December 5, 2001
Volume 3, Issue 49
Midwifery Today E-News
“Effects of Labor Drugs”
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Researchers collected data on self-reported cigarette use and urine cotinine concentration from 1583 pregnant smokers at the time of study enrollment--at the first or second prenatal visit regardless of gestational age--and in the third trimester. As indicated by urine cotinine measurement, 1349 women were actively smoking at enrollment and 234 were not. Women who quit smoking before enrollment and those who quit after enrollment delivered infants with the highest adjusted mean birth weights (3492 and 3491 g, respectively). Women who reduced their cigarette use had a mean adjusted infant birth weight 32 g heavier compared with those who did not change their cigarette use, but the difference was not statistically significant (p = 0.33). Infant birth weight initially declined sharply as third-trimester cigarette use increased. However, the decline leveled off at more than eight cigarettes per day.

- Am J Epidemiol 2001;154:694-701


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Effects of Labor Drugs

The risks of epidurals convert normal labor to a high-tech event. An IV must be started to help counteract the tendency of epidurals to cause hypotension. Electronic fetal monitoring is necessary because epidurals can cause fetal distress, and the mother's vital signs must be closely monitored to warn of maternal adverse reactions. If the needle or catheter pierces a blood vessel, which is easy to do in pregnancy because blood vessels are enlarged, or the needle goes deeper than the epidural space, convulsions, respiratory paralysis, and/or cardiac arrest can occur. Tests are done to confirm proper placement before giving the full dosage, but these are not completely preventative. Trained personnel, resuscitation equipment, and medication must be immediately available.

In labor, epidurals increase the need for oxytocin, instrumental delivery, episiotomy, and bladder catheterization. The first-time mother is more likely to have a cesarean. Temporary postpartum complications include urinary incontinence, nerve injury causing muscle weakness or abnormal sensation, and headache that can last for days and is excruciatingly painful. Instrumental delivery and episiotomy increase the probability of deep perineal tears. Backache and headache may become chronic. In the newborn, epidurals may cause jaundice, and there may be adverse behavioral effects.

- Henci Goer, Obtetric Myths Versus Research Realities, Bergin & Garvey 1995

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Induction with Cytotec should never be attempted anywhere, most especially in out-of-hospital settings. Incredibly, the American College of Obstetricians and Gynecologists (ACOG) recently approved Cytotec induction in spite of lack of FDA approval; in spite of a letter to doctors from Searle, the manufacturer of Cytotec, imploring doctors not to use it for induction; in spite of lack of approval from the Cochrane Library (the best scientific opinion); and in spite of the fact that it is not approved or used for induction in any country in Western Europe.

ACOG quotes studies of Cytotec induction, none of which have a sufficient number of research subjects, and consequently none of the studies quoted have sufficient statistical power to detect small but potentially important risks such as uterine hyperstimulation and uterine rupture. Furthermore, because published studies of Cytotec induction have such wide methodological variability, meta-analysis is impossible and the published attempts at such meta-analysis are seriously flawed.... Midwives should stay as far away as possible from such vigilante obstetrics--obstetricians taking matters into their own hands while ignoring the recommendations of the real judges.

- excerpted from "Midwives and Cytotec: A True Story, by Marsden Wagner, MD, Midwifery Today Issue 57

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As a new doula, I'm curious how other doulas feel about suggesting/offering herbs (teas to calm nausea, strengthen uterus, for overall health) to their pregnant clients. To me, it feels like a natural thing to share my knowledge of herbs with a mom-to-be. I consider a huge part of my role to be nurturing and empowering her to learn about and take care of her body through this whole process. But I also realize it may become sticky if my client is working with a doctor (or midwife) who opposes the use of herbs or who doesn't communicate well with me, or medically if there was some kind of condition that she didn't share with me, etc. I also wonder about the legalities.

- Kiva

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Q: Does anyone have experience with pregnancy coexisting with kidney stones? My lady had kidney stones with her first pregnancy. There has been a recurrence with her second pregnancy. Her urologist felt it necessary to insert a nephrostomy tube to remain in for the duration of the pregnancy whereupon she'll probably have lithrodisropy. Her pregnancy is normal and she wishes to have a vaginal delivery. I wish to support her in this and am hoping there are some of my sister midwives who've taken care of ladies like this.

- Anne Walters, CNM

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Q: When you attend homebirths, what do you keep in your kit ahead of time for those unexpected, middle-of-the-night calls? And what is the most effective way to organize and carry your materials and supplies?

- B.H.

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I am a PhD student in prenatal and perinatal psychology. It seems these days babies often get "dropped out of the picture" during birth till they're in mom's arms. I am fascinated by this huge transition into the world that every person makes and the power and enduring effects of that event. Because I don't know of actual studies about this transition, yet we know babies are conscious and aware at birth, I am looking for anecdotal information about baby-to-other communication during birth: what was communicated, when, and how they communicated, or how the communication was experienced by the recipient (i.e. visual image, sensation, energy, a "knowing," a voice speaking, an emotion, or anything else). I also want to know the reason for the communication: functional ("Tell mom to squat so I can get unstuck") or related to emotion or something unresolved that needed help. Please clarify the circumstances under which the communication took place and where (home, prenatal visit at office, hospital, etc.) and if anyone else was present and aware or unaware of the communication. Send a paragraph or a page or so to me.

