Cochrane Review: women should get labor epidurals as soon as they want them

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The folks at Cochrane Reviews have just crushed a number of the most cherished myths of natural childbirth advocates:

Pain during childbirth is arguably the most severe pain some women may experience in their lifetime. Epidural analgesia is an effective form of pain relief during labour…

We conclude that for first time mothers in labour who request epidurals for pain relief, it would appear that the time to initiate epidural analgesia is dependent upon women’s requests.

That’s three dead myths in only 3 sentences:

1. Contractions aren’t surges but the most severe pain experienced.

2. Epidurals are very effective in managing that pain.

3. A woman should get an epidural when she asks for one since the timing has no impact on outcome.

The Review, Early versus late initiation of epidural analgesia for labour, was published yesterday.

The authors explain the methodology and findings:

We included nine studies with a total of 15,752 women.The overall risk of bias of the studies was low, with the exception of performance bias (blinding of participants and personnel).

The nine studies showed no clinically meaningful difference in risk of caesarean section with early initiation versus late initiation of epidural analgesia for labour (risk ratio (RR) 1.02; 95% confidence interval (CI) 0.96 to 1.08, nine studies, 15,499 women, high quality evidence). There was no clinically meaningful difference in risk of instrumental birth with early initiation versus late initiation of epidural analgesia for labour (RR 0.93; 95% CI 0.86 to 1.01, eight studies, 15,379 women, high quality evidence). The duration of second stage of labour showed no clinically meaningful difference between early initiation and late initiation of epidural analgesia (mean difference (MD) -3.22 minutes; 95% CI -6.71 to 0.27, eight studies, 14,982 women, high quality evidence). There was significant heterogeneity in the duration of first stage of labour and the data were not pooled.

There was no clinically meaningful difference in Apgar scores less than seven at one minute (RR 0.96; 95% CI 0.84 to 1.10, seven studies, 14,924 women, high quality evidence). There was no clinically meaningful difference in Apgar scores less than seven at five minutes (RR 0.96; 95% CI 0.69 to 1.33, seven studies, 14,924 women, high quality evidence). There was no clinically meaningful difference in umbilical arterial pH between early initiation and late initiation (MD 0.01; 95% CI -0.01 to 0.03, four studies, 14,004 women, high quality evidence). There was no clinically meaningful difference in umbilical venous pH favouring early initiation (MD 0.01; 95% CI -0.00 to 0.02, four studies, 14,004 women, moderate quality evidence).

Catherine Pearson at HuffPo interviewed a number of clinicians on their thoughts about the review:

“This review — performed through the rigorous Cochrane methodology — provides a high level of medical evidence that early epidurals do not extend labor time, especially the pushing stage,” Dr. Sng Ban Leong, deputy head and senior consultant with the department of women’s anesthesia and KK Women and Children’s Hospital in Singapore, wrote in an email to The Huffington Post. Leong was an author on the review.

And:

“Epidurals these days are very different from the ’80s and ’90s,” Dr. J. Christopher Glantz, a professor of obstetrics and gynecology in the division of maternal-fetal medicine at the University of Rochester Medical Center, told The Huffington Post. Many hospitals now offer lower-dose walking epidurals, which can leave women with enough strength to move throughout labor and may help them push more effectively.

And:

“The takeaway message is that when women experience labor pain, and they choose to have early epidural pain relief, they [should] be reassured that this does not have any adverse effects to their labor outcomes,” Leong wrote.

When should a woman get an epidural in labor? According to the folks at Cochrane Reviews: whenever she wants it!

  • Nina Worthe

    I’ve been reading about this recently, trying to find good information. Like so much related to birth, it seems, there’s an incredible quagmire of woo to wade through, and so many biases.

    What do you make of this response to the Cochrane study:
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1481670/

    I quote their conclusion:
    “Contrary to the conclusion of the Cochrane meta-analysis of EA compared with narcotic analgesia, EA given before the active phase of labour more than doubles the probability of receiving a CS. If given in the active phase of labour, EA does not increase rates of CS. Meta-analysis can be helpful and timesaving for busy practitioners, but we need to be vigilant about which studies get into the meta-analyses and ask ourselves if they make clinical sense. And, unfortunately, we need to continue to read the individual studies that make up meta-analyses—especially if they are likely to actually change practice—to determine whether study conditions represent our clinical reality.”

    Now, at other points in the article they seem rather ‘natural’ biased, which typically would ring alarm bells, but their interpretation is indeed valid. I’d be greatly appreciative of another opinion.

  • Nicole Nikole

    I wish I had read this article on December 1st 2015, the day I went into labor with my daughter Hunter. Those assholes made me wait for hours. It was torturous.

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  • LJ

    My great aunt eventually died from having a botched epidural during childbirth, after being fully paralyzed for years. I will never have an epidural and I will not accept being portrayed as crunchy – to use a popular word on this blog – for that decision.

    • Bombshellrisa

      A lot of women choose not to have an epidural. This, in and of itself, does not make them crunchy. Choosing to forgo an epidural because they are coping well without one or after talking about the risks and benefits and deciding they wish to decline based on their own circumstances is not crunchy. What a lot of crunchy types will do is make a decision based on something they heard, on facts that applied to other people or based on facts that are out of date. Epidurals have come a long way, and discussing the risks and benefits with an anesthesiologist can help you make this decision based on what is best for you, with current practice in mind.

    • Amazed

      Since no one here describes the simple desire not to have an epidural as crunchy, you can be assured that you aren’t in danger of being labeled so. Many of the commentors here, including Dr Amy, have had unmedicated births, so lower your weapons.

      Your great aunt… how many decades ago did she give birth? Medicine has come a long way and those who desire epidurals can be assured that they are much safer than they used to be.

