Becky and all ,
Here's the stuff I prepared for our staff as a rebuttal to their requests
that I encourage epidurals because they are the community standard. Many
thanks for everyone's input.
Marie Davis
---------------
Epidural Anesthesia
The epidural rate in most U.S. Hospitals is in excess of 85 %. <our
hospital's name deleted> rate is 25 % Our nurses provide excellent labor
support, we should be proud of that fact.
The available studies reviewing the drug content of the epidural conclude
that the drug(s) do not pass to the infant. However, lactation consultants
and nurses report that babies born following epidural anesthesia are
lethargic and have uncoordinated suck-swallow patterns for a period of days
after birth, regardless of feeding method.
Perhaps what needs to be taken into account is the idea of "informed consent"
for the use of epidural anesthesia in labor. It is within the patient's
bill of rights to know ALL the risks and benefits of any medical intervention
so they can make an informed choice. The choice cannot, should not, be made
for or by any laboring mother unless there is a complete discussion of all
the possible consequences and/or side effects of the procedure; headache,
paralysis, effects on the infant including feeding problems, the remote
possibility that the mother could die, etc... The same is true of any
procedure.
Epidurals do have their place in some labors with those who need or opt for
medication, but a number of mothers have admitted they had NO idea of the
consequences prior to the epidural. The community and the media give glowing
reports to expectant mothers touting the use of epidural anesthesia. A
balance must presented somewhere.
The Expectant Parents class is an orientation for new parents to our
hospital. The idea is to introduce them to our policies and let them know
about the classes we offer plus give them some idea about when to come in
etc... During the lecture we medication availability and epidurals are
disscussed. This usually results in a flurry of discussion on epidurals.
This is what we say if we are asked for specifics:
1) An epidural is not a little shot in your back-- The procedure involves
threading a small tube up next to your spinal cord. Medication is given
slowly through a machine that will drip it around the nerves. You will be
numb from your waist down. Once the epidural is started, you cannot get up
and walk and you may need help turning in bed. (Amazingly, more women are
afraid of an IV than an epidural. Somehow they don't make the needle
connection until we say it.)
2) As with all things there is some risk involved.
a) It may slow or stop your labor
b) You have to have an IV
c) One researcher reports that more than 65% have back problems
for up to a year (see references below)
d) There may be some effects on the baby including feeding
difficulties
3) No one should plant the seed that you need one or have to have one before
you are in labor--it should be mother's choice. Don't decide that you can't
have a baby without an epidural. If you need it, you need it, we don't
expect you to suffer
4) Further questions should be directed to the anesthesia department.
The following chart was presented to both the pediatric MD staff and the
perinatal nurses in the month of March 1996
Epidural Anesthesia
Known Effects
Labor Slows Down: May require pitocin augmentation. Pitocin is indicated to
restore or strengthen contractions, and control postpartum hemorrhaging.
Listed under "precautions" is this statement: "Water intoxication: Oxytocin
has an intrinsic antidiuretic effect, acting to increase water reabsorption
from the glomerular filtrate. consider the possibility of water intoxication,
particularly when oxytocin is administered by continuous infusion and the
patient is receiving fluids by mouth."
Relaxed Pelvic Muscle Tone: The mother lacks the normal bodily reflexes that
turn the head into the optimal position for delivery. The normal decent of
the baby's head is inhibited. May cause the infant's head to remain
mal-positioned (posterior or transverse) for long periods of time. This may
result in poor or slow dilatation and effacement of the cervix.
Pushing Phase Prolonged: The mother lacks the normal bodily reflexes that
signal the urge to push, vacuum extraction, forceps and/or cesarean delivery
may result.
Elevates Maternal Temperature: Baby's heart rate increases and can mimic
fetal distress. As a result of the temperature elevation in labor,
unnecessary tests for neonatal sepsis and costly antibiotic regimens for the
mother may be used.
Narcotics Before Epidural: Further complicates labor and neonatal outcomes.
Large Infusions of I.V. Fluids: Generalized edema in both the mother and
the infant,the infant's birthweight may be "inflated." Infant postnatal
weight loss may be more than allowable amounts.
Needle Accidently Pierces The Dura: Spinal headaches. Treatment and pain
control along with additional days in the hospital are costly.
Epidural Bibliography
Belsey, EM, Rosenblatt, DB. et al. "The Influence Of Maternal Analgesia On
Neonatal Behavior: I. Pethidine." Br. J. Obstet Gynaecol, 88, 399-407.
Brazelton, TB. "Effect Of Prenatal Drugs On The Behavior Of The Neonate."
Am J Psychiatry vol. 126, March 1970, 1261-1266.
Fusi, L., Maresh J., Steer, P Beard, R. "Maternal Pyrexia Associated with
the Use of Epidural analgesia in Labor." Lancet 1 (1989):1250-1252.
