111: Dr Anne Doherty Unlocking the Truth About Epidurals

Anne, our resident expert anaesthetist, offers a candid look at the epidural procedure, breaking down the steps with precision and empathy. From the first sting of the local anaesthetic to the teamwork involved in ensuring comfort and safety, Anne and Afif shed light on how understanding the process can alleviate fear and guilt. For those curious about mobile epidurals, we explore the balance of pain relief and mobility along with the real-world challenges of making it accessible to all. Celebrate the resilience of women in childbirth and burst through the myths surrounding epidurals with our engaging, insightful episode that champions both clarity and comfort. Sponsored by: www.happytummy.ie Learn more about your ad choices. Visit megaphone.fm/adchoices

Transcript

SPEAKER_00 0:01

This show is part of the Headstuff Podcast Network.

SPEAKER_05 0:06

The Baby Tribe is proudly sponsored by Happytummy.ie, the exclusive distributor of Bayagaya Probiotics, providing support for gut and oral health for the whole family. Hello everybody and welcome to another episode of the Baby Tribe Podcast. My name is Afif Elkafash, neonatologist, pediatrician, and co-host of this fabulous podcast.

SPEAKER_04 0:34

And my name is Anne Dority, obstetrokinesith, and co-host with my darling husband Afife.

SPEAKER_05 0:39

Now, we don't have a guest today because if there is one topic that never fails to stir a reaction from parents, it's epidurals. And guess what? Anne happens to be an expert. No pressure like on epidurals. Because the moment we asked you guys for questions, my inbox on my Instagram absolutely lit up. Hundreds of you wanted to know everything from what does it actually feel like to why didn't mine work? To is the needle really that big? Yeah, I've seen the needle. It is very big.

SPEAKER_04 1:07

It's not. Okay, stopping the drama.

SPEAKER_05 1:09

Anyway, we're gonna talk about that. And honestly, these are all fair questions because for something that has been used for decades, there's still so much mystery, sometimes fear, and a fair bit of myth around it. So today's guilt. And guilt, exactly. Good point, Anne. See, that's why you're the co-host. So today, Anne and I are diving right into it. What an epidural really feels like, what happens when it doesn't go to plan, and what's new and the so-called walking or mobile epidural that a lot of you have asked us about as well. We'll talk about the good, the bad, and the mildly terrifying looking needle with the needle again. And also why most epidurals work beautifully and safely when you know what to expect. Sorry, Anne, you know I have a needle phobia.

SPEAKER_04 1:48

I was about to say, I I you're really misleading people here because you have a needle phobia. So the tiny little needles that we'd use on like babies look enormous to you if they're pointed at you. So I wouldn't don't listen to them.

SPEAKER_05 2:03

That is fair. That is fair. So we're gonna talk about all of that now. Anne has done an episode on epidurals previously.

SPEAKER_04 2:09

I have. That's why I thought this was done and dusted. And then Afif was like, no, we need to do another one. No, we need to do another one. I need to know what I haven't covered, so that's why you put out the question box.

SPEAKER_05 2:18

So go back and listen to that episode because Anne talks about the medical aspects, the risks, the indications, and things like that. We might touch on that again today, but we're gonna focus on what you guys asked us, and what I wanted Anne to come and say to us is what it actually feels like to get an epidural and things that mums need to know and maybe do in order to help um, you know, the whole the whole kind of the whole kind of process. Because like increasingly I'm realizing that I'm just the bystander in this and Anne is the real star.

SPEAKER_04 2:48

Bystander in what?

SPEAKER_05 2:49

In this podcast. Because stop now with the drama.

SPEAKER_04 2:52

Again, I don't know what's going on with you today, Faith. Like seriously, this whole self-deprecating business. It doesn't, it doesn't suit you, love.

SPEAKER_05 2:59

Because every time anybody mentions the podcast to me, guess what? They don't say, Oh, I love the podcast. Well, they do say that, but they say Anne is great. Oh, we love Anne, and this and that, and I love that.

SPEAKER_04 3:09

I think that's disproportionately represented in your mind because you're jealous of anything.

SPEAKER_05 3:14

No, not really. Not really. To know. Not really. But anyway, Anne and I are um feeling great because we had our first night away without the kids.

SPEAKER_04 3:24

In ages.

SPEAKER_05 3:25

Yes. And guess what? Our kids are now old enough to be left in the house.

SPEAKER_04 3:30

The older one can mind the younger one.

SPEAKER_05 3:32

Yes. And um even Buddy survived.

SPEAKER_04 3:36

I know.

SPEAKER_05 3:36

I was very happy about that. So when Anne did the sort of 9 p.m. phone call to check on the kids while we were away, my main concern was whether Buddy ate. How's Buddy feeling?

SPEAKER_04 3:47

Buddy was fine.

SPEAKER_05 3:48

Is Buddy okay?

SPEAKER_04 3:49

Buddy was grand.

SPEAKER_05 3:50

He was great. Yeah.

SPEAKER_04 3:51

But he was well minded by his older minders.

SPEAKER_05 3:54

But the kids minded him so well.

SPEAKER_04 3:56

And it just And they minded themselves well and the house well. The whole thing okay.

SPEAKER_05 4:01

Nobody got hurt. Yeah. The house didn't catch on fire.

SPEAKER_04 4:04

No.

SPEAKER_05 4:04

And Buddy behaved. He protected them really well, I think.

SPEAKER_04 4:07

I think so.

SPEAKER_05 4:07

What are you gonna dress up as um for Halloween?

SPEAKER_04 4:11

You know I don't dress up for Halloween. I'm wondering where he's going with this. What are you dressing up as for Halloween?

SPEAKER_05 4:17

Well, Buddy has got his outfit.

SPEAKER_04 4:19

Oh, are you taking Buddy trick-or-treating?

SPEAKER_05 4:21

I'm taking Buddy trick-or-treating. He he's he has um a Mike Wazowski Monsters Inc. outfit, and it's so cute. And I'm thinking of going up going as Sully.

SPEAKER_01 4:32

Are you serious?

SPEAKER_05 4:33

Yeah. Oh my god.

SPEAKER_01 4:39

Are you no you're actually seriously gonna go out trick-or-treating with a dog? Me and Buddy, the kids don't want to go trick or treating with dogs. I know, because they're like old.

SPEAKER_05 4:47

They're teenagers, yes. Yeah. Is it weird? Yes, trick-or-treating with a with a dog. Yes, very do people not have like treats for the dogs? No.

