The Zepherina Veitch Memorial Lecture June 2009: The Challenge of Normality in an Epidural Culture
Introduction
The following story from a midwife typifies the complexity behind promoting normal birth within an epidural culture. She had taken over from another midwife, looking after a woman, having her second baby who had been in the latent phase of labour but had recently shown signs of her labour accelerating. In the short time it took to get the handover, the woman had become very distressed. The midwife rapidly tried to develop a rapport with her and gave some advice about focusing on breathing during the contractions. This was not enough and she began on entonox within a short period. The contractions were long and intense, with the fetal heart descending on the abdomen. The midwife recognised the familiar manifestation of transition but by then the women was shouting loudly ‘to go home’, ‘caesarean now’ and ‘get me an epidural’. Her distress was greater on the bed so the midwife encouraged her to get up, though she was continuously monitored because of meconium-stained liquor. She coped a little better upright or on the floor but still vocalised her distress in no uncertain terms. The midwife was faced with a dilemma. She was sure 2nd stage was imminent but the recourse to the epidural would have calmed the woman and made monitoring the fetal heart easier as she would have been semi-recumbent on the bed. After another 15 minutes, the woman was bearing down strongly and birthed a healthy baby boy.
Later both an anaesthetist and another midwife suggested an epidural was wholly appropriate in this situation and a lively discussion ensued.
Discussion about epidurals is often linked to the broader discussion of medicalisation of childbirth because epidural typifies the ‘cascade of intervention dynamic’ that contributes to medicalisation. Public health concern has prompted the Department of Health in the United Kingdom (UK) to measure normal labour and birth outcomes as well as normal birth outcomes (ICCHS, 2008). A working definition has now been agreed as to what constitutes a normal labour and birth and rightly excludes induction of labour, epidural or spinal anaesthetic, forceps or ventouse, caesarean section and episiotomy. The difficultly of reaching agreement across a multi-disciplinary group is reflected in the fact that it can include augmentation of labour, artificial rupture of membranes, entonox, opioids, electronic fetal monitoring and a managed third stage of labour (Werkmeister et al, 2008). The fact that the Consensus Group had to compromise to accommodate the various positions of the stakeholders represented, indicates how certain procedures and drugs are now considered normal in labour. The ubiquity of oxytocin augmentation and epidural is demonstrated in Mead’s (2004) survey of low risk women when she found that rates varied between 14% and 57%. Furthermore, Symon et al (2007) demonstrated the stark contrast in low risk women’s self-reported intervention rates between midwifery-led units and consultant units – pain agents 25% in the former and 77% in the latter.
The Epidural Epidemic
Epidural rates have doubled in the UK from 17% in 1989 to 33% in 2007-8 (BirthChoiceUK, 2009). There are many reasons for this. The following are possible contributors:
· Elective epidural provision is now a benchmark of good practice in maternity units
· Two generations of women have had access to epidurals so now the mothers of pregnant women are recommending them
· Celeb birth and media portrayals of childbirth often include epidurals
· The professional project of obstetric anaesthetists (e.g. increase in the number of obstetric anaesthetist posts) promotes epidural use
· Over recent decades, there has been a loss of ‘rites of passage’ meaning to childbirth so that pain and stress are viewed negatively (Leap & Anderson, 2008)
· A techno-rationalist society considers pain as either preventable or treatable (Lauritzen & Sachs 2001)
· The pain relief paradigm is dominant in maternity services (Leap & Anderson, 2008)
· The movement to institutional birth (93% hospital v 7% home and birth centres currently) reinforces medical solutions to clinical symptoms such as pain (Walsh, 2007)
· Fragmented models of care and loss of continuity contributes to greater use of pharmacological agents in labour (Hatem et al, 2007)
· Informed choice as an ethical imperative influences practitioners’ response to maternal requests for pain relief in labour (Walsh, 2007)
· The risk discourse predisposes to childbirth intervention including the use of pain-relieving agents (Walsh, 2006b)
