Thursday, May 25, 2006

Are natural childbirth advocates honest about pain?

There is a fair amount of antipathy from other women toward advocates of natural childbirth. I think some of this comes from the fact that many women feel betrayed by their natural childbirth educator who downplayed the nature of labor pain. I certainly have had quite a few patients who said "no one ever told me what it would really be like". I wonder why natural childbirth educators are often not honest with the women they teach.

I came across this humorous take on the subject. From "Natural" Childbirth--the Big Lie:

To my untutored mind, the words "natural childbirth" conjured up visions of the brainwashed masses whose childbirth experiences had been unnatural: distorted and deformed from God's intent by the immoral overuse of pain relief. I saw in my mind's eye hoards of cowardly, superficial crybabies hooked up to IVs and epidurals in chemically sterile tombs. Those women, the unnatural ones, had fled from the miracle that is birth and had sold their souls to the corporate modern devil in order to escape a little bit of temporary discomfort. I had no respect for them and refused to join their ranks. I, the authentic woman, was going to do it the Natural Way.

Oh, they had me all right.

When I got to the class, my instructor was a very lovely, friendly woman who had either given birth multiple times herself or who had seen hundreds of other women do it. She had all the couples sit in a cozy circle and told us how simple it was for strong women to control and enjoy the birth experience, and congratulated us for choosing to be there. "I can tell you really care about your babies," she said. After a few weeks of such treatment, if she had told us all to go rob abank we would have done it and believed it proved how much we loved our babies.

She had a name, but I will call her Liar.

Liar wanted us to believe that her so-called "natural" method would allow us to really experience birth and thereby become closer to our babies. She taught us to breathe in a regular rhythm and stare at some symbolic object, in order to focus our minds elsewhere and take our focus off the discomfort (there was never pain in Liar's class-- only discomfort). Now, years later, I see the contradiction in that. If one can only get through the birth experience by thinking about something else, one is emphatically NOT getting closer to one's baby during the experience. But I digress.

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By Blogger Mama Liberty, at 4:22 PM  

You know, my natural childbirth was less painful than my epidural childbirth.

With my oldest son I thought I would have a natural childbirth, but I hadn't done much preparation. I was induced and was being pumped full of pitocin, so I was begging for an epidural by 3 cm. The experience was awful. I felt scared and completely out of control. I believe that the fear/pain cycle in childbirth is very real.

With my third birth I did hypnobirthing and it was lovely. It didn't actually hurt until transition. The pushing sensation was out of this world, as well. There is no way I could have been "coached" during pushing because it completely overtook me and was basically involuntary. Crowning hurt, but the sensation right after the baby slipped out was amazing.

I credit my relatively pain free natural birth with the fact that I was able to break the fear/pain cycle. I was VERY knowledgeable about the process and felt very in control. I credit the care of my labor support, midwife, doula, friend and husband, and my environment (home) with providing me the feeling of safety and control I needed to have such a lovely birth.

I am not ashamed to talk about the experiential aspect of it because the mother and baby's experience are entwined. What is good for the mother is also good for the baby. It is a shame that so many women (majority?) have birth stories that are more like war stories. Tragedy and complication certainly occur, but that should be the exception, not the rule.

By Blogger Mama Liberty, at 4:26 PM  

I went med free because I was annoyed at my doctor, I wanted to see if I could do it, my labor was not too long, and I have a decent pain tolerance (migraine and cluster headaches when I was in grad school). Med free is not for everyone though and unfair for folks to say that it is.

By Anonymous Joanna, at 4:29 PM  

I certainly have had quite a few patients who said "no one ever told me what it would really be like".

I have many clients say the same thing. How can you tell anyone what it will be like when only they can tell how it was after birth was complete? I had women tell me the worst pain I'd ever have was labor, but they'd never crushed their talus and split their tibia, and fibula all at once. Give me labor any day over that, but I am not going to project how I think it will feel on anyone else.

By Anonymous MetroMidwife, at 4:41 PM  

I loved being in natural labour. Yeah it hurt, but mowhere near as bad as my hospital labour. I also recovered quicker from my painful labour.... Give me pain ovedr epidural any day.

By Anonymous Anonymous, at 4:53 PM  

"no one ever told me what it would really be like"

This is barely interesting, because it is based on a fallacy, implying that there is some Truth that is being kept from women in natural childbirth classes. What is it really like? "The worst pain you will ever feel"? It might be, or it might be entirely painless, or it might be somewhere in between.

Labor is experienced differently by everyone. Some women have back labor, and some dilate to 10 cm without realizing it. And everyone should have choices about where and how they labor.

Do you think that there is one correct answer that will convey to a woman what her labor is going to be like?

And addressing her point that natural childbirth does not bring you any closer to your baby because you are using distraction to deal with labor, well, I think this is missing the point. It isn't the "experience of pain" that most natural birthers feel is the important part. It is the absence of drugs. It is when your drug-free baby looks up at you and tries to breastfeed right away and is alert and calm.

You're going to find fanatics on every side of an issue, Amy, so there certainly are some teachers giving women bad instructions and bad advice. Does this represent the entire movement? Is this what you want to focus your criticisms on, the fringes of the natural birth advocates? If so, then I'll stand with you and criticize them as loudly as you do.

One more question. Does the inevitability of some negative experiences and disappointment necessarily mean that the principles are incorrect? Shall we discuss the feelings of betrayal women have due to their treatment at the hospital, by nurses and doctors, or the lack of information or downright lies women are told by their care providers, during pregnancy and birth?

Wanna talk about honesty???

By Anonymous Anonymous, at 5:00 PM  

I would say that natural childbirth advocates are as honest about pain as docs and nurses are about iatrogenic complications.

