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A Look at the Research: The Link Between Epidural Analgesia and Breastfeeding

June 21st, 2011 by avatar

It’s probably fair to say that most women who decide to have an epidural during labor don’t consider its possible impact on breastfeeding. Perhaps this is because no thought is given generally to any possible links between drugs and breastfeeding success (or otherwise). Instead, both pregnant (or laboring) women and caregivers usually assume that breastfeeding is a separate issue. Evidence from early research certainly doesn’t seem to support that view and a little common sense would also lead us to challenge it further…

Considering drugs used in labor generally, Jordan, et al (2009) provide some evidence that drug use in labor and birth has an impact on breastfeeding rates at 48 hours postpartum. (Of course, when women have already given up on breastfeeding two days after giving birth, it’s unlikely that they will re-establish breastfeeding later, even though this might be possible.) However, although Jordan et al’s conclusions are fairly clear, we also need to take into account the fact that many anesthesiologists wouldn’t accept these researchers’ conclusions simply because their data is retrospective (i.e. it looks back at what happened in the past, and tries to establish causal links); anesthesiologists (like many other specialists) consider prospective randomized studies to be more reliable. In any study, cause-effect relationships are difficult to prove—and epidural usage and its impact on breastfeeding success is no different in this respect.

Nevertheless, there are also prospective studies which have reported fairly clear problems with narcotics used in labor (Beilin, et al, 2005; Camann, et al, 2007; Torvaldsen, et al, 2006). In the study by Beilin, et al researchers concluded: “Among women who breastfed previously, those who were randomly assigned to receive high-dose labor epidural fentanyl were more likely to have stopped breastfeeding 6 weeks postpartum than women who were randomly assigned to receive less fentanyl or no fentanyl.” (Most women nowadays receive fentanyl as part of the epidural cocktail. Bupivicain, the drug it partly replaces in the epidural cocktail, causes paralysis in the lower part of the body so substituting part of this with fentanyl reduces this effect. However, some research suggests that problems with breastfeeding develop as a result of using fentanyl in the epidural cocktail. The study by Torvaldsen, et al concluded: “Women in this cohort who had epidurals were less likely to fully breastfeed their infant in the few days after birth and more likely to stop breast-feeding in the first 24 weeks”. Despite making this statement, the researchers felt they were unable to say whether there was a causal link between epidural anesthesia and breastfeeding difficulties. This was despite the fact that “Intrapartum analgesia and type of birth were associated with partial breastfeeding and breastfeeding difficulties in the first postpartum week” and the fact that women who had epidurals were more likely to stop breastfeeding than women who used non-pharmacologic methods of pain relief.

Having said all that, an article by Pandya (from a Department of Anaesthesia in India) in 2010 claims that any impact on breastfeeding is not statistically significant. A study conducted on a small number of women (87) in Toronto, Canada, by Wieczorek et al (2010) also concludes that breastfeeding is unaffected by epidural use. An editorial by Camann (see references below) provides a good overview of research done up to and including 2007 and an article by Loubert et al (2011) summarises research up to the present day.

A study by Lin et al (2011) somewhat less clearly but nevertheless significantly, indicates a possible link between the use of narcotic analgesia in the epidural mix and later actual or perceived breastfeeding problems. Another study by Reynolds at St Thomas’ Hospital in London (2009) concludes: “Successful breastfeeding is dependent on many factors, therefore randomized trials are required to elucidate the effect of labour analgesia.” Wilson et al’s randomized controlled trial did take place after this recommendation (2010) and the conclusion was, in fact, that epidurals had no impact on breastfeeding. Devroe et al (2009) came to a similar conclusion.

Common sense might lead us to view even these studies which find no link between epidurals and breastfeeding with some caution. After all, the following need to be taken into account as well:

  • Epidurals are associated with a general medicalization of birth (since they usually and/or frequently involve IV lines and urinary catheters, as well as electronic fetal monitoring and ongoing monitoring of blood pressure) and this may contribute to greater maternal discomfort postnatally, meaning that breastfeeding could be affected.
  • Epidurals are known to be associated with a higher rate of instrumental delivery and caesarean.  Postpartum perineal discomfort, or pain as a result of abdominal surgery, will also inevitably make breastfeeding less comfortable, and therefore less likely to occur.
  • Epidurals can influence the fluctuation of hormone levels that play an important role in breastfeeding. A study conducted by Handlin et al (2009) found that medical interventions in connection with birth influence the activity of the hypothalamic-pituitary-adrenal axis 2 days after birth. (Adrenal gland activity, which is dependent on pituitary gland activity, which in turn is dependent on the activity of the hypothalamus is affected.) As a result of this influence, hormonal production is likely to be compromised, which will of course affect the success of breastfeeding, which depends on the release of the hormones oxytocin and prolactin.

Furthermore, most studies conducted so far are unlikely to have compared physiological, unmedicated active labor with epidural labors. Comparing breastfeeding success after epidural birth to opiate-medicated birth (or birth with other forms of analgesia, such as Entonox) is not the same as comparing physiological birth to epidural birth.  Of import are the sizes of the associated studies which inform our understanding of epidural analgesia and its impact on breastfeeding.  While the studies by Belin, et al, Wieczorek, et al and some of the studies cited in Loubert’s review are all modest in size (Belin, n=66; Wieczorek, n=87) others boast larger numbers (Wilson via Loubert, n=1054; Torvaldson, n=1280; Jordan, n=48,366).

Our overall conclusions then are clearly not only based on incomplete evidence, but also on research which is perhaps comparing two scenarios which are both unconducive to successful breastfeeding: birth with opiate analgesia (e.g. Demerol) and birth with epidural analgesia. Clearly, too, many people involved in the debate have vested interests in continuing to promote epidurals. Caregivers who are unfamiliar (and therefore uncomfortable) supporting ‘noisy’, mobile and ‘demanding’ women (who are laboring without an epidural) are perhaps unlikely to want to change their more convenient practice; anesthetists have their livelihood to think about; drug companies which manufacture drugs such as fentanyl also have enormous profits to lose should women decide that epidural is, after all, not ideally conducive to breastfeeding success.

 

Posted by:  Sylvie Donna, author of Birth: Countdown to Optimal published by Fresh Heart Publishing. Available from www.freshheartpublishing.com or from any other online shop (e.g. Amazon). Read the Science & Sensibility review of Birth:  Countdown to Optimal by Christine Hurst Praeger.

 

 

References

Beilin Y, Bodian C, Weiser J, et al. Effect of labor epidural analgesia with and without fentanyl on infant breast-feeding: a prospective, randomized, double blind study. Anesthesiology, 2005, Dec;103(6):1211-7

Camann W. Labor analgesia and breast feeding: avoid parenteral narcotics and provide lactation support. International Journal of Obstetric Anesthesia, 2007, Jul; 16(3):199-201

Cardiff Births Survey. BJOG: International Journal of Obstetrics & Gynaecology, 2009, online publication on 1 Sept

Devroe S, De Coster J, Van de Velde M. Breastfeeding and epidural analgesia during labour. Curr Opin Anaesthesiol. 2009 Jun; 22(3):327-9.

Handlin L, Jonas W, Petersson M, Ejdeback M, Ransjo-Arvidson AB, Nissen E, Uvnas-Moberg K. Effects of sucking and skin-to-skin contact on maternal ACTH and cortisol levels during the second day postpartum-influence of epidural analgesia and oxytocin in the perinatal period. Breastfeed Med. 2009 Dec;4(4):207-20.

Jordan S, Emery, S, Watkins A, Evans JD, Storey M, Morgan G. Associations of drugs routinely given in labour with breastfeeding at 48 hours: analysis of the

Lin SY, Lee JT, Yang CC, Gau ML. Factors related to milk supply perception in women who underwent cesarean section. J Nurs Res. 2011 Jun;19(2):94-101.

Loubert C, Hinova A, Fernando R. Update on modern neuraxial analgesia in labour: a review of the literature of the last 5 years. Anaesthesia 2011 Mar;66(3):191-212. doi: 10.1111/j.1365-2044.2010.06616.x.

Pandya ST. Labour analgesia: Recent advances. Indian J Anaesth. 2010 Sep;54(5):400-8.

Reynolds F. The effects of maternal labour analgesia on the fetus. Best Pract Res Clin Obstet Gynaecol. 2010 Jun;24(3):289-302. Epub 2009 Dec 11.

Torvaldsen S, Roberts CL, Simpson JM, et al. Intrapartum epidural analgesia and breastfeeding: a prospective cohort study. International Breastfeeding Journal, 2006,Dec11;1:24

Wieczorek PM, Guest S, Balki M, Shah V, Carvalho JC. Breastfeeding success rate after vaginal delivery can be high despite the use of epidural fentanyl: an observational cohort study. Int J Obstet Anesth. 2010 Jul;19(3):273-7. Epub 2010 Jun 2.

