Epidurals in childbirth – a personal perspective
July 15, 2009 at 5:56 pm | In Birth, Breastfeeding, Midwife, Winds me up, childbirth | 30 CommentsTags: assisted delivery, Denis Walsh, epidurals, increasing risk in labour
What man would be brave enough to suggest that the pain of labour is ‘a good thing’? Dr Denis Walsh, that’s who. Now the doctor title may be slightly misleading as, rather than being a medical ‘doctor’ the title is a PhD, he is actually a midwife, admittedly an extremely senior practitioner, but midwifery is his profession, even if he is ‘not able to provide midwifery care at this time’ (NMC register). He is now also the cause of huge discussions everywhere, ranging from a well-constructed defence of his opinion by Feminist Philosophers to a series of expletives, tempered with some thoughtful comments, on the Mumsnet forum.
What do I think? I think that epidurals are over-used. That they do adversely affect the progress of labour. That they change, what for 70% of women is a normal, physiological process, into a medical event. That the use of epidural anaesthesia increases the risk of an instrumental delivery. That the opiate used in the epidural passes into the woman’s blood stream and so across the placenta to the baby and may affect breastfeeding.
So now I have stated my thoughts about epidurals BUT I would never deny a woman her choice of an epidural, in fact there are times when I actually advocate the use of epidurals in labour. What I do attempt to do is support the woman in normal labour, to encourage her to accept that the pain of the contractions is not a sign that something is abnormal but, if she still wants the epidural, then she gets one.
I get annoyed when I hear women say that they don’t want pethidine because ‘it affects the baby but an epidural doesn’t’. Rubbish. Even before I read the research suggesting that epidurals adversely affect breastfeeding I was only too aware that having an epidural increased the chance that baby would be delivered by a ventouse or forceps, both of which are capable of causing severe physical damage to baby. How about the woman? Yes she will probably have a pain-free labour (not all epidurals work though). Labour will be longer, but that’s not a problem, for her, if she can’t feel anything, might distress baby though. She may not be able pass urine, her bladder may become overful and obstruct baby’s head descending, no bother though as she can always have a cathater, but that does run the risk of giving her a urinary tract infection (cystitis). It’s more likely that she will need an episiotomy, but at least she won’t feel it, or the stitches, until the epidural wears off. The epidural may cause her blood pressure to fall dramatically, but her feeling faint and sick as a result, like the fall in baby’s heartrate, will be sorted out quickly by the intravenous fluids being increased and rolling her onto her left-side. The woman’s temperature may well rise as a result of the drug used in the epidural, but the staff can’t say definitely that the drug is the cause so the treatment has to be as if there is an infection present. The woman having a raised body temperature may also cause the unborn baby to demonstrate an increase in heartrate, if this persists then the medics will wish to investigate further and fetal blood sampling may be required. Following the birth the baby may well have to undergo investigations to rule out infection or, there may be a decision to use intravenous antibiotics prophylactically.
There it is then. If you hear, or have heard, of a midwife refusing a woman an epidural it wasn’t me, but if the story entailed a midwife trying to encourage a woman to cope without one it may well have been me as I have seen all of the above too many times to believe that epidurals are the innocent pain reliever many would like you to believe they are.
If anyone would like to read more from Denis Walsh about epidurals this ‘Zephrina Veitch Lecture’ is great.
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Wow, what a fascinating post. I was always led to believe that epidurals were basically wonderful and put baby at no risk at all, though in my gut I didn’t feel like I would want one. It is very interesting to hear a midwife say what she really thinks of them. I remember on my hospital tour late in my pregnancy, the midwife saying “Epidurals are wonderful, we really push them here” and I thought “So you prefer your labouring women quiet, still and no bother then”.
I pray that we do not get to the point they are at in America where epidurals are the rule rather than the exception. Obviously they are necessary if labour is particularly painful or prolonged, but otherwise I believe women are equipped mentally and physically to deal with childbirth (maybe with the help of a bit of gas and air!). But I feel that we are often told that we will not be able to cope, that we will find it too painful and need an epidural. This, I feel, is doing a disservice to women.
Comment by Cave Mother — July 15, 2009 #
Cave Mothe – Thank you for your comment. I believe we are fast approaching the epidural mindset which exists in the US, hence the type of submission from Dr Walsh. There are several agencies which are attempting to at least slow, if not reverse, the current attitude to labour as it being a problem which needs curing, rather than, in the majority of women, a natural physiological function of the female body. It is when it is a problem, some inductions, prolonged labor etc that epidurals should be offered.Womn should be physically and mentally able to cope with labour but somtimesI think it is the ‘mentally’ component which has been affected by media talking more about spiritual experiences etc. than emphasing that labour is painful, exhausting and sometimes distresing, but it lasts a finite amount of time and that the important end result is a well Mum and baby.
