Leigh Milner had one requirement for her upcoming birth: she wanted epidural pain relief. “I dreaded being in agony and knew I’d enjoy my pregnancy if I could avoid suffering during labour,” she says. “Following the advice from my National Childbirth Trust [NCT] course, I put my epidural request at the top of my birth plan in block capitals and bold type. Then I laminated it.”
Few birth plans make it out of the hospital bag, and Milner’s glossy manifesto was no exception. On February 1 2023, two weeks before her due date, Milner, 34, was rushed into hospital with high blood pressure and suspected pre-eclampsia.
Pre-eclampsia is a serious condition that can be fatal to both mother and baby, so the hospital said Milner needed to be induced right away. “As the midwife prepared for me this, I asked for an epidural,” says Milner, who works as a news presenter for BBC Look East. “The midwife batted me off with a number of excuses, telling me I needed to be on the labour ward, it was too busy – there would be time to do it later.”
The midwife broke Milner’s waters, and her labour progressed with shocking speed. “The pain was immediately so brutal that I threw up on the way to the labour ward,” she says. “I was screaming that I wanted my epidural, begging the staff over and over again. They came up with all sorts of reasons to delay: that they needed to get the results of a blood test, and that certain forms had to be signed.”
The gas and air machine on the unit was broken and Milner was offered only paracetamol. When a monitor indicated that the baby’s heart rate was dropping, Milner was prepped for a caesarean. She desperately wanted to avoid surgery, and steeled herself for one last push – to aid her delivery, she was given an episiotomy, or a surgical cut to the perineum. Milner had no pain relief apart from an injection of local anaesthetic that had no time to take effect. Theo was born safely, weighing 6lb 4oz, but Milner was traumatised.
“The whole thing was medieval,” she says.
Over the next few months, Milner suffered flashbacks and nightmares about the pain she experienced, to the extent she needed therapy. “I later had a meeting with the hospital, and they told me I should have been offered an epidural at the time I was induced,” she says. “They said there had been no need for this mysterious blood test. I’m 100 per cent certain I would not have suffered all this distress if I’d had an epidural.”
Pain-relief politics
The issue of pain relief in childbirth has always been political – and now it is entering the election race. In their manifesto, released this week, the Green Party remarked on the “escalation” of medical interventions, and their disapproval of such. “We will work to reduce the number of interventions in childbirth and change the culture of the NHS so that birth is treated as a normal and non-medical event,” they said.
According to guidance released in 2012, “natural” childbirth, as defined by the Royal College of Obstetricians and Gynaecologists includes births “without induction, without the use of instruments, not… caesarean sections, spinal or epidural anaesthetic before or during delivery”.
If the Green Party had their way, mothers-to-be like Milner would be even less likely to receive pain-relief.
This flies in the face of better news about the health consequences of epidurals. Last week, the issue was in the news again: a report published in the BMJ revealed that women who had epidurals during labour were a third less likely to develop life-threatening conditions such as sepsis or heart attacks after giving birth than those who did not.
An epidural is a type of local anaesthetic given into the lower back, which numbs the nerves that carry the pain impulses from the birth canal to the brain. “The idea is to numb the sensory nerves, which affect pain, but not the movement nerves that affect feeling,” says Dr Fiona Donald, the president of the Royal College of Anaesthetists. “The range of anaesthesia can vary: patients can vary from feeling nothing, to a sense of tightening when their contractions take place,” she says. A few hospitals offer “mobile epidurals” where the patient is free to move around.
The procedure is safe, says Donald, though by its very nature, an epidural makes a birth more “medicalised”. “It has to be given by an anaesthetist, the patient needs to be in bed, attached to a drip and have one-to-one midwife care in case their blood-pressure dips too much,” she says. “The baby’s heart rate also needs to be monitored.”
There is a one in 10 risk of the anaesthetic “failing”, as well as a small risk of negative consequences such as a postdural puncture headache (which happens in around 1 per cent of births) and one-in-10,000 chance of permanent nerve damage.
Fiona Gibb is director of professional midwifery at the Royal College of Midwives. “Different areas operate under different guidelines, but epidurals are usually given when a woman is in established labour – having three contractions in the space of ten minutes – and her cervix is around 3 to 4cm dilated,” she says. “Epidurals are also often given before an induction.”
In certain scenarios, epidurals can be “contraindicated” – not performed because it may be harmful to the mother. “This can happen if the woman has certain pre-existing medical conditions such as low blood clotting levels, has cardiac instability, or has had spinal surgery,” says Gibb. “An epidural might also be contraindicated if the baby is descending quickly, or the woman is not able to lay still or sit upright.”