By Anonymous Anonymous, at 5:16 PM  

Are OBs as honest about pain and recovery time after episiotomy or cesarean? I rarely hear reports from mothers that they were fully informed of the pain and risks of interventions.

I've had many women tell me that their recovery after a cesarean was nothing as easy as "six to eight weeks". For them it was weeks of pain and months of recovery and that they can't possibly do that again and care for a toddler. They'd like a natural vbac next time because natural childbirth couldn't possible be as difficult as recovering from major surgery and having a baby all in a day.

Women do report they perceive their experiences as less painful in the comfort of their own home where they're free to nourish themselves and move freely about, vocalizing as needed.

I share with them that it will probably be harder than they can imagine, but not more than they can usually handle, given a normal labor. It's usually over when it's over, which is often fairly quickly.

By Anonymous seriously, at 5:17 PM  

keee-rist, doesn't anyone here have any experience in real discussion?=

If you want to talk about a complicated subject, you HAVE to split it up. You can--at the end--go back and add up all your various "parts" but you CANNOT talk about them all at the same time--it's just too damn difficult.

It's a topic. The topic is in the post. Before you constantly post the general commentary about doctors, yadda yadda, can you at least consider if it passes the

"Intelligent person's relevance test"

which works like this:
If what you say is TRUE, is the statement affected at all?
If not--it's not relevant. Go say it somewhere else.

Here's how it works:
"Are natural childbirth advocates honest about pain? I think not".

You are dying to come on and post about the dishonesty of doctors.

Does that matter?

NO!!!!

Why?

Well, boys and girls, even if every doctor in the world were a dishonest misogynist who wanted to hurt women, it would make NO DIFFERENCE AT ALL about whether natural childbirth advocates were honest!

And because that's true, it's not relevant! See, it's simple!

By Blogger sailorman, at 5:17 PM  

Why not just be honest?

Why not just say that many women feel it is the worst pain of their lives, while others feel that it is manageable? Why not say that it's important to wait until you actually feel the pain to see whether you want pain medication?

"It is when your drug-free baby looks up at you and tries to breastfeed right away and is alert and calm."

I have delivered more than a thousand babies and had four of my own. I have never seen any correlation between epidurals and nursing behavior, nor have I seen any research to indicate that that any babies are sedated by an epidural (yes, it has been studied).

I think that this is just what the writer may have been getting at in her post, this false dichotomy between mothers whose babies are alert and nurse right away, and mothers who have pain medication, the "good" mothers and the "bad" mothers.

Besides, why would every baby want to nurse right away? Some are hungry, some are not. They have had their body chemistry maintained perfectly until about 5 minutes before. Each of my four children behaved differently based on their inanate personalities.

I have seen women repeatedly try to get a baby to latch on within minutes after it was born. They thought they were supposed to do that because that was what a "perfect" birth was supposed to be like. The only problem was that nobody had told the babies. Some of them are simply not hungry. Some of them are extremely curious. Some of them really want to look at faces without a breast in the view. Some of them are still trying to figure out the whole breathing thing and can't breathe well enough to nurse yet.

I think that this is a very important source of disappointment for women. Many people paint an idealized picture of what is "supposed" to happen in labor and delivery and immediately after birth. Sometimes the idealized version happens; most times it does not.

I always told patients and I still tell friends, take it one moment at a time; don't have specific expectations. Motherhood is HARD. Don't be hard on yourself if it doesn't come easily to you or if the knack of it doesn't come right away.

So many, many women find that birth and motherhood are not what they expected and partly that's because people set them up with unrealistic expectations.

By Blogger Amy Tuteur, MD, at 5:36 PM  

Amy, this is really sad.

Your blog here is called "homebirth debate." I've read as you have attacked homebirth advocates for all the things you claim they do and are. Not any specifically, but the whole group of them. And I've only been around here a few days.

Now, you want to attack natural childbirth advocates. And you've done it by using the words "lie" and "dishonesty." As the previous poster said, we can talk about dishonesty all you want - but you will have to talk about what the medical birth culture is lying about every day. It is not so subjective as what exactly labor pain is like, that's for sure!

To have a lie, you must have a truth. The pain experienced during childbirth is subjective as to its severity and is, as others have pointed out, different for every woman. If you have patients that say "no one ever told me what it would really be like" you can't take that seriously because no one knows what it is "really" like. There is no objective measurement of what it is "really" like.

Of all the students I've taught in 4 years, not one has given me anything but praise over their preparation for birth. They didn't all do it unmedicated, but they all felt they were prepared.

So, I guess to answer your question: most are, some aren't.

By Anonymous Christine, at 6:03 PM  

On the contrary, research is showing that there may be effects upon the newborn baby with regards to breastfeeding (despite your anecdotal evidence).

Even if there aren't any 'direct' effects, epidurals can cause other problems with regards to mums breastfeeding. I suggest you look it up. But then I guess you will always find a way around it and say the studies and the results are crap.

By Anonymous Anonymous, at 6:06 PM  

Amy wrote:
Why not just be honest?
So many, many women find that birth and motherhood are not what they expected and partly that's because people set them up with unrealistic expectations.

Where are most childbirth educators employed, classes offered, and condensed, controlled curriculums written by and approved of?

The majority of women are not getting their CBE from comprehensive, independent OOH courses.

By Anonymous seriously, at 6:08 PM  

I've never liked the method of pain control by disassociation. Never bought into it myself, but I realize it's popular.
One reason we can't tell new mothers what it's going to feel like, is that it feels like nothing else. I've heard it described as menstral cramps, which is bogus, of course.
But maybe it DID feel like menstral cramps to the person describing it. Who knows.
To me, 40 hours of unmedicated labor, with freedom of movement, no interventions (except occational listening to FHT)constant presence of a doula, and use of counterpressure, water, food/drink, ice, and other comfort measures felt intense, exhausting, and sometimes painful. Certainly not the terrible stabbing agony I hear described by others.

