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.