Several of these factors work in tandem. Techno-rationalist society (Lauritzen & Sachs 2001) is short hand for a society that equates scientific advances with progress. In relation to pain, technology and drugs have successfully either prevented pain from emerging or treated it effectively when it does. It is counter cultural in such a society to see a purpose to pain, especially physical pain related to biological function which is how traditional and indigenous societies have viewed childbirth over thousands of years. Childbirth is one of life’s great ‘rites of passage’ transitions within traditional societies (Jordan, 1993). Allied to an antipathy to childbirth pain is a risk discourse that carries within it several paradoxes. In the west, it has never been safer to have a baby yet it appears that women have never been more frightened of the processes and of what might go wrong. Hence another paradox is a high degree of risk aversion, yet a willingness to embrace medical interventions like drugs and surgery that carry risks themselves. Mixed messages coexist like a public health message to avoid any form of drug pre-conceptually and prenatally, but accept an epidemic of drugs during intrapartum care. The risk discourse has foisted on women the relative risk conundrum. How do I make choices against a backdrop of arithmetic possibilities? How do you weigh a 1 in 100 risk of a poor perinatal outcome, compared with say the risks associated with driving a car or living in a smog-filled city. The risk discourse can also overplay theoretical risks and rare negative cases in defining clinical guidelines. Finally, its puts a hierarchy on particular risks at the expense of other risks. The recent change in the NICE Guideline (NICE, 2007) regarding spontaneous rupture of membranes at term is an example of this. The risk of neonatal infection overrides others risks of augmenting women at 24 hours. A number of maternity units are noticing their intervention rates increasing in this group.
Side Effects of Epidurals
When it comes to specific risks associated with a medical procedure, epidurals have many. These have been outlined in the literature in some detail. They can be summarised in bullet format thus:
Side Effects on Labour
· increase length of 1st & 2nd stage of labour
· need for more oxytocin
· increase incidence of malposition
· increase instrumental delivery
· (Anim-Somuah et al, 2008)
· increase 3rd/4th degree tears (Rortveit et al, 2003)
· may increase in C/S if sited early (Klein, 2006)
Side Effects Maternal
· loss of mobility
· loss of bladder control
· hypotension, headache
· pyrexia (Yancey et al, 2001)
· up to 30% of women get partial but not complete relief
· reduces breast-feeding rate on discharge from hospital (Wiklund et al, 2009)
Side Effects Fetal
· tachycardia due to temperature rise
· neonate more likely to be hypoglycaemic
· diminishes breast-seeking and breast-feeding behaviours (Ransjo-Arvidson et al, 2001)
· Requires continuous CTG
Added to these established side-effects are the following psycho-social and midwifery practice factors:
Psycho-Social
· woman becomes a ‘patient’ in the sense that additional monitoring is required
· choice for epidural is associated with fear of childbirth, giving control over to professionals and passive compliance (Heinze & Sleigh, 2003)
· commonly precipitates cascade of medical intervention
Midwife Practice Effects
· care becomes more technical
· there is a greater need for surveillance
· psychological support needs are less demanding
· midwives are less able to utilise intuitive skills
· the whole package induces obstetric nurse ‘feel’
These latter comments reflect some personal reflections of individual midwives that not all midwives would agree with or see a problem with.
All of these negatives have to be balanced with the fact that an epidural is an excellent procedure in the following situations:
· its makes caesarean section safer
· it can make assistant vaginal birth more humane
· it is valuable for protracted, induced or augmented labours
· it is useful for some women with tocophobia or post traumatic stress disorder
Few childbirth professionals would argue against epidural availability and use in these or similar situations. The pivotal point for discussion is its role for normal labour. A related question is to what extent ‘informed choice’ has become an ethical imperative regardless of context and prior preferences. In the story at the beginning of this article, the scenario of a multiparous woman requesting an epidural in late first stage of labour has been used as an exemplar for the application of informed choice. Many UK midwives would express the tension between responding to a woman’s request in this situation and knowing that this is a transient and challenging part of the labour that will soon pass. Midwives from other countries have expressed surprise when this scenario has been presented in workshops, concluding quite unequivocally that an epidural is not appropriate.
