"Mainly, in all of the groups of labor pain medications and delivery method, we found that mothers who received labor pain medications were 2-3 times more likely to report [delay in the onset of lactation] DOL compared to mothers who did not use labor pain medications and delivered vaginally."

May 28, 2013:

In today’s post, I have pulled out five of the most common drugs used for epidural anesthesia.  I am not passing judgment on families that choose an epidural.  There are definitely times when the benefits outweigh the risks.  Each family has to make the choice that is right for them.

To be clear – we are not anti-care provider or anti-drug.  We are grateful for modern medicine that saves lives in circumstances when Mother Nature needs help.  It exists for a reason, and we are thankful for the opportunity to meet all the Healthy Moms and Healthy Babies when we hold a class reunion.

Please read and consider this information as you prepare for the birth of your baby.  I included the link to find the complete drug label on-line.  Everything underneath the drug name is in quotations because I *literally* pulled it off the label available online and onto this entry.

“Lidocaine readily crosses the placental barrier.”

“Systemic toxicity may result in manifestations of central nervous system depression (sedation) or irritability (twitching), which may progress to frank convulsions accompanied by respiratory depression and/or arrest.” 

“The adverse experiences under Central Nervous System and Cardiovascular System are listed, in general, in a progression from mild to severe.”

“Central Nervous System: CNS reactions are excitatory and/or depressant and may be characterized by light-headedness, nervousness, apprehension, euphoria, confusion, dizziness, drowsiness, tinnitus, blurred or double vision, vomiting, sensations of heat, cold or numbness, twitching, tremors, convulsions, unconsciousness, respiratory depression and arrest. The excitatory reactions may be very brief or may not occur at all, in which case, the first manifestation of toxicity may be drowsiness, merging into unconsciousness and respiratory arrest.”

“Cardiovascular System: Cardiovascular reactions are usually depressant in nature and are characterized by bradycardia, hypotension and cardiovascular collapse, which may lead to cardiac arrest.”

“Local anesthetics rapidly cross the placenta, and when used for epidural, caudal, or pudendal block anesthesia, can cause varying degrees of maternal, fetal, and neonatal toxicity.”

“Maternal hypotension has resulted from regional anesthesia. Local anesthetics produce vasodilation by blocking sympathetic nerves. Elevating the patient’s legs and positioning her on her left side will help prevent decreases in blood pressure. The fetal heart rate also should be monitored continuously and electronic fetal monitoring is highly advisable.”

“Epidural, caudal, or pudendal anesthesia may alter the forces of parturition through changes in uterine contractility or maternal expulsive efforts. Epidural anesthesia has been reported to prolong the second stage of labor by removing the parturient’s reflex urge to bear down or by interfering with motor function.   The use of obstetrical anesthesia may increase the need for forceps assistance.”

“The use of some local anesthetic drug products during labor and delivery may be followed by diminished muscle strength and tone for the first day or two of life. This has not been reported with bupivacaine.”

“Clonidine Hydrochloride Injection (epidural clonidine) is not recommended for obstetrical, postpartum, or peri-operative pain management.  The risk of hemodynamic instability, especially hypotension and bradycardia, from epidural clonidine may be unacceptable in these patients.  However, in a rare obstetrical, post-partum or peri-operative patient, potential benefits may outweigh the possible risks.”

“Clonidine readily crosses the placenta and its concentrations are equal in maternal and umbilical cord plasma; amniotic fluid concentrations can be 4-times those found in serum.  There are no adequate and well-controlled studies in pregnant women during early gestation when organ formation takes place.  Studies using epidural clonidine during labor have demonstrated no apparent adverse effects on the infant at the time of delivery.  However, these studies did not monitor the infants for hemodynamic effects in the days following delivery.  Clonidine should be used during pregnancy only if the potential benefits justify the potential risk to the fetus.

“Labor and Delivery:  There are no adequate controlled clinical trials evaluating the safety, efficacy, and dosing of clonidine in obstetrical settings. Because maternal perfusion of the placenta is critically dependent on blood pressure, use of clonidine as an analgesic during labor and delivery is not indicated (see WARNINGS).”

“Nursing Mothers:  Concentrations of clonidine in human breast milk are approximately twice those found in maternal plasma.  Caution should be exercised when clonidine is administered to a nursing woman.  Because of the potential for severe adverse reactions in nursing infants, a decision should be made to either discontinue nursing or to discontinue clonidine.”

Labor and Delivery

“Fentanyl readily passes across the placenta to the fetus; therefore, DURAGESIC® is not recommended for analgesia during labor and delivery.” 

“Serious or life-threatening hypoventilation may occur at any time during the use of DURAGESIC® especially during the initial 24-72 hours following initiation of therapy and following increases in dose.”