Wilson MJ, MacArthur C, Cooper GM, Bick D, Moore PA, Shennan A, COMET Study Group UK. Epidural analgesia and breastfeeding: a randomised controlled trial of epidural techniques with and without fentanyl and a non-epidural comparison group. Anaesthesia. 2010 Feb;65(2):145-53. Epub 2009 Nov 12.

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  1. June 21st, 2011 at 21:06 | #1

    An interesting piece, but you really ignore what drives these studies: selection bias.

    As a whole, the population of women who choose epidurals contains fewer women who are very likely to breastfeed than the population of women who declines epidurals. It isn’t the epidural, its the woman who chooses an epidural.

  2. avatar
    Penny in Texas
    June 21st, 2011 at 22:06 | #2

    I’m sure there is some amount of selection bias going on, but given that the majority of women in the US have epidurals (approx 75%) and, supposedly, the majority of women in the US initiate breastfeeding (also about 75%), the two groups wouldn’t seem to diverge as much as Dr. Fogelson seems to think. Even if all of the moms who avoided epidurals were breastfeeding moms, 1/2 of the mothers initiating breastfeeding still had an epidural delivery.

    In my experience, the main driver in breastfeeding woes I see from epidural use is the greater level of edema in mom’s body/breasts after hours and hours of IV fluids (made worse if mom was induced as well, as is all too common). Baby can’t latch well and nipples get sore quickly, deterring those mothers with a superficial interest in breastfeeding, and leading to a cascade of interventions such routine nipple shield recommendation rather than actual help correcting latch, a quick move to exclusive pumping (generally with a consumer-grade pump rather than a hospital grade pump), relief bottles of formula, etc.

  3. June 21st, 2011 at 22:45 | #3

    I’m sure the connection is multifactorial in some way. Selection bias plays a big part in those studies I think.

    Your point about divergence is appropriate, but one wouldn’t expect a 1 to 1 correlation. Its about population averages. None of the studies suggest that there is 0% breastfeeding success rate among epidural takers either.

    Breastfeeding is a cultural issue that requires systemic support to be helpful. I don’t see epidurals as being something that discourages breastfeeding. I do see in my practice a population of poor women who routinely seek epidurals and don’t have a predominant culture of breastfeeding. I also see a population of very well to do women who tend to have epidurals, and also have productive jobs they tend to want to return to, making long term breastfeeding problematic. All of this adds to the selection bias of the quoted studies.

  4. avatar
    Sarah Richardson
    June 22nd, 2011 at 10:07 | #4

    I had epidurals with both of my sons and I successfully breastfed my first son for two years (exclusively for six months) and am now into my third month of my second.

    I do not believe that my epidurals had any effect on my breastfeeding.

    Just wanted to add the other side to this article in the form of my personal experience.

  5. avatar
    Jacqueline (Jackie) Levine
    June 22nd, 2011 at 15:17 | #5

    This post reminded me, with pleasure, of the great, comprehensive, powerful, scholarly, eminently informative and readable article by Linda J. Smith, “Impact of Birth Practices on the Breastfeeding Dyad”, published in the Journal of Midwifery and Women’s Health 2007;52 (6),Nov-Dec. The theme of her article jumps off the 2005 Jordan BJOG study on analgesia. She quotes the theme from that study: “Because ‘failure to breastfeed’ is not recognized as a possible harmful effect of medication, there are few methodological precedents in this area. The complex, but under researched, physiological processes involved in establishing lactation are not generally considered vulnerable to pharmacological influences. The transitory nature and “ordinariness” of “switching to bottle feeding” render the usual algorithms for identifying adverse drug reactions inadequate, inapplicable, or even irrelevant. Susceptibility to bottle feeding is often regarded as determined exclusively by socio- cultural factors”.
    The quote illustrates what became the bedrock of the theme of the Smith article. I quote her: “In other words, breastfeeding initiation and continuance is generally viewed as solely the mother’s decision; therefore, interventions have been focused on maternal motivation. The newborn’s role in breastfeeding initiation, especially the ability to suck, swallow, and breathe normally, was assumed to be a “given” except when obvious abnormalities were present. In addition, professional segmentation makes it difficult for some providers to see the short- and long-term outcomes of their practices: obstetricians are rarely involved in establishment of breastfeeding; anesthesiologists are only peripherally involved in pediatric care; and pediatricians rarely interface with mothers before birth”.

    While some studies mentioned in this post show weak-or- no correlation of epidural and breastfeeding, lactation professionals see the effects of epidural drugs on newborns every day. We see weaker suck, we see disorganized behavior states, we see breasts engorged from bags of IV fluids that go along with the epidural. We see that the disrupted newborn behaviors can last several weeks until the baby catches up with itself. Meanwhile, those first weeks are heartbreaking for a new mother and she needs tons of support to get through that time. Where will she get that support as a matter of course? Women choose epidurals to deal with “pain”…and as Ms. Donna points out, “they don’t consider its possible effects”. But they are never told about the possible side effects of the drugs and the concomitant protocols that will have such a powerful impact on their first weeks with their newborns. Who will even mention that possibility during antepartum care? I believe that’s where the importance of Linda Smith’s words should be considered: the “professional segmentation” she mentions is very relevant to a mother’s experience. Read her article for its acute perspective. Where did I hear it said that we won’t have normal breastfeeding until we again have normal birth?

  6. avatar
    SF Mom & Psychologist
    June 22nd, 2011 at 18:45 | #6

    Jackie – why do you put “pain” in quotation marks? It seems to suggest that it is imaginary or false, and it can feel very insulting to some women when we read things like that, just FYI. Why else would women choose epidurals? Labor IS very painful for many women – plain and simple. Please, stop demonizing/patronizing/rejecting women for seeking pain relief in labor.

    In my socio-economic and geographic slice of life, nearly every single mother I know breastfed. About half of us had epidurals, and half did not. While simply anecdotal, there was zero correlation, and the women I know who had the most trouble with it, interestingly, were hard-core natural birthers (undersupply, excessive pain, latch problems) who had no pain relief in labor. I totally agree with Dr. Fogelson that breastfeeding is a multi-systemic issue that is affected FAR MORE by issues like culture/family history, personal preference (gasp), professional demands, maternal/infant health, etc. If you are REALLY worried about breasfeeding success, target more significant than epidurals. Or, just go ahead and keep scorning women who want real pain relief in labor.

  7. June 23rd, 2011 at 07:49 | #7

    Interesting article. My thoughts mirror that of Dr. Folgelson – that perhaps women who are more likely to choose an epidural would already be less likely to breastfeed for a long period of time. Perhaps if women were surveyed prior to labor and asked what their plans on feeding their baby were, as well as asking detailed questions as to why they stopped nursing, it could help sort the data.

    I received an epidural for my second birth (after going au natural with my first), and I am still (occasionally) nursing him, nearly nine months later. He was, however, a little more drowsy during the first two days, so I had to really commit to nursing him, but now he’s enormous, thank G-d. I still plan on getting epidurals with my future (G-d willing) pregnancies.

  8. June 23rd, 2011 at 09:23 | #8

    Based on the evidence to date, we certainly CANNOT conclude that epidurals have a causal effect of impairing breast-feeding, which is a complex activity subject to many different influences. Individual experiences, while interesting, are by definition anecdotal, and do not answer the question at hand. I am a firm believer in pain relief during and after labor and delivery, and of having the mother in control of the situation. I do this by providing patient-controlled epidural pain relief during labor and then continuing it into the postpartum period if it is anticipated to be painful. Here’s one example: women who have had a lot of babies tend to have severe after-pains during breast-feeding that are often more painful than labor. I give these women the option of simply keeping the epidural in for a couple of days so they can administer a dose of medication before each nursing session. It’s a walking epidural dose, of course, so it doesn’t limit their mobility. But it does give them ideal pain relief without side effects. And it takes the pain out of nursing. It’s a wonderful way of encouraging breast-feeding! To read more about this topic, check out my blog:
    http://www.epiduralwithoutguilt.com/archives/category/pain-control-and-breast-feeding

    p.s.:
    SF mom and psychologist : you are, of course, 100% correct. And are you aware of the literature linking unrelieved pain in labor top post-partum depression and even PTSD? Pain can have serious side effects (apart from the obvious suffering at the time)

    Rivki- the drowsiness you noticed for two days in your baby would be hard to pin on the epidural. I don’t know what you received, of course, but it doesn’t make sense, medically, that is. All the Best!

