Before we dive into a discussion of epidural analgesia I’d like to clarify my intention in writing this series in light of some of the comments on previous articles.

The purpose of this series on natural childbirth is to demonstrate that homebirth is as safe – if not safer – than hospital birth for low risk pregnancies, and that medical interventions commonly used in hospital births such as epidurals, induction with synthetic oxytocin and cesarean sections have risks and complications that are often not communicated to pregnant women.

Currently fewer than 1% of births happen at home in the U.S., and I believe this is largely due to misconceptions about its safety. My intention here is to correct those misconceptions.

The purpose of this series is not to condemn the use of these interventions in all circumstances. All of them have their place, and can be very helpful and even life-saving (for mothers and babies) when used appropriately. In fact, I said the following in bold text at the end of the first article in this series:

I want to be clear: no matter where birth takes place, complications may arise that require medical intervention and I am 100% in support of it in these cases.

There is still much we don’t understand about birth, and even more we don’t have direct control over. In some cases, despite a woman’s best efforts to have a natural, undisturbed birth, complications arise that require medical attention (and transfer to a hospital if she started laboring at home). In these circumstances, I absolutely endorse taking advantage of whatever interventions may protect the health and safety of both the mother and baby. At the end of the day, that is far, far more important than the method by which the baby was born.

I also want to be clear that I am not judging women who choose to have hospital births, receive epidurals, induce with Pitocin or end up having a cesarean section. I respect the right of women to choose a method of childbirth that feels safe and comfortable for them.

My purpose, instead, is to tell the side of the story that women are often not told, and to raise awareness of the risks associated with these procedures so that when it comes time to make their own decision, women are adequately educated and informed to do so.

What is an epidural and how common are they?

Dr. Leonard J. Corning, a neurologist in New York, was the first physician to use an epidural. In 1885 he injected cocaine into the back of a patient suffering from spinal weakness and seminal incontinence.

Today, epidurals are by far the most popular method of pain relief during labor in U.S. hospitals. According to the Listening to Mothers II survey (2006), more than 75 percent of women reported that they received an epidural, including 71 percent of women who had a vaginal birth. In Canada in 2005-2006, 54 percent of women who gave birth vaginally used an epidural, and during those same years in England, 22 percent of women overall had an epidural before or during delivery.

In an epidural, a local anesthetic – still derived from cocaine – is injected into the epidural space (the space around the tough coverings that protect the spinal cord). Epidurals block nerve signals from both the sensory and motor nerves, which provides effective pain relief but immobilizes the lower part of the recipient’s body.

In the last decade, a new type of epidural has been developed (called “walking epidurals”) that reduce the motor block and allow some mobility.

Spinal analgesia (a.k.a. “spinals”) are also used for pain relief during labor, but unlike conventional epidurals, they allow women to move during labor. In a spinal, the analgesic drug is injected directly into the spinal space through the dura, producing fast-acting, short-term pain relief.

Epidurals have significant impacts on all hormones of labor

In the last article, Natural Childbirth IV: The Hormones of Birth, we discussed the exquisite orchestration of hormones during birth and the risks of interfering with the body’s natural hormone regulation.

Unfortunately, epidurals interfere with all of the hormones we discussed.

They inhibit beta-endorphin production, which in turn shuts down the shift in consciousness (“going to another planet”) that characterizes undisturbed birth.

Epidurals reduce oxytocin production or keep it from rising during labor. They also blunt the oxytocin peak that would otherwise occur at the time of birth because the stretching receptors of a woman’s lower vagina (which trigger the peak) are numbed.

As Dr. Sarah Buckley explains ¹:

A woman laboring with an epidural therefore misses out on the final powerful contractions of labor and must use her own effort, often against gravity, to compensate for this loss. This explains the increased length of the second stage of labor and the increased need for forceps when an epidural is used.

Epidurals have also been shown to inhibit catecholamine (CA) production. Remember that CA can slow or stop labor in the early stages, but it promotes the fetus ejection reflex in the second stage of labor. Thus inhibiting CA production may make delivery more difficult.

