Anesthesia and future learning disabilities…

Ok, I just read about this study, and haven’t really “ruminated” on it, which I normally do, so I’m just shooting from the hip with this. Basically, researchers went back and reviewed birth records of children born in one locality in Minnesota from 1976-1982, to see if they were born vaginally or by C-section, and if by C-section, then with the mom under regional or general anesthesia. Then, they looked at the children to see if they had any learning disabilities during school…

I’d like to read the entire article, and not just the abstract. I wonder if they controlled for enough stuff in this study. I was born in another state during the time period of this study, and my mom was knocked out during a routine vaginal birth; I assume I was dragged out by the head with forceps. Obviously, I have no learning disability — or if I do, imagine just how brilliant I would have been, if I hadn’t been born that way! ;-P But just because a woman gave birth vaginally does not mean she did not have general anesthesia nor regional anesthesia. Was this controlled for? It appears that all vaginal births were lumped into one group, regardless of whether or not a woman had drugs either for pain (such as an epidural, pudendal block, IV or IM or SQ narcotics or other drugs), or to speed up her labor (pitocin); it also is not noted in the abstract whether there were any forceps or vacuum (if applicable at the time) births; nor was the neonates’ condition noted (such as Apgars, NICU admittance, etc.).

Some women may have gotten general anesthesia, and were “under” a lot longer with their babies inside of them, during a vaginal birth than during a C-section — a typical C-section takes an hour, but the actual time from giving drugs to getting the baby out is in the neighborhood of 5-15 minutes — quicker if an emergency, slower if not. I recently read a nurse’s first experience with attending a C-section with general anesthesia, and she said the doctors worked in double-quick time, because they wanted the baby out as quickly as possible, so it wouldn’t have negative effects from the drugs given to the mother. I don’t know how long women were usually knocked out for either vaginal or C-section births, but this would seem to be  a relevant factor. After all, sometimes a little of something might not be bad, but a lot of it could be. Drugs definitely fall into this category.

I find it interesting that “drugs don’t harm the baby” yet somehow babies whose mothers were given regional anesthesia for C-sections had fewer LDs than mothers given general anesthesia for the same operation. It would seem, then, that general anesthesia was more harmful to babies than regional anesthesia. Were there *any* mothers not given *any* drugs? These should have been the control, not just “vaginal birth” which can come with a plethora of drugs and other interventions.

I first read about the study on “Mommy Myth Busters,” and they look at this from another angle, and include more information, including that “The team is investigating whether use of an epidural on a mother during natural labor has similar effects on the incidence of learning disabilities in children as a C-section with an epidural.” So, this research doesn’t look at women who give birth vaginally or by C-section with an epidural. If I remember correctly, the drugs and procedures used 30 years ago were quite different from what is the current norm today, with much of the then-standard practices going the way of pubic shaves and 3-H enemas (high, hot, and a helluva lot).

So, I think this research may be important, but it is probably going to be pretty well mangled by the press, leading women to think that their babies may even be better off to have a C-section with an epidural than to have them vaginally without drugs. When that wasn’t what was even looked at in the study. We’re looking back through time at what was perhaps standard operating procedure three decades ago, which is quite a bit different from current norms.

Allow me to say that this myth may not be quite as “busted” as one might think from reading the popular press. I remain skeptical. Perhaps time will tell…


14 Responses

  1. I have one theory and may dig up the study and give my full treatment to it on Science & Sensibility. I’m also shooting from the hip.

    There’s an article called Skin-to-skin contact may reduce negative consequences of “the stress of being born”: a study on temperature in newborn infants, subjected to different ward routines in St. Petersburg in which the authors conclude that “Allowing mother and baby the ward routine of skin-to-skin contact after birth may be a “natural way” of reversing stress-related effects on circulation induced during labour.”

    My understanding from this study and others is that babies experience a surge of adrenaline during second stage which dramatically alters blood flow, but skin-to-skin contact facilitates the reversal of this stress response. My guess is that neither the c-section group or the vaginal group would have had the skin-to-skin contact, since it is unfortunately (criminally) not the standard of care for healthy mothers and babies. But the vaginally born babies would have had the adrenaline surge, whereas the cesarean born babies would not have. I can certainly imagine how depriving babies of this compensatory mechanism might cause subtle, or not so subtle, brain changes.

    I’m interested to hear what others think, especially anyone who has read the study.

  2. I am very skeptical of anesthesia causing LD in children. It is possible, but I believe the home environment plays the greatest role. They used to believe that cocaine babies were doomed, when in a nurturing home environment they fare just as well as non-drug exposed infants.

    “My guess is that neither the c-section group or the vaginal group would have had the skin-to-skin contact, since it is unfortunately (criminally) not the standard of care for healthy mothers and babies.”
    Hey, don’t come and arrest me please! The policies I write for my hospital explicitly say to recover the baby on mom’s chest (unless she declines). I also teach to place infant’s skin to skin for thermoregulation when I teach NRP (neonatal resuscitation), even though it is not included in the program. Come to think of it, and need to write the authors of NRP to include this in the the 2012 guidelines. Let’s see if they do it!

