Pampered Pregnancy – Blissful Birth

What effects might an epidural have on your baby?

AJOG did a systematic review of all of the literature on epidurals. It’s tricky – because most of the studies do not have random assignment – so that makes the study less powerful because it’s possible there is a difference in the types of women who elect epidurals from the kinds that don’t. For example, women are more likely to request an epidural during a prolonged or difficult labor, which in turn is more likely lead to an assisted vaginal birth. But from the few studies that were sound, they did conclude the following:

Epidurals cause:
Longer labors
Higher incidence of forceps/vaccuum deliveries
No increase in C-section rates
Higher risk of fever in mom (20% vs 7% for natural deliveries), but it turns out that most epidural fevers are not caused by infection, and don’t necessarily need to be treated with antibiotics, and are resolved very quickly. Even so, some pediatricians may be over cautious and may prescribe antibiotics for neonates. Early antibiotic exposure has implications for future antibiotic resistance.
No differences in lactation outcomes
No difference in apgar or other neonatal outcomes
No other significant differences on other measures

There are some articles on effects of epidural and lactation, but at this point they are mainly anecdotal and published findings do not demonstrate a causal pathway (ie maybe women who are more likely to stop breastfeeding earlier, are also more likely to request pain medication – the relationship might be reverse.) All of the (few) randomized studies have found no difference in lactation and lethargy of babies that were born under epidural anesthesia. So the main documented (very small) effect on baby is a a slightly elevated chance of receiving antibiotic treatment.

Of course there are still other reasons to opt for an epidural free birth – prolonged labor and operative deliveries are not a walk in the park. But if you are concerned just about baby, you can approach the epidural question logically, and discuss your choice with your doctor.

http://www.ajog.org/article/S0002-9378%2802%2970181-6/abstract

You might be surpised to hear endorsement for an induction from a Doula.  But I am the “evidence based doula” and there is a lot of evidence out there that inductions might be a good choice for many women.

The current ACOG recommendations are to not let a pregnancy go past 42 weeks.  There is some more recent research coming out though that suggests inductions on or before 41 weeks actually may produce a better prognosis.  Why?  Chances of infant mortality go up after 41wks0day.  There are no significant differences in health of baby or mother when mothers are randomly assigned at 41 weeks to an induction or expectant management of waiting it out, but retrospective studies show that the rates of  operative delivery, perineal damage and hemorrhage go up with each week after 40wks0 days.  C-section rates remain constant from 38-42 weeks, ie it is not any higher if you induce at term than if you want until 42 weeks.  A better predictor of C-section outcome is station of the baby – the more engaged babys head is, the less likely you will have a c-section.  Finally, mothers randomly assigned to an induction at 41 weeks report more positive feelings about their birth than those waiting it out in the expectant management group.

So inductions at term don’t seem so evil – they don’t cause higher C-section rates, they don’t cause a higher incidence of mother or infant health problems, and mothers report being happier having a scheduled induction at 41 weeks.  At the same time, if you go past 41 weeks infant mortality rates go up, and going past 40 weeks increases your chance each week of operative delivery, perineal tears and hemorrhage

With all of these research studies – I still endorse “natural” induction methods when you can use them.  If you are at term and are able to start doing some of the mainstream recommended natural induction techniques (breastpumping, walking, acupressure, membrane sweeping etc) you’re setting yourself up for a better chance of spontaneous labor, or at least a better chance for a successful induction.  As usual – all of these issues are worth a good talk with your doctor about the risk and benefit for you as their patient in your choices for your postterm pregnancy.

And now the research:

Bruckner et al looked at only one outcome measure – infant mortality.  Of course this is such a low risk, but the worst outcome it it happens.  They found that chances of mortality go up at a significant rate after 41wks0days.  http://www.ajog.org/article/S0002-9378%2808%2900558-9/pdf

Heimstad looked at other measures of health of baby and mother, apgar, operative delivery rate, cesarean rate, umbilical cord pH etc.  Moms at 41 weeks were randomly assigned to induction or expectant management (waiting it out) and there were no significant differences in any of the measurable outcomes.

Shin et al showed the that risk of cesarean is not greater for women who undergo inductions at 41 weeks vs. any other week of gestation.  What they did observe is that babies that are not engaged in the pelvis at 41 weeks are more likely to result in cesarean – so at 41 weeks the station of your baby is a better predictor of your risk of cesarean.  http://www.ajog.org/article/S0002-9378%2803%2900909-8/abstract

Caughey et al show that maternal complications increase after 40 weeks, including higher rate of forceps/vaccum, more perineal tears, and hemorrage.  http://www.ajog.org/article/S0002-9378%2806%2901178-1/abstract

Heimstad et al did an interesting study that assessed mothers feelings about their postterm pregnancy courses.  At 41 weeks they were randomly assigned to an immediate induction, or fetal monitoring and waiting it out.  When asked about their experiences, 74% of the induction group would do another induction, whereas only 38% would choose to wait it out again.  http://informahealthcare.com/doi/abs/10.1080/00016340701416929

In doing some research on “Big Babies” since I found an interesting study in AJOG where doctors predicted a large baby (larger than about 9 pounds); and compared these to births with actual 9 pound babies (ones that weren’t given the predicted label of Macrosomia “big butts”).

Inductions in the suspected big baby group were 42.1% vs. 13.6% in the control group.  And C-sections were  57.1% in the suspected group vs. 16.7% in control.  That’s a huge difference.  But what’s even more interesting, when they compare the maternal and neonatal outcomes of all babies – there is absolutely no statistically significant data in health of baby or health of mother between the suspected big babies, and the actual big babies.

Essentially – if you are getting the label of “big baby” you’re more likely to receive an “unecessary” medical intervention.  And even with a big baby, there are better outcomes in having natural spontaneous labor than a medical intervention based on a macrosomia diagnosis alone.  Food for thought.

http://www.ajog.org/article/S0002-9378%2804%2901574-1/fulltext