  • Ash

    i looked at the chapter about epidurals in the book “expecting better”. literally a single sentence was devoted to the benefits of pain relief. “the benefit of epidurals is pain relief”. the rest was about possible risks of epidurals to mom and baby. can you imagine a book about dealing with cancer, and a single sentence saying “the benefit of pain management is pain relief” while going over risks of pain management programs?

    the chapter says at the end that it’s a woman’s choice, but it’s disingenuous to talk about risks for a whole chapter and devote 1 sentence to the purpose of epidurals: alleviating pain!

  • DiomedesV

    How common is it for women to be denied local anesthetic for suturing? I feel like I’ve heard this many, many times. I can’t think of any other laceration where withholding anesthetic would happen so often.

    • KG

      I have not ever witnessed an non-medicated mother to be denied local anesthetic for a repair. However, I have sadly seen many women with epidurals denied a local anesthetic. In my experience, Epidurals often deliver poor coverage to the perineum. I say all women deserve the option of a local during repair.

  • guest

    Here’s my question, there’s quite a few OBs around my town who allow early epidurals. I talked to a CRNA who said his big issue is that by the time the patients get to transition the epidurals aren’t as effective and he isn’t able to get the women comfortable. Thoughts?

    • Stacy48918

      “Uncomfortable” is better than excruciating, screaming pain.

      Now, I’ve never had an epidural but after 2 unmedicated births I’d still rather have a partially effective one than another unmedicated birth.

      • guest

        I just wonder if that piece of information should enter the conversation. I know I’ve talked to some OBs (I used to work in an L&D, but not as a medical professional) who said they encouraged patients to wait till after 4cms, if they could, for that reason – not that it stalled labor in any way, but that their patients would get really upset when they were in pain again towards the end.

        But I also wondered to what extent it was purely anecdotal, or if there was anything to back the idea of loss of effectiveness up.

        • Stacy48918

          I think it should. If it’s true that there’s a “wearing off” better to let women know that.

          Then if it does wear off – it’s expected and no hard feelings.
          If it doesn’t then the anesthesiologist looks awesome.

          I’m all about setting expectations low sometimes, haha. 😛

          But again, I have no idea if that’s true at all, or just the CRNA’s anecdotal opinion.

    • AlisonCummins

      Yes, I have a similar question. A friend recently gave birth in screaming agony. She was told she had to wait for her epidural because they could only give two boluses and then she wouldn’t have it when she really needed it. She waited, got her two boluses, and they had worn off by the time the baby was delivered so she had no pain relief for delivery including the large episiotomy and major suturing.

      Does this make sense? (It sounds to me as though she might have been a candidate for c-section. She asked for one but was told no, because it’s major surgery.)

      • araikwao

        Good golly, could they not have used some local for the suturing?? That is unacceptable.

        • AlisonCummins

          I asked my friend if I got my info right and this is what she said: “Most of the information is correct except that the first epidural was given after the accelerant and I was screaming in pain because the needle fell out of my spine. It took them a while to figure out the drugs weren’t getting in. The told me there’s a max of 2 even though my first dose was sabotaged. They gave me another drug for the pushing which did not take away much pain but made me unable to control my legs (couldn’t feel them). No local anesthesia for the suturing. The C-section was a last resort and I was constantly on the verge of having one- pushed through and finally got [baby] out on my “last push” or else.”

          • MaineJen

            That whole thing sounds beyond cruel, and absolutely absurd. Two doses of pain medication, and then you’re done? I have never been so thankful to have given birth in a compassionate place. WTF is up with people thinking labor pain is the only kind of pain that doesn’t deserve to be treated? What kind of asinine policy is this? *fuming*

          • araikwao

            I cannot fathom why the suturing would need to be done without any analgesia. That is so cruel. (or why only 2 boluses could be given via the epidural..)

          • DiomedesV

            No local anesthesia for suturing?! #$@!@$!!!

    • Can’t speak for the norm, but I got my epidural around 9am, shortly after my membranes were ruptured by my OB. Keep in mind, I was 40 weeks with a HUGE baby, so I went in the night before for Cervidil. The next morning, I was still high, thick and closed. But again, big baby on board. I wasn’t a 10 until 7pm that night, pushed for almost two hours with very little success….thanks to my pelvis, not the epidural, and at 10pm I was rolled back for a section. I don’t remember the CRNA messing with my epidural much at all during the day…don’t remember getting bolused, although it may have happened. I had pain management all day, and while I know they clearly had to change things up when I rolled into the OR, I’m pretty sure the bulk of the day, almost 12 hours, were pretty maintenance-free as far as the epidural.

    • theadequatemother

      Is he constrained by the system somehow? Ie below someone mentioned only two boluses through the epidural catheter allowed for the entire labour? What kind of policy is this, btw. That’s not how we run our epidural service. We run PCEA with or without a background infusion. Women are typically allowed 3-5 self-administered boluses an hour depending on bolus volume.

      I mean, it’s a catheter. If someone is uncomfortable put some more stuff through it. It really is that simple. But I am an MD anesthesiologist and we don’t have any CRNAs in our system so I’m not sure if they are constrained in a way we aren’t by “policy.”

    • theadequatemother

      FYI everyone…although epidurals are really good for uterine/ contraction pain, they are less reliable for the somatic perineal pain of the second stage. In lots of people the epidural just won’t spread to cover S1-3.

      • Stacy48918

        Thanks!

  • Amy

    And sure enough, one of my too-crunchy-for-you Mama friends on Facebook has posted a link to an article about this study, bemoaning the likelihood that now women will ask for epidurals sooner and doctors will give them to them, and “we all know” that getting a epidural increases the likelihood of a c-section, and that this study is no good because it compared early epidurals to late epidurals.