“Respiratory depression from opioids is manifested by a reduced urge to breathe and a decreased rate of respiration, often associated with the “sighing” pattern of breathing (deep breaths separated by abnormally long pauses). Carbon dioxide retention from opioid-induced respiratory depression can exacerbate the sedating effects of opioids. This makes overdoses involving drugs with sedative properties and opioids especially dangerous.”

“Skeletal muscle rigidity is related to the dose and speed of administration of sufentanil. This muscular rigidity may occur unless preventative measures are taken (see WARNINGS).”

“Decreased respiratory drive and increased airway resistance occur with sufentanil. The duration and degree of respiratory depression are dose related when sufentanil is used at sub-anesthetic dosages. At high doses, a pronounced decrease in pulmonary exchange and apnea may be produced.”

"There are insufficient data to critically evaluate neonatal neuromuscular and adaptive capacity following recommended doses of maternally administered epidural sufentanil with bupivacaine. However, if larger than recommended doses are used for combined local and systemic analgesia, e.g., after administration of a single dose of 50 mcg epidural sufentanil during delivery, then impaired neonatal adaption to sound and light can be detected for 1 to 4 hours and if a dose of 80 mcg is used, impaired neuromuscular coordination can be detected for more than 4 hours."

"The use of epidurally administered sufentanil in combination with bupivacaine 0.125% with or without epinephrine is indicated for labor and delivery. (See INDICATIONS AND USAGE and DOSAGE AND ADMINISTRATION.) Sufentanil is not recommended for intravenous use or for use of larger epidural doses during labor and delivery because of potential risks to the newborn infant after delivery. In clinical trials, one case of severe fetal bradycardia associated with maternal hypotension was reported within 8 minutes of maternal administration of sufentanil 15 mcg plus bupivacaine 0.125% (10 mL total volume)."

“Lactation: excreted in breast milk”

Side effects: “Nausea, vomiting, constipation, dry mouth, flushing, sweating, lightheadedness, dizziness, drowsiness, and pain/redness at the injection site may occur. If any of these effects persist or worsen, notify your doctor or pharmacist promptly… Tell your doctor right away if you have any serious side effects, including: slow/irregular/fast heartbeat, mental/mood changes (e.g., confusion, hallucinations, nervousness), numbness, shakiness (tremors), trouble urinating, severe stomach/abdominal pain, change in the amount of urine.  Get medical help right away if you have any very serious side effects, including: slow/shallow breathing, fainting, seizures.”

“Before using this medication, women of childbearing age should talk with their doctor(s) about the risks and benefits. Tell your doctor if you are pregnant or if you plan to become pregnant. During pregnancy, this medication should be used only when clearly needed. It may slightly increase the risk of birth defects if used during the first two months of pregnancy. Also, using it for a long time or in high doses near the expected delivery date may harm the unborn baby. To lessen the risk, use the smallest effective dose for the shortest possible time. Tell the doctor right away if you notice any symptoms in your newborn baby such as slow/shallow breathing, irritability, abnormal/persistent crying, vomiting, or diarrhea."

"This drug passes into breast milk and is unlikely to harm a nursing infant. Consult your doctor before breast-feeding.”

Disclaimer: 
The material included on this site is for informational purposes only.
It is not intended nor implied to be a substitute for professional medical advice. The reader should always consult her or his healthcare provider to determine the appropriateness of the information for their own situation.  Krystyna and Bruss Bowman and Bowman House, LLC accept no liability for the content of this site, or for the consequences of any actions taken on the basis of the information provided.  This blog contains information about our classes available in Chandler, AZ and Payson, AZ and is not the official website of The Bradley Method®. The views contained on this blog do not necessarily reflect those of The Bradley Method® or the American Academy of Husband-Coached Childbirth®.

When looking up the drugs used that stimulate uterine contractions, Oxytocics, I also noticed that this post needs to include the drugs that are used to reverse the effect of those drugs, a group called Tocolytics.  As with the two previous posts in this series, I have listed the FDA Pregnancy category, included links to the complete drug profiles, and then pulled out the warning, adverse reaction, and contraindication sections for you to read right here and right now.

• Anaphylactic reaction
• Premature ventricular contractions
• Postpartum hemorrhage
• Pelvic hematoma
• Cardiac arrhythmia
• Subarachnoid hemorrhage
• Fatal afibrinogenemia
• Hypertensive episodes
• Nausea
• Rupture of the uterus
• Vomiting
• Excessive dosage or hypersensitivity to the drug may result in uterine hypertonicity, spasm, tetanic contraction, or rupture of the uterus.”

•   Bradycardia
•   Premature ventricular contractions and other arrhythmias
•   Permanent CNS or brain damage
•   Fetal death
•   Neonatal seizures have been reported with the use of Pitocin.

