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Epidurals and Other Drugs

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General



See also: Posterior and Epidurals



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Scary New Research About Epidurals Causing Harm to the Baby


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

Supporting the Woman with an Epidural - excellent slideshow from 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:

Effect of Labor Pain Medication Timing on Cesarean Section: New England Journal of Medicine Study, February 2005

They've also got some other great articles on "The Nature and Management of Labor Pain" project (best evidence on many labor pain topics).
and evidence-based guidance for pregnant women,  How will I cope with labor pain?


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.)


The Epidural Epidemic by Jeanne Ohm, D.C., F.I.C.P.A. - a chiropractic perspective


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?
Issue 95, July/August 1999
By Joanne Dozer and Shannon Baruth


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
Epidurals: What No OneTells You About
The Cascade of Interventions
Epidural's Effects on Babies
Self-Esteem and Positive Birth Experience


Choosing Epidural Anesthesia



Demerol



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.



Morphine



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.


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.

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!)



Nitrous Oxide / Gas and Air



Wikipedia says it best.



Inhaled analgesia for pain management in labour [9/12/12] - Cochrane Collaboration:

There were no significant differences found for any of the outcomes in the studies comparing one strength versus a different strength of inhaled analgesia, in studies comparing different delivery systems or in the study comparing inhaled analgesia with TENS.


Laughing gas returning as option for laboring moms [2/16/11]



Nitrous Oxide from childbirthconnection.org



Nitrous oxide - no laughing matter by Andrea Robertson from birthinternational.com



Entonox - 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 .



Inhaled Analgesics Take the Edge Off Labor Pain [10/29/12] - Although inhaled analgesic pain relief during labor is generally not an option in the United States and most other countries, except the United Kingdom and Canada, researchers have found that inhaled nitrous oxide and flurane derivatives are an effective means of reducing the intensity of labor pain.


"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.



Other Drugs



Fentanyl during labor may impede breastfeeding

The impact of intrapartum analgesia on infant feeding
Sue Jordana, Simon Emeryb, Ceri Bradshawa, Alan Watkinsc Wendy Friswellb
BJOG: An International Journal of Obstetrics & Gynaecology 112 (7), 927-934.

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).


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

Comparison of the effects of meperidine and nalbuphine on intrapartum fetal heart rate tracings.
Dawes GS
Obstet Gynecol 1996 Jan;87(1):158-9

Effect of labor analgesia with nalbuphine hydrochloride on fetal response to vibroacoustic stimulation.
Poehlmann S, Pinette M, Stubblefield P
J Reprod Med 1995 Oct;40(10):707-10

Comparison of the effects of meperidine and nalbuphine on intrapartum fetal heart rate tracings.
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

[Post-asphyctic encephalopathy of the neonate following administration of nalbuphine during childbirth].
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

[Opiate analgesia in labor--use of nalbuphine in comparison with administration of the combination Dolantin/Atosil/Haldol].
Schwickerath J, Wolff F
Geburtshilfe Frauenheilkd 1991 Nov;51(11):897-900

Sinusoidal fetal heart rate pattern after administration of nalbuphine.
Zeller W, Kueck J, Tennis G
J Am Board Fam Pract 1991 Jul-Aug;4(4):261-2

Intravenous pethidine and nalbuphine during labor: a prospective double-blind comparative study.
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.



Why Do Women Get Epidurals?



"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.



Epidurals



See also: Epidurals and Autism



Cochrane Collaboration on Epidurals for pain relief in labour [Published Online: December 7, 2011]

Pain relief is important for women in labour. Pharmacological methods of pain relief include inhalation of nitrous oxide, injection of opioids and regional analgesia with an epidural for a central nerve block. Epidurals are widely used for pain relief in labour and involve an injection of a local anaesthetic into the lower region of the spine close to the nerves that transmit pain. Epidural solutions are given by bolus injection, continuous infusion or using a patient-controlled pump. Lower concentrations of local anaesthetic are needed when they are given together with an opiate, allowing women to maintain the ability to move around during labour and to bear down. Epidural analgesia may sometimes give inadequate analgesia, which may be due to non-uniform spread of local anaesthetic. Combined spinal-epidural involves a single injection of local anaesthetic or opiate into the cerebral spinal fluid for fast onset of pain relief as well as insertion of the epidural catheter for continuing pain relief. Side effects such as itchiness, drowsiness, shivering and fever have been reported and rare but potentially severe adverse effects of epidural analgesia do occur.