SPEAKER_04 4:56

You know this is odd. Okay, you know, you're please, God, you know this is odd.

SPEAKER_05 5:00

I might have to revisit the plan, but anyway. Let's talk about epidurals. So many people want to know what it feels like to actually get an epidural. But maybe before we do that, tell us why do people get epidurals? Why do mums get epidurals?

SPEAKER_04 5:21

Two reasons mainly. So I assume you're asking about epidurals relating to labor pain relief.

SPEAKER_05 5:27

Yes.

SPEAKER_04 5:28

Okay.

SPEAKER_05 5:29

Why can you get epidurals for other reasons?

SPEAKER_04 5:31

You can have it for surgery, certain surgeries, certain non-obstetric surgeries, they might decide that an epidural would be a good idea for you for different reasons as well. Oh really?

SPEAKER_05 5:40

I didn't know that.

SPEAKER_04 5:41

Yeah, we do them for like say like big abdominal surgeries and stuff like that.

SPEAKER_05 5:45

Really? Yeah. And the the patient stays awake.

SPEAKER_04 5:49

Because they go in before well, no, the patient goes asleep, but you use it as pain relief. Okay, so you use it on top of the general anesthetic as well. And for women who may who who may be like needing hysterectomy or something like that in later life, if they're going in through the like through the abdominal wall, okay, not just like keyhole surgery and not vaginal um hysterectomies, um then it's it's a good idea to have either a spinal or an epidural or something like that, um, as well as the general anesthetic, because it helps with your post-hoc pain relief and kind of recovery and that kind of stuff. So like it's not just women in labor who have epidurals, it's something that could be suggested to anybody at any point in their life if they're going for surgical procedures. And for people with back pain, with chronic back pain, um and neuropathic back pain, where say a disc is very inflamed and it's dripping inflammatory juices literally down onto a nerve and really irritating the nerve, or it's compressing a nerve. Um, sometimes uh people get epidural steroid injections into the epidural space, and that calms down that disc and the inflammation in the disc and kind of helps it to move away from the nerve a little bit, or stop dripping that inflammate inflammatory exudative stuff onto it and irritating it. So there's loads of reasons why people would have an epidural, it's not just women in labour.

SPEAKER_05 7:12

I'd say many people didn't know that.

SPEAKER_04 7:14

Well, I'd say good few people did.

SPEAKER_05 7:16

Well, yeah, well, okay. Well, I didn't.

unknown 7:18

Okay.

SPEAKER_04 7:20

I you see, I this is my problem though. Like I assume everybody knows what I know. So I that's why I have to kind of like go back to the beginning.

SPEAKER_05 7:28

Well, you've studied for you know so many years to accrue this knowledge, not many people know it, so let's let's share it. Let's go. Okay, so in labor. Well, hold on a second. Yeah. When we asked the questions, what I found was really interesting is that I normally do a weekly QA and but for this one, the speed at which I started getting the questions was incredible. There's so much curiosity there, but I also found maybe some not misinformation, but information that needs correcting, and there's a lot of fear um there as well. And that's why I thought it would be nice to have an episode geared towards addressing those things about epidurals. Sure. So before we launch into the episode, can you tell us who gets epidurals during labour?

SPEAKER_04 8:17

There's two reasons really why somebody might decide to have an epidural. They may decide that they would like an epidural or need an epidural because for pain relief. So purely elective procedure to deal with um labour pain. Okay, um, and not uh we're back to again about language, and a lot of people don't like using the word pain in relation to labor, okay. And some people think that they would rather use the word pain because that's what they feel they experienced, and they feel like they're not being heard if if somebody starts saying, Oh no, you have to say surges and stuff like that. Okay, so for some people, labour is painful, and they decide that uh an epidural is their best option for pain relief in labor in order to give them a break and make them feel like it's their best labour experience, or it gives them a greater sense of control in the situation, and that's perfectly fine. So that's one population, and then there's another population that would need what we would call a medically indicated epidural. So if you have epilepsy, if you have um certain cardiac conditions, if you have preoclampsia, if you have high blood pressure, if you have all of these kind of things, um, having an epidural in labor helps decrease your risk of what we call severe maternal morbidity. So somebody who would potentially require admission to a monitored bed like a high dependency unit or something like that, it can actually decrease the risk of that. So there was a big Scottish population study done by Rachel Cairns and it was really good. And I've said this before because what it does is it quantified the benefit of um that epidurals confer to patients, especially when they're medically indicated. Okay, so it can if if you are told you should have an epidural or consider having an epidural for a medical reason, it can drop your risk of severe maternal morbidity, so needing admission to a high dependency or an increased level of monitoring by 50%, 5-0%. So that's really significant in terms of women's health. And I just think that that is something that people, I think everybody in the world should know. And since then, now it's prompted a lot of studies into ensuring that there's equal access for all patients of all ethnicities, socioeconomics group, socioeconomic groups, and everything, just to make sure that people who have met who require medically indicated epidurals have access to it.

SPEAKER_05 10:51

Okay. Um, we'll talk about what it feels like in the process, but I think while we're on this topic, rather than sort of chop it up and go back to it, let's talk about the effect of an epidural on labour and delivery. There's a there there was in the questions a conception that it may increase the risk of tears, forceps, and epizurp.

SPEAKER_04 11:09

I love it, a conception, a perception. Did I say perception? Because we're talking about pregnancy.

SPEAKER_05 11:15

There's a perception that it increases the risk of tears, forceps, and epiz epiz I can never say this word.

SPEAKER_04 11:21

Episiotomies.

SPEAKER_05 11:22

Episiotomies, episiot episiotomies.

SPEAKER_04 11:26

Okay, excellent. Good man. You're really tongue-tied today.

SPEAKER_05 11:28

I am very tongue-tied. Although I keep harping on on how tongue-tied doesn't affect people.

SPEAKER_04 11:36

God damn it, we keep on using you're really uh I can't I can't find a word either. Okay, so hmm, again, I think we did cover this in the past episode, but I'll I'll go to it again because it seems to be an ongoing belief. Um, so there's been a lot of RCTs, double-blind RCTs, um, meta-analyses, Cochrane reviews, all of these kind of things. Epidurals in 2017 there was a Cochrane review and it looked at all of kind of the newer techniques for administering epidurals. I'm gonna go into these in more detail. We don't give the big hefty, hefty concentrations of local anesthetics anymore. We give you as little as we can get away with, is is kind of the approach, okay? Um, so to to cover as much of your discomfort while trying to keep as much of your muscle function and your your legs being minimally heavy, right? Um, and when we do that, we know that there is no increased rate of instrumental deliveries.

unknown 12:47

Yeah.

