The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS,
a homebirth midwife in Mountain View, CA
The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS,
a homebirth midwife in Mountain View, CA
|
The AMA wants to make birth centers illegal, along with homebirths,
even though
Read more about the ACOG 2008 Press Release from The Big Push for Midwives and Childbirth Connections You can also educate yourself week-by-week in your pregnancy with theLamaze Weekly Pregnancy Newsletter for Parents |
See also: Posterior and Epidurals
Quiz: Is a natural childbirth
right for you? from Dr. Gayle Peterson
Aletha Solter's new book, Raising
Drug-Free Kids: 100 Tips for Parents, begins at conception and includes
a discussion of how the drugs used in
labor and birth predispose children towards drug abuse.
Weighing
the Pros and Cons of the Epidural By Penny Simkin
A routine epidural turns deadly - Julie Ellis and Chris LeMoult were excited parents-to-be. Did a hospital infection turn the happiest day of their lives into a nightmare? [Dateline NBC 6/4/06]
What happened to Julie? - What started out as one of the happiest days
in a family's life ended as the most tragic. Did a hospital infection cause
an apparently healthy 28-year-old woman to be in critical condition?
The
risk of cesarean delivery with neuraxial analgesia given early versus late
in labor.
Wong CA, Scavone BM, Peaceman AM, McCarthy RJ, Sullivan JT, Diaz NT,
Yaghmour E, Marcus RJ, Sherwani SS, Sproviero MT, Yilmaz M, Patel R, Robles
C, Grouper S.
N Engl J Med. 2005 Feb 17;352(7):655-65.
CONCLUSIONS: Neuraxial analgesia in early labor did not increase the rate of cesarean delivery, and it provided better analgesia and resulted in a shorter duration of labor than systemic analgesia.
Read the critique, When
Research is Flawed: Does the Timing of an Epidural Influence Risk for C-Section?
by Henci Goer
There's been a lot of criticism about the methodology of the above study . . . in particular, their "control" group still involved epidurals; there was no comparison to unmedicated labors. Here's a good rebuttal:
They've also got some other great articles on "and evidence-based guidance for pregnant women,
Epidural
Analgesia During Labor Tied to Improved Neonatal Acid-Base Status [medscape
registration is free]
"Jan 23, 2003 - Although epidural analgesia during labor may be linked
to short-term maternal side effects, its beneficial effects on neonatal
acid-base status probably outweigh these adverse effects, according to
a recent report." Gee, that just about makes epidurals sound like
the greatest thing since sliced bread, right? Well, not if you read
the fine print. 'Analysis of data from the randomized studies revealed
that epidural analgesia was associated with significantly higher fetal
pHs than was systemic opioid analgesia. " Yep. I'll be the
first to say that systemic opioid analgesia (i.e. IV narcotics - e.g. stadol,
nubain, fentanyl) is worse for the baby, but has medicine so given up on
rational discourse that nobody thought to consider how either of these
compared to birth without any drugs other than the mother's own endorphines
- nature's own pain relief. (NOTE - women who labor in anxiety-producing
environments without adequate labor support will not be relaxed enough
to benefit from the endorphines nature provides along with contractions;
they may well feel that they need some pain relief, and epidurals do seem
to be less damaging to the baby than IV narcotics.)
Fear, Pain
and Epidurals ~by Lisa Bobrow - about epidurals and alternatives from
a mother's point of view.
FDA APPROVED
OBSTETRICS DRUGS: THEIR EFFECTS ON MOTHER AND BABY
This is a fabulous article from Mothering
Magazine:
Epidural
Epidemic - Drugs in Labor: Are They Really Necessary. . . or Even Safe?
FDA APPROVED OBSTETRICS
DRUGS: THEIR EFFECTS ON MOTHER AND BABY by Doris Haire
Drugs
in Labour: What Effects Do They Have Twenty Years Hence?
Drugs
& Labor: A Special Report (from Mothering
Magazine)
Pain
- with a Purpose: A Doctor Speaks
For those of you in hospital settings, especially, are you still seeing
a lot of demerol being used for moms who don't get epidurals and want meds?
I have never been particularly impressed with demerol as a pain reliever
and I am wondering how it got to be so widely used when other medications
are potentially more effective in relieving pain..... thoughts anyone?
Maybe this is one that some of our physician colleagues on the list have
more insight into.
My experience agrees with yours and I have met only a few midwives who
like demerol.
Male-medical-model driven! Probably right up there with how episiotomies
got to be used so injudiciously!
Pharmacologist Tom Hale, author of "Medications and Mothers Milk" has
recommended against meperidine (demerol) use in labor and post-partum because
it has an active metabolite (normeperidine) with a half life in newborns
of over 50 hours. He believes this leads to excessive sedation and failure
to breastfeed effectively for the first few days of life. He prefers alfentanil
and sufentanil for epidurals and morphine for parenteral administration,
if any narcotic is given.
I have never been particularly impressed with demerol as a pain reliever.
I can manage (I hate that word!) most moms so that they labor drug free.
But there is that small percentage (abuse victims, prolonged latent/prodromal,
abnormal labors) where a narcotic is indicated.
If so, I like to use a narcotic that is pure narcotic (not agonist/antagonist
like nubain or stadol), does not have a toxic metabolite (like meperidine/pethidine/demerol)
and has a proven track record of efficacy. Hence morphine. I agree, it's
a very controversial opinion to hold. But it is carefully thought through.
I do not know of much real research on the efficacy of various narcotics
in labor, just a few studies comparing narcotic to epidural.