Epidurals limit release of prostaglandin F2 alpha, a lipid compound that stimulates uterine contractions and is thought to be involved with the initiation of labor. Prostaglandin F2 alpha levels should naturally rise during an undisturbed labor. However, in one study women with epidurals experienced a decrease in PGF2 alpha and a consequent increase in labor times from 4.7 to 7.8 hours.

Epidurals interfere with labor and have side effects for mothers

Epidurals have been shown to have the following effects on labor and laboring mothers:

• They lengthen labor.
• They triple the risk of severe perineal tear.
• They may increase the risk of cesarean section by 2.5 times.
• They triple the occurrence of induction with synthetic oxytocin (Pitocin).
• They quadruple the chances a baby will be persistently posterior (POP, face up) in the final stages of labor, which in turn decreases the chances of spontaneous vaginal birth (see below).
• They decrease the chances of spontaneous vaginal delivery. In 6 of 9 studies reviewed in one analysis, less than half of women who received an epidural had a spontaneous vaginal delivery.
• They increase the chances of complications from instrumental delivery. When women with an epidural had a forceps delivery, the amount of force used by the clinician was almost double that used when an epidural was not in place. This is significant because instrumental deliveries can increase the short-term risks of bruising, facial injuries, displacement of skull bones and blood clots in the scalp for babies, and of episiotomy and tears to the vagina and perineum in mothers.
• They increase the risk of pelvic floor problems (urinary, anal and sexual disorders) in mothers after birth, which rarely resolve spontaneously.

One important thing to note about these studies: in most of them, the women in the “control” groups were given opiate painkillers, which are also known to disrupt the natural hormonal processes of birth. We can assume, then, that a comparison of women using no drugs during labor would have revealed even more substantial differences.

Epidural also have side effects for babies

It’s important to understand that drugs administered by epidural enter the baby’s bloodstream at equal and sometimes even higher levels than those present in the mother’s bloodstream.

However, because babies’ immune systems are immature, it takes longer for them to eliminate epidural drugs. For example, the half-life of bupivacaine, a commonly used epidural analgesic, is 2.7 hours in an adult but close to 8 hours in a newborn. ²

Studies have found detectable amounts of bupivacain metabolites in the urine of exposed newborns for 36 hours following spinal anesthesia for cesarians.

Some studies have found deficits in newborn abilities that are consistent with the known toxicity of drugs used in epidurals.

Other studies have found that local anesthetics used in epidurals may adversely effect the newborn immune system, possibly by activating the stress response.

There is evidence that epidurals can compromise fetal blood and oxygen supply, probably via the decrease in maternal blood pressure that epidurals are known to cause.

Epidurals have been shown to cause fetal bradycardia, a decrease in the fetal heart rate (FHR). This is probably secondary to the decrease in maternal CA caused by epidurals which in turn leads to low blood pressure and uterine hyper-stimulation.

Epidurals can cause maternal fever, which in turn may affect the baby. In a large study of first-time moms, babies born to mothers with fever (97% of whom had epidurals) were more likely to be in poor condition (low APGAR scores) at birth, to have poor tone, to require resuscitation and to have seizures in the newborn period, compared to babies born to mothers without fever.

Older studies using the more exacting Brazelton Neonatal Behavioral Assessment Scale (NBAS, devised by pediatricians) rather than the newer, highly criticized Neurologic and Adaptive Capacity Score (NACS, devised by anesthesiologists – can you say “conflict of interest”?) found significant neurobehavioral effects in babies exposed to epidurals.

In one such study, researchers found less alertness and ability to orient, and less mature motor abilities, for the first month of life. These findings were in proportion to the dose of bupivacaine administered, suggesting a dose-related response.

Epidurals may interfere with mother-baby bonding and breastfeeding

Some studies suggest that epidurals may interfere with the normal bonding that occurs between mothers and babies just after birth.

In one study, mothers given epidurals spent less time with their babies in the hospital. The higher doses of drugs they received, the less time they spent.

In another study, mothers who had epidurals described their babies as more difficult to care for one month later than mothers who hadn’t had an epidural.

