Sunday, November 22, 2009

Do Epidurals Affect the Baby?

In class last week, I had a couple express surprise when I said that all drugs get to the baby, including epidurals. They have friends that are doctors that have said otherwise. I have spent the week looking up several articles and resources, and, my friends, epidurals indeed adversely affect the baby. I do not want to make this an overwhelming post, so I will touch on the highlights of how the babies are affected.

First, it is important to note that the "older" studies with very significant data were largely done by pediatricians. The newer studies, found to not be nearly as complex, have been done by anesthesiologists. Obviously, there is a conflict of interest there!

There are a couple of problems that researchers have run into with these studies. The first is that so many women that have epidurals also have other "pain relieving" drugs in their bodies that also influence and affect the babies. This makes it difficult to assess the effects of just the epidural. In addition, epidurals have different drugs in them. Different anesthesiologists and/or hospitals will often use different drugs in their epidurals.

So many of the effects on the baby have to do with the effects on the mother from the epidural. I am not focusing on the effects for the mother in this post, however, but some of these effects on the mother is what creates a problem for the baby from the epidural. For example, maternal fever is very common and can cause complications for the babies. So is a drop in maternal blood pressure. This is why a woman will receive IV fluids before the epidural is administered -- it is a preventative measure.

Effects of the Epidural on the Baby

Epidurals can change the Fetal Heart Rate (FHR), indicating that the baby is lacking blood and oxygen. This will often occur in the first 30 minutes after an epidural is placed. Opiate drugs, common in spinals and epidurals, are the likely culprit. These changes in FHR will often resolve themselves if the mom is allowed to move a bit or change position. If the baby's heart rate does not bounce back, the woman may have a cesarean section.

The supine position (lying on your back), also contributes to changes in fetal heart rate. A woman with an epidural is mostly in this position, which can deprive the baby of oxygen, affecting the baby's brain. In my case, this is why I nearly had a c-section. I had the epidural, pitocin, etc., etc., and my baby's heart rate would not come up after contractions. Moving from side to side after each contraction is what helped his heart rate. Had I remained on my back, his heart rate would not have come back up, and I would have had surgery. Had my sister-in-law, a doula, not been there, I would have had a c-section. The nurses or doctors certainly weren't telling me what to do. They would have been happy to perform surgery, I have no doubt.

Babies that are born to mothers who developed a fever from the epidural in labor are more likely to have a low Apgar score -- poor muscle tone, require resuscitation (11.5% versus 3%), or have seizures in the newborn period. One of the most common problems from the maternal fever is that the doctors do not know if the fever was from an infection involving the uterus or from the epidural. They will typically do a sepsis, or evaluation, of the baby. This involves prolonged separation from the mother, invasive tests, and almost always, antibiotics until the test results are available. In a study of first-time mothers, 34% of epidural babies were given a sepsis evaluation, but only 9.8% of nonepidural babies underwent the evaluation.

It is important to note that a newborn's ability to process and get rid of drugs is much less than an adult's. It must also be considered that the drugs are often stored in the newborn's tissues such as the brain and liver where they are more slowly released. Epidural babies are more likely to have jaundice. The reasons are not entirely clear on this, but it is suspected that it is related to an increase in assisted delivery (forceps or vacuum extraction) or to the increase use of pitocin with epidurals.

Neurobehavioral Effects
Epidural babies have been found to have a depressed NBAS (Neonatal Behavioral Assessment Score, devised by pediatricians) Score at five days old, with difficulty "controlling their state." Babies that received pitocin as well as the epidural had even more depressed NBAS scores, as well as higher rates of jaundice. At one month of age, epidural mothers found their babies "less adaptable, more intense, and more bothersome in their behavior."

Other differences between epidural babies and unmedicated babies include: less alertness and ability to orient themselves. The epidural mothers typically spent less time with their babies while in the hospital, finding the more drugs they received, the less time they were with their baby.

In another study, researchers found that at three days old, epidural babies cried more easily and more often and aspects of this continued for the entire six weeks of the study. In the conclusion of this particular study, researchers expressed concern about "the importance of first encounters with a disorganized baby in shaping maternal expectations and interactive styles."