SPEAKER_04 12:48

Okay. Um, episiotomies are different because that is a decision made between either the midwife or obstetrician and the patient, depending on kind of the the kind of how the fetal head is emerging through the perineum. Okay. Um, and that's a separate thing. Okay, so but for instrumental deliveries, uh uh depending on the kind of instrument used, frequently an epesiotomy would be indicated to prevent any tearing that could result in um a tear going down toward the anus or the anal canal. Okay, yeah, so that's a different epesiotomies is slightly different, okay. So instrumental deliveries with the newer techniques of epidurals, there is no increased risk of instrumental delivery.

SPEAKER_02 13:39

Okay.

SPEAKER_04 13:39

Okay, and that's looking at big, like big numbers of populations. Okay. Things that would potentially impact that is when people have very, very dense blocks. Sometimes it that so back in the day 20, 30 years ago, when we used to use very high concentrations of local anesthetics, people would have pretty much anesthetic level blocks, like surgical level blocks, rather than just pain relief blocks, you know. Um, so it'd be like, you know, essentially giving somebody a full anesthetic instead of giving them the equivalent of like two paracetamol kind of thing, you know what I mean? Yeah. For a headache. You know what I mean? You go in and with overkill. And so if somebody has a very dense block, then potentially that can change that risk profile. But on a big number of population, the epidural per se, when you give lighter doses, doesn't change that, if that's clear enough.

SPEAKER_05 14:31

Yep. What about its impact on labor, duration of labor? We talked about this before. Yeah, we did.

SPEAKER_04 14:36

So again, we're still looking at about 40 minutes for the first stage of labor, so going from zero to 10 centimetres, and about 15 minutes for the from 10 centimeters to delivery of the baby.

SPEAKER_03 14:50

Yes.

SPEAKER_04 14:50

So 15 minutes longer for that, 40 minutes longer for the first. And that is like it's been studied again and again and again and again. And what they've done is they've needed huge numbers in the studies to account for all of the other factors that can really impact in that. Because obviously, if somebody's having a very difficult labour with and the baby's in a very awkward position as it descends through the pelvis, the mother will be will likely find that more uncomfortable.

SPEAKER_02 15:18

Yeah.

SPEAKER_04 15:18

Okay. And that labour will be longer.

SPEAKER_02 15:21

Yeah.

SPEAKER_04 15:21

Okay. And also, if the labor is just a long labor, people get very tired and they just want a break. And both of those populations will will look for an epidural more than somebody who's having uh uh an easier labor and a faster labour. So there's a there's a selection bias there that they had to account for.

SPEAKER_05 15:42

But also you mentioned before that in some women it can actually expedite labour.

SPEAKER_04 15:47

Um yeah, so that's more here. I don't, to be honest, that the data has never really looked at that because it's not saying, oh, can we speed up the labour using an epidural? The obstetricians will and the midwives will say, you know, this particular person, um, you know, if if she can get a little bit more comfortable, like her contractions are very efficient, you know, all of these things are good. It's just that she's struggling because of the pain and it just might help smooth things along. But I don't think any of us can turn around and go, in a certain X amount proportion of the population, getting an epidural means that their labor gets X minutes faster. Yeah, that data doesn't exist.

SPEAKER_05 16:31

Okay, oh there's a bit that I can talk about. Um baby outcomes. There's a lot of misconception about the impact an epidural has on babies.

SPEAKER_04 16:38

I can talk about that too, so we can both come at that one.

SPEAKER_05 16:41

Excuse me, babies is my area.

SPEAKER_04 16:43

Oh, so sorry, sorry, am I impinging? Am I overstepping?

SPEAKER_05 16:46

Stay in your lane, Dr. Doherty.

SPEAKER_04 16:47

Oh, great. Do you want to tell me about the acid-based balance and the neonates born and the huge big population studies? Hit me.

SPEAKER_05 16:55

Um maybe it can contribute a little bit. It doesn't make your baby sleepy.

SPEAKER_04 17:03

No, it doesn't.

SPEAKER_05 17:04

Okay, so there's a lot of um uh worry that it can actually make baby sleepy. And you know some of them.

SPEAKER_04 17:09

Why do you think why would people think that the epidurals make babies sleepy?

SPEAKER_05 17:12

Because that is pushed by some free birthers on the internet. And I see all the time.

SPEAKER_04 17:17

There's zero mechanism for that.

SPEAKER_05 17:20

100%. Yes.

SPEAKER_04 17:22

The ones that would actually make a baby sleepy would be things like pethidine if you have it within four hours like prior to delivering your baby because it's still in your baby system.

SPEAKER_05 17:31

And and also there is concern out there that it may impact the success of breastfeeding. But there is uh enough data, both externally meaning done outside the rotunda, and data that we have done ourselves in first-time mothers showing that when you account for confounders, an epidural does not impact breastfeeding.

SPEAKER_04 17:51

No, it does not.

SPEAKER_05 17:52

It is the reason why sometimes an epidural is required that breastfeeding may be impacted. For example, you have complications of labor or you have gestational diabetes, or you know, so when you account for these things, an epidural in itself does not have an impact.

SPEAKER_04 18:07

And just to clarify, the gestational diabetes impact on breastfeeding, is that relating to just the baby's sugars being a little bit unstable and needing to be monitoring, and therefore they're not like breast adjacent continuously.

SPEAKER_05 18:21

Not necessarily, but sometimes when breastfeeding on its own does not maintain the baby's blood sugars, and we may need to top up. Okay. And but that again, you can completely exclusively breastfeed with gestational diabetes. So I'm not saying, but it's just increases the risk. Yeah. But it's just that's just one example. So tell us about the other gobbledygook acid-based stuff that you wanted to talk about.