I have long held the controversial and minority opinion that if a woman
in labor truly needs a narcotic medication (and that is another can of
worms I won't address just now) that morphine is safer and more effective
than demerol, both for her and her baby. All narcotics carry risks, the
most widely disseminated one being that of fetal respiratory depression.
Morphine, being a pure agonist narcotic, is readily and completely reversed
by Narcan, something that doesn't seem to be true of Nubain and Stadol.
It also doesn't have the toxic metabolite (normeperidine) that Brazelton's
studies in the 1960s showed hung around in the newborn for a week after
mom's intrapartum exposure. It also works very well.
I, too, like Morphine. When a mom has been going at the latent phase
for "days" and doesn't seem to be getting any rest I would prefer to start
out with Vistaril 100mg IM. This is because I can send her home after the
injection. The hospital policy states that any mom given Morphine must
stay. But if the mom looks truly wasted, doesn't have a quiet supportive
environment to go to, dehydrated, support people aren't, etc..... I will
admit her and "sleep" her. I don't use Seconal in combination with the
Morphine. Some do. When she wakes, if she is in active labor--GREAT. If
not in labor--GREAT. She got some much needed sleep and can now get on
with whatever she needs to do--labor or continue to rest.
Why not just give her Vistaril 100mg po to take home and take once she's
home. This usually works, although occasionally women describe not being
relaxed after taking it.
Because I used to give PO Vistaril and didn't get the results that I
get with IM. Too many pts were back in two hours complaining of no relief.
So I have gone to IM as my first choice.
Like others, I never use seconal. Too much hangover for mom, FH is not
reactive (so the nurses get upset and want to do continuous monitoring.....and
that's a whole big fight to get mom off the monitor once she is in active
labor).
Having come from a place where (as a labor nurse eons ago) Demerol was
the only narcotic available, I will NEVER use it again! Too much
vomiting, and the metabolite (normeperidine) lasts longer than the demerol
itself, and it has a much longer lasting respiratory depressive effect
on the neonate.
We use nubain/vistaril if necessary in labor. Not great, but
no vomiting, no major probs with the newborn. (of course my favorite pain
relief measure is the shower!)
Gas
and Air - This is a 50-50 mixture of nitrous oxide and oxygen that
you inhale through a mask or mouthpiece. It acts in about 30 seconds and
makes you light-headed for a minute or so before wearing off.
It enters your bloodstream and crosses the placenta, but in tiny amounts
as it's exhaled almost immediately. It has little effect on your baby .
"Gas and air" appears to be used frequently in the UK as a self-administered
relaxing agent, both in and out-of-hospital.
In some ways, I think it would be a fabulous option for women in the
US as well. I've heard that some hospitals are starting to offer
it, and I would like to see its use investigated for homebirth as well.
Fentanyl
during labor may impede breastfeeding
The impact of intrapartum analgesia on infant feeding
Conclusions A dose response relationship between fentanyl and
artificial feeding has not been reported elsewhere. When well-established
determinants of infant feeding are accounted for, intrapartum fentanyl
may impede establishment of breastfeeding, particularly at higher doses.
Phenobarbital Linked to Lower IQ
I see a small amount of Demerol here in eastern Atlanta. The drug of
choice seems to be Stadol. Some Nubain, and Fentanyl for short term relief
(< 1 hour).
I've seen the same thing. I ordered Stadol and phenergan once and the
nurses and other midwives thought I was from another planet. I really hate
Nubain and there is a pretty good article in the green journal discussing
the woes of Nubain's effect on the fetal heart rate tracing (will look
for it if someone wants the exact citation).
Comparison
of the effects of meperidine and nalbuphine on intrapartum fetal heart
rate tracings.
Effect
of labor analgesia with nalbuphine hydrochloride on fetal response to vibroacoustic
stimulation.
Comparison
of the effects of meperidine and nalbuphine on intrapartum fetal heart
rate tracings.
[Post-asphyctic
encephalopathy of the neonate following administration of nalbuphine during
childbirth].
[Opiate
analgesia in labor--use of nalbuphine in comparison with administration
of the combination Dolantin/Atosil/Haldol].
Sinusoidal
fetal heart rate pattern after administration of nalbuphine.
Intravenous
pethidine and nalbuphine during labor: a prospective double-blind comparative
study.
Issue 95, July/August 1999
By Joanne Dozer and Shannon Baruth
Epidurals:
What No OneTells You About
The
Cascade of Interventions
Epidural's
Effects on Babies
Self-Esteem
and Positive Birth Experience
Demerol
Morphine
Morphine as a Uterotonic
When John Hobbins was at Yale as Chief of OB (he has since married a midwife
and is in Denver), he was pretty insistent that morphine is a uterotonic
drug....ie actually improved/strengthened contractions. I think this is
why it works so well when we sleep someone with prolonged latent phase.
I routinely see someone wake up 6-7 cm after morphine and vistaril.
Nitrous Oxide / Gas and Air
Other Drugs
Sue Jordana, Simon Emeryb, Ceri Bradshawa, Alan Watkinsc Wendy Friswellb
BJOG: An International Journal of Obstetrics & Gynaecology 112
(7), 927-934.
Nubain's Effects on the Fetus
of neonatal resuscitation, low Apgar scores, and umbilical artery pH among
growth-restricted neonates.
Levy BT, Dawson JD, Toth PP, Bowdler N
Obstet Gynecol 1998 Jun;91(6):909-16 monitoring of nalbuphine:
transplacental transfer and estimated pharmacokinetics in the neonate.