  9. avatar
    sasha
    June 23rd, 2011 at 11:37 | #9

    pain during breastfeeding is positive in the sense that it teaches. it lets you know that perhaps the baby is not latching correctly, sliding down the nipple, not positioned correctly to nurse effectively. if a mother/baby are not nursing correctly it will inhibit milk production and teach the baby the wrong way, will eventually lead to severely cracked/bleeding nipples, babies won’t thrive and mothers won’t enjoy breastfeeding. why would you want to take away one of the best clues that something is amiss? if it hurts, something is incorrect. ask for help. and if need be, ask again and again until both mother and baby have it down. breastfeeding is not supposed to hurt. medicating that pain is counterproductive to overall success in nursing.

  10. avatar
    sasha
    June 23rd, 2011 at 11:42 | #10

    about the effects of epidurals on breastfeeding – i think this is a tremendously complex issue, as others have pointed out. i don’t quite understand the reluctance by some to admit that there could be any negative correlation though. for those of you who see no negatives, do you also see no negatives to epidurals in labor? given the long list of potential risks and the known effects on baby and mother, that would be hard to believe. should epidurals never be used? of course not. they can be effective for pain relief. because of that one benefit should we blind ourselves to the many other effects? especially with incredibly widespread use? can we please have more complex views about this stuff? does it always have to be “good” or “bad” and the other side is wrong? as nurses, doulas, doctors, educators we are extremely biased by our own care practices and the care practices of our colleagues (not to mention our organizations, education, etc). let’s please try to see past the tip of our own noses.

  11. June 23rd, 2011 at 19:57 | #11

    @sasha
    I was not referring to nipple pain. The epidurals I recommend for pain during nursing is due to uterine contraction pain (know as after-pains). The epidural does not numb the nipples, so nothing to worry about here.

  12. June 23rd, 2011 at 20:00 | #12

    @sasha
    Really good point Sasha. Thank you. Something I discuss, that very few others do, I’ve noticed, is that AVOIDING an epidural has risks also, because unrelieved pain is not a good thing for the mother or the baby (physiologically or psychologically). Of course there are risks to epidurals, but a woman trying to decide what to do for her delivery should also understand there are risks to unrelieved pain.

  13. June 23rd, 2011 at 20:00 | #13

    Interesting comments… Two points strike me as being important. 1) Women’s choices in childbirth are paramount, but of course they need to be informed choices. As yet, we don’t have sufficient information for that to be possible and too few people know what natural birth can really be like. However, we do know a great deal about the complexity of the natural interplay of hormones and there is an obvious risk of disturbing their flow. It’s now a question of how this knowledge can be kept alive in caregivers’ minds so that they fairly represent the choices available to women, while also dealing with all the conflicting research evidence. 2) The sensations of birth (which most women experience as intense, even outrageous pain) can be marshalled positively when labor is supported and facilitated properly (i.e. in silence, with minimal disturbance and only non-pharmacological pain relief) – and when this is the case (which is rarely true, unfortunately) I am convinced that women experience LESS pain than when they have epidurals. This is because of the postpartum pain (physical and emotional) which seems inevitable after pharmacological pain relief. In fact, I am so convinced of this after many years of research that I like to use inverted commas for the phrase ‘pain relief’ – because I think it’s relief which triggers even more physical and emotional pain later. The exquisite interaction between mother and baby after a completely unmedicated birth can never be repeated and it is facilitated by extreme alertness, energetic mobility and sensitivity (emotional and physical) – as well as by an extremely powerful suck from the newborn baby! It’s something I’ve experienced myself three times… It’s a tragedy for women if they miss out on even hearing about this, let alone experiencing it. However, as I said, it needs to be a woman’s choice which way she goes. I just hope that sufficient numbers of caregivers remain on the planet who really understand how wonderful undrugged postpartum euphoria can be – and how healthy in terms of starting off breastfeeding and the whole of the mother-baby relationship. In Fresh Heart books there are numerous accounts by other women who’ve experienced the joy of life postpartum after an unmedicated birth – and there is information about how birth can be facilitated so that it is a good experience, however it turns out. These books are one attempt among many to alleviate women’s pain in childbirth and make it a positive experience.

  14. avatar
    Jacqueline (Jackie) Levine
    June 23rd, 2011 at 22:01 | #14

    Addressing my use of quotation marks around “pain” to SF Mom and others…The quotes are for emphasis as to what moms look for in an epidural, since, as the post says, women “don’t consider” its effect on breast feeding. But how *could* they consider those effects, since they are looking for “pain” relief. I’m saying that they are not *told* of possible effects on their babies, so how could they consider the effect on something they’re never even told about. They are looking for “pain” relief..That’s the disconnect that I have hoped to point out,so please to read what I said with care. Your accusal that I am demonizing/patronizing/rejecting women when talking about labor and pain and knowledge of what happens to us when we have babies is based on my use of quotation marks, it seems. As a doula who has been in over 160 labor rooms , where I support moms with and without epidurals, the possible effects on baby and mother where breastfeeding is concerned are never mentioned. It can’t be that you think that I believe pain is false or to be scorned…I work to make mothers more comfortable and in control of their births whether or not that means control over pain with drugs or with other means..and the right to choose either. I have volunteered my time as a doula to assist underserved women and teens every week for years. I admire and respect and support them for many hours in this most profoundly important time in their lives. Mothers are not always told of all the side effects of the epidural, and certainly, while not everyone experiences all those effects, babies are rarely if ever mentioned… for example, what happens to the baby when there is a precipitous drop in maternal BP, or mother winds up with fever? It can hardly surprise anyone that if a drug affects the mother,it must have some effect on the baby as well. If there are some good studies making a connection to newborn behavior, (and some studies even looking at routine use of pitocin linked in some causal way to ADD and ADHD)…we know the baby must be impacted in some way, however subtle and not immeditely apparent. If you think that when I say that mothers want epidurals for “pain” that’s insulting to women, then you have presumed to know something about me that couldn’t possibly be known from the the way I use quotation marks.

  15. June 23rd, 2011 at 23:01 | #15

    @sasha
    Sasha -

    Please try to find the actual data that shows that epidurals have a measurable negative effect on mothers and babies. Such data is talked about a lot, but I’ve never seen it in any obstetrics journal. The reality is that there are no prospective randomized trials of epidural or no epidural, so such ‘data’ is actually either a fabricated idea or retrospective analyses fraught with bias.

    To answer your question specifically, no I don’t think there is any harm in getting an epidural.

  16. June 23rd, 2011 at 23:02 | #16

    There are of course very rare complications with epidurals, but I’m not really talking about that.

  17. June 24th, 2011 at 17:05 | #17

    @Nicholas Fogelson, MD
    Excellent points, Dr Fogelson. Readers may be interested in this recent publication by Dr. Felicity Reynolds, of St Thomas’ Hospital, London, UK:”The effects of maternal labour analgesia on the fetus,” published in Best Pract Res Clin Obstet Gynaecol. 2010 Jun;24(3):289-302.
    Here are some quotes from the abstract:
    Maternal labour pain and stress are associated with progressive fetal metabolic acidosis. Neuraxial analgesia [epidural and/or spinal] has maternal physiological and biochemical effects, some of which are potentially detrimental and some favourable to the fetus. Actual neonatal outcome, however, suggests that benefits outweigh detrimental influences. Meta-analysis demonstrates that Apgar score is better after epidural than systemic opioid analgesia, while neonatal acid-base balance is improved by epidural compared to systemic analgesia and even compared to no analgesia.
    …..so …..we see that epidurals and spinals given to relieve a woman’s labor pain result in newborns who have better acid-base balances than newborn born to moms who labored “naturally.” Interesting, eh? (although it makes perfect sense scientifically). I wonder if this fact is ever mentioned in “childbirth education classes? (just kidding, I’m not really wondering).
    :-)

  18. avatar
    Jacqueline (Jackie) Levine
    June 24th, 2011 at 18:17 | #18

    To Dr.Fogelson: I am a great fan of your efforts to make DCC (delayed cord clamping) “standard” obstetric practice, a protocol change that you have lobbied for, and I especially admire, as you’ve said in your blog..AcademicObGYN… your plea to your colleagues to pay attention to the data, even if DCC was a practice “championed” by midwives…Your sensible reading and sharing of the studies that pointed to a more evidence-based way to treat newborns should be greatly heeded. When it comes to most OB’s favorite protocol, the epidural, we surely should be looking at the data, as YOU have already “championed” in your blog. The Milbank Report tells us that, in an analysis of practice bulletins issued by ACOG between 1998 and 2004, only 23% of those practice recommendations were based on Level A evidence (consistent science), 35% were assessed as Level B (inconsistent or limited evidence) and 42% were Level C (based on consensus or the opinions of experts). (Sakala C, Corry M, 2008.) Those numbers are reflected in the dismal ratings that the WHO gives the US: we are 49th in maternal mortality and 29th in infant mortality of 141 developed countries (WHO 2006). Clearly, we’re not doing everything right and we all hope to see the day when evidence-based maternity care becomes the standard, replacing the existing welter of practices.
    Surely, as a scientist, that’s something you’d like to see as well since practices vary from doc-to-doc and hospital-to-hospital. Therefore, with great hope, and as a follower of your evidence-based penchant, I quote the following from the Linda J. Smith article (Impact of Birth Practices…) to you to satisfy your request to Sasha for some studies that are not “fabricated” or “fraught with bias.” You may find the portion I quote below a bit pedestrian, but I hope that your curious mind and your ethical, evidence-based bent will prevail. Remember, clinicians don’t go home with mothers and help them in their real-life first days and weeks with their newborns. There are many studies noted below the following quote that might pique your interest and lure you to do more thinking along the lines of your DCC article (which is a gem)… we all need more independent,evidence-based thinking in the world of maternity care.