My experience leads me to believe there was something different about my labor that helped me to experience it this way. And, I'm not alone. Others who give birth out of hospital, under the care of a midwife also experience labors which are not agony. Many women have birthed both places.

I don't know what it is about a midwives care that makes labor less painful. But I suspect it's management style.

Clearly nobody can tell somebody else how they will experience labor. But I think it's fair to share my experience with others... because people need to hear the 'other side' too.

By Anonymous Anonymous, at 6:57 PM  

'I have delivered more than a thousand babies and had four of my own. I have never seen any correlation between epidurals and nursing behavior, nor have I seen any research to indicate that that any babies are sedated by an epidural (yes, it has been studied).'

You may want to actually do some research in this area Amy. This has been studied as you pointed out, and it's pretty clear that undrugged babies behave much differently than drugged ones. (yes, even your beloved epidural-ly drugged ones)

By Anonymous Anonymous, at 7:06 PM  

I have always said if men were to be pregnant , give birth and nurse- they would only do it once and they would never do another thing unless they wanted to the rest of their lives.
but having been a person who is very sensitive to pain my whole life- my mom left town when i was pregnant with # 1 because she did not want to be around me in labor-- but the pain was different for me than any other- it came with the contraction and then let up - I was able to manage- I just had to stay relaxed and let my body do the work- in early labor I cooked and cleaned - and then at a point I had DH kick my sister's friends out of the house because they were too noisy- and it was irritating , I also went for a walk and took a shower at some point before I left for the hospital-
I have had kidney stones and I would say that the degree of pain is similar but kidney stones don't let up- and to me I could have mapped out every inch of my ureter - but with contractions there was a bit of fuzzing after a while- I was also looking forward to having the baby- although I wanted the kidney stone out I would not say it was anything to look forward to.
is that honest enough about pain for you Amy
the truth is yes some people have painless births or nearly painless births- but you never know if you are going to be that person or not so I recommend learning some classes in order to help with relaxation and surrender.
take care ladies.

By Anonymous Anonymous, at 7:27 PM  

" This has been studied as you pointed out, and it's pretty clear that undrugged babies behave much differently than drugged ones."

What studies showed that?

I don't think there is any evidence and this is the kind of thing that irks so many other women: "I gave birth without drugs so my baby is better at breastfeeding." No, you gave birth without drugs because you wanted to give birth without drugs. It made no difference to the baby's ability to breastfeed.

Furthermore, what happens in the first few minutes and hours after birth is not particularly meaningful. Do you really mean to suggest that a woman who has an emergency C-section with general anesthesia because of bleeding placenta previa is not going to be able to breastfeed her baby? Do you really believe that the baby is going to be permanently harmed by the general anesthesia on board at the time of delivery? I hope not, but that is what you are implying.

By Blogger Amy Tuteur, MD, at 8:34 PM  

"the truth is yes some people have painless births or nearly painless births"

I've seen women have painless labor, but they weren't women who were committed to natural childbirth; they just happened to have painless labor.

By Blogger Amy Tuteur, MD, at 8:36 PM  

"I gave birth without drugs so my baby is better at breastfeeding."

This is the kind of nonsense I have heard more times than I can count as something a woman has said to another. At the risk of Amy-fying myself I don't belief this actually comes out of anyone's mouth as much as they interpret what was really said. I've heard some crafty La Leche-Speak in the last 11 years but never something that direct.

I was once nursing my baby in the comfort of my home when my mom said, "You know, you were bottlefed and your IQ is just fine." I've never said a word to anyone on the face of this planet about IQ and breastfeeding yet apparently I had said it merely by nursing my baby.

By Anonymous Anonymous, at 8:48 PM  

sailorman wrote:
"keee-rist, doesn't anyone here have any experience in real discussion?"

ok you are cracking me up.
I agree that there are advocates out there that project all sorts of information- my earliest bits of info on this were written by some of the Victorian doctors- claiming that pain in labor is abnormal... but as a midwife projecting that labor is going to be pain free does not help my job at all- best it to come to a resolve that you are going to have the baby- it may be pain free bonus for you but please don't expect it to be one way or another- labor is what it is and each one is different-

By Anonymous Anonymous, at 9:25 PM  

I don't really support the rough way things are stated here on either side but do think that there is bit of info on this subject- I saved it out the other day looking for long term studies- of which I have found none.

J Am Board Fam Pract. 2003 Jan-Feb;16(1):7-13.

Effect of labor epidural anesthesia on breast-feeding of healthy full-term newborns delivered vaginally.

Baumgarder DJ, Muehl P, Fischer M, Pribbenow B.

Department of Family Medicine, University of Wisconsin Medical School, Milwaukee
Clinical Campus, St. Luke's Medical Center, Aurora Health Care, Milwaukee, USA.

