What is it?
If you have a BMI over 40, the RCOG recommends you “should have an antenatal consultation with an obstetric anaesthetist”. This is regardless of whether you’ve expressed any interest in receiving an epidural or not! So, what happens at this anaesthetic referral, and when does it take place?
When?
Generally in the third trimester of pregnancy.
Before Covid, the anaesthetic referral generally consisted of checking your lower back, having a quick chat about pain relief preferences, and that was that. Now reviews are often taking place remotely over Zoom. This seems less valuable, given they can’t physically examine you, but what would I know!? At least they’re less inconvenient, in terms of sitting waiting in hospital corridors for hours!
How?
If a physical examination, the anaesthetist prods your spine to feel the vertebrae and see how much fat there is. The idea is that it helps them assess how easy or difficult it might be to site an epidural.
They may also look at your face and neck and ask you to jut out your lower jaw. This is to see if there might be any problems with intubation if you need a general anaesthetic.
They will likely examine your hands to see if there is easy access to a vein, if needed.
If they have any concerns they will note this and a plan made to address any issues.
Why?
The RCOG states it’s so “potential difficulties with venous access, regional or general anaesthesia can be identified”.
It is likely that you’ll be advised that if you’re considering an epidural, to request it earlier in labour. This is because for some bigger people, it can take longer to get it in place and working effectively. So, rather than hold on until you are desperate, if you’re thinking of requesting one they suggest you don’t wait.
However, the study used by RCOG to illustrate this only shows that it was the midwives who expressed dissatisfaction about the epidurals in larger women. The women themselves showed no difference in satisfaction scores! It was shown that epidurals were more likely to need re-siting on larger people, however.
The RCOG also recommends that anyone with a BMI over 40 should have ‘venous access established’ early in labour. This is to avoid the potential for delay in an emergency situation. This recommendation is based on level ‘D’ grade evidence – that is to say based on no research, merely expert opinion.
In practice, this means a cannula (large needle with a plastic socket) inserted in the back of your hand. Be aware that it usually can’t get wet, so rules out baths, birth pool etc! This is often a consequence they forget to mention when suggesting it and gaining your consent!
One benefit of the anaesthetic referral is that they can check your hands and note if this recommendation is (un)necessary.
Why not?
You may feel like you have no intention of using an epidural or other anaesthesia while in labour, and that therefore such a consultation is unnecessary, but other than potentially being a waste of time, there is no real reason to refuse.
The consultation is relatively quick, is non-invasive, and could prove valuable in the event of complications or if you change your mind. After all, you never really know how you’re going to feel when in labour until you’re actually there.
What about the epidural?
It is worth remembering the downsides of epidural anaesthesia however, before you jump for the ‘pain free’ option; lack of mobility, catheterisation because you are no longer able to sense when you need to urinate, longer labours, ‘disconnection’ with your labour as you may be unable to feel contractions or when to push, greater likelihood of instrumental (forceps or ventouse) delivery, increased risk of caesarean section, possibility of nausea or itching, and the rare but risky potentially serious complication of puncture of the spinal cord or infection, amongst others.
Some studies have shown that how labours are managed may in some part be responsible for impacting on how those labours turn out. You can read about that here: The Impact of Negativity on Labour and Birth.
As always; get all the information available and make the decision that’s right for you. Don’t forget to use the BRAIN acronym to ensure you cover everything you need to make informed decisions about your care!
So if you feel herded into having an epidural, or even into having one sited ‘just in case you want one later’ when you really don’t think you want to, don’t be afraid to stand your ground and say no. But if you do want one, don’t let anyone tell you you shouldn’t have one either! Remember, professionals are there to advice and recommend options to you – it’s your right and responsibility to consider the options and make your own decision!