    “All drugs administered for pain relief to the laboring
    woman cross the placenta.20 Drugs administered into the
    epidural space require a higher absolute dose than those
    administered intravenously. Most of the pain-relieving
    drugs used to help women during labor are highly lipid
    soluble and rapidly diffuse into the fetus. The pediatric
    half-life (PHL) of commonly used analgesics is longer
    than the maternal half life, including bupivacaine (PHL,
    8.1 hrs) and meperidine (PHL, 6–32 hrs).21
    Fentanyl
    Fentanyl is emerging as particularly problematic for
    breastfeeding dyads. Jordan et al.5 conducted a retrospective
    review of the determinants of bottle feeding in 425
    primigravidas who delivered term infants. Logistic regression
    was used to control for factors known to affect
    infant feeding choices. After controlling for the effects of
    antenatal choice, other analgesics, and mode of delivery,
    these authors found a dose-response relationship between
    the dose of fentanyl used and subsequent bottle feeding
    at the time of hospital discharge (odds ratio [OR], 1.004;
    95% confidence interval [CI], 1.000 –1.008, and 90% CI
    for each microgram administered [range, 8–500 _g]
    was 1.001–1.007). Beilin et al.22 prospectively studied
    women who were already successful breastfeeders, randomly
    assigning them to high or low doses of fentanyl or
    no fentanyl. At 6 weeks postpartum, more women who
    were randomly assigned to high-dose epidural fentanyl
    were not breastfeeding (n _ 10; 17%), compared to
    women who were randomly assigned to receive either an
    intermediate fentanyl dose (n _ 3; 5%) or no fentanyl
    (n _ 1; 2%; P _ .005).
    Epidurals
    Research evidence of the risks of epidurals to breastfeeding
    is accumulating. Mothers who use epidurals during
    labor when compared to mothers who do not use epidurals
    have less interaction with baby,23 less mastery
    over motherhood,24 less maternal movement in labor,
    more malpresentations,25 and often more pain that then
    requires more medications.
    Other sequelae of epidural use can also impact subsequent
    breastfeeding success. Overhydration by intravenous
    fluids may result in breast edema, which can cause
    latch and breast problems.26 Although the effect of
    intravenous hydration on breast edema and delayed
    lactogenesis has not been adequately investigated, many
    have observed negative effects of postpartum edema of
    the breast.26 Breast fullness (“engorgement”) on days 3
    or 4 is partly caused by a rapid increase in fluid volume
    during lactogenesis II, which can be exacerbated by poor
    management practices that limit milk removal.27 Some
    lactation professionals have observed that prolonged
    intravenous hydration seems to increase edema in breast
    tissue. Using the term “engorgement” to refer to all
    postpartum breast fullness is confusing, because breast
    edema is different from milk stasis, suggesting different
    management strategies. It appears that excess interstitial
    fluid may inhibit the expansion of milk ducts and
    consequent release of milk during the milk-ejection
    reflex.28
    Dewey et al.29 investigated the incidence of and risk
    factors for suboptimal infant breastfeeding behavior,
    delayed onset of lactation, and excess neonatal weight
    loss among mother–infant pairs in a population of
    women with high educational levels and motivation to
    breastfeed. By carefully separating infant-related problems
    from maternal motivation and other maternal issues
    affecting breastfeeding initiation and duration,
    they found that excess newborn weight loss was associated
    with primiparity, long duration of labor, use of labor
    medications (in multiparas), and infant status at birth.
    Baumgarder et al.30 studied the relationship between
    labor epidural anesthesia and early breastfeeding success.
    They reported that despite the opportunity to breastfeed,
    many babies exposed to epidural anesthesia were unable
    to latch and suck effectively. In one of the first published
    reports in an obstetric journal of breastfeeding outcomes
    related to birth drugs, Volmanen et al.31 reported that
    67% of the mothers who had labored with epidural
    analgesia and 29% of the mothers who labored without
    epidural analgesia reported partial breastfeeding or formula
    feeding at 12 weeks (P _ .003). Henderson et al.32
    investigated the effect of intrapartum epidural analgesia
    on breastfeeding duration and reported that epidural analgesia but not narcotic analgesia was significantly
    associated with reduced breastfeeding duration (adjusted
    hazard ratio, 1.44; 95% CI, 1.04 –1.99). Torvaldsen
    et al.33 investigated the effects of epidural analgesia on
    breastfeeding initiation and continuance to 24 weeks in
    the Australian Capital Region, where breastfeeding initiation
    exceeds 90%. They reported that intrapartum
    analgesia and type of birth were associated with partial
    breastfeeding and breastfeeding difficulties in the first
    postpartum week (P _ .0001). Analgesia, maternal age
    and education were associated with breastfeeding cessation
    in the first 24 weeks (P _ .0001), with women who
    had epidurals being more likely to stop breastfeeding
    than women who used non-pharmacological methods of
    pain relief (adjusted hazard ratio, 2.02; 95% CI, 1.53–
    2.67).
    Finally, the results of epidural anesthesia and operative
    vaginal birth may work together to further adversely
    affect breastfeeding. Fentanyl and bupivacaine decrease
    maternal pain, which decreases the production of maternal
    endorphins. This results in lower levels of maternally
    acquired endorphins in the newborn and possibly more
    pain in the newborn from any cause, including forceps or
    vacuum-induced injuries. Colostrum has twice the
    amount of beta-endorphin as mother’s blood, and these
    levels remain elevated for at least 10 days.34 However,
    elective cesarean section without labor and some epidural
    drugs significantly lower milk endorphin levels.34
    Therefore, the infant who is exposed to these labor
    interventions may experience higher than usual pain, will
    definitely be less likely to suck well, more likely to be
    separated, and less able to access the analgesic effects of
    skin-to-skin contact and breastfeeding.35 Furthermore,
    even if the newborn remains with the mother and can
    suck, the milk of women who have elective cesarean
    sections is less “pain relieving” than the milk of women
    who give birth vaginally. “

