L E T T E R S

Publishing Benefits I published an article in JOG” in October 1994 regarding nursing sup- port during labor. Since that time I have had numerous requests for my instrument, as well as my article. I have had requests from China, Rus- sia, and recently, Egypt. As well, I was cited by Sally Olds in her 1995 edition and by a presenter at the re- cent AWHONN conference. This has been very rewarding for me. I really appreciated the opportunity to pub- lish in JOG” and now realize the benefits of publishing in an interna- tional journal.

Janet Bryanton, RN, MN P. E.I. Reproductive Care Program,

Charlottetown, Prince Edward

Canada

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Epidural Analgesia I wish to make a few comments o n “Epidurals Redefined in Analgesia and Anesthesia: A Distinction With a Difference,” by Youngstrom, Baker, and Miller (May 1996 JOG”). While the distinction between epidural an- esthesia and epidural analgesia is an important one, the article did not dis- cuss some of the side effects of this intervention. Epidural analgesia not only is portrayed as solving the side effects and problems caused by epi- dural anesthesia but also is presented as a therapy for the normal physio- logic changes that accompany the la- boring process. A woman’s body pre- pares her to meet the challenges of labor. Many of these changes are beneficial. Epidurals may relieve pain, but they often do not alleviate stress. Supportive care helps relieve undue stress. However, a study ex- amining how much time intrapartum

unit nurses spent providing support- ive care showed that only 6.1% of their time actually was devoted to supporting the laboring woman; 27.3% of a nurse’s time was spent off unit and 47.6% was spent in indirect care out of the room (Gagnon bz Waghorn, 1996). Thus 74.9% of nurses’ time was spent separated from the patient. Use of epidurals e n - courages more emphasis o n techni- cal care and expertise; less contact between nurses and patients; more nursing time spent on reporting, charting, preparing equipment and drugs; and a reduced need for R N staK-precisely the environment that supports the institution, not the pa- tie n t .

Epidural analgesia also affects newborns. Loftus, Hill, and Cohen (1995) compared three groups of in- fants whose mothers had various epi- dural medications. Group 1 received .125% bupivacaine, group 2 received .125% bupivacaine plus 80-265 pg total fentanyl, and group 3 received .125% bupivacaine plus 12-29 pg to- tal sufentanil. Using the Neurologic and Adaptive Capacity Score (NACS) at 15 minutes, 2 hours, and 24 hours of age they found that by 24 hours, the scores of newborns in groups 1 and 3 had all improved. However, in Group 2, the scores failed to improve at all and were actually lower than they were at 2 hours. The authors at- tribute this to the slow clearance of fentanyl by the neonatal liver. At 24 hours, many newborns are dis- charged from the hospital. De- pressed neurobehavior affects new- born’s ability to breastfeed and may be responsible for some of the prob- lems seen with those who demon- strate inefficient and undeveloped feeding skills.

Epidural analgesia is claimed to restore a woman’s confidence in her

3 The JOCNN editor welcomes readers’ comments. Address letters to the edi- tor, JOCNN, 700 14th St., NW, Suite 600, Washington, DC 20005-2006. All letters should be typed double-space and signed by the author. Letters will be published at the editor’s discretion, and JOCNN reserves the right to edit all letters.

ability to master labor and delivery and encourage thought and behavior that are n o longer dominated by pain. What behavior would this be? Quiet, nondemanding, obedient, and watching TV? Pain is what guides a woman through her labor. Studies show that the key to a positive labor experience is mastery-a sense of control over events. When a woman has an epidural, control is totally turned over to the medical staff.

Another side effect of epidurals was demonstrated in a study by Sep- koski, Lester, Ostheimer, and Brazel- ton in 1992. Mothers who had epi- durals spent less time with their new- borns while in the hospital, 9.7 hours versus 13.7 hours in the nonmedi- cated group. The newborn’s early disorganization was thought to affect mother/newborn interaction. In ani- mals, epidural analgesia has inter- fered with maternal attachment and the onset of mothering behavior by blocking sensory stimuli for the re- lease of oxytocin.

I think nurses have a responsibil- ity to inform women of the possible side effects of epidural anesthesia and epidural analgesia, including the fact that this medication does reach and can have an effect on the fetus. Mothers should be encouraged to keep their newborns with them dur- ing their entire stay in the hospital, including at night. It is sad to see epi- durals of any kind decreasing the em- powerment of women by redefining the nature and goals of the birth ex- perience.

Marsha Walker, RN, IBCLC Lactation Associates Weston, MA

References Gagnon,A. J. , &Waghorn, K. (1996). Sup-

portive care by maternity nurses: A work sampling study in an intrapartum unit. Birth, 2-3, 1-6.

Loftus, J . R., Hill, H., & Cohen, S. E. (1995). Placental transfer and neona- tal effects of epidural sufentanil and fentanyl administered with bupiva- caine during labor. Anesthesiology, 83, 300-308.

Sepkoski, C. M . , Lester, B. M . , Ostheimer, G. W., & Brazelton, T. B. (1992). The effects of maternal epidural anesthesia on neonatal behavior during the first month. Deuelopmental Medicine C CbildNeuroIog)), 34, 1072-1080.

650 J O C N N Volume 25, Number 8