From: bwolfe@trentu.ca (BEN WOLFE)
Subject: Pain Relief in Labour: Ben's Reply (Long)
News-Software: VAX/VMS VNEWS 1.41    
Organization: Trent University Computer Services Department
Date: Mon, 14 Sep 1992 18:13:00 GMT

After a very busy few days I've finally had time to catch up on the posts 
in the "Missing out" (was. re:  Justin...) thread, pick myself up off the 
floor and think about a response.

There's a lot to deal with, so this post is going to be in two parts. This 
one will cover the medical evidence about the risks of epidural
anaesthesia in labour. The second one will be more about the tone of
the debate.

QUICK RECAP

If you've been following this thread for a while you may recall that Judy 
Drake posted a very positive story about her epidural, followed by this 
comment:

>> I still don't understand why so many people choose pain over
>> no pain when the health of the baby is not affected.

This statement was what set me off, since it's both untrue and dangerous. 
(If you still have any doubts, please read on.) I thought it could 
encourage some of the people who follow this newsgroup to turn to an 
epidural in the interest of duplicating Judy's "enjoyable and exhilarating" 

birth, in  the mistaken belief that the safety issues involved were minimal 
or non-existent. I replied:

> I find it pretty scary to read posts like this. Everyone is fully
> entitled to make their own informed choices about birth, but doing
> so requires access to proper information.
> 
> There is a wealth of solid -- in fact indisputable -- medical evidence
> that drugs for pain relief during birth have a negative effect on the
> baby. Certainly there are situations in which their use is warranted,
> but if you believe "the health of the baby is not affected" then your
> doctor is disturbingly out of touch with the medical literature.
>
> [Long supporting quotation from Sheila Kitzinger.]
>
> Please, understand the seriousness of the choice when you accept pain
> relief in labour. Prepare yourself for the best possible birth by 
learning
> about non-pharmacological alternatives. There are many, but they're 
> not taught in North American medical schools. They include massage, 
> bathing in warm water (which by the way has been shown to be entirely 
> safe and is practiced in many other developed countries), visualization, 
> breathing exercises and, above all others, proper companionship and 
> support.
>
> If you try all these things and find that medical pain relief is still
> necessary, then you will have the satisfaction of accepting it with
> full knowledge that you have made a responsible and necessary choice
> for yourself and your baby, having exhausted the alternatives.

Hmm. Pretty tame, I thought. It's the same advice you'll find in virtually 
every childbirth book now on the market: be fully prepared and informed, 
choose less interventive methods of pain relief first, and accept drugs if 
they become necessary. Hardly revolutionary.

But apparently a few of you didn't think so. Some of you (i.e. Paula Burch 
and Cathy Kearns), asked some very fair questions, in the interest of 
furthering the debate. Others (i.e. Judy Leedom Tyler and Elise Wade) 
turned on the flame throwers, and came back with an amazing mixture of 
ignorance and venom.

1. EVIDENCE ABOUT THE RISKS OF EPIDURALS

Let's start with Judy Leedom Tyler (judy@locus.com), who writes:

> So while it is important to know what medications will HARM your 
> fetus or interfere with your newborn's ability to survive, going into 
drug 
> hysteria is unnecessary.  In the case of the epidural, there is very, 
very 
> little chance that any of the drug will even get to the fetus.  And if 
some 
> small amount does, there is no evidence that it in any way harms the 
> child.

And later, in response to someone who supported what I said:

> you used a very broad brush stroke here and painted a whole lot of
> women as "scum" for using something which could hurt their babies.
> And that is just patently false.  And that is why we/they are angry.

Judy, did you know that it's a *legal requirement* that bupivicaine (the 
drug most commonly used for epidurals) carry a package insert warning 
that it crosses the placenta and causes maternal, fetal and neonatal 
toxicity? If you don't believe me, check the *Physician's Desk Reference* 
at your local library, or the International Childbirth Education 
Association (ICEA) *Position Paper on Epidural Anesthesia for Labor*.

