Thursday, September 25, 2014


(by Poppy)
Several years ago, in 2010, I posted Dangerous Drugs, in which I explored my thoughts and concerns about the adverse effect of opiate drugs on a baby's ability to function normally in the first few days of life.  In that post the narcotic (opiate) drug endone came under the spotlight, as it was being (and still is) used liberally in early postnatal settings, particularly after caesarean births or when women complain of perineal pain.

[Note to readers:  If you would like to check the information about any drug, you can search the myDr medicines site.  For example, Endone tablets. ]

In 2012 I completed an accredited course in Pharmacology, the Graduate Certificate in Midwifery at Flinders University, and subsequently received endorsement of my registration as a midwife prescriber, and obtained my own prescription pads.  I and many other Australian midwives have used social media for discussion of prescribing issues, in the Midwife Prescriber group.

Any medicine that contains opiates (including over the counter medicines such as panadeine [paracetamol+codeine]) is metabolised into morphine as well as other substances, and has a similar analgesic action to endone for the mother, and is transmitted via breast milk to the baby.  There is a great deal of variability in the way an individual metabolises opiate medicines, transferring the substances from the stomach, via the liver, to the blood stream, and to pain receptor sites.  The existence of ultra-rapid metabolizers of codeine should be noted by any midwife or doctor or pharmacist who prescribes or recommends oral opiates for women who are breastfeeding, and the medicine should not be used if the baby appears affected (excessively sleepy/lethargic) after being fed with mother's milk.  (??? aren't babies supposed to be sleepy after breastfeeding?  Yes - not lethargic though.)

Pethidine (meperidine)
After that rather lengthy introduction, today I would like to focus on another opiate, pethidine, or meperidine (Demarol) in some countries.

Peer reviewed medical literature has for more than a decade drawn attention to the neurotoxic effect of metabolites of pethidine, in both the adult and in the breastfed infant.  In 2006, the New Zealand Medical Journal published a paper by Shipton, stating that "Pethidine is no longer considered a first-line analgesic. ... Clinicians around the World recommend its removal from health systems
or restriction of its use." (p1)

Anderson published A Review of Systemic Opioids Commonly Used for Labor Pain Relief (Journal of Midwifery and Women's Health, 2011), and stated that,
"Meperidine [Pethidine] and its metabolites accumulate in colostrum and breast milk and may be associated with newborn neurobehavioral alterations and unfavorable effects on developing breastfeeding behaviors. Wittels et al43 conducted a prospective, randomized study of breastfeeding women who underwent cesarean births and compared intravenous PCA administration of meperidine to intravenous PCA administration of morphine. Meperidine was associated with significantly more neurobehavioral depression in breastfeeding newborns on the third and fourth days of life when compared with the behavior of the newborns in the morphine cohort (P .05), despite similar overall doses of morphine and meperidine." (page 227)

A question posted at the Midwife Prescriber site a week ago indicated that pethidine is currently used liberally in labour and postnatally, except in public hospitals in New South Wales, where I understand its use has been restricted.  Old habits die hard!

Here's a recent case (true story) -
A woman who is a well informed registered professional, having her second baby by elective caesarean for transverse lie, at a public teaching hospital in Melbourne:
  • requested that the IV be inserted in a vein on her left arm rather than the back of her hand, because she wanted freedom to hold and feed her baby after the birth.
  • was surprised that the young anaesthetic doctor was very reluctant to do this - had to insist - and eventually got what she requested
  • asked not to be given pethidine which is the standard in that hospital, preferred morphine via a PCA, as she was aware of concerns about metabolisation of pethidine, and transfer to colostrum, and felt she could have more control over the amount of drug in her system this way
  • once again found that she had to argue with the anaesthetic doctor in order to achieve this preference. No valid reason was given for the hospital's preference of pethidine. The doctor said that "the midwives don't like PCA and don't know how to manage it" (which I think is nonsense)
  • and after this doctor had (albeit reluctantly) complied with the woman's wishes, said to the woman. "You're right you know, we don't like using pethidine. It's a 'dirty drug'. And not siting the IV on the back of your hand is a no brainer."