Nicolle E, Devillier P, Delanoy B, Durand C, Bessard G
Eur J Clin Pharmacol 1996;49(6):485-9
Dawes GS
Obstet Gynecol 1996 Jan;87(1):158-9
Poehlmann S, Pinette M, Stubblefield P
J Reprod Med 1995 Oct;40(10):707-10
Giannina G, Guzman ER, Lai YL, Lake MF, Cernadas M, Vintzileos AM
Obstet Gynecol 1995 Sep;86(3):441-5
CONCLUSION: In the early intrapartum period of normal term
pregnancies and at commonly used dosages, nalbuphine had a significant
effect on FHR tracings, whereas meperidine had no effect, as determined
by computer analysis.
Resolution
of marked intrapartum fetal tachycardia following intravenous nalbuphine
hydrochloride.
Sherer DM, Cooper EM, Spoor C, Serletti BL, Woods JR Jr
Am J Perinatol 1994 Sep;11(5):367-8
van Nesselrooij BP, Roumen FJ, Da Costa AJ, Maertzdorf WJ, Stricker
BH, Garbis-Berkvens JM
Ned Tijdschr Geneeskd 1992 May 30;136(22):1073-6
Schwickerath J, Wolff F
Geburtshilfe Frauenheilkd 1991 Nov;51(11):897-900
Zeller W, Kueck J, Tennis G
J Am Board Fam Pract 1991 Jul-Aug;4(4):261-2
Dan U, Rabinovici Y, Barkai G, Modan M, Etchin A, Mashiach S
Gynecol Obstet Invest 1991;32(1):39-43
Data analysis points to a possible transient depressive effect
induced by nalbuphine on the fetal or neonatal central nervous system.
Perinatal
adverse effects of nalbuphine given during parturition.
Guillonneau M, Jacqz-Aigrain E, de Crepy A, Zeggout H
Lancet 1990 Jun 30;335(8705):1588
[There are more articles from before 1990 that might be of interest.]
I've been following the digest postings on this with some interest. in my opinion, formed from somewhat limited experience (doing L & D nursing in hospitals for about 2 years, but the first year and a half was at a 25 bed hospital where we only did 150 births/year and didn't use nubain), demerol is almost never a good choice. actually, this opinion first formed when my pharmacology professor would go into rants about demerol, which he hated with a passion (he said there were two standards of care for pain management--aspirin and morphine :-)), but be that as it may, my experience with demerol is it makes people puke. if you combine it with phenergan, as docs often do, it makes people puke a little less, but they have to deal with the phenergan in their system, which can last quite a while and make you quite woozy.
so when i'm talking with my laboring moms, and they're interested in options (as opposed to the sad majority who come in just wanting their epidurals as soon as possible), i encourage nubain over demerol any day. we used stadol at the hospital i used to work in (the 25 bed one), but in lower doses than the docs seem to order here, and the couple times i've given the higher doses it's really seemed to zonker the moms out considerably more than the other meds do.
anyway, we tend to call nubain the "marguarita shot," and for some women it really works wonderfully--it enables them to really relax and go into that "nubain slide" that two of my moms did last week, both going from 4-5 centimeters to delivery in half an hour (and one was a primip). for other women it enables them to hang on long enough for their epidural. of course, it definitely affects the baby--both those babies last week needed narcan, but then they both did great after that.
"BIRTH CONTROL - When
did the movement to empower pregnant women to make informed choices turn
into a guilt-laden cult?" by Nina Shapiro. This controversial
article about epidurals and other drugs for labor generated a number of
responses that may help you to figure out what you really want your labor
to be about. This copy of the article is hosted at a very interesting
French site (with articles in English) called
Sorceresses Reborn.
OUT
OF THE WOMB, INTO THE FIRE - The Myth of the Safety of Hospital Childbirth
- (A Response to Nina Shapiro’s article "Birth Control" in The Seattle
Weekly, November 26, 1998) by Jock Doubleday
A letter in response
to the article, written by Ronnie Falcao, emphasizing the harm that
epidurals do in depriving a baby of pain relief during labor and depriving
the mother and baby of the bonding hormones at birth.
Ok guys. Help me out here. How would you, as a midwife or educator, respond to the increasingly common statement: "Oh, I loved my epidural. It is the only way to go. Yes, I did end up with Pitocin and then because of low heart tones, a cesarean. But I would definitely have another epidural."
I know that in certain cases epidurals are very helpful. However, they
are becoming the only way to go where I teach. Women, even after knowing
of the possible side effects, still want them. I feel like we are going
backwards here. On the other hand, midwives are becoming increasingly available.
So, that is at least good news. However, the general population seems to
be clamouring for epidurals. Whatever happened to the natural childbirth
movement? Is it dead?
I taught childbirth classes for 10 years and used to feel the same way that you do. Now I'm on the other side of the coin, an RN in L&D and my viewpoint is changing. First of all, most couples are not motivated to go "natural". While they may take classes and say that they want to go without the use of drugs, when she hits active labor, this all changes. Very rarely do I see a truly supportive significant other that helps with the labor support techniques learned in class. When the alternative is there to be "pain free" and not to "suffer", 99% of the time, they will opt for the epidural.
On the other hand, as an L&D nurse, I find myself not discouraging the use of an epidural. We are a very busy unit, I have done as many as 8 deliveries in one 12 hour shift, and I simply cannot be there to help labor support this woman. I usually have 2 laboring patients, and if one or both have an epidural, it makes my job easier. I can usually catch up on my charting so that I don't have to stay 1-2 hours of overtime to do it. As selfish as this sounds, this is the reality with most nurses. If you work the next night, the last thing you want to do is lose more sleep than you already will.
