Epidural analgesia is a resource which can be extremely beneficial to women in labour and approximately 20% of women in the UK will use this method for pain relief (Department of Health (DH), 2005). An epidural is an injection of local anaesthetic into the lower spine in order to block the nerves that feed the uterus and birth canal and is considered an effective use of reducing pain in labour (Howell, 2001).
Evidence suggests that the setting in which a midwife practices will alter her model of care (Freeman, 2006). Thus midwives who practise in a more traditional role may be more confident in managing a pharmacologically pain-free mother than one who assumes more of an ‘obstetric nurse’ role where epidural analgesia may replace key midwifery skills. Madden et al (2011) has found that obstetricians had a greater preference for pharmacological pain relief whereas midwives preferred physical pain relief methods such as water and massage. However, it could be argued that the birth setting would also affect the decision making with some midwives preferring the pharmacological route also. This choice would impact the care of the mother in labour.
Epidural analgesia increases the risk of instrumental birth and its associated risk factors (Anim-Somuah et al, 2011). In view of this, there are long-term implications for the care of women in their future pregnancies and the midwifery practice that is undertaken by future generations of midwives.
If a woman requests an epidural in labour, an anaesthetist rightly discusses the risk and benefits of the procedure in advance but who is undertaking this role for the outcomes for birth? A Cochrane review on the use of epidural in labour highlighted further implications of the use of epidural analgesia such as a prolonged second stage of labour, use of oxytocin, urinary retention and immobilisation after birth (Anim-Somuah et al, 2011). It could be suggested that in order to gain true informed consent this should be discussed with the woman prior to the anaesthetist being contacted in the birth room.
Once the request is made, the midwife must leave the woman in the room without the support of a knowledgeable professional who is there solely to support the process of birth, in order to alert the anaesthetist of the woman's wishes. However, the evidence suggests that the presence of someone with strong midwifery knowledge even in a supporting capacity, such as a doula to support labour reduced both caesarean section rates and the risk of epidural analgesia (McGrath and Kennell, 2008). This American study is of particular interest as women were only booked to have care under a private obstetrician within a hospital setting. Furthermore, the support women receive in labour does have a direct impact on their outcome in reducing the risk of caesarean section, instrumental birth and analgesia in the intrapartum period (Hodnett et al, 2012).
Let's consider for a moment that when a woman requests an epidural in labour what she is actually saying is ‘Am I doing OK?’ or ‘I am not sure I can do this for much longer’. This is a crucial point where midwives should truly be ‘with woman’. Encouragement and support is required at this point and leaving the room is not useful when the woman and her family may need a midwife the most. The Birthrights dignity in birth survey (2013) showed some women were dissatisfied with their choice and availability of pain relief in the obstetric setting (10 and 15%, respectively). This dissatisfaction increased further for women who had an instrumental birth for both choice and availability of pain relief (18 and 23%, respectively). Conversely, only 1% of respondents who gave birth in a birth centre were unhappy with their choice of pain relief implying that women may regret the use of epidural analgesia and other pharmacological forms of pain relief after their labour as this choice is not available in a birth centre setting.
Therefore, as midwives we must ensure that if, in our clinical opinion, a woman does not require an epidural we advise them of this. Unlike midwives, women do not see labour every day so the best person to advise the family will be the midwife.
Of course, it is the woman's choice so if she still requests an epidural after discussion she should be able to access one. Midwives' in the UK are very lucky to be part of a service where access to the different levels of care can happen 24 hours a day. However, there may be a group of women using epidural analgesia as a call for help and a verbal expression of their fear and pain. For such women, support at this time may make the difference to their birth experience. This may be especially pertinent for the group of women who had planned to not use epidural analgesia for birth.
I have been told many times over the years that midwives are afraid of complaints if they refuse epidural analgesia but the point has been missed yet again. I am not advocating that women are ‘refused’ anything. This word should not be in our vocabulary. It is the woman's choice to make that decision with the full facts and support, not the midwife's choice to ‘refuse’. Midwives must also realise that compassion, empathy and kindness are just as important in labour as the ability to manage a syntocinon drip or an epidural analgesia. Women can understand that labour was too quick or that there was no time for epidural analgesia. They cannot understand why the midwife did not support them in labour or show them any kindness. The Birthrights Study (2013) has suggested that a fear of litigation, a culture of blame and defensive practice is contributing to midwives inability to offer true choice to women.
We need to consider ways to stem this tide of intervention: communication and negotiation are the most basic but important factors in this. Assessing what the woman wanted for her birth is the first step and the birth plan is therefore vital to understand the woman's thoughts prior to birth. This is especially important as you may meet the mother for the first time in labour.
Unfortunately, in a recent survey only 50% of the women said that they were happy with the birth that they had and only 57% of the women who were surveyed felt that they had control over their birth. On closer inspection, this sadly decreased for the group of women who were having their first baby (45%). When comparing a birth centre to a hospital setting, 87% of women whose babies were born in a birth centre felt they had control over their birth in comparison to only 54% in a hospital setting. (Birthrights, 2013).
The use of epidural analgesia has contributed to changes and adaptations in midwifery practice in order to maintain the safety of the women who required the use of this service in the intrapartum period. However, I propose that this is now the ‘red herring’ within midwifery practice with midwives in an obstetric setting accessing the anaesthetist without fully ensuring the woman understands the repercussions of using an epidural. Unfortunately, due to this, it could be argued that in this scenario midwifery practice is now contributing to increasing epidural rates as a substitute for the support in labour.