    • RR,

      In the MMB article I linked to, they included a link to a report of a previous study which looked at children who received doses of anesthesia for surgery in the first three years of life, and a single dose of anesthetic did not appear to harm them, but two or more doses doubled the risk of future LDs. But then, in addition to whatever drugs I got when my mom was knocked out at my birth, I also had two heart surgeries, so I definitely fall into that category. Of course, “double the risk” does not mean “definite LD”. Plus, the researchers admitted they couldn’t separate the anesthesia from the surgery itself, and whatever effects *could* be solely attributable to that.

      Although the MMB article pointed out that it wasn’t talking about epidurals, it didn’t talk much if at all about the now-defunct policies and procedures that were in place 30 years ago, so judging by the title, or if you happened to overlook the brief paragraph about it not being about epidurals, women might conclude that it is talking about epidurals. My concern would be that women might think that it is safer for their babies to be born by C-section with them having an epidural than for them to be born vaginally, when a multitude of research shows that babies born by C-section fare worse than their vaginally-born counterparts in numerous ways, including risk of death, NICU admission, asthma, etc. It seems untenable to me that babies born by unnecessarean would fare better in this area, when in every other area, they seem to do worse. I could be wrong, and this might have a protective effect but I doubt it. I would prefer other research than this before saying that the myth is “busted.”

    • I know *you* do skin-to-skin at your hospital, but it’s still not happening in a lot of hospitals. And these births occurred in the 70’s and early 80’s, so I suspect SSC was even less frequent. I love the idea of getting SSC incorporated into NRP guidelines. Along with delayed clamping and no routine suctioning (already in there but not explicit enough, IMO). I know a team of researchers including Judy Mercer asked the NRP folks to incorporate delayed cord clamping and years have passed with no action. So it might be more complicated than just writing to them. Change happens slowly…

      • I know one letter won’t change a practice, that’s why you should write them too.
        Routine recovery of a healthy newborn SSC is such a no brainer to me. Plus, NRP is an international program. A lot of countries do not have such high tech equipment as radiant warmers, so I would assume SSC must be being taught as part of NRP elsewhere. I will investigate.
        Routine suctioning is a big no, no. It causes a vagal response which can lead to bradycardia. It can also cause oral aversion in the infant, so they may have trouble breastfeeding/bottle feeding later.
        The delayed cord clamping issue will be the toughest practice to change.
        *OK, I will stop hijacking Kathy’s blog with my off-topic comments. Although they are giving me ideas to write about*

  3. RR — please keep hijacking! 🙂 Most people don’t even question the standard procedures surrounding birth, especially “is it possibly harmful?” and assume that if it’s what is normally done then it is necessary, beneficial, and evidence-based. What you show is that it is not always *any* of those.

  4. I put a request into my school for the full study from the link in your original post. Will let you know when I receive the journal article.

  5. Well I don’t have some breakthrough scientific information to add. Instead I have my experience. I had an epidural with both of my daughters’ births. Both of them are above-average and very, very intelligent for their ages.

    I think that there are so many environmental issues that can affect our learning (in other words, too many variables) and to restrict this study to just the use of anesthesia while in labor, whether it was vaginal or a c-sect, wouldn’t be conclusive.

  6. The question I would ask would not be the presence of anesthesia but the presence of a depressed infant and were they given expert resuscitation immediately. If a baby is deprived oxygen at birth, that is a cause for problems. Babies whose mothers have general anesthesia often will be depressed. Did the Nicu team follow NRP? Did they intervene in time. OR did they just continue to stimulate the crap out of the baby when ppv was indicated? So I have a lot of questions.

    • That’s true. — Were they still holding babies upside down and smacking them on the butt or the feet to get them to breathe at this time? “Welcome to the world, baby, *SMACK*SMACK*SMACK*”

      Again, we’re dealing with three-decades’ old procedures here — antepartum, intrapartum, and postpartum — so who’s to say that something like neonatal stimulation, rough stim, or lack of anything, didn’t have something to do with any difference.

      • Ugh, it’s so sad/scary to think about how terrible newborn care was back in the day. The idea of screaming babies being held upside down and slapped, or healthy babies separated from their mothers for days rather than minutes gets me really depressed. We’ve come a long way, but we’re still not quite there yet.

  7. Learning disabilities aside the other problem is that nobody can ever know whether they would have been smarter by a bit. Learning disabilities basically represent only cognitive damage that’s severe enough to make a kid stand out enough to be diagnosed as having a learning disability. If your IQ just drops from 120 to 110 nobody’s going to diagnose you with anything, but you still lost what could have been.
    Of course such a thing is nearly impossible to ever prove in a study, because so many other factors effect IQ you would have to test both parents and account for every socioeconomic factor then compare all those children again, which just isn’t going to happen (also physicians aren’t exactly apt to want to research something new and vague and unprovable for patients to sue about).

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