Basically, couples today are not prepared, or motivated to do it on
their own. I believe we will continue to see this until insurance companies
stop paying for them.
See also: Epidurals and Autism
EPIDURAL ANALGESIA FOR
CHILDBIRTH - a comprehensive site from www.sblomberg.com
Normal
Vaginal Delivery Rate Is Improved With Low-Dose Epidural Techniques
[Medscape registration is free] - again, they don't compare this with midwifery's
gold standard . . . birthing tubs, a doula, and a supportive environment!
Most women don't need any drugs with the right preparation and supportive
care.
Effects
of Epidurals from the International
Chiropractic Pediatric Association (I.C.P.A.)
Medical
Risks of Epidural Anesthesia During Childbirth By Lewis Mehl-Madrona,
M.D., Ph.D.
How Safe are Epidurals?
from babycenter.com
Epidurals - Real Risks for Mother and Baby by Sarah Buckley, MD [This is one of the free articles available from BirthLove - Leilah McCracken's site. In general, this is a subscription site - well worth the $10 membership fee.]
or a similar article - Epidurals - Real Risks for Mother
and Baby, by Sarah
J. Buckley, MD, from the section on Medical
tests and procedures at Women
of Spirit
Types of Regional
Analgesia for Labor & Birth from Suzanne
S. Powell, ICCE, CD
Overview
of the epidural insertion procedure and various pros and cons by Pamela
Hood, RN, LCCE, FACCE
Reported
Side Effects of Epidural Anesthesia - Compiled by Vicki Elson, CCE
Epidural Home Page - sponsored by anesthesiologists, so this shows only the good side of an epidural. It downplays the immediate risks from the procedure and ignores secondary risks such as effects on labor and the baby.
Here's a study they did in which they acknowledge that "Epidural analgesia is thought to . . . have a greater incidence of complications than IV analgesia.". Notice that they do not compare the risks of both these forms of analgesia with non-pharmacological forms of pain relief, such as birthing tubs, doulas, hypnobirthing, TENS units, etc. After all, they don't profit from non-pharmacological pain relief.
Analgesia
for labor pain: a cost model. [Full
text]
Macario A, Scibetta WC, Navarro J, Riley E.
Anesthesiology. 2000 Mar;92(3):841-50.
At the 2001 APPPAH conference, Dr. Lewis Mehl-Madrona explained a presumed mechanism for the pitocin/epidural/autism connection. Because the newborn neurological system does not yet have the protective myelin layers around the brain and nerves, they are inflamed by the bupivicaine used in epidural anesthesia; it destabilizes the membranes of the developing brain.. When pitocin is also used (either for induction or augmentation), this results in greater exposure to the oxytocin family than would occur in a normal birth. Because of the nerve inflammation, the nerves develop an adverse reaction to the high levels of oxytocin . . . sort of an allergic reaction. Later in life, when the child responds to social situations by the normal production of oxytocin, this serves as a trigger for the allergic reaction to oxytocin, and the child develops an adverse response to social situations.
Breastfeeding is a social situation, stimulating oxytocin production
in both the mother and baby. Prolonged exposure to both pitocin and
epidural during labor could trigger the same sort of aversive response
to breastfeeding.
I know that epidurals can cause fevers, but why?
My understanding is that it has something to do with the nerves that
allow your body to sweat being numbed. Therefore, while your body is doing
the hard work of labor, it can't cool itself off the natural way (sweating).
My BIL is an anesthesiologist, and I believe that is what he said. I would
like to be corrected if this isn't right though.
Fever During Labor Linked to Infant Brain Damage
Fever
in labour and neonatal encephalopathy: a prospective cohort study.
Impey L, Greenwood C, MacQuillan K, Reynolds M, Sheil O
BJOG 2001 Jun;108(6):594-7
NEW YORK (Reuters Health) - Women who run a fever during labor have an increased risk of giving birth to a child with a type of brain damage called encephalopathy, according to a new report.
Since fever is often a sign of inflammation, the finding provides additional evidence that inflammation may play a role in some birth defects that affect the brain, the study's authors explain.
Studies have shown that both infection and fever during labor increase the odds that a woman will give birth to a child with cerebral palsy, and fever has been suspected of increasing the risk of encephalopathy in infants. Some children with encephalopathy die soon after birth and others develop permanent neurological problems.
Despite the tentative link between fever during labor and encephalopathy, it has been uncertain whether fever causes the brain damage or is simply a sign, or "marker," of some other factor that is the real cause.
Dr. Lawrence Impey of The John Radcliffe Hospital in Oxford, England, and associates studied nearly 5,000 pregnant women who were judged to be at low risk of having a baby with birth defects. Overall, 336 (nearly 7%) of the women had fever during labor, according to their report in the June issue of the British Journal of Obstetrics and Gynaecology. Sixteen newborns developed encephalopathy.
After taking into account several factors that could have affected the risk of encephalopathy, including whether a woman had given birth previously, the length of pregnancy and labor, and whether labor was induced, the researchers calculated that the risk of encephalopathy was increased nearly fivefold in babies whose mothers ran a fever during labor.
"These data show that maternal fever in labour is strongly associated
with neonatal encephalopathy," Impey's team concludes. They suggest that
fever itself may somehow cause the brain damage, although they do not rule
out that fever is a marker of a chronic or low-grade infection that might
be the true cause of encephalopathy. [SOURCE: British Journal
of Obstetrics and Gynaecology 2001;108:594-597.]
Intrapartum
maternal fever and neonatal outcome.
