Friday, May 26, 2006

Drugs at homebirth

I just learned something that surprised me. I thought that there were never any medications for pain relief at a homebirth. I was perusing Angela Horn's Home Birth Reference Site and read the section on pain relief at home:

Entonox [nitrous oxide and oxygen] appears to be a harmless drug which is quickly cleared from the mother's body. It is inhaled by the mother from a mouthpiece or mask. Midwives will routinely bring it to home births in many areas of the UK. The only problems associated with it seem to be if the mother gets too 'high' and cannot push effectively in the second stage, or if she finds herself depending on the drug and then the canister runs out.

It is fairly common for supplies of Entonox to run out at home births and you may have to wait some time for a new canister to arrive from the hospital. It is also fairly common for canisters and mouthpieces to be faulty, so if you feel very strongly that you want to have Entonox available, perhaps your birth partner could ask the midwife to test her stash when she first arrives. The National Birthday Trust study found that Entonox was used at 50% of home births surveyed, and 73% of the hospital births.



I wonder why there is opposition to epidurals. The medications in epidurals do not enter the bloodstream at all or in very small amounts, but nitrous definitely crosses the placenta and affects the baby. It also calls into question the assertion that childbirth at home is less painful than in the hospital, or that natural childbirth techniques make the pain manageable.

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20 Old Comments:

I've never heard of this gas, and am pretty sure it is never or rarely used in the US.

By Anonymous Anonymous, at 7:05 PM  

I have heard of it being used in the UK. We have a few European trained midwives practicing here in Canada... as far as I know, none of them do it here (*in a homebirth setting). I do not see it listed as equipment on my lists... I will ask around on Monday.

By Anonymous Anonymous, at 7:18 PM  

this is something not done in the US. Direct entry midwives in other countries have very different skills and abilities

By Anonymous Anonymous, at 8:35 PM  

I have never heard of this being used at homebirths in the US. I believe if it was, most of the homebirth movement would frown upon it!

By Anonymous Anonymous, at 8:51 PM  

Its very occasionally used at homebirths here (NZ) - women can choose to hire it themselves. Most homebirth midwives dont carry it because the focus is on drug free birth.

Where on earth was it said that homebirth is less painful than hospital birth???

By Anonymous Anonymous, at 6:44 AM  

I don't know if it is the epidural alone that the home-birth movement objects to, but the epidural plus all the other things that it leads to adding more risk to both mother and baby. I suspect that the same would happen with this gas, although I don't know anything about it.

It's clearly not safe to have an epidural at home! I can't say the same about the gas, because I don't know anything about it.

By Anonymous Anonymous, at 10:30 AM  

Let me clarify something,

'I thought that there were never any medications for pain relief at a homebirth.'

There are not many, if any, pharma's used for pain relief at a home birth. However, there are many 'alternative treatments' for pain that are effective without adding the risk that accompanies drugs and risky medical procedures.

By Anonymous Anonymous, at 10:35 AM  

"Where on earth was it said that homebirth is less painful than hospital birth???"

I said that somewhere. I believe in the case where a woman feels fearful in a hospital, but safe at home, the perception of pain would be different. Fear increases pain. I'm not saying that across the board homebirth is less painful than hospital birth, but that was my experience, even WITH an epidural in the hospital!

There might be something I'm missing about this gas thing, but I can't understand why you would want to have a homebirth if you are interested in medical options for pain relief. In that case I would think it better to go to the hospital.

By Blogger Mama Liberty, at 11:56 AM  

I wonder if this reflects the fact that European, Australian and New Zealand mothers are less likely to have a particular agenda about birth than American women.

Is it possible that in Europe and elsewhere the decision to have a baby at home is just a decision about place of birth, and not a decision about an overarching philosophy that assumes that "natural" is good?

By Blogger Amy Tuteur, MD, at 2:31 PM  

"I wonder if this reflects the fact that European, Australian and New Zealand mothers are less likely to have a particular agenda about birth than American women."

Where is that fact to be referenced?

"Is it possible that in Europe and elsewhere the decision to have a baby at home is just a decision about place of birth, and not a decision about an overarching philosophy that assumes that
"natural" is good?"


The over-medicalization of normal childbirth is a common issue.

