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Reducing Infant Mortality

  1. #41
    thanka2 is offline Registered User
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    I submitted my last post without finishing the list.

    Here is the continuation:

    epinephrine
    * Studies on animals show adverse effect and toxicity on fetus.
    * No adequate and well controlled studies done on pregnant women.
    * Drugs should be given only if the potential benefit outweighs the potential risk to the fetus.
    # Teratogenic (capable of causing developmental abnormalities) in some animals.
    # No well controlled human data but suggested possible association with eye, ear, digital defects and club foot during first trimester exposure, and with musculoskeletal defects and umbilical hernia during exposure anytime during pregnancy.
    # It may cause uterine vessels spasm and potentiate the effects of oxytoxic drugs on the uterus resulting in fetal hypoxia and bradycardia.


    morphine
    * Studies on animals show adverse effect and toxicity on fetus.
    * No adequate and well controlled studies done on pregnant women.
    * Drugs should be given only if the potential benefit outweighs the potential risk to the fetus.
    * Crosses human placenta rapidly.
    * No adequate data in first trimester exposure but reported association with inguinal hernia after anytime use during pregnancy.
    * Chronic maternal use of the drug causes neonatal withdrawal and respiratory depression.


    So, the things that stick out about this information to me are:
    -in every case "no adequate and well controlled studies [have been] done on pregnant women"
    -almost every item has been found to have adverse effects and toxicity to the fetus in animals
    -the reason why the narcotics are given is to make the effects of the drug last longer, otherwise there would be little point in going through the trouble of putting the needle in if the drugs would not hold for the length of the labor or c-section
    -the drugs all pass the placenta and in the case of morphine it does so "rapidly" (as I had heard several people argue that "oh, these drugs only effect you--they don't ever get to the baby")
    -and something I may or may have not mentioned is that right now at 7 months pregnant I'm allowed to take up to two panadol "safely" for any pain I have (and I've had some really serious back pain this time--that renders me incapable of working some days) and the doctor will continue to tell me that this is the appropriate dosage of pain medicine. I asked if I might use a topical pain reliever called voltaren which is simply a cream that is applied to the skin that many people use for arthritis pain or cramps. I was told strictly that this could be harmful to the baby and I should not do it. This is a rather "weak" topical treatment compared with an epidural. Yet, if I go to the hospital and I'm in labor, the thing that was deemed "harmful to the baby" the day before all of a sudden is administered without any reference to the possible risks. To me, that seems very unbalanced. I wonder if you ask most pregnant women, "So, what exactly is in an epidural and what are the potential side-effects and risks to mother and baby? Did your doctor go over this with you?"--how many women could say, "Yes, I was informed about this by my doctor" unless the woman herself was very proactive and asked the doctor and then hounded him for specific information. Maybe I'm completely wrong and doctors here and elsewhere do a great job of informing their patients of the risks.

    In an unrelated thought--it is similar with birth control pills which carry an increased risk for blood clotting problems. I was never informed of this when I was prescribed the medication and not only that the doctor didn't even ask about my family history to see if I was at risk for this (which I am--my maternal grandmother had blood clotting problems and died of a blood clot and my mother has also had issues in the past). Eventually I started having chest pains and problems and only then discovered the risk I was taking with "the pill." I wonder how many other women experience this sort of situation.

  2. #42
    thanka2 is offline Registered User
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    Quote Originally Posted by Shenzhennifer View Post
    I also find myself wondering what is classified as a heavy narcotic. All narcotics are opiate-based; the drug in spinal epidurals most certainly is not.
    What are the types of epidurals?

    There are 2 basic epidurals used today. However, hospitals and anesthesiologists vary on the dosages and the combinations of medication they use. You will want to ask your care providers at the hospital about their protocol.
    • Regular Epidural: After the catheter is in place, a combination of narcotic and anesthesia is administered through either a pump or periodic injections into the epidural space. The narcotic, such as fentanyl or morphine, is given to replace some of the higher doses of anesthetic, such as bupivacaine, chloroprocaine, or lidocaine, which helps reduce some of the adverse effects of anesthesia. You will want to find out your hospitals policies about staying in bed and eating.
    • Combined Spinal-Epidural (CSE) or “Walking Epidural”: An initial dose of narcotic, anesthetic or a combination of the two, is injected beneath the outermost membrane covering the spinal cord, and inward of the epidural space. This is the intrathecal area. The anesthesiologist will pull the needle back into the epidural space, threading a catheter through the needle, withdrawing the needle and leaving the catheter in place. This allows you to move more freely in the bed and change positions with assistance. With the catheter in place you may decide later to request an epidural if the initial intrathecal injection is not enough. You will want to find out your hospital’s policy on moving around and eating/drinking after the epidural has been placed. With the use of these drugs, muscle strength, balance and reaction is reduced. CSE should provide pain relief for 4-8 hours.