Attitude to Labour Pain
Professionals’ attitude to labour pain is a key area to examine. Leap and Anderson have developed and written about the approach of ‘working with pain’ which addressed this area directly. They contrast ‘working with pain’ with ‘pain relief’ (Leap & Anderson, 2008). The following Table summarises the main differences between these two approaches.
Table 1
Pain Relief Approach
- language suggestive of pain - language suggestive of pain as
as a problem
- paternalistic, ‘we can protect
you from unnecessary stress’
- techno/rationalism age, pain is - labour pain timeless component of
preventable/treatable
- neutral impact of environment
- clinical expertise of professional
carers
- special session/focus in antenatal - woven throughout labour
education
- ‘menu approach’ to options for - supportive strategies for
coping with pain
- pain as a ‘management issue’ for - pain as one dimension of labour
assembly-line birth
- contributes to trend of rising - contributes to trend to less
epidural rates
- risks of pharmacological agents - ‘cascade of intervention’ dynamic
outweighed by benefits
- first birth special case for ‘menu - first birth optimal opportunity for
approach’
- informed choice means all
options must be presented birthing plan and philosophy
(Walsh, 2007)
It is an interesting exercise for midwives to note the number of times the phrase ‘pain relief’ is used in birth settings over the course of a working week. Though the use of the phrase does not necessarily mean that the user signs up to the whole paradigm, it never-the-less conveys a meaning to all who hear it that pain is a problem.
The ‘working with pain’ paradigm is predicated on labour physiology that requires pain to be present for the release of endorphins. These naturally occurring pain easing hormones also contribute to the dynamic behind oxytocin release so that it is neither under stimulated nor over stimulated (Buckley, 2004). Endorphins effects are beautifully captured in Hannah’s birth, a short DVD produced by Sheena Byrom, consultant midwife at Blackburn. What the DVD also captures are the empathic responses from Hannah’s birth companions. Moberg (2003)in her captivating book, The Oxytocin Factor, suggests that this hormone is secreted in both men and women, especially during therapeutic touch. She highlights the necessity to bathe a birth setting in love, not fear. When this occurs, the synergy created is more than the sum of individual parts. Hence the centrality of empathic relationships to the birth process, the importance of an optimum environment and of minimising disturbance. All of this takes on an urgency in an institutional birth setting where some of these factors are already compromised.
Endorphin effects are masked and undermined by epidurals, opioids and syntocinon. If caring for a woman with an epidural is more instrumental and task orientated than intuitive and empathic, one senses a vicious cycle of oxytocin antagonism being set up. Is it any wonder that labours become dysfunctional?
The Transforming Power of Labour
One of the key questions for childbirth professionals in the 21st century is what will happen to the narratives of transformation and growth in childbirth if normal labour is effectively anaesthetised by the epidural epidemic. These are the countless number of personal testimonies that women share about an experience of growth and empowerment through childbirth. The vast majority of these are characterised by drug-free or low intervention labours, though not all (Thompson, 2004). The most moving ones are from vulnerable women who lives prior to birth had been blighted by abuse or disempowerment. Phrase like ‘my greatest achievement’ (Esposito, 1999), ‘I can do anything now’ (Spitzer, 1995) and ‘I feel so strong’ (Walsh, 2006a) litter these stories and pose a profound challenge to the ‘pain relief’ paradigm. It is difficult to debate the topic because it implies criticism of women who chose or needed intervention, almost suggesting they could be poorer mothers because of it. Emerging evidence that normal labour and birth primes the bonding areas of a mother’s brain better that caesarean or pain-free birth adds to this perception (Swain et al, 2008). In recognition that caesarean birth may undermine birth physiology, obstetricians have been researching the so-called ‘natural caesarean’ to see if normal physiology can be harnessed in this situation (Smith et al, 2008). The advent of the ‘mobile epidural’ illustrates how obstetric anaesthetists are trying to engage with labour physiology around movement and upright posture to recruit those benefits for women with epidurals.