It’s important to note that neither of these studies prove that epidurals were the cause of the behavioral changes observed. However, if epidurals were at fault, the effects are most likely caused by their interference with the natural orchestration of hormones we discussed in the previous post, and may also be influenced by drug toxicity and the complications associated with epidural births: long labors, forceps and cesareans.

There is also evidence that epidurals may decrease breastfeeding efficiency.

In one study, researchers used the Infant Breastfeeding Assessment Tool (IBFAT) and found scores highest amongst unmedicated babies, lower for babies exposed to epidurals and IV opiates, and lowest for babies exposed to both.

A large prospective study found that women who had used epidurals were more than 2 times as likely to have stopped breastfeeding by 24 weeks compared with women who used non-pharmacological pain relief.

Conclusion

Epidural analgesia is a highly effective form of pain relief and a useful intervention in certain circumstances.

However, epidurals and spinals also cause unintended side effects in both the mother and baby, and interfere with the natural birth process and bonding between mother & baby.

In some cases epidurals may be beneficial, but the evidence suggests that they should not be used as routinely as they currently are in the U.S. and other industrialized countries.

Articles in this series:

• Natural childbirth I: is homebirth more dangerous than hospital birth?
• Natural childbirth IIa: is ultrasound necessary and effective during pregnancy?
• Natural childbirth IIb: ultrasound not as safe as commonly thought
• Natural childbirth III: why undisturbed birth?
• Natural childbirth IV: the hormones of birth
• Natural childbirth V: epidural side effects and risks
• Natural childbirth VI: Pitocin side effects and risks
• Natural childbirth VII: Cesarean risks and complications

Statins are the most popular drugs in history. Drug companies made $26 billion selling statins alone in 2008. 25 million Americans take them, and the number is growing each year.

One reason why statins are the best-selling drug category by far is that 92% of people taking them are healthy. The FDA has approved the prescription of statins to people at low risk for heart disease and stroke, who don’t even have high cholesterol. Two years ago the American Academy of Pediatricians recommended that statins be prescribed for kids as young as eight years old.

With sales statistics like this, you’d think statins are wonder drugs. But when you look closely at the research, a different story emerges. Statins have never been shown to be effective for women of any age, men over 65, or men without pre-existing heart disease. Early studies did suggest that statins are effective for men under 65 with pre-existing heart disease, but later, more rigorous clinical trials has not confirmed this benefit.

In addition, statins have been shown to have serious side effects and complications in up to 30% of people who take them. Studies have also shown that the majority of these adverse events go unreported, because doctors are largely unaware of the risks of statins.

Watch the two videos below to learn the whole story. Or, you can read this article for a concise summary of the evidence.

Video Presentation

Handouts

• Statin research summary: lists the eight statin studies performed in 2008 – 2009, including the drugs and populations studied and the results. If you’re currently taking a statin, you might consider printing this out and taking it to your doctor as a springboard for a conversation about whether statins are right for you.

References

ENHANCE
KasteleinJJ, AkdimF, StroesES, for ENHANCE investigators. Simvastatin with or without ezetimibe in familial hypercholesterolemia. N Engl J Med 2008;358:1431-43

CASHMERE
O’Riordan M. CASHMERE: no IMT effect with atorvastatin over 12 months. (link)

ACHIEVE
O’Riordan M. ACHIEVE stopped: IMT study with Niacin/Laropiprant halted by Merck & Co. (link)

SEAS
Rossebø AB, Pedersen TR, Boman K, et al. Intensive lipid lowering with simvastatin and ezetimibe in aortic stenosis. N Engl J Med 2008;359:1343-56

GISSI-HF
GISSI-HF Investigators, Tavazzi L, Maggioni AP, Marchioli R, et al. Effect of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomized, double-blind, placebo-controlled trial. Lancet 2008;372:1231-9

CORONA
Kjekshus J, Apetrei E, Barrios V, et al. Rosuvastatin in older patients with systolic heart failure. N Engl J Med 2007;357:2248-61

AURORA
Fellström BC, Jardine AG, Schmieder ME, et al for the AURORA study group. Rosuvastatin and cardiovascular events in patients undergoing hemodialysis. N Engl J Med 2009;360:1395-407

JUPITER
Ridker PM, Danielson E, Fonseca FA, et al, for the JUPITER Study Group. Rosuvastatin to prevent vascular events in men and women with elevated C-Reactive protein. N Engl J Med 2008;359:2195-207

Dr. John Briffa wrote a post worth reading on his blog today about the significant side effects of statin drugs, and the considerable effort pharmaceutical companies and the medical establishment spend trying to convince people that these drugs are safe.