This story illustrates unprofessional behaviours, particularly by the anaesthetic doctor, who was probably doing exactly what she or he had been told to do.  As a teaching hospital, one would expect evidence to be critically examined and applied.  If pethidine is not the best available medicine, it should not be used.  Passing the blame to the midwives is outrageous.  Most of the midwives working in hospitals have not studied pharmacology, and do not have authorisation to prescribe.  The person who signs the medications chart is the person who takes responsibility for the prescription.  If there are problems with the equipment, sort that out.

Drugs such as pethidine, morphine, endone, OxyContin, and others are DANGEROUS DRUGS.  They are kept in the DANGEROUS DRUG cupboard in hospital wards, and protocols must be followed to ensure that these medicines are signed out and administered correctly.  They are called DANGEROUS DRUGS because they are DANGEROUS!

The challenge is that when a dangerous drug is required, such as after major surgery, what is the least dangerous option for the mother and her new baby?

Sunday, September 21, 2014

possibly postmature

Possibly postmature
possibly not!

Midwives follow systematic processes in reaching the estimated due date for each pregnancy. 
  • the date of the first day of the last period
  • the normality of the last period
  • the date of quickening
And, if ultrasound is used, there are additional pieces to add to the puzzle.

Usually we are fairly confident, but it's still an estimate.  Today I would like to reflect on a case in which the calculated estimated due date was probably wrong.  The pregnancy progressed past 41 weeks, past 42 weeks, and labour commenced spontaneously leading to the birth of a healthy baby boy at (estimated!) 42weeks+5days.

A few midwives faced with this scenario - those at the far 'natural' end of the spectrum - would possibly shrug their shoulders and say the baby will come when it's ready.

Most midwives would observe, auscultate, palpate, assess, and discuss a plan with the mother.  We have the ACM National Midwifery Guidelines for  Consultation and Referral, which list 42 weeks as a decision point.

A colleague phoned me one morning, to discuss a case.  The mother was a healthy primigravida, whose pregnancy was now at 42 weeks.  The mother was planning homebirth.  There had been no reason to question the accuracy of the estimated due date, as the mother's fundal height measurements had been consistent with the gestation throughout the pregnancy.  The midwife had advised the mother to be reviewed at the local public hospital, explaining that the hospital would do some fetal monitoring and ultrasound, and that the process is usually reassuring to all concerned.  The hospital may advise induction of labour as preferable to doing nothing. 

The mother was adamant in her refusal - she would not go to the hospital.

My colleague, the midwife, asked me at what stage I would withdraw from caring for this woman.  +3 days. + 5 days, 43 weeks ....?


          Simply because the estimated gestation had passed an arbitrary date.

How sure are you of the estimated due date?

          Fairly sure, but ...

So, have you considered that the pregnancy may actually be just 41 weeks, and that there is nothing complicated or out of the ordinary?

With the benefit of hindsight, this question, and the only reasonable response, sounds obvious. 

There is a real ethical dilemma when the advice to intervene (for example, in this case, to induce labour) is promoted by the midwife because there is a small statistical increase in risk to the baby if the pregnancy truly is 'postmature'.    This youtube video, published on 10 Jun 2013, is a short excerpt from Elselijn Kingma's contribution to the panel discussion: Perinatal Mortality in the Netherlands: Facts, Myths and Policy at the first Human Rights in Childbirth conference in the Hague, the Netherlands in 2012.

No midwife works in an 'ideal' setting, and no woman gives birth under 'optimal' conditions.  That's life! 

Homebirth midwifery in Melbourne, as in most of Australia, today, is far from ideal.  Despite the obvious privileges of high levels of education and health, and good access to emergency services, we often experience poor communication with hospital maternity staff.  Midwives who have attempted to establish collaborative agreements with hospitals are weary from the uphill push, over many years.

Midwives are not immune to fear.  There is fear that something might go wrong, fear of punitive action by the regulatory Board, fear of loss of livelihood.  Other midwives have been down these paths.

I would like to encourage any midwives reading this post to maintain calm and logical thinking processes as you weigh up (possible) risk against (actual) wellness.  In a case such as this one, the mother was strong, her unborn child was strong.  The dates were possibly incorrect.  The decision at 42 weeks to not intervene, to 'do nothing', was a rational and supportable one.  The mother's refusal to seek consultation with hospital services was also rational and supportable.