not qualified for "informed consent" or dissent for that matter.
2) why you have to "sign up" in advance; if this is a public hospital there should be an anaesthetist or a trainee on site or on-call...
3) in addition there is no evidence that epidurals are associated with long-term backpain over and above that which is associated with childbirth. Nor has it been demonstrated that they cause forceps deliveries; they are *associated* with forceps deliveries, but you would expect that (big baby = painful labour and = difficult extraction) anyway.
4) That said, there are certainly risks including paralysis and for that matter death but the key is that they are rare (paralysis = 1 in ~ tens of thousands for example). It is of course at least as risky to get in a car and drive to the hospital. And far less risky than getting pregnant in the first place.

Roger Thornhill said...

mark: they are *associated* with forceps deliveries, but you would expect that (big baby = painful labour and = difficult extraction) anyway.

Ah, yes, correlation mutating in to causation. What has happened to logic and critical reasoning in UK Education these last decades?

p.s. thanks for the clarification on epi's.

Trixy said...

Am appalled that someone has to sign up for an epi. Why is there this opinion that women should suffer during child birth?

We fund the NHS through our taxes, it's not some charity we are being given.

I am so unbelivably sick of this country, and the NHS in particular, I can't wait to emigrate!

haddock said...

playing Devil's Advocate on Devil's site..... choice is the current buzz word.
Choices are a) accept free health care that others have paid for with some sort of gratitude b) pay for private health care and select level of care required. c) return to home country of Romania and take chances there.

Mary said...

Trixy - "Why is there this opinion that women should suffer during child birth?"

Blame the bible, apparently it's punishment for our sins. "Notwithstanding she shall be saved by childbirth" or some such. Guy called Timothy.

I reckon than even for non-fundies, it's a concept that might have kind of wormed its way into our social consciousness.

Z said...

Katy, my concern is for your friend, who seems to be being bullied. It's too late for her to go to ante-natal classes that can teach her to cope with labour and not to be afraid of it, but has she got a birth partner who speaks good English and can be relied upon to support her and make clear her wishes without quarrelling with the hospital staff? If her husband's English isn't up to it, maybe she needs a good friend.

Chuck Unsworth said...

This girl - your friend - should:

a) Write to the NHS Trust, recorded delivery, and explain her real outrage at being treated in this offhand and cavalier manner.

b) Invite the local rag to come down and photograph her weeping and distraught - and write her story. It's a cheap filler for the paper and, what with her being young and photogenic, it'll get a decent position

c) Write to the local MP (unless it's that cretinous Hewitt bint) and embarrass him/her.

These NHS 'Managers' and their astoundingly stupid underlings must not be allowed to get away with this.

Katy Newton said...

Choices are a) accept free health care that others have paid for with some sort of gratitude b) pay for private health care and select level of care required. c) return to home country of Romania and take chances there.

Ha. Unfortunately none of your choices apply. This isn't a public/private healthcare issue, nor is it an "ungrateful foreigners coming over here and then complaining about our healthcare" issue.

Epidurals are available on the NHS for any woman who wants one.

This is about an NHS midwife's failure to carry out what midwives say is their job: to act as an advocate for women in hospital, make sure they are fully informed about their choices, and support them in the choice that they make.

Roger Thornhill said...

katy: make sure they are fully informed about their choices, and support them in the choice that they make.

Is it possible some midwives might be reading this as: make sure you are fully informed (told) about their (the midwives') choices, and support them (each other - as in other midwives) in the choice that they (the midwives) make (on your behalf).

Mark Wadsworth said...

Katy (in reply to your question), my Mrs read all the books and talked to midwives and doctors and stuff, they all said that there are risks involved (yeah, shoving a needle into your spine, of course it's risky) and they reminded her of this again before she consented, whether she had to sign anything I can't remember.

I posted my reservations about the particular midwife on another thread recently.

Katy Newton said...

Incidentally, Haddock, my friend has been working and paying tax in this country since she arrived here five years ago and is now naturalised. Her taxes now fund the NHS considerably more than the made-in-Britain pondlife which lives in a house paid for by you, me and her, and hasn't got off its arse except to pocket its dole money, also paid for by you, me and her, once a week for the last thirty years.