Finally, the effects of an epidural on breastfeeding must be addressed. The first hour is a critical time to establish breastfeeding and if a baby has poor muscle tone or sucking reflex, or mom is hemorrhaging (more likely with an epidural), breastfeeding may be put off until well past that hour. As I write this, I have mixed feelings. It is crucial that mothers understand the effects of their actions in choosing an epidural, but if something happens and for whatever reason you cannot breastfeed immediately, do not give up since you missed out on that first hour. Babies and moms can figure this out! With that being said, I will continue on the effects of the epidural on breastfeeding.

Oxytocin is a breastfeeding hormone. If a mom has been induced with pitocin, administered an epidural, had an instrumental delivery, etc., this hormone was not allowed to be present in its natural form. There were just too many disruptions. This can adversely affect how well breastfeeding gets started. If mom is tired, baby is still feeling the effects of the drugs and not sucking well, the nurses, and even the pediatrician, may be pushing formula on this baby. And then starts the vicious cycle of nipple confusion. The baby doesn't have to work to get milk from the bottle, and when he is put to the breast, gets frustrated. Mom gets frustrated and resorts to those stupid formula samples she's been receiving on her doorstep for months!

Epidural mothers are less likely to breastfeed exclusively compared to nonepidural mothers. Epidural mothers are more likely to report having "not enough milk."

It is unfortunate that doctors are leading people to believe that the epidural is safe for moms and babies and there are no risks. There are risks, not just to our health, but to how we parent our babies. The more attached you are, the better you will appreciate your baby. You will trust your body to breastfeed and your baby will be eager to nurse.

I'd like to end with a quote by musician, Ani DiFranco, talking about her unmedicated birth: "I'm really happy in the end that I felt every last bit of the pain, and was as present as I could be. Whenever you go through something terrifying and come out the other side, you grow and have more self-respect in terms of your own strengths. I wanted that more than I wanted whatever sort of numbing the hospital would have offered."

What's good for mom is good for baby. Just say NO to the epidural! You are strong and powerful. You can do this, just like millions of women before you have done this. Giving birth is giving life. You and your baby deserve the very best start down this new road. Surround yourself with positive people who believe in you and your abilities.

Thursday, November 19, 2009

Part II: Will a Mandate to Circumcise Newborns Reduce the Spread of HIV in the United States?

I am hoping that you read the last post about the Studies that this possible mandate is based. If not, I encourage you to do so.

I have thought about the statistics all week long. When I hear that circumcision lowers risk for HIV infection by 50-60%, I automatically think in crazy numbers. When worded that way, it leads the reader to think that only 40-50% of the circumcised males may contract the HIV virus. Or that the uncircumcised males have a 50-60% increased risk of contracting HIV.

I'd just like to point out again that this 50-60% rate that keeps getting thrown in our face is based on a HALF PERCENTAGE POINT. There were many factors involved that were not kept track of. The men received extensive counseling on the benefits of using condoms and approximately 98% of the men did not contract the HIV virus.

Circumcising Newborns:
This would be a "preventative" measure that we would not see the effects of for many years. The complication rate ranges from 20%-35% (based on those African studies!), and this must be considered when weighing benefits and risks.

Ironically, we have an HIV epidemic in the US now, and the majority of those males are circumcised. The use of condoms has been shown to reduce the spread of HIV, and there has been no evidence that being circumcised and wearing condoms is any better than just using condoms alone. We have twice as many HIV infected males in the US as does Europe and our circumcision rates are significantly higher. According to many medical organizations, including the American Academy of Pediatrics, in 2005, stated that the "data on the potential medical benefits of circumcision are not sufficient to recommend routine neonatal circumcision."

The way that HIV is transmitted in the US is so different from Africa, it is hard to even compare the two. We actually have an effective social program in place with education, safe-sex practices, and consistent condom use. These methods do not require surgery, are much more cost-effective, and they work! In fact, consistent condom use reduces the lifetime risk by 20% compared to only 8% for circumcision. A recent report from South Africa shows that condom use is increasing and the HIV rates are beginning to level off. There is no evidence that circumcision will aid in this progress.

Quite honestly, it is irresponsible for the CDC to even consider promoting an intervention that will create a false sense of security, while actually increasing the risk to women. Promoting circumcision will drain resources that should be put into safe-sex education and condom promotion.

