Epidural hysteria

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Judy Slome Cohain doesn’t know anything about pharmacology, but that doesn’t stop her from making hysterical, unsubstantiated allegations about epidurals.

Two million American women will take an epidural trip this year during childbirth. In most cases, they’ll be ill-informed as to possible side effects or alternate methods of pain relief. In many ways, epidurals are the drug trip of the current generation. Similar to street drug pushers, most anesthesiologists in the delivery rooms maintain a low profile, avoid making eye contact and threaten to walk out if they don’t get total cooperation. Women get epidurals for one of the main reasons so many women smoked pot in the 1970s—their friends are doing it.

Gee, Judy, why don’t you tell us what you really think about epidurals and the women who choose them?

Today, health authorities tout epidural analgesia as the safest, most effective method of pain relief available for childbirth. You could not pull that off on my generation. We lost enough creative artists—Janis Joplin, John Belushi, Jim Morrison and Lenny Bruce—to injectable pain killers. We are aware of the potential of painkillers that are injected into your body—let alone into the delicate spinal cord—by someone else …

While we can figure out why Judy is hysterical: she is desperate to convince women to forgo the most effective form of pain relief in labor, her utter ignorance of chemistry and biology may not be as apparent to the lay people who read her garbage article. Judy is very, very confused. She does not know the difference between intravascular injections and epidural injections. And she apparently thinks the placenta is a sieve, allowing direct transmission of everything in the mother’s blood stream. Judy needs a lesson in pharmacology.

The basics:

1. To get to the baby, a medication needs to get to the mother first. Specifically, the medication must enter the mother’s blood stream. A medication can enter directly through intravenous administration, but if the medication is injected elsewhere, only some of it will find its way to the mother’s bloodstream. Epidurals are injected into the epidural space and that means that considerably less medication (local anesthetics and/or opiods like fentanyl) ends up in the mother’s blood stream.

2. Dose counts. In her frantic rush to indict epidurals, Cohain conveniently forgets to mention that the effect of a medication depends on the dose. Janis Joplin, John Belushi, Jim Morrison and Lenny Bruce OVER-dosed on medication. They were not using the drugs in question for approved uses, either.

3. The placenta is not a sieve. Cohain imagines that whatever is in the mother’s blood stream always and easily crosses the placenta. The reality is quite different. The chapter of the Obstetric Anesthesia Handbook entitled Perinatal Pharmacology has a brief explanation:

Substances in the maternal circulation can cross the placenta by one of four mechanisms. The majority of substances are subject to passive diffusion, in which the compound flows across lipid membranes down a concentration gradient… Some substances are subject to facilitated diffusion, in which a carrier protein in the lipid membrane aids passage of the substance … Glucose crosses from the maternal to fetal circulation in this way. Active transport refers to an energy-requiring process in which a transporter molecule moves the substance … Amino acids appear to cross from the maternal to fetal circulation in this way, co-transported with sodium… Finally, some large molecules, such as immunoglobulins, are transferred via pinocytosis …

And even molecules that theoretically can pass freely across the placenta (passive diffusion), there are additional factors that modify how much gets across. These include utero-placental blood flow, maternal protein binding, and lipid solubility, among others.

The bottom line is that what is gets to the baby is far smaller than the amount of medication injected into the mother’s epidural space. Therefore, if an epidural does not sedate the mother, it certainly won’t sedate the baby.

  • Laurie KaSarr Browne

    So what the author is saying is that the epidural WILL cross the placenta to the baby. Saying if it doesn’t sedate the mother it won’t sedate the baby is assine!!! A baby is usually less than 10% the size of the mother, of course it’s going to affect the baby differently. The biggest side effect, is that epidurals ‘can’ affect breastfeeding efforts making the first few days very difficult for both mother and child.

    • Amy Tuteur, MD

      You know what’s really asinine? Someone who doesn’t know the first thing about pharmacokinetics (who’s probably never even heard of it!) telling me she knows more than I do about the pharmacokinetics of the medications in epidurals.