Lieberman E, Lang J, Richardson DK, Frigoletto FD, Heffner LJ, Cohen
A
Pediatrics 2000 Jan;105(1 Pt 1):8-13
Much of fever during term labor may not be infectious but rather a consequence of the use of epidural analgesia. . . . Intrapartum maternal fever, particularly if >101 degrees F, was associated with a number of apparently transient adverse effects in the newborn. Larger studies are needed to investigate the association of intrapartum fever with neonatal seizures and to determine whether any lasting injury to the fetus may occur.
Epidural Ups Fever, C-section Risk
Immune
alterations associated with epidural analgesia for labor and delivery.
Fehder WP, Gennaro S
MCN Am J Matern Child Nurs 1998 Nov-Dec;23(6):292-9
Several explanations have been proposed to account for increased maternal temperature with the administration of epidural analgesia. The pain relief associated with epidural analgesia may result in decreased maternal hyperventilation, resulting in decreased heat loss by this mechanism. However, reduced sweating due to sympathetic blockade and reactive vasoconstriction as well as a dissociation in warm and cold sensation due to the sensory blockade of the epidural analgesia may account for an increased incidence of fever (Fusi, et al 1989). Furthermore, it has been postulated that epidural analgesia results in altered thermoregulatory transmission from the periphery to the hypothalamus, increasing the temperature set point and resulting in fever (Camann, Hortvet, Hughes, Bader and Datta, 1991).The Fusi reference was in Lancet, 8649, 1250-2, and the other from the British Journal of Anesthesia, 67, 565-8.
The rest of the MCN article really didn't have much exciting to say, just that the WBC and other phenotypic measures measures of leukocytes are not affected by epidurals. And contrary to what you might expect from the title, they concluded that epidurals appeared not to alter immune measures of infection in pp women.
Epidural
analgesia, intrapartum fever, and neonatal sepsis evaluation.
Lieberman E, Lang JM, Frigoletto F Jr, Richardson DK, Ringer SA, Cohen
A
Pediatrics 1997 Mar;99(3):415-419
To summarize the above study results, babies born to women receiving epidurals have:
Women who chose epidural analgesia in this study had a markedly increased risk of intrapartum fever; likewise, their newborns were more likely to require a sepsis work-up and antibiotic treatment. It remains uncertain whether epidural analgesia causes maternal fever or is just a risk marker. Nevertheless, based on the strong association found in this study, family physicians providing obstetrical care should discuss with patients considering epidural analgesia the possible increased risk of fever, sepsis evaluation and antibiotic treatment of their neonates, in addition to the increased risk of operative delivery (1).
Is An Epidural Bad for a Newborn? Controversial
Parenting Magazine Article
Response to Parenting Magazine Article Downplaying
Epidural Risks
I know this lady who just had a baby in the hospital. She got an epidural.
VBAC was successful. Now here is the problem. She got a terrible headache.
Turned into a migraine. Cannot lift her head off of the pillow.. The Labor
Nurse said that something went wrong when the anesthesiologist did the
epi. Took him 45 minutes and much frowning. Labor nurse said that it usually
takes him 15 minutes to do one. Would not tell her what went wrong. They
checked her back and told her she was leaking spinal fluid!!
The anesthesiologist should be notified ASAP. This mom has a super duper bad SPINAL headache because the epidural needle (which is bigger bore than a spinal needle) accidentally punctured into her spinal canal and caused the fluid to leak out. She has a headache because her brain is not getting as much cushioning as usual. There are effective treatments for this. The one that the anesthesiologist can do is called an epidural blood patch. Another effective treatment is to infuse sterile saline into the epidural space. Things that the mom can do to help include drinking LARGE amounts of fluids and ingesting caffeine.
If the doctor will not see her promptly, the nursing supervisor should
be called and asked to find a dr. (of anesthesia) who will. If needed,
this should be taken up the chain of command in the hospital. This is totally
unacceptable behavior, to leave a person in pain of this kind due to a
medical complication of her anesthesia. It should not be tolerated by anyone.
Unfortunately the anaesthetist has punctured the dura of the spine causing
leakage of cerebrospinal fluid in turn causing a postdural puncture headache!
Apparently it happens in 1% of epidurals.
Epidural analgesia in
labor - A Review from
the Journal of Family Practice Web site
Reviewed by Craig W. Robbins, MD and David Slawson, MD
The
effect of epidural anesthesia on the length of labor.
Johnson S, Rosenfeld JA
J Fam Pract 1995 Mar;40(3):244-247
Effect of epidural anesthesia
on labor - A Review from the Journal of Family Practice Web site
Reviewed by Mark H. Ebell, M.D.
Thorp JA et al. (1991) Epidural Anesthesia and cesarean section for
dystocia: Risk factors in nulliparas. American Journal of Perinatology.
8(6) 402-410.
This study is even better, because they separately analysed and compared
groups of women receiving epidural at different dilations and stations
with groups of women receiving no epidural and then further grouped them
by their progress in labor and were therefore able to compare the effect
of the epidural on labor progress and dystocia. It is fairly confusing
to abstract, but the whole text makes clear that epidural women were more
likely to have oxytocin and cesareans for dystocia.
Morton SC, Williams MS, Keeler, EB,Gambone JC, Kahn KL (1994). Effect
of epidural analgesia for labor on the cesarean delivery rate. OB/GYN.
83(6) 1045-52.
A meta analysis of published studies on above topic reveals a 10% increase
in sections when epidural was used.
Listers might be interested to know that a large multi-centre trial is being mounted in Calgary, enrolling 1600 women. This trial will hopefully address the methodological problems of some of the previous work done in this area, including the problem with cross-over. Outcome measures are: effect on progression of labour; pain relief; a newborn's first day of life; breastfeeding; fever; and back pain after delivery.