SPEAKER_04 18:43

Gobbledygook, excuse me. Um, yeah, notice that there's been huge again, population studies looking at outcomes, and there's no like so what people look at is kind of apgars and the uh cord blood acid base balances and stuff at delivery, and whether or not you have an epidural, the epidural in isolation does not affect any of that. Yeah, and that's really, really doesn't really important. And again, it's looking at those long, difficult labors where the baby might get tired. Okay. Um, now the one thing I will say is, and I know that there was a question in about a change in baby's heart rate relating to the epidural. That was gonna be my next question. There you go, I'm psychic. Yeah, um about 20 minutes after you have an epidural, okay, that's when it's starting to really kick in. Okay, and and again, I alluded to this before, um, because there's a balance in your body at that point in time between the hormones, the oxytocin that's driving the uterine contractions, okay, and the stress hormones that's your body's naturally producing in response to discomfort and the physiological work that your body's doing, okay. Um, they they're beta agonists, and beta agonists inhibit uterine contractions, and there's been a natural balance in somebody's body while they're in that experiencing that. And obviously, if you have quite a painful labor, you have a lot of stress hormones, a lot of beta agonists going on, um, and that's co um that's counteracting the oxytocin. So then when the epidural kicks in, sometimes because now your stress hormones drop a little bit, so the uterine um the uterine contraction um is less opposed, okay, um, which can I suppose increase the efficiency of it, but it can also increase the strength of it, and that can kind of cause a wobble in the baby's heart rate a little bit if the uterus clamps down a little bit on them.

SPEAKER_03 20:40

Okay.

SPEAKER_04 20:41

So now that usually is very transient, it can be associated with the change in maternal blood pressure as well, um, when the blood when the epidural starts to work, and that's usually about 20 minutes after it's kicked in, and that's why we always have intravenous access. So everybody has a little IV line placed before we put in an epidural, so we can give you IV fluids, we can give you any medication for blood pressure support. Um, but and that little wobble in heart rate is usually self-limiting.

SPEAKER_02 21:08

Okay.

SPEAKER_04 21:08

Okay, if there is any change in the baby's heart rate longer than a few minutes, it's usually related to like it's unmasking a stressor that was already there.

SPEAKER_03 21:21

Okay.

SPEAKER_04 21:21

Um, and the reason we can say that is because we know that overall, if you look at the big populations, that there is no impact having an epidural has on the fetal well-being in isolation.

SPEAKER_05 21:35

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SPEAKER_04 22:26

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Your support means the world to us and helps us keep bringing you the content you love. Thank you for listening and for being part of the Baby Tribe community. Okay, the bit that everybody's waiting for. What does it actually feel like? I want you to talk me through positioning, cleaning, the local anesthetic.

SPEAKER_04 23:17

The whole whammy, the full shebang.

SPEAKER_05 23:19

The main needle, the catheter. Yes, let's do it. So let's l let's roleplay.

SPEAKER_04 23:23

So I'm you're you're the needle phobic.

SPEAKER_05 23:26

I'm the needle phobic lady in the person you are. And and like I'm I'm in a lot of pain. I want an epidural, and I only want Dr. Anne to do it and nobody else.

SPEAKER_04 23:35

Stop now. Don't be weird about it.

SPEAKER_05 23:38

I want Dr. Anne to do it. Dr. Anne, talk me through it.

SPEAKER_04 23:41

Okay, well, Dr. Anne would come in and consent you, first of all, and go through the risks and benefits, and we've discussed them in depth in the other podcast so we won't go through it again. Yes. Um, and Dr. Anne would also highlight the fact that Dr. Anne has the exact same risk of complications as every other anesithist of her experience.

SPEAKER_05 23:59

Oh, yes, there was there was there was a question, I guess it's from a colleague. If you would want any of your other colleagues to do um an epidural on you, Anne, who would it be?

SPEAKER_04 24:09

I would take any and all of them.

SPEAKER_05 24:10

And why is it not Rose?

SPEAKER_04 24:12

Oh stop now, you're so mean. I would take any and all of them. They're fabulous people. There you go.

SPEAKER_05 24:18

There you go. There you go.

SPEAKER_04 24:20

Like there's a standardized kind of incidence of risks, and no matter how many thousands and thousands I have done in my career, like I know that there's an incidence of this happening. And we've talked we've talked about this. That's just the way it is, right? So I'd go in, I'd make sure that the patient is fully consented.

SPEAKER_02 24:38

Okay, I'm just really important.

SPEAKER_04 24:40

And that's done not just because of medical, legal, and ethical requirements, but out of respect to the person as well, you know? Um, because I always say this is very much a team approach, okay? And the patient is a hugely important part of the team, okay? So the patient would she would always have an IV-sighted before we do anything, because as a fief would, as would happen with the fief, a fief could get a strong weakness when I go at him with an epidural needle out of sheer nerves. But that's okay too. Um, and then what happens is you get into position, okay? So the position that people would ideally need is sitting upright and in a very kind of slouchy position, nearly like a little banana position, okay? If that helps you, where kind of your back is rounded, okay, right? Not arched, rounded, so bad posture essentially.

SPEAKER_02 25:35

Okay.

SPEAKER_04 25:36

We don't need you tied into some kind of pretzel situation where it takes months of yoga to prepare for the epidural position. We just need somebody in a position where their lower back is quite rounded as much as possible.

SPEAKER_05 25:47

And does that open up the vertebral spaces for you?

SPEAKER_04 25:50

It does. If you can kind of think like the vertebrae, the back part of the vertebrae kind of overlap each other.

SPEAKER_03 25:56

Yeah.

SPEAKER_04 25:56

And when you curl into that position, it kind of opens up the chinks in the armor, if you know what I mean, and gives people an opportunity to find the little pathway in.

SPEAKER_05 26:04

Okay, so so I'm hunched over, and what are you doing next?

SPEAKER_04 26:07

So the next thing that happens is your back is sprayed down with um uh a sterilizing spray just to soup keep everything super duper clean. Okay. Okay, it's bloody freezing cold. It feels very cold. It feels like we put it in the fridge, but I promise we don't.

SPEAKER_02 26:22

Okay.

SPEAKER_04 26:23

Okay, it's just that it also, as well as the chlorhexidine, it contains alcohol, and alcohol evaporates off the body very quickly and it takes a lot of the heat with it, and that's why it feels cold.

SPEAKER_05 26:32

That's why it feels cold when you rub it on your hand. Yeah. Oh.

SPEAKER_04 26:36

Did you not know that?

SPEAKER_05 26:37

Uh yeah, I did.

SPEAKER_04 26:39

I'm just now that's why. Okay. Okay, so that's why it feels very cold. It feels like it actually feels like going for a spray tan.

SPEAKER_05 26:46

Yeah, okay. All right, okay.

SPEAKER_04 26:47

Okay.

SPEAKER_05 26:48

Okay, so you've done that. Do you give me a local anesthetic?

SPEAKER_04 26:51

So stop running ahead now.

SPEAKER_05 26:53

Sorry.