    5. Jordan S, Emery S, Bradshaw C, Watkins A, Friswell W.
    The impact of intrapartum analgesia on infant feeding. BJOG
    2005;112:927–34.
    20. Loftus JR, Hill H, Cohen SE. Placental transfer and neonatal
    effects of epidural sufentanil and fentanyl administered with bupivacaine
    During labor. Anesthesiology 1995;83:300–8.
    21. Hale TW. Medications and mother’s milk, 2006. Amarillo,
    TX: Hale Publishing; 2006.
    22. Aarts C, Hornell A, Kylberg E, Hofvander Y, Gebre-Medhin
    M. Breastfeeding patterns in relation to thumb sucking and pacifier
    use. Pediatrics 1999;104:e50.
    23. Sepkoski CM, Lester BM, Ostheimer GW, Brazelton TB.
    The effects of maternal epidural anesthesia on neonatal behavior
    during the first month. Dev Med Child Neurol 1992;34:1072– 80.
    24. Poore M, Foster JC. Epidural and no epidural anesthesia:
    Differences between mothers and their experience of birth. Birth
    1985;12:205–12.
    25. Lieberman E, Davidson K, Lee-Parritz A, Shearer E.
    Changes in fetal position during labor and their association with
    epidural analgesia. Obstet Gynecol 2005;105(5 Pt 1):974–82.
    26. Cotterman KJ. Reverse pressure softening: A simple tool to
    prepare areola for easier latching during engorgement. J Hum Lact
    2004;20:227–37.
    27. Snowden HM, Renfrew MJ, Woolridge MW. Treatments for
    breast engorgement during lactation. Cochrane Database Syst Rev
    2001;2:CD000046.
    28. Ramsay DT, Kent JC, Owens RA, Hartmann PE. Ultrasound
    imaging of milk ejection in the breast of lactating women. Pediatrics
    2004;113:361–7.
    29. Dewey KG, Nommsen-Rivers LA, Heinig MJ, Cohen RJ.
    Risk factors for suboptimal infant breastfeeding behavior, delayed
    onset of lactation, and excess neonatal weight loss. Pediatrics
    2003;112(3 Pt 1):607–19.
    of labor epidural anesthesia on breast-feeding of healthy full-term
    newborns delivered vaginally. J Am Board Fam Pract 2003;16:
    7–13.
    31. Volmanen P, Valanne J, Alahuhta S. Breast-feeding problems
    after epidural analgesia for labour: A retrospective cohort
    study of pain, obstetrical procedures and breast-feeding practices.
    Int J Obstet Anesth 2004;13:25–9.
    32. Henderson JJ, Dickinson JE, Evans SF, McDonald SJ, Paech
    MJ. Impact of intrapartum epidural analgesia on breast-feeding
    duration. Aust N Z J Obstet Gynaecol 2003;43:372–7.
    33. Torvaldsen S, Roberts CL, Simpson JM, Thompson JF,
    Ellwood DA. Intrapartum epidural analgesia and breastfeeding: a
    prospective cohort study. Int Breastfeed J 2006;1:24.
    34. Zanardo V, Nicolussi S, Carlo G, Marzari F, Faggian D,
    Favaro F, et al. Beta endorphin concentrations in human milk.
    J Pediatr Gastroenterol Nutr 2001;33:160–4.
    35. Gray L, Miller LW, Philipp BL, Blass EM. Breastfeeding is
    analgesic in healthy newborns. Pediatrics 2002;109:590 –3.

  19. June 24th, 2011 at 18:33 | #19

    Nicholas Fogelson, MD :
    @sasha
    Sasha -
    Please try to find the actual data that shows that epidurals have a measurable negative effect on mothers and babies. Such data is talked about a lot, but I’ve never seen it in any obstetrics journal. The reality is that there are no prospective randomized trials of epidural or no epidural, so such ‘data’ is actually either a fabricated idea or retrospective analyses fraught with bias.
    To answer your question specifically, no I don’t think there is any harm in getting an epidural.

    Back in February, I wrote “Straight Talk on Epidurals for Labor” for S&S: http://www.scienceandsensibility.org/?p=2215#comments There is a link to a page with its sources at the bottom of the post. One of them is a Cochrane Database systematic review http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD000331/frame.html, which includes 21 randomized controlled trials of planned epidural versus nonepidural pain relief. The large degree of crossover in most of the trials (women assigned to nonepidural group received an epidural) diminishes differences between groups, but even so, chief among harms, epidurals were found to increase likelihood of instrumental vaginal delivery. This is problematic because instrumental vaginal delivery increases risk of anal sphincter injury, especially in the U.S. and Canada, where median episiotomy (cutting straight towards the anus) is the norm. Nor is it true that 1) only randomized controlled trials produce valid evidence or 2) randomized controlled trials are free of bias. As Drs. Jadad and Enkin, experts in evidence-based medicine and authors of *Randomized Controlled Trials: Questions, Answers and Musings* wrote:

    “We believe that the . . . tendency to place RCTs at the top of the evidence hierarchy is fundamentally wrong. Indeed, we consider the very concept of a hierarchy of evidence to be misguided and superficial. There is no ‘best evidence’, except in reference to particular types of problem, in particular contexts.”

    And so long as human beings determine what research questions get asked, what comparisons are made, what outcomes are considered important, how results are interpreted, and what implications are seen, bias cannot be eliminated from any study, RCTs included. Indeed, what we often see with medical model research is what Phil Hall, an obstetrician as witty as he was wise (may he rest in peace) called “decision-based evidence making.”

  20. June 25th, 2011 at 15:22 | #20

    Henci – there’s no doubt that one can produce a valid retrospective trial, but there is far more opportunity to create systemic bias. Randomized trials can also be biased, but its much more difficult, and usually its a result of inadequate power. The huge bias in these retrospective trials is, as I mentioned in my original post, is the selection bias of the women themselves. Some of the quoted references seem to try to control for this, others don’t.

    Patients that desire epidurals want them because they don’t want pain in labor. Whether or not there is a small impact on breastfeeding is pretty irrelevant. Women who want to breastfeed will breastfeed will do so, and those that don’t won’t. If a mother got some fentanyl, close enough to delivery, the of course the baby will have some fentanyl in its bloodstream and might be a little more drowsy because of it. But in the end, the fentanyl will be gone in an hour or less, so its pretty hard to peg long term breastfeeding success on this.

    My concern for breastfeeding success is not about epidurals at all. Its about whether or not hospitals and pediatricians are going to do the things that make breastfeeding success likely. For example, in my hospital I see actual lactation consultants recommend that infants be supplemented with formula while milk is coming in, which seems pretty destructive to breastfeeding. This seems supported by pediatrics as well. Issues like this seem a far greater concern that an epidural, which clearly has a substantial benefit for the woman.

  21. June 25th, 2011 at 15:33 | #21

    I want to make it clear about something. I really don’t think epidural have a substantial effect on breastfeeding, but more importantly, I absolutely don’t care.

    I do not buy in to this ridiculous idea that there is something good about experiencing pain. I have worked with over a thousand women delivering their infants, and most of them wanted to have epidurals. They wanted them because they were in pain. I am absolutely stunned how the natural birth community wants to talk all about the perceived evils of epidurals, and to continuously deprecate the benefit of pain relief from what is likely to be the most painful experience of a woman’s life. Its just stunning to me.

    If a woman is of the mindset that she wants a natural birth without pharmacologic pain control, then it is very likely that she is going to be breastfeeding. But if she is not of the mindset, the idea that an epidural could theoretically have some small negative impact on breastfeeding success is really not going to suddenly make her refuse pain control.

    A lot of folks have success with various techniques of isolating themselves from the pain of labor, or perhaps welcoming it, or whatever words one wants to use. To me it seems that women who are able to experience the pain of labor without fearing that pain seem to do great. But a lot of women can’t do that, or haven’t been trained to do so, or just have no interest in enduring anything. And those women need pain control to avoid an absolutely miserable experience. I have seen plenty of women who wanted epidurals but for some reason couldn’t have one, and believe me they found labor to be a traumatic experience that they remember negatively.

  22. June 25th, 2011 at 16:17 | #22

    Okay, this comment rocks. @SF Mom & Psychologist

  23. avatar
    Anda
    June 26th, 2011 at 10:40 | #23

    Purely anecdotal evidence, but I had an epidural, it was GREAT (no pain and I managed to sleep a bit, so when it was time to push, I totally had the energy to do it) AND right now, TWO YEARS after the birth I’m STILL breastfeeding.

  24. avatar
    Kristy
    June 27th, 2011 at 11:36 | #24

    Coming in late, but here’s my beef:

    I don’t care if you want an epidural.
    I don’t care if you DON’T want an epidural.

    I honestly, truly, deep-down believe that each woman should have the choice available to them that they want, and I won’t even cloak it with a back-handed “as long as they are well-informed.”

    My beef? Any woman walking into a “mainstream” hospital today will be 100% supported in her choice to have an epidural. Not ONE person will discourage her, nor will they put protocols/actions/tasks in place such that they inhibit her choice to have an epidural. This is NOT the case with a woman who wants to try to avoid an epidural. The woman who wants to avoid an epidural is faced with skepticism at best, and protocols that actively disrupt her ability to cope with the pain with out an epidural. If I see one more woman forced out of the shower whilst coping beautifully there to get “on the monitor” (where a doppler reading for several minutes would MORE than suffice), and watch her lose her coping mechanism as a result, I am going to scream (figuratively speaking, of course).

    You won’t hear me (or, quite honestly, a big contingent of “natural childbirth advocates”) try to prove an epidural is an evil. Honestly, I think it is a welcome tool when a mom wants it. But, gosh darn it, why not give ALL moms appropriate support for their choices. Period.