BACKGROUND: Epidural anesthesia is commonly administered to laboring women. Some studies have suggested that epidural anesthesia might inhibit breast-feeding. This study explores the association between labor epidural anesthesia and early
breast-feeding success. METHODS: Standardized records of mother-baby dyads representing 115 consecutive healthy, full-term, breast-feeding newborns delivered vaginally of mothers receiving epidural anesthesia were analyzed and compared with 116 newborns not exposed to maternal epidural anesthesia. Primary outcome was two successful breast-feeding encounters by 24 hours of age, as defined by a LATCH breast-feeding assessment score of 7 or more of 10 and a
latch score of 2/2. Means were compared with the Kruskal-Wallis test. Categorical data were compared using the Mantel-Haenszel chi-square test.
Stratified analysis of potentially confounding variables was performed using Mantel-Haenszel weighted odd ratios (OR) and chi-square for evaluation of interaction. RESULTS: Both epidural and nonepidural anesthesia groups were similar except maternal nulliparity was more common in the epidural anesthesia group. Two successful breast-feedings within 24 hours of age were achieved by
69.6% of mother-baby units that had had epidural anesthesia compared with 81.0% of mother-baby units that had not (odds ratio [OR] 0.53, P = .04). These relations remained after stratification (weighted odds ratios in parenthesis) based on maternal age (0.52), parity (0.58), narcotics use in labor (0.49), and first breast-feeding within 1 hour (0.49). Babies of mothers who had had epidural anesthesia were significantly more likely to receive a bottle supplement while hospitalized (OR 2.63; P < .001) despite mothers exposed to epidural anesthesia showing a trend toward being more likely to attempt breast-feeding in the 1 hour (OR 1.66; P = .06). Mothers who had epidural anesthesia and who did not breast-feed within 1 hour were at high risk for having their babies receive bottle supplementation (OR 6.27). CONCLUSIONS: Labor
epidural anesthesia had a negative impact on breast-feeding in the first 24 hours of life even though it did not inhibit the percentage of breast-feeding attempts in the first hour. Further studies are needed to elucidate the exact nature of this association.

PMID: 12583645 [PubMed - indexed for MEDLINE]
--------------------------------------------
Anesthesiology. 2005 Dec;103(6):1211-7.

Comment in:
Anesthesiology. 2005 Dec;103(6):1111-2.

Effect of labor epidural analgesia with and without fentanyl on infant breast-feeding: a prospective, randomized, double-blind study.

Beilin Y, Bodian CA, Weiser J, Hossain S, Arnold I, Feierman DE, Martin G, Holzman I.

Department of Anesthesiology, the Mount Sinai School of Medicine of New York
University, Box 1010, One Gustave L. Levy Place, New York, NY 10029-6574, USA.
yaakov.beilin@mountsinai.org

BACKGROUND: The influence of labor epidural fentanyl on the neonate is controversial. The purpose of this study was to determine whether epidural fentanyl has an impact on breast-feeding. METHODS: Women who previously breast-fed a child and who requested labor epidural analgesia were randomly assigned in a double-blinded manner to one of three groups: (1) no fentanyl group,
(2) intermediate-dose fentanyl group (intent to administer between 1 and 150 microg epidural fentanyl), or (3) high-dose epidural fentanyl group (intent to administer > 150 microg epidural fentanyl). On postpartum day 1, the mother
and a lactation consultant separately assessed whether the infant was experiencing difficulty breast-feeding, and a pediatrician assessed infant
neurobehavior. All women were contacted 6 weeks postpartum to determine whether they were still breast-feeding. RESULTS: Sixty women were randomly assigned to receive no fentanyl, 59 were randomly assigned to receive an intermediate dose,
and 58 were randomly assigned to receive high-dose fentanyl. On postpartum day 1, women who were randomly assigned to receive high-dose fentanyl reported difficulty breast-feeding (n = 12, 21%) more often than women who were randomly
assigned to receive an intermediate fentanyl dose (n = 6, 10%), or no fentanyl (n = 6, 10%), although this did not reach statistical significance (P = 0.09).
There was also no significant difference among groups in breast-feeding difficulty based on the lactation consultant's evaluation (40% difficulty in
each group; P = 1.0). Neurobehavior scores were lowest in the infants of women who were randomly assigned to receive more than 150 microg fentanyl (P = 0.03). At 6 weeks postpartum, more women who were randomly assigned to high-dose epidural fentanyl were not breast-feeding (n = 10, 17%) than women who were randomly assigned to receive either an intermediate fentanyl dose (n = 3, 5%) or
no fentanyl (n = 1, 2%) (P = 0.005). CONCLUSIONS: Among women who breast-fed previously, those who were randomly assigned to receive high-dose labor epidural fentanyl were more likely to have stopped breast-feeding 6 weeks postpartum than
woman who were randomly assigned to receive less fentanyl or no fentanyl.

Publication Types:
Randomized Controlled Trial

PMID: 16306734 [PubMed - indexed for MEDLINE]
-----------------------------------------------------------------------------------
Int J Obstet Anesth. 2004 Jan;13(1):25-9.

Breast-feeding problems after epidural analgesia for labour: a retrospective cohort study of pain, obstetrical procedures and breast-feeding practices.

Volmanen P, Valanne J, Alahuhta S.

Department of Anaesthesiology, Lapland Central Hospital, Rovaniemi, Finland.
petri.volmanen@lshp.fi

Various clinical practices have been found to be associated with breast-feeding problems. However, little is known about the effect of pain, obstetrical
procedures and analgesia on breast-feeding behaviour. We designed a retrospective study with a questionnaire concerning pain, obstetrical procedures and breast-feeding practices mailed to 164 primiparae in Lapland. Altogether 99 mothers (60%) returned completed questionnaires that could be included in the analysis, which was carried out in two steps. Firstly, all accepted questionnaires were grouped according to the success or failure to breast-feed fully during the first 12 weeks of life. Secondly, an ad hoc cohort study was performed on the sub-sample of 64 mothers delivered vaginally. As many as 44% of the 99 mothers reported partial breast feeding or formula feeding during the first 12 weeks. Older age of the mother, use of epidural analgesia and the problem of "not having enough milk" were associated with the failure to breast-feed fully. Caesarean section, other methods of labour analgesia and other breast-feeding problems were not associated with partial breast feeding or formula feeding. In the sub-sample, 67% of the mothers who had laboured with epidural analgesia and 29% of the mothers who laboured without epidural analgesia reported partial breast feeding or formula feeding (P = 0.003). The problem of "not having enough milk" was more often reported by those who had had
epidural analgesia. Further studies conducted prospectively are needed to establish whether a causal relationship exists between epidural analgesia and breast-feeding problems.

