Obstetric Interventions: Epidural
Epidural pain relief has major effects on the hormones of labor. It inhibits beta-endorphin production (1) and therefore also inhibits the shift in consciousness that is part of a normal labor. When an epidural is in place, the oxytocin peak that occurs just before birth when the labor has been undisturbed is also inhibited, because the stretch receptors of a birthing woman's lower vagina, which trigger this peak when stretched by the descending baby's head, are numbed. This effect probably persists even when the epidural has worn off and sensation has returned. This is because the nerve fibers involved are smaller than the sensory nerves and therefore more sensitive to drug effects (2). A woman laboring with an epidural therefore misses out on the fetal ejection reflex, which helps her birth her baby quickly and easily, so she must use her own effort, often against gravity, to compensate this loss. This explains the increased length of the second stage of labor and the extra need for forceps when an epidural is used (3).
The use of epidurals also inhibits catecholamine release (4), which may be advantageous in the first stage of labor. Close to the time of birth, however, a reduction in CA levels will further inhibit the fetal ejection reflex, which involves catecholamines as well as oxytocin.
Release of the important uterine stimulating hormone prostaglandin F2 is also adversely affected by epidurals. The level of this hormone rises during an undisturbed labor; however, women with epidurals experience a decrease in PGF2 alpha and a prolongation of labor (5).
Drugs administered by epidural enter the mother's bloodstream immediately and go straight to the baby at equal, or sometimes greater, levels (6,7). Some drugs will be preferentially taken up into the baby's brain (8), and almost all will take longer to be eliminated from the baby's immature system after the cord is cut. One researcher found bupivacaine and its breakdown products in the circulation of babies for the first three days (9).
Epidural anesthesia, used for cesareans, has also been associated with more acidemia (acid blood levels) in healthy newborn babies than has general anesthetic - an indication that epidurals can compromise fetal blood and oxygen supply (10) possibly through a drop in the mother's blood pressure.
Mothers given epidurals in one study spent less time with their babies in the hospital, in inverse proportion to the dose of drugs they received and the length of the second stage of labor (11). In another study, mothers who had epidurals described their babies as more difficult to care for one month later (12). Such subtle shifts in relationship and reciprocity may reflect hormonal dysfunctions and/or drug toxicity and/or the less-than-optimal circumstances that often accompany epidural births — long labors, forceps and cesareans.
- Sarah Buckley, Midwifery Today Issue 63
1. Bacigalupo G. et al. Quantitative relationships between pain intensities during labor and beta-endorphin and cortisol concentrations in plasma. Decline of the hormone concentrations in the early postpartum period. J Perinat Med 1990;18(4):289-96.
2. Goodfellow CF et al. Oxytocin deficiency at delivery with epidural analgesia. Br J Obstet Gynaecol 1983; 90:214-9.
3. McRae-Bergeron CE et al. The effect of epidural analgesia on the second stage of labor. AANA 1998; 66(2):177-82.
4. Falconer AD, Powles AB. Plasma noradrenaline levels during labor. Influence of elective lumbar epidural blockade. Anesthesia 1982; 37: 416-20.
5. Behrens O. et al. Effects of lumbar epidural analgesia on prostaglandin F2 alpha release and oxytocin secretion during labor. Prostaglandins 1993;45(3):285-96.
6. Fernando R, Bonello E. Placental and maternal plasma concentrations of fentanyl and bupivicaine after ambulatory combined spinal epidural (CSE) analgesia during labor. Int J Obst Anesth 1995; 4.
7. Brinsmead M. Fetal and neonatal effects of drugs administered in labor. Med J Australia 1987;146:481-6.
8. Hale T. The effects on breastfeeding women of anesthetic medications used during labor. Paper presented at Passage to Motherhood Conference, Brisbane 1998. Contact CAPERS bookshop, Brisbane for abstracts or tape: www.capersbookstore.com.au.
9. Belfrage P. et al. Lumbar epidural analgesia with bupivicaine in labor. Am J Obstet Gynecol 1975;123:839-44.
10. Mueller MD et al. Higher rate of fetal acidemia after regional anesthesia for elective cesarean delivery. Obstet Gynecol 1997 Jul; 90(1): 131-4.