I have no patience with anyone who wants to try and twist this into immigrant-bashing, really.

Katy Newton said...

Mark - my friend hasn't seen a doctor. That's the problem. I have no doubt that a doctor would have talked it through with her properly and left it up to her.

PhD scientist said...

Mark the anaesthetist is dead right

- It is nothing whatsoever to do with the midwives whether the woman wants an epidural. It is down to the woman, advised by the relevant health care bod (an anaesthetist), and backed by her partner/ supporter(s) (the moral support) to make the decision.

Sadly, some midwives (not all) pull this crap, either through prejudice ("women should suffer"), or obstruction / jobsworth-ery ("you can't have one unless you've been pre-selected"), or ignorance / misunderstanding ("it makes it more likely you'll need an assisted delivery" - an urban legend not well supported by actual evidence), or sometimes just through sheer laziness (just about to go off shift and don't want to hang around / middle of night and about to have cup of tea / don't feel like finding the anaesthetist etc etc).

It is also sometimes a stock response the first time the woman asks ("because every labouring woman asks for an epidural at least once, and they don't all really mean it at the time").

The trick is to get ASSERTIVE AND VOCAL and INSIST on seeing the on-call anaesthetist to discuss pain control NOW.

So it shouldn't happen like this, but it does on occasion. You just have to not let them fob you off. I can just about understand the "first time they might not mean it" line, but it only works if they are good at judging who really DOES mean it (jury out on that one) and also on them being sensible enough to ask people again "how is the pain? Do you need help with it?", and also on them appreciating that some people don't understand that if you didn't get one now, you can change your mind an hour later.

But for them to do what you describe to a clearly frightened woman in pain and with English language difficulties is appalling. She should lodge a formal complaint, if you ask me.

*sigh* One of those scenarios Dr Crippen likes to comment on where assertive middle-class people get a better deal from healthcare as they are prepared to push for it (no pun intended), and also tend to look to the people being lazy/silly like the kind of annoying folk who really WILL complain formally / trigger an investigation.

My other half, who used to put in epidurals for the delivery unit, needed an epidural putting in at 3 am the night she had our first. The maternity ward midwife was a bit reluctant (Catholic belief in suffering plus added laziness, we suspect). The Missus was on her own but being (i) a doctor (ii) an anaesthetist and (iii) fairly fierce, she knew to tell the midwife firmly to stop p*ssing her about and get the duty anaesthetist pronto, which did the trick

PhD scientist said...

PS

Sorry, re-reading the post see she is still 1 wk out. My misunderstanding.

Anyway, she should take an assertive friend (Like Katy?) with her to the hospital and INSIST on talking to someone about pain control when she books in.

Based on our experiences, inc. my wife's time working on the maternity unit, midwife-led births are great IF you get a good midwife.

A midwife that rules out an epidural and says "oh you won't need pain control, you're young and strong" is not a good midwife. Rather the opposite.

Sometimes you have to make a fuss to get proper service, sadly. But don't settle for less.

Chairwoman of the bored said...

Haddock - Before you start saying things like 'Go back to Romania and take her chances there', you need to enquire about their health service, which beats ours into the proverbial cocked hat.

Did you know that once a year all Romanians go into hospital for three days for a complete health check up? Did you know that pregnancies and births are supervised by obstetricians there, and midwives here? Did you know that their GPs have more up-to-date scanning equipment in their surgeries than most of our hospitals' Obstetrics and Gynaecology Departments?

It seems to me that Katy's friend is taking her chances here.

haddock said...

I know little of conditions in Romania,and care even less. I assumed a Romanian does and could make an informed choice. It is obviously bash-a-midwife week and any opinion contrarywise will result in an attack as being an 'immigrant-basher'.
If someone is 'afraid of giving birth and afraid of the pain' a good time to consider life's choices would have been nine months ago and not nine days before giving birth.
I have listened to midwives' comments about the problems of their job.... most get fed up with the hard physical work, back pain and the abuse and move on.... hence the shortage of midwives.

