It’s always interesting to address the concerns about epidural anesthesia during labor.  While there are a number of common questions, epidural anesthesia has taken on almost a mythical status for some patients, and it’s kind of incredible to hear what is attributed to this type of pain relief during labor.  Here I’ll try to offer some insight on epidurals, how they work, and how they do (or don’t) affect labor and delivery.

First, what is an epidural?  An epidural is regional anesthetic.  This means, as opposed to IV pain relief, it isn’t expected to go into the blood stream, make you loopy or cross the placenta to the baby and sedate him/her.  A simple way to think of the difference between an epidural and a spinal is that typically an epidural procedure involves placement of a small catheter attached to a pump for continuous, but usually lighter, anesthesia than a one-time injection in a spinal.  If you think about it, that makes sense.  Pushing and movement are required during labor whereas we don’t want you moving anywhere during a cesarean section.  Some techniques involve a combination of the two, but that’s probably best explained by an anesthesiologist.

So, does an epidural slow down labor and increase risk of cesarean section?  The answer to the first question is yes…sort of.  The first stage of labor (dilation of the cervix) actually has no significant difference in duration regardless of when an epidural is placed.  The second stage of labor (pushing and delivery of the baby) takes about 15 minutes longer on average with an epidural vs without.  That, too, makes sense as walking with feet that have fallen asleep is going to be a little slower going than on feet that aren’t a little numb.  As for increasing the risk of cesarean section, there is no apparent increased risk of cesarean section with epidural, although we do see slightly higher incidence of operative vaginal delivery, i.e. vacuum or forceps.

Can an epidural harm mom or baby?  More common side effects for mom can be nausea/vomiting, low blood pressure, itching and difficulty with urination.  While more severe effects such as infection and nerve damage are possible, they are fortunately very rare.  Backache or headache can also occur, but these are not expected to persist if they do.  Generally, sensation and ability to walk returns with a few hours after stopping an epidural.  As for effects on the baby, because the anesthesia is regional, we don’t expect it to cross the placenta into the baby’s blood supply.  Occasionally, we can see a decrease in blood flow to baby from mom if blood pressure gets to be very low, but if present, this is usually quickly corrected by treatment of mom’s blood pressure.  Otherwise, much like numbing a tooth for extraction doesn’t affect your toes, the effect on baby from epidural is expected to be rather minimal.
             
For some women, epidural anesthesia can be a very effective option for pain control during labor, delivery and any laceration repair (hopefully, you don’t have any vaginal tearing during labor, but if you do, numb is good!).  Other women either don’t need it or don’t want it.  I’ve had some moms say that better pain relief allowed them to be more in the moment and really enjoy their baby more, but others felt that abstaining from pain relief allowed them to be more present during labor.  Fortunately, unless there are medical reasons you can’t have an epidural, it’s a decision that you can make in conjunction with your OB and anesthesia providers.  Be sure to discuss with them any concerns that you may have, and also pay close attention to your anesthesia provider to clarify all of the risks, benefits, alternatives and indications prior to proceeding with any medical procedure.  Good luck with whatever decision is the right fit for you, and as always, we wish you your healthiest pregnancy, delivery and baby 😊

Dr. Nick

​Depression is one of the most commonly diagnosed mental health conditions in America.  It is estimated that 16 million adults in the US suffer from depression- that is 6.7 percent of all American adults!  About 25 million Americans have been taking antidepressants for at least 2 years, and this is a 60% increase since 2010.  These statistics are staggering.  Despite so many people being on antidepressants, I often hear – I don’t feel any better or I don’t think it works as well as it used to. 
These medications were originally only used to treat moderate to severe depression and only for short periods of time (6 to 9 months).  Now there are many individuals that are using it for mild to moderate depression and they remain on these medications for years.   So, the first question is do antidepressants work for mild to moderate depression? 

Studies have not shown that antidepressants provide much more benefit than placebo when used to treat mild depression.  What is more alarming is the side effects of antidepressants are very unpleasant: sexual dysfunction, decreased libido, erectile dysfunction, insomnia, and weight gain, to name just a few.  Fortunately, there are nonmedicinal options that may also help.  Even something as simple as exercise has been shown to work better (in some cases) than antidepressants for mild depression.  In 2005, the staff at Duke University devised a study where they compared the antidepressant effect of the popular antidepressant sertraline to aerobic exercise for four months.  What they found is rather interesting-the group that exercised at a moderate level about 40 minutes 3 to 5 days a week experienced more of an antidepressant effect than the group that took Sertraline. 