11. Sepkoski CB et al. The effects of maternal epidural anesthesia on neonatal behavior during the first month. Dev Med Child Neurol; 34 :1072-80.
12. Murray AD et al. Effects of Epidural Anesthesia on Newborns and Their Mothers. Child Dev 1981; 52: 71-82.
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Forum Talk: Labor Pain
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Question of the Week: Group B Streptococcus
Q: How are midwives treating group B streptococcus-positive women wanting a homebirth? I am having trouble establishing a protocol that I feel comfortable with.
Send your responses to firstname.lastname@example.org.
Question of the Week Responses: Antidepressants
Q: My best friend, who is 26, is hoping to get pregnant soon. She has been taking antidepressants since she was in high school. Will this cause damage to the baby? Is her body too medicated to reproduce? She is also wondering if she can breastfeed when the baby comes.
A: Motherisk is a highly respected program through the Hospital for Sick Children in Toronto. Years ago, they received inquiries from women who were on antidepressants and decided to track outcome. Although the numbers were small, they found no significant newborn anomalies.
Research has been ongoing since that early study, and SSRIs appear to be safe in pregnancy and breastfeeding. For more information, go to the Motherisk Web site.
Motherisk is up to date with all the latest research and can answer specific questions. I urge your friend to contact them. As with any medication, the benefits must outweigh the risks. If a pregnant or lactating woman was at any risk of doing harm to herself or her baby (or anyone else), clearly the benefits of medication outweigh the risks of not taking them.
Very interesting research on the use of omega 3 oils/essential fatty acids and depression (also for manic depression and schizophrenia) may interest your friend. These oils are ingested through fatty fish (salmon, trout, herring and sardines in particular - eat tuna no more than once a month in pregnancy due to the high mercury content) as well as fish oil (see below for EFANATAL), evening primrose oil, flax oil, Udo's oil and/or hemp oil. The equivalent of 4000 mg (4 g) a day is the average daily dose for capsules; for liquid oil, up to 2 tablespoons a day. It can take weeks or months to notice a significant shift in mood when taking omega 3 oils, but because these oils are essentially a food, it is considered safe for the general population (those on blood thinners may wish to monitor their oil intake carefully with their MD).
Research shows that the average North American woman is significantly deficient in the products provided by omega 3 oils and becomes even more deficient with each pregnancy. Postpartum depression can be significantly reduced if omega 3 oils/essential fatty acids are used in much the same way that prenatal vitamins are now. Clinically, I notice faster labors, with an average of 4-6 hours for active labor for nulliparas, but the oils must be taken through the pregnancy, not in the last few weeks. European research shows a significant reduction in preterm delivery (in those at risk for preterm birth) and possible reductions in preeclampsia and IUGR.
In addition, the developing baby needs these oils from the mother - especially for proper brain development and eye development - not only in the pregnancy, but also with breastfeeding. Lower IQ for bottlefed babies is due to the lack of DHA in formula - an element that is normally present in breastmilk (if the mother is ingesting adequate supplies). Deficiencies of these oils are implicated in such things as learning disabilities, ADD/ADHD and poor infant sleep patterns, to mention a few.
EFANATAL is half fish oil and half evening primrose oil. The fish oil is tuna that has been extensively tested for contaminants. It is free of vitamin A, which is present in many fish oils. It is specifically designed for pregnancy. My recommendation is 8 capsules daily throughout pregnancy. Your friend can start to take it now, before conception. Even better, she could see a naturopath to correct any imbalances that may exist after years of medication use. Additional general recommendations include significantly reducing fried foods and eliminating "hydrogenated" foods to address omega 3/essential fatty acid deficiencies.
More information about EFANATAL (usually available in health food stores) can be found at Nutricia Canada Inc. 35 Webster Street, Suite 103, Kentville, NS, Canada B4N 1H4, 1.877.458.6400 or www.nutriciacanada.com. They can direct you to American resources, if needed.
(I am not affiliated with either Motherisk or Nutricia Canada.)