  3. #43
    thanka2 is offline Registered User
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    Quote Originally Posted by Shenzhennifer View Post
    I was one of the women who wanted a drug-free vaginal birth with no interventions. But hey, things changed, and I asked for an epidural after a couple hours on oxytocin. We all have different pain thresholds. I didn't feel it would adversely affect my baby. Furthermore, since I later had a c-section, I received more of the drug into my epidural, and then some more since it wasn't working well. My son came out kicking and screaming like a wild animal and got perfect responses in his apgar. He has not had a single serious health issue coming up on 2 years now. I can't say the same would have been true if he was born vaginally, who knows what might have transpired?
    Granted, if you have to have an emergency c-section, of course you're going to have to have to have pain medication for that. I've just heard a lot of my friends say very lightly, "Oh, well, if it hurts, I'll just take an epidural but, I'm going for a drug-free birth."

    Yes, there are situations that are out of our hands and there is a time and place for everything but it just makes me wonder how informed women really are about what they're putting into their bodies that could influence their child--if it's just as easy to choose an epidural (which if a woman plans to use one and it's not administered in an unplanned or emergency case, is administered in early labor before one would know for sure if they need it or not) as it is to pop a couple of panadols--as far as the thought process that goes into that choice (for many of my friends and acquaintances at least).

    And one of the things that hasn't been adequately studied, I feel, is the long-term effects of these drugs on childrens' development. They may be breathing fine at birth and pass all the initial vital sign testing but that doesn't tell us down the road if the drugs have had any cognitive effect on the child. And I think maybe some of the problems children come up against in development later that are attributed to other things (or attributed to "we don't know why") possibly could linked back to things such as drug exposure at birth. No way to know because although "adequate studies have not been conducted" the drugs are assumed to be safe.

  4. #44
    thanka2 is offline Registered User
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    Quote Originally Posted by LLL_Sarah View Post
    If you would like to read an excelent book on this topic I recommend,
    Impact of Birthing Practices on Breastfeeing by Linda J. Smith
    (To be truthful the book is about how interventions in our birth affect the next stage of reproduction - but then that is my area of knowlegde!)
    Best wishes,
    SARAH
    This is an Podcast interview with her that I came across. She is talking about the subject matter from her book. Worth a listen.

    http://www.llli.org/mp3/LLL_Podcast_...astfeeding.mp3

    A few quotes from the interview:

    "When I was having my children I learned one La Leche League's ten concepts...alert and active participation in birth makes a difference initiating breastfeeding."
    "As a lactation consultant in the early 90s, as the epidural rate started going up I started encountering more and more normal, healthy, full-term babies that couldn't suck and this was very distressing to me because it wasn't the mother's motivation, these were kids who were otherwise fine but would open their mouth, go to breast and stop. So, I started digging and researching and I found at least five contributing factors that were responsible for the types of babies I was seeing and those five were caesarean birth, epidural anaesthesia, induction, forceps and vacuum. Now, not every baby that has those comes up with sucking problems, on the other hand, of the babies I saw for a three-year period, over 70% of the suck problems were attributed to one or more of those. It was only a survey of my clients in one mid-western city. I started digging further...."
    She goes on to talk specifically of a large medical study published in the British Journal of OBGYN talking about fentanyl (one of the drugs I posted about further up that is routinely used in epidurals) showing that it is dose-related to problems with infant feeding.

    She speaks of how OBGYNs often don't focus on infant outcomes and often pediatric doctors often don't feel that they have any say or influence in OBGYN care. The focus of the OBGYN is essentially the mother and her welfare and comfort and the baby secondary to that.

    She also sites other studies that show that when two drugs from the list (in epidurals, posted above) bupivacaine and sufentanil were administered, the babies often had motor delays (which affects the sucking reflex) for up to a month after they are born--and the study stopped measuring children at a month old so they don't know how much longer the affect is present.

    She added that many will argue that the drugs and methods of administration have changed over the year (and presumably better) but she adds that in her line of work the effects that they see have not changed.

    She talks about the fact that vaginal birth is healthy for the baby as it forces the release of endorphins in the baby but when the baby and there are quite a few interesting things surrounding that--that actually this eventually affects the quality of milk that the mother can give (milk has natural pain relievers in it--but because of anaethesia those pain relievers are dulled and not present in the milk after the birth).

