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HOW many women realise they may receive an injection of heroin when the midwife or obstetrician offers something to take away the pain in labour ?

At a guess, not many. And yet diamorphine - which in Scotland is rapidly overtaking pethidine as the pain- killing drug of choice in labour - is another name for heroin.

And, like all drugs, some diamorphine will cross the placenta and reach your unborn baby. The question is, should we be concerned?

Although the word heroin sends shivers down most mothers' spines, it is, in fact, a useful drug when correctly used in a medically-controlled environment for a specific medical purpose. So, should we simply be grateful that it is generally effective in taking away the worst of the pain?

Here, opinions are divided.



YES - heroin at birth may trigger drug addiction in later life.

ALARMING research came out of Sweden at the end of the Eighties. In 1987, Bertil Jacobson, of the Karolinska Institute, published a paper linking drug addiction to opiates given to the addict's mother during his or her birth.

In 1988, Jacobson, together with five colleagues including midwife Karin Nyberg, published a research paper examining the links between pain relief medication administered during labour and the risk of the baby becoming an amphetamine addict in later life.

They looked at birth records of 200 addicts born in Stockholm hospitals and compared them with their siblings.

They discovered that, during labour, the addicts' mothers were more likely to have had nitrous oxide ("laughing gas") for pain and for longer.

Nitrous oxide, therefore, was viewed as increasing the risk of later amphetamine addiction.

Finally, in 1990, the Jacobson and Nyberg team's work appeared in the British Medical Journal, comparing birth records of addicts with their siblings.

One quarter of mothers of addicts had been given opiates (morphine or pethidine), barbiturates, or both in labour compared with 16 per cent for their siblings. The authors concluded that imprinting at birth - a type of memory which stores certain stimuli in the brain - could be the mechanism by which some young people are trapped into addiction after trying drugs, while others are not.

When an individual tries heroin in later life, a "gratifying emotional state" is re-experienced.

They write: "This might be one explanation why certain people are more easily trapped into dependence when testing drugs under peer pressure.

"When seeking for the imprinting stimulus, mammals and birds show an apparent anxiety; in the presence of this stimulus, their wellbeing seems to be increased.

"Relief of anxiety through re- experiencing the imprinted stimulus might be one of the rewards for which addicts strive."

Boys are more at risk of drug addiction because they have more testosterone circulating at birth and this hormone also helps imprinting.

NO - addiction claims are "absolute rubbish".

PROFESSOR Edith Hillan, Professor of Midwifery at the University of Glasgow, says: "Why try to frighten women by suggesting there is an association between opioid use in labour and drug addiction?

"There is no substantive research evidence to suggest that the use of diamorphine or pethidine in labour is likely to cause subsequent problems of drug addiction in either the mother or baby.

"The sample size required to make this kind of correlation would be absolutely enormous.

"You would also need to have information about the entire lifespan.

"For instance, how do you know it was the opioid in labour that caused the problems rather than the opioid they were given at some point to relieve the pain of their broken arm or when they needed pain relief after an appendicectomy?

"Women in labour are likely only to have one, or occasionally two, doses of an opioid at the very most, because of concerns about the drug's sedative effect on the baby.

Therefore, to suggest that one or two injections might cause subsequent addiction in either the mother or the baby is very far- fetched." Diamorphine is widely used as an effective analgesic in all sorts of areas in the UK - particularly in post-operative pain management - and there is no evidence that it causes any problems with regard to addiction when it is used on these occasions, either.

Professor Hillan adds: "After an operation, a patient might have four- hourly doses of opioids for pain relief for up to 72 hours after surgery (i.e. up to 18 doses) and there is no evidence that this is linked to subsequent addiction.

"Women need good research-based information, so that they can make informed decisions about their care during labour.

"This kind of anecdotal rubbish doesn't help them at all."

More research needed

JEAN Robinson, research officer of the Association for Improvements in the Maternity Services (AIMS) and Visiting Professor at the University of Ulster, says: "Of course, we don't know for sure at the moment if there is a connection between diamorphine at birth and later drug addiction. What I am calling for is more research.

She says she's tried on a number of occasions to discuss this research with UK obstetricians, anaesthetists and paediatricians, "but no- one seems to want to know".

She adds: "No-one, despite our pleas, has tried to repeat the Swedish research. Yet, if it is true, the implications are scary."

There is also the effect on the baby to consider.

She points out: "In the National Birthday Trust (a charitable organisation now administered through the Royal College of Obstetricians and Gynaecologists Research Advisory Committee) survey of pain relief to mother in labour, 12.3 per cent of babies exposed to diamorphine in labour had Apgar scores (a measure, at birth, of the baby's responsiveness) of seven or less at one minute, and 2.3 per cent had Apgars of seven or less at five minutes.

"Of the babies born to women who had no drugs in labour, on the other hand, 7.5 per cent had an Apgar score of seven at less than one minute and one per cent at five minutes.

"Entonox had little effect on Apgar scores - 9.1 per cent of babies had an Apgar of seven or less at one minute and 1.2 per cent at five minutes.

"With pethidine, it was 12.3 per cent and 1.3 per cent."


INDEPENDENT midwife Lynn Walcott, of the Association of Radical Midwives, says: "It is the doctor or midwife's role to ensure the woman has informed choice.

"She should be fully aware of the side effects. The best time to be given that information is during antenatal care.

"One of my concerns about heroin in labour would be in cases when the woman is a user or has been in the past.

"If she has been honest with her medical history, that will be known. But it might not have been recorded if she has chosen not to give that information.

"If she has built a relationship with her midwife, there are less likely to be secrets, but when a stranger is caring for you in hospital, it's harder to be honest."


JEAN ROBINSON calls for more patient choice over how birth takes place.

More obstetric interventions, means more pain and increases the need for pain- relieving drugs.

"Women need to be free to get up and move around if they want to. They should be able to give birth in any position they choose - kneeling, standing or squatting. Lying flat on your back is the worst possible thing because it slows down birth. The temptation then is to give drugs to speed up labour, which then increases pain."

Birth guru Sheila Kitzinger, author of Birth Your Way: Choosing Birth At Home Or At A Birth Centre (Dorling Kindersley) who has spent a lifetime promoting natural birth, agrees.

She says: "We tend to use drugs which have a strong effect on the mind and not just the body. They cut the woman off from her body in childbirth. Sometimes this may be essential, but there is a great danger the experience will become one of distressing chaos.

"These drugs are used too freely. After the birth, when a woman looks back and is unable to piece together the bits of her experience, she feels she wasn't there.

"There isn't only one method of pain relief. As with sex, body and mind work together in childbirth if you give them the chance to.

"For that reason, you can't expect the body to work rhythmically and spontaneously, if you have images of fear and ugliness in your mind.

"Yet that is the case for so many women, because we live in a birth culture which focuses on the risks of birth all the time.

"Women are told that giving birth is dangerous. No wonder they approach it with fear.

"It is important to try to replace those images with ones of calm, relaxation and the beauty of the experience.

" There are so many alternative ways of relieving pain, other than drugs."
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Title Annotation:Vital
Publication:Daily Record (Glasgow, Scotland)
Date:Aug 14, 2002
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