PMID: 15321436 [PubMed - indexed for MEDLINE]
---------------------------------------------------------------------------------------
Birth. 2001 Mar;28(1):5-12.

Comment in:
Birth. 2001 Mar;28(1):20-1.

Maternal analgesia during labor disturbs newborn behavior: effects on breastfeeding, temperature, and crying.

Ransjo-Arvidson AB, Matthiesen AS, Lilja G, Nissen E, Widstrom AM, Uvnas-Moberg K.

Division of Reproductive and Perinatal Health Care at the Department of Women and Child Health, Karolinska Institutet, Stockholm, Sweden.

BACKGROUND: Newborns not exposed to analgesia, when placed on the mother's chest, exhibit an inborn prefeeding behavior. This study was performed to assess the effects of different types of analgesia during labor on the development of
spontaneous breastfeeding movements, crying behavior, and skin temperature during the first hours of life in healthy term newborns. METHODS: Video recordings were made of 28 newborns who had been dried and placed in skin-to-skin contact between their mother's breasts immediately after delivery. The video recordings were analyzed blindly with respect to infant exposure to analgesia. Defined infant behaviors were assessed every 30 seconds. Group 1 mothers (n = 10) had received no analgesia during labor, group 2 mothers (n = 6)
had received mepivacaine via pudendal block, and group 3 mothers (n = 12) had received pethidine or bupivacaine or more than one type of analgesia during labor. RESULTS: All infants made finger and hand movements, but the infant's massage like hand movements were less frequent in infants whose mothers had received labor analgesia. A significantly lower proportion of group 3 infants made hand-to-mouth movements (p < 0.001), and a significantly lower proportion of the infants in groups 2 and 3 touched the nipple with their hands before suckling (p < 0.01), made licking movements (p < 0.01), and sucked the breast (p < 0.01). Nearly one-half of the infants, all in groups 2 or 3, did not breastfeed within the first 2.5 hour of life. The infants whose mothers had received analgesia during labor had higher temperatures (p = 0.03) and they cried more (p = 0.05) than infants whose mothers had not received any analgesia.
CONCLUSIONS: The present data indicate that several types of analgesia given to the mother during labor may interfere with the newborn's spontaneous breast-seeking and breastfeeding behaviors and increase the newborn's temperature and crying.

PMID: 11264622 [PubMed - indexed for MEDLINE]
------------------------------------------------------------------
Minerva Anestesiol. 2005 Sep;71(9):527-32.

Toxicological aspects of perinatal analgesia.

Nencini C, Nencini P.

Department of Anesthesiology, Emergency and Pain Therapy, Policlinico Umberto I Hospital, Rome, Italy.

Perinatal exposure to analgesics and anesthetics is responsible of acute effects which are relatively easy to detect and, accordingly, a large number of clinical
and experimental observations has been gathered. On the contrary, the possible long term consequences of perinatal administration of these drugs have recently become the object of great interest. It is possible, infact, that perinatal
exposure to neurotropic agents may lead to long term neuropsychopharmacological effects that outlast the effective presence of the drug in the newborn. The conceptual framework of this hypothesis is provided by the modern concept of
neuroplasticity, according to which early life experiences that serve to set the operating characteristics of the brain may represent the target of pharmacologically-induced chan-ges. Clinical studies have already provided evidence of the association between labour analgesia and the development of maladaptive behaviour in adult life, while experimental studies suggest that maternal care can actively program differences in gene expression through stable effects on the epigenome. Although they require to be confirmed by further
studies possibly performed on wider cohorts, these results suggest caution in the use of obstetric pain relief methods that permit substantial passage of
drugs through the placenta.

Publication Types:
Review

PMID: 16166912 [PubMed - indexed for MEDLINE]
--------------------------------------------

By Anonymous Anonymous, at 9:45 PM  

"Baumgarder: Labor epidural anesthesia had a negative impact on breast-feeding in the first 24 hours of life even though it did not inhibit the percentage of breast-feeding attempts in the first hour. Further studies are needed to elucidate the exact nature of this association."

This is an example of one of the most common mistakes in research. Correlation does not equal causation. We have discussed elsewhere that one of the most important factors, perhaps the most important factor, in breastfeeding success is maternal commitment. Most women say that they are going to breastfeed and most women give it up within 3 weeks.

Nothing in this study suggests that there was any impact on the babies' ability to latch on and nurse, so there is no reason to think that the epidural "caused" the mothers to accede to bottle feeding.

Beilin: Fentanyl is a narcotic that is rapidly cleared. If it were to have an effect; the effect would be noticed early and fade over time. That's not what happened here. It is unlikely to represent a real phenomenon.

The other three studies don't really tell us anything at all about the effect of epidural anesthesia on breastfeeding.

Interestingly, none of the studies asked about the most important factor, the mother's commitment to breastfeeding success.

By Blogger Amy Tuteur, MD, at 10:15 PM  

I'd also add Jan Riordan's study on epidurals and bfing. Free full text is available.

By Blogger Jamie, at 10:16 PM  

We have discussed elsewhere that one of the most important factors, perhaps the most important factor, in breastfeeding success is maternal commitment.

Do you have a citation for that, Amy? In my experience it's complex. There are maternal factors other than motivation (like milk production, and PPD, just to name a couple); there are familial factors (if dad and grandparents are unsupportive, it's a lot harder); there are other social factors (is her workplace breastfeeding-friendly? is her doctor's office clued in?); there are baby-related factors. I've been helping in a situation where a mother is extraordinarily motivated to breastfeed but her baby is micrognathic with a bubble palate and a posterior tongue tie. She is hanging on by her fingernails to their breastfeeding relationship, and if she opts to wean it won't be because she wasn't determined enough. May I encourage you to think about phrasing that differently? Motivation is very important, but it's only one piece of the puzzle.