You might find these interesting:

Safer Childbirth?: A Critical History of Maternity Care by Marjorie Tew
http://fampra.oxfordjournals.org/cgi/content/full/16/3/321-a

A Pleasing Birth: Midwives and Maternity Care in the Netherlands
by Raymond De Vries

http://www.birthinternational.com

By Anonymous seriously, at 4:00 PM  

I am not anti-epidural at all costs. I have attended births where the administratin of an epidural made the difference between a vaginal birth and a c-section - allowing an exhausted mother to rest and regroup prior to second stage.

That said, you may wish to look into how the medications in an epidural do affect the baby. Epidural babies are frequently sleepy and it is often much more difficult to establish breastfeeding when this is the case. I have read that the effects of the epidural can remain in the baby's bloodstream for as long as six weeks and can sometimes cause disorganized behavior in the infant.

By Blogger Des, at 11:19 AM  

Des:

"That said, you may wish to look into how the medications in an epidural do affect the baby."

That topic is currently being discussed in the thread "Are natural childbirth advocates honest about pain?"

I'm pretty dubious about the epidural papers for the reasons that I discuss in the thread. However, there is no doubt that nitrous affects that baby.

By Blogger Amy Tuteur, MD, at 11:51 AM  

I wonder if this reflects the fact that European, Australian and New Zealand mothers are less likely to have a particular agenda about birth than American women.

I don't have any clients with a birth plan. Ever. Midwives of any variety don't have in their scope of practice (or their supervising doc's depending on the state) the ability to provide pain relief in the form of pharmaceuticals.

By Anonymous Anonymous, at 12:19 PM  

At my last babies homebirth there was gas and air and pethidine available. I hadn't wanted to use anything, I did use gas and air, wish I hadn't but never used the pethidine. I am in the uk. Next baby I want to be completely natural.

I have noticed in this country (uk) that something strange has happened to natural childbirth. The term natural seems to now be used in place of vaginal, so some consider themselves to have had a natural birth despite having had an induction and epidural.

I had a homebirth, not a natural birth, but that is my aim next time.

By Anonymous Anonymous, at 5:34 PM  

>>"......and not a decision about an overarching philosophy that assumes that "natural" is good?"<<

As opposed to what? An overarching philosophy that assumes that "natural" is bad?

I chose home birth because I saw how horribly battered my sisters and their babies were after they were saved by the medical staff that ignored them, in one case until she insisted the baby was coming no matter what time the clock said. And then one nephew was given a spinal tap because my sister has a slight fever.

Spare me your pseudo public health arguments. The fact remains that the number of babies needing help after a home birth is minute compared to what happens after a modern U.S. hospital birth.

And this whole claim about the epidural not effecting the baby since it's not in the blood stream ... I don't know the physiological aspect, but it is very well known among lactation consultants that epidural babies behave quite differently that babies born without the mom having drugs.

Yes, safety is the number one reason I chose a home birth. The ironic thing is that the science shows all the procedures in the hosptial are basically bad for the mom AND the baby. But because the god-playing medical establishment can charge in on their white horses and rescue the mom and babe, it's all "okay". All's well that ends well, except it doesn't always end so well.

I believe the risk of death at home is approx. equal to death or severe life-changing injury and trauma in the hospital. Then home birth bounds ahead in that there are vastly fewer injuries and infections.

Of course, women should just shut up and be grateful they have a live baby. Right? The sad fact is, sometimes babies die. It is a fact, but it is no more likely that you will have a devestating outcome at home than in the hospital.

By Anonymous Anonymous, at 11:58 PM  

"The fact remains that the number of babies needing help after a home birth is minute compared to what happens after a modern U.S. hospital birth."

Evidentally, it's not minute, since the neonatal death rate is HIGHER at home than in the hospital.

"I don't know the physiological aspect, but it is very well known among lactation consultants that epidural babies behave quite differently that babies born without the mom having drugs."

You may believe it, but that doesn't make it true. There is simply no scientific evidence to support that claim.

"It is a fact, but it is no more likely that you will have a devestating outcome at home than in the hospital."

You're wrong. It is more likely that you will have a devastating outcome at home. All the research done to date demonstrates that. If you think otherwise, you must supply PROOF.