The review identified 38 randomised controlled studies involving 9658 women. All but five studies compared epidural analgesia with opiates. Epidurals relieved labour pain better than other types of pain medication but led to more use of instruments to assist with the birth. Caesarean delivery rates did not differ overall and nor were there effects of the epidural on the baby soon after birth; fewer babies needed a drug (naloxone) to counter opiate use by the mother for pain relief. The risk of caesarean section for fetal distress was increased. Women who used epidurals were more likely to have a longer delivery (second stage of labour), needed their labour contractions stimulated with oxytocin, experienced very low blood pressure, were unable to move for a period of time after the birth (motor blockage), had problems passing urine (fluid retention) and suffered fever. Long-term backache was no different. Further research on reducing the adverse outcomes with epidurals would be helpful.


Straight Talk on Epidurals for Labor [February 21st, 2011] by Henci Goer from Science and Sensibility


EPIDURAL ANALGESIA FOR CHILDBIRTH - nice list of pro's and con's and an extensive list of links.

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.


BabyCenter | How Safe Are Epidurals?


Epidurals: risks and concerns for mother and baby by Sarah Buckley, MD


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


An Educational Website For Pregnant Women on Labor and Delivery Analgesia from Brigham and Women's Hospital


Learning the essentials of epidural anesthesia - a nice article from nursingcenter.com


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.


from: Birth: Countdown to Optimal: Information and Inspiration for Pregnant Women  by Sylvie Donna, Sheila Kitzinger and Michel Odent

reposted with permission by Linda Bennett

Sylvie Donna, a British clinician [I think she's a midwife], has written a new book.  Here are some research excerpts from the book Optimal Birth: What, Why & How by Sylvie Donna (Fresh Heart, 2011). You can reach Sylvie at:  <sylvie@freshheartpublishing.co.uk>
Book available from Amazon or directly from Fresh Heart at the Fresh Heart

Sylvie recently agreed to share some of her research notes on epidural anesthesia from the book Optimal Birth: What, Why & How (Fresh Heart, 2010). In order to evaluate epidurals as a form of pain relief, she told us that she decided to focus on these topics:
   Effect of epidurals on labor
   Efficacy of epidurals for pain relief
   Alertness postpartum
   Breastfeeding rates

Effect of epidurals on labor:

The following studies strongly suggest that the physiological processes are dramatically compromised when a woman has pharmaceutical pain relief. It seems there is an inhibition of catecholamine release (Jones, 1985) as well as an inhibition of the oxytocin peak, which typically occurs during a physiological labor (Goodfellow, 1983).

Goodfellow CF, et al, Oxytocin Deficiency at Delivery with Epidural
Analgesia, British Journal of Obstetrics & Gynaecology, 1983, 90:214-219

Jones CR, McCullouch J, et al. Plasma catecholamines and modes of delivery: the relation between catecholamine levels and in-vitro platelet aggregation  and adrenoreceptor radioligand binding characteristics. British Journal of Obstetrics & Gynaecology, 1985, Jun; 92(6):593-9

Efficacy of epidurals for pain relief:  it is clear from various studies that anesthesia and analgesia options now available are far from being totally effective. See the following:

Agaram R, Douglas MJ, McTaggart RA, Gunka V. Inadequate pain relief with labor epidurals: a multivariate analysis of associated factors. International Journal of Obstetric Anesthesia, 2009, Vol 18,10-14,2009   Le Coq G, Ducot B, Benhamou D. Risk factors of inadequate pain relief during epidural analgesia for labor and delivery. Canadian Journal of Anaesthesia, 1998, Aug;45(8):719-23

In the first study (Agaram, et al) the researchers initially concluded (from women's reports) that 16.9% of women who'd been in the cohort (of 260 subjects) experienced inadequate pain relief. Problems were associated with insertion of the epidural at more than 7cm dilation, women's past experience of opioid tolerance, previous failed epidural and insertion of the epidural by a trainee anesthesiologist. After adjustments, the researchers concluded that epidurals were ineffective in only 9.3% of cases. The second study (Le Coq, et al), which observed 456 women (instead of interviewing them), found that epidurals provided inadequate pain relief in labor in 5.3% of cases, and during 'delivery' (birth) in 19.7% of cases. Reasons for inadequacy (in order of importance) included inadequate first doses (so that two top-ups were needed), posterior position, pain when the epidural was sited, epidural being in place for more than six hours, and the epidural being in place for less than one hour (meaning it was less effective for 'delivery'). Another related angle is to do with later memories. In one study (which clearly needs to be repeated), even when women reported good pain relief as a result of an epidural, they generally reported
lower levels of satisfaction with the birth overall a year after the birth.