If you want to read more about it, go to the
Web page.
Go to the August 15,1997 issue to the News and Analysis section.
I agree that it would be good to see epidurals compared to no pharmaceutical
pain relief. Unfortunately, a sad state of affairs when the investigators
likely realize that they couldn't recruit enough women if the control group
was randomized to nothing for pain. Using doulas would be nice, but likely
would be considered a confounding variable.
Prospective Studies Show Epidurals Cause Cesarean
Sections
The epidural anaesthesia was performed with bupivacaine in a lateral position. [Please e-mail the reference for this if you have it. Thanks!]
Results: After the insertion of the epidural needle a change in the oscillation amplitude and an increase in variable and late decelerations was observed. There were no significant changes in the other CTG criteria and no changes in maternal heart rate and blood pressure.
This is extremely interesting. This is something that I had noticed
clinically and while it used to be blamed on the drop in maternal BP,
now anesthesia staff is saying it is an effect of the narcotics which
they are using (in combination with bupivacaine, marcaine and others).
Since this study based on those receiving the traditional anesthetic
without narcotic combo, would seem to indicate that narcs. aren't
the problem. We see a lot of problems with airway clearance
and babies that don't begin rooting within the hour after birth - and
I was just sure it was the narcotics causing the problem.
Intrapartum
epidural analgesia and breastfeeding: a prospective cohort study. [full
text]
Torvaldsen S, Roberts CL, Simpson JM, Thompson JF, Ellwood DA.
Int Breastfeed J. 2006 Dec 11;1:24.
CONCLUSION: Women in this cohort who had epidurals were less likely
to fully breastfeed their infant in the few days after birth and more likely
to stop breastfeeding in the first 24 weeks. Although this relationship
may not be causal, it is important that women at higher risk of breastfeeding
cessation are provided with adequate breastfeeding assistance and support.
The
effects of maternal epidural anesthesia on neonatal behavior during the
first month.
Sepkoski CM, Lester BM, Ostheimer GW, Brazelton TB
Dev Med Child Neurol 1992 Dec;34(12):1072-80
"The epidural group showed poorer performance on the orientation and
motor clusters during the first month of life. Epidural mothers reported
spending less time with their infants while in the hospital; post hoc analyses
showed that they had longer labor, more forceps deliveries and a greater
amount of oxytocin. Controlling for the effects of these medical variables,
a dose effect was found for the mean orientation and motor cluster scores.
The results are discussed in terms of possible effects of the infant's
early disorganization on the mother-infant interaction"
Thorp is, unfortunately, no expert on trial methodology, as he demonstrated with his own. He committed at least two major breaches of protocol, and later admitted that he hadn't even been aware that what he had done broke the rules. I have never run a trial, and don't consider myself an expert, either, but as soon as I read Thorp's paper, I knew he was in trouble. Sure enough, the mistakes were pointed out in the letters to the editor, and Thorp's reply was where he had to admit he didn't even know what those rules were. (Nothing unethical, just matters of maintaining proper blinding, and under what conditions you can properly terminate a trial prematurely, as they did.)
In short, Thorp is in a pretty awkward position to be criticizing the
methodology of anybody else's study.
Can you tell me more about what his mistakes were? I'd be really interested
in learning more about how they may have thrown off his results.
A couple of other people asked this, so I'm taking the liberty of posting a response to the list. The answer, unfortunately, is technical and boring.
Trials sometimes are terminated prematurely if a clear advantage of one treatment or the other is emerging. But there are a few rules about doing this. First, the data have to be examined by somebody outside the trial. If one of the people conducting the trial peeks at the data prematurely, they become "contaminated"--this is because they may become convinced (by some slight advantage showing up) that one treatment is better, and thus not treat all enrolled patients equally. (The physician's belief in the efficacy of a treatment has repeatedly been shown to have an independent effect on the strength of the treatment measured.) Thorp looked at the data himself several times, but then continued running the trial.
Second, to eliminate the possibility that random fluctuations in the
trend of the accumulating data are mistakenly interpreted as being significant
when they are not (e.g., 8 of the first 10 patients may improve with treatment
compared to 1 with placebo, just by chance, while if the trial is allowed
to continue the trends may even out and the treatments turn out to be equivalent).
Therefore, you have to use a more stringent level of statistical significance
when evaluating the data prematurely than you would at the end of the trial.
Thorp used the end-of-trial statistical methods, instead of the peek-at-the-data-prematurely
methods. We will, unfortunately, never know whether the big difference
Thorp's study found would have remained if they had continued to enroll
all the patients they had planned to. (Thorp himself admitted in the response
to the letters that he thought their results overestimated the real difference
in c-section rates that epidurals cause.) It's really too bad, because
otherwise their methodology was pretty darn good, and had the best chance
yet of nailing down a definitive answer as to whether epidurals increase
the risk of c-section, but because he blew these critical points, fans
of epidurals can dismiss his results and say the relationship is still
unproven.
[from ob-gyn-l]
There is, as you probably all know, great controversy over whether the use of epidurals increases the likelihood that a woman in labor (especially a nulliparous woman) will be diagnosed with dystocia (nonprogressive labor) and therefore get a cesarean section. There have been 2 randomized controlled trials in the US (that I'm aware of), both of which I read carefully yesterday, and a couple of others outside the US, which I haven't read. The 2 US studies both had significant methodological problems. One was terminated early (and, it turns out, improperly) due to apparent achievement of statistical significance much earlier than the authors had anticipated. The other went so far out of its way to allow women freedom to opt out of the assigned trial arm that they couldn't analyze by intention-to-treat, and therefore severely compromised the whole point of randomization. There are also numerous retrospective studies on this question, with conflicting results.