• Low Apgar scores at five minutes
• Neonatal jaundice
• Neonatal retinal hemorrhage

Cervidil is contraindicated in:

"- Patients with known hypersensitivity to prostaglandins.

- Patients in whom there is clinical suspicion or definite evidence of fetal distress where delivery is not imminent.

- Patients with unexplained vaginal bleeding during this pregnancy.

- Patients in whom there is evidence or strong suspicion of marked cephalopelvic disproportion.

- Patients in whom oxytocic drugs are contraindicated or when prolonged contraction of the uterus may be detrimental to fetal safety or uterine integrity, such as previous cesarean section or major uterine surgery (see PRECAUTIONS and ADVERSE REACTIONS).

- Patients already receiving intravenous oxytocic drugs.

- Multipara with 6 or more previous term pregnancies."

"Warnings

Women aged 30 years or older, those with complications during pregnancy and those with a gestational age over 40 weeks have been shown to have an increased risk of postpartum disseminated intravascular coagulation. In addition, these factors may further increase the risk associated with labor induction (See ADVERSE REACTIONS, Post-marketing surveillance). Therefore, in these women, use of dinoprostone should be undertaken with caution. Measures should be applied to detect as soon as possible an evolving fibrinolysis in the immediate post-partum period.

The Clinician should be alert that use of dinoprostone may result in inadvertent disruption and subsequent embolization of antigenic tissue causing in rare circumstances the development of Anaphylactoid Syndrome of Pregnancy (Amniotic Fluid Embolism)."

"Precautions

General: Since prostaglandins potentiate the effect of oxytocin, Cervidil must be removed before oxytocin administration is initiated and the patient's uterine activity carefully monitored for uterine hyperstimulation. If uterine hyperstimulation is encountered or if labor commences, the vaginal insert should be removed. Cervidil should also be removed prior to amniotomy.

Cervidil is contraindicated when prolonged contraction of the uterus may be detrimental to fetal safety and uterine integrity. Therefore, Cervidil should not be administered to patients with a history of previous cesarean section or uterine surgery given the potential risk for uterine rupture and associated obstetrical complications, including the need for hysterectomy and the occurrence of fetal or neonatal death.

2. Drug Interactions: Cervidil may augment the activity of oxytocic agents and their concomitant use is not recommended. A dosing interval of at least 30 minutes is recommended for the sequential use of oxytocin following the removal of the dinoprostone vaginal insert. No other drug interactions have been identified."

"Post-marketing surveillance:

Immune System Disorders: Hypersensitivity

Blood and lymphatic system disorders: Disseminated Intravascular Coagulation (See WarningsSection)

Reproductive system: Reports of uterine rupture have been reported in association with use of Cervidil some required a hysterectomy and some resulted in subsequent fetal or neonatal death.

Vascular Disorders: Hypotension

Pregnancy, Puerperium and Perinatal Conditions: Amniotic fluid embolism"

"Contraindications:

Hypersensitivity to dinoprostone, prostaglandins, or any components of the product; patients in whom oxytocic drugs are contraindicated or when prolonged contractions of uterus are considered inappropriate; ruptured membranes; placenta previa; unexplained vaginal bleeding during current pregnancy; when vaginal delivery is not indicated; acute pelvic inflammatory disease; active cardiac, pulmonary, renal, or hepatic disease (suppository only)."

"General advice:

Carefully examine vagina to determine degree of effacement and appropriate length of endocervical catheter to be used for application of gel (10 mm if 50% effaced, 20 mm if no effacement).

Patient should be in dorsal position for administration and remain supine for 15 to 30 min after administration of cervical gel.

Following administration of vaginal suppository, the patient should remain in the supine position for 10 min.

Following administration of the vaginal insert, the patient should remain in a recumbent position for 2 h.

Inserts do not require warming prior to administration.

Suppositories and gel must be brought to room temperature. Do not use external sources of heat (eg, hot water bath, microwave oven) to decrease warming time.

Wait at least 6 to 12 h after administration of gel before using IV oxytocin; a dosing interval of at least 30 min is recommended after removal of insert.

Do not use dinoprostone vaginal suppository for extemporaneous preparation of any other dosage forms or for cervical ripening or other indications in the patient with term pregnancy."

"May augment effect of other oxytocic agents; avoid concomitant use. For the sequential use of oxytocin following dinoprostone cervical gel administration, a dosing interval of 6 to 12 h is recommended. A dosing interval of at least 30 min is recommended for the sequential use of oxytocin following the removal of the dinoprostone vaginal insert."

"Pregnancy Category C. Contraindicated if fetus in utero has reached viability stage except when cervical ripening is indicated."

"Lactation: Undetermined."

