Giving birth was, for Kate, like going “through a war”. She had repeatedly asked for an epidural; instead, she was allowed only gas and air and two paracetamol. She was “exhausted, dazed, torn, bloody and frightened” by the time her healthy son was placed in her arms.
“I asked three times for an epidural,” Kate says of her 26-hour labour to deliver her baby, who was back to back and breech. “The first time the midwives said I wasn’t far enough along. The second time, they said I didn’t need it. Finally, they said I was too far along.
“It was an excruciating and technically difficult birth. I was in such agony for so long,” she says. “I believe it almost certainly contributed to the crippling postnatal depression I suffered for three years afterwards … I shouldn’t have had to beg and plead, or shout and argue not to be treated cruelly.”
There is no such thing as a predictable or usual birth: having a child is a highly complex, individual and volatile experience. Mary Cork, who gave birth in 2018, says she is glad that her pleas for an epidural weren’t granted: “Despite it being something that I knew I had wanted [on arrival at the hospital], not having it made the recovery much easier and I was able to go home the same day.”
At the other end of the spectrum is Cathy, who had her request for an epidural granted: “I wish the doctor had had the conversation that maybe I shouldn’t have the epidural,” she says now. “Afterwards, the doctor said he couldn’t insert it properly. It only numbed the top half of my belly. Because I’d had it, I wasn’t given any other painkiller. I was hysterical with the pain. There is no way I would ever get pregnant again.”
While every woman’s birth experience is different, the one thing that links all women is the fear of what happens if the pain becomes too much: will they be given sufficient pain relief to ensure the safety of themselves and their baby? Epidural blocks are a pain-relieving spinal injection. They are highly effective but not risk-free: they have to be given by an anaesthetist in an obstetric unit and, among other risks, can lead to a precipitous drop in blood pressure.
NHS guidelines say that women can ask for pain relief at any time during labour and should be given information and support to choose what is right for them. However, a Sunday Telegraph investigation in January claimed that some women were being denied epidurals because of what it called a “cult of natural childbirth” in some NHS trusts. Matt Hancock, the health secretary, promised an investigation, the results of which have now been released to the Guardian. The Department of Health and Social Care has concluded that women are not receiving pain relief when they ask for it, contrary to Nice (National Institute for Health and Care Excellence) guidelines on epidurals. Nor are they being kept fully informed of the potential outcome of their choices on pain relief. This week, the government will write to NHS Trusts, reminding them of Nice guidance regarding pain relief during childbirth, to ensure it is being followed.
The Guardian did a call-out recently, asking women for their experiences of epidurals. We received positive and negative accounts. But perhaps most striking were the anaesthetists who said they were denied the epidurals they wanted when giving birth. One consultant anaesthetist, Anna, said: “I’m still traumatised. Even as an anaesthetist, I wasn’t listened to. I have a lot of experience in obstetrics and labour yet I didn’t get adequate pain relief when I requested it during and after labour. I was screaming in pain, which isn’t necessary.”
While the most commonly discussed risk associated with an epidural is a drop in blood pressure, there is a one-in-10 chance of the anaesthetic failing, a one-in-100 chance of a headache so bad it can render women bedbound, a one-in-1,000 chance of temporary nerve damage, a one-in-10,000 chance of permanent nerve damage and a one-in-100,000 to one-in-250,000 chance of spinal infection, haematoma and injecting in the wrong place, which can cause loss of consciousness and cardiac arrest.
Gill Walton, the chief executive of the Royal College of Midwives (RCM), says that any woman who has questions about her birth experience should return to the unit and ask to be taken through her notes. This, she says, can be done even years after the event. “We want women to have good birth experiences and if they haven’t, it can be hugely helpful to sit down with a midwife and your notes and have the decisions explained to you.”
Still, there is much disagreement among medical staff as to when it is appropriate to give an epidural. “Epidurals can’t be given until a woman is in established labour, which is when women have regular painful contractions often associated with dilation of the cervix to 4cm,” says Walton. “It’s too late for an epidural when women are in transition, which is when the cervix is fully dilated and just before they start pushing. Transition is the really intense bit when lots of women ask for epidurals. But if you listened to women in transition, you’d find yourself giving epidurals to women who are just about to push their baby out,” she says. “There wouldn’t be time for it to start working.”
But Dr David Bogod, a council member of the Royal College of Anaesthetists and a consultant at Nottingham University Hospitals NHS trust with a special interest in obstetrics, strongly disagrees. “All that stuff about ‘too early’ and ‘too late’ is nonsense that’s not supported by evidence and specifically runs counter to national guidance that says women should be given an epidural if they want one,” he says.
“It’s never too early and never too late, if that’s what a woman wants,” he says. “An epidural can be effective within 25 to 30 minutes of an anaesthetist walking into a hospital room. It’s also not true that anaesthetists can’t give epidurals to women having contractions because they move around too much,” he adds. “That’s when most women want an epidural, so that’s the situation in which we get most practice and are most skilled at inserting them.”
This is not the only area where there is disagreement. A significant proportion of women responded to our call-out with tales of midwives telling them that they couldn’t have an epidural because the anaesthetist wasn’t available – often for the entire length of a prolonged labour.
Walton says that sometimes, anaesthetists just aren’t available because they are dealing with emergencies elsewhere on the labour ward. Bogod, however, says it’s not always so simple. “Labour wards are amply supplied with anaesthetists. The most common reason for women to be denied an epidural is because of a lack in midwife numbers. We have a drastic national shortage of midwives – the NHS in England is short of the equivalent of almost 2,500 full-time midwives. My obstetrics unit should have 10 midwives but often operates with half that – and sometimes less.
“The national standard is that a woman should be given an epidural within 30 minutes of asking for one and must be given it within an hour. That’s an entirely achievable target in most units.”
Bogod suggests another reason for women being denied epidurals. “There’s reasonable, anecdotal evidence that some midwives will use the excuse that an anaesthetist isn’t available if they themselves feel an epidural isn’t appropriate for the woman based on their own beliefs around intervention-free births,” he says. Bogod points to the scandal at Morecambe Bay, where babies and mothers died preventable deaths, at least partly because midwives had a focus on making women give birth without medical intervention. He also points to the leaked interim report of the scandal at Shrewsbury and Telford hospital NHS trust, where similar allegations have been made about malpractice. “I’m not saying it’s common or regular but there are anecdotal cases,” he says. “And it’s completely unacceptable.”
Lessons have been learned from these tragedies. Andrea Sutcliffe, the chief executive and registrar for the Nursing and Midwifery Council, says that “excellent maternity care happens when women are empowered to make informed choices – and when those choices are respected. I believe it’s critical that everyone involved in the care of women during pregnancy and birth work together to ensure that they are listened to and treated with respect – making safe, person-centred care the norm.”
Despite this, University Hospitals Bristol NHS trust was criticised this month for advising pregnant women to avoid having epidurals. After the advice was reported in the press, the trust deleted it from its website and accepted it was “outdated”.
Dr Pat O’Brien, a consultant in obstetrics and gynaecology at University College London Hospitals and spokesperson for the Royal College of Obstetricians & Gynaecologists, says although there may still be pockets of bad practice – of midwives encouraging women to have non-medicalised births against their wishes – things have changed drastically in the past few years. “There has been a real culture shift,” he says.
The reiterated guidelines will hopefully help to eradicate the last remaining pockets of any outdated ideological support of so-called “normal births”, but funding – and the resulting staff shortages – remains an issue. As one woman said when asked if she had complained about being refused an epidural: “Who could I complain to? The country voted for a decade of austerity, so how can I be surprised by staff shortages?”
Some names have been changed.