Most women say that they are going to breastfeed and most women give it up within 3 weeks.

That's improving -- take a look.

I wouldn't say that epidurals cause breastfeeding problems because I agree with you that the standard for establishing causal relationships is high. But there does seem to be a positive correlation between epidural anesthesia in labor and subsequent breastfeeding difficulties.

On fentanyl -- my references say its half-life is 2-4 hours. Do you agree? The BFHI fourth step is bringing babies to breast within an hour of birth, in large part because babies who nurse early tend to nurse better. There seems to be a window early on that makes a difference in future breastfeeding. So it doesn't have to be the case that the fentanyl or bupivacaine or what have you is circulating for hours and hours and causing problems directly. If it leads to a baby's being less interested in the breast during that early window, there can be repercussions after the anesthetic has been metabolized.

By Blogger Jamie, at 11:12 PM  

Have you seen this abstract? My homebirths were markedly less painful than my hospital births.

With my youngest son, I thought I was hours from delivery when the midwife arrived. I was more uncomfortable and impatient than I expected to be in early labor, and I was eager to find out how far along I was. I still have to laugh at the memory: almost nine centimeters. "No wonder I wasn't feeling very patient!" I said.

By Blogger Jamie, at 11:21 PM  

Amy wrote:" Beilin: Fentanyl is a narcotic that is rapidly cleared. If it were to have an effect; the effect would be noticed early and fade over time. That's not what happened here. It is unlikely to represent a real phenomenon."

here we go Amy more content--
Beilin et al. 2 randomly assigned multiparous patients who had previously been successful in breast-feeding an infant for at least 6 weeks into three groups. Patients were excluded if they did not intend to breast-feed, received intravenous opioids, or had a cesarean delivery. All patients received epidural analgesia for labor. Patients in group 1 (n = 60) received no epidural fentanyl, patients in group 2 (n = 59) received less than 150 μg epidural fentanyl, and patients in group 3 (n = 58) received more than 150 μg epidural fentanyl. The dosing was accomplished by adjusting the fentanyl content of the bolus doses and maintenance infusion. At 24 h, the mother and a lactation consultant did a global assessment of breast-feeding and filled out 9- and 12-item questionnaires, respectively, containing descriptors of breast-feeding problems at that time. Because the sample size was based on a pilot study that observed feeding difficulties early in labor, we must assume, because it was not stated explicitly, that the primary outcome of the study was breast-feeding difficulty at the time of initiation.
---------------
Breastfeeding is complex, and there may be many causes for lack of continuing to breastfeed- but what this does say to me is bigger study-- the random assignment I like - now how about a multi-center study-- (oh wait, money)
-

By Anonymous Anonymous, at 12:05 AM  

I guess I could mention the effects of fever- you don't really want all the abstracts here right? I don't know how to do that one word connect business- but look at the lit- fevers related to infection or not like fever from epidural = seizures in some infants
Lieberman E has free full text- on more than one study
any way more food for thought-

By Anonymous Anonymous, at 2:17 AM  

The culture of natural childbirth, without an epidural, may correlate to a higher rate of maternal committment to breastfeeding.

Anyway, as far as pain during childbirth goes, I'm with the "it's different for everyone" crowd. My sister, for instance, will admit to a very low pain tolerance. She does not progress well at all until she gets an epidural.

I've done it both ways. I think I can honestly say that the epidural was, in some ways, superior to not having an epidural because I simply did not have to do any of the work of overcoming the pain. Instead of moving towards transition sweating and shaking, everything was remarkably calm.

I even told my husband, smiling and laughing a little, "I don't think anything is happening". There was no way, I thought.

Nurse came in to empty my bladder at pretty much that moment, and I was fully dialated. Waited a bit for the doctor, four pushes (would have been less but for the "stop for a moment" because a cord was around his face) and baby was out. Baby was very alert. He latched on well and nursed better than some of my other babies where I had not experienced an epidural. Every baby is different.

The anesthetist came in the next day and asked me if I'd choose it again. My answer: "It would depend on the circumstances and my mood."

By Anonymous Amka, at 3:24 AM  

How do you know that the epidural studies reflect effects on the baby, and not the behavior of the mothers? It seems to me that that is far more likely. The ASSUMPTION in all these studies is that the mothers behavior was completely unaffected by the medication she receieved or the group she was willing to be assigned to. That is a huge unjustified assumption.

There is a very serious problem with all of the studies you referenced about breastfeeding. They are not randomized. Therefore, there is a huge confounding variable, the mother's attitude toward breastfeeding. You couldn't do a randomized study because it wouldn't be ethical, but you could at least try to measure the mother's attitude.

By necessity, the only women in the epidural group are women willing to have an epidural. That almost certainly represents a group with a different philosophical outlook toward things that are not "natural". So, for example, the women who felt that an epidural is acceptable may also feel that bottle feeding is not a big deal. That makes a tremendous difference in how they will respond to the challenges and sacrifices of breastfeeding.

Since it is not possible to randomize the participants, there are only a few ways to directly control for this confounding factor. One way would be to restrict the entire study to women who had no commitment to natural childbirth. That way, their decision about whether to get an epidural would reflect their level of pain or the speed of their labor. Then you could compare women who never received an epidural and those who did.

Another way (less effective) would be to try to capture the mother's attitude to breast and bottle feeding and correct for that in the study.

I am not saying that medication couldn't affect breast feeding behavior; it is certainly possible. I am saying that any study that does not attempt to take into account the mother's attitudes, philosophy and commitment is a deeply flawed study.