Thursday, November 12, 2009

Part 1: Will Circumcision Prevent HIV?

Two steps forward, three steps back describes the direction circumcision is taking in the United States. We have seen the newborn circumcision rates gradually decrease over the years as parents have researched and discovered that there are benefits to keeping the foreskin intact. In many states, Medicaid, as well as many insurance companies, have stopped paying for circumcisions, declaring it "cosmetic" surgery. The American Academy of Pediatrics took the stand, essentially, to "leave it alone." Is all of this education and hard work about to be dismissed? The possibility is very real thanks to a couple of poorly-done studies. The CDC is said to have an official statement on mandatory circumcision for newborns by the end of this year.

Here's the fuss: The studies have concluded that circumcision reduces the risk of contracting HIV by 50-60% in heterosexual males only. First of all, this group is not the greatest at risk, which is -- no surprise -- men who have sex with other men. If it is truly an issue of a circumcised penis being protected from HIV , wouldn't he be greater "protected" no matter what, no matter who he is having sex with?

The reasons for contracting HIV in Africa are numerous. Heterosexual sex only accounts for about a third of cases. The rest is likely transmitted through unsafe medical procedures, including injections, transfusions, and other contact with infected blood. In fact, in the journal of the American College of Epidemiology, it has been suggested that some HIV infections are resulted from circumcisions themselves.

The Studies:
This is a lot of information and when you read so many numbers, I think a lot of us glaze over. I am going to try to make this as uncomplicated as possible.

Most people are aware that the area of the world hardest hit by the AIDS epidemic is Africa. It is important to note from the beginning that heterosexual sex is NOT the leading cause of contracting HIV in Africa. Conditions are very poor in many parts of the continent.

There were two studies done over a 24 month period, one in Uganda and the the other in Kenya. In Uganda, researches began with almost 5000 men and randomly divided them into 2 groups, circumcising one group and leaving the other group intact. For whatever reason, the intact group of men had almost 50 more men in its numbers than the circumcised group. The men were given extensive counseling on the use of condoms, but the researchers made no attempt to determine the HIV status of their female partners, which is a major flaw with both studies. After the 24 months, both groups were tested for HIV. The circumcised group had 22 positive results, while the uncircumcised group had 45 test positive. The researchers derived a 55% risk-prevention figure from the numbers.

The Kenyan study was very similar. They began with almost 2500 men and divided them evenly, circumcising half of the men. Two years later, 47 of the uncircumcised men and 22 of the circumcised men tested HIV positive.

Concerns with the Studies:
First of all, the number of men tested was such a small number to apply to large populations. In the Ugandan study, 0.8% of the circumcised men tested positive and 1.7% of the non-circumcised men tested positive. The numbers sound quite different when read in actualities. Plus, look at it from the flip-side: About 98% of the men remained HIV negative, possibly because of the extensive counseling about condoms. The actual numbers from the Kenyan study are: 1.5% circumcised men became infected, while 3.3% of the intact men became infected.

The timing of the release of these results is significant. They were released to the media in conjunction with UN World AIDS Day, 2 months before being released anywhere else. This unusual move "produced world-wide publicity that was heavy on eye-catching headlines and light on details because, in the absence of the published studies themselves, few journalists took the time to dig beyond the press releases made available to them."

Another concern is the short duration of the studies. Short time span and small numbers. The men who participated in the study were paid, which was significant, also, because more than half of them were unemployed when they signed up. They also received free health care for 2 years. For these reasons, it is impossible for their experience to reflect the larger population in other parts of Africa. In addition, there are more than 60 pre-existing conditions that can trigger an HIV false-positive result, including pregnancy, influenza, tuberculosis, hepatitis, and malaria.

There are other findings in the study. Circumcision does not appear to protect women. As mentioned earlier, it does not protect gay men either. Here's the reasoning behind believing that circumcision protects against HIV: "The mucosal tissue of the foreskin is more susceptible to HIV and can be an entry portal for the virus." More research has been done and has found the following: Langerhans cells in the foreskin have a protective effect against pathogens (including HIV) by secreting langerin. The original idea, stated earlier, believed these cells were an entrance point for viruses, and while this is partially true, the true mechanism at work is the cells set a trap for viruses in order to destroy them with langerin.