SPEAKER_04 26:53

So we do that, spray you down, and then um a uh a plastic, a sterile plastic drape goes on your back. Okay, again, just keeping everything super, super sterile, okay. Um, um the anesthetist looking after you will have already done an equipment check on the what's available, what needs to be on the tray. All of this is done sterily, and they'll have done a two-person medication check with the midwife who's also looking after you, to just so two people check all of the medications that's going in, and that's just a safety precaution. Yeah. Two pairs of eyes are both. So you'll hear that happening behind you. You'll hear that happening as well. That's them. That is that is a very safe, standardized thing to do. Yeah. Okay. Um, and then what happens is ideally the anesthesia will be chatting to you. You're going to be getting contractions. We know you're going to be getting contractions, okay? And generally we do a team approach where you tell us when the contraction is ebbing off or when you feel like it's a good time to start, and we start then. Okay. You'll feel somebody feeling your hips and feeling your back and finding the right level and the right place to start at. And we start.

SPEAKER_05 28:03

And is it lower? It's lower back, isn't it?

SPEAKER_04 28:05

It's lower back and it's below the level where the spinal cord would end. So where you're going in is mainly fluid with a little bit of free-floating nerves.

SPEAKER_02 28:13

Okay.

SPEAKER_04 28:14

Um, if you were doing a spinal, yes. Okay. For an epidural, you're stopping short of that fluid level. You're coming out, you're outside the little sack of fluid, but we always go lower than the level of the spinal cord. Yeah. Okay. Um, so then what happens is you get a little um local anesthetic injection into your back, and that feels like a bee sting.

SPEAKER_05 28:34

Okay, that's sore.

SPEAKER_04 28:35

It's it's it's really stingy. Yeah. It is really stingy. Okay, and that's what? And that's lignocaine, a local anesthetic to numb the skin and just the subcutaneous tissues.

SPEAKER_05 28:45

And how soon does it start numbing the skin?

SPEAKER_04 28:47

Pretty much straight away. Within a minute, like you you will you'll feel just pressure then. Okay. Okay. So if you get your knuckle and you rub it on on your forearm or on the muscle up in your upper arm, that achy little pressure you feel is what you would feel then.

SPEAKER_02 29:03

Okay.

SPEAKER_04 29:04

Okay. So what happens is when it's a good time to start and everybody's in this in a good place, the anaesthetist will then start to insert the epidural needle. Okay.

SPEAKER_05 29:13

That's the big needle that people talk about.

SPEAKER_04 29:15

That's the epidural needle.

SPEAKER_05 29:17

Okay.

SPEAKER_04 29:18

It's the same width as probably the cannula that went into your hand. Yeah. Because we usually put in an 18-gauge cannula and it's an 18-gauge epidural needle. It just looks dramatic, but it's it's the same width.

SPEAKER_05 29:28

Yeah. Right? So the length doesn't really matter.

SPEAKER_04 29:31

The length is there because and it's it's graduated by centimeters. So we can see how many centimeters it took to get to that person's epidural space and then know how many centimeters of catheter to leave in that epidural space. So we can calculate what the right length for you is.

SPEAKER_05 29:51

And the reason it it is long is because in some patients the fat layer between the skin and the vertebral body varies.

SPEAKER_04 30:02

Everybody's it's different. You know, like I've seen people with very shallow epidural spaces of about three centimeters from their skin. Yeah. And I've seen people with epidural spaces of 10, 11, 12 centimetres, depending on how their body is arranged.

SPEAKER_05 30:16

Okay. So in terms of the patient, once that needle goes in and they feel that pressure, because it is sort of um there's a local anesthetic there, what happens next? You thread a catheter in.

SPEAKER_04 30:30

So for the pressure is there, yeah. Okay. And often there'll be a communication with the very nice patient about how it feels, whether it feels markedly on one side or the other. And the reason is that we are trying to go as close to spang on midline, and I mean midline within millimeters.

SPEAKER_02 30:48

Yeah.

SPEAKER_04 30:48

Okay. To try and hit the middle of a triangle, which is very hard to do.

SPEAKER_02 30:53

Yeah.

SPEAKER_04 30:54

Okay. Um, and the reason why we want to do that is we want to do our best to optimize the position of the catheter and optimize the spread of the local anesthetic.

SPEAKER_02 31:03

Yeah. Okay.

SPEAKER_04 31:04

It's very hard to hit the center of a triangle.

SPEAKER_02 31:06

Yeah.

SPEAKER_04 31:07

Blind. So, because you can't see where you're going. It's all done by touch and feel. So when we when it's a loss of resistance technique, so when we lose resistance on the needle, okay, through a little syringe that we're measuring, okay, with either saline or air in it.

SPEAKER_06 31:22

Yeah.

SPEAKER_04 31:23

Um, when we lose that resistance, we know we're in we're in this potential space. And it's called a potential space because what it is is it's not just a space that's sitting in your body waiting to be filled up like a cup, right? What it is is it's it's between two layers of ligament tissue.

SPEAKER_02 31:40

Yeah.

SPEAKER_04 31:41

Okay. Um, and we go in with a needle, and already in there are blood vessels, it's there's nerves adjacent to it on each side, okay, which is another reason why we try and hit it bang on to avoid those, okay. Um, because that can be uh it can give people a little jump in their leg or a little shoot, and people don't like that, obviously. Yeah, um, but it if you do get that, it doesn't mean that anything harmful has happened, it just and it you can't control it either. It's us, right? It's just it stimulates that nerve to jump a bit, um so and there's little just normal fat tissue and all those kind of things in there, okay? So we go in and we thread in the catheter, okay. We usually leave about four or five centimeters of catheter in the epidural space, and when that is threading, it feels like a weird little scratchy sensation in your back.

SPEAKER_02 32:31

Okay.

SPEAKER_04 32:31

Okay, not horrendously scary or horrendously painful or anything like that, just weird. It just feels weird, okay. Um, and then the needle comes out and the catheter stays in. And through that catheter, then we can give you some local anesthetics that essentially works like a dental block works. When you go to the dentist and you get that numbing injection, it's local anesthetics along the track of a nerve that numbs the nerve. And that's essentially what we're doing. Yeah, and that's what an epidural is.

SPEAKER_05 33:00

And again, we spoke about this before, but it's worth mentioning is that it reduces the pain, but you still feel pressure.

SPEAKER_04 33:07

So this is it, right? Back in the day, as I keep on saying, back a long time ago, we used to go in with very hefty concentrations of local anesthetic, okay? Um, anaesthetic concentrations. Because if you think about it, like different stimuluses are going to need different levels of numbing, okay? For something that is a physiological process, but it can be a painful physiological process, that is still different than a surgical stimulus where somebody's performing surgery on you. Yeah. So there should be a difference in the local anesthetic that's given to you in terms of its concentration. You shouldn't like most people wouldn't need the same level of numbing for the former as they would the latter. Is that fair?