Katy Newton said...

Haddock, are you suggesting that women who want epidurals should just not have children at all?

haddock said...

katy, did I say that ? I was suggesting that everyone, male or female, English or Romanian, is aware that childbirth can be bloody painful.There is enough written and spoken about it to make me think that anyone expecting a painless birth is a bloody fool.I was present at the birth of no1 son and found it to be a truly horrible experience seeing a loved one in so much pain and being so helpless; for that reason I did not attend no2's birth. 37 years ago epidurals were not routinely used and a whiff of gas was about as much any woman could expect.
It seems that as techniques are invented and move into limited usage they suddenly become a 'right'no matter what.
The much maligned midwife probably has things to do other than explain the risks of epidural injections in great detail, difficult enough to explain in non-technical colloquial english to a native english speaker, and next to impossible to explain to someone that she has percieved as perhaps unable to understand English.
It could be that the pain of childbirth is part of the bonding process between mother and child; it could be.... I don't know.... and importantly, neither do you.

potentilla said...

But luckily, I do...

The pain of childbirth is because our forebears were four-legged creatures giving birth to small-headed young, and we went and evolved an upright stance and a big brain. The result is an uneasy engineering compromise all round; human babies are born very helpless and still have heads big enough to be routinely life-threatening to their mothers.

Katy Newton said...

The much maligned midwife probably has things to do other than explain the risks of epidural injections in great detail, difficult enough to explain in non-technical colloquial english to a native english speaker, and next to impossible to explain to someone that she has percieved as perhaps unable to understand English.

What absolute crap. When I say to my midwife "I want an epidural" she'll fucking well say yes or explain why I can't have one. You clearly have a problem with the fact that my friend is not English and it is blinding you to the basic fact that women are supposed to get epidurals if they ask for them. I don't care if epidurals weren't used routinely thirty years ago: they are now, they are supposed to be available to women who want them and the fact that my friend was born in Romania does not excuse the fact that the midwife ignored her request for one.

I was present at the birth of no1 son and found it to be a truly horrible experience seeing a loved one in so much pain and being so helpless; for that reason I did not attend no2's birth

How lucky you were to have the option of not attending. Not an option that was open to your wife, though, was it? But nice to know that you'd have her go through it alone again for the sake of "bonding". What a prince you are. I bet she'd have bitten off her own arm for an epidural by the end of it.

You, sir, are a tit, and have only demonstrated your lack of qualifications to comment. Have your next operation or dental work without anaesthetic, why don't you.

As for your suggestion that the pain of childbirth is in some way a bonding mechanism between mother and baby, I suggest you shove that in a bowling ball, stick it up your arse, shit it out without analgesia over one or two days and then come back and tell me how you feel about it.

haddock said...

I remember the time when we could have a debate here in the Kitchen.
I didn't notice the rule change. This is the Devil's Kitchen for fuck's sake not the 'we all hate the nasty midwife site'. DK seldom (never ?) attacks those with no means of defence, midwives as a group.... perhaps fair game, politicians and media types, always fair game.... they have their soapboxes... when it gets to attacking one or two midwives personally without presenting the whole story there needs to be opportunity to present other opinions.
Have you ever considered why women ever wanted more than one child ? Or are you sugesting it is always a case of rape by we nasty men ? Women died in childbirth because of many things, but pain was not one of them.
I did not "have her go through it alone again for the sake of "bonding"" the decision to have another child was joint ( and as it happens the second birth was quick and relatively painless)
As for lack of qualification to comment, just what the fuck does that mean ?; I have attended one birth, you have attended, I guess, none, so one up to me. You are not a nurse or a doctor and neither am I, so level on that score. You have never given birth and neither have I, level on that one. Yet you are the one qualified to talk because you have a friend who cried...
As for the tit remark,if you need or want a slanging/swearing match I'm well up for it as they say these days. I was looking for a debate though.....

Katy Newton said...

This is a debate, chum, although you might not like my answers. No one's stopping you from posting whatever you like. And the post is about midwives, not a midwife, although I use her as an example.