Exercise works in a similar way to antidepressants when combatting depression.  Exercise increases the blood flow to the brain causing the release of endorphins which is essentially the body’s own natural antidepressant.  It also causes the release of neurotransmitters like serotonin naturally.  Antidepressants like sertraline work by increasing the amount of serotonin at receptor sites.  However, over time your body compensates and has fewer receptors available, essentially decreasing the antidepressant effect over time.  So, if antidepressants don’t work very well or for very long for mild depression and have nasty side effects like sexual dysfunction and weight gain, then why do so many people stay on these meds for so long?

​The reason they stay on it for so long is because the withdrawal symptoms are so severe that they are unable to wean themselves off the medication once they feel better.  Also, a lot of patients on antidepressants mistake the withdrawal effects for relapse.  For instance, stopping antidepressants, especially suddenly, can cause depression and anxiety, which can be confused with the original symptoms these medications were used to treat.  Other side effects of stopping depression medications can include headaches, dizziness, fatigue, nausea, insomnia and even flu-like symptoms.

If you suffer from mild depression and feel like your current therapy regimen is not working talk to your health care provider.  There may be other therapy options available for your mild depression like exercise and psychotherapy that could be more effective for treating your symptoms.  That being said, be sure to talk to your provider before making any changes in your current medical regimen, and if you begin to worry about harm to yourself or others, then be sure to go directly to your nearest emergency department.  Remember, you aren’t alone, and there are a number of both nonmedicinal and medicinal treatment options available.  Mental health issues should be taken seriously, so take a minute to discuss any concerns with your healthcare provider.

Dr. Pam

One of the more common complaints during annual exams involves weight gain, and while the tendency is to want to blame it on hormones, the truth is that, with the exception of thyroid function, hormones play less of a role in weight gain than many people think.  Unfortunately, to some degree, our body’s metabolic rate simply slows down with age, and that change in metabolism begins as early as 25.  We generally see about 150 calories per day decline in energy expenditure (how many calories your body burns with activity) and also another 2% of the basal metabolic rate (how many calories we burn at rest) each decade following a person’s 20s.  Even though there’s not a lot that we can do to change the aging process, the good news is that about 2/3 of the expected decline in metabolism is in our control, and there are things that we can do to help minimize those changes.

​First, the bad news.  We lose about 2% of our basal metabolic rate (the amount of calories burned per day by doing absolutely nothing) per decade after our 20s.  That means even if you ate the same and exercised the same in your 30s as in your 20s, you will gain weight and body fat.  By your 50s, this process accelerates even faster.  To put it in perspective, you are about 40 calories per day less efficient in your 30s vs your 20s at using energy if you baseline needs are 2000 calories per day.  That means 80 calories less efficient by your 40s and so on.  While 40 calories per day may not sound like much, it equates to a 4 lb weight gain per year, and about 20 lbs in 5 years by having the exact same diet and activity level in your 30s vs 20s.  Or 40s vs 30s, etc.  This inevitable change means that either calorie intake has to be decreased or activity increased just to maintain your current weight.

There is some good news, though.  Total energy expenditure, how active you are, is in your control.  We generally see about 150 fewer calories utilized per day each decade, and if you think about it, that makes sense.  Whether you participated in sports or marching band or cheer or even just riding your bicycle to your friend’s house, chances are good that you were more active as a kid.  Then as jobs start or babies come, the time you previously had to yourself and also the previous motivations for fitness (making the team, impressing a cute boy, etc.) can begin to slip away.  As your activity level declines, the amount of calories burned each day does as well, but by finding time to keep up with exercise, your body can continue to burn nearly the same amount of calories as before.

Need some added motivation to get back into an exercise routine?  In addition to burning the calories during exercise, activity also boosts the resting metabolic rate (RMR).  For instance, women who were active for 9 hours per week had a RMR about 70 calories per day higher, about 10% less body fat and a little over 15 lbs less body fat than their sedentary counterparts.  There are a number of factors that contribute to the improved body composition, including increased muscle mass (muscle burns more calories than fat, even at rest), increased production of growth hormone (this helps build muscle and reduce fat), and also the increased calorie utilization to help your body recover from the exercise.

Staying fit is hard, and avoiding weight gain is an active process.  As an unavoidable part of the aging process, nutritional needs change as we get older, but we do have some control over how our metabolism changes affect us. By being proactive and monitoring changes in our weight, we can make some small tweaks in diet and exercise to closely maintain our fitness, or if needed, bigger changes to work toward a healthier lifestyle.  Good luck in making the second half of 2019 your healthiest year yet!

Dr. Nick