Questions:
I hope I'm not prematurely cutting off votes, but here are the results:
Do you believe that it has been adequately demonstrated, scientifically, that use of an epidural increases a woman's chance of c-section?
Yes: 4
No: 14
Other: 2
Does your personal experience lead you to believe that it does, independent of the published literature?
Yes: 5
No: 9
Other: 5
We see again the need for a pilot survey to work out unanticipated problems
with question wording. For example, some people wanted to say that it increases
the risk for some patients and lowers it for others, or that it increases
the risk if given early but not if given late. I tried to put these into
"other." I had to disregard 1 or 2 free-form answers that I couldn't figure
out how to classify.
Epidural Consent Form with Notes from Midwifery
Today Tape on Epidurals
The decision came after a number of serious problems were identified from a 6-year UK study carried out between 2000 and 2005.
"Although relatively rare, these complications are serious and point to the need for regular surveys to be carried out after epidural pain relief to identify risk factors and the scale of the problem," said Iain Christie from Derriford Hospital in Plymouth.
The scientists discovered that 12 out of 18,100 patients developed major complications after receiving epidural pain relief.
Six patients developed epidural abscesses, three suffered from meningitis, and three developed blood clots.
"We would strongly recommend that all acute pain services supervising epidural pain relief after surgery perform a regular survey to identify patients who have suffered one of these complications," said Christie.
"These results should then be stored in a national database to provide a more accurate estimate of the risk of these complications," he added.
"This register might also identify other relevant risk factors such
as methicillin resistant Staphylococcus aureus (MRSA) infections."
Major
complications of epidural analgesia after surgery: results of a six-year
survey.
Christie IW, McCabe S.
Anaesthesia. 2007 Apr;62(4):335-41.
Personally, I wouldn't risk having the epidural during labor just because
the doctor wants it there as a precaution for c-section. Having the epidural
will definitely put you at greater risk for c-section as it is part of
the "cascade of interventions" you often hear about on this list. An epidural
can stall your labor necessitating pitocin, or it can cause a deep relaxation
of the uterus and cause the babies to be "stuck" in a position unfavorable
for delivery.
Eight Hours of Torture - Horrible Epidural Experience
Ends in Cesarean
Epidurals Cause Physical Problems for Babies
The
effects of maternal epidural anesthesia on neonatal behavior during the
first month.
Sepkoski CM, Lester BM, Ostheimer GW, Brazelton TB
Dev Med Child Neurol 1992 Dec;34(12):1072-80
The epidural group showed poorer performance on the orientation and motor clusters during the first month of life.
It took years, and a number of people telling me I was off base, to
understand how epidurals cause variable decelerations. Epidurals cause
a generalized vasodilation and a subsequent drop in blood pressure. This
I speculate causes vasodilation of the arterial blood supply feeding into,
and probably within the placenta bed itself. Causing some kind of change
in pressure gradient that gets passed on to the baby. If more of the fetal
blood is in the placenta, then the intraumbilical hydrostatic pressure
will be lower and the any cord compression will be exaggerated. Also, when
they drained this woman's overdistended bladder, that caused a big shift
of fluid within her body that could cause a temporary drop in blood pressure,
producing variables. Just like when a pp mom walks to the bathroom, pees,
then passes out. Also, great trivial pursuit question: What's the number
one cause of fever in labor??? Epidurals!
[from ob-gyn-l]
Anesthesia induced bradycardia is unfortunately common. It results from peripheral vasodilatation and a "steal" phenomenon from the uterus with a drop in blood flow/oxygenation. This has been well documented in fetal lambs and cannulation of maternal uterine vessels. It occurs even in the absence of a drop in maternal blood pressure (there is almost always a widening of pulse pressure and a drop in mean arterial pressure). The treatment is ephedrine for the mother, which results in a prompt recovery of the fetus.
It is NOT a reason for c/section. An obstetrician who would section
for a bradycardia when the cause is known and treatable without the trauma
and risk of a stat c/section, IMHO needs re-education and supervision by
his/her peers until his/her decision making improves.
This is a phenomenon we have all seen. My question is how long would
you wait for the bradycardia to resolve? Would you give ephedrine even
if the maternal BP is normal?
Depends on how the strip looked just prior - if it had good beat to beat variability and accelerations - I might be more patient, knowing we started with good cardiac reserve.......and whether it is accompanied by hypertonus.
The decel typically lasts 5 to 8 agonizingly long minutes. It is usually
followed by a tachycardia with decreased beat to beat variability (due
to rate) and then a return to baseline and normal variability. The tachycardia
is required since in a fetus
CO (cardiac output) = HR (heart rate) ......since they don't really
vary their stroke volume.
How about a study looking at the effects on mother-infant bonding and epidurals? I see a real difference in the way a mom will greet and bond with their baby if they have had an epidural. Especially the epi. for their convenience as opposed to the rare mom where it really does get the baby out when nothing else has worked.
And what about a study looking at the effect of a long duration epidural on the baby's ability to have a coordinated suck? It can take these babies 24 hours or more to get their sucking act together. Anyone else seen this?
One hospital here has a 80-85% epidural rate and a 29% section rate.
I can't believe that they are not related. This new "epidurals are wonderful
and have no side effects. Everyone should get one!" trend is such a disservice
to women and their babies. What are they thinking?