    Anaesthetic drugs reach the baby in 15 seconds to 2 minutes according to Hale and other pharmacologists. They are designed to go to the nerve centers in the mother's brain. They are very fat-soluable drugs because the brain is very high fat--it's over 50% fat. And they [the drugs] go to the baby's brain very quickly. The anaesthsia literature shows that it [the drugs] shows up in cord blood. Some of it [the drugs] that take 20-30 minutes to be half gone [the half-life] from the mother may take 8 or more hours to be half gone from the baby. And it takes about 5 half-lives for it [the drugs] to clear 98.something% from the baby's body--if the liver is doing well....assuming there are no other injuries to the baby [forceps caused etc.] and that the baby is healthy and thriving otherwise...
    She also points to the fact that the research shows that having a trained advocate or birth partner or doula assisting cuts the c-section rate in half and dramatically decreases womens' use of drug pain relief and results in better outcomes for babies and mother.

    Research has shown that mothers mother their babies the same way they were cared for in labor.
    She points out that women should be free to move about and adopt any position to help facilitate labor, allowed to eat and drink freely--self-regulated (it gives her more energy allowing the uterus to contract better), allowed to get into a tub of water or use water birth--all of these things help facilitate labor

    Squatting opens the pelvis by some 30% and allows the baby to descend easier...If you're laying horizontal...I mean, who wants to push uphill? Gravity works.
    Last edited by thanka2; 12-12-2010 at 01:18 AM.
    “Many women have described their experiences of childbirth as being associated with a
    spiritual uplifting, the power of which they have never previously been aware …
    To such a woman childbirth is a monument of joy within her memory.
    She turns to it in thought to seek again an ecstasy which passed too soon.”

    ~ Grantly Dick-Read (Childbirth Without Fear)

    Mother of Two
    JMW, boy, born November 29, 2007, 9:43 pm, USA
    MJW, girl, born March 17, 2011, 4:14 pm, HK

  5. #45
    laial is offline Registered User
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    1. Voltaren is a non-steroidal anti-inflammatory, which has a completely different mode of action to opioids. It can cause premature closure of the fetal ductus arteriosus and is absolutely contraindicated especially in the third trimester. On the other hand, opioids, despite being considered a “stronger” analgesic, have different pharmacological properties and are not contraindicated.

    2. Perinatologist = neonatologist

    3. It is true that there are “no adequate and well controlled studies done on pregnant women” for most drugs, and this is largely because it is very difficult to get ethics approval for most things in pregnancy. Do the studies done on fetuses in animals take into account things like drug levels in maternal circulation? (because most epidural drugs are only in small quantities in the maternal circulation and have minimal effect on the fetus at this level, however at higher levels they can cause adverse effects). Also for risk of being sued, drug companies will rarely say that any drug is 100%safe in any situation – they will usually caution every little thing (take a look at your paracetamol packet info next time you take some – they have lots of cautions on them, however we still take them like lollies). It is known that paracetamol causes adverse effects when taken at doses exceeding the 4g/day, but that won’t stop you from taking it below that threshold. To have a truly holistic approach, one would not even take paracetamol for back pain – one would try other “natural remedies”.

    4. The squatting position does indeed help bub descend easier, but it has also been associated with an increased risk of 3rd and 4th degree tears. Gravity is great, but it doesn’t control the rate at which bub comes out – hence the perineum bears the grunt of it. So as I’ve said previously, there are pro’s and con’s to everything and it is up to the individual to decide on where they place their priorities.

    5. “Obstetricians don’t focus on infant outcomes” – if this was the case, why are obstetricians often guided by fetal heart rate traces and fetal scalp blood samplings when it comes to whether or not to do an emergency delivery? Why would obstetricians do so many ultrasounds (apart from the insurance money) to monitor baby’s growth and wellbeing? Everyone wants a healthy baby. Obstetricians, however, as it is their specialty, also have to focus on the mums; where as the paediatrician’s specialty is to focus on bubs. There’s a reason that there are different specialties. If I was having a caesarean section, I certainly wouldn’t not want a paediatrician to be doing it. Lets not forget that obstetric emergencies can also be extremely serious for mums. What’s the point in having a healthy baby if mum has died during childbirth?