Another study (by Cooper, et al, is due out soon on this too. See:   Morgan BM, Bulpitt CJ, Clifton P, Lewis PJ. Analgesia and satisfaction in
childbirth (the Queen Charlotte's 1000 mother survey) Lancet, 1982, 2 (Oct 9) 808-810

Cooper, et al Satisfaction, control and pain relief: short and long term assessments in a randomized controlled trial of low-dose and traditional
epidurals and a non-epidural comparison group. International Journal of Obstetric Anesthesia, 2009. [Full reference not available at time of going to
press.]

Alertness postpartum:
Wittels, et al (1997) compared the alertness (amongst other things) of newborns exposed to either epidural morphine or intravenous patient-controlled analgesia. Of course, because the focus was on newborns of mothers who'd had a cesarean it was impossible to compare the alertness of babies born with drugs in their systems and that of babies who'd been born with absolutely no drugs in their system, so only 'relative' alertness could be tracked. Yet another study, back in 1981 (Rosenblatt, et al) looked at the influence of maternal analgesia (epidural bupivacaine) on the newborn. Significant effects were found: Immediately after delivery, infants with greater exposure to bupivacaine in utero were more likely to be cyanotic [blue-skinned] 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 organization, his ability to control his own state of consciousness and his physiological response to stress were also observed. A recent study by Henrichs, et al (2009) considered whether alertness could be affected by a factor such as fetal size in mid- or late pregnancy. (The conclusion was that it could.) In a study such as this, I would imagine there could be numerous confounding factors, the principal one being the use of anesthesia or analgesia (or not) during labor. Personally, I would only trust the results of this study if all fetuses measured in utero had been born without any drugs in their systems. After all, while the motivation of these researchers appears to have been a desire to investigate behavioral  problems in newborns (e.g. infant irritability), they do not appear to have taken into account the fact that one of the primary characteristics of narcotics-addicted neonates is that they are 'substantially more irritable' (Strauss, et al, 1975). Given the vital importance of good bonding in the sensitive one-hour period following birth (from the point of view of later mothering behavior), I very much hope that other researchers will look further into the issue of alertness, particularly in relation to drug-use in labor.

See:
   Bonta BW, Gagliardi JV, Williams V, Warshaw JB. Nalaxone reversal of mild neurobehavioral depression in normal newborn infants after routine obstetric analgesia. Journal of Pediatrics, 1979. Jan;94(1):102-5
   Volikas I, Butwick A, Wilkinson C, Pleming A, Nicholson G. Maternal and neonatal side-effects of remifentanil patient-controlled analgesia in labour. British Journal of Anaesthesia, 2005, Oct;95(4):504-9. Epub 2005 Aug 19

   Wittels B, Glosten B, Faure EA, Moawad AH, Ismail M, Hibbard J, Senal JA, Cox SM, Blackman SC, Karl L, Thisted RA. Postcesarean analgesia with both epidural morphine and intravenous patient-controlled analgesia: neurobehavioral outcomes among nursing neonates. Anesthesia & Analgesia, 1997. Sep;8 (3):600-6
   Rosenblatt DB, Belsey EM, Lieberman BA, Redshaw M, Caldwell J, Notarianni L, Smith RL, Beard RW. The influence of maternal analgesia on neonatal behaviour: II. Epidural bupivacaine. British Journal of Obstetric Gynaecology, 1981. Apr;88(4): 407-13

   Henrichs J, Schenk JJ, Schmidt HG, Arends LR, Steegers EA, Hofman A, Jaddoe VW, Verhulst FC, Tiemeier H. Fetal size in mid- and late pregnancy is relat
ed to infant alertness: the generation R study. Developmental Psychobiology, 2009,Mar; 51(2):119-30

   Strauss ME, Lessen-Firestone JK, Starr RH Jr, Ostrea EM Jr. Behavior of narcotics-addicted newborns. Child Development, 1975. Dec;46(4):887-93