    • Young CC Prof

      Learning new things means taking a risk of changing your mind. It’s very dangerous that way.

    • Cobalt

      Even if having an epidural increases your odds of needing a cesarean, and having an epidural early increases it even more, it’s still a safe and valuable intervention. The risks of cesarean are not nearly high enough to medically justify delaying or denying an epidural.

    • araikwao

      I think she should rejoice – she’ll be able to feel superior to so many more mothers now!!

  • L&D RN

    OT: Hospital transfer from the Farm in TN has ended in a baby’s death. https://www.facebook.com/jacky.baken?fref=nf No details on what happened. The FB site owner is the mother’s sister who apparently lives in the Netherlands. She’s posted running updates for the past several hours. Under the one where it says she is having a section, she gives the info about being at the Farm.

    • Bombshellrisa

      Of course, that baby will not be considered a “Farm” loss, it will be the fault of the hospital. Most certainly a preventable death.

      • Trixie

        The Farm has its 3% cesarean rate to preserve.

    • Mishimoo

      Oh, that poor baby and parents. So sorry for their loss!

    • Guest

      So, so sad. I’m so sorry for their loss.

      Just as a question, if this were being counted in the MANA stats, would they count this as a loss? Or does this go down as a hospital loss? Does anyone know?

      • Trixie

        I think it would depend whether the baby was ever found to be alive at the hospital in utero.

        • Ash

          They would have called it at the hospital, so hospital death.

      • Young CC Prof

        For CDC stats, no. But for MANA stats, if this midwife reported, yes, it should, since labor started out of hospital. If it got reported.

        • Trixie

          The mother is Dutch — I wonder if she got risked out of homebirth in the Netherlands, and didn’t understand that Farm midwives are just uneducated hacks.

          • Young CC Prof

            That sounds horribly plausible.

            What a tragedy. I am so sorry for this whole family.

          • Stacy48918

            I have a horrible feeling you may be right. AMA, first baby…terrible homebirth candidate.

            What a predictable, likely, preventable tragedy. 🙁

            ETA: But of course homebirth is “as safe or safer” for “low risk moms and babies”….but when you completely ignore risk….

          • Amazed

            Completely possible – and if so, I’m sorry to be the person who spoils the “poor mom, poor family” group sentiment around here but…

            What the hell was this loon thinking? I am sorry for her just as much as you are. Losing one’s child is a tragedy, no matter the circumstances. But I am also angry. Midwives PRAISE the system in Netherlands that is based on low-risk – high risk scenario. But the moment she heard she was not low risk, she fled to those who would give her what she wanted, high risk or not.

            If she was Dutch and risked out of a homebirth, she killed her baby. Loon. Just a Netherlands one.

            But then, I was always one of those who insisted that homebirth mothers were not sweet little children who can be absolved of ALL blame. If Trixie’s scenario is the right one, this one will need much absolving.

          • Trixie

            She might have thought that Ina May was “the best in the world” or something. Certainly she didn’t think she was taking a step down in safety. Although I agree, anyone who has risked out of Dutch home birth should really realize that they should not be outside of a hospital. Again, pure speculation on my part.

          • The Bofa, Being of the Sofa

            Midwives always point to the Dutch as such a great system, and say, look how good they are! We can be like that!

            And we counter that the Dutch have strict guidelines regarding qualifications of midwives and types of cases that can be done with homebirth, and that US HB don’t follow them.

            Here we have the Great Ina May, Patron Saint of Homebirth Midwifery, accepting a patient that HAS BEEN DEEMED INELIGIBLE for homebirth in the Netherlands.

            How much clearer can it be US HB midwives lack any standard at all, and that their attempts to invoke the effectiveness of the Dutch system (which it really isn’t) is a complete sham.

            They don’t want the Dutch system – they want a free-for-all.

            A MW group tries to put together minimum standards for MWs based on the lowest common denominator standards of international midwifery, and US midwives balk. Now Ina May flaunts it by accepting a patient who was ineligible in Holland?

            These people have NO standards.

          • Trixie

            Agreed, except, again, I’m only speculating.

          • AmyP

            Yeah, there’s such a cult surrounding Ina May.

          • LJ

            Apparently, she didn’t understand the difference between US and Dutch midwives – the latter are more qualified medically. Also, apparently she was towards the end of her fertile years and had already suffered multiple miscarriages – I imagine that she’d lost faith in the conventional medical system and was probably trying out alternative things just to see if they worked. She was naive rather than having a hardcore desire for a non-hospital birth.

          • Amazed

            Sure, I’m all for alternative things. In fact, today I treated my hair with cocoa oil and rose water in the hopes of making it look better. If it works out – great. If it doesn’t – well, there are the old conventional things I usually use.

            But to see if it worked… when the thing that might NOT work is your baby’s life? That’s like the worst reason ever. I can get my redo on Monday. She cannot get one. Ever.

            Too high a price for trying out alternative things.

    • Stacy48918

      I’m sure Ina May won’t mention that in any of her talks….

      Poor family.

    • Stacy48918

      I hate this…there are photos now of mom and her poor little baby. Yet another death that quite likely no midwife will acknowledge, take responsibility for or face penalties for. 🙁 🙁

      • Trixie

        The mother looks to be over 35.

        • Stacy48918

          Now, now Trixie…we all know “age is not a disease”. *Sigh*

          First baby too from the comments about “waiting so long” for this baby.

          • Trixie

            Andrew William.

          • Stacy48918

            One more name…

            I wonder if the midwives remember the babies’ names like we do.

          • Trixie

            Further down on 10/1 it says she was flying to the US to have her baby.

          • AmyP

            Awful.