- Shawn Gallagher, BA, RM, C.CHt
A: A lot of conflicting evidence exists out there, mostly because some doctors aren't up to date on the latest research. Some medications are safer than others. For breastfeeding, sertraline (Zoloft) comes highly recommended as it does not seem to transfer to the breastmilk or baby in significant amounts (I think it's barely measurable). Psychiatrists will have the person consider the risks vs. benefits to the mother as well as the baby. Some studies have examined a few of the common antidepressants and they have found few or no serious side effects. I don't want to go into details because I am *not* a psychiatrist, but I have spoken with a local expert (psychiatrist) here in Seattle, WA, who has 15+ years of experience working with depression in postpartum and pregnant women.
A fetus can suffer effects from a seriously depressed mother, even before birth, such as elevated stress hormones and the possibility that the woman might not take proper care of herself during the pregnancy. I have never heard of antidepressants causing any degree of infertility.
- Tina Tsiakalis
A: My friend has had two very successful pregnancies while on Zoloft. She has very severe posttraumatic stress from childhood abuse and she cannot be without this medication at this point in her life. Her doctors agreed that it was safe for her and the baby. Her first child was born while she was not always and consistently medicated and the postpartum depression became very severe until she went back to Zoloft while nursing. She did not nurse this infant very long, however. Her second child is now three months old, totally breastfed, and in very good health. She was on Zoloft for the entire pregnancy. I wish of course that she could be off it during her childbearing years but she cannot and it appears to not be affecting the baby. If it were not for this medication I think she would not be able to be a mother due to the severity of her symptoms.
- Theresa Baton, RN
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Midwifery Today magazine Question of the Quarter
Theme for Issue No. 65: Tear Prevention
Question of the Quarter
What new or old techniques have proven useful to you in preventing tears during childbirth?
Please submit your response by December 31 to email@example.com.
Theme for Issue No. 66: Birth Environment
Question of the Quarter
What do you do to create a positive birth environment? In your experience, what have you seen that disturbed or facilitated the birth environment?
Please submit your response by March 1, 2003 to firstname.lastname@example.org.
(All responses subject to editing for space and style.)
From Susan Hodges of Citizens for Midwifery:
Many of you have already heard about the yet-to-be-published Associated Press 4-part article about prosecutions of midwives (Prosecutions, jailings highlight debate on safety and choice" by Martha Mendoza). We are expecting to see papers publish the articles in the next few days, on the weekend, or next week. Many of you are or will be angry over the tone of the articles and will want to write letters to your local newspapers. Don't get sucked into the author's tone and framework. This is an opportunity! Think through the ONE MESSAGE you want to convey in a letter that will be read by people in your community. Because the series covers quite a lot of material and omits mention of many issues that are important to us, it may be hard to write an effective letter, so here are some suggested dos and don'ts.
You will be more effective if you DO:
*Reframe the issue to focus on the real problem: lack of a regulatory structure in most states. Develop a state regulatory structure based on national certification standards, and consumers will have access to safe, effective out-of-hospital maternity care, and midwives will have access to the disciplinary due process (civil law) afforded other healthcare professionals. Voila! No more expensive prosecutions.
*Use the "Midwives Model of Care" in your letter. This phrase refers to a defined and described kind of care and was developed to be used far and wide as a public education tool. Because the phrase has a specific definition, it is much more effective than "midwifery model of care" which anyone can use and for which the meaning depends on who is using it. You can include a URL for the Midwives Model of Care: www.cfmidwifery.org/mmoc/.
*Mention your support for the nationally recognized certified professional midwife credential. The American Public Health Association recommends increased access to nationally certified and state-regulated direct-entry midwives. Remember that all but one state that regulates direct-entry midwives uses the written exam for the CPM as the licensing exam.
*Keep as an alternate reframing of the issue the idea that the real problem is the over-medicalization of childbirth. Take care not to get lost in statistics or overstate the facts. (You can find some good facts and information in the CfM Web site's Resources - Fact Sheets.)
You will also be more effective if you remember to NOT take a defensive approach or try to address specific cases that the reporter brought up because that puts more focus and disproportionate attention on negative cases instead of the benefits of midwifery.
Finally, remember that letters to the editor should be:
- Timely! Should be about (or related to) something published very recently in that paper.
- Brief! Usually the limit is about 250 words.
- Stick to one main point. The short length doesn't allow too much detail — you really must hone it down to the essentials for the one point you want to make.
Prepare. Read letters and editorials in your target newspaper to get a feeling for the style and content that newspaper tends to publish.
Write clear simple sentences; omit unnecessary words.
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