As an anesthesiologist in training (and thus am still a bit malleable, I
hope!), I really like Dr. Righard's theory -- having never heard about it
until now. :)  Knowing that toxicity of local anesthetics initially
manifests as nervous system excitation (ringing in the ears, peri-oral
numbness, even seizures), it seems very unlikely that transfer of local
anesthetic to infant, which does occur in small amounts, would result in a
"drowsy" baby.  Fentanyl may very well have some effect on an infant's
behavior immediately following birth, but it is very rapidly metabolized and
I would think that we would see much more bradycardia and respiratory
depression in all these otherwise normal infants, two "side effects" that we
see all the time when giving fentanyl IV but that are not necessarily
worrisome (depending on the extent!)

I know I've posted about this before, but virtually all epidurals nowadays,
whether for labor analgesia or surgical anesthesia, are given as a mix of
local anesthetic and narcotic.  We use fentanyl at our hospital, along with
different local anesthetics depending on the case and anesthesiologist
preference.  The addition of narcotic really adds to the *quality* of the
block, giving a denser block without affecting motor nerves.  For mothers in
labor, this is considered ideal because it can allow adequate analgesia
(pain relief) without completely removing mom's ability to move and push.

After placing an epidural and providing a bolus of bupivacaine and fentanyl
to get moms comfortable, at our institution we all start an infusion of
ropivacaine (a local anesthetic similar to bupivacaine, but somewhat weaker
and without the risk of cardio-toxicity seen in bupi) and fentanyl.  I
honestly cannot remember the last time I placed an epidural with an
appropriate initial bolus where mom did not need me to come back in some
hours later and bolus her again.  The mix of ropi and fentanyl we use, while
in a decently high concentration, is simply not strong enough for most moms
-- they expect and the nurses foster the belief that the epidural should
make them completely numb.  And while I try to explain away the fact that we
cannot completely eliminate all sensation (a bald-faced lie, as I had a
*complete* sensory block myself when I delivered and had no trouble
pushing), moms virtually always *need*/want a stronger epidural solution
than what we usually run in.

So in my experience, no moms, at least at our hospital, would tolerate a
lower-dose infusion or an infusion without narcotic.  Neither would the
anesthesiologists, who would then be called even more frequently to come
"top up" the epidural with a stronger medication.

Anyway, I hope this was of some help.  Let me know if there are further
questions I can answer...  Am on OB call today so am already plotting how I
can perhaps tweak our epidural infusions and set them as a
patient-controlled pump so I'm able to maybe get some sleep there tonight. :)

-Sarah Reece-Stremtan M.D.

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