  25. avatar
    Walker Karraa, MFA, MA, CD
    June 27th, 2011 at 11:37 | #25

    Wow! Walking epidurals really exist???? I have worked in over twenty hospitals here in Los Angeles where that theory remains just that—theoretical and not practiced. The stringent liability protocol policies for private and public hospitals here prohibit any movement out of bed period once a woman has had any form of epidural, bolus, non-bolus, doesn’t matter. Once she makes that choice, she is in bed, with a Foley. Even the high-profile clients I have had who pay for the four-poster mission-style birth suite at Cedars are still in the bed with a cath after the epidural. I would love to hear how you accomplish this in your practice. What does that look like? And is the current position paper of the ASA on board with this? Very interesting. @Gilbert J Grant MD

  26. avatar
    Walker Karraa, MFA, MA, CD
    June 27th, 2011 at 11:41 | #26

    You are referring to the combined spinal epidural yes? While range of movement in bed is greater, do your patients actually walk around?

  27. avatar
    Gilbert J. Grant, MD
    June 27th, 2011 at 12:36 | #27

    @Walker Karraa, MFA, MA, CD
    Thank you for your comments. “Walking epidurals” are actually a misnomer, because the ability to walk can be achieved with a spinal, with an epdiral, or with a combined spinal-epidural. It’s simply a matter of the dose of medication that is used. Most women prefer to relax in bed after receiving pain relief, but if they do want to walk, they are allowed to, assuming they are able to perform a deep-knee bend at the bedside. Most women receiving a “walking epidural” dose are able to do so. But, in practie, the only place most of them walk is to the bathroom. Which is a very nice thing, unless they prefer to use a bed pan. If their obstetrician agrees, they could walk around the halls as well, but this is a rarity in my hopsital. What’s the point, anyway? Walking doesn’t do anything to speed labor along (in spite of the myths to the contratry). The main advantage of the “walking epdidural” is to allow women to postion themselves comfortably for delivery. For example, to have the ability to squat if they so desire for delivery. And to feel the pressure of the descending baby without the pain. It’s a beautiful thing. By the way, we routinely use a walking epidural AFTER delievery for women who have had cesareans or traumatic vaginal deliveries. These new moms walk all over the place – the dose is even lower than the dose we use in labor, but it works to releive their pain – so they are alert and pain free – and in great shape to nurse and bond with their newborns.

  28. avatar
    Ex-Granola Girl
    June 27th, 2011 at 13:46 | #28

    Nicholas Fogelson, MD :

    A lot of folks have success with various techniques of isolating themselves from the pain of labor, or perhaps welcoming it, or whatever words one wants to use. To me it seems that women who are able to experience the pain of labor without fearing that pain seem to do great. But a lot of women can’t do that, or haven’t been trained to do so, or just have no interest in enduring anything. And those women need pain control to avoid an absolutely miserable experience. I have seen plenty of women who wanted epidurals but for some reason couldn’t have one, and believe me they found labor to be a traumatic experience that they remember negatively.

    Trust me, there are plenty of us who “trained” for a natural birth and still found it traumatic, Dr. Fogelson. My thought, immediately after delivering the placenta, was “Geez, that hurt like hell, and anyone could have done it if they had to. Where’s the rush? The endorphins? Why the heck are people scamming others into going through that with no epidural?!”

  29. avatar
    SF Mom & Psychologist
    June 27th, 2011 at 15:48 | #29

    Jackie – Perhaps I misunderstood your intended meaning, and I apologize. I can’t be totally certain that I did, as your reply is long and nuanced, and I think I may be missing your point. However, I STRONGLY encourage you and other representatives of the NCB movement to pause, absorb the feedback I am giving you, and reflect.

    Whether or not you (and plenty of others, don’t worry) *intended* to make me (and plenty of others) feel patronized and scored is irrelevant. The fact is that you DID make me feel that way. So much of the dialogue present around NCB has that effect on mr. Your (collective) intentions may be beautiful, but the message and its delivery have insulted me, scared me and alienated me from your movement. Consider my posting like customer service feedback or content from a marketing focus group. Quotation marks, inferences that I am uninformed or unprepared and scare tactics send me running as far away from NCB propaganda as I can get.

    In my community, the NCB folks are far more dogmatic, far more closed-minded about options and far more divisive than the traditional medical community. You can explain away your comments and reject my feelings, or you can reflect on how your words make some women feel.

  30. avatar
    Gilbert J. Grant, MD
    June 27th, 2011 at 16:40 | #30

    @Ex-Granola Girl
    You’ve identified one of the key fallacies of the natural childbirth movement. The teaching is that it’s “natural,” so it shouldn’t hurt, it’s “natural,” so it’s inherently safe, and pain relieving medication are “un-natural,” so should be avoided at all costs becaue they’ll just mess everything up. Well, here in the real world, natural isn’t always the best. I mean, it’s natural for a lion to use it’s massive jaws and teeth to rip up and devour a sheep. Does that make “natural” good for the sheep? I dn’t think so. And it’s “natural” for the muscle of the uterus to hurt like heck during a contraction, when the blood is squeezed out of it. But is that good for the owner of the uterus? I don’t think so. And it’s “natural” for some women, who’ve experienced an excruciating unmedicated labor and delivery, to suffer serious psychiatric sequelea as a result of being exposed to that trauma. But is that good for the new mom or her newbaby? Again, I don’t think so. Look, if someone truly is presented with all the data and chooses to forego pain relief, understanding the potential consequences of so doing, that’s her right, of course. Everyone should choose their own course. The problem is that everything “natural” is presented as good and safe, and the fact of the matter is: that’s far from the truth.

  31. avatar
    Walker Karraa, MFA, MA, CD
    June 27th, 2011 at 18:06 | #31

    For another perspective on the use of the word “natural” regarding women’s reproductive life spans, I highly recommend the work of eco-feminists (Maria Lugones, Carolyn Merchant, and Val Plumwood). Unpacking this from a postpositivist paradigm is useful to me–plain and simple, we are all caught in some pretty heavy dualistic thinking about the word “nature”.

    Unintentionally, (at least for the most part)we are create lots of firm boundaries around our words, and their meanings—with the intention to radically separate ourselves from “other”. Black and white, Cartesian thinking has NEVER served women well, has it?

    Herles (2000) noted: “Various concepts of ‘nature’ are heavily laden with normative assumptions, and such conceptions have the potential to be used as mechanisms for control or to justify oppression” (p. 114).

    Tethering our selves to a word used to represent purity (or closeness to God), or wilderness (not civilized) is part of a fallacy. And context is important, as Dick-Read was a non-board certified, white, Christian, conservative, highly religious man who had his epiphany while watching a poor woman labor. He also manufactured a line of maternity lingerie with snaps and such. His work is about his view of the religious role of women in birth. Nature was not discussed; God sure was. And any movement away from birthing as God intended, was considered neurotic (another lovely word of the zietgeist of the early part of the century).

    So this neurotic, hysterical, unnatural, mother-earth, wild-woman, wants to give the word “nature” back. Can’t we come up with something better?

  32. avatar
    Walker Karraa, MFA, MA, CD
    June 27th, 2011 at 18:08 | #32

    sorry…forgot the citation, how un-natural:
    Herles, C. (2000). Muddying the waters does not have to entail erosion: Ecological feminist concerns with purity Internatioal Journal of Sexuality and Gender Studies, 5(2): 109-123.

  33. June 28th, 2011 at 08:03 | #33

    @ Dr. Grant: I think it is important here to step back and look at reality: very few advocates of normal birth tell their students that childbirth doesn’t hurt. I know I certainly don’t. It is simply unfair of you to make this unsupported assertion. For anyone choosing to disseminate this inaccurate idea of CE classes, I urge you to sign up for and attend at least three different courses–all the way through–taught by different instructors, certified through different organizations. (Having attended classes led by not only Lamaze certified instructors, but ICEA and Bradley instructors as well, I can tell you there are differences in curricula, but all of those classes I have attended discussed both pharmacological and non-pharma methods of pain relief/coping.)

    The purpose of spending several class sessions discussing pain coping methods is because we acknowledge that uterine contractions, cervical dilation, the stretching of the perineum…do, in fact, hurt. (Sit down and really engage with postpartum women, and they will describe the sensations using different words like, “pain,” “pressure,” “burning,” “twinges,” “excruciating,” etc. For each woman, her perceived experience–as well as her coping mechanisms–are unique.) Are there some women out there who, following the births of their babies, describe their experience as something other than “painful?” Yep, you bet. (Thus, the crux of the film Orgasmic Birth.) Are there others who end up feeling traumatized by a particularly difficult and painful experience? ‘Yes’ to that too. That’s the point of covering all pain-relieving options in childbirth preparation classes–so women will know all their options and be able to choose aptly when the time comes.