          • Dr Kitty

            She flew after 36 weeks?
            Most airlines require very extenuating circumstances to fly beyond 36 weeks (“I want to have my baby at The Farm” doesn’t count).

            But then someone who would choose to give birth at the farm may have few qualms about the risks of going into labour at 35,000ft or a transatlantic flight home with a newborn.

            I am sorry for her loss, but it looks like there were a lot of avoidable risks taken even before she reached the Farm.

          • DiomedesV

            Maybe she lied about how far along she was. Also, if a woman didn’t want to share that she was pregnant, couldn’t she hide it?

          • toni

            Yes I would think a lot of people could. Also if someone asks you could just deny that you’re pregnant and act all offended. They’d probably drop the subject pretty quickly!

          • Karen in SC

            This reminds me of the mothering.com idiot who wanted to go on a cruise very late in pregnancy. I wonder what happened?

          • Stacy48918

            She went on her cruise, came back smug as can be and still sees nothing wrong with what she did.

          • Roadstergal

            So the cruise ship accepted a note from a non-credentialed midwife? Sweet, the next time I need a physician’s note, I’ll ask a friend to sign it “Dr.” Jones and call it good. And the next time I need a DOJ background check, I’ll ask my friend who read a lot of Encyclopedia Brown as a kid to take care of it.

          • Trixie

            She could’ve been under 36 weeks on 10/1.

        • Stacy48918

          Found an interesting note in another poster’s comment in another thread:
          “I am British but my first baby was born in The Netherlands. I was not
          eligible for a home birth, too old at 27, a possibility that had never
          crossed my mind, anyway.”

          http://www.skepticalob.com/2014/01/homebirth-midwives-reveal-death-rate-450-higher-than-hospital-birth-announce-that-it-shows-homebirth-is-safe.html#comment-1576727376

          • Karen in SC

            I have to wonder if that was a typo and she meant to say 37.

          • Trixie

            Too old at 27? Not 37?

    • Trixie

      She just posted pictures of the family. This is horrible.

    • moto_librarian

      I’m trying to find out more. I live in TN. Will update everyone if I figure anything out.

    • Trixie

      Meanwhile, on the official Ina May fan page:

      • Young CC Prof

        I reloaded but I still don’t see a picture?

        • AlisonCummins

          I think there’s nothing to see…

          • Young CC Prof

            Ah, yes, that makes sense.

    • Ash

      I just looked up the Farm’s location on a map–they are really far from the closest hospital with an obstetrics unit (approximately 30 mins)

      • moto_librarian

        And they are at minimum 90 minutes away from Vanderbilt, which would be the closest tertiary care center.

        • D/

          The two hospitals that receive Farm transfers are each ~ 30 minutes away. One has a Level IIB NICU (staffed by Vanderbilt Neonatology). The other is one in a 3 hospital “system” that all together have <350 deliveries per year.

          • moto_librarian

            So they would automatically be transferring to a low-volume, rural facility. If a baby or mom is in real trouble, LifeFlight is taking them to Vandy. I looked at the photos, and it doesn’t look like Mom is at Vandy, but I’m not 100% sure.

          • D/

            I believe there is a Vanderbilt LifeFlight outpost within ~15 miles of the Farm that would certainly improve transit time for tertiary access. I’d be willing to bet though that is a far beyond rare (or most likely never) event for a LifeFlight Farm obstetric transfer.

            The local NICU option is actually a very good facility, but then in a neonatal crisis taking 30 minutes to arrive anywhere by area ambulance is nothing but a mushrooming disaster.

          • moto_librarian

            1,500 deliveries a month is much better! They likely could have handled things well had the transfer occurred earlier in labor. It’s just such a shame all around.

          • D/

            From what I’ve heard the transfer was not to that facility though. Most definitely a shame … all around!

    • moto_librarian

      There is no newspaper for Summertown, TN (where The Farm is located). I have sent an inquiry to The Advocate, which is the newspaper for Lawrence County. I really want to know what happened.

    • OldTimeRN

      I’m so naive, I can’t believe a place like this exists in the US.

      Bless this little baby who died because his mother apparently wanted an awesome birth experience in another country, on a farm. A FARM!!!!!

      • Bombshellrisa

        Still trying to understand what is so great about it. My husband’s grandmother gave birth to 11 children at home on a farm with midwives. She finally gave birth to her 12th in a hospital and then was able to have a few surgeries to fix the damages from the previous births.
        A really awesome birth experience includes a live, yelping newborn.

        • guest

          A week or so ago, I was watching one of the old SNL episodes from the ’70s. It was hilarious! Steve Martin was a medieval physician “curing” people with blood letting, bat’s blood, and various herbal concoctions, and I thought, damn, he could be a HB midwife..

          • Roadstergal

            “Who’s the barber here?”

          • guest

            Yep.

    • L&D RN

      I asked my friend who is a friend of the woman who’s been posting on FB, if she has any more details. All she knows about the delivery is what the sister has been posting on FB. She did say that this couple has been married for 20 years (which means the mother is definitely AMA and should have been risked out of homebirth) and this was their first baby carried full term. She also said this couple is not stupid or naive, and not even really the crunchy type. She suspects that they just didn’t know the difference in US midwives. Absolutely heartbreaking!

      • L&D RN

        Do you think the hospital will launch any kind of investigation into what happened? Is there no way to bring some kind of consequences to these negligent midwives??

      • Young CC Prof

        After all, the Farm always says they’ve never lost a baby. We know it’s a lie, how was she supposed to know that?

      • lawyer jane

        Ok, not stupid or naive or crunchy, but clearly SOMETHING strange is going on with them if they flew, AMA, after apparently having previous losses, to a different country to give birth on a commune far away from modern hospital care. I’m at a loss to understand it. I guess they just had a poor understanding of how to analyze the risks and benefits, or are just unduly optimistic to the point of failing to understand the risks?

