The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA
This brief but well-referenced post analyzes cesarean rates relative to differences in maternal diagnoses or pregnancy complexity. On average, the likelihood of cesarean delivery for an individual woman varied between 19 and 48 percent across hospitals.”
Birth attendants often claim that their high cesarean rate is due to their clientele - that they provide care for a lot of high-risk clients. This analysis shows that:
Among lower risk women, likelihood of cesarean delivery varied between 8 and 32 percent across hospitals.
Among higher risk women, likelihood of cesarean delivery varied between 56 and 92 percent across hospitals.
Hospital variability did not decrease after adjusting for patient diagnoses, socio-demographics, and hospital characteristics.
This shows that practice variation in cesarean rates is real, substantive, and not just a reflection of the mother’s risk level.
Tips for Choosing a Care Provider - great overview! from Henci Goer
Local-regional anesthesia during childbirth: effect on newborn behaviors.
Standley K, Soule AB 3d, Copans SA, Duchowny MS
Science 1974 Nov 15;186(4164):634-5
Abstract: Administration of local-regional anesthesia during normal deliveries was correlated significantly with newborn behaviors as evaluated by the Brazelton Neonatal Assessment Scale. Three days after birth, infants whose mothers received local-regional anesthesia were more irritable and motorically less mature than those infants whose mothers were not medicated.
That same year, Scanlon (Scanlon JW, Brown WU, Weiss JB, Alper MH. Anesthesiology 1974; 40:121.) found limited effects of epidural anesthesia on newborn behavior after epidural but used a control group in which spinal anesthesia, local anesthesia, and no anesthesia were all lumped together. Nor was the effect of analgesic drug administration (narcotics) controlled for.
Standley, et al. found that local-regional anesthesia was correlated significantly with decreased motor maturity and greater irritability. Jerky movements in small arcs, startles and tremulous motions, and frequent state changes and crying were more common in babies of mothers who received anesthesia. Analgesia usage was significantly related to lower scores on motor maturity.
Medication effects were also correlated. the most alert, least irritable, and motorically most mature behaviors were shown by those babies whose mothers had received no medication. Anesthesia appeared to have more of an impact on the infant than analgesia. When the effect of analgesia was controlled for by comparing babies whose mothers had received no analgesia, the anesthesia and no anesthesia groups were significantly different on irritability and motor maturity scores; the difference for alertness approached significance. On the other hand, when the effect of anesthesia impact on the infant than analgesia. When the effect of analgesia was controlled for by comparing babies whose mothers had received no analgesia, the anesthesia and no anesthesia groups were significantly different on irritability and motor maturity scores; the difference for alertness approached significance. On the other hand, when the effect of anesthesia was controlled for by comparing the four groups of babies whose mothers received anesthesia and varying doses of analgesia, no significant differences were found on the infant measures. Product-moment correlations between analgesia and the three BNBAS clusters were nonsignificant when only those subjects who received anesthesia were included in the analysis.
The three Brazelton clusters did not correlate significantly with other factors related to the difficulty of delivery: length of labor, use of forceps (in the anesthetized group), Apgar scores, and infant birth weight.
The study was conducted on 60 first-born, full-term, healthy infants between 48 and 72 hours of age. All were born of white, middle-class women who had received routine antenatal care and had medically uneventful pregnancies and deliveries.
The authors responded to criticism from the anesthesiology community (Hodgkinson R, Marx GF. Local-regional anesthesia during childbirth and newborn behavior. Science 1974; 189(4202):571-2.). The critics could not believe the results because of lack of biochemical explanation. At that time, it was not known that epidural anesthetics reached the fetal circulation. The authors responded well to the small sample criticism, as well (Standley K, Klein RP, Soule AB., same reference):
They said, "We, too, wish that this group was larger; however, the small
sample size works against finding significant differences because it reduces
the power of the statistical tests (Cohen J. Statistical Power Analysis
for the Behavioral Sciences. New York: Academic Press, 1969, pp 1-16)."
The authors argued for larger studies, as everyone today should still continue
I'll quote William Emerson here:
"Most parents and professionals consider it ordinary for infants to awaken during the night, cry for long periods, have gastrointestinal distress, or be irritable. Few parents or professionals have seen trauma-free babies, so few have experienced babies who are symptom-free. In addition, few have glimpsed the human potential that is possible when babies are freed from the bonds of early trauma."