Katy Newton said...

I have been present at a birth and I am not sure why you assume that I haven't been. But you clearly think that women should have to go through pain in childbirth. I don't. I don't understand why you think that. I think you are wrong. I don't see either of us moving from those positions. Headaches have hurt since time began as well, but I don't see you legislating to ban paracetamol.

Devil's Kitchen said...

I realise that there is a certain irony in your humble Devil urging everyone to keep calm, but I only do so because the debate does not really seem to be moving along here.

First, let me point out as someone who has no children (that I know of!) and no births attended, I am not in the least qualified to discuss this. But then, that's never really stopped me, eh?

At any time on The Kitchen, topics tend to come in waves. My abuse of Miliband tends to be clustered, my writings on global warming tend to be clustered, etc. In other words, because one story about midwives caught my attention, any midwifery stuff is likely to happen at around the same time. In a few days, I'll get bored and move onto something else.

I would also like to point out that it is not simply we ignoramuses who are bashing midwives; Crippen and Doctors.net.uk are also doing so. There does seem that, as a profession, they tend to be seen as arrogant and unfeeling. As I pointed out above, I am unqualified to comment authorititavely; on the other hand, almost no one comments when I say that all politicians are lazy, venal and corrupt.

My take on this is that it seems to me that we have a word for unnecessary cruelty, the inflicting of unnecessary pain: torture (hence my post entitled "Lazy torturing scum", or whatever it was).

No, it seems to me that any numbing of the central nervous system (CNS) is going to affect other parts of the body; in this case, I believe that epidurals can have an affect on the strength of contractions and possibly increase the frequency of a forceps-aided birth.

Now, as Potentilla obliquely pointed out, the human body is not as well-designed as we would like to think. In fact, around the pelvic area, it is particularly poor; the strain on the hips of walking two-legged is rather more than they are actually designed to cope with (evolution might change this except that we, in the West at least, have more or less removed our species from selective pressures) and the birth canal is simply too small to cope well with the birth of such a large-headed object.

There are adaptations that have been made. A baby's skull bones, for instance, do not knit together properly until some years after birth; during birth, the skull bones flex and slide over one another in order to decrease the size of the head.

However, this does not alter the fact that a baby is a very large object to force through a tunnel that most men would have severe difficulty fitting their fist into.

It seems to me that a lot of the criticism of midwives is based on their (perceived?) assertion that "natural is best".

Thirty years ago, far more people died of cancer than do now. A hundred years ago, people died of diseases that we barely notice. Two hundred years ago, people died of diseases that we have all but wiped out.

Natural is not necessarily better; as a species, humans have been consistently disproving that theory for at least 3,000 years. So, let's knock that argument on the head.

Now, in the case of epidurals, we should only consider whether the pain relief that they bring is worth the risk to the natural flow of the birth (and to the woman concerned). I believe that a great many women think that it is. The risk of a forceps birth being required is increased, but it's still small and, more importantly, if done correctly (as it fucking well should be), there is almost no risk to the baby.

There is a very tiny risk of paralysis in the case of the woman too, but we libertarians believe in assessing risk and then taking decisions based on those assessments, do we not? Is that not why we object to the state attempting to destroy risk by removing our choices?

Haddock, you talked about the trauma of seeing someone you loved in such pain -- would you not feel angry if you knew that pain could be relieved and the staff refused to administer that relief? I know I would.

The true problem here is that the epidural needs to be administered by a qualified doctor, not a midwife or nurse practitioner. As such, we come down to the fact that we have a shortage of facilities in our hospitals.

Now, the best way to use these limited resources is to book the epidural; if the woman decides half-way through the birth, a doctor has to be taken from some other duty in order to administer that procedure. This will always be necessary in occasional cases but, generally, booking it in is the best use of our limited resources.

So, what do we have? We have an incredible pain-relieving procedure that carries a very small (and non-fatal) risk to mother and baby, and limited resources.

Midwives should not be pressuring women not to have an epidural. They should inform women of the risks in a balanced and neutral way, however.