   Hill D. Remifentanil patient-controlled analgesia should be routinely available for use in labour. International Journal of Obstetric Anesthesia, 2008, 17(4),336-339.
   Van de Velde M. Controversy. Remifentanil patient-controlled analgesia should be routinely available for use in labour. International Journal of Obstetri
c Anesthesia, 2008 Oct;17(4):339-42. Epub 2008 Jul 9

Breastfeeding rates:
In a retrospective study conducted by Jordan, et al (Jordan, et al, 2009), which looked at 48,366 healthy women birthing singleton babies at term (i.e. women having healthy births), it was found that at 48 hours after the birth, rates of breastfeeding definitely seemed to be affected by epidurals, opioid analgesia (Demerol, diamorphine, etc) and ergomentrine (used in the third stage of labor). The researchers point out that failure to breastfeed increases morbidity and mortality in both mothers and children in developed and developing countries, so the impact of any possible effects of drugs used unnecessarily could be
enormous. In this study, beyond sociological factors, which have long been known to affect breastfeeding rates, lower breast-feeding rates were associated with induction with pessaries (prostaglandins), epidurals and opioid analgesia, and ergometrine used for the third stage of labor. (Oddly, they found that first-time mothers who'd had gas and air were more likely to nurse. Could this be because these mothers were determined to avoid drugs in labor as much as
possible, so as to have as 'natural' a birth as possible, and to nurse successfully too? Any determination to avoid everything except gas and air could be a particularly British attitude, which is misguided, in my view, for other reasons, as I shall explain later. The view that it is considered 'nothing' is reflected in the off-hand statement made by many women postpartum: Oh, I only had gas and air.) Anyway, the study by Jordan, et al does provide some evidence that drug use in labor and birth has an impact on breastfeeding rates at 48 hours postpartum, which obviously will affect longer term rates too, although it must be said that this evidence is not accepted by all anesthesiologists as prospective randomized studies are seen as more reliable.After all, women usually request epidurals because of difficulties, so it is not necessarily epidurals per se which cause later problems. Cause-effect are difficult to establish.Other (prospective) studies reported fairly clear problems with narcotics used
in labor (Beilin, et al, 2005; Camann, et al, 2007; Torvaldsen, et al, 2006
). In the study by Beilin, et al researchers concluded: Among women who breastfed previously, those who were randomly assigned to receive high-dose labor epidural fentanyl were more likely to have stopped breastfeeding 6 weeks postpartum than women who were randomly assigned to receive less fentanyl or no fentanyl. (Fentanyl was added to the drug bupivacain, in the epidural cocktail as bupivacain causes paralysis in the lower part of the body; adding fentanyl reduces this effect. Clearly, though, it's a problem if too much is used.) The study by Torvaldsen, et al concluded: 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 breast-feeding in the first 24 weeks, although the researchers felt they were unable to say whether there was a causal link between epidural anesthesia and difficulties. This was despite the fact that Intrapartum analgesia and type of birth were associated with partial breastfeeding and breastfeeding difficulties in the first postpartum week and the fact that women who had epidurals were more likely to stop breastfeeding than women who used non-pharmacologic methods of pain relief. Camann's editorial (below) provides a good overview of this topic. See:
   Jordan S, Emery, S, Watkins A, Evans JD, Storey M, Morgan G. Association
s of drugs routinely given in labour with breastfeeding at 48 hours: analysis of the Cardiff Births Survey. BJOG: International Journal of Obstetrics & Gynaecology, 2009, online publication on 1 Sept
   Beilin Y, Bodian C, Weiser J, et al. Effect of labor epidural analgesia with and without fentanyl on infant breast-feeding: a prospective, randomized, double blind study. Anesthesiology, 2005, Dec;103(6):1211-7

   Camann W. Labor analgesia and breast feeding: avoid parenteral narcotics and provide lactation support. International Journal of Obstetric Anesthesia, 2007, Jul; 16(3):199-201
   Torvaldsen S, Roberts CL, Simpson JM, et al. Intrapartum epidural analgesia and breastfeeding: a prospective cohort study. International Breastfeeding Journal, 2006,Dec11;1:24
Sylvie says:  If research data which has emerged in the last year has dramatically changed the picture, I'd like to hear about it. The chapter on epidurals that Michael Klein recently wrote just a few weeks ago for the upcoming Fresh Heart title Promoting Normal Birth: Research, Reflections & Guidelines suggests that the outlook for epidurals still looks the same.

Sylvie Donna Fresh Heart Publishing
PO Box 225, Chesterle Street
DH3 9BQ, UK
www.freshheartpublishing.co.uk
www.freshheartpublishing.com



Epidurals and Autism



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.