    6. Intervention in pregnancy and labour (as with the rest of medicine) is continually under research and evolving all the time. It is not without its flaws (neither is anything else), which is why there is so much research. No intervention is ever done without being proved by research. But I do wonder how much research goes into “non-intervention” and not doing anything? – eg if bub’s heart rate has been sitting at 60beats per minute for the past 10 minutes, why don’t we do a trial and see what would happen if we didn’t run for an emergency caesarean section? (that was sarcastic by the way). If you were in an emergency situation and bub was in distress, a truly holistic approach would be to decline an emergency delivery and let the baby deliver “naturally” with your doula present. It’s not very nice to be saying that obstetricians are bad and you “take what they say with a grain of salt” because they intervene too much, but when push comes to shove and bub’s getting distressed, you expect them to come and deliver your baby.

    7. Bottom line is, as this thread is about “infant mortality” – it has been shown that infant mortality rates in the western world is significantly better than those in the developing world. The main reason for this is medical advances and “intervention”. All intervention have benefits and risks – it’s all well and good to go on about how risky they are and how much harm they are doing, but let’s not forget the benefit that they can also provide.

  6. #46
    laial is offline Registered User
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    By the way, if a mum wants to have an epidural, she is a grown adult and can make her own decisions - so let her have one. It is not for anyone else to judge her decision. Same goes with caesarean sections and everything else - even though I am an advocate for normal vaginal deliveries, if a mum wants a caesarean for whatever her reasons are, given that she knows the facts, it is not for anyone else to judge or comment her decision.

  7. #47
    Shenzhennifer is offline Registered User
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    My favourite person during my labour was the anaestesiologist (until my doc delivered my baby, of course). He was the only person in the whole process that properly helped me with that awful pain:)
    It's nice to say that I would like to have a drug free natural birth, but when push came to shove and my pitocen-inspired contractions were frequent, long and tripling up, with a still closed cervix, I welcomed relief.

  8. #48
    thanka2 is offline Registered User
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    1. Voltaren is a non-steroidal anti-inflammatory, which has a completely different mode of action to opioids. It can cause premature closure of the fetal ductus arteriosus and is absolutely contraindicated especially in the third trimester. On the other hand, opioids, despite being considered a “stronger” analgesic, have different pharmacological properties and are not contraindicated.
    Thanks for clearing that up.

    2. Perinatologist = neonatologist
    Thanks for clearing that up.

    3. It is true that there are “no adequate and well controlled studies done on pregnant women” for most drugs, and this is largely because it is very difficult to get ethics approval for most things in pregnancy. Do the studies done on fetuses in animals take into account things like drug levels in maternal circulation? (because most epidural drugs are only in small quantities in the maternal circulation and have minimal effect on the fetus at this level, however at higher levels they can cause adverse effects). Also for risk of being sued, drug companies will rarely say that any drug is 100% safe in any situation – they will usually caution every little thing (take a look at your paracetamol packet info next time you take some – they have lots of cautions on them, however we still take them like lollies). It is known that paracetamol causes adverse effects when taken at doses exceeding the 4g/day, but that won’t stop you from taking it below that threshold. To have a truly holistic approach, one would not even take paracetamol for back pain – one would try other “natural remedies”.
    I never said that I have taken paracetamol. I took one dosage (in October this year at about 20 weeks pregnant) because I was in pain but I had misgivings about it for exactly the reasons you mentioned. I have just sucked it up and not taken anything for pain since and there has been a lot of pain to deal with. But, I did inquire with the doctor to see what the treatments are as a friend had mentioned voltarin but the three doctors I've seen have said the same thing.

    4. The squatting position does indeed help bub descend easier, but it has also been associated with an increased risk of 3rd and 4th degree tears. Gravity is great, but it doesn’t control the rate at which bub comes out – hence the perineum bears the grunt of it. So as I’ve said previously, there are pro’s and con’s to everything and it is up to the individual to decide on where they place their priorities.
    Interesting. I totally advocate the squatting position or kneeling (tried both and many other variations on position) but at the time when I actually gave birth I was exhausted and my legs were cramping so neither ended up working for me. I physically didn't have the strength.

    5. “Obstetricians don’t focus on infant outcomes” – if this was the case, why are obstetricians often guided by fetal heart rate traces and fetal scalp blood samplings when it comes to whether or not to do an emergency delivery? Why would obstetricians do so many ultrasounds (apart from the insurance money) to monitor baby’s growth and wellbeing? Everyone wants a healthy baby. Obstetricians, however, as it is their specialty, also have to focus on the mums; where as the paediatrician’s specialty is to focus on bubs. There’s a reason that there are different specialties. If I was having a caesarean section, I certainly wouldn’t not want a paediatrician to be doing it. Lets not forget that obstetric emergencies can also be extremely serious for mums. What’s the point in having a healthy baby if mum has died during childbirth?
    I think what the heart of what I was saying that the obstetricians primary focus is the mother and the baby is secondary to that--of course they are both priority. Too bad you can't have the benefits of having a doctor who is equally specialized in both fields. Yes, there are emergencies but not every birth is an emergency. A great many births might be pulled off without a hitch were it not for unneccessary interference, in my opinion.