If a woman wants a completely natural birth, then they can choose that (and many do). But we should never, ever confuse "natural" with "automatically good"; we don't in any other sphere of life: why this one?

Some points to get you started, anyway!

DK

potentilla said...

Gosh, and not an insult in sight; congratulations.

One minor quibble with your masterful summary; I would love to believe that booking one's epidural actually has some knock-on effect on the availability of anaethetists, but I don't. Medical administration (public or private) is uniformly dismal by normal standards, and in this case, it would be a particularly difficult problem to administer, as on the whole the time that the anaesthetist would be needed is not known in advance. So I doubt the efficient-use-of-resources argument washes. (Actually I would be interested to know whether women are really told they have to 'book an epidural' - I'm not doubting Katy, just wondering how widespread the practice is, and/or whether the midwife in question made it up on the spur of the moment, or if it is indeed common practice, why that is).

Rachel said...

As long as you're not delivering your child in an NHS hospital there is an anaesthetist available. In fact in most places there will be several at all times of day - the on site on call juniors (who can safely perform an epidural independently) and seniors who may be on call from home.
"Booking in" epidurals sounds like madwife paperworkery gone mad. Women have birth plans - these are guidelines set out way in advance for how they think they'd like things to run. A good midwife will make it clear that other options always remain open. A bad one, or an officious one, or a misinformed ignorant one might not.
And women may not have died fromt he pain of labour but they bloody well did from "natural labour." Proponents of the natural life need to do a detailed list of friends and family who have had their lives saved by sanitation, vaccinations, antibiotics, and refrigeration. And then rethink.

Rachel said...

Sorry - that should have said as long as you ARE delivering your child in an NHS hospital!!!

PhD scientist said...

The point about "trade off of risks" is a key one here.

An associated problem is how the risks (inc. risk figures) are presented, and how they are perceived.

Hence the sense in the epidural-in-labour context of discussing it properly in advance IF people are unsure.

For instance, let's say for the sake of argument that the RELATIVE increased risk of an "assisted" delivery (forceps or vacuum cap) with an epidural is about 40%.

That is a number, but it's not the whole truth.

You would also want to know what your ABSOLUTE statistical likelihood of having an assisted delivery was if you DIDN'T have an epidural.

For instance, suppose the overall risk is 1 in 10, or 10 in 100 women having their first baby, getting an assisted delivery. The epidural in my hypothetical calculation then increases this risk to 14 in 100.

Four extra chances in a hundred of an assisted delivery may sound rather different to "a 40% increased risk".

Or what if the corresponding numbers were "1 in 5 / 20 in 100 without epidural" and 28/100 - "nearly a third!" - with epidural. People might feel differently when the numbers start hitting things that they can put a meaning on - "one fifth", "a quarter" etc.

This is a classical problem with presenting medical statistics - the increased relative risk is not all that helpful if you don't know the absolute risk.

If you want an example, remember all the kerfuffle about Herceptin and breast cancer, where the relative risk numbers were quoted ad nauseam in news story after news story, while the absolute risk figures appeared once (in the broadsheets) or never (in the tabloids).

This kind of lazy obfuscation with risk statistics routinely drives scientists and doctors nuts, because it means people operate on basically erroneous information.

As if readers here needed reminding, politicians are also tremendous fans of picking the statistic to suit the message.

BTW, I don't know whether it should make us laugh or cry, but many of the standard "tricks" with statistics were described in Darrell Huff's classic book "How to Lie With Statistics" over half a century ago.

http://en.wikipedia.org/wiki/How_to_Lie_with_Statistics

The situation has not notably improved since then.

flashgordonnz said...

"This is a classical problem with presenting medical statistics - the increased relative risk is not all that helpful if you don't know the absolute risk."

Well put, phd sci: You increased my understanding of this issue three-fold. From 30% to 90%!

BTW, funny how:
"No" means "no"
but:
"I want an epidural" doesn't mean
"I want an epidural"

Mark said...

"Did you know that once a year all Romanians go into hospital for three days for a complete health check up?"