Comment by midwifemuse — July 15, 2009 #
After my first birth (epidural, scalp monitor on baby, syntocinon, several catheters, ventouse, forceps) I ended up with endometritis which I put down to the number of people and instruments grubbing about up my nether regions.
Comment by wildduck — July 15, 2009 #
wildduck – Interesting . I had never imagined an association between endometriosis and interventions in childbirth. I can feel a lot of reading coming on!
Comment by midwifemuse — July 15, 2009 #
Not endometriosis. Endometritis.
They made the same mistake on my GP notes transcribing the letter from the hospital.
Comment by wildduck — July 16, 2009 #
wow, so much info in this post, and very well put.
I’m sure it must often be difficult to weigh up risks against benefits. I opted against epidural to do everything to avoid a c-section, yet looking back I think it may have benefited my situation. Or it may in fact have led to a c-section which I just about managed to avoid.
The best we can do is be as informed as possible so thanks for this very well researched post!
Comment by cartside — July 15, 2009 #
cartside – All research, to date, has not shown a link between the rising CS rate and the rise in epidural use however, when I asked te midwife in charge of audit within our trust to plot the section rate rise and the use of epidurals over the last 12 years, the curve was remarkably similar. I am not convinced that epidurals are not an additional factor leading to CS.
Comment by midwifemuse — July 16, 2009 #
Yet again, I completely agree with your views. I’d hate the thought of having an epidural but respect a woman’s right to have it if there is good cause.
For myself, I’d have had a high tech delivery second time round I think, if I hadn’t constantly walked around whilst in labour. I wouldn’t have been able to do that if I’d had an epidural!
Anji – X
Comment by Blue Spice — July 16, 2009 #
Blue Spice – Have you heard of mobile epidurals? I worked in a unit here we had these, three problems though. The first was that most women, once they were pain free, would not feel the need to mobilise and would lie on the bed. The second was that after about 4 hours the epidural would start affecting motor function and they wouldn’t be able to walk around and the additional problem was that, due to the epidural, they needed continuous monitoring, that in itself reduces complete freedom of movement.
Comment by midwifemuse — July 16, 2009 #
How times have changed. My children are 21 and 24 and were born in the US where epidurals were heard of but not encouraged because of.. well, some of the things mentioned in the post. My mother had one against her will in the late ’60’s with her last child (her doc called away on an emergency, she tried to convince the doc that popped in that she was about to give birth, but he ordered an epidural anyway – she hated it).
I’m in the camp that says it wouldn’t have been for me, but if anyone else wants to do it, that’s their call…but my kids were born at a time when doing it the natural way seemed to be very popular, and I had straightforward pregnancies and comparatively easy births…the only medication I needed was something for the stitching from tearing the first time and being cut the second time. Not as painful as it sounds…
Comment by mygrain — July 16, 2009 #
mygrain – My first child is now in her 30’s and the midwives advised me to have an epidural, posterior baby, induction but I was adament that I was not having a needle stuck in my back and I was not going to end up with a forceps birth, I had seen a couple as a student nurse and they horrified me. After 22 hours my daughter was born, certainly not an easy birth, but the tirednss and the pain did not kill me, damage me or affect how I felt about my daughter. I expected hard work and lots of pain and was prepared to put up with it, albeit noisily, if it meant that my baby did not have a sore head for the first few days of her life. Obviously, if at any time there had been concerns about how baby was coping with it all, I would have demanded that the got her out any way they could.
Comment by midwifemuse — July 16, 2009 #
Last time round I didn’t want an epidural because hey, there’s no way anyone’s putting that needle anywhere near me. This time round I’m still feeling that same way, but having read your post, I know there’s more to it than that. I’m going in armed!
Comment by Vic — July 16, 2009 #
Vic – Wow, are you having another baby, must nip over to your blog. Congratulations.
Comment by midwifemuse — July 16, 2009 #
“What do I think? I think that epidurals are over-used. That they do adversely affect the progress of labour. That they change, what for 70% of women is a normal, physiological process, into a medical event. That the use of epidural anaesthesia increases the risk of an instrumental delivery. That the opiate used in the epidural passes into the woman’s blood stream and so across the placenta to the baby and may affect breastfeeding.”
I think you must have seen only epidurals that were badly done, in that case. In my experience as a midwife [since 1967, which was before epidurals, actually, which began to be used widely about 1970], a well-done and managed epidural does NOT affect labor [except occasionally speeding dilatation], does not affect breast feeding, only the most minute amount of the medication ever gets into the maternal, and from there, to the baby’s bloodstream, and does NOT affect breastfeeding.
