Epidurals: Do they prevent postpartum depression?

Leonardo da Vinci

Leonardo da Vinci

Do epidurals prevent postpartum depression? That’s the intriguing conclusion some people are drawing from a study published in this month’s issue of Anesthesia and Analgesia. But is that conclusion correct?

In a study of 214 women at Peking First University Hospital in Beijing, researchers found that 14% of women who received epidural analgesia during labor reported symptoms of postpartum depression (PPD) six weeks later, compared with 34.6% of women who refused epidurals. The authors point out that their findings don’t necessarily prove that epidurals can prevent PPD, but the language in the discussion sure sounds like that’s what they believe.

But…the premise of this study is flawed from the start, because the investigators compared epidural analgesia to, well, nothing:

“Each parturient made a decision by herself to have epidural labor analgesia or no pain relief at all. Other forms of analgesia are not available at our hospital.”

What does “no pain relief at all” mean at Peking First University Hospital?  Were spouses/doulas/other support people allowed in the room? Did the mothers labor alone? Does “no pain relief at all” mean no freedom to move about, no bath/massage/music/visualization exercises/birth balls, none of the myriad other comfort measures that can reduce pain during labor? It obviously means no nitrous oxide, and I presume no tylenol or ibuprofen, either. In this particular hospital it seems, the choice is pretty stark: you get an epidural or you tough it out.

Which means we’re left with a study of unaddressed labor pain and postpartum depression, not the benefits of epidurals.

Karl Gauss, inventor of Twilight Sleep

Not exactly “new news”: Dr. Karl Gauss, inventor of Twilight Sleep

It’s hardly news that uncontrolled pain can lead to postpartum depression. One of the main drivers in the “painless childbirth” movement of the mid-19th century and the development of Twilight Sleep in the early 20th century was the prevention of neurasthenia—a debilitating combination of anxiety and depression that haunted many postpartum women.* 

This study would be more compelling if the authors had compared epidurals with other pain relief modalities in the setting of a well-supported labor. Otherwise we’re left with the conclusion that uncontrolled labor pain can make women miserable, and medically obliterated pain makes them less so. 

I can’t think of any other form of human pain that would be studied in such an all-or-none way.

* * *

* Department of Shameless Self-Promotion: You can read more about the history of painless childbirth, as well as what a lousy labor coach I was, in my book, Birth Day: A Pediatrician Explores the Science, the History, and the Wonders of Childbirth.  

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Filed under Birth Day, Labor pain, Maternal-child health, Natural childbirth

Is it the cesarean, or the absence of labor?

Stem cells, pondering the future

Stem cells, pondering the future

I’ve written a fair amount about the association between cesarean birth and the increased risk of immune-related diseases like asthma, diabetes, celiac disease, and even obesity. Most of the research out there has focused on the newborn gut microbiota—the collection of bacteria that colonize a baby’s intestines at birth and play a key role in the development of the immune system. These bacteria are primarily acquired from the mother’s birth canal and rectum during a vaginal birth, but for cesarean-born babies those “pioneer” bacteria are often derived from the hospital environment. Such “wrong” bacteria in the bowel early on can lead to inflammation and, the theories go, to immune-related diseases later in life.

But is the cesarean per se at the root of all this? Or might the absence of labor (or an incomplete labor) have something to do with it? Childbirth is, after all, a fabulously complicated dance of maternal and fetal hormones, anti-oxidants, and other chemicals that are known to influence the immune system. What happens to the newborn’s immune system development when that dance is cut short, or never starts in the first place?

A study from Sweden’s Karolinska Institutet published in the current issue of the American Journal of Obstetrics and Gynecology has me wondering about the “absent-labor” scenario again. The study’s authors compared cord blood samples from babies born by elective cesarean section (ECS) with those who were vaginally born (VB). They looked specifically at hematopoietic stem cells—the precursor cells that go on to become, among other things, the white blood cells that play a critical role in the human immune system.

Here’s what they found: the DNA in stem cells from ECS babies was significantly different from that of the VB babies, particularly in an area devoted to production of antibodies. The study’s genetic analysis is way above my pay grade, but boiled down to the essentials, the differences are all about epigenetics, which is defined as:

 “…the study of changes in gene function that are mitotically and/or meiotically heritable and that do not entail a change in DNA sequence.”