Sadly, they’ve been largely successful. Some time ago a physician in the UK by the name of Dr. John Reckless (you can’t make this stuff up) suggested that statins are so safe that they should be put in the water supply!

That’s ridiculous, of course. Statins are dangerous drugs. What’s more, they don’t reduce the risk of total mortality (death from any cause) for 95% of the population. See my articles The Truth About Statin Drugs and More Statin Shenanigans for more on this.

If you’re wondering why you haven’t heard more about the danger of statin drugs, check out another great post Dr. Briffa wrote a couple of weeks ago called Adverse effects of drugs are “neglected, restricted, distorted or silenced”.

There’s big money in the drug business, folks. The total pharmaceutical industry is worth hundreds of billions, and drug companies make $25 billion on statin sales alone. Do you think they’re going to go out of their way to tell everyone about the side effects and risks of these drugs? They’re legally obligated to maximize profits for their shareholders, as are all corporations, and maximizing profits means selling as many pills as they can.

That’s just the way it works. Unfortunately, people like you and I and our families are the victims of this profit-driven health care system.

This week’s article in my continuing series on depression and antidepressants will examine the physiological, psychological and social consequences of antidepressant use.

Although these drugs are generally considered to be safe by the media and amongst medical professionals and patients, a close look at the evidence suggests otherwise. Antidepressants have serious and potentially fatal adverse effects, cause potentially permanent brain damage, increase the risk of suicide and violent behavior in both children and adults, and increase the frequency and chronicity of depression. Chronic use of antidepressants also promotes dependency on drugs rather than empowering people to make positive life changes, and places a tremendous burden on healthcare systems in the U.S. and abroad – but I will discuss those issues in next week’s article.

Physiological side effects

The adverse effects of antidepressants include movement disorders, agitation, sexual dysfunction, improper bone development, improper brain development, gastrointestinal bleeding, and a variety of other lesser known problems. These are not rare events, but the most significant harm comes only after months or years of use, which leads to the false impression that antidepressants seem quite safe.

More than half of those beginning an antidepressant have one of the more common side effects (Brambilla et al. 2005).

While some side effects may not carry serious health risks, others do. Gastrointestinal bleeding can become a life-threatening condition, and improper bone development in children is a serious problem that can lead to increased skeletal problems and frequent bone fractures as they age. It has been shown that serotonin exposure in young mice impairs their brain’s cerebral development (Esaki et al. 2005), and many researchers believe that the use of SSRI medications in pregnant mothers and young children may predispose children to emotional disorders later in life (Ansorge et al. 2004).

Another problem with the side effects caused by antidepressants that is often not discussed is the likelihood that additional medications will be prescribed to control them. It is well-known that Prozac produces anxiety and agitation, so physicians often prescribe a sedative (typically a benzodiazapene) along with it. Since recent studies have shown that antidepressants cause gastrointestinal bleeding, doctors are starting to prescribe acid-inhibiting drugs such as Nexium to prevent this side effect. These drugs also inevitably cause side effects, which may lead to the prescription of even more drugs. (This is not uncommon, as I pointed out in last week’s article.)

Psychological side effects

Perhaps the best known psychological side effect of SSRIs is “amotivational syndrome”, a condition with symptoms that are clinically similar to those that develop when the frontal lobes of the brain are damaged. The syndrome is characterized by apathy, disinhibited behavior, demotivation and a personality change similar to the effects of lobotomy (Marangell et al. 2001, p.1059). All psychoactive drugs, including antidepressants, are known to blunt our emotional responses to some extent.