This is all part and parcel of the mythology of homebirth. There is no scientific evidence that epidurals hurt babies; there is no scientific evidence that epidurals impede nursing; there is no scientific evidence that babies are being killed by being delivered in the hospital. Homebirth advocacy is based on a series of myths that advocates believe because it SUITS them to believe it. There is no evidence for it at all.

By Blogger Amy Tuteur, MD, at 12:51 AM  

"I don't know the physiological aspect, but it is very well known among lactation consultants that epidural babies behave quite differently that babies born without the mom having drugs."

You may believe it, but that doesn't make it true. There is simply no scientific evidence to support that claim.


Amy, I haven't been participating much in the discussion of epidurals' effects on breastfeeding because I haven't read the primary literature and that seems to be your standard for having a conversation. But I am going to recommend for the ?fourth? time that you read Kroeger and Smith's book, The Impact of Birthing Practices on Breastfeeding, because it reaches very different conclusions. I've spent several hours listening to Linda Smith speak and she is thought-provoking, articulate, and committed to evidence-based thinking.

As I mentioned once before, the effect of epidurals on breastfeeding is complex. It's not just the medications in the bloodstream: it's the timing of the first feed, the volume of IV fluids given to the mother (loosely correlated with degree of areolar edema, which can impede latch attempts), and other factors to boot.

(BTW, you could fit what I know about pharmacology in a thimble with room left over for a shot of ouzo, but I wanted to correct what I believe was an error down below. Sailorman said that epidural medications can't cross the blood-brain barrier. AFAIK, it depends on the medication. Fentanyl, an opioid, crosses the barrier easily.)

It's true that lactation consultants are vulnerable to observer bias, just like any group; as a population, we may tend to prefer natural birth. But our priority is the needs of breastfeeding dyads after the baby arrives. My own clinical observations, and those of the LCs I know, suggest that epidurals can interfere with the establishment of breastfeeding.

Do you know of research to the contrary?

By Blogger Jamie, at 8:59 AM  

Jamie:

"Do you know of research to the contrary?"

Yes, most of the epidural/breastfeeding studies that we have already discussed.

This issue is emblematic of so much of what is wrong with homebirth advocacy. Yes, there is a correlation between women who get epidurals and women who won't start or quit breastfeeding. That doesn't mean that it had anything to do with the epidural itself.

I haven't looked it up, but I bet the proportion of women with advanced degrees who breastfeed is higher than the proportion of women who didn't finish high school. That doesn't mean that failing to graduate from high school leads to difficulty breastfeeding.

Everyone recognizes that breastfeeding is primarily dependent on maternal commitment. It is closely associated with maternal income level and education level, too.

I'm sure that you don't believe that if you had had the bad luck to require a C-section for a complication, you would have failed to breastfeed that child. So if you wouldn't believe it about yourself, why would you believe it about someone else?

By Blogger Amy Tuteur, MD, at 11:22 AM  

I haven't looked it up, but I bet the proportion of women with advanced degrees who breastfeed is higher than the proportion of women who didn't finish high school. That doesn't mean that failing to graduate from high school leads to difficulty breastfeeding.

Not a causal relationship, no, but the association is worth considering. What kind of support do women with less education need to breastfeed successfully? That's part of why LLL developed its Peer Counselor program, because resources developed by educated white women weren't doing the job for minority women or those with less education.

That's what I'm talking about here: associations. If epidurals are associated with breastfeeding problems, and the research I've seen and my own clinical experience both suggest it's the case, women should have that information available to them before they give birth. How can LCs be most helpful to women having trouble initiating breastfeeding after a difficult birth? It's worth talking about because it can make a difference to breastfeeding dyads.

For the third time, I'm not aware of research showing that maternal motivation is the primary factor predicting breastfeeding success. The correlation is strong, absolutely, but there are lots of other things going on, some of which I detailed in an earlier comment. We cannot assume that women who weaned early just didn't want to breastfeed badly enough.

By Blogger Jamie, at 12:16 PM  

Jamie:

"That's what I'm talking about here: associations."

That's not true. You are trying to imply that epidurals directly affect the baby's ability to nurse. That would be like trying to imply that the fact that its mother did not graduate from high school directly affects the baby's ability to nurse. In both cases, epidural and high school diploma reveal things about the mother that may affect or correlate with her commitment to breastfeeding. No more, no less.

By Blogger Amy Tuteur, MD, at 7:18 PM