Hattori, R. "Autistic and Developmental Disorders After General Anesthetic
Delivery (letter)." Lancet vol. 337, 1991, 1357-58.
Jacobson B et al. "Perinatal Origin Of Adult Self-Destructive Behavior."
Acta Psychiatr. Scand. 1987: 76, 364-371.
Jacobson B, Nyberg K, et al. "Obstetric Pain Medication And Eventual Adult
Amphetamine Addiction In Offspring." Acta Obstet Gynecol Scand 67: 677-682,
1988.
Jacobson B, Nyberg K, et al. "Opiate Addiction In Adult Offspring Through
Possible Imprinting After Obstetric Treatment." Br. Med J vol. 301, 10 Nov
190, 1067-1070.
Kennell, J. Klaus M., Mc Grath S., Robertson. S. Hinkley, CW "Labor
Complications Associated with Epidural Anesthesia." Pediatric Research 29
(1991):220A.
Kraemer, H. "Obstetric Drugs And Infant Behavior: A Re-Evaluation." J Peds
Psych. vol. 10, 1985, 354-353.
Kron RE, Stein M, Goddard KE: "Newborn Sucking Behavior Affected By Obstetric
Sedation." Pediatrics 37: 1012-1016, 1966.
Kuhnert B. "Obstetric medication and neonatal behavior: current
controversies." Clin Perinatal Vol 12, June 1985,423-440.
Lester BM, Als, H. and Brazelton, TB. "Regional Obstetric Anesthesia And
Newborn Behavior: A Reanalysis Toward Synergistic Effects." Child
Development 1982, 53: 687-692.
Loftus J, Hill H, Cohen S: "Placental transfer and neonatal effects of
epidural sufentanil and fentanyl administered with bupivacaine during labor."
Anesthesiology 1995; 83(2):300-308. [suggests a lower Neurologic and Adaptive
Capacity Score (NACS) at 24 hr. in one group after an epidural delivery, but
says, "Despite our findings, we do not believe that the differences in NACS
indicate neurobehavioral depression with fentanyl that is of clinical
concern... To date, no adverse long term effects have been associated with
transient drug-related neurobehavioral depression."]
MacArthur C, Letis M, Knox EG. "Investigation Of Long Term Problems After
Obstetric Epidural Anesthesia." British Medical Journal Vol. 304, 16 May
1992, 1279-1282.
Mac Arthur, C., Lewis M., Knox EG and Crawford JS. "Epidural Anesthesia And
Long-Term Backache After Childbirth." British Medical Journal 301
(1990):9-12. [Statement " Researchers in England have discovered a
significant increase in backaches among mothers who have had epidural
anesthesia. Of women who reported backache, 69 percent had it for more than
a year after giving birth" ]
Matthews MK. "The Relationship Between Maternal Labour Analgesia And Delay
In The Initiation Of Breastfeeding In Healthy Neonates In The Early Neonatal
Period." Midwifery 1989: 5, 3-10.
Murray AD, Dolby RM et al. "Effects Of Epidural Anesthesia On Newborns And
Their Mothers." Child Development 1981, 52: 71-82.
Poore, M and Foster JC. "Epidural And No Epidural Anesthesia: Differences
Between Mothers And Their Experience Of Birth." Birth vol. 12:4, Winter
1985, 205-219.
Righard L and Alade, MO. "Effect Of Delivery Room Routines On Success Of
First Breast-Feed." Lancet 1990, vol. 336, 1105-07. Righard L and Alade.
Rosenblatt DB, Belsey EM, et al. "The Influence Of Maternal Analgesia On
Neonatal Behavior: Ii. Epidural Bupivicaine." British Journal of Obstetrics
and Gynecology April 1989, vol. 88, p. 407-413.
Scanlon JW, Ostheimer GW, et al. "Neurobehavioral Responses And Drug
Concentrations In Newborns After Maternal Epidural Anesthesia With
Bupivicaine." Anesthesiology 45: 400-405, 1976.
Sepkoski CM, Lester BM, Ostheimer GW, Brazelton TB. "The Effects Of Maternal
Epidural Anesthesia On Neonatal Behavior During The First Month."
Developmental Medicine and Child Neurology, 1992: 34, 1072-80.
Thorp, J., Parisi,V.Boylan,P. And Hohnson D. "The Effect of Continuous
Epidural Analgesia on Cesarean Section for Dystocia in Nulliparous Women."
Amer. J of Obstretics and Gynecology 162 (1989):670-675.
Tronick E, Wise S, Brazelton TB, et al. "Regional Obstetric Anesthesia And
Newborn Behavior: Effect Over The First Ten Days Of Life." Pediatrics Vol
58, no. 1, July 1976, 94-100.
Widstrom, AM, Wahlberg V, et al. "Short-Term Effects of Early Suckling And
Touch Of The Nipple On Maternal Behavior." Early Human Development, 21
(1990) 153 163.
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