SPEAKER_05 33:53

Yes.

SPEAKER_04 33:54

Okay. So what we've tried to do over decades is find a sweet spot and balance it between the amount of pain relief that somebody would need to give them a sense of comfort and control in while doing a tough job.

SPEAKER_02 34:11

Yes.

SPEAKER_04 34:12

Okay. Um, and not go down the road of giving everybody the same.

SPEAKER_02 34:16

Yeah.

SPEAKER_04 34:17

Okay. Um, so and this is where we talk about walking epidurals as well.

SPEAKER_05 34:22

We'll mention walking epidurals in a couple of times.

SPEAKER_04 34:24

Because all of this comes down to the same thing. Yes. Okay. You want to give somebody as little as they need to give them the best experience. Okay. But so pain relief and maternal satisfaction are linked, but not actually necessarily the same thing.

SPEAKER_03 34:41

Yeah.

SPEAKER_04 34:42

So what would give me the best experience isn't necessarily what would give the person beside me the next experience, the best experience for them. And part of it is because my labor is going to be different to hers, my baby might be in a different position, facing a different way to her baby. So the stimulation is going to be different.

SPEAKER_02 35:01

Yeah.

SPEAKER_04 35:02

Okay. Um, but also I might be okay with feeling some discomfort because once it's manageable, I'm okay with that.

SPEAKER_03 35:10

Yes.

SPEAKER_04 35:11

But she might feel like I really hate the pain, it's freaking me out. I feel like I'm going to lose control. I need to be a little bit number.

SPEAKER_05 35:19

And that is that is completely okay. Yeah. And I I wanted to ask you before we talk about walking epidurals is how do you support anxious patients? You're very good at that, I have to say.

SPEAKER_04 35:29

Um He's never in the room when I'm doing it.

SPEAKER_05 35:31

So I because the women tell me when I check their babies.

SPEAKER_04 35:38

Anyway, communication, it all comes down to communication, and that is always going to be the case for everything.

SPEAKER_02 35:44

Yeah.

SPEAKER_04 35:45

The drugs will do so much, but again, every woman needs to be given information in a context that is relevant to them.

SPEAKER_02 35:55

Yeah.

SPEAKER_04 35:56

And I think if people receive information in the context that is relevant to them, they then make an informed decision that is right for them. Yeah. And therefore, they are less anxious. It to me, it kind of comes down to just that.

SPEAKER_02 36:10

Yeah.

SPEAKER_04 36:10

You know? And often if an epidural isn't providing the kind of pain relief that uh somebody needs it to provide, like uh there's no point in me going in, going, Oh, this is the problem. Like, if you if I ask the very nice person who's perfectly compass mentis and able to express herself exactly what she's experiencing versus what she needs it to be, that's the starting point. And then I'll try and figure it out.

SPEAKER_05 36:35

Let's briefly talk about walking epidurals. A lot of mums have asked about that. What is it?

SPEAKER_04 36:40

So a walking epidural is essentially you get an epidural placed, okay? Same process, same process, and then essentially the medications are limited. So the kind of local anesthetics that's that's used tries to minimize the impact on the nerve supplying your muscles, so to optimize your muscle power, um, but also the dosing would be quite limited. So this would not be an epidural that you are necessarily, you know, completely comfortable with and never have any pain. This is an epidural that there is a trade-off. So, with all of this, there's a trade-off because the dosing will kind of determine how much your muscles are affected. And if you need to be mobile, you need little or no weakness in your muscles to be safe. Yes. So, therefore, your dosing will also always be lower than that needed to affect muscle power. Yes. In that situation, then often there is some residual discomfort, but it's manageable.

SPEAKER_05 37:46

Yeah.

SPEAKER_04 37:46

Um, and again, so that's again down to maternal satisfaction stuff.

SPEAKER_05 37:50

And I was gonna ask, why would somebody want to walk in epidural?

SPEAKER_04 37:52

Birth is a physiological process, yes, um, and mobility in birth is hugely beneficial, and being people being able to maintain their mobility, people being able to be free in the positions that they choose to give birth in and stuff like that, is is and that level of autonomy is very, very important to people sometimes. Um, and then there are other women who are like, just take the pain away, and I'm happy to go side to side with the peanut ball and stay in bed because I'm bloody wrecked this journey's been going on for two days already, you know. So, again, maternal satisfaction is very different for different people's experiences, but not every hospital offers mobile epidurals. I know the coom does at the moment.

SPEAKER_05 38:32

So why not?

SPEAKER_04 38:33

Um, part of it is staffing, part of it is I suppose drug availability, um, part of it is just the available training. Because if you have a mobile epidural, right, you every time you press it, okay, so there's no continuous automatic drugs given, okay? You get a limited dose, and then 20 minutes later there's a check done to make sure that you have enough muscle power and everything's good that you can mobilize within a limited area, okay, under direct supervision at all times, okay, and then you see how you can work with the pain relief that is offered by that dose, and then see how you go for a while.

SPEAKER_02 39:17

Okay.

SPEAKER_04 39:18

You know, so again, it is it's it's uh every time you get some epidural medication 20 minutes later, you have to have that checked on. Then you you can mobilize if you fulfill the requirements to show that your muscles are still good and strong and you're safe.

SPEAKER_05 39:33

So there's there's trade, there's a trade-off, yeah.

SPEAKER_04 39:35

There is there's a trade-off in pain control uh versus autonomy, and again, you know, if you're labouring very well and and things are progressing and your labour isn't very difficult, that may be all you need. Yes, right, but again, it depends on the situation. Okay, you know, so it's just one of the things, but it it it's it's um it's not available for everyone, and it's not available in every hospital.

SPEAKER_05 40:01

Why do epidurals sometimes fail?