By Blogger Amy Tuteur, MD, at 7:08 AM  

Jamie offered this study:

Home birth and hospital deliveries: a comparison of the perceived painfulness of parturition.
Morse JM, Park C.
Res Nurs Health. 1988 Jun;11(3):175-81

Cognitive assessments of the amount of pain associated with childbirth by parents electing either homebirth (n = 282) or hospital delivery (n = 191) were compared using Thurstone's univariate scaling method of paired comparisons. Subjects compared the pain of childbirth with 8 other painful events. The hospital birth group rated childbirth pain significantly higher than the homebirth group. In the homebirth group, females considered the pain to be less than the males, and in the hospital birth group, the females rated pain higher than the males.

This study is not very useful because it is based on patient reports. There is no truly objective way to assess pain, but at least the ratings should be done by someone other than the patient, and someone who doesn't know whether the patient refused an epidural or just didn't want one.

This is especially relevant in light of the humorous piece that started this thread. The author of that piece was saying that natural childbirth advocates deliberately minimize the pain of childbirth for a variety personal reasons, and therefore, they do not give a truthful account to other people.

By Blogger Amy Tuteur, MD, at 7:15 AM  

"Furthermore, what happens in the first few minutes and hours after birth is not particularly meaningful. Do you really mean to suggest that a woman who has an emergency C-section with general anesthesia because of bleeding placenta previa is not going to be able to breastfeed her baby?"

You can't really believe this! Wow, ok. So, blinders on, keep moving past the experiences of milions of women and we'll look for the hard, "scientific" evidence. This discussion is really useless.

By Anonymous Christine, at 8:52 AM  

Well Amy in a sense it really doesn't matter as far as in the instance of breastfeeding does it - breastfeeding like pregnancy is a mother/baby pair thing, participation by both- if something is happening to the mother to change how she breastfeeds and that in turn changes the
neuro-development of the baby there you have it.

but I would also say that there are the fever effects-

By Anonymous Anonymous, at 9:27 AM  

"I wouldn't say that epidurals cause breastfeeding problems because I agree with you that the standard for establishing causal relationships is high. But there does seem to be a positive correlation between epidural anesthesia in labor and subsequent breastfeeding difficulties."

Unfortunately that correlation alone doesn't really show anything at all. There are simply too many possible explanations for the correlation.

To name an obvious one, it is quite possible that women who do not get epidurals are more interested in, ir more knowledgeable about, or more commited to, or get better assistance than, women who get epidurals.

Is this the explantion? I don't know. Is it the epidural? I don't know. Nobody knows.

So because you don't know, it's best not to make a snap judgement on what appears to be a correlation.

By Blogger sailorman, at 9:55 AM  

first do no harm-

By Anonymous Anonymous, at 12:09 PM  

so in the study where all were getting epidurals there was a difference in breastfeeding in the amount of a particular drug given---
"randomly assigned multiparous patients who had previously been successful in breast-feeding an infant for at least 6 weeks into three groups. Patients were excluded if they did not intend to breast-feed, received intravenous opioids, or had a cesarean delivery. All patients received epidural analgesia for labor. Patients in group 1 (n = 60) received no epidural fentanyl, patients in group 2 (n = 59) received less than 150 μg epidural fentanyl, and patients in group 3 (n = 58) received more than 150 μg epidural fentanyl. The dosing was accomplished by adjusting the fentanyl content of the bolus doses and maintenance infusion.....CONCLUSIONS: Among women who breast-fed previously, those who were randomly assigned to receive high-dose labor epidural fentanyl were more likely to have stopped breast-feeding 6 weeks postpartum than
woman who were randomly assigned to receive less fentanyl or no fentanyl "-- the abstract is above on this including authors and publication.

By Anonymous Anonymous, at 12:18 PM  

That study wouldn't recommend against epidurals, but which drug to use for an epidural. It would represent progress in the use of birth anesthesia.

By Anonymous Amka, at 12:55 PM  

what it shows is it needs to be studied more- and it does show the potential for changing breastfeeding- even if we don't understand why or how- and yes maybe there can be improvement by learning about this or maybe the docs will have a flip answer- like must be wrong because it is moves through fast.... and it could take until the drug company offers the next latest and greatest thing go buy-
comments have been made that there are long term studies- show me direct me-- I just can't find um-- I want a long term follow-up group like -- the Canadian one done on marijuana and cigarettes started in the late 1980's and has followed up on the babies to adulthood-- that is a long term study and that is what I am asking about

By Anonymous Anonymous, at 2:25 PM  

The problem is that pain is very personal and very subjective. For many women labour and birth is not that painful, yet for others its unbearable. Fact is, I have yet to hear of anyone dying of the pain though...

I was told that it would be the worst pain ever to be endured. That was flat out wrong. It was unpleasant at times and I hate crowning, but I wouldnt rate birth in my most 10 painful experiences.

Ripping my toenail off was the worst pain I have ever had - I begged for amputation a week later when it was being dressed daily.

Gall bladder pain with fine gravel is a hundred times worse than labour pain for me.

The pain of a pterygium (overgrowth of the conjunctiva) being removed (after the local wore off) was 5 days of sheer unbearable hell (16 stitches for the graft, taken from under my eyelid).

Having an IUD inserted was so painful I went into vasovagal shock and lost consciousness for several minutes.

But labour and birth - sure its uncomfortable, even unpleasant near the end, but honestly and truly, its not much worse than period pains for me. On a scale of 1 to 10 (10 being the worst pain I have endured), it would be a 3.

So HOW can educators begin to describe the pain of birth?

By Anonymous Anonymous, at 12:04 PM  

"So HOW can educators begin to describe the pain of birth?"