Otherwise, according to Gibb, all women should have the choice to have an epidural, “as long as the hospital can provide a safe, clinical environment”.
However, as Milner discovered, many labouring women find they do not have access to adequate pain relief. Statistics show that, despite the safety and effectiveness of the procedure, significantly fewer epidurals are given in the UK than in other Western nations.
A 2020 report in Anaesthesia, the journal of the Association of Anaesthetists, revealed just 22 per cent of women who gave birth in the UK between 2007 and 2020 received an epidural. This compares quite starkly with the United States, where between 70 and 75 per cent of women have epidurals. In France, it’s 82 per cent.
Even before the Green Party edict, epidurals came with oddly political connotations. In some middle-class circles, it almost seemed a badge of honour to “not need” an epidural. Childbirth education organisations such as the NCT seemed opposed to – or at best ambivalent – towards them. There was the sense that epidurals were the gateway to all manner of unpleasant interventions such as a ventouse or forceps delivery or – the biggest failure of all! – an emergency caesarean section.
New mum coffee mornings were full of the sense that, the more pain relief you had requested, the more you had “failed”. Do you feel less of a mother because you didn’t “breathe your baby out” in a cloud of lavender oil? Good, you deserve it.
This approach now appears – thankfully – outdated. “It’s not true that epidurals make an intervention more likely,” says Donald. “Though it’s also the case that the local anaesthetic is less strong than it used to be.” A 2018 Cochrane Review paper found that: “the need for an assisted vaginal birth no longer appeared as an outcome when adjusted for modern anaesthesia approaches”.
Maxine Palmer is a former antenatal practitioner and head of service development at the NCT. While she defends the notion that an epidural given too close to birth can slow down the pushing stage, she accepts there has been a culture change within the organisation.
“The ‘cascade of intervention’ was incorrectly correlated,” she says. “The evidence is now clearer as to what causes birth complications, especially as epidurals are now given at a lower dose. The NCT’s main task is to educate women to understand their pain relief options and have a flexibility of mindset in the context of the clinical situation.”
Resource constraint
So why, despite this culture change, are women still struggling to get sufficient pain relief? An investigation by The Telegraph as recently as 2020 identified six NHS trusts where women pleading for pain relief were refused it, with one woman talking about “a cult of natural childbirth”.
Palmer of the NCT denies any nefarious plan on the part of midwives. “It’s true that in this country we have more of a culture of vaginal birth than places like the US,” she says. “In other countries, births are more medicalised: you can’t have gas and air in America, for example. There is also far more of a culture of birth litigation in the US, though it is getting worse here. Trusts are now spending a third of their budget on claims where a birth has gone wrong.”
According to Palmer, the main reason we aren’t getting epidurals is because of “resource constraint” – there simply aren’t the midwives or the anaesthetists available for the personalised care needed for the epidural process. “This was beginning to brew before the pandemic,” she says. “People were starting to leave the profession, and now they aren’t being retained. It started to stabilise in 2023, but after that we had the Ockenden Report.” (The Ockenden Report found a string of catastrophic failures in the maternity services at the Shrewsbury and Telford Hospital NHS Trust, leading to the death of more than 200 babies.) “Since then, more resources are going into safety concerns than the continuity of care,” says Palmer.
For while the number of epidurals is going down, the number of caesareans and inductions is rising. NHS figures from 2022 revealed 35 per cent of births in the previous year were through a caesarean, up by a quarter in the past decade. This is partially because of complex births related to ageing and increasingly overweight mothers-to-be. Plus, if a first baby is born by C-section, their sibling will almost certainly enter the world in the same way. Then there is the renewed emphasis on safety since the maternity unit scandals, meaning that pregnant women are now able to elect a caesarean section, even if this is not for medical reasons.
For those who have had difficult births, Gibb suggests it can help to later reflect on their labour with the help of a hospital professional. “This can be an informal chat with their midwife, some areas offer a programme, which is a dedicated clinic,” she says.
New mother Milner made use of her “Reflections” appointment at the Essex hospital where she had her son, but for her this was ultimately a case of too little, too late. “After my awful experience giving birth to Theo, I will question every decision in my next pregnancy,” she says. “In fact, I am almost certainly going to opt for a planned C-section. Lots of my mum friends feel the same way. We no longer trust the NHS.”
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