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Sunday, November 7, 2010

Before you get that epidural ...

In many US hospitals, it's
reported that as many as
90 percent of women choose
an epidural when giving birth. 
Many people think that babies - especially newborns - are just floppy, drooling blobs that sit there and do nothing, completely unable to move under their own volition. This incredibly awesome video shows us how they can move up to their mother's breast - many within less than an hour of being born.

There are two groups: those who were the product of a natural, non-medicated birth, and those whose mothers had epidurals. Their behavior is markedly different, and yet most people think that medicated labors do not produce any effects in the newborn.

I don't know how that's possible. We know that babies can be effected by things in utero that we ingest; even taking Sudafed while nursing, for instance, can produce a jittery baby. There is some debate as to whether the medication crosses the placenta, and I think we can see in this video that there is definitely something going on, to say the least.

I've heard many people say this, including a labor and delivery nurse with supposed years of experience. I'm guessing she hasn't seen many unmedicated births in a while - and she holds the notion that painful childbirth is unnecessary and "why bother?" when you can get pain meds. One mom I talked to said she had an unmedicated birth and that hospital staff were "amazed" at how alert her baby was. No kidding!

In this PregnancyToday question and answer forum, a nurse who teaches childbirth classes asked if epidurals cross the placenta, mainly because a Bradley instructor was telling her clients that they do. The concerned nurse said that it was "her experience" that they didn't. I'm wondering how many natural births she's attended to know what to compare it to - it's a sad reality that many doctors and nurses have never, or very rarely, ever attended a non-medicated birth to know the difference in newborn behavior.

The response (it doesn't say from whom, by the way) immediately slams the Bradley instructor as having an 'extreme' view, and I'm not even sure the answer they gave makes any sense, really:

"As with every extreme position, there is a string of truth. Here are the facts: Local anesthetics cross the placenta. Local anesthetics are used in epidurals. Some local anesthetics placed into the epidural space will be absorbed into the bloodstream and cross the placenta. The small amount of local anesthetic from a properly placed epidural that is absorbed into the bloodstream and crosses the placenta should not affect the mentation of the baby. The lack of affect on the mentation on that baby is an advantage that regional techniques, such as spinals/epidurals, have over intravenous medications."

I'm not sure this really answers the question, and assumes way too much before suggesting that it doesn't ever affect the baby. In one breath, they say the drugs will go into the bloodstream and cross the placenta. Then they turn around and say they should not affect the "mentation" of the baby, but we can see, and some women experience, that it does in fact. Does that mean there are lots of bad anesthesiologists running around, giving bad epidurals? And does this mean they should really admit that the Bradley instructor is right?

I had two cesareans, so obviously I had a spinal for both. In my vaginal birth, I had Nubain but no epidural. I noticed a huge difference in behavior between my babies after birth. Coupled with my inexperience at breastfeeding the first time around, it was difficult to get my oldest to latch on and we spent days - literally - working at it before we were successful. With my second, she took to the breast as soon as I offered it (which, unfortunately due to mother/baby separation that is so typical in American hospitals, was probably at least an hour or two after her birth) and behaved much differently than her brothers did. I don't remember my third being that particularly alert or interested in the breast after birth (again, after being separated from me for several hours).

It could be said that in some babies, the epidural or similar anesthesia can diminish or totally destroy a successful breastfeeding relationship between mom and baby, or at the very least, create a more difficult start to breastfeeding than need be. An inexperienced breastfeeding mom may take this as a sign that baby is totally uninterested in her, and will decide before she even leaves the hospital that breastfeeding is not for her.

It's important to realize that epidurals can be great tools for allowing the mother to relax and labor to progress. But in some cases, they can slow down labor. This is another point of contention among some, but just the other day I heard the amazing birth story of a first-time mother who said that her labor was going pretty fast, and she noticed how the epi slowed it down. For her, this was a good thing because she felt that it allowed her to get her thoughts together. For others, it can be a nightmare that leads to more (and more) interventions, that can sometimes lead to a cesarean - or at the very least, a rather traumatic, difficult vaginal birth.

Studies have shown that epidural use can increase the need for tools such as vacuum suction and forceps - mostly no doubt because some women can't feel what's going on, nor can they get up and change positions when an epidural is in place. Many talk about "light epidurals" (even an anesthesiologist told me about these) but still lots of women say they were completely unable to move due to having one. Again, the jury is out as to whether this is really widespread and may depend on a number of factors, including mother's position and doctor/anesthesiologist preference.