      • moto_librarian

        The aunt says that she is flying into Nashville. I have been unable to locate a death notice for the baby, but I have sent an inquiry to The Tennessean.

      • The Bofa, Being of the Sofa

        She also said this couple is not stupid or naive, and not even really the crunchy type. She suspects that they just didn’t know the difference in US midwives.

        Isn’t that “naive” pretty much by definition?

      • Sally RNC-NIC

        I wonder how much influence The Farm (The Farm? Really?) had on getting this gal to come to the States. After all, being able to boast that a woman from the Netherlands – the mecca of homebirthing – chose to travel so far to deliver with THEM exclusively. I mean, that’s PR gold. Well, it would have been….

        • D/

          While it changes nothing in the tragic outcome, the speculation down thread that she traveled from outside the US specifically to deliver may have been a misinterpretation. Appears they likely traveled to the Farm … but from the US Midwest not from the Netherlands.

          • Oh wow – thanks for the update. I couldn’t wrap my head around traveling to another country to have a baby…and the citizenship of that baby, and traveling home during flu season, and a million other things I couldn’t stop worrying about. I wonder where in the midwest…(said the Kansas City girl).

          • D/

            Cincinnati area.

          • Interesting. (sigh)

      • AmyP

        The Farm has so much hype around it that I kind of understand how this happened.

        The Farm gets a big plug in one of the episodes of the Business of Being Born series (the follow up to the movie).

        So, blame Ricki Lake?

        • Stacy48918

          The Farm was famous long before BoBB. They gave it more publicity maybe but their poor practices predate Ricki Lake.

    • Stacy48918

      I’m sorry, this is a bit of a rant…but the whole “his life was not in vain” claptrap….

      Yes it was. It absolutely f-ing was. His mother wanted an experience and he died for it. Nothing to gain, no benefit to him. Just a completely selfish desire to birth outside of a hospital and a dead baby. A dead baby that will result in exactly ZERO changes at the Farm. That’s the very definition of in vain.

      Gah! I’m so angry. At the midwives, at the mother, at her family for not speaking up (before this…and now), at this whole system that exists that allows babies to die this way and thinks nothing of it.

      • I finally decided to check out this FB page, and man oh man. “He’s in Heaven where he’ll experience no more pain, no war….” That’s one way to look at it. The other way to look at it is he shouldn’t be dead. So let’s deal with that. Instead of self-southing with generic condolences, let’s look at this for what it is: an unnecessary death in the name of natural birth. I sure do hope it was worth it for everyone involved.

        • Stacy48918

          I recognize that serious introspection is likely difficult at this time…but still…it just makes me so furious and so very sad. 🙁

          • True-dat Stacy. As I’m sure you do….I love, love, love introspection. I always try and respect every single angle possible…I love learning and growing by thinking outside of the box…but in this situation, it just is what it is. This baby died a preventable death. I’m so sorry there is no way to sugar-coat it or make it better. This is a bad situation. Our actions have consequences. The end. They just do. This is an action that had a major consequence. I’m sad for the family, but they should have known better. Sad face.

        • Trixie

          It looks like the parents are still staying at the Farm.

          • Stacy48918

            That was my thought about that cozy little cabin too…

    • Stacy48918

      Looks like an earlier C-section and being, I don’t know, *IN* the hospital would have saved little Andrew William. Question was “When did he die? Before or after arriving at hospital?”

      “No
      louella, he died minutes before they got him out.. This makes it so so
      hard. So many questions as to why couldn’t be just get trough this very
      last minutes after 9 months of pregnancy…”

      When seconds count, the hospital’s only minutes away… That poor little baby.

      • D/

        Earlier c-section and being in the *right* hospital actually. From what I’ve been able to gather it seems the transfer was most likely to the smaller facility with “more than 300 deliveries per year” and only normal nursery facilities. If that is indeed the fact, it would have taken a MUCH, MUCH earlier decision to transfer. This is not a facility of choice if anticipating an even remote possibility of neonatal resuscitation.

  • Jessica

    AMEN! One of my biggest regrets from my son’s birth was waiting to get the epidural – the magic 4cm! I was being induced, and it got very painful very quickly. Once my water was broken it was the most excruciating pain of my life. Once the epidural was in place I pretty much passed out. I don’t remember much of the labor and wish I hadn’t been so damn tired. Next time, I’m getting the epidural before the pitocin is started (if I’m induced) or upon admission, no ifs ands or buts.

  • Julia

    I just had my fourth two weeks ago today. I got an epidural as soon as they knew they were keeping me. It was the best experience. I got to focus on getting ready to meet my daughter. My husband got a nap in. I was able to hold off on pushing so I didn’t tear (much). So much nicer for me than unmedicated.

    • Mishimoo

      Oooh congratulations on the new arrival!

    • Amazed

      Congrats! Pleased that you’re both fine!

  • SisterMorphine

    I’m past the point of getting PG again but I definitely plan to forward this among my younger friends, some of whom have been taken in by the NCB cult.

    Somewhat OT: Descriptions of labour pain always make me glad that I had a C-section. I had “dreams” at the time of a beautiful home waterbirth–yeah, I’m ashamed now, but then it seemed so “cool”–but my OB ruled out a vaginal birth pretty early on for reasons that seemed iffy at the time. I still don’t know if they were or not, but all I can say is, my son’s birth was far more “peaceful” than that dream homebirth. We got up on the scheduled day, went to the hospital, nurse starts an IV….then pretty much over. I was awake, got adequate pain meds by IV for the first two days, then a prescription to take home. The pain was gone before the meds were. I know that c-sections are called “major surgery” and that things can go wrong, but I really wonder what the mortality and/or severe injury rate is. My ex was a pathologist, and he always told me that the whole “c-sections death rate” was caused by women who, say, for instance, got in near-fatal auto accidents, strokes from high blood pressure, other injuries, etc, who then had c-sections performed in order to a) allow for effective resuscitation of the mother and b) attempt to save the child. I have no idea if this is true, since I never went through his files, but perhaps the doctors & nurses on this forum can answer my question?

