I am back, after having been bumped twice due to problems with my
access.  I decided it was easier to read the weekly digests on weekends
than to follow up on my bumps. I miss the immediacy, but I am able to get
other things done during the week (like provide health care, earn a
living, maintain relationships).  I never introduced myself before, I got
too involved in the dialogue.  I am a family physician in a town of 3,000
in central MO (really getting beautiful now) and I help run a free
standing birth center and a home birth business with a CNM partner in
Columbia, 30 miles away.  Nursing mothers have taught me what I know
about breastfeeding, with lots of help from a very patient LLLL.  I
became active with the state breastfeeding task force the last year
(serving as the chair until this week--whew) and boy have I learned a lot
more!!  I had a micarriage this summer--my first pregnancy, and now I
have recurrent dreams of nursing.  Hope to repeat the pregnancy passage
this spring. The big joke when I was pregnant was my friends and patients
would ask me what hospital I was going to have my baby in, and what kind
of formula I was going to use.

I reviewed the litterature regarding medications in labor and their
effect on breastfeeding for a conference last October.  What I got from
this review is :
1.  No really good studies have been done, no randomized studies
available.  The only studies were observations of routine care in labor
and delivery units.  And the study groups were women receiving drugs and
those who did not.  The drugged groups usually included women who
received more than drug, or who received different drugs.
2.  All the studies, flawed as they were, consistently showed that the
infants of mothers who received drugs had more difficulty nursing than
infants of mothers who had drug-free births.
3.  Contrary to what I was taught, the effect of these drugs seemed to be
LESS if given within on hour of birth.
4.  Narcotics and other drugs used in labor are poorly cleared from the
newborn brain, and the newborn liver metabolizes them slowly.  Measurable
effects were demonstrated for 5 to 7 days in both breast and artificially
fed babies.
5.  Narcotics are secreted in breastmilk (this was an old study and I
have not looked up more recent ones) and so breastfed babies can get
narcotics form their mothers for several days after birth)
6.  No comparison studies between one drug and another have been
published.  Since drugs in a class tend to have the same activity, it is
the responsibility of the manufacturers of these drugs to do the studies
before they claim (or allow others to claim) that their product is
different.  So if any one says that x drug doesnt sedate babies as much,
ask for the citation and read it--I dont think these studies exist.  Like
in much of medicine we are flying blind.
7.  The first hour after birth is a very crowded and sensitive developmental
stage.  It is the  opportunity for the newborn to learn to breath, to
maintain temperature, to see, to smell, to hear without the muffling of the
mothers body, to  re-recognize mother, to find the breast, to attatch, to
suck and swallow,  and to defecate.  It is also the time for the infant
to become colonize   with maternal bacteria, for which s/he will receive
protective  antibodies.  This developmental stage should be spent in
skin-to skin  contact with the mother, unless the infant needs
resucitation involving  intubation, chest compressions, medications, or
surgery.
8.  Asking an infant to accomplish these tasks in a drugged state is
asking for some difficulties.  Asking them to do it through drugs and in
separation from the mother is,. . . it is hard to finish this sentence
politely.
9.  When a woman needs something  in labor, what she usually needs is
support and touch and encouragement.  Thinking that drugs will fill her
needs is like thinking that a bottle can comfort a child the way nursing can.
10.  Women deserve informed consent with regards to these issues.  They
deserve to hear BEFORE LABOR "There are ways to control pain in labor
(list the non durg ways) Drugs can also be used.  They will not eliminate
pain, but they may help you relax.  They may also distort your perception
and make your pain more difficult to handle. They will enter your baby's
body and will affect his/her ability to adapt to life outside the womb,
including his/her ability to learn to nurse.  This effect on your baby
may last as long as a week or more.  Some think the effect lasts a month.
Except for this effect, we think these drugs are safe for use in laboring
women.  There are no studies to indicate that there are any drugs that
cause fewer effects than others." Personally, I believe that all laboring
women deserve doula care and that for those who become exhausted,
conduction epicurals should be used.

UPDATE
The women I previously wrote about who had her ovaries removed at 24
weeks gestation has given birth---a beautiful birth in hands and knees in
a labor bed into the hands of the father.  Her transition was intense.
After she asked for drugs, she received the continual verbal and physical
support of her husband, her doula, and her physician.  She barely pushed,
I have no idea when she became complete, I had to rush to get gloves on.
She was so relieved to not push 2 hours like she did last time.  OK this
is not the midwifery list--so on to the interesting part.  She is nursing
with no problems.  Every sign of newborn thriving is present.  And after
going on line, asking every expert in the country I could think of and
not finding anyone who had had experience with this--turns out the
perinatologist in Columbia had managed 3 cases!!  Sometimes the expert is
the guy next door.  Anyway, I am happy to report that this woman seems to
be lactating without ovaries very well.  Oh, I forgot to say--the baby is
one of the most lovely little girl I have ever seen.

Elizabeth A. Peyton, MD,family physician, [log in to unmask]