Lastly, we must look at the standard procedure for birth in many hospitals: the mother is likely allowed no food or drink in labor, is encouraged to lie down frequently for cervix checks, is hooked up to a monitor for continuous fetal monitoring, and as a result, is not allowed to move around or really change positions. When it comes to pushing, she is often told she must assume the lithotomy position (flat on her back). When you add all that up, it's not a wonder so many women ask for epidurals and it's amazing a woman can even birth a baby at all.

Remaining upright in early labor can actually make the first stage of labor go faster, and being mobile during labor can help mothers cope with the pain better. Being flat on your back , confined to bed, does not.

It's important to realize that studies have been done, some of which produce completely counterintuitive results. Like, it would seem perfectly plausible that epidurals - especially ones that are "heavy" and allow the mother no sensation whatsoever - would slow down labor. Studies have shown, apparently, that this is not the case. But it's not just as simple as that: it's a multi-faceted issue with lots of pieces to the puzzle that need to be put together before you can draw any conclusion. Since many hospitals and doctors have little idea what normal birth is like, we base the results of many studies - and thus our conclusions about birth - on a completely skewed model of care. Therefore it's important to remember that some studies, however official-sounding, are inaccurate and inherently flawed, especially if they do not take into account those differences.

As I wrote about in this old post , if you choose to get an epidural, that's your decision. It should not be one that's taken lightly, but rather with as much information as possible, so that you have made an informed decision, not one that's based on someone else's perception of pain.

Do epidurals cross the placenta?
Facts on Epidural Anesthesia


Ethel said...

Let us also remember that with an epidural a small amount of narcotic is used and in addition what would cross the placenta (and there is some) is diluted by the mother's entire body, so the effect on any one other then the mother is minute at best. Sort of like taking a pipettor and dispensing 1 microliter in 10L of fluid, it creates no appreciable difference.

As for the infant, I am sorry but if the epidurals I had caused any effect I am not sure the delivery room would have stayed standing - each one came screaming loudly. Besides, better an epidural then a c-section especially when for some women (like myself) they for some reason tend to aid in dilation (I am not saying in all women, some).

The Deranged Housewife said...

If it's such a small amount of narcotic, what good does it do? I remember one of the main ingredients in an epi (when I made them) was Fentanyl. I can't remember much more than that because it's been probably a decade since I've done them. I do think there are a number of factors - it depends on the anesthesiologist's preference, I'm guessing, because I've had two and had very different results. One I can assume was morphine - it made me itch like crazy, which is an allergic reaction. The second one had something - epinephrine, maybe? - that made me extremely agitated and I nearly wanted to jump off the table and run around the room (if only i could). Both were pretty miserable experiences.

But that's beside the point. Anyway, my point is not to degrade women who choose one; just to make those people who want one dispensed like candy that they do have risks. Obviously those side effects don't happen to everyone, but they must happen enough to some that they're considered side effects. The dosing can have a lot to do with that as well and how much the newborn may be effected - if you are totally numb and can't feel anything, versus able to move somewhat, then you may notice less of an effect in your baby. And you might not. Who knows.

erin said...

I wouldn't by any means say that mother baby seperation after birth will prevent a successful breastfeeding relationship. I had a drug free birth but unfortunately a retained placenta, and as a result was seperated from my son for about 5 hours after birth. He had one bottle of formula and nursed like a champ as soon as we were back together. Still nursing at 11 months. Breastfeeding is a relationship that takes time to evolve, just like any other. I don't think it's so much that you nurse in the first hour as it is what kind of support you get one day, one week, one month later.

The Deranged Housewife said...

Actually I meant that the epidural/drowsy or uninterested baby could diminish or destroy the breastfeeding relationship. My son had not much interest in nursing for nearly 2 1/2 days after his birth, which was very frustrating. Had I not had the adamant desire to nurse, I probably would have given up and started bottlefeeding. Couple that with separation, aggressive nurses who decide to feed the baby a bottle without asking, or ask to feed your baby for you "so you can get some sleep" (they did this with my second, which I found bizarre). If your baby happens to be one of the ones who gets nipple confusion, it's even more frustrating and can totally undermine the nursing relationship.