Ouch!

Plain English version (mine): Epigenetics is the study of how genes are turned on and off, typically by the addition of methyl groups (ouch, again!) to genes. The timing of all this light-switch-like activity, and the potential for permanent change, has big-time implications for health throughout life.

The Swedish researchers found that stem cell DNA methylation (the addition of methyl groups to genes) increased steadily with the duration of labor. So one could conclude, couldn’t one, that normal labor plays an important role in preparing future white blood cells for their task, and, ergo, the absence of labor is why everyone’s so chubby these days? Sure, one could conclude that…but one would be jumping the gun, big time.

Hold that smokin' gun, pardner!

Hold that smokin’ gun, pardner!

Why? Because this was a small, observational study—the kind of study designed to make readers sit up and take notice (Hmm…that’s interesting!”) but that requires much more research before any guns start smoking. The small numbers of subjects in this study makes it easier for error to creep in, for example, and there were significant differences between the mothers as well—the ECS group was significantly older than the VB group, and their babies were born an average of a week and a half earlier, factors which might cause their own epigenetic effects.

It’s going to take much larger studies to see if these findings are in fact true, and if so to tease out how significant such cesarean-related epigenetic changes may be in the grand scheme of childhood immune system diseases. A lot of vaginally born kids end up asthma, after all. Including me.

But still, how fascinating! I’m looking forward to reading more about this.

* * *

Photos courtesy Joseph Elsbernd, Jim Sher

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Filed under Asthma, Cesareans, Gut microbiota, Natural childbirth, Obesity

Shout-out #1: Enlightened Mama in the Twin Cities

Such a place!

Such a place!

I’ve given a couple of talks in the Midwest this month, and I want to give a shout-out to two very worthy organizations: Enlightened Mama in St. Paul, Minnesota (this post) and Southwest Tech in Fennimore, Wisconsin (coming soon).

I first met Liz Abbene, Enlightened Mama’s founder and “Alpha Mama,” a couple of years ago when I was speaking at the 2012 REACHE conference in Seattle. As we chatted about the conference I was impressed by Liz’s ability to carry on a coherent conversation while buried in children (she has four beautiful kids). Anyone who could keep that many balls in the air at one time, I figured, must run a pretty interesting business.

When the conference wound down, Liz extended me an invitation to speak at Enlightened Mama if I was ever in the Twin Cities. Sure, I said, figuring what are the chances of that ever happening? I’d never been to the Twin Cities and didn’t really have any plans to travel there.

Liz Abbene

Liz Abbene

Ah, but life has a way of changing one’s plans. Last year I enrolled in the University of Minnesota’s Masters in Public Health program, which requires online students to spend a couple of weeks on campus during the year. So I came to the Twin Cities for UMN’s Public Health Institute in early June and, as Liz had willed back in Seattle, I wound up at Enlightened Mama talking on the wonders of the newborn microbiome.

Space does not allow me to describe all that Liz does at Enlightened Mama. Suffice it to say that along with doula services she and her staff and partners provide lactation support and breastfeeding classes; massage, acupuncture and chiropractic care; family therapy and career counseling; and a number of other classes and services that promote wellness before, during, and after childbirth. Alas, there is no brewpub or nail salon at Enlightened Mama, but for all I know these are in the works.

Enlightened Mama is a great resource for families in the Minneapolis-St.Paul area. So if you live there and you’re pregnant, give Liz a call!

P.S: When I asked one St. Paul mother how her town differed from Minneapolis, she told me this:

“People from Minneapolis love to tell you how cool it is to live there. People from St. Paul already know we live in a cool town. No need to brag about it.”

I remain neutral in the matter…

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Filed under Breastfeeding, Doulas, Maternal-child health, Natural childbirth

An anniversary of sorts

Kind of looked like this...

Kind of looked like this…

Today marks the 35th anniversary of my first day of pediatric internship at the University of Michigan. The first day is nerve-wracking for any doctor-in-training, and mine was even more wrack-y because I was assigned to Wayne County General Hospital, a forty-minute drive from my apartment in Ann Arbor. Not much for planning ahead in those days, I didn’t think to take a trial run beforehand to see where I needed to go.