      • Laurie KaSarr Browne

        As a patient who has probably had at least a dozen epidurals in her life and as a birth Doula, I know plenty…. I dare say I know MUCH more than you do about the effects of medications on a birthing baby. You obviously have no idea that medications given to the mother during labour can remain in the baby for days and even weeks after birth having an adverse effect on breastfeeding amongst other side effects…. or you simply don’t care. Are you an MD or an Anesthesiologist because I have yet to meet an Anesthesiologist would ever dismiss the effects of an epidural on a birthing baby. An epidural is only ONE of many successful ways to manage pain during labour.

        • Amy Tuteur, MD

          Not only are you ignorant, but you are arrogant in your ignorance. Do you have any idea how stupid you sound?

          • Laurie KaSarr Browne

            What a mature and responsible response.

          • Wren

            Actually, I think it’s a serious and valid question.

            OBs are not trained in labour and delivery? OBs do not understand the effects of medication given during labour and delivery?

            If those are your claims, then yes, I wonder as well if you realise you sound stupid.

          • Laurie KaSarr Browne

            Fact based article citing REAL research on the effects of epidurals on both mothers and their babies.

            https://www.birthinternational.com/articles/birth/15-epidurals-real-risks-for-mother-and-baby-

          • Wren

            REAL research the most recent of which is nearly 2 decades old?

            I am particularly fond of this line: “Morphine also causes oral herpes in 15% of women”. Actually, it has been linked to a reactivation, but is hardly the cause of oral herpes on its own.

          • Bugsy

            She’s serious that someone who has had personal experience with epidurals and is a self-taught doula gives her more experience than someone who has spent years studying medicine & birth?

            By that theory, I qualify as a dentist. You know, I have teeth and all.

        • momofone

          Great question–MD OR anesthesiologist? Please explain the difference.

          • Laurie KaSarr Browne

            In the States, an Anesthesiologist has an additional 4 years of schooling on top of their MD. An MD is a medical doctor. An OB specializes in obstetrics and gynacology and is a surgeon. They are not trained in labour and delivery the way a midwife is (4 years medical training) or a certified doula is (2 years training specifically in labour, birth, and postpartum).

          • momofone

            Exactly. Both are MDs. And thank God they aren’t trained like midwives or doulas; MDs have actual medical training and are accountable for outcomes.

        • attitude devant

          “probably had at least a dozen?” You mean you don’t know how many you’ve had? Did they cause memory loss too?

    • demodocus

      Anecdotally, my little lamprey had no problem latching right away. Also, he surprised the nurses by lifting his head off my chest. He didn’t seem much bothered by my epidural. It’s not like epidurals directly enter the bloodstream; they’d have put it into my iv if it did.

      • Wren

        I had a spinal, but a very similar experience once he was born.