"Special Risk Patients

Use with caution in patients with asthma, glaucoma, or raised IOP, hypotension or hypertension, CV or renal or hepatic impairment, anemia, jaundice, diabetes, epilepsy, compromised uterus, infected endocervical lesions, acute vaginitis, in patients with cases of non-vertex or non-singleton presentation, and in patients with a history of previous uterine hypertony.

-Anaphylactoid syndrome of pregnancy Intracervical placement of dinoprostone may result in inadvertent disruption and subsequent embolization of antigenic tissue, and rarely leads to development of anaphylactoid syndrome of pregnancy (amniotic fluid embolism).

- Incomplete pregnancy termination If dinoprostone pregnancy termination is incomplete, take other measures to ensure complete abortion.

- Postpartum disseminated intravascular coagulation An increased risk has been described in patients whose labor was induced by physiologic means. Women who are 30 y and older, those with complications during pregnancy, and those with gestational age more than 40 wk are at risk.

- Pyrexia Transient pyrexia (temperature elevations in excess of 2°F), possibly due to the dinoprostone effect on hypothalamic regulation, was observed in 50% of patients receiving suppositories at the recommended dosage. Temperature returned to normal on discontinuation of therapy.

- Ruptured membranes Exercise caution when administering dinoprostone cervical gel or vaginal insert to patients with ruptured membranes.

- Uterine hyperstimulation Placement of dinoprostone cervical gel into the extra-amniotic space has been associated with uterine hyperstimulation. When using the vaginal insert, if uterine hyperstimulation is encountered or if labor starts, the vaginal insert should be removed."

"Generic Name: misoprostol (MYE-soe-PROST-ol) Brand Name: Cytotec Do not take Cytotec to reduce the risk of stomach ulcers caused by nonsteroidal anti-inflammatory drugs (NSAIDs) if you are pregnant. Cytotec may cause abortion, premature birth, or birth defects if taken during pregnancy. Life-threatening..."

(My note: yes - this is just how it appears - with the ellipsis there)

"Misoprostol has been assigned to pregnancy category X by the FDA. Animal studies have failed to reveal evidence of fetotoxicity and teratogenicity. In studies of women undergoing elective first trimester abortion, the administration of misoprostol 400 mcg for two doses caused increased uterine contractions and bleeding in 41% of cases, and partial or complete expulsion of uterine contents in 11% of cases." 

"Breastfeeding Warnings

Misoprostol is rapidly metabolized in the mother to misoprostol acid which is biologically active and is excreted in human breast milk. There are no published reports of adverse effects of misoprostol in breast-feeding infants of mothers taking misoprostol. The manufacturer recommends that caution should be exercised when misoprostol is administered to a nursing woman."

"What should I discuss with my healthcare provider before receiving Pitocin (oxytocin)?

You should not receive this medication if you have ever had an allergic reaction to oxytocin."

"To make sure oxytocin is safe for you, tell your doctor if you have:

genital herpes;

diabetes;

• high blood pressure;
• a heart rhythm disorder;
• a history of cervical cancer;
• a history of severe infection in your uterus;
• a history of difficult labor because you have a small pelvis;
• if you have ever had surgery on your cervix or uterus (including a prior C-section);
• if your pregnancy is less than 37 weeks; or
• if you have had 5 or more pregnancies.’’

"Tell your caregivers at once if you have a serious side effect such as:

fast, slow, or uneven heart rate;

excessive bleeding long after childbirth;

headache, confusion, slurred speech, hallucinations, severe vomiting, severe weakness, muscle cramps, loss of coordination, feeling unsteady, seizure (convulsions), fainting, shallow breathing or breathing that stops; or dangerously high blood pressure (severe headache, blurred vision, buzzing in your ears, anxiety, confusion, chest pain, shortness of breath, uneven heartbeats, seizure)."

"Less serious side effects may include:

• nausea, vomiting;
• runny nose, sinus pain or irritation;
• memory problems; or
• more intense or more frequent contractions (this is an expected effect of oxytocin)."

"For Health Professionals

Hepatic side effects have included neonatal jaundice."

Read more at HERE 

"Genitourinary

Genitourinary side effects have included pelvic hematoma. Excessive doses have produced pelvic fracture, uterine hypertonicity, spasm, tetanic contraction and rupture."

"Hematologic

Hematologic side effects have included postpartum hemorrhage and fatal afibrinogenemia."

Read more HERE 

"General side effects have include low Apgar scores at 5 minutes. Fetal death has been reported."

Read more HERE 

• Is Mom okay?
• Is Baby okay?
• What are the benefits of using this drug?
• What are the risks of using this drug? (You have the right to read the drug insert for yourself in the care facility)
• What else is going to happen if we say yes? (Additional procedures, time in bed, time being monitored, position for mom, etc.)
• What are the expected results?  What if we don’t see them? 
• What are the alternatives if we choose not to do this?
• What does our intuition tell us?
• What happens if we choose to do nothing?