La Acción Colectiva Contenciosa en Ecuador, en el período 2008-2013

The idea that children might be traumatized by their contact with our system of medical care has been largely rejected for over a cen-tury. This concept was primarily based on the unfounded opinion by most physicians that infants could not process information, remem-ber, learn, or for that matter feel pain, before myelination of frontal and limbic pathways has occurred. It was not until 1988 that the American Medical Association declared in a report on the most re-cent research that infants could feel pain. Before that date, many sur-gical procedures on infants were performed with only curariform paralysis without the benefit of general or local anesthesia.

Until about 1986, surgery for patent ductus arteriosus, involving insertion of arterial catheters and chest tubes, and thoracotomy with rib retraction, was performed in infants under only curariform paraly-sis. This traumatic experience involved one and one-half hours of ex-posure to complete helplessness and overwhelming pain without any concept of the effects of this trauma on the infant.⁹² Chamberlain documents the case of a boy, born at twenty-nine weeks gestation, who underwent ventriculo-peritoneal shunting for hydrocephalus un-der curariform paralysis.⁹³At fifteen, he was severely phobic about doctors, hospitals, medical procedures, and the sight of adhesive tape and bandages. He would not allow anyone to touch his head, neck, or abdomen, the site of his surgical incisions for the shunt operation.

Clearly this neonate had experienced and processed the existential traumatic stress to which he had been exposed. Processing of trau-matic memory takes place through implicit memory mechanisms and centers, many of which have achieved myelination during and even before the neonatal period. There is every reason to believe that per-ception and processing of pain experiences in the neonate are more than sufficient to induce the process of traumatization.

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There is also ample evidence for early sentient interaction of new-born infants with their environment. Newnew-borns and even fetuses in utero have been shown to be capable of classical habituation and con-ditioning.^94,95Fetuses confronted with an amniocentesis needle invad-ing the uterus have been shown to exhibit fearful and defensive behavior.⁹⁶Intrauterine needling of the fetus has been shown to elicit a full-blown stress-related increase in plasma cortisol and B-endorphin levels, with evidence that modulation of the stress response is slower than in the adult.⁹⁷Fetuses can also learn to adapt their behavior to con-trol the environment. Through regulating the frequency of sucking on a nipple, an infant will learn to access his mother’s voice when presented with a sequence of voices through headphones.⁹⁸ The evidence for learning in utero by the unborn fetus, in the pediatric intensive care unit by the premature infant and in the normal full-term newborn, is over-whelming.⁹⁹The assumption that infants in all stages of development do not experience pain, do not register arousal with threat, and do not process a response to traumatic stress is clearly outdated and invalid.

The risks of induction of traumatic stress in the medical management of the premature newborn and as-yet unborn fetus cannot be underesti-mated. When one takes a history of childhood trauma from a patient one usually addresses psychological, physical, and sexual abuse in the first decade. Little if anything in the PTSD literature addresses the ter-rible trauma to which premature infants are exposed, or the long-term behavioral and emotional sequelae of that trauma.

The other major threat facing the newborn infant is the modern day obstetrical theater. Infants born in the hospital face a cold, brilliantly bright, noisy environment associated with fetal monitoring probes in-serted in their scalp, metal forceps on their heads, the jabs of lancets in their heels, suction tubes in their noses, mouths, and tracheae, and caustic liquid instilled into their eyes. They also face separation and isolation from their mothers at the moment of birth, the most critical period for infant-maternal bonding, the period most important for early attunement. I personally viewed a “natural childbirth” video, developed for prenatal education classes, in which a mother gave birth to her infant in an unmedicated delivery with her husband in at-tendance. After the umbilical cord was cut, instead of placing the baby on her mother’s breast, the nurse took the infant to a bassinet, where she began to perform vigorous nasotracheal suction. The infant exhibited a vigorous Moro (startle) reflex, but after two or three

assaultive suction sequences, the infant became limp and unrespon-sive. When the infant was finally placed on the mother’s breast, it re-mained limp and immobile, locked into its very first freeze response in the face of needless and brutal traumatization by a supposed caregiver.

The current medical philosophy of birth appears to be driven by the pervasive fear of injury to the newborn infant that, unfortunately, is partly based on medicolegal concerns, as well as the increasing worship of the technology of medicine. Although there is over-whelming evidence that fetal monitoring and a higher rate of cesarean sections has not lessened fetal mortality or morbidity, the standard use of these invasive procedures has now been established as a benchmark for obstetrical care. Fetal morbidity in the absence of these procedures is considered a red flag for litigation.

Birth is an inherently natural process. It provides the earliest op-portunity for enhancement of infant brain development required to provide resiliency in the face of threat through early maternal bond-ing. The brain at this stage of life is not at its most adaptable state; it is rather at its most vulnerable. Exposing the newborn to traumatic stress through thoughtless invasive and painful medical procedures is senseless and dangerous. Many child psychologists feel that the roots of societal violence, at least in part, relate to birth trauma.⁹³A large study of 4,200 consecutive births revealed that the combination of birth complications and maternal separation were powerful predic-tors of violent crimes in later life.¹⁰⁰

Male infant circumcision, still often performed without anesthe-sia, continues to be one of the most blindly accepted but inherently traumatic experiences of the neonate. While the male newborn is im-mobilized by wrapping it in a sheet, the penis is swabbed with alcohol to induce an erection, a clamp is placed over the penile foreskin and painfully tightened, and the foreskin excised in a circular fashion with a scalpel. The procedure is so “simple” that most medical stu-dents, including myself, have been allowed to perform it. The infant will be observed to cry bitterly, often exhibit a series of Moro re-flexes, and then lapse into immobility. Only recently have physicians begun to advocate local anesthesia when performing circumcisions.

Recent studies reveal that circumcised boys show significantly more severe emotional response to vaccination injections at ages four and six months than boys who have not been circumcised.¹⁰¹Over 60 per-cent of American male infants continue to be circumcised.¹⁰² In

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March 1999, the American Academy of Pediatrics established a pol-icy recommending that newborn males receive pain relief for circum-cision, admitting that the pain experienced by infants at circumcision could have long-lasting side effects.¹⁰²