All these attempts to engage with childbirth physiology in the context of medical procedures that undermine them serves to highlight how science struggles to mimic precisely what is natural. The complexities behind oxytocin secretion remind biomedicine that altering one variable (skin to skin in caesarean and movement in epidural) will never reproduce the conditions for maximising physiology. That requires a whole systems approach (Downe & McCourt, 2008), examining environment, attitudes and beliefs, practices, relationships etc. If pain plays an integral role in optimising labour physiology and priming the woman for motherhood, then it is hard to see how an epidural can fit into this whole systems approach.
Elective Epidural Service
In the light of this discussion so far, a rationale certainly exists for questioning the appropriateness of an elective, ‘on-demand’ epidural service, especially if there is public health commitment to increasing the rate of normal labour and birth in the UK. However, given its embeddedness in UK maternity service provision, it would be a brave person who would take up such a position. This paper’s intent is to simply encourage debate about these issues. If the present course is pursued so that in another 30 years epidural rates are 60%, it cannot be predicted what that may mean for women, babies and families. It is unlikely that Zepherina Veitch, the founder of the Royal College of Midwives would have welcomed such a future. She was more concerned with social reform and public health and would probably have resisted the advent of drugs in normal labour.
An anecdote is told of an anaesthetist who used to refer to epidurals as ‘happidurals’. In the context of a fragmented model of care with no continuity, in a clinical environment with little resemblance to home, where women are kept on beds while continuously monitored, it is understandable that epidurals are a welcome relief. But it is important not to confuse system failure with woman’s preference. In fact all over the UK in different birth settings, women are birthing entirely drug-free, even with their first baby. This latter group can be found in midwifery-led units, birth centres and at home. First birth mothers stories of drug-free labours tend to remain hidden in small scale birth settings because they are seldom told beyond these settings. Their testimonies are so important for labour ward midwives and obstetricians to hear because they are routinely exposed to the opposite. Case reviews in maternity hospitals tend of the negative variety. Like the following anecdote from a student midwife, midwives may be losing skills. She feared qualifying because she was not sure she could be alongside women in pain without her own discomfort manifesting. She was also not sure she could spot natural endorphin effect because she had seen so few natural labours.
Conclusion
The evidence is incontrovertible that epidurals undermine childbirth physiology. That rates are now double what they were 20 years ago says much more about the context of childbirth and childbirth professionals’ attitudes than it does about the current generation of women’s ability to adjust to labour pain. In fact there is considerable anecdotal evidence that women adapt their expectations to the service provision so the rare consultant unit that does not have an elective epidural service has not seen a fall in bookings. Similarly, co-located and free-standing birth centres remain very popular. However with these, along with homebirth, representing around 7% of UK total births, the vast majority of women enter a large hospital model where epidural provision is electively available. In this context, the impact on normal birth intervention rates is profound. Addressing this context requires a rethinking of pain paradigms, attention to birth environment, and a move to more relational models of care. Finally, there needs to be a robust debate about whether epidurals really serve society and families best by being an elective choice, especially in relation to normal labour and birth.
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Abstract
With epidural rates doubling in the United Kingdom over the past 20 years, the impact on normal labour and birth in profound. Rates if labour and birth interventions have risen inexorably over that time. Changes have also occurred in wider birthing milieu such as the rise of a risk discourse, the diminishing of a ‘rites of passage’ meaning to birth, the growth of obstetric anaesthetic services and the advent informed choice in maternity care policy. This paper discussed the impact of these changes on normal birth, and, in particular on the attitude to pain in labour. An elective epidural service is critiqued and a call made for an urgent debate on how maternity services and ultimately society should respond to these profound changes.
Key words: epidural, normal birth, risk, pain
Author:
Dr Denis Walsh, Associate Professor in Midwifery, Nottingham University, UK
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