So early on the morning of June 25th, 1979, I rolled my silver Mercury Bobcat (more or less a thinly disguised Ford Pinto) under a large gate with “Wayne County General Hospital” arched overhead in wrought iron. The hospital was about as far from what I’d expected as it’s possible to get: an ancient, sooty, red brick pile, with cracked front stairs and crumbling, mossy masonry. Cardboard covered a row of windows. A broken gutter leaked the last of a morning shower. Toss in a few bats, some lightning bolts and a couple of flapping shutters and it would have made a perfectly fine Munster Mansion.

I stood rooted on the sidewalk, all starchy white coat and black doctor bag (actually, a repurposed shaving kit with a waterproof, royal blue liner), not sure whether to pull open the massive front door or flee. But I had my assignment—the County’s neonatal intensive care nursery—and punched-out windows be damned, I wasn’t about to let those babies down. A deep breath, a squaring of the shoulders, and in I went.

The inside of the place was, if anything, worse than the outside: peeling paint, mildew, broken lighting, the strong smell of urine. An elderly security guard dozed behind a small wooden desk. Behind him, far down the hallway, a snoring man lay fastened to a bed by leather restraints. They seemed to be the only people in the place—no scurrying crowds of doctors and nurses, no gurneys wheeling by, no overhead pages of impending medical catastrophes. Just an old man at a desk, a tied-up snorer, and now me.

I cleared my throat. The guard startled awake, clearly irritated by my intrusion. “What?” he croaked. “What?

I smiled my shiniest please-please-help-me smile. Would he be so kind as to direct me to the neonatal intensive care nursery? Please?

“Nursery?” He leaned back in his chair. “You mean with babies and such?”

Yes, I assured him, with babies and such. And other people besides the three of us, hopefully.

He paused for a moment, lost in thought, and then slapped his hands hard on the table. “You want a nursery? With babies? Now that’s rich!” He threw back his head and let out an eerie, Jack-Nicholson-in-The-Shining-caliber cackle. The racket soon woke the tied-up man, who commenced howling. Things got very loud, very fast; this was not at all how I’d expected my morning to go.

“There’s no babies here, son!” The guard wiped tears from his eyes. “There ain’t never been no babies here!” I scanned the empty hallway, my heart sinking. Then where were the babies? I wondered a bit desperately. What had he done with them? The cackling resumed.

The noise slowly died down, and at last the guard fell silent. He rose from his chair and spun me toward the door. He pointed to a newer, reassuringly hospital-like building across a large parking lot. “Try them folks,” he said. “I’m pretty sure they got your babies over there.”

He held the door open, waving me on my way. “This here’s the loony bin, son,” he called out as I race-walked across the lot. “I don’t expect you’ll make that mistake again.”

I never did.

* * *

Photo courtesy of anoldent: https://www.flickr.com/photos/anoldent/

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Filed under Weird History

“Birth Day” is out in paperback!

Better than Hemingway

Better than Hemingway

And now, time for some shameless self-promotion…

At long last, Birth Day is out in paperback! What a great gift for you, your partner, your pregnant friends, your non-pregnant friends, your friends with ten kids, your friends who swear they’ll never have kids…basically, Birth Day is a great gift for anyone who has ever been born. (Am I forgetting anybody?)

Birth Day is available from Amazon and other online booksellers, or you can get a signed-by-me copy by ordering directly from my website. It’ll set you back $12.99 plus shipping, but hey, it’s a darned good book:

From the Washington Post:

“Sloan is a graceful writer, and his narrative, like the works of Jerome Groopman, flows easily between memoir, anecdotal reporting and hard science. Birth Day has a natural audience in curious, new and expectant parents. But anyone interested in the complex and, yes, miraculous way we all make it into this world will find lots to wonder over and ponder here, too.”

Aw, shucks…

Okay, commercial’s over! Back to blogging.

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Starvation and the infant gut

Even worse for babies...

Even worse for babies…

The gut microbiota—the collection of trillions of bacteria that populate the bowel in humans—goes through somewhat predictable developmental stages in infancy and early childhood. Some types of bacteria dominate right after birth, while others increase in number as the diet changes from milk to solid foods over the course of the first two years of life. The final profile is largely set by about age 3—what you’ve got in your gut at that point is basically what you’ll have into adulthood.

