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10: Documentation

10: The position, asserted by some medical experts, that the unborn child remains in a coma-like sleep state that precludes the unborn child experiencing pain is inconsistent with the documented reaction of unborn children to painful stimuli and with the experience of fetal surgeons who have found it necessary to sedate the unborn child with anesthesia to prevent the unborn child from thrashing about in reaction to invasive surgery.

DOCUMENTATION:

a.The position, asserted by some medical experts, that the unborn child remains in a coma-like sleep state that precludes the unborn child experiencing pain…

1. Royal College of Obstetricians & Gynecologists, 2010, Summary, para.2, “Furthermore, there is increasing evidence that the fetus never experiences a state of true wakefulness in utero and is kept, by the presence of its chemical environment, in a continuous sleep-like unconsciousness or sedation.”

Fetal Awareness: Review of Research and Recommendations for Practice.  Report of a Working Party.  Royal College of Obstetricians and Gynecologists.  March 2010.

2. Fitzgerald, 2005, p.513, col.1, para.2, “Despite the existence of sensory reflexes from the first trimester of human fetal life, it is unlikely that the fetus is ever awake or aware and, therefore, able to truly experience pain, due to high levels of endogenous neuroinhibitors, such as adenosine and pregnanolone, which are produced in the feto-placental unit and contribute to fetal sleep states144. In preterm infants below 32 weeks most pain responses, including facial expressions, seem to be largely subcortical145.”

Fitzgerald M.  The Development of Nociceptive Circuits. Nature Reviews: Neuroscience. 6 (2005) 507-520.

3. Mellor, 2005, p.464, col.2, para.4, “We conclude that there is currently no strong evidence to suggest that the fetus is ever awake, even transiently; rather, it is actively kept asleep (and unconscious) by a variety of endogenous inhibitory factors.  Thus, despite the presence of intact nociceptive pathways from around mid-gestation, the critical aspect of cortical awareness in the process of pain perception is missing.”

Mellor DJ, Diesch TJ, Gunn AJ, Bennet L. The importance of ‘awareness’ for understanding fetal pain. Brain Research Reviews.  49 (2005) 455-471.

b. … is inconsistent with the documented reaction of unborn children to painful stimuli and with the experience of fetal surgeons who have found it necessary to sedate the unborn child with anesthesia to prevent the unborn child from thrashing about in reaction to invasive surgery.

1. Van de Velde, 2005, p.256, col.2, para.2, “In our trial inadvertent touching of an immobilized fetus resulted in fetal ‘awakening.’”

Van de Velde M, Van Schoubroeck DV, Lewi LE, Marcus MAE, Jani JC, Missant C, Teunkens A, Deprest J.  Remifentanil for Fetal Immobilization and Maternal Sedation During Fetoscopic Surgery: A Randomized, Double-Blind Comparison with Diazepam.  Anesthesia & Analgesia. 101 (2005) 251-258.

2. Giannakoulopoulos, 1994, p.77, col.2, para.3, “We have observed that the fetus reacts to intrahepatic vein needling with vigorous body and breathing movements, which are not present during placental cord insertion needling.”

Giannakoulopoulos X, Sepulveda W, Kourtis P, Glover V, Fisk NM. Fetal plasma cortisol and β-endorphin response to intrauterine needling. Lancet. 344 (1994) 77-81.

3. Lee, 2005, p.951, col.1, para.3, “…they [fetal anesthesia and analgesia] serve other purposes unrelated to pain reduction, including (1) inhibiting fetal movement during a procedure.63​-65

Note: Lee et al. believe that pain is an emotional and psychological experience, possible only after 29-30 weeks gestation.  Nonetheless, they recognize the necessity of immobilizing the unborn child during surgery before this point due to coordinated movements in response to invasive procedures.

Lee SJ, Ralston HJP, Drey EA, Partridge, JC, Rosen, MA. A Systematic Multidisciplinary Review of the Evidence. Journal of the American Medical Association. 294:8 (2005) 947-954.

63Seeds JW, Corke BC, Spielman FJ. “Prevention of fetal movement during invasive procedures with pancuronium bromide.” American Journal of Obstetetrics & Gynecology. 155 (1986) 818-819.

64Rosen MA. Anesthesia for fetal procedures and surgery. Yonsei Medical Journal. 42 (2001) 669-680.

65Cauldwell CB. Anesthesia for fetal surgery. Anesthesiology Clinics of North America. 20 (2002) 211-226.

4. Van Scheltema, 2008, p.319, para.2, “Besides the argument of achieving adequate fetal anaesthesia, there are other purposes that justify the administration of drugs: the inhibiting fetal movement during a procedure…15,67-72

Van Scheltema PNA, Bakker S, Vandenbussche FPHA, Oepkes, D. Fetal Pain. Fetal and Maternal Medicine Review. 19:4  (2008) 311-324.

15 White, MC, Wolf, AR. Pain and Stress in the Human Fetus. Best Practice & Research Clinical Anaesthesiology. 18 (2004)  205-220.

67 Seeds JW, Corke BC, Spielman FJ. Prevention of fetal movement during invasive procedures with pancuronium bromide. American Journal of Obstetetrics & Gynecology. 155 (1986) 818-819.

68Rosen MA. Anesthesia for procedures involving the fetus. Seminars in Perinatology.  12 (1991) 410-417.

69 Rosen MA. Anesthesia for fetal procedures and surgery. Yonsei Medical Journal. 42 (2001) 669-680.

70Cauldwell CB. Anesthesia for fetal surgery. Anesthesiology Clinics of North America.  20 (2000) 211-226.

71Smith RP, Gitau R, Glover V, Fisk NM. Pain and stress in the human fetus. European Journal of Obstetrics and Gynecology and Reproductive Biology. 92 (2000) 161-165.

72Schwarz U, Galinkin JL. Anesthesia for fetal surgery. Seminars on Pediatric Surgery.  12 (2003) 196-201.

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