Despite fewer epidurals, the majority of women in midwife-led units were happy with their pain relief

MOST IRISH first-time mothers opt for the epidural as their pain relief of choice during labour. But reducing the pain levels doesn’t necessarily mean a more satisfying birth experience, according to a recent study that found a high level of satisfaction among women who gave birth in one of the country’s two midwife-led units.

The HSE report involved a study of 1,653 women who had babies in the Midwifery-led Units (MLUs) at Our Lady of Lourdes in Drogheda and Cavan General Hospital from 2004 to 2007. It found that despite having fewer epidurals, 83 per cent of women in the midwife-led units expressed satisfaction with their pain relief, compared with 68 per cent of women in the consultant-led unit.

The report concluded that midwife-led care was as safe as consultant-led care, resulted in less intervention, gave birthing mothers greater satisfaction and was more cost-effective.

The argument for and against the use of the epidural during childbirth was the topic of discussion over the weekend at the second annual scientific meeting of the Faculty of Pain Medicine, College of Anaesthetists of Ireland on Pain in Women.

Outlining the role of the midwife in pain management in pregnancy and the peripartum period, Denis Walsh, associate professor in midwifery at Nottingham University in the UK, said that the epidural was very effective in complicated labours, for example where the birth was being induced or sped up.

However, in normal pregnancy there was evidence that three forms of care reduced epidural use: one-to-one care in labour given by a midwife; access to water immersion, ie getting into a tub during labour; and access to self- hypnosis or hypnobirthing.

“When those three forms of care are widely available for women, we see quite a low rate of epidural, even in first-time births. These forms of care are available in birth centres and in home birth situations, but are generally not available on a wide scale, although provision is increasing in the UK.”

Prof Walsh pointed out that the downsides of epidural use were very clearly set out in the Cochrane Review. They included an increase in forceps or vacuum delivery, a lengthening of labour and an increased need for oxytocic drugs to induce labour.

“Research on women’s satisfaction with labour has found that the one-on-one support they got from the midwife was a much more important part of the actual experience than the experience of pain. Paradoxically, a lot of women talk about a high level satisfaction along with a high level of pain.”

Dr Peter Boylan, clinical director of the National Maternity Hospital in Dublin and author of The Irish Pregnancy Book, had a different opinion on the use of epidural during labour. "The epidural is undoubtedly the most effective form of pain relief in labour certainly for a first birth, there is no question about that. A lot of women find that it transforms what is a miserable experience into one they actually enjoy because they are not suffering the awful pain," he said. "However, because there is no pain during labour with the epidural, the pain afterwards can be more acute. Women who have pain during labour tend to find the pain is not as bad in the peripartum period."

While 70 per cent of Irish women opt for the epidural on their first birth, this rate drops to 30 per cent on second or subsequent births. This is often down to the fact that labour is so much faster after a first birth, and there is simply no time for an epidural, explained Dr Boylan.

“There are very few downsides of epidural, apart from a slight increased chance of a forceps or vacuum delivery in a first birth. Many women complain of back pain after giving birth, but there is no link whatsoever between the epidural and back pain. During pregnancy, the hormone relaxin loosens all the ligaments that bind the joints together and there is a lot of pressure on the back both during and after pregnancy, when the women is carrying the extra weight of the baby around. This is the main reason women have lower back pain after birth.”

While many Irish women chose to have an epidural on their first birth, others decide they want a natural birth with as little intervention as possible. The most important factor in all of this, according to Dr Boylan, is that the woman makes this decision herself.

An epidural is a form of regional anaesthesia which is a common method of relieving pain during labour. It involves the injection of drugs through a catheter placed in the epidural space, which is part of the human spine. The injection can cause both a loss of sensation and a loss of pain, by blocking the transmission of signals through nerves in or near the spinal cord.

It provides rapid pain relief in most cases and is well proven to be more effective than gas and air, opioids, Tens, and other common forms of pain relief used in childbirth.