As for your statement that "there is no evidence that it in any way harms 
the child," the ICEA paper lists the following effects of epidural 
anaesthesia on mother and baby (about half of a longer list):

- an increase in fetal heart variability (4 supporting studies cited)
- an increased likelihood of fetal malpositioning (5 studies cited)
- lowered neurobehavioral scores of infants (5 studies)
- reduction in the muscle tone and strength tests of infants (5 studies)
- a decreased suckling ability of infants (1 study)
- an increase in infant blood concentration of medication given to the 
     mother (2 studies)
- an increased length of first-stage labor (6 studies)
- an increased length of second-stage labor (10 studies)
- a reduction in the bearing-down reflex of the laboring woman (8 studies)
- an increase in maternal cardiac arrest (6 studies)
- decreased newborn infants' responsiveness to surroundings (2 studies)

And for those of you concerned about completely unnecessary birth 
injuries:

- "Epidural anesthesia significantly increases the incidence of outlet and 
     midforceps delivery." (14 studies)

(This paper is dated 1987, and is easily available from the ICEA if anyone 
is interested. I'll post their address on request.)

*Flame warning.* Judy Tyler, your ignorance is fine if you keep it to 
yourself. But when you put it on the net it becomes contagious. For God's 
sake, don't try to put yourself across as an authority when you haven't got 

the vaguest clue what you're talking about.

Now back to Sheila Kitzinger. Cathy Kearns (cathy@octel.com), Paula 
Burch (pburch@bcm.tmc.edu) and others asked for references to the 
quotation I posted from *The Crying Baby* by Sheila Kitzinger. Fair 
enough. Here are the key parts of the passage again, with the footnotes 
restored:

> When pethidine (demerol) is given within a period of four hours before 
> delivery, the baby tends to have breathing difficulties at birth, is 
sleepy
> and slow to suck, and does not orient so skilfully to the human voice.

         E. Tronick, et al., "Regional obstetric anesthesia and newborn 
         behaviour: effect over the first ten days of life," Journal of 
Pediatrics, 
         58, 1976, pp. 94-100.

         E.M. Belsley et al.,fluence of maternal analgesia on 
         neonatal behaviour I: pethidine," British Journal of Obstetrics 
and 
         Gynaecology, 88, 1981, pp. 398-406.

> All analgesics and tranquillizers are associated with early feeding
> difficulties and the mother may have to work hard to keep her baby
> interested in sucking.

	Carol Sepkoski, "Maternal obstetric medication and newborn 
         behaviour," in J.W. Scanlon (ed.), Perinatal Anesthesia, Oxford, 
         Blackwell, 1985, pp. 131-74.

> It is often claimed that epidural anaesthesia does not affect the baby. 
In 
> fact, when women ask, doctors often reassure them that bupivicaine -- 
> the drug most often used -- does not reach the baby since it is an 
> injection only into the epidural space and does not cross the placenta. 
> This is not true. Bupivicaine, especially in large doses and over a long 
> period of time has been shown to reduce a baby's alertness and may 
> modify the ability to orient to visual and auditory stimuli for as long 
as 
> six weeks after birth. 

	D.R. Rosenblatt et al., "The influence of maternal analgesia on 
         neonatal behavior II: epidural bipuvicaine," British Journal of 
         Obstetrics and Gynaecology, 88, 1981, pp. 407-13.

And the one some of you were particularly concerned about:

> This in turn affects the developing relationship between the mother and 
> her baby. A baby who does not interact with the mother in a lively way is 

> cared for differently from one who is alert and responsive. One study 
> suggests that interaction between the mother and child can be affected 
> for many years, and that, following an epidural birth, even after five 
> years the child's cognitive development is slightly slower.

	Carol Sepkoski, "A five-year follow-up study of obstetric 
medication 
         effects: bipuvicaine epidural anesthesia," paper presented at the 
         Third World Congress on Infant Psychiatry and Allied Disciplines, 
         Stockholm, 1986.

To Paula Burch: Perhaps you might want to check MEDLINE again, 
using these references as a starting point and see what the keywords are. 
If you do, I think you'll find dozens more articles on the subject.

IMPORTANT ISSUE OF INTERPRETATION

If you're like me, you may find this stuff pretty disturbing. But you may 
also be wondering about the seeming conflict between this list of hazards 
and the very positive birth stories posted by women who had epidurals. I 
saw the ones from Judy Drake, Donna Diloreto, Kathy Wilk, Paula Burch 
and Judy Tyler. There may have been others.

Actually, I have no problem with these stories at all. I think there's a 
basic 
misunderstanding going on here about how medical research works and 
how the negative effects of medications manifest themselves.