And what a waste of time and money that would be. What on earth would they be looking for - and how would they do it? How many come out with gastro and MRSA? Do any of these "all Romanians" say "sod off commissars, I'd rather go skiing?"

Mark said...

"And women may not have died from the pain of labour"

I'll bet some have (arrhythmias, myocardial infarctions, stroke).

Chairwoman of the bored said...

mark - Katy's friend hadn't heard of MRSA. They don't have commissars any more, BTW, and I don't think the check ups are compulsory.

But Katy's friend's husband was found to have very high blood pressure at his check-up three years ago (he was 31 at the time). He had never had his BP checked here, as he is young and incredibly healthy looking, and hadn't seen his GP here for anything BP related.

Are you saying it would be a bad idea for us all to have some sort of annual check-up where things pof this ilk are looked for in people who aren't presenting with related problems.

This is no reflection on our hard-pressed GPs, as these things appear not to be built in to our system.

Rachel Joyce said...

As a doctor I agree with Mark the anaesthetist that in hospitals there is always an anaesthetist who can perform an epidural - but you might have to wait.
The only exception is home births, or a birthing centre. It may be that she has been booked into a birthing centre.
Midwives have one thing they take real pride in - completely natural births. They have never liked handing over the birth to doctors - forceps, caesarians etc. suppose it is a matter of professional pride. I They don't like epidurals as they feel they have failed, and often women are made to feel they have also failed. They do increase risk but in my opinion not sufficiently so to make people feel guilty.
In fact, there is research that shows that women encouraged to have birth plans and be all "natural" are then more likely than others to have post-natal depression if they don't have this wonderful natural birth thing that shows what a good mother they are.
The answer is more realistic expectations.

monoi said...

I cannot remember a problem for my wife to have an epidural.

The 1st time, we met the anesthetist a few weeks before hand and he could not have been more professional and good. The epidural was done within 15mins of the call, and he let my wife in charge of the pain control. The 2nd time, the anesthetist was not so good and was going by the protocol. Which is all well and good, except that protocols do not account for different people, and there was a lot more pain.

What I do not understand in this story is what the father is doing ?

I am lucky that my wife is 5'11" and German, so she would not have put up with "young and strong" nonsense, but I would certainly not have let that comment slide.

Also, what I find interesting is the fact that DK often despairs of the nanny state, and here we have someone who cannot tell a midwife to go get a life. I understand it is a friend, but I would have thought that if you have decided to have a child, a bit of backbone would come in handy.

PhD scientist said...

I guess another possibility, not yet raised I think, is that the mother-to-be could have been signed up for one of the "Domino" type schemes where most of the action happens at home and they only bring you in for the last bit in hospital. With these there is a definite chance that, by the time you get to hospital, you are too late-stage in labour to put in an epidural.

As Katy said on Dr Crippen's blog, however you look at it, it sounds like the woman here did not get an appropriate level of explanation and support from the midwives / antenatal service.

Mark said...

Critical point.

Midwives seem to be pushing midwife-led units.

The Government also appears to be pushing these, but of course, in reality they are just dumbed down obstetric units often with no proper obstetric care on site*, and are therefore cheaper.

Therefore, women now *do* have to make a choice. If they think they may want an epidural, then there's no point in booking into a midwife-led unit. Anecdotally, many women are coerced into these substandard units by misinformation and malpractice**.

Natural is not best. Maternal mortality was decreasing until recently. No member of my family will ever give birth in a unit where someone is not on hand to deliver the baby operatively and where there aren't trained staff to resuscitate the baby.

*obstetric care = IMHO is that required to deal with childbirth and any possible complications. It is not pretty wallpaper.

** in ten years time with the benefit of the retrospectoscope, midwife led units will be the thalidomide of their day.

PhD scientist said...

We picked a midwife-led unit, Mark, but one where there was full medical cover inc. O&G SHO/reg, on-call anaesthetists, and paeds up the corridor. It can be done, but it takes top-notch midwives with a lot of skill, and training, and insight.

As Mrs PhD had worked on the unit as an anaesthetics SHO, we knew exactly what we were going to be getting, which always helps.