- Claire Winstone
Reply to: claire@speaking4baby.com

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In response to the link between obstetric drug use and future substance abuse in the baby: This possibility is explored in Michel Odent's video "Midwives, Lullabies, and Mother Earth." A doctor presented a graph, presumably of his data, showing how the baby's risk of later drug use jumped with each dose of meds given.

- Melissa Schuppe
Virginia

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For midwives interested in the long-term effects of drugs in the pre- and perinatal period (including drugs in labour) I refer them to the writing of Stanislav Grof. He refers to studies and his own work in Holotropic Breathwork on the effects of birth trauma, drugs etc. in these and other of his books:

  • Psychology of the Future: Lessons from Modern Consciousness Studies, State University of New York Press, 2000.
  • The Holotropic Mind, (with Hal Zina Bennett), Harper, San Francisco, 1990.
  • The Stormy Search for The Self, Thorsons, 1991 (with his wife Christina Grof).

I have found Grof's work and transpersonal psychology to be a very useful theoretical framework in which to capture the essence of many birth experiences I have shared with women and their babies.

I am an independent midwife in Canberra, Australia, and have been attending homebirths here for 14 years. At present, homebirth/independent midwives are having difficulty obtaining professional indemnity insurance so I have closed my practice for a while.

- Emma Baldock

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In regard to Claire's letter about the relationship between use of epidurals in labor and later drug dependency in the children (Issue 3:47) and the letters from Melissa Jonas and Natalie Bjorkland disputing this (Issue 3:48), I offer the following research study reported in Epidemiology 2000;11:715-716.

Maternal Medication During Labor May Affect Offspring's Drug Dependency

Women who wish to lower their offspring's risk of drug abuse may decide to forego some of their own drug use during labor and delivery, according to the results of a prospective study. Dr. Karin Nyberg, of the University of Goteborg in Sweden, and associates evaluated data collected on children born between 1959 and 1966. Of the 693 subjects ages 18 to 27 years who were interviewed, 69 met DSM-III diagnostic criteria for drug abuse and/or dependence on cocaine, hallucinogens, narcotics or other drugs. Thirty-three non-drug abusing siblings served as controls.

Multiple doses of strong pain medication were used during labor preceding the birth of 23% of the drug abusers and 6% of the controls. The researchers estimated an unadjusted odds ratio of 4.7 for drug dependency in offspring whose mothers received at least three doses of opiates or barbiturates within 10 hours of birth. The occurrence of meconium-stained amniotic fluid was also associated with an elevated risk of drug dependence, but this was confounded by prenatal drug exposure in 5 of 17 cases. Other potential factors - prolonged labor, asphyxia, birth order, and low birthweight - were similar among cases and controls. Dr. Nyberg and her colleagues report that their results replicate previous findings in humans and animals regarding prenatal exposure to high doses of medications at birth and adult offspring's drug dependence.

Additionally, Beverly Lawrence Beech wrote to this topic in her paper "Drugs in Labor: What Effects Do They Have Twenty Years Hence?"

"...In a well-designed case control study at the Karolinska Institute in Stockholm in 1990, researchers compared children exposed to pain-relieving drugs in labor with those who were not and discovered an increased risk of drug addiction later in life (Jacobson et al., 1990). In 1988 they showed that when nitrous oxide was given to the mother, the child was five and a half times more likely to become an amphetamine addict than a brother or sister born to the same parents. In their paper in the British Medical Journal (1990), patients who had died from opiate addiction were compared with brothers and sisters; the researchers found that if the mothers had been given opiates or barbiturates or larger doses of nitrous oxide the risk of opiate addiction to the child in later life was increased 4.7 times. In a further study, researchers discovered that the risk of drug addiction was related to the hospital in which they were born. In other words, the likelihood of a child developing drug addiction in later life depended on the labor ward policies of the hospital the mother chose for the birth, and I quote: "For the amphetamine addicts, hospital of birth was found to be an important risk factor even after controlling for residential area" (Nyberg, 1993). Jacobson and Nyberg's research suggests that the use of opiates, barbiturates and nitrous oxide in labor causes imprinting in the babies, and we are now reaping the whirlwind...."

She quoted the following studies as her references:

Jacobson, B. et al. (1990). Opiate addiction in adult offspring through possible imprinting after obstetric treatment. British Medical Journal, 301:1067-1070.
Nyberg, K. et al. (1993). Obstetric medication versus residential area as perinatal risk factors for subsequent adult drug addiction in offspring. Pediatric and Perinatal Epidemiology, 7: 2332.