    Are the medications delivered via the epidural “unnatural?” Of course they are. Does that make them universally “bad?” No. I am meeting you in the middle here, by acknowledging that there are times in which this method of pain relief is not only warranted, but likely the best choice. But, in using your lion and lamb metaphor…would it be 100% a good thing for the lion to NEVER kill another animal for food? No–that would result in the extinction of the lion. Same goes for the sheep: if every single sheep were wiped out by a predator, that would result in the loss of another species, and the resultant imbalance of the food chain, as it were. Similarly, it is not appropriate to say “all epidurals are bad,” or “natural childbirth is the ONLY way to birth.” Those conclusions are neither realistic, nor factual.

    Until normal birth advocates, non-medical and medical birth, and maternity care professionals can actually meet in the middle during these debates, the pregnant and laboring woman will remain in the middle of a philosophical tug-of-war, not knowing who to trust.

  34. June 28th, 2011 at 15:59 | #34

    This reply is brilliant. And so well written. You are an advocate for all advocates. Here is to middle ground!@Kimmelin Hull

  35. June 28th, 2011 at 18:48 | #35

    @Kimmelin Hull
    “I think it is important here to step back and look at reality: very few advocates of normal birth tell their students that childbirth doesn’t hurt. I know I certainly don’t. It is simply unfair of you to make this unsupported assertion.”
    Ms. Hull, believe me, I am all for living in reality. So please allow me to describe the reality that I see every day in the labor room: I see many, many women who are surprised by how much labor hurts, because the pain of labor is typically downplayed by the teachers of their Lamaze classes. Not every teacher, mind you, and not every mother-to-be either. But it is the reality that childbirth educators tend to downplay the severity of the pain of labor and delivery. The result? Many women needlessly experience pain. Of course this does not apply to those women who would prefer to experience the pain and who would not desire an epidural or spinal regardless of the severity of their pain. I am speaking about those women who would like pharmacologic pain relief, but delay it because of unrealistic expectations. Grantly Dick-Read, the forerunner of Lamaze was an interesting guy, to say the least. One of the foundations of his work is that normal labor does not hurt. It is only western women, he stated, who anticipate that labor will hurt, who have pain. He stated that “primitive” women don’t experience pain during the course of normal labor. As a scientist, I find these claims bizarre. As a human, I find them racist. But this is the key underpinning of natural childbirth. I am happy to hear that you teach that childbirth hurts. But I stand by my assertion. It is supported by nearly 30 years of caring for women having babies. Many childbirth instructors significantly downplay a basic fact: for most women, childbirth hurts like heck.

  36. avatar
    Walker Karraa, MFA, MA, CD
    June 28th, 2011 at 19:24 | #36

    Dear Dr. Grant,
    Wow. You, as they say to women who dig their heels in, are “passionate.” Please note that the ties between Grantly Dick-Read (now there’s a name for you) and Lamaze are circumstantial, at best. I refer you to a wonderful (2011) book, “Get Me Out:History of birth from the garden of eden to the sperm bank” by medical journalist Randi Hutter Epstein, MD. http://www.amazon.com/Get-Me-Out-History-Childbirth/dp/0393064581 A brilliantly unbiased, and accurate assessment of the natural birth movement. BTW, Lamaze founder Elizabeth Bing originally wanted to call natural birth ‘prepared birth,’ I wonder how different these conversations would be had it stuck. @Gilbert J Grant MD

  37. avatar
    Gilbert J. Grant, MD
    June 28th, 2011 at 21:39 | #37

    Thank you. The reason I mentioned Dick-Read is because Ms. Hull quoted him on a sister blog here, along with his “fear-tension-pain” claim. In my humble opinion, I don’t think that Dick-Read’s whacko theories have a place in a reasoned discourse. I had the pleasure of meeting Dr. Epstein last year at a lecture she gave about her book. Just to be clear, I am all in favor of preparaton, and I am a firm believer that every woman should make an informed decision about what type of delivery and pain relief (if any) she desires. If that choice doesn’t involve an epidural – great! Whatever floats your boat. The problem, which I have observed consistently, is that far too many women go into labor with a less than optimal understanding of the facts. And this leads to considerable unecessary pain and suffering. By the way, if you’re interested, here is an excellent book by Dr. Donald Caton about the history of pain relief for childbirth: http://www.amazon.com/What-Blessing-She-Had-Chloroform/dp/0300075979/ref=sr_1_1?ie=UTF8&qid=1309313859&sr=8-1

  38. avatar
    SF Mom & Psychologist
    July 1st, 2011 at 15:49 | #38

    To Kimmelin Hull: I appreciate your middle ground. Why is it so hard to find in the NCB community? I don’t know any doctors who actively discourage natural childbirth, as long as those doctors can still practice evidence-based, safe medicine. (Some insensitive doctors/nurses may roll their eyes or make snide remarks, yet in my opinion, they are not communicating a message that it is a tragedy or bad outcome to birth naturally as long as mom and baby are safe).

    Yet I know dozens of childbirth professionals and women who consider medical pain relief to be a “failure.” Births that involve medical pain relief are absolutely considered sub-par outcomes in my socio-economic circles, and there is frequent insinuation that a mother was poorly prepared, uneducated about how to manage pain naturally, or abused by her doctors if she chooses an epidural. The middle ground you communicate above is a healthy, balanced perspective. Shout it from the rooftops, please! Stop making us moderate women drag it out of you. I think you would dramatically increase your following if such balanced views were easier to come by.

  39. avatar
    Dreamy
    July 1st, 2011 at 23:07 | #39

    I don’t know any doctors who actively discourage natural childbirth, as long as those doctors can still practice evidence-based, safe medicine.

    Huh. I know quite a few who actively and passive-aggressively discourage it, believing it’s pretty much always in conflict with “safe medicine”– though that perspective is, of course, wrongheaded and very much not evidence-based. Even most of those doctors would agree natural birth is not unsafe in theory, but in practice, natural birth and most of its tenets are, yes, actively discouraged by many doctors IME.

  40. avatar
    Dreamy
    July 1st, 2011 at 23:25 | #40

    And I hear more women saying they were made to feel like failures by “NCB advocates” than NCB advocates actually calling women failures (directly or indirectly). I am not suggesting that women who feel scorned are lying or anything of the sort… However, I do think this is a bit like the whole “breast is best” phenomenon… Something much better-articulated by folks other than myself. That is– and this seems especially among Americans– that there are so many harmful effects of pedestalizing something that “should” be considered normal and standard, and not “best.”

    By which I mean… “Natural is best” is generally agreed-upon as an axiom. We’re supposed to think, “Well, of course, if you can do it without an epidural, that’s best…” but hey, we all eat fast food sometimes, we don’t floss as often as we should, we’re only human and cannot always (or even often) do “what is BEST”… Therefore, by setting up “natural-as-best” (which I don’t think began with NCB advocates, if you follow me), we as a society set up “epidurals-and-highly-medicalized-birth-as-standard” (or “average”). So women who have a lot of interventions– particularly epidurals, as that is by far the mainstream focus (relatively few women consider Pitocin-or-no-Pitocin around the water cooler)– are both normal and “not doing what is best” and should feel shamed for it. Kinda like women who are 20 pounds “overweight”– totally typical, completely average in the US, yet somehow they’ve “failed.” And on the other hand, women who do give birth without epidurals and/or a lot of medical intervention are not supported, because they are kind of… Getting ahead of their stations, are they not? They are trying to be “perfect” by doing what is “best”– when we “all know” that we can’t be Martha Stewart or whomever. So just by being, they are kind of “rubbing it in.”

    In fact, their most grievous offense is when they show up in any appreciable numbers and say things like, “it wasn’t a big deal– if I can do it, anyone can do it” (not at all strictly true)– or even “if more women had the support, most of them who wanted to could do it” (probably true). Because saying those things threatens the idea that “NCB” is “best”– which means that highly-medicalized birth (when not necessary) becomes sub-par. We can’t believe that 95% of women are getting sub-par treatment in some respect, so it actually serves those who defend non-evidence-based obstetrics for normal birth to at least give lip service to the idea that “NCB is best (but…)”

    In fact, most NCB advocates I know want to see it normalized, NOT put on a pedestal. They DON’T want women to get extra praise for it (which in reality, doesn’t happen much, for the reasons outlined above). They want it to be a realistic, truly supported option– perhaps even the standard– for all those women for whom it’s practical. The whole “NCB is best/ideal/special/deserving of praise” thing– like “breast is best”– is about 90% undermining lip service that serves no one.

  41. July 7th, 2011 at 18:02 | #41

    @Kimmelin Hull

    I don’t think the sheep cares about what happens to the lion.

  42. avatar
    SF Mom & Psychologist
    July 8th, 2011 at 16:11 | #42

    To Dreamy: How about this? I will accept your perspective that doctors actively or passively-aggressively discourage natural birthers. It has never been my experience, but I can accept that it is others’.