SPEAKER_04 40:03

There's a lot of reasons they can fail mechanically and pharmacologically, okay. Okay, and um and I suppose to a degree they can fail because they don't keep up with the physiology. Okay. Okay. So mechanically, because we we try and hit the middle of a triangle that we can't see, okay? It sounds improbable. We we do it all the time, okay? It's done by touch, right? So because we try and hit that middle of a triangle, it's very hard to so inevitably it will usually lie slightly to one side or the other. So people will often have be slightly number on one side than the other, okay? And to overcome that, what we try and do is use um the the spread of the local anesthetic to try and spread it evenly. So we use a volume, low concentration, higher volumes at a pressure that will give you good spread, that is still safe, okay. Um and sometimes if the epidural catheter is too far over to one side, you just can't overcome that, okay. And sometimes if the epidural catheter has not threaded into that space between those ligament layers, those tissue layers, it's not going to spread where you want it to either. And it just needs to be recycled. These are all placement issues, mechanical issues, mechanical issues, yeah. Pharmacological, okay. If you just happen to be unlucky and you need a higher concentration or a different medication to hit that particular kind of pain. So if the baby is uh kind of sunny side up where they're facing their the back of their head is against your sacrum, yeah, bloody sore, it it it that's that's a a tough labor to the labor pain to get on top of, and local anesthetics won't necessarily do it. So you may need a different medication, okay, or a higher concentration and just accept the muscle weakness, yeah, depending on again, these are conversations to have with somebody, you know. Um, and then the last thing is the physiological bit. So if you get an epidural, it takes about I'd say 90 minutes probably to really start to cover your perineal region because that comes the the the uterus nerves come off at the lumbar region, okay, and then the perineum and the lower vagina, those nerves come off at the sacrum, okay, come out of the sacrum. And it takes a while for the epidural to sink enough down and numb those nerves. So if the baby gets ahead of us and you labour quite quickly and you deliver within, I'd say about 90 minutes of having epidural, your perineum may not be fully numb, and you may feel all of a sudden I can feel the head. Um, and and that is just a a kind of a factor of how low how epidurals work.

SPEAKER_05 42:55

Yeah.

SPEAKER_04 42:56

And it it was it just the baby ran ahead of us.

SPEAKER_05 42:59

Um are there any situations where there is an anatomical reason for the epidural not to work? Because I've had a couple of mums get a message saying that it didn't work on three different occasions on the like is there scar tissue or some anatomical reasons why that might happen?

SPEAKER_04 43:17

People who do have scoliosis, it can be challenging. Now, it doesn't mean that they have like I can't comment on any individual cases because I don't know.

SPEAKER_05 43:27

Yeah, no, what I what I'm saying is most of the time Do you see anatomical reasons why it might be?

SPEAKER_04 43:31

So most of the time, if an epidural doesn't work on one occasion, um it's the epidural, it's it's just it didn't sit the way we wanted it to. It's one of the above reasons, okay, and it's nothing to do with the patient, their back is perfect and they're a perfectly normal person. Okay. If it's a recurring issue, um it's it's hard to know. Like this could be somebody who labours very quickly, and their version of it not working was I could feel. The baby crowning, and it's just that we can't get ahead of it. Yeah. Okay. It could be that again, their labor is they feel a lot of the bone pain and they need a different drug.

SPEAKER_02 44:10

Yeah.

SPEAKER_04 44:10

Okay. It could be that sometimes with people who have scoliosis, it's not actually a curve, it's more of a rotation. And it's very hard when something, when you think something is straight ahead, but it's not, it's veering off to the left, but you can't see that. So it's it's hard to do that. And then the other times that epidurals, you have a much higher chance of an epidural not working for you if you've had um instrumentation in your back. So spinal fusions for scoliosis, those kind of things, you have a much higher chance of having a problem because if if a neurosurgeon has gone into your back and done multi-level spinal fusions or those kind of things, you may not have an epidural space because it'll heal by scar tissue and that's very sticky.

SPEAKER_05 45:00

Yeah, that's a good point.

SPEAKER_04 45:01

Um so you might not have an epidural space to go into. Okay. Um it doesn't mean you can't have a spinal, though, that's a different thing.

SPEAKER_05 45:06

Yeah, are there any neurological conditions? Um like MS, for example?

SPEAKER_04 45:11

Okay, so no, people with MS can have epidurals. Okay, there used to be a whole caveat around it, but really again, it's it's an informed consent situation.

SPEAKER_03 45:22

Okay.

SPEAKER_04 45:23

I've had people with a history of MS say, please, I don't want any local anesthetics, so I'd prefer a general anesthetic if I needed to have a spinal, and I definitely don't want an epidural, and that's perfectly reasonable, that's fine. Nobody is going to sneak up on you with an epidural or a spinal, I promise. Um with those kind of neurological conditions, because local anesthetics act on nerves, right? This is something that people may not know, okay? Every drug that you take to act on a part of your body is actually a poison. The only thing that's stopping it being a poison is the dose, yeah, right? And that's why pharmacology and pharmacy is so nuanced, researched, regulated, and overseen. Okay, because everything that you take that is a medicine in the wrong dose is a poison, okay? But what we know with people who have degenerative neurological conditions is that the local anesthetics, because they act on nerves, those nerves can be far more sensitive to kind of um to those local anesthetics if they're injured. Okay, so it can unmask plaques that were previously asymptomatic, you can get delayed recovery of previously um of kind of if you have a neuropathy, it can you can get delayed recovery again from that, yeah. From the having a spinal nerve, uh an epidural there because it's acting on the nerves that were previously injured.

SPEAKER_05 46:54

Okay. Um when is it too late to have an epidural? Now I heard one Anissa to say when you're walking out with a baby out of the house.

SPEAKER_01 47:01

Oh, that's my lovely colleague, yeah.

SPEAKER_05 47:05

Um so But practically, when is it too late?

SPEAKER_04 47:08

I suppose when you're crowning.

SPEAKER_05 47:09

When you're crowning, yeah.

SPEAKER_04 47:11

So it depends, right? An epidural itself, as we talked about, yeah, if you want it to cover the the very late stages of birth and delivery, and women will know what I mean when I talk about the ring of fire, it is where the baby's head is crowning and you get tenting of the perennium. And you know, people experience that even if they've had an epidural an hour ago because the local anesthetic hasn't spread, okay, and they've laboured really quickly. Um, so you know, in hindsight, uh a combined spinal epidural or something like that, because the spinal acts quicker would have been useful, but again, you don't always know that that's going to be the case.

SPEAKER_03 47:48

Yeah.

SPEAKER_04 47:48

So, you know, if you're actively delivering your baby, given that it takes, you know, 10 or 15 minutes to cite the epidural, probably, and another 10 or 15 minutes for it to really start to work, and it's going to take an hour and a half for it to cover crowning.

SPEAKER_05 48:03

Like, yeah, there's no point.

SPEAKER_04 48:05

I I think that probably what's happening is you're gonna take on the risk of the procedure without necessarily getting the benefit of the epidural. But we come to the room all the time in those situations and try and help regardless.