    6. Intervention in pregnancy and labour (as with the rest of medicine) is continually under research and evolving all the time. It is not without its flaws (neither is anything else), which is why there is so much research. No intervention is ever done without being proved by research. But I do wonder how much research goes into “non-intervention” and not doing anything? – eg if bub’s heart rate has been sitting at 60beats per minute for the past 10 minutes, why don’t we do a trial and see what would happen if we didn’t run for an emergency caesarean section? (that was sarcastic by the way). If you were in an emergency situation and bub was in distress, a truly holistic approach would be to decline an emergency delivery and let the baby deliver “naturally” with your doula present. It’s not very nice to be saying that obstetricians are bad and you “take what they say with a grain of salt” because they intervene too much, but when push comes to shove and bub’s getting distressed, you expect them to come and deliver your baby.

    Hmmm....I disagree that a truly holistic approach means that you "do nothing"--there are many things that you can do that don't involve major interventions. A good doula or midwife will do just as good of a job as a doctor--I know this because I had one. It's not that they "do nothing"--they just do things very differently with a very different mindset/approach. They don't take a completely hands-off approach and to consider holistic medicine as a completely hands-off approach is a pretty big misunderstanding. But, it's like this analogy. Giving birth (especially for the first time) is similar to swimming. It's something that the body can and was designed to do. Doctors and midwives should be seen as lifeguards. If I know how to swim and I'm in the pool swimming but maybe I'm breathing a little hard or it's difficult, is it appropriate for the lifeguard to jump in and try to yank me out of the water in an effort to save me? Actually, these professionals are there in case something goes truly wrong. My main argument is that the more they meddle with the natural course of things (I'm not talking about truly emergency situations here as well--which seems I've been misunderstood on this point. I suffered a truly emergency situation myself during my birth and my midwife responded appropriately--she in no way took a hands-off approach.) the more chance there is for things to actually turn into an emergency.
    I wasn't speaking only of obstetricians when I said I take what most doctors say "with a grain of salt." I never said that they were bad (another phrase that was put into my mouth). I do believe that the culture/mindset of the profession is to meddle. Not all doctors do. But, I have noticed in Hong Kong especially that the system is very "doctor centric"--many doctors do carry an attitude of, "Sit down, shut up because I'm the doctor." Very rarely have I encountered actual discussions about my health where I was a respected contributor. The doctors here are used to just giving out orders without discussion from their patients--most people don't question their doctor here, I think. The majority of traditional doctors I've see, obstetrician or otherwise, have not done much good for me healthwise and I have simply found from personal experience much more relief and genuine healing in holistic methods.

    7. Bottom line is, as this thread is about “infant mortality” – it has been shown that infant mortality rates in the western world is significantly better than those in the developing world. The main reason for this is medical advances and “intervention”. All intervention have benefits and risks – it’s all well and good to go on about how risky they are and how much harm they are doing, but let’s not forget the benefit that they can also provide.
    Why do you think then, that over the past 20 years (since the rates of c-section, induction and epidural went up significantly) infant mortality rates have done a reversal and started to rise, whereas in the previous 50+ they were falling? One other culprit that I've read about may be obesity. What do you think? When you say "it has been shown" what are you referring to? Also, what do you make of the correlation between elective c-section rates in the United States and infant mortality vs. say, statistics from Europe?

    Could it also be that infant mortality rates in the western world are significantly lower because women eat better, have access to medical care and give birth in sterile environments? I don't think that this video was at all saying that interventions have not in many cases added a great deal of good to the health of mothers and babies. I think this video talked about their overuse.
    Last edited by thanka2; 12-17-2010 at 04:08 PM.
    “Many women have described their experiences of childbirth as being associated with a
    spiritual uplifting, the power of which they have never previously been aware …
    To such a woman childbirth is a monument of joy within her memory.
    She turns to it in thought to seek again an ecstasy which passed too soon.”

    ~ Grantly Dick-Read (Childbirth Without Fear)

    Mother of Two
    JMW, boy, born November 29, 2007, 9:43 pm, USA
    MJW, girl, born March 17, 2011, 4:14 pm, HK

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