The risks of obstetrical drugs are a matter of probabilities, not of 
direct, 
one-to-one cause and effect. Individual stories are important as evidence, 
but you have to put a lot of them together to get a good sense of what the 
odds of different outcomes are. That's what research is: an attempt to 
isolate specific factors, under controlled circumstances, with a 
statistically 
significant number of patients, over a meaningful period of time.

In other words there's no reason to question any of your stories, but 
unfortunately it's wrong to draw any general conclusion from them that 
epidurals are safe or desirable. Some women (in fact the majority) will 
have no problems with epidurals. Others will have minor or serious side 
effects. A few women and a few babies will suffer permanent disabling 
damage. Being informed means knowing the odds before you decide to 
have the needle inserted in your back.

(Cathy Kearns, I hope this answers some of your questions about the 
Carol Sepkoski study that Kitzinger quoted.)

SUPPORT FROM ADDITIONAL DATA; CONCLUSION

For anyone interested in following this up, Sheila Kitzinger's booklet 
called *Some Women's Experience of Epidurals: A Descriptive Study*, 
(London: The National Childbirth Trust, 1987) summarizes the 
experiences of more than 900 women who had epidurals, half in Britain 
and half in Australia. The study is unusual because it actually asks what 
the 
women themselves thought rather than relying strictly on the observations 
of doctors.

Some of the key results are as follows:

- 47% of the British women reported a completely positive experience
- 76% of the Australian women reported "no problems" with their 
     epidurals (a slightly different question)
- some of the women in this category described the experience as "pure 
     magic", "a blessing" and "a miracle" -- echoes of some of the 
     comments posted here by the satisfied.

On the other hand:

- 18% of the Australian women reported only partial pain relief and 5% 
     reported "little or no pain relief"
- *24%* of the British women had forceps deliveries
- 26% of the Australian women reported short-term side-effects due to 
     the epidural.
- 19% of the British women and 25% of the Australian women reported 
     *long-term* side-effects due to the epidural. These included 
     backaches, headaches, tingling, numbness and urinary problems. 
     Some quotations:

     "I had numbness in the bladder region for about four months, i.e.
     nearly incontinent."

     "It is now five months and I still have numb patches on both feet."

     "I experienced a numbness in the lower region which lasted
     approximately six months."

     "Twelve months later I still get numbness at the bottom of my spine."

     "For some weeks after my sense seemed to be up the creek. Hot 
     things felt cold, and vice versa, sharp things blunt and vice versa."

There's also a fairly chilling section of quotations from women who felt 
terrified, and out of control during the experience, and/or felt anger, 
regret and feelings of failure afterwards, but I hesitate to quote it for 
fear 
of being accused once again of trying to make women feel guilty. The 
unfortunate fact is that some women who have negative experiences with 
epidurals *do* feel guilty. Some of those who initially feel positive later 

have misgivings and wonder if they made the best choice. **Some**, I 
emphasize, not all. A minority, in fact -- but one that I can't imagine 
anyone arguing should be ignored.

What are the odds? Here's a summary. Remember that due to the 
nature of the sample used, these women were better prepared and 
better informed than average:

- In total, Kitzinger reports that "Fifteen percent had an epidural which 
     did not work well or which produced distressing side effects." (pg. 
34.)
- Only 53% of the Australian women said they would choose an epidural 
     again in their next labour.
- 18% of the British women specifically expressed "regret" at having an 
     epidural

Kitzinger offers the following observation:

     "Women were most likely to express regrets when they had felt under 
     pressure to have an epidural, when the epidural failed to relieve pain 

     effectively or had distressing side-effects, and when they ended up 
     with a forceps delivery. Almost half of those who wrote detailed 
     accounts describe in many different ways a dominant feeling of being 
     trapped and robbed of autonomy during labour. Thus, paradoxically, 
     women who chose to have an epidural in order to maintain or regain 
     control found that this choice entailed other interventions which made 

     them feel out of control." (pg. 31)

A side note on the issue of informed choice:

- 60% of the Australian women reported they were *not* told about any 
     possible side effects of the drugs

(Note that because of the specific nature of the study it provides no data 
about effects on the baby.)

If you're still with me, I'm sorry that this is so long, but there were 
some 
points of fact that needed to be cleared up. You can interpret the data as 
you will, and read and explore further, but the message my wife and I 
took from it all was that epidural anaesthesia, like many other obstetrical 

interventions, is a crap shoot with many significant risks for mother and 
baby, and that if possible it was to be avoided.

Ben Wolfe

Newsgroups: misc.kids