Many factors can affect the final profile—I’ve written about cesarean birth, antibiotic use, and the typical high-calorie, high-fat western diet as likely culprits. As you might suspect, these are problems of affluence. We can debate the effects of too many cesareans, too much antibiotics, and too many calories, but in developing countries there’s another potent shaper of the developing gut microbiota in childhood: starvation.

A recent study performed by Washington University in St. Louis and the International Center for Diarrheal Disease Research in Dhaka, Bangladesh, showed that children with severe acute malnutrition (SAM) have immature gut microbiota profiles—the types of bacteria in the bowel didn’t change over time as would be expected in well-nourished infants and children.

The study followed Bangladeshi infants and toddlers with SAM over the course of acute treatment and for several months afterwards. The malnourished children did gain weight rapidly with very high-calorie diets, but they were unable to achieve or maintain a normal weight once the treatment ended and they switched to a more typical diet. Signficantly, their gut microbiota remained immature—the bacteria present in the gut both before and after treatment were woefully inefficient at extracting calories from food.

So now we have evidence that the gut microbiota plays an important role in two very different nutritional diseases: obesity and malnutrition. Future SAM research will be aimed at supplementing probiotic bacteria as well as calories in hopes of promoting healthy, long-lasting changes to the microbiota.

The sooner the better, given the terrible toll malnutrition takes on children in many parts of the world.

Photo courtesy of Chris Turner

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Filed under Gut microbiota, Nutrition, Obesity

Why boy babies get sicker than girl babies…

Uh-oh...

Uh-oh…

One of the things I learned years ago in the intensive care nursery was that the key to a good call night’s sleep was to have mainly girl babies as your patients. It was (and I imagine still is) common wisdom in NICUs everywhere: boys just did worse than girls. Their lungs seemed weaker and their immune systems punier; they got sicker, and quicker, than the girls did. Thinking back, most of the harrowing patients I can recall were boys.

I didn’t spend a whole lot of time wondering or worrying about what seemed to me to be an obvious case of neonatal gender injustice. I figured it was all part of Mother Nature’s grand cosmic scorecard: if boys didn’t have to grow up and have babies, they could stand to suffer a bit more on the front end of life. (A philosopher, as you may have noted from previous posts, I am not…).

Now researchers at the University of Adelaide in Australia have come up with a genetic explanation for this boys-have-it-worse NICU phenomenon. In an article titled (deep breath…) “Integrative transcriptome meta-analysis reveals widespread sex-biased gene expression at the human fetal–maternal interface,” Dr. Claire Roberts, the lead investigator in Adelaide, explains it all:

We obtained gene expression data for .300 non-pathological placenta samples from 11 microarray datasets and applied mapping-based array probe re-annotation and inverse-variance meta-analysis methods which showed that .140 genes (false discovery rate (FDR) ,0.05) are differentially expressed between male and female placentae.  

To which I say: Who didn’t already know that?

In a closer approximation to spoken English, Dr. Roberts continues:

There is strong evidence that human males and females differ in terms of growth and development in utero and that these divergent growth strategies appear to place males at increased risk when in sub-optimal conditions.

Which means: Boy + Prematurity = Bad News.

The reason for the poorer outcomes in boys seems to be related to gender differences in how certain genes are expressed during pregnancy. In females these differences–and there are about 140 of them known to date–mean that there is more emphasis on placental development, the maintenance of pregnancy, and maternal immune tolerance. According to Dr. Roberts, girl babies are more “risk-averse” toward development and survival in utero than boys, which translates into better neonatal outcomes. Meanwhile, the gene expression differences  in boys mainly just make them get bigger than girls.

So if I understand this correctly, girl fetuses are smaller and smarter about survival than boy fetuses, and the boys are bigger and “less risk averse” than the girls. Sounds a lot like high school.

In fairness, the study is written for molecular biologists, who no doubt gobble this “inverse-variance meta-analysis” sort of thing right up. For those on the NICU front lines, though, it confirms the advice once given to me by a senior resident while we awaited a middle-of-the-night premature birth: “Bottom line, Sloan–if you want to sleep tonight, pray it’s a girl.”

Photo by Rosa’s Cakes https://www.flickr.com/photos/rosasck/

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June 1, 2014 · 3:39 pm