I have, however, seen many unmedicated labors where women wound up in the OR because of labor stalling and exhaustion, or forceps or vacuum deliveries for the same reason. I have seen women whose experience of unmedicated labor actually made them think twice about having any more children. And as for breastfeeding, there are so many factors involved, including motivation [it is SO much easier to explain that breastfeeding failed because of that nasty epidural than because the woman really didn't want to do it but felt pressured], that I have the gravest suspicions when a woman tells me this.
The art of midwifery is matching the treatment to the patient. I don’t think women are held down and given epidurals against their will, they WANT pain relief in labor and cannot see why, in the 21st century, they should experience pain unnecessarily. If a woman wants to go the unmedicated route, that’s fine too — but the decision should be the woman’s, not the midwife’s.
Comment by Antigonos — July 16, 2009 #
Antigonos – I was interested to read the research suggesting that the use of epidurals affects successful breastfeeding as I had no made the correlation, mainly as I wouldn’t say that I have observed this, however the research is there. I have observed, and read research, demonstrating that epidurals do affect the progress of labour as they reduce the production of oxytocin. Perhaps this what you are referring to when you write ‘well managed epidurals’ in that augmentation is used to manage the labour?
Sorry, interesting dicussion but have to sign off now as grandchild demanding attention. Be back later to continue!
Comment by midwifemuse — July 16, 2009 #
Antigonos – Back again! I do agree with your ‘matching the treatment to the patient’ sentiment, hence me saying that I would never deny a woman an epidural and neither would I allow her choice to affect the care I provide. I find it very interesting (don’t know if this happens in Israel) that the anaesthetist will outline the possible side-effects of epidurals i.e back-ache, dural tap, etc but they never mention the possibility of cathaterisation, augmentation and assisted delivery, all of which are well documented and reliably researched. If a woman is making a choice I want her to be accurately informed. I don’t believe that this is always the case where epidurals are concerned and I’m not certain that the cascade of intervention concept has been fully explained.
Comment by midwifemuse — July 16, 2009 #
The article encouraged me to write down my birth story: http://allgrownup06.blogspot.com/2009/07/my-birth-story-read-at-your-own-peril.html
I was desperately naive about wanting a natural childbirth with no pain relief. On the day, symphasis pubis dysfuction, a back labour and 50 hrs had me tearfully changing my mind. However, in the ambulance to the hospital from the birthing centre (to get my epidural), labour sped up, and it was too late for an epidural. I was in so much pain, I pushed without contractions to bring about the end of my labour. As a result, baby came fast and I spent 4hrs in surgery with 3rd degree tears. 19 m later, I have permanent nerve damage, the thought of riding a bike, for example, is abhorrent. Perhaps an epidural slowing my progress may have been no bad thing……
Comment by All Grown Up — July 16, 2009 #
All Grown Up – A prolonged ‘back labour’ is one of the occassions I would actively encourage the use of an epidural, not to slow progress but as it generally accompanies a baby who is lying with it’s back to Mum’s so, unless baby rotates*, labour will be longer with the pushing and birth more problematic.
Horrible experience for you and why weren’t you transferred earlier?
*Sometimes baby will respond to much marching, stair climbing, rotating of the pelvis, or bumpy ambulance rides and turn round, at which point the whole process speeds up.
Comment by midwifemuse — July 16, 2009 #
I don’t think I would have coped without my (mobile) epidural. Mine was a very medical labour – waters broken by a doctor with a midwife pressing down on my belly to avoid cord prolapse, then hooked up to a syntocinon drip and wired to monitors, not allowed to use my tens machine, didn’t even notice any impact from the pethidine, not allowed to get up and move around, and finally manual removal of the placenta in theatre, so I had to have a full epidural then anyway. I’m not planning on having any more babies, but if I were, I would fight tooth and nail for the right to an epidural. I did so much preparation for an active labour, and it all came to nought – but I do have a wonderful baby boy (with his first two teeth today!).
I am glad though that neither forceps nor ventouse were needed – I have a friend who has ongoing medical issues from the use of forceps in her daughter’s birth (baby was fine). They tried a ventouse first but the cap bit kept falling off!
Comment by Anne — July 16, 2009 #
Anne – Once again, induction of labour with synto is a labour where epidural use is understandable, the epidural is a result of a cascade of intervention, not the cause.
It is not labours like yours or All Grown Ups where I question the use of epidurals, both of you had ‘unnatural’ labours. The times I question their use is for women where labour is progressing entirely normally and no compliations are anticipated.