Clinical studies of SSRIs report that agitation is a common side effect. When Yale University’s Department of Psychiatry analyzed the admissions to their hospital’s psychiatric unit, they found that 8.1% of the patients were “found to have been admitted owing to antidepressant mania or psychosis” (Preda et al. 2001). Agitation is such a common side effect with SSRIs that the drug companies have consistently sought to hide it during clinical trials by prescribing a tranquilizer or sedative along with the antidepressant. Studies by Eli Lilly employees found that between 21% and 28% of patients taking Prozac experienced insomnia, agitation, anxiety, nervousness and restlessness, with the highest rates among people taking the highest doses (Beasley et al. 2001).

From their inception, antidepressants have been recognized as having a worrisome capacity to incite changes between episodes of depression (characterized by dysphoria, insomnia, low energy, poor concentration, reduced appetite and diminished libido) and episodes of mania (characterized by euphoria, increased activity, rapid speech, racing thoughts, diminished need for sleep, hypersexuality and diminished impulse control).

Several reports suggest that SSRIs are associated with movement disorders such as akathisia, Parkinson’s disease, dystonia (acute rigidity), dyskinesia (abnormal involuntary choreic movements) and tardive dyskiniesia (Gerber & Lynd 1998).

These movement disorders are serious enough on their own. However, what is even more alarming is the potential for akathisia to induce aggression and suicide. Akathisia, a condition of inner restlessness or severe agitation, is the most commonly occurring movement disorder associated with psychoactive drug use. Akathisia-related violence receives specific attention in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Akathisia has been shown to increase violent behavior and suicide, and antidepressants are known to cause akathisia.

Suicide

After years of foot-dragging and thousands of excess suicides, the FDA finally admitted that “two to three children out of every hundred” could be expected to develop suicidal thoughts or actions as a result of antidepressant therapy (Harris 2004). The risk of suicide events for children receiving SSRIs has been three times higher than placebo. (Healy 2005). Amazingly, no bans or restrictions have been placed on their use in children in the U.S.

While the increased risk of suicide in children has become better known, most people are unaware that a similar risk exists for adults. When adult antidepressant trials were re-analyzed to compensate for erroneous methodologies, SSRIs have consistently revealed a risk of suicide (completed or attempted) that is two to four times higher than placebo (Healy 2005).

Turning short-term suffering into long-term misery

A growing body of research supports the hypothesis that antidepressants worsen the chronicity, if not severity, of depressive features in many subjects. Antidepressant therapy is often associated with the poorest outcomes. In a large, retrospective study in the Netherlands of more than 12,000 patients, antidepressant exposure was associated with the worst long term results. 72-79% of the patients who relapsed received antidepressants during their initial episode of depression. In contrast, only one of the patients who did not relapse received no antidepressants during or following the initial episode. (Weel-Baumgarten 2000)

Longitudinal (long-term) follow-up stuides show very poor outcomes for people treated for depression in both hospital and outpatient settings, and the overall prevalence of depression is rising despite increased use of antidepressants (Moncrieff & Kirsch 2006).

Epidemiological observations have long held that most episodes of depression end after three to six months. However, almost half of all Americans treated with antidepressants have remained on medication for more than a year (Antonuccio et al. 2004).

Long-term effects of antidepressants

Antidepressants have been shown to produce long-term, and in some cases, irreversible chemical and structural changes to the body and brain.

The administration of Prozac and Paxil raises cortisol levels in human subjects (Jackson 2005, p.90). Given the fact that elevated cortisol levels are associated with depression, weight gain, immune dysfunction, and memory problems, the possibility that antidepressants may contribute to prolonged elevations in cortisol is alarming to say the least.

In a study designed to investigate the anatomic effects of serotonergenic compounds, researchers at Thomas Jefferson University found that high-dose, short-term exposure to SSRIs in rats was sufficient to produce swelling and kinking in the serotonin nerve fibers (Kalia 2000). Research performed by a different team of investigators demonstrated a reduction in dendritic length and dendritic spine density, and in contrast to the previous study, these changes did not reverse even after a prolonged recovery period. The results were interpreted to suggest that chronic exposure to SSRIs may arrest the normal development of neurons.