    But will you please, please accept my perspective that a lot of natural birthers and their propaganda (books, web sites, seminars, classes, etc.) make women who had other-than “normal” (e.g. natural) births feel like they failed or got cheated or abused? I will happily give you a dozen examples if you want them – just shout out. (Otherwise, I’ll spare everyone a long post.) They are real examples of NCBers expressing values, judgment, and approval/disapproval of just how birth happens. And perhaps you and the other naturally inclined folks here could listen and reflect on how your movement communicates its values without deciding that I just have an inferiority complex.

    I’ll do it for you – will you do it for me?

  43. avatar
    Jacqueline Levine
    July 10th, 2011 at 22:39 | #43

    To SF Mom, the Psychologist: I certainly accept your apology. And I apologize for getting back to your comment so tardily…I had a busy couple of weeks with 8 new moms… half of whom had epidural anesthesia. And as for your not being sure that you have indeed gotten my point,let me state it unequivocally: none of the 4 mothers that I was with these last two weeks who had epidurals were told of all of the side effects.
    Some were told of a few, 1 was told of 2. Epidural drugs affect the mother, her temperature, her blood pressure, and other physiological aspects; it affects her fetus as well, whether or not the studies are all done or will never be done. I’ll gladly stack up all the good studies I’ve read that really try to establish some facts against anyone who says there just aren’t any effects on the baby. The mothers who had epidurals had them for pain relief…simple as that, and back to the beginning, the effects on their babies were never mentioned. Not once. I don’t know if it would have affected their decisions, but that’s indeed my point. They didn’t know, and since there are many studies that point to some effects on babies, it is important that they be given the info. That’s it. That’s all. Ask Dr. Fogelson how long it takes for studies to mount and finally change practices. Ask him how long it took for medical schools to stop teaching routine episiotomy…snipping for all perineums…30 years? And how he looked back on all those years and saw the harm that was done before anyone even studied the effects of episiotomy. And ask about his wonderful push to get DCC to be “the standard of obstetric care”. That’s my point. Nothing to do with NCB…nothing to do with insulting you or anyone else,just hoping that evidence-based care is available to all along with the info to help mothers-to-be to make informed decisions. There’s enough info at this point to mention the possible effects of epidurals on babies. I mentioned just 2 in my first response to you. If mothers are never informed, we are all poorer in the end. I have never said anything about NCB, nor have I denigrated those using epidurals. I understand epidurals are about pain. But their practitioners should be about informing mothers as well as dispensing pain relief. That is my only point. And sometimes, believe it or not, epidurals don’t work. That’s true info about them as well and should be told. We are all on the same side here. We’re the ones who have the babies, and some of us need support and some of us don’t and some need to experience labor in a physical way and some need to be insulated from that physicality. As a mother and grandmother, labor and breastfeeding person, I respect the choice each mother makes, and when she makes her choice from an informed position, she is more powerful and happier in the end. That was and still is the only point I’ve have tried to make. Perhaps I have succeeded?

  44. July 12th, 2011 at 11:31 | #44

    @Nicholas Fogelson, MD
    No, but the overall biological structure does. Ever read Barbara Kingsolver’s Prodigal Summer? Although presented in a novel, it is based on Kingsolver’s work as a biologist and naturalist–depicting the finicky balance of predation and what happens when one actor in that balance is removed (as you can guess,the ensuing alteration of the food chain unfolds far beyond the single element that is altered).

    Going back to the lion/lamb analogy in terms of epidural use: this is not just about two factors: do or don’t use an epidural for pain relief. It is not just about the physical effects on the mom and baby at that one point in time. It is about the down-hill effects that can result whether it is impact on breastfeeding (I know you’ve said you “don’t care” whether or not epidurals affect breastfeeding, but for the women struggling to get bf’ing to work with their newborns…I can guarantee you, THEY CARE), maternal-infant interaction in the hours post-birth, or in the epigenetics which we are now just beginning to understand. Similar to the lion/lamb analogy or the predator/prey system, we must always be willing to look at the macroscopic impact of our microscopic choices.

  45. July 12th, 2011 at 11:35 | #45

    @SF Mom & Psychologist
    If you go back through the past year on this blog, you will find my “middle ground” perspective is repeated. It has not been singularly “dragged out of me” via this one conversation.

  46. avatar
    Dreamy
    July 12th, 2011 at 14:34 | #46

    SF Mom & Psychologist :
    To Dreamy: How about this? I will accept your perspective that doctors actively or passively-aggressively discourage natural birthers. It has never been my experience, but I can accept that it is others’.
    But will you please, please accept my perspective that a lot of natural birthers and their propaganda (books, web sites, seminars, classes, etc.) make women who had other-than “normal” (e.g. natural) births feel like they failed or got cheated or abused? I will happily give you a dozen examples if you want them – just shout out. (Otherwise, I’ll spare everyone a long post.) They are real examples of NCBers expressing values, judgment, and approval/disapproval of just how birth happens. And perhaps you and the other naturally inclined folks here could listen and reflect on how your movement communicates its values without deciding that I just have an inferiority complex.
    I’ll do it for you – will you do it for me?

    I don’t think you have an inferiority complex. Well, no more than any of us do, being part of a class that is systematically oppressed (women, et al.). That was definitely a big chunk of my point about unproductive pedestalizing and denigrating on all “sides.”

    And you don’t need to provide me with any examples of “NCB-supportive” women “behaving badly”– I’ve witnessed it and I threw out a couple of my own (if mild) examples in my post. There are many worse examples– which I personally jump to correct or argue with. You have a group of subjugated people, part of what you get is the crabs-in-a-barrel phenomenon. You know the metaphor– how one crab tries to escape, and the others pull it down with them?

    All of that is rather my point.

    It’s not at all hard to find a dozen examples of loud, extreme voices on the “natural” “side.” A dozen? I could dig up 100. That doesn’t mean they represent the majority– certainly, by their volume, they take up more “space” than they have a right to*. But they absolutely exist. Indisputably.

    But then– they exist in every movement. In any group of people at all. Extremists, crackpots, the ignorant– some clearly extreme, some just extreme enough to be dangerous.

    It’s using those people to paint the movement that is also a problem, IMO. That’s typical as well– pointing out the fringe, the mistaken, those with twisted personal agendas… and saying “If only you’d shut that part of your ‘movement’ up, maybe we’d listen to you.” A bit of the “tone argument,” as it were, and generally– to be blunt– a lie. And an impossible to implement request in any event.

    Even portraying it as a cohesive “movement,” with specific characteristics and types– rather than just a shared common-sense desire for evidence-based care– is a sort of a defensive tactic used by folks with stakes in established standards of care. And not necessarily maliciously– it’s generally just avoidance of cognitive dissonance IMO.

    Telling people how they “really” feel is BS. Pushing an extreme and unsupportable agenda is BS. That occurs on all “sides.”

    What is also BS is ignoring the well-thought-out arguments (whether ultimately “right” or not) that generally make up the majority thrust of a movement. What is BS is ignoring them in favor of the more entertaining and viscerally satisfying crabs-in-a-barrel model of focusing on extremes and painting the other side as extremists in order to maintain a precious worldview.

    I’m not for that. Why? It doesn’t advance my cause, which I believe is quite worthy.

    That’s why I interject– to give just one example– nearly every time someone makes a crack about doctors paying for their BMWs with all the dough they rake in with C-Sections. Not only are OBs rarely that callous and calculating– not only is it unfair to suggest that– but when you don’t understand the real motivations of the other “side,” how can you address the issue? How can you solve what you believe is the problem? And how can you gain support when your fallacious argument is so easily knocked down?

    I’m not saying I never get snarky, sarcastic, whatever. But the painting of women who support more evidence-based care– INCLUDING “non-natural” options, etc.– as extremists, freaks, judgmental hypocrites, etc… Well, it’s not very evidence-based.

    *I will say, too– and this exists on all sides of every argument– that sometimes people who share a common philosophy will “shorthand” ideas and this shorthand can be taken to mean something much more extreme than it is meant to. This is especially true when, even if loaded with disclaimers, the idea may already sound “extreme” to the mainstream. Of course, there are plenty enough examples of people who are not using shorthand when they make seemingly extreme statements, too, and it’s not like one can always tell the difference as a 3rd party anyway.

  47. October 15th, 2014 at 08:46 | #47

    How about an update on this article? Any more recent research? Pretty sure I saw something new in the past year.

  1. July 3rd, 2011 at 12:29 | #1
  2. August 11th, 2011 at 11:37 | #2
  3. November 17th, 2011 at 12:42 | #3
  4. January 24th, 2012 at 20:07 | #4
  5. August 10th, 2012 at 17:15 | #5