Comment by midwifemuse — July 16, 2009 #
I completely agree with you about epidurals. I hate the thought of having a tube inserted into my spine, and spending labour bedbound. My first baby is due in four weeks, and it didn’t take me long to decide I wanted to try to have a homebirth, as I witnessed almost ten years ago, at the birth of my youngest brother how birth can suddenly turn into a medical emergency, endangering the lives of mother and baby, caused by medical intervention in the first place.
I do think that in some cases epidurals are probably necessary, and, not having had a baby myself before, I can’t really know how I am going to cope with contractions. But I can give it a good try! On the bottom line, I think that labour is only temporary, and a few hours/days of it are certainly not going to kill me.
Thank you for a very informative post!
Comment by tuilelaith — July 17, 2009 #
tuilelaith – In a nutshell ‘ labour is only temporary, and a few hours/days of it are certainly not going to kill me.‘ Virtually what I said to myself, and very true! Hope all goes as hoped for in 4+ weeks.
Comment by midwifemuse — July 17, 2009 #
thanks for sharing your experience of this!
i had my first child in a big, busy maternity hospital in london, where the midwives seemed very happy to be little more than doctor’s assistant, and where lying on your back with an epidural and fetal monitoring belt was treated as the only proper way to do it–american-style, in other words! (i actually (meekly) asked the midwife ‘can i try pushing in a different position?’ when the second stage was going nowhere, and i swear she looked at me as if i was asking her to have anal sex with me; she seemed really grossed out by my suggestion!) it ended horribly: forceps delivery, nasty episiotomy scar, and 12 days in hospital with my baby who was acutely jaundiced and suffering intermittent hypothermia as a result of the severe bruising and fat necrosis he sustained from the forceps. (and of course, breastfeeding was a nightmare with a lethargic baby with a swollen bruised face.) as if that weren’t bad enough, i had retained placental fragments from the doctor reaching in and ripping the placenta out with his hands, and no one caught this for 10 weeks. so i was dog sick for weeks and everyone kept telling me that ’sometimes it just takes a while to feel yourself again’. i didn’t actually have a single moment, i don’t think, of feeling happy about having my baby until my son was probably 6 months old. and even then (and even now!) i feel completely traumatized by the birth experience.
anyway, i wanted to come on to tell you thanks for the kind words about my post on feministphilosophers, and thanks for sharing your first-hand experiences of these issues! and please do come round to ours and put your two cents in, if you like!
Comment by extendedlp — July 17, 2009 #
extendedlp – Sounds like a childbirth, early weeks nightmare, and a graphic example of a cascade of interventions. I shall certainly make you one of my stop-offs when exploring the web. Thank you.
Comment by midwifemuse — July 17, 2009 #
just to say that I’ve got an award for you over at mine.
Interesting that you pointed out that there’s no definite link between epidurals and c-section risk. It was something stressed at NCT and Hypnobirthing classes. Maybe there was an agenda behind it.
Comment by cartside — July 17, 2009 #
Interesting to see this from a midwife’s point of view. Thank you. My first birth was not ideal and I almost had an epidural and almost had a CS, but she turned just in time and came out – still with ventouse and a cut (can’t remember the term at the moment!). This time, I have discussed all my issues with my (wonderful) midwife and we are hoping to avoid all the same problems. Unfortunately, Rosemary was early 36 + 5 (very annoying 2 days off 37 weeks) and I had no choice but to go to the hospital instead of the midwife-led unit, which I believe is where all the problems stem from. There’s no real way to guarantee that doesn’t happen again, this time, but I am keeping my fingers crossed.
I am planning to write my birth story some time soon, as it’s quite high up in my mind at the moment, with only 3 months to go. Will let you know when I do.
Comment by Coding Mamma — July 19, 2009 #
Coding Mamma – Episiotomy is the term! Fingers crossed that you get to 37 weeks this time.
Comment by midwifemuse — July 19, 2009 #
[...] I’m not a doctor or a midwife (you can read one midwifes’ perspective of epidurals here) so I can’t comment on the medical aspect of his point of view. What I can comment on though is [...]
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[...] I’m not a doctor or a midwife (you can read one midwifes’ perspective of epidurals here) so I can’t comment on the medical aspect of his point of view. What I can comment on though is [...]
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wildduck – My mistake as I thought that you had spelled it wrongly, in fact it was me who was being ignorant. I am no longer quite so ill-informed and am now able to say that I wouldn’t be at all surprised if all that ‘grubbing around up nether regions’ hadn’t played a major, major part.
Comment by midwifemuse — July 16, 2009 #