LadyBanana said...

It's nothing new, 19 yrs ago at the birth of my 3rd child I begged for an epidural only to be told that as I had already given birth twice before there was absolutely no need for one.

Not true I screamed - to no avail!

Midwifemuse said...

http://www.cochrane.org/reviews/en/ab000331.html
The above link is to the cochrane review database and is concerning Epidural versus non-epidural or no analgesia in labour. I believe some of the commentators, interestingly enough one an anaesthetist, have said there is no correlation between epidurals and assisted deliveries whereas there is.
Back to the topic, women should have informed choice. It is a midwives role to be an advocate and that necessitates supplying correct, impartial, non-judgemental information.
Pro's and cons must be discussed or supplied and also the limitations of the service i.e anasthetists not always being immediately available and some units having a staff ratio which means that only a certain number of women with epidurals can be cared for at the same time. (As soon as a woman has an epidural sited she becomes a consultant case and requires increased medical surveillance.)
Why is it always the midwives who are the bad guys? We can request an anaesthetist to attend and site an epidural, there is not always an immediate response, is that the midwife's fault?

Katy Newton said...

Also, what I find interesting is the fact that DK often despairs of the nanny state, and here we have someone who cannot tell a midwife to go get a life.

Firstly, DK did not write this post, I wrote it. Secondly, this is a perfect example of the nanny state in action: the midwife did not bother to give my friend the information she needed to make the decision, but presumed to make it for her.

I understand it is a friend, but I would have thought that if you have decided to have a child, a bit of backbone would come in handy.

Thanks for that. I'll go and tell my friend it was all her fault. What a stupid woman she was, trusting the self-styled birth expert to tell her what she needed to know.

What I do not understand in this story is what the father is doing

The father has a job to go to and cannot attend every single appointment with the website.

Do you not see that it is supposed to be the midwife's job to make sure that a mother-to-be has all of the information that she needs to make decisions about things like epidurals? Do you not appreciate that this happened not because my friend is stupid or lacks backbone, and not because her husband didn't come with her, but because the midwife didn't do her job properly?

I believe some of the commentators, interestingly enough one an anaesthetist, have said there is no correlation between epidurals and assisted deliveries whereas there is.

I don't think that is what has been said. No one has denied that there is a correlation between epidurals and assisted deliveries. I think that what is suggested is that in fact it is the complicated births and assisted deliveries that lead to the need for an epidural rather than the other way round.

Why is it always the midwives who are the bad guys? We can request an anaesthetist to attend and site an epidural, there is not always an immediate response, is that the midwife's fault?

That's not what happened here though, is it? What happened here is that my friend had an appointment with her midwife and said she wanted an epidural and was dismissed out of hand without any attempt to properly discuss it with her. My friend was not in labour at the time that she had this conversation. In fact she still hasn't gone into labour. In this case, the reason the midwife is the bad guy is because... she was the bad guy.

Katy Newton said...

The father has a job to go to and cannot attend every single appointment with the website.

Bugger. I meant, of course, "with the midwife". Apologies. It is late and I am tired.

PhD scientist said...

Midwifemuse

I think we were saying that "epidurals lead to extra assisted birth" is a misleading statement, since (i) real numbers, including ABSOLUTE risk, are hard to find (even in the Cochrane review) and debated; and (ii) sometimes it is the difficulty of the birth rather than the epidural per se that is the culprit.

For instance, if assisted deliveries are more common in past-term inductions, which often involve longer more painful labours and hence epidurals, is the assisted delivery attributable to the past-term induction, or to the epidural?

My main point was that giving people who WANT information the words "there is an increased risk..." without some meaningful numbers is actually misleading.

"(As soon as a woman has an epidural sited she becomes a consultant case and requires increased medical surveillance."

I don't think that can be universal Mwm. We had our first in a midwife-led unit, with an epidural put in by the on-call anaesthetist but topped up later by the midwife. We didn't see the doctor (apart from a brief "say hi" until the O&G reg appeared at the point of delivery.

Obviously none of us were there in the room in the consultation Katy is talking about, but it does sound as if Katy's friend was rather badly served by the midwife.