    • Sally RNC-NIC

      Interesting question. My only contribution stems from one mom who triaged at 35 weeks in crisis….dropped, seized, and was emergently sectioned. She was taken off life support 6 days later, and her death was attributed to HELLP Syndrome. Which sort of falls under one of the categories you mention above. I can’t imagine her c-section was in any way associated with her death….however, I’m continuously shocked by crazy information that seems to make absolutely zero sense. (As a nurse, this story will forever be my most valuable memory. If you’re interested in the story, here ya go: http://prettythoughtsindeed.com/8/post/2014/05/twelve-hugs.html )

      • Guesteleh

        That made me bawl. Beautiful tribute to Leila and her family.

        • Sally RNC-NIC

          Thank you so much for reading Leila’s story. That week changed my life forever, and I just want her to keep living on and on and on.

          • Medwife

            Tears here. You told her story beautifully.

          • Sally RNC-NIC

            Thank you. I still find typos and grammatical errors every time I read it, but I never correct them because I feel like that’s just part of trying to tell a story like this. I’m just so, so, so happy new people are being introduced to this amazing, amazing, amazing mama. I think of her every day.

          • Dr Kitty

            It is a very lovely tribute.
            So great that her family gave their permission and were involved in it, allowing you to make it about Leila and not an anonymised patient.

      • WordSpinner

        Blaming the c-section for that woman’s death seems akin to blaming chemo for a cancer patient’s death.

        • Sally RNC-NIC

          Exactly. We all know she was actually gone before the section even took place. As for the paperwork? Who knows. Who knows if someone who really wanted to link a death and a c-section could potentially bedazzle a situation like this into a thing. I mean, who knows. People are crazy.

          • SisterMorphine

            Before I went to law school I got an MS in statistics, and an education on how frighteningly easy it is to manipulate them. So yes, if NCB’ers were to do a “study” on how “dangerous” a C-section is, they’d certainly count your patient. Ditto, a woman who suffered a gunshot wound at eight months–the gunshot wound would be the COD, but she would “count” as a C-section “fatality.”

            It’s a bit like this: A friend of mine working for a think-tank is currently working on a study of supposed opiate-related hospital admissions & deaths. In the current Oxycontin panic, you hear scary “statistics” like “5978 (whatever) ER-admissions are prescription drug related!” But consider: You badly twist your foot & take a leftover Percocet from your last root canal to help w. the pain. A couple of days later, it’s not getting better, so you go to the ER to see if you broke anything & admit you took a Percocet. Congrats, you’re now one of those “opiate-related admissions.” A longtime cancer patient, either deliberately or just to try to deal with the pain, ODs. Bam, an “opiate fatality.” While no one is denying abuse of prescription drugs exists, turning the problem into a boogeyman helps neither addicts nor patients who legitimately need the drugs. But that’s a whole ‘nother story….

            Bottom line: The reliability of statistics depends on the quality of data, the models used for assessing it, and the integrity of the people interpreting it. Often one or more is in short supply.

        • The Computer Ate My Nym

          Not that that’s never happened either…

      • DiomedesV

        What a terribly tragic story. Is the prognosis for the baby good?

        • Sally RNC-NIC

          Yes! He’s doing great. I actually went to his 1st birthday party in August. He’s amazing. He was actually discharged from the NICU two days before Leila’s funeral. He totally rocked it.

    • sdsures

      Can epidurals reduce the risks of complications from high blood pressure? (BP generally increases with extremely high levels of pain.)

      • Medwife

        We encourage people with htn issues to get epidurals for this reason. (Also makes it faster if we have to rush to section, of course)

    • The Computer Ate My Nym

      C-sections, like any surgery, can go wrong. That being said, yes, the majority of c-section deaths are related to pre-existing problems, not to the surgery itself.

  • theadequatemother

    the thing is…we’ve known this for almost 10 years. Cynthia Wong’s RCT of early vs late (where late is after 4 cm) epidural analgesia was published in 2005 and the other large RCT from China wasn’t too far behind. And yet the vast majority of info on the web regarding epidurals, even materials published by hospitals, mentions the possiblity of labour slowing. Most of that is based on poor data from the 1980s comparing epidural to systemic opioids or retrospective studies of epidurals vs nothing. Those studies are biased of course, if you don’t request anything or there isn’t time for anything labour is probably tickety-boo and when they tried to randomize women to opioids vs epidural there was a ton of crossover because opioids just didn’t cut it. NCB advocates favorite argument against epidurals on demand (ie wait as long as possible if you can’t avoid an epidural) is that these studies compare early to late epidurals not epidurals vs “natural.” It’s too bad the cochrane reviewers didn’t add in breastfeeding and bonding outcomes…but I guess the rampant hatting would have been too confounding.

    • Ceridwen

      I’m curious about your thoughts on the Cochrane review of epidurals vs. narcotics/no pain relief which show higher rates of instrumental delivery and augmentation.

      • Elaine

        Well, if it’s only retrospective, then the moms who opt for epidurals are probably more likely to be those who have longer/more complicated labors. And therefore they’re more likely a priori to end up with instrumental delivery and augmentation anyway–both the desire for the epidural and the difficult delivery come from the same cause, rather than one causing the other.