A local lactation consultant told me about a study involving sheep.
The sheep were anesthetized (w/epidural?) during their labor and delivery.
Each ewe that was anesthetized abandoned its baby. Anyone have more
information about this study?
Peridural
anesthesia disturbs maternal behavior in primiparous and multiparous parturient
ewes.
Krehbiel D, Poindron P, Levy F, Prud'Homme MJ
Physiol Behav 1987;40(4):463-72
I was at ICEA in Atlanta this past weekend. The absolute highlight for me was Dr. Michel Odent OB/GYN from France speaking on the Future of Civilization if we continue to bring babies into the world under epidural anesthesia. He spoke of ewes that were given epidurals over in Europe and then studied. He said that basically they abandoned their young. And that on a basic mammalian instinctual level, that is what is going on right now. That human intelligence keeps us from being totally removed, but that the basic comparison is definitely there.
The ICEA conference manual has a complete bibliography. Dr. Michel Odent lists the lamb study as coming from Khrebiel, et al., 1987.
He also listed a study of taking the blood from mother rats immed pp
and injecting the blood into virgin rats. The virgin rats then behaved
as mothers. Terkel and Rosenblatt 1968.
There was recently a maternal death from misplacement of an epidural
by an anesthesiologist under the influence of drugs.
This seems to be a very different issue. It is less about the safety
of the procedure and more about the incompetence of the medical professional
involved. The problem appears to have arisen as a result of the MD's substance
abuse and not directly from the procedure itself. This would be a risk
no matter who the healthcare provider was and no matter what the medical
approach was.
Yes, it is a risk, and it should be mentioned in informed consent. I think it would be particularly interesting to know what the rate of drug abuse among MDs is.
I've heard it's relatively high, given their easy access to drugs and
the abusive conditions of residency; it's very tempting to take drugs that
will make you feel like you have extra energy.
I, too, have read and heard on television shows that the rate of drug abuse among the medical profession is higher than that of the general population. As you stated, it is due to the easy access to medication and a stressful job situation. Also, my opinion is that they might perceive the drugs they have access to as "safer" than those you buy on the street. In addition, this type of drug use may be easier for them to rationalize since they are not buying them "illegally." The drugs may be readily available in pill form, rather than by injection, which is easier to take and view as not as bad.
This information must be taken into consideration for any woman consenting
to an epidural.
I agree the temptation and the availability of drugs is greater to medical
professionals but I think these are the things one must consider when choosing
their birth professional. Although not everyone has as easy access to prescription
medication as MD's (and nurses for that matter), all adults in our culture
have easy and legal access to alcohol which when abused , can have disastrous
effect.
I have never heard of anyone's choosing which anesthesiologist would place their epidural. Typically, the anesthesiologist on duty wanders in when the woman is in enough discomfort that she might actually want him to go ahead and place the epidural even if she knew for a fact that he were under the influence.
Did anyone out there actually select their anesthesiologist ahead of time?
I'm beginning to attach new meaning to the little remarks that sympathetic
nurses make when they hear that Dr. So-And-So is on duty to come place
an epidural. Sometimes they'll say something like, "Oh, they're very good."
Well, what does that mean about the others, who maybe aren't so good?
My friend had a terrible epidural headache from a botched epidural placement.
She got the blood patch and it worked. The Dr told her that the other Dr
screwed the epidural up. Blamed it on lack of sleep!! She still has the
headache though. He said that this could last awhile.
05:17 PM ET 09/03/98 - Reuters
Young UK doctors have drink, drug problems-survey
LONDON,
Sept 4 (Reuters) - Many young British doctors drink too much and use cannabis
and other illegal drugs, according to a survey released on Friday.
The poll of 114 junior doctors in northeastern England, published in a
letter in The Lancet medical journal, showed that more than 60 percent
drank more alcohol than the recommended safe limits.
Over 35 percent of male doctors and 19 percent of female physicians also
admitted using cannabis and up to 13 percent also took other drugs.
``The current drinking habits, illicit drug use, and stress in some junior
doctors is of concern, not only for their own well being, but also how
they affect patients' care,'' said Dr Farhad Kamali of the University of
Newcastle, who conducted the study said.
The British Medical Association (BMA) said the findings were consistent
with its own research into the habits of junior doctors.
The survey was released a day after Dr Patrick Dixon, a British AIDS expert
and author, called for random drug testing of doctors because alcohol and
drug abuse.
Dixon, the author of book ``The Truth About Drugs,'' said the problem posed
a significant threat to public health because patients' lives were being
put at risk.
``With around 10 percent of all doctors either intoxicated or withdrawing
(from drugs or alcohol) we are faced with the fact that significant numbers
of doctors have impaired judgment because of addiction,'' Dixon said in
a telephone interview.
He claimed that more than 1,000 addicted doctors in London were addicts
but said their colleagues were reluctant to identify them because of fear
of retribution.
The BMA released a report earlier this year that confirmed drug and alcohol
addiction was a problem in the profession.
``Our estimate is that up to 10 percent of doctors may have a drug or alcohol
problem at some time in their working lives,'' a BMA spokeswoman said.
But she said the BMA was not convinced of the benefits of random testing
which would also involve civil liberty issues.
``Up to now we haven't seen evidence that a random drug testing policy
is justified and would be effective and fair,'' she said.
"The drugs used for surgical or dental anesthesia can linger in the body for quite some time. One dose of homeopathic Phosphorous 30C can help to cleanse the body of anesthetic drugs and relieve any unwanted side effects." For other tips on homeopathics, see the EMAZING.com archives of the Homeopathic Health Tip of the Day
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