[Ed: People sometimes ask why there would be a difference between pitocin and natural oxytocin.  There may be chemical differences, but one obvious difference is that pitocin is often given before the uterus is fully mature, so the uterus hasn't acquired all the oxytocin receptors of a term pregnancy.  So the amounts of pitocin used are often much greater than the body would naturally produce.]



Epidural Fevers



Scary New Research About Epidurals Causing Harm to the Baby

For a long time, we've known that epidural use was associated with maternal fever during labor.  We used to think these "epidural fevers" were harmless to the baby.  New research shows that they are actually associated with harm to the baby.  I hope they'll do a lot more research to figure out what's really going on here.  We need epidurals to facilitate vaginal births on occasion.  And women who are opting for epidurals as a first resort need to know the real risks.

Elevated Temperature With Epidural Analgesia Linked to Neonatal Harm [Medscape, 1/30/12]
by Ricki Lewis, PhD

January 30, 2012 — Maternal fever that accompanies epidural analgesia is associated with neurological depression in the neonates, according to a study published online January 30 in Pediatrics.  . . .  Of women receiving epidurals, 535 (19.2%) developed fevers compared with 10 of 425 (2.4%) of those not receiving epidurals.  . . . The researchers conclude that "increased maternal temperature, regardless of etiology, may have implications for the fetus." After adjusting for confounding factors, they associated maternal fever above 101°F with a "two- to sixfold increase in the occurrence of all adverse neonatal outcomes examined," they write.

Intrapartum temperature elevation, epidural use, and adverse outcome in term infants.
Greenwell EA, Wyshak G, Ringer SA, Johnson LC, Rivkin MJ, Lieberman E.
Pediatrics. 2012 Feb;129(2):e447-54. Epub 2012 Jan 30.

CONCLUSIONS: The proportion of infants experiencing adverse outcomes increased with the degree of epidural-related maternal temperature elevation. Epidural use without temperature elevation was not associated with any of the adverse outcomes we studied.


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:

Maternal fever after epidural analgesia - A Review from the Journal of Family Practice Web site
with Recommendations for clinical practice
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).

Epidurals Can Cause Fever


Epidural Fevers


Is An Epidural Bad for a Newborn? Controversial Parenting Magazine Article


Response to Parenting Magazine Article Downplaying Epidural Risks



Epidural Headaches



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.



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. 

Epidurals And Dystocia




 Epidural Prolongs Second Stage of Labor by More Than 2 Hours
[Medscape, 2/5/14]

Clinical question -Does epidural analgesia interfere with labor and consequently increase the risk of complications?

Randomized trial of epidural versus intravenous analgesia during labor.
Ramin SM, Gambling DR, Lucas MJ, Sharma SK, Sidawi JE, Leveno KJ
Obstet Gynecol 1995 Nov;86(5):783-789

Epidural analgesia in labor - A Review from the Journal of Family Practice Web site
Reviewed by Craig W. Robbins, MD and David Slawson, MD 


Timing in Epidural use in nulliparas associated with prolonged labor.

(Reuters) Less-advanced cervical dilation upon hospital admission, along with early epidural placement, are strongly associated with prolonged labor, (defined as lasting more than 12 hours) according to Dr. Fergal D. Malone from Ireland, and colleagues. When the epidural was placed early in labor, that is before 2 centimeters dilation, the risk increased 42-fold. Dr. Malone says, "...that it is not the presence of the epidural that predisposes a woman to a prolonged labor, but that the cervical dilation at the time of epidural placement may be important."
Obstet Gynecol 1996;88:211-215. 

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.


Epidurals Linked to Cesarean Sections

Thorp, JA et al. (1993) The effect of intrapartum epidural anesthesia on nulliparous labor: a randomized, controlled, prospective trial. American Journal of OB/GYN. 169 (4) 851-858.
Nulliparas in spontaneous labor were randomized to epidural (n=48) or narcotic (n=45 analgesia. The only cesarean in the narcotic group was the only woman who opted out into the epidural group. The risk of cesarean with epidural was 50% at 2cm, 33% at 3cm, 26% at 4cm, and nil at 5cm. They stopped the study early on ethical grounds when the results became clear to the researchers.

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



Epidurals And Fetal Distress



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.



Epidurals And Breastfeeding Problems



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.