The only study that I know of right now that looked at the epidural
effects on the babies was done by a Sepkowski, where her first study showed
that at one month follow up there were differences in development and responsiveness,
and significant lower scores on the Brazelton Scale (he was a member of
the study team). She followed up these children for 5 years, and
the same publication would not publish the paper. Apparently they felt
that publishing these results "would scare mothers". There is clearly
a great deal of pressure 'that" there be no published data
against epidural anesthesia in the US and abroad. A great deal
of biased studies however are being designed and carried out by Association
of Anesthesiology and ACOG to support epidural use and decrease the support
for doula/midwife one-on-one support. All of which have been released dramatically
to the public to support the use of epidurals and the lack of need for
labor support. I want to close my note by asking if anyone
had reference to the study that was posted on the midwifery list that was
"being" analyzed as babies experiencing painful births had more trouble
"later in life"-therefore Medications for pain were positive not only for
mother but for baby? We would like to critique that study.
I am consistently amazed at the studies done in the late 70's and early 80's on the effects of epidurals on newborn behavior. The doses studied were well within the range of doses used today. The conclusions were that newborn effects were not simple dose-response, and that even small doses could adversely affect some infants. So why did studies suddenly stop. Not a single one really after 1985. Doris Haire has told us that one researcher at Harvard did a study showing adverse effects 5 years after an epidural and her job was threatened if she published it. I suspect a conspiracy.
New data is emerging from Hollander at Mt. Sinai, that the combination of epidural and oxytocin predisposes to autism. I can say that among my 16 autistic patients, every single child was born with epidural and oxytocin. This is not to imply causality, rather, predisposition. I suspect the two agents produce subtle brain damage that later viruses and vaccinations exploit to produce devastating neurodevelopment effects.
influence of maternal analgesia on neonatal behaviour: II. Epidural bupivacaine.
Rosenblatt DB, Belsey EM, Lieberman BA, Redshaw M, Caldwell J, Notarianni L, Smith RL, Beard RW
Br J Obstet Gynaecol 1981 Apr;88(4):407-13
Summary: Four areas of neonatal behavior have been assessed at delivery and during the following six weeks in a group of infants whose mothers were given epidermal bupivacaine during labour. The influence on such behaviour of the total maternal dose of bupivacaine and umbilical cord blood concentration of the drug has been examined with the confounding effects of other maternal and obstetric variables controlled. Significant and consistent effects of bupivacaine throughout the assessment period can be demonstrated. Immediately after delivery, infants with greater exposure to bupivacaine in utero were more likely to be cyanotic and unresponsive to their surroundings. Visual skills and alertness decreased significantly with increases in the cord blood concentration of bupivacaine, particularly on the first day of life, but also throughout the next six weeks. Adverse effects of bupivacaine levels on the infant's motor organisation, his ability to control his own state of consciousness and his physiological response to stress were also observed. Muscle tone alone appeared to improve with increases in the values of the drug variables [LM: but with a loss in coordination and organization, e.g., sounds like spasticity]. These results show that the neonate differs from the adult in respect of both the nature of effects of the drug and sensitivity to it.
Here's the text that I found interesting:
Bupivacaine ... is known to enter the maternal blood stream rapidly from the epidural space, and from there cross the placenta so that a measurable concentration is present in the fetal circulation within ten minutes of epidural injection (Caldwell J, Moffatt JR, Smith RL, Lieberman B, Beard RW, Snedden W, Wilson BW. Determination of bupivacaine in human fetal and neonatal blood samples by quantitative single ion monitoring. Biomed Mass Spectrom 1977; 4:322-5.)
The dose of bupivacaine studied was 10-14 ml of a 0.375% solution injected at a constant rate over 10 minutes with the patient in the left lateral position. This is well within today's doses, though 0.25% solutions are now used, given more frequently than the 0.375% solution. From the data in this article, I can't see how that really changes the infant's exposure to the drug.
In the study, the infant's pre-delivery exposure to the drug was measured by the umbilical cord blood concentration multiplied by the time from first administration to delivery.
Results: The mean maternal dose of bupivacaine given in one or more injections was 119.8 (SE 17.4) mg.
Higher pre-delivery exposure to bupivacaine resulted in shorter time intervals both before the infant cried and before he opened his eyes. The number of 15 second intervals in which the infant blinked was directly associated with the umbilical cord blood concentration of bupivacaine, while the number in which he scanned the room was inversely related to drug exposure. Infants with higher exposure to the drug were also more likely to be cyanotic and undergo mucus extraction for longer, but spend less time in an alert state or in a cot. None of the measures of infant behavior was found to be dependent on the total maternal dose of bupivacaine.