HIV infection is about behavior, not biology! Circumcision cannot prevent the spread of HIV. In fact, if men believe that they are safe because they are circumcised, that could make the problem worse! Circumcised men do contract HIV, they transmit HIV, and circumcised men die of AIDS. Anyone who participates in high-risk behavior, intact or not, carries a risk of contracting HIV and other STDs.

Tuesday, November 10, 2009

Why Take a Children at Birth Class

I had the privilege of spending time with a family this morning who is due with their fourth baby in a couple of weeks. This particular mom had an epidural with her first 3 babies and has decided that she wants to give birth without medication this go-round. Her and her husband have been taking my class by DVD, but we added a couple of live classes too: Techniques of Relaxation and Children at Birth.

I rarely have the opportunity to teach my Children at Birth class. As you may have noticed, there's not a lot of demand for a class preparing children for witnessing the birth of their sibling!

I've been thinking about this topic a lot lately, knowing that I would be teaching this class. There is something very special about a mom who wants her other children to be present for the birth of her new baby. It becomes the birth of a family, really. With each child the family dynamics change, and inviting older children to be a part of that is so special. Sacred, really. She is placing enormous value on her older children by allowing them this opportunity to be a part of this wonderful, life-changing event.

A few years ago, I had a dear friend who was pregnant with her fourth baby. When she told her children that they were going to have another baby, it was the oldest child that had the hardest time with it. After days of crying and consoling, she finally got to the root of what the real issue was that he was struggling with -- he remembered her going to the hospital and being gone for a long time, someone else taking care of him and the house, and then mom coming home with a baby that took up all her time! And to think, we worry about the younger babies and how they will handle a new sibling! We often think that the older ones have done this before and will be just fine. I've often wondered, if he had been invited to the birth, even after leaving the hospital after the birth, he probably would have been okay with Grandma, or whoever, running the house for a couple of days.

When I was pregnant with our last baby, we had not had any ultrasounds during the pregnancy. We just knew she'd be a boy! Two out of three of our children chose to be present for the birth. Had our only boy not been there, I think it would have been much more devastating that "he" was a "she." He found out with the rest of us. He felt a part of it. He was the first child downstairs the next morning, climbing into bed to snuggle up next to the baby, declaring, "I love her more than anything in the world." I have replayed this over and over in my mind over the years and it always comes back to him being a part of the birth.

I so enjoyed the children I met with today. The oldest was a 10-year-old boy and the younger (invited) child is a 6-year-old girl. The two-year-old will NOT be attending the birth! We talked about the process of labor and their roles and what mom will need from them. We talked about the sounds and facial expressions mom might make. We talked about the placenta, the umbilical cord, vernix, IVs, and monitoring. We watched a video where children are present for the births of their siblings. It's so good to see how these other children are "handling" birth. It's quite different to talk about birth versus actually seeing a birth. In the end, the 6-year-old decided that she may not want to be there. (My one child who chose not to be there was also six at the time.)

It is so important that children be allowed to make that decision. But how wonderful to be invited to a birth. It's an honor, no matter your age or profession, but a very rare opportunity for a sibling.

Thank you, Katie and Nick, for inviting me into your home today to teach your children. It is a special thing you are doing, not only for them, but for yourselves and your family. Make sure everyone records it in their own special way. Good luck and I'll be looking forward to hearing about this wonderful birth.

Friday, November 6, 2009

Free Pregnancy e-newsletter Through Mothering

I just stumbled upon a great resource for pregnant moms and I wanted to share. When you put in your due date, it will be "tailored to the timing of your pregnancy." Best of all, it's FREE, and second best, it's put on by Mothering.

To sign up, click here.

Find out what's happening in your body and what's happening with your baby. Lots of great info to help you along this journey and to make the most of this special, sacred experience.

Petition to CDC: Do Not Make Circumcision Required for Newborns

It took me about 2 minutes to add my name to this petition. I have done my research -- I just haven't sat down to write a post about this topic. The CDC is declaring, falsely by many accounts, that circumcision might reduce the risk of HIV for males. There is a lot to talk about, as you can imagine. In the meantime, add your name to the petition.