They can say that it is subjective, but that MOST women describe it as the most painful experience of their lives. Just as important, they could advise postponing any decisions about pain relief until a woman knows what she personally will feel and how she will react to it.

It is the emphasis on making the choice to forgo pain relief BEFORE you experience the pain that I find particularly objectionable. In order to get women to make such a decision beforehand, many natural childbirth advocates dramatically downplay the level of pain that is experienced by most women. It is almost as if they are trying to trick women into natural childbirth.

That's why the woman who wrote the humorous post about her natural childbirth experience referred to the educator as "Liar".

By Blogger Amy Tuteur, MD, at 12:17 PM  

It is the emphasis on making the choice to forgo pain relief BEFORE you experience the pain that I find particularly objectionable. In order to get women to make such a decision beforehand, many natural childbirth advocates dramatically downplay the level of pain that is experienced by most women. It is almost as if they are trying to trick women into natural childbirth.


I doubt anyone here would object to a childbirth educator who works to PREPARE pregnant women for labor.

Let us be clear: Not all natural childbirth advocates are going to downplay the pain aspect. Many of us are interested in real preparation for labor, ways of dealing with the pain, and there is no disadvantage in learning techniques to deal with pain and discomfort. If the woman decides in labor she wants an epidural, she should not be judged. Many do, and that's fine.

If all you were objecting to was that some educators aren't preparing their class members for labor, then I agree. But I don't see any harm in preparing oneself for a natural birth. I don't understand your issue with this.

By Anonymous Anonymous, at 1:10 PM  

"It is the emphasis on making the choice to forgo pain relief BEFORE you experience the pain that I find particularly objectionable."

Look, if for some reason you don't want pharma pain relief... (perhaps philosophical reasons, perhaps you don't want the risk), you really do have to prepare to deal with the pain in other ways. It is NOT helpful to have nurses or the doc offering you pain relief every hour and poo-pooing your committment to non-pharma pain relief. You can't decide in labor whether or not you want medical pain relief because you have to prepare ahead of time. For me it was hypnobirthing. I practiced an hour per day for ten weeks before my birth.

By Blogger Mama Liberty, at 10:34 PM  

Mama Liberty:

"Look, if for some reason you don't want pharma pain relief... (perhaps philosophical reasons, perhaps you don't want the risk), you really do have to prepare to deal with the pain in other ways. It is NOT helpful to have nurses or the doc offering you pain relief every hour and poo-pooing your committment to non-pharma pain relief."

Maybe so, but that's not what I am talking about. I am talking about the fact that many first time mothers have told me that natural childbirth educators and natural childbirth books were not HONEST about the amount of pain involved in childbirth.

I have read it myself. "It is the fear that makes childbirth painful." "Many women don't experience severe pain." Some women find the contractions to be 'orgasmic'". That's all a bunch of BS and anyone who has actually had a baby knows that. So why are some natural childbirth educators and writers deliberately trying to trick other women?

By Blogger Amy Tuteur, MD, at 8:31 PM  

I have read it myself. "It is the fear that makes childbirth painful." "Many women don't experience severe pain." Some women find the contractions to be 'orgasmic'". That's all a bunch of BS and anyone who has actually had a baby knows that.

With my last homebirth, I dilated completely without ever having a painful contraction. I had moderate pain with pushing, but it was truly not a big deal.

With my previous homebirth, I worked harder (my third son was 9#12; the fourth was an 8# peanut), but I remember thinking during transition, "This is a huge sensation but it isn't really painful." I was cracking jokes all the way through, saying to my husband, "Next time, you do the pushing. I'll do the puking; I'll do the pregnancy. You have to push, though, okay?" I assure you that "next time" was the furthest thing from my mind during my two hospital births. I was not cracking jokes during those second stages either.

I don't say this boastfully or because I think anyone else "ought" to have the same experience; I'm just reporting that sometimes it happens that way. I do not have a high pain tolerance. When I knock a can off the shelf, I flinch and say "ouch" before it even hits my toe. (Then I feel very silly when it lands on the floor.)

My homebirths don't rank very high on the list of painful things I've experienced in my life. (The hospital births do, even the epidural birth.) Just for comparison, with my third son I complained more about the stitch for a small first-degree tear than I did about any of the contractions or the sensation of delivering a 38+ cm head.

Some women do experience orgasmic birth. Have you seen the picture in Ina May's Guide to Childbirth of the primip smiling delightedly at crowning?

Childbirth educators should be clear that there's a range of normal experiences, and not emphasize the easier end of the spectrum. For my part, I'm vexed by materials that say or imply, "It's too painful; just ask for the drugs."

By Blogger Jamie, at 12:35 AM  

"So why are some natural childbirth educators and writers deliberately trying to trick other women?"

We might be able to judge results, but how can we make accurate judgements about the INTENT of childbirth educators? Do we have any evidence that there is deliberate effort to deceive?

We might also want to specify which method of "natural childbirth" is under scrutiny. In my (admittedly anecdotal) experience, Bradley was quite effective. I would never call my labor painless (it was quite hard, actually), but it was also within my capabilities. (Perhaps I was fortunate in that my instructor was "honest" about what I might feel?

Thanks for reading -

By Anonymous Anonymous, at 3:37 PM  

I have read it myself. "It is the fear that makes childbirth painful." "Many women don't experience severe pain." Some women find the contractions to be 'orgasmic'". That's all a bunch of BS and anyone who has actually had a baby knows that. So why are some natural childbirth educators and writers deliberately trying to trick other women?


Maybe that was all BS for you. I've had a baby, and it wasn't that difficult. It wasn't orgasmic either, but I have a friend for which it was. It's no crime to publicly state that we were made to give birth to our children, and it does not have to be all that hard.

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