  • attitude devant

    So here’s the thing: I’ve been using epidural anesthesia for my patients since 1987. It’s amazing pain relief and has some truly beneficial side effects (improved placental circulation, relaxation of the pelvic floor). I practice at an institution that prides itself on evidence-based care, but I cannot convince our medical director to stop insisting that we wait until four centimeters before offering regional anesthesia. I’ve been posting every reference I can find on this issue in our lounge, and she keeps tearing them down. So now I’m marching over there with renewed ammunition.

    • theadequatemother

      Yep yep yep. Our standing admission orders to LDR have “epidural when requested on them” but there is a culture of “coping without as long as possible” and a scarcity of anesthesia resources that delays them. And you can’t even get admitted in spontaneous labour before 4 cm unless there is something else going on (prolonged latent phase with maternal exhaustion or dehydration for example).

      • araikwao

        Yeah, I was wondering who gets admitted (in spontaneous term labour) at <4cm..

        • Box of Salt

          “I was wondering who gets admitted (in spontaneous term labour) at <4cm"
          GBS+ with ruptured membranes get admitted immediately.

          • araikwao

            Yeah yeah, I was just looking for a quick, all-encompassing description of low-risk women in spont labour, not high-risk. Just thinking here and in the UK about how many women in early labour get sent home, even if they’re in loads of pain.

          • Dora

            Me. Admitted at 1/2 cm, membranes having ruptured more than 12 hours previously. Very mild contractions. I stayed home so long because I assumed they’d send me home. Just leaking, until the internal exam once I got to the hospital, when there was a gush. I took my OB at her word about getting the epidural as soon as I wanted it. Got it after a couple of hours on pitocin. After over 8 hours on it, I was still at a 1/2 cm. had a lovely c-section. Held my daughter within five minutes, was in recovery and nursing within about twenty minutes.

          • Joy

            I’m in the UK. We are told not to call until the contractions are every three minutes. I called and argued with the midwives who kept saying I couldn’t be in labour because I could talk through the contractions. As it turned out, I had developed ICP and the test results came back a few minutes later. I went in for monitoring; they checked the fetal hr for about 45 minutes; they checked me and I was about 7 cm. So yeah, no one I knew here was in at less than 4 cm and they don’t do GBS tests as standard.

          • toni

            I didn’t know GBS screening was not recommended there. Found this explanation http://www.screening.nhs.uk/groupbstreptococcus. I was negative but glad to have had the test. One less thing to worry about. They seem way too chill about this stuff over there.

            That does not sound like a very scientific way of determining whether someone is in labour. I could talk during my ctx almost right up to delivery

          • Joy

            The explanation sounds good, although the UK is one of the few countries where GBS infections at birth are rising. The US and Canada saw drops of 90%. I paid privately to be tested and my NCT teacher was horrified. If you positive, you can’t use the birthing centre.

          • toni

            http://blog.kiddicare.com/2014/07/isnt-nhs-testing-group-b-strep/
            http://www.telegraph.co.uk/women/womens-health/10392503/Group-B-Strep-For-months-I-believed-Id-killed-my-baby.html
            Found these stories.
            And more explanation why screening is not routine from RCOG https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/pregnancy/group-b-streptococcus-infection.pdf
            They say it could do more harm than good to test everyone and treat all carriers with abx. Exposing many women and babies to treatments they don’t need. I understand there is a concern of overexposure to antibiotics and the possible repercussions of that… would treating every GBS+ pregnant woman with abx cause more than 75 deaths and disable more than 40 further people a year though?

          • Joy

            I know they sort of fudge the numbers on that one. They are talking about an older type of less sensitive test. I can understand the concern about resistance, but the amount of antibiotics a baby infected gets is far more than the dose a woman would get in labour. This site gives more information. http://gbss.org.uk/what-is-gbs/about-gbs/gbs-prevention/

          • toni

            It seems to me, albeit as a complete layman, that the complication rate of GBS in a newborn is so high they should do all they can to prevent it. It says in one of those articles that the majority of babies (7/10) recover from it, as if that’s a comfort. So three out of ten are handicapped or die from it? But they also say something about most affected babies being preemies born before the test is even done, but then also that all women going into labour before 37 weeks automatically get the IV abx. So are they suggesting the treatment isn’t effective for preemies?
            Idk, it’s hard not to get the impression from reading their statements that they are a bit too comfortable with these preventable deaths. ‘Only’ 75 deaths per year isn’t very reassuring IMO and especially if you’re one of the unlucky ones whose baby succumbs to the infection.

          • Cobalt

            Three minutes?! I’ve had labor where my only contractions that are 3 minutes apart were the last few before crowning. This last baby went from 7 to 9 minutes to 30 seconds and was born within three involuntary pushes. My labors aren’t fast overall, but my contractions are useless indicators of progress.

          • araikwao

            Ha ha, in the luxury of the Aussie system, we get to call when they’re at 5min

          • Joy

            Well, I suppose we can call whenever, but they don’t want you to come in until they are every three minutes.

          • araikwao

            I guess that’s calling with the intention of coming in..

          • AmyP

            Awful.

            At three minutes, how do you even get to the hospital?

            Living in the US, I dawdled a bit with my second (took a shower at home, etc.), wound up dealing with a congested labor and delivery ward, had to wait a long time for triage (I believe I was at 5 cm at that point), had to wait for a real room, and then barely got an epidural before it was time to push. It was a 4 hour labor and delivery and was probably an 80+% unmedicated. I was so surprised–I had been counting on an epidural. (My first had been 13 hours, hence my belief that I could follow the conventional advice about waiting at home.)

            I would never advise anybody (especially a second or more time mother) to wait at home longer than necessary.