I want to emphasize that what I’ve covered here is only the beginning of the story when it comes to the adverse effects of antidepressants. There are volumes of published research and many books which present this information with much more detail. I recommend Peter Breggin’s landmark “Brain Disabling Treatments in Psychiatry” and Grace Jackson’s “Rethinking Psychiatric Drugs” as resources if you are interested in pursuing this further.

I just came across a recently published study which revealed that SSRIs (the most popular class of antidepressants) can cause gastrointestinal bleeding. The first thing I always do when reading a study is check to see who the authors are, where they receive funding from and who the sponsor is.

So you can imagine my surprise when I learned that this study, which casts antidepressants in an unfavorable light, was sponsored by a large pharmaceutical company (AstraZeneca).

Could drug companies be experiencing a change of heart? A pang of conscience? Could this mark a new era of integrity and honesty in the reporting of results from drug trials?

Not so much.

Being the skeptic that I am, I thought for a moment about why a drug company would sponsor and then publish a study investigating the side effects of antidepressant when the results are so clearly negative? We know from my previous article on conflicts of interest in the medical field that drug companies are under no obligation to publish study results – and often they do not when the results are unfavorable.

One reason came immediately to my mind: what if that company happened to manufacture a drug that could be used to counter the side effects antidepressants? And what if their study not only demonstrated the side effect antidepressants, but also the effectiveness of their drug in mitigating or treating that side effect?

Turns out that’s exactly what’s happening here. AstraZeneca is the manufacturer of Nexium, one of the most popularly prescribed medications for heartburn. Nexium works by inhibiting the production of acid in the stomach.

Now, check out how the study was designed. There were three groups. The first group was people taking SSRIs only. The second group was people taking SSRIs and NSAIDs (ibuprofen, aspirin, etc.) and other anti-inflammatory drugs known to be harmful to the stomach lining. The third group took SSRIs along with acid-suppressing agents (agents like Nexium, for example).

People taking the SSRIs were more likely to have G.I. bleeding than people on placebo, and those taking both SSRIs and anti-inflammatory drugs were even more likely to bleed than people on SSRIs alone.

But guess what? Acid suppressing agents (like, um, let’s say… Nexium) were associated with a reduced risk of upper GI bleeding in those taking SSRIs.

We can see where this is leading, right? The solution to the G.I. bleeding caused by SSRIs is not to stop taking the SSRIs. The solution is to take another drug! In this case, a drug that is manufactured by the company who sponsored the study.

Unfortunately, this vicious cycle of medication use is very common. A common scenario might be someone takes an SSRI for depression, but it causes anxiety. So the doctor prescribes something for anxiety. Unfortunately, many medications for anxiety also cause constipation. But there’s a pill for that too, which the doctor also prescribes. Then the patient finds they’re getting some acid reflux (a side effect of some of the medicines for constipation), so the doctor prescribes an acid-suppressing agent.

You might be laughing (or crying) as you read this, but I am not exaggerating. This is very often how it works, especially in the elderly who now take an average of 6-8 medications every day.

And this is bound to continue to happen as long as research is primarily sponsored by pharmaceutical companies. The author of the study, Dr. García-Rodríguez, has received “unrestricted research grants from Pfizer Inc., AstraZeneca and Novartis Pharmaceuticals Group”.

There’s no way to prove that Dr. Garcia-Rodriguez’s work is being unduly influenced by his close connection with drug companies. But common sense, as well as many published scientific studies, indicates that this is very likely. For example, several studies have shown that researchers who produce data that is contrary to the interests of the pharmaceutical industry risk legal, professional, or even personal attack – directly or indirectly financed by the industry. (Bosley, 2002; Healy, 2002; Monbiot, 2002).

Fortunately, many influential leaders are calling for changes to be made to the way medical research is performed and distributed. But they are facing the opposition of a $500 billion dollar industry with more lobbyists than there are members of Congress. It’s not going to be easy.