Epidurals And Long-Term Effects



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's Methodology Flawed



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:

  1. Do you believe that the scientific evidence to date adequately supports the proposition that epidurals increase the c-section rate?
  2. Separately, does your personal, anecdotal experience lead you to believe that epidurals increase the likelihood that the recipient will end up with a c-section?

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



Risks to the Mother



Database of epidural complications needed

Experts have called for the establishment of a national database to identify the major complications that arise from epidural pain relief.

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.


Epidural Risks


Bacterial Meningitis After Intrapartum Spinal Anesthesia — New York and Ohio, 2008–2009 - "Four were confirmed to have Streptococcus salivarius meningitis, and one woman subsequently died."


Epidural Horror Story



Case Study of Respiratory Arrest and Cardiac Arrest after Epidural Placement



Childbirth turns tragic, then joyful
A lifeless woman (Tracy Hermanstorfer) and her baby are revived in a Colorado hospital on Christmas Eve.
This newspaper report omits the mention of the epidural.


Exclusive Interview with ABC News / Good Morning America [12/30/09]
This is where she says, "After they started the pitocin and stuff like that, I felt a little weird."
Sitting up for the epidural, and it wasn't until afterwards that she lay down and said that she was tired, and that's when the whole nightmare started.
She started going numb and everything in her legs, so she laid down to take a nap, and she wasn't waking up.

It's worth listening to this interview to hear how the OB dances around the possibility that the epidural could have caused this crisis.  She says she doesn't have a great explanation. She talks about all sorts of things and kind of blurs the effects of cardiac arrest from an epidural and cardiac arrest from eclampsia, where we do not expect woman to recover so quickly.  And she doesn't mention whatever drugs they were busily giving the woman to reverse the effects of the epidural drugs . . . Narcan maybe?

I wonder how much the problem with the unusual effects of the anesthesia also affected the baby.  Fortunately, it appears that the baby responded well to normal resuscitation efforts.

And an aside to the interviewer who said that they were doing the surgery without anesthesia.  An epidural is a form of anesthesia; it's called regional anesthesia rather than general anesthesia, where someone is unconscious.


After listening to this interview, it seems pretty clear that the respiratory arrest and cardiac arrest happened pretty soon after the administration of the epidural. These are known risks of epidural:

Medical Risks of Epidural Anesthesia During Childbirth by Lewis Mehl-Madrona, M.D., Ph.D. and Morgaine Mehl-Madrona

Best evidence about effects of epidural or combined spinal-epidural analgesia from the Cochrane Collaboration
"Potential side effects during labor include . . . life-threatening complications (severe low blood pressure, respiratory or cardiac arrest, convulsions, severe allergic reaction) (Mayberry and colleagues 2002, a systematic review). "

Every birth is a miracle, and I don't wish to detract in any way from the miracles of c-section, CPR, and Neonatal Resuscitation when lives are in danger; each of these interventions worked marvelously to save the lives of this mother and baby once the crisis occurred.  But I think it's a disservice to this family and all birthing families to pretend that the epidural isn't the most obvious cause of the crisis in the first place.

The mom's quick recovery and the baby's straightforward resuscitation suggest that there was no underlying pathology and that the life-threatening situation could be attributed completely to the epidural and associated interventions.

But if the family wants to focus on the miracle of birth, I'm sure the doctors and the hospital aren't going to try to change their minds.  After all, which sounds better:

1) They were the anointed instruments in the hands of God to effect a Christmas miracle and save the life of this mother and baby.

2) The procedures they did on the mother (epidural, etc.) nearly killed her and her baby.

Happy New Year!


Honestly, I question the quality of care this woman was getting if she was carrying a 7 pound baby at 33 weeks and nobody noticed!  The baby wasn't in the NICU that night, so we can assume he wasn't really premature. I hope they did an ultrasound to check the baby's size before they started pitocin with a 33-week baby.


Learning the essentials of epidural anesthesia - a nice article from nursingcenter.com

"If the epidural needle or catheter enters the subarachnoid space, either during insertion or because of catheter migration, the relatively high volumes of epidural anesthetic can cause high spinal anesthesia, increasing the loss of function in the respiratory muscles. The patient will have trouble breathing, leading to apnea, increasing numbness, or paralysis. This is an emergency. Immediately calm and reassure the patient. Call the emergency response team and the anesthesia provider. Have emergency airway equipment, emergency medications, and suction at hand to maintain the patient's airway and cardiovascular status. Follow basic life support guidelines to protect and support the patient's airway, breathing, and circulation.