Are we sure we can separate the effects of different pain-relieving drugs from the effects of epidurals? Is it truly worth taking the risk? There should always be a weighing of the risk-benefit factors. I believe there is a time when an epidural is worth the risk - but I know they are much overused in the United States and I have serious questions about the ethics of encouraging mothers to sign up in advance for their epidurals during their childbirth education classes. I assist at both hospital and homebirths where moms are supported through their labors with no drugs whatsoever and have beautiful drug-free birth experiences! Of the 31 vaginal births I've attended, 24 moms have elected not to have an epidural (or other drugs) - 77% - and 5 of the 7 who elected to have epidurals had labors exceeding 18 hours. Someone said recently that you can't control birth, but you can make an impact on how it will be by your thoughts and feelings. That's an awesome responsibility for doulas and midwives!

- Helen Moore, CD(DONA)
hmoore01@home.com

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I was homebirthed but I feel some of the symptoms Claire mentioned, i.e., "feeling disconnected from their bodies, fuzzy thinking when under stress, feeling inadequate and incapable of completing things they start" so I didn't give these symptoms much credence and almost skipped the rest of her piece. In the end, I did like what she said about making sure that the mother is informed of the possible risks of any intervention. This is so important.

I had read about the risk of epidural and increased incidence of substance abuse in an issue of Mothering magazine (No. 99 Mar/Apr 2000). The article by Beverley Lawrence Beech cites studies that found an increase risk of substance abuse for those babies delivered anesthetized [see above].

In another article in the same issue, Penny Simkin writes that an epidural puts the baby at the risk of the following: bradycardia and hypoxia; tachycardia and fever; subtle changes in newborn reflexes and neurobehavior, including suckling; more difficulty in self-soothing or being consoled. She lists a few references in her article.

- Colleen Morris

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Regarding the tummy exercises mentioned in Issue 3:47 for diastasis of the rectus abdominii: It is important to EXHALE your breath while flexing; that is, breathe out when you pull yourself up into the crunch and flex the abdominal muscles. The exercises are much more effective that way.

I was taught a low stress/high result version of the exercise: lying on back on firm surface with hands behind head, pelvis tilted, then exhale and raise your head and shoulders just a little while pulling your abdominal muscles in toward the spine. Then inhale while relaxing. Do this several times per day for as many repetitions as you find comfortable. Remembering an ounce of prevention, we might add the exercises prenatally and before pregnancy, as well, along with our Kegels.

- Julia Swart

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In reference to the techniques to turn breech [Issue 3:48], I believe they meant to say the "Bladder 67 technique."

- Colleen Morris

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For separated abdominal muscles: You may want to consider some herbs not only to help your muscles heal but also to help you recover from your pregnancy. Astragalus and Cordyceps would be great for you. A formula called Bu Zhong Yi Qi Tang (Ginseng and Astragalus Combination - it usually doesn't contain ginseng) would probably benefit your muscles and help your energy. Cordyceps is a great herb to help nourish your primal energy, which women lose during childbirth. There are many herbs that can do this.

It would be best if readers see a licensed acupuncturist or Chinese herbalist for the herbs. As every person is individual, it is difficult to say what would be the best dose. Also, every herb company will have different recommended doses for their formulas so it is best to follow manufacturer suggested doses unless otherwise advised. Doses are usually 6-12 grams boiled in 2 - 3 cups of water.

- Colleen Morris, L.Ac

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To H. Henderson, who asked about paths to midwifery [Issue 3:48]:

It's wonderful that you want to be a midwife--there's no more rewarding job. You will find it easier if you sort through some decisions about what kind of midwifery you want to practice. Find midwives in your area and ask them if they have time to chat with you about their own practice or even let you hang out with them for a day and observe them on the job. Think about several issues about your future job:

  • How important is your income level to you?
  • Do you want to practice homebirth, birth center birth, or in a hospital?
  • Do you want to be self-employed or be the employee with the perks and restrictions that come with working for a hospital/clinic/doctor?
  • Is it important to be able to practice freely and legally in any state in the US or are you likely to stay in California?
  • What kind of client are you drawn to--do you see yourself working with self-directed women who want natural birth or working with low-income women on state insurance who need a midwife to advocate for them in the hospital setting and help them seek empowerment?
  • What is it that draws you to birth - what kind of images come up in your mind when you imagine yourself as a midwife working with women and families?
  • Do you want to focus on pregnancy and birth or would you like to also do full-spectrum gyn care involving birth control, STD testing, colposcopy of the cervix, well-women care, menopausal care, etc.?

The short answer is, if you want to be a licensed homebirth midwife, you don't need to be a nurse first. It might be difficult to let go of some of the medical culture learned in nursing school once you study midwifery, yet nursing education offers a lot of valuable training for healthcare. On the other hand, if you want to be a certified nurse-midwife, you must complete your bachelors in nursing as a prerequisite.

Best wishes to you on your journey.

- Kathleen Murray, CNM

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