          • Joy

            I was told they would send an ambulance if it came to it, but it just didn’t sound like I was in labour. I wouldn’t put much faith in the ambulance getting down the overcrowded motorway at rush hour though.

        • Ceridwen

          I got admitted in spontaneous labor at 2cm. They hooked me up to the monitor for 20 min, checked dilation, and then gave me the option of staying or going home. They said they had seen some decels on the monitor that were slightly worrying (and made them suspect nuchal cord) but that they were willing to send me home if I wanted. I opted to stay because 1) I’d been in labor with regular contractions for 12 hours already and was already fucking exhausted, 2) I had two male roommates and little interest in laboring all over our house with them around, and 3) why would I want to go home and forgo monitoring if there was anything even slightly worrying going on?

          I was 40+1 and we were supposed to schedule my induction at my OB appointment that morning, so I suspect my doc (who happened to be doing rounds when I showed up) is the one who convinced them to let me stay. He’s also the one who convinced them that they should give me the epidural (12 hours later) at 3cm instead of making me wait for 4cm. I <3 him.

        • KarenJJ

          I did. Membranes had ruptured at 41+weeks. I’d been having regular contractions since 5am, waters broke at 12noon and it was 2pm when I was admitted. It was found that baby still hadn’t engaged, I hadn’t dilated and some meconium was found (not too bad, but it was there).

        • antigone23

          Where I live, it’s pretty standard to admit as soon as your membranes rupture regardless of anything else. I was admitted at 1 cm with no contractions. I took a wait and see approach to the epidural but if I remember correctly I was less than 4cm when I got it.

        • MJ

          You know, I’ve had three vaginal deliveries with midwives in an Australian hospital and I don’t recall being told what my dilation was at any time during any of them. I don’t remember even having a vaginal exam until my third when my midwife wanted to check that my waters were completely broken. Mind you, mine were all induced or augmented so they probably figured they could just keep me going until something happened!

        • Amy M

          I had a bit of an unusual scenario I guess: I had been dilated to 4cm for 4wks, but stable. Water broke spontaneously, few/weak contractions, twins, 36wks. Of course, I was admitted right away…I imagine anyone with broken membranes, at 36wk would be, even with a singleton and no dilation?

      • Cobalt

        I really don’t get the “hold out as long as you can” method, unless you’re really just hoping it’ll be too late and it won’t happen at all, which is an evil thing to do to someone (or yourself). I understand going into labor with a wait and see mindset, but once you’ve seen the need, stop waiting.

        • Elaine

          For me, particularly with my second, it was kind of “this might not take too long, so is it worth the hassle of getting hooked up to all those tubes and wires?” If I did it all over again knowing what I know now, I might have opted for an epidural with my first birth, wouldn’t have bothered with my second (in reality I didn’t have one with either). Since time travel is obviously not possible, my conclusion instead is that if I have another and labor is as painful as with my first, I’ll use the lessons I learned from that experience to decide.

          • Cobalt

            Sometimes the epidural isn’t worth it, but when it is, the benefit really is tremendous. I did mine without and was fine, but I have seen it go the other way.

        • araikwao

          That’s what MW’s do here. I’ve seen it with my own, disappointed eyes.. “you’re doing really well, the anaesthetist’s a bit busy….oh, now it’s too late, you’re at 9cm”.

          • Mishimoo

            This is why I’m glad that my favourite CNM has gone on to teaching at uni. She offered a few times to get me one at 9cm, because I said that I was getting tired. I really hope she passes that on to her students.

          • sdsures

            That sounds like malpractice on the MW’s part!

          • araikwao

            Oh, it’s not “midwife”, it’s”midwives”! The ones that do childbirth education classes are quite open about their stalling tactics. And as a first-time parent-to-be, I know I just listened, wide-eyed and accepting. Now the injustice makes me cranky.

        • Guest

          I was admitted at 1.5 cm with a ruptured membrane and regular weak contractions for several hours. Only minimal amount of water leaked so they freaked out that it might have been leaking for longer that I thought without noticing so the OB put me for induction and prophylactic antibiotics. Once my OB told me I needed induction I requested an epidural. The nurse was trying hard to change my mind about it and convince with pethidin injection instead! and kept telling me the anesthesiologist was busy. Then she finally arrived after I was 5.5 cm dilated (if not more). Once she was done and while collecting her stuff I was 10 cm dilated!. I was awake for more than 24 hours I could have relaxed or take a nap during all these hours instead of suffering. Then when I needed a vaccum the MWs kept blaming me for taking the epidural!. Well! if I just got that epidural sooner I might be stronger to push effectively!

          • Cobalt

            Not only better rested for pushing, but labor overall may have been shorter. I don’t know what the scientific consensus is, but I believe the pain/fear/tension circle can reduce the effectiveness of labor, making the whole thing last longer. Too many stories of “I finally got an epidural and suddenly was at 10 and ready to push”.

            I really feel that an epidural should be had as soon as you know you want one. And from a practical standpoint, if you’re going to have the risks and drawbacks of an epidural, it makes sense to get the maximum benefit from it, which means earlier is better than later. My cousin had it a few months ago. Finally got her epidural (nurses really encouraging holding out), dilated almost immediately to 10, and delivered. The epidural barely had time to start working before she was done, and she got an awful spinal headache for 6 hours before she got a blood patch. 6 hours of spinal headache, plus 12 hours of unmitigated labor pain. 20 minutes of relief from the epidural. She could have saved herself a lot of that suffering.

      • KarenJJ

        Is it the scarcity that is the issue why hospitals are reluctant to change policy and start offering them more liberally?

        Potential job boom for anaesthetists 🙂

    • KarenJJ

      Maybe a box of sticks for women to bite on with “epidural delayer” with instructions to implement orally prior to 4cms could be provided in the lounge…