When we train health professionals - like the medical students I teach - we spend ages and ages banging on about communication. With a frightened woman with poor English it is the health professional's job to make sure the person understands properly. If the HP doesn't, that is bad work, whether they are a midwife or a doctor (and I've seen it from both).

bobtipping said...

a

bobtipping said...

Oops

midwifemuse...

I will happily concede that there is an increased risk of instrumental delivery but there is no mention of causation in the review that I could see. Perhaps those deliveries that required epidurals were more complicated deliveries that were more painful so there was a higher usage of epidurals.

The same review showed an improvement in pain relief. Importantly, there was no increase in CS rates (often used by midwives as a reason not to have one), backache (frequently blamed by midwives on the epidural and not the delivery).

While I gratefully (as one who puts the things in) accept that many women do not require an epidural, I do think that they should have the choice to have one if they wish without being made to feel a failure for doing so.

Midwife-led units are great when based in hospitals so patients can have all the whale music and essential oils that they want but if they need intervention (whether it be anaesthetic or obstetric) it is available on-site. Distant units that would require an ambulance transfer for emergency caesarian section in a mother who may be bleeding at a rate of her whole circulating blood volume every five minutes seems inherently unsafe.

Finally, I am impressed that you are prepared to put your head above the parapet in a discussion where your colleagues are already on a very sticky wicket. This almost certainly means that you are one of the midwives at which this vitriol is NOT aimed!

Layla said...

Great post. Apalling but not surprising, unfortunately. When I was a medical student, every single midwife I came across (in three different hospitals in SE England/London) had a shocking attitude towards epidurals. The woman would ask for one early on in labour, to which the midwife would either reply, 'It's too early, you may not even need one, wait a while', or 'The anaesthetist is busy in theatre' (without even checking to see if that was indeed the case). A few hours in, the woman would be screaming for an epidural. She would be told by the midwife that an anaesthetist was on his way, before the midwife would take me aside to say, triumphantly, 'by the time he gets here she'll have delivered'.

I never saw a single epidural given. The midwives used tactics including blatant lies, bullying and delay in order to deny women pain relief (other than 'gas and air', which the majority of my friends who have sprogged tell me is next to useless). I found the general attitude towards women who cried out in pain was, 'Oh don't make such a fuss. It's natural.'. Women who wanted epidurals were viewed as being weak and whingy. The overall atmosphere was one of 'midwife knows best'.

It's enough to put you off having children. Luckily for me, I suppose, I am a pushy middle class doctor and I will damn well have an epidural if I want one.

Henry North London said...

layla is indeed correct. I was once a medical student doing my deliveries and the ( she'll deliver before the anaesthetist gets here) is an old chestnut.

Luckily Im not a woman so I dont even have to think about childbirth anymore but if I were thinking about delivering I would drive to Denmark or Sweden and get delivered there rather than think about trying the NHS. I suppose the E111 does have some perks

Amy Tuteur, MD said...

There are additional reasons why midwives discourage or prevent the use of epidurals:

Fundamentally, midwives are not knowledgeable about the risks. They literally have no idea of the actual magnitude of the risks and how that compares to other risks. It is axiomatic in midwifery that the risks are "too high". Yet, the risk of death from homebirth is 1-2/1000 and the risk of maternal death from a labor epidural is on the order of 1/7,000,000. Therefore, the risk of dying from a labor epidural is literally less than the risk of dying from a lightning strike AND the risk of death at homebirth is more than 100 times higher than the risk of death from a labor epidural.

Competitive mothering. It is axiomatic among "natural" childbirth advocates that unmedicated childbirth is "better" and that, therefore, women who have unmedicated childbirth are better mothers and more authentic women.

The overweening desire of some people to control other people. The Royal College of Midwives actually has a campaign to promote "normal" birth. The hubris and self importance of the RCM is laughable. THEY, among eveyone in the world, are in charge of the definition of "normal" birth. Of course, "normal" birth is not birth as it occurs in nature; it is birth according to the dictates of an RCM midwife.