The Brazelton Neonatal Behavioral Assessment Scale (BNBAS) scores (Brazelton TB Neonatal Behavioural Assessment Scale. Spastics International Medical Press, London, 1973).) received by infants whose mothers had received bupivacaine were found to be dependent on drug levels considerably more often than infants receiving pethidine (Lieberman BA, Rosenblatt DB, Belsey EM. The effects of maternally administered pethidine or epidural bupivacaine on the fetus and newborn. Br J Obstet. Gynecol 1979; 86:598-606.). The infant's inanimate visual orientation response, his tracking of a bright inanimate object, was impaired on days 1, 7, 21, and 42 by a high cord blood concentration of the drug and on days 7 and 42 by drug exposure. Increases in cord blood concentration and drug exposure were associated with decreases in the infant's inanimate auditory orientation response, the extent to which he turned to the sound of a rattle, on day 3, and days 3 and 7, respectively.
Animate visual and animate visual and auditory orientation responses (the infant's ability to track a face or the tester talking) and alertness were all adversely affected on days 1 and 42 by high cord blood concentration and exposure to bupivacaine.
Of the areas of neonatal behavior assessed during the first six weeks after delivery, muscle tone appeared to improve with increases in bupivacaine levels, while motor organization was impaired. High exposure to the drug resulted in better general tone on day 4, although cord blood concentration had the opposite effect of day 7. Elicited tone when pulled to a sitting position (pull-to-sit) was directly associated on days 3 and 7 with bupivacaine exposure, and also on day 7 with cord blood concentration. However, infants with a higher cord blood concentration or drug exposure were more likely to make fewer and less successful attempts to remove a cloth placed over the face (defensive movements) on days 1, 3, and 7. Activity was affected later, and by varying drug measures, being inversely related to cord blood concentration on day 7, dose on day 42. The infant's attempts to move his hands towards or into his mouth were impaired only on day 1, by total maternal dose.
Associations between drug levels and reductions in the infant's ability to control his own state of consciousness were observed mainly on day 3, although scores on two items were still affected at six weeks. Infants whose cord blood concentration had been higher were likely to be irritable and make more changes from state to state (from sleep to alternates or crying, or vice versa) on day 3. A greater number of changes from state to state on days 1 and 3, and increased irritability on day 3, were also directly associated with the bupivacaine exposure. Similarly, high drug exposure impaired the infant's ability to quiet himself on days 3 and 42, and caused him to cry more often when handled (peak of excitement) on day 42.
Both items measuring physiological response to stress showed adverse drug effects throughout the six week assessment. Drug exposure was associated with increases in tremulousness on days 1, 7, and 42, and in startles on days 3, 21, and 42. More startles were observed on day 3 and day 7 in infants who had high cord blood concentration of bupivacaine, while total maternal dose was related to tremors on day 21 and startles on day 42.
Discussion: Maximum effects of drug levels on the BNBAS scores were observed on day 1. For some items, these effects decreased with time, but in many cases they were still evident at 6 weeks. Umbilical cord drug concentration and drug exposure were the most sensitive indicators of drug related behavioural differences.
In the period immediately after delivery those infants with a greater exposure to bupivacaine were apt to be cyanotic and unresponsive to the environment, although they cried and opened their eyes earlier....
On the first day visual skills and alternates were substantially depressed by bupivacaine and those effects continued for the next 6 weeks. It is now well accepted that the neonate is a sophisticated organism who is ready and able to learn from his environment, and it may be that infants whose attention and social responsiveness are consistently dampened because of high cord levels or greater exposure to bupivacaine are missing opportunities to interact. Because these infants are also less able to modify their states in the first few days, and cry easily and often when tested on day 3, their mothers might also find such behavior trying, and in turn, be less likely to interact positively with them......
Bupivacaine is a central nervous system depressant, which first causes stimulation by inhibition of inhibitory pathways, followed by depression and convulsion. Spinal reflexes are also depressed.... it is clear that the newborn differs from the adult both in the nature of the effects of the drug since only depressant actions are evident, and in sensitivity, since the plasma levels obtained in the newborn are very low compared with adults. This may be due to the greater ease of penetration of the blood brain barrier by the drug in newborn infants.
.....In contrast to pethidine, however, whose effects were not noticeable at one week, high levels of bupivacaine depressed a number of oriented and alerting skills, not only on the first day after birth when one would expect drug effects to be maximal, but also throughout the next 6 weeks.
.... The relationship between maternal medication and infant behavior is not a simple one between the amount of drug given to the mother, and gross and obvious alterations in newborn function, rather it is determined by the rate of change in concentration of a particular compound over time and the individual infant's ability to metabolize or excrete it. Variations in the latter mean that it has not been possible to find a cutoff point for the maternal dosage above which a drug is likely to produce adverse effects in the newborn or to determine a time at which administration would be most beneficial to the mother and least harmful to the infant.
....As direct observation of the infant's performance is available only
to six weeks, examination of long term effects must await the results of
follow-up studies. [LMM:& mmm. These authors never published
a follow-up study; unless anyone can find one I have missed).
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