"Patient movement can cause the catheter to migrate into an epidural vein. If unnoticed, this can result in epidural medication being inadvertently injected into the bloodstream, causing an overdose. The patient will have ringing in his ears, a metallic taste in his mouth, a sense of impending doom, and hypotension, which can progress to unconsciousness and cardiac arrest. To prevent this complication, the patient should be moved slowly and carefully by several caregivers and positioned with the least amount of aid by the patient whenever possible."


I wonder if the mom's heartbeat resumed after the baby was out because they were finally able to do more effective heart compressions.  That would bring oxygenated blood to the heart so it could start beating again.  Thank goodness!


Yes, thank goodness for CPR!  This is exactly the situation where it is most effective: an essentially healthy person who has stopped breathing for some reason.  You just get some oxygen into those lungs, compress the heart to circulate it, and then everything is nicely jumpstarted.


The mom says this is the first time she's needed an epidural after two previous births.  I wonder if the additional pain was caused by the pitocin contractions or whether she was just stressed out if she really thought her baby was coming prematurely.  This seems like a situation where good prenatal care and good labor support would have avoided the need for an epidural and thus prevented the crisis in the first place.


The mom's quick recovery and the baby's straightforward resuscitation of the baby suggest the possibility that there was no underlying pathology and that the life-threatening situation was caused completely by the epidural and associated interventions.


I wouldn't expect an average family who's just had a baby to be able to think critically about what happened, especially with the distraction of all the media attention they're getting.  But I do wonder about a doctor who cannot think of any explanation for why a woman who had just gotten an epidural might have cardiac and respiratory arrest.  And I really wonder that she couldn't explain how the mom might have been revived by the drugs they must have given her, and she apparently couldn't explain that CPR is explicitly designed to revive people who are inherently healthy but have had some kind of short-term insult.


This is not the first story where I have heard a woman say thank goodness for the cesarean because It saved me and baby's life. Then come to hear the full story where either mom or baby clearly had a bad reaction to the epidural and needed the immediate section. Not one of the people who have shared this with me ever said it was the fault of the epidural. Never did anyone freely tell them that it was the most likely cause, which makes me wonder- is it even written in the records that the bad reaction occurred and it is most likely caused by the epidural?  I doubt it is, and it is scary because if the woman needs the same meds again for birth or other procedures her reaction (especially if it was an allergic reaction versus blood pressure) will likely be worse the second time!

Often times when I talk to nurses or OBs about medications, I feel like they live in a different dimension than I do. Their observations of the effects of these medications seem quite different than mine.  I guess it should not surprise me though, since I have observed many OBs and nurses not even realize when a woman was contracting without the damned computer!!! One of the latest births I attended, my client asked about the risk of the epidural slowing down labor and the nurse said that does not happen. Then a minute later explained that she would need Pitocin with the epidural. When my client asked why, she said, well why not? It shortens labor and you would not be feeling anything anyway!  My client was well educated (of course) and decided not to use the epidural. She told me later that one of the reasons why she decided she did not need it was because it scared her that she knew more about the epidural than the nurse!


Is there any way to find out if this incident was properly reported to the Society for Obstetric Anesthesia and Perinatology'Serious  Complication Repository (SCORE) Project to track adverse complications in obstetric anesthesiology?  If you're curious, here's their web site section on Patient Education.


Thank goodness they were able to revive the mother and save the baby!

I'm expecting to see a case study in Public Relations after the way this family and doctor presented the case in the media!



Risks of Routine Placement of Epidural



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 Harm the Baby



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.

Decels/Bradycardia

Look at an EFM printout and you see that it does affect the baby. The baby's heartbeat stops reacting to the contractions after the epidural is administered. We accidentally videotaped the EFM screen before and after the epidural and it is very different. Carol Ann was born perfectly healthy (except for the fever it gave her that dropped less than an hour after she was removed). So I guess the only harm was the 3 days that she had to live with no mom, in a plastic box with IV's and wires all over her body. Grrrrrrr!

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.


Other Ways Epidurals Harm Baby

Epidurals Cause Problems for Mother-Infant Bonding - Research about the effect of epidurals on mother infant bonding


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.



Dangers of Epidural Placement by Incompetent Anesthesiologist



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.



Recovering from Pharmaceuticals Received during Labor and Birth



"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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