SPEAKER_05 48:20

Yeah. We did talk extensively about the side effects and things that can happen after an epidural in the previous episode. We're not gonna dwell on it again. And the long-term effects, if any, we talked about that as well in the previous episode. So please go back. One question, one burning question people had was how many babies were named after you, Anne, after putting an epidural in mums?

SPEAKER_04 48:40

None that I know of.

SPEAKER_05 48:41

Yeah, nobody, nobody, nobody says Anne. Nobody uses the name Anne anymore.

SPEAKER_04 48:45

No, but I'm okay with that.

SPEAKER_05 48:47

Anne is a lovely name. I think more girls should be called Anne.

SPEAKER_04 48:51

I think I actually think that everybody should just call their baby who they want. How they want to call their baby. It's perfectly fine. I don't think I I don't it doesn't make a difference.

SPEAKER_05 49:02

You had an epidural, didn't you?

SPEAKER_04 49:04

I had two spinals for two C-sections.

SPEAKER_05 49:06

Yeah. How like how is it for you getting it done?

SPEAKER_04 49:09

It was fine.

SPEAKER_05 49:10

Anne is so brave when it comes to these things.

SPEAKER_04 49:12

You just have to go with it like, yeah. Um the other question that I wanted to talk about actually was people were talking about nerve uh delayed recovery from epidurals in terms of nerve weakness and stuff like that, and I wanted to address that. Do that, okay, because I do think that it is something that is it's one of those um kind of misleading things. Okay. Okay. So when we look at, and there's been extensive looks at this, okay. The chances of having permanent nerve injury, okay, and I this is like literally a num a small numb patch that just never recovers, okay, is one in the tens of thousands. And the nerve injury related to epidural's permanent nerve injury goes all the way up to like one in 170,000 for like a little blood clot that would put pressure on your spinal cord. That's one in 170,000. And you have to remember that p patients when they're pregnant are very, very clotty, so they tend not to bleed very much at all in terms of like small injuries. It's different in terms of delivery people can bleed. That's the a whole other situation. Um, but so the the chances of permanent nerve injury from a spinal ana from an epidural is is really really small. The vast majority of kind of dead legs and kind of dragging foot feet and stuff like that that happen actually are related to the delivery process itself, not necessarily the midwives or the obstetricians.

SPEAKER_05 50:45

It's damn it, can we not blame them?

SPEAKER_04 50:46

Well, no, no, because it it really isn't like there's there's so many points in your pelvis that your baby's head can put pressure on the nerves that run down along the side walls of your pelvis, and people don't think about it. And then between that and things like being um in a pushing position or squatting position for a long period of time, you can impinge your femoral nerve, your obturator nerve. Um, being in stirrups for a while, though, as well, you can get a little drop foot. But most of these things do recover within days, if not weeks. And the things that people that we worry about as anaesthetists and what we would screen and see people for are if you have an epidural or a spinal anesthetic, four hours after your last dose, you should be able to lift your heels off the bed. That's all you have to be able to do. Okay, and if you can't do that, and most hospitals actually pop little bracelets on people now to remind them to try and do that after four hours. If you can't do that, then let your midwife know, they'll call us, okay, and we'll come and say hi. And it's a really useful early screening for any central neurological issues, okay. Um that would be exceedingly rare, yeah. Okay, and usually if there was any evolving central neurological issues related to an epidural or spinal, it would most likely affect both legs and most likely be progressive. So you'd get a progression of symptoms, sensory and muscle weakness, okay? Uh in both legs. Okay. Most of the obstetric neuropathies, and they're called obstetric neuropathies because it's related to obstetrics and having a baby, not because the obstetrician comes in and makes it happen to you. Um, but it the obstetric neuropathies related to the birth itself, they are usually one-sided. Now they can be quite dense. There's a very small minority of people who have a quite a dense, heavy leg for a period of time, but with good physio, it does usually recover, and it can take a period of days, if not weeks, but it does usually recover.

unknown 52:59

Okay.

SPEAKER_04 52:59

And I just wanted to clear that up.

SPEAKER_05 53:02

And the shit that women go through, sort of. I swear to God, I don't know how men are in positions of power and not women because Do you know what?

SPEAKER_04 53:08

It's because they don't know. It's because they don't know.

SPEAKER_05 53:12

Like, I I I would I would fail as a woman. Seriously, like I was like, I would not.

SPEAKER_04 53:19

I think you'd be fine.

SPEAKER_05 53:21

No, I would not.

SPEAKER_04 53:22

Like I said, we train for this. We train from this from when we are smaller FIFA. I swear. It's crazy. Our brains and our bodies, we train for this. It's crazy. I know we're elite athletes, athletes, we're fabulous.

SPEAKER_05 53:32

I know. Women like the bodies. The like the the the oh no.

SPEAKER_04 53:37

Anyway, what's the name of that um American comedian? What's her name again that you really like?

SPEAKER_05 53:42

Janine Harooney.

SPEAKER_04 53:44

Oh, yeah, yeah, yeah, yeah, yeah. I saw her um a clip from her on Instagram, and she was like, So I gave birth to my child, and everyone's like, Yay! And she goes, 'I am a god. My husband is an ingredient.' And I just kind of thought, fair.

SPEAKER_05 54:00

Yeah.

SPEAKER_04 54:00

And also, but then dads kick in, and dads are fab. But in terms of the pregnancy, yeah, we are fabulous. And no, you couldn't even.

SPEAKER_05 54:09

No, no. And I just want to end on a positive note that most epidurals work perfectly.

SPEAKER_04 54:14

No, they don't. Most epidurals work well.

SPEAKER_05 54:17

Most epidurals work well. Um, Anne is the best anaesthetist in the world. That's not true either. And you'd be lucky to have her.

SPEAKER_04 54:26

No, I think I'd happily work with any patient and be on her team, but that's different.

SPEAKER_05 54:31

Excellent. Well, until next time, thank you for listening. And please remember to subscribe, rate, review, and follow because Anne gets really upset if you guys don't give us good ratings.

SPEAKER_01 54:42

Again, completely untrue.

SPEAKER_05 54:43

The Baby Tribe is proudly sponsored by Happytummy.ie, the exclusive distributor of Bayagaya probiotics, providing support for gut and oral health for the whole family.

SPEAKER_00 54:54

This show is part of the Headstuff Podcast Network, a hub for the creative and the curious. Shows are produced in association with Headstuff and the Podcast Studios Dublin. Find out more or become a member at Headstuff Podcasts.com.