  • Alice

    I realize nobody is probably reading this article anymore, but, I wanted to add my two cents. There are two ncbi studies worth including in considering whether to have an epidural; the first, notes that, in small amounts, drug administered during an epidural do reach the baby, though they clear the system in 24 hours. http://www.ncbi.nlm.nih.gov/pubmed/3578847 The second, indicates that labors are typically longer, more complicated, and induce fever in the laboring woman when epidurals are involved. http://www.ncbi.nlm.nih.gov/pubmed/12011872/ These are two, objective, impersonal studies, and now, I’d like to add my story to the mix. With my first child, I labored for 13 hours at home, had transition level contractions, but when I arrived at the hospital, I had no dilation. The pain was excruciating, and I had a shot of morphine. Immediately, I dilated to 3 cm. Because they would not give me another shot of morphine, and because I was terrified of the pain, I elected an epidural at that point. Unlike other women on these posts, the experience was pleasant for me; on that note, I have nothing to complain about. However, only 15 hours later did I dilate to 10 cm (much slower rate). I not only had fever, but I also had caught some kind of extreme cough the day before – and I could barely inhale through the oxygen mask (so yes, there was also that complication – unrelated to an epidural). My bag of waters did not pop on its own, and when they unpopped it and did a cervical exam, I was back to 8 cm. It is unclear whether I re-dilated but, either way, by the time the baby’s head descended – something it seems we still weren’t clear on whether happened all the way or not – they gave me 15 minutes to get him descended (which I tried to do by numb, supported squatting, to no avail) because at this point the baby’s heart rate was “decelerating”. Ultimately, with the diagnosis “fetal distress” an emergency C-section was done. That was only the beginning though. I was furious nobody let me hold the baby, until I was told that his APGAR was 1 – imagine the odds for someone having gone into a spontaneous labor at 40 weeks and 4 days – the chance is like 1% – AND he was not holding temperature. They kept him from me for 3 days in an incubator, and I had to hobble over all cut up to breastfeed him. Was not a pleasant experience. I could not regain full functionality for 5 weeks. My pediatrician sister, who was there for the birth, said it was the “most horrible birth” she’d ever seen. Why am I sharing all of this? Because I strongly feel it was the epidural that led to the fetal distress. Having read the ncbi studies, a picture forms for me: the labor slowed to the point where, after so many hours, the baby could not deal with things; why did it slow? Clearly, the epidural. I had fever, and could not oxygenate well; baby had breathing problems at birth consequently. Baby’s heart rate slowed down – and he went into fetal distress, something that is statistically more likely with epidural use. Even if it were only partially responsible for the unfavorable result, I think it’s almost undeniable the epidural had a negative effect on the labor (for the baby, not for me). Recently, reading that the epidural drugs are a derivative of cocaine, I feel all the more ashamed I elected it. I feel ashamed, and yet, I could not deal with the pain. This time I’m going to try to use numorphine so as to be able to walk around, but even with this, I still feel ashamed. The critics that point out you are doing drugs with a baby inside you are correct; that is literally what you are doing. If you weren’t doing it in labor, people would be all over you. As it is, few people come up to me and say “don’t you feel ashamed to have drugged yourself with a child inside you?”, thankfully because context matters a little. But, I don’t think we should mince words, or imagine that just because the percentage of drug that reaches the child is small, that it’s insignificant: it may not be. My situation may be worse than most people’s because I did not just get an epidural and quickly have C-section; I had drugs for 15 hours straight. Miracle of miracles, my baby’s APGAR went up to 8 at 5 minutes, and despite the extremely rough start, he is ahead on all his milestones. But, on that note, I feel, I got lucky. In 18 days I am going to try for a VBAC. I have little hope it will work but, if it does, I will feel better about myself if I can avoid the epidural, even if I am doing numorphine.

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  • As a hit-job against Judy Sloam Cohain, this is nothing short of a masterpiece. Unfortunately, this critique of Ms. Cohain wouldn’t be made worse by a little fact checking all its own. After all, what’s good for the goose is good for the gander, right?

    First, after having read the article, the author never made any claim consistent with those implied within this article. Her piece was obviously written from a different perspective, but her article was meticulously sourced, something which cannot be said of this piece. This is only problematic because this piece was written from an authoritative standpoint, with the primary focus seemingly entailing the rebuking of Ms. Cohain.

    Her article made no assertions that opinions expressed therein were anything but. The factual points she cites were all sourced without exception – and the sources checked out, fwiw.

    Rather than lobbing typographical grenades at competing authors, it might not be an altogether terrible idea for the author of this piece to endure a few lessons in journalism, particularly as it pertains to the credibility of the author… If nothing else, at least brush up on the basics before decrying a competing author as a know-nothing using a poorly sourced article to discredit a well-sourced article.

    • MLE

      Rather than posting painfully contrived metaphors, why don’t you sum up your thesis in one sentence so we don’t have to suffer through your three paragraph screed.

      • The Bofa on the Sofa

        IOW, “What the hell are you talking about”?

    • PrimaryCareDoc

      Interesting. You consider a well-sourced article to be one that cites http://www.myobsaidwhat.com and mothering.com?

    • DaftPunkd

      There was no source cited for her claim of paralysis from epidural. Probably because it’s not true.

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