PLANTEAMIENTO DEL PROBLEMA.

The other issue that greatly concerned the midwives was the level of epidurals, and, again they linked these to instrumental births. Lucy took an opportunity to explore the epidural rate for herself:

I just decided one day I would look up the previous 100 births and out of the 100 births there were 85% epidurals and out of that 85% epidurals more than 50% ended up instrumental34 or caesarean. Lucy (3, 19-20)

Mary, a junior midwife, categorised women into those who expected to have an epidural for labour, and those who were looking for, or were at least open to the possibility of a more natural birth:

. . . the type that come down for induction and the type that are spontaneous. Now you kind of know the spontaneous ones that will do ‘it’ (have a natural birth) and the ones that won't do ‘it’ (labour without intervention), you just kind of know. So the induction ones, they come down . . . and you just know with the Syntocinon they are not going to go the whole way so I always advise

the epidural. Mary (6, 29-35)

This applied to women in spontaneous labour and also those having their labour induced:

. . . And they are all looking for ‘their epidural’, even the women who come in, in spontaneous labour look for the epidural. Sarah (3, 16-19)

As with labour inductions, this was perceived to be more common for women who had private obstetric care:

Some of the primigravidas are told (by their consultant that) the minute they get a pain ‘to come straight in and demand your epidural’ before you have even had an examination to know whether you are in established labour or not.

Susan (3, 8-11)

As will be discussed in Chapter 13, midwives had various methods of managing requests for epidurals and if there were opportunities to discuss alternative methods of pain relief, this was done. However, for the women looking for what was described as, ‘my epidural’, the midwives obtained this when requested because, as Sheila stated:

a lot of them want, 'my epidural' as they call it, and you don't want to be seen

34 _{Refers to a forceps or vacuum delivery}

to be talking them out of it. Sheila (2, 20-21)

This was reiterated by Patricia, who admitted to changing her practice on this issue:

. . . if that is what they want you are not going to talk them out of having an epidural. There was a time when I used to think I could, but they give you no

thanks for it. Patricia (6, 11-14)

Midwives had received complaints when an epidural was not provided when requested and this reflected badly on their care:

It is a difficult one because we have had women complaining . . .

Sandy (10, 24-25)

As will be seen later, the woman’s judgement on the midwife’s care had gained a pre-eminence that had not been apparent in the earlier interviews. When an epidural could not be obtained, it could be distressing for both the midwife and the woman. Sarah related this experience:

I spent half an hour looking for an anaesthetist while this woman is in strong established labour. And I go back because I can't get anyone and 5 or 10 minutes later she has the baby. Now I spent all that time looking for an anaesthetist . . . I just said, ‘I couldn't get anyone, sorry, I tried’.

Sarah (5, 35-41)

Though the midwife’s role is to support women through labour, Sarah spent time away from this woman when her labour was progressing rapidly. Because an epidural was not available this was an unsatisfactory experience for both.

Giving birth without an epidural was valued, but in some situations, midwives would suggest to a woman that she should avail of one, principally where labour was perceived to be particularly difficult:

. . . it is difficult when they are in so much pain to not advise them about the

epidural . . . Mary (6, 21-22)

anticipated:

. . . I always advise the epidural, I tell them that it (induced labour) is a long labour, I examine them first and I talk them through it and that it is a long labour and that while I'd appreciate they'd like to go as far as they could, sometimes they can get so exhausted, you are not able for the pushing and it ends up then that you have an assisted delivery. Mary (6, 35-38)

For Mary, epidurals were associated with labour inductions and she noted with surprise when one induced woman gave birth without one:

We had one lady who sat on the ball for the whole night and she had her Syntocinon and she got to fully (dilated) and she needed no epidural . . . but

she did it. Mary (5, 40-42)

It must be noted, Mary was the most junior of the midwives I interviewed.

Despite the prevalence of epidurals and midwives declared preferences in caring for women without one, this was not something they could decide for themselves and all stated that they were prepared to care for all ‘types’ of woman. Elaine expressed the views of many by saying:

It doesn't make a difference, if she really, really wants (an epidural), personally I prefer doing a delivery without one, I think it is easier, the day goes much quicker but it depends what (the woman) wants, if she is adamant that she wants an epidural then I have no qualms, I will give it to her, we'll

organise it. Elaine (4, 26-29)

For Elaine, and for all the midwives, there was greater satisfaction in providing care to women without an epidural. Strategies midwives used to steer women away from epidurals will be explored later.