Epidurals
and Breastfeeding
Jan Riordan, RN, EdD, IBCLC,
FAAN, Wichita, Kansas
from Breastfeeding Abstracts,
November 1999, Volume 19, Number 2, pp. 11-12.
The promotion of epidural
analgesia for labor pain is a controversial topic that can be viewed
either as a conspiracy that undermines natural childbirth or as an affirmation
of a woman's inalienable right to relief of labor pain. Whatever one's
viewpoint, most observers agree that the epidural rate is high. In many
medical centers, especially those with obstetric residents and an obstetric
anesthesia service, epidural analgesia is used in 80to 90percent of
labors. (7, 28) Despite the fact that most American women receive epidural
analgesia for labor, and most begin breastfeeding, little research has
been done on the effect of labor epidurals on breastfeeding.(23) Do
epidurals affect breastfeeding? There is evidence to show that epidural
anesthesia probably does diminish the neonate's early ability to suckle.
Epidurals are expensive compared
with other forms of labor analgesia because a certified anesthesia provider
must be available the entire time the epidural catheter is in place.
Many hospitals make a profit on epidurals; however, they can be unprofitable
for managed care organizations unless a sufficient number of epidurals
is given to pay the cost of the anesthesia provider. As a result, epidurals
are sometimes actively marketed to women in prenatal childbirth education
classes or as they enter the hospital in labor.
During the 1970s natural
childbirth was finally accepted and became widely practiced. Epidurals
became popular in the 1980s because of the superior analgesic effects
obtained by combining narcotics and a regional anesthetic. The percentage
of American women who received epidurals for labor pain skyrocketed,
but at the same time, anecdotal reports began to appear of disorganized
suckle in sleepy babies of mothers who had received a labor epidural.
(15)
Epidurals are more common
in women who are first-time mothers, privately insured, under the care
of obstetricians, and who deliver a heavier infant.(14, 19, 27) Whether
there is an association between epidural analgesia and cesarean birth
rates depends upon the hospital where the births take place, the type
of practitioner who delivers the baby, and the way the statistics are
calculated.(28) If the practitioner is a certified nurse-midwife who
stays with the mother throughout labor, the chances of a first-time
mother having a cesarean birth because of epidural analgesia are much
lower than if the practitioner is an obstetrician.(6) The use of labor
epidural varies worldwide. Although U.S., Canadian, and European women
have the option of an epidural during childbirth, epidurals are used
less often in other areas of the world.
Labor medications commonly
given epidurally for pain are fentanyl, an opioid narcotic, and a regional
anesthetic, usually bupivicaine. Morphine is used if the delivery is
cesarean. The regional anesthetic and narcotics are used together to
potentiate their action so that, presumably, a smaller total dosage
is needed. An "epidural lite" is one that uses lower dosages
of medications. The mother who receives an "epidural lite"
can walk if only a narcotic is given and not the anesthetic.(11) One
injection is usually given if labor is expected to last a couple of
hours. Another injection can be given or a catheter can be inserted
for repeated doses. An epidural takes around fifteen minutes to take
effect. In the early years of combined medications in epidurals, higher
dosages were used. They have been gradually lowered as anesthetists
have found that lower dosages effectively control labor discomfort.
The effect of epidurals on the newborn is dosage and time-dependent.
In general, the greater the medication dosage the more pronounced the
alteration in neonatal function. However, this relationship is neither
simple nor uniform as it is affected by the newborn's ability to metabolize
or excrete the medication.
Few dispute that epidurals
reduce labor pain. However, as with all medical procedures, epidurals
have risks. A major danger is a sudden drop in the mother's blood pressure
right after the epidural is given that compromises the oxygen supply
to the mother's and the fetus's vital organs. Other risks are longer
labors,(4, 13, 26) a higher rate of instrumental deliveries,(12, 18,
21, 26) fetal bradycardia, and anal sphincter damage in the mother.(10)
Other studies show that if the epidural is not given until the mother
is 5 cm dilated, neither the average length of labor (9) nor the rate
of dystocia-related cesarean deliveries (5) is increased.
Labor epidural analgesia
typically accompanies a host of other interventions such as confinement
to bed, intravenous fluids, electronic fetal monitoring, oxytocin to
stimulate labor, indwelling bladder catheter, and restriction of oral
fluids and food,(19) After delivery, women who received epidurals were
also more likely to suffer from pruritus, headache, nausea, vomiting,
urine retention, and maternal fever that resulted in unnecessary, expensive
neonatal sepsis evaluations and antibiotic treatment.(17)
Do labor epidurals have an
effect on breastfeeding? Attempts to answer this question can be faulted
on two counts. Studies of epidurals almost never compare mothers who
have no pain-relieving medication during labor and delivery with those
who do, and they have lacked a valid measure of breastfeeding. Part
of the problem is that in medical centers where such studies are done,
very few women give birth without some type of pain-relieving medication.
Fortunately, it is now possible
to measure feedings at the breast using a valid breastfeeding assessment
tool. In a recent study on epidural analgesia and breastfeeding, (25)
the investigators used the Infant Breastfeeding Assessment Tool (20,
24) to assess breastfeeding scores in 127 babies. The 92 infants whose
mothers had analgesia were compared with 37 babies whose mothers had
an unmedicated labor and delivery. Lactation consultants in three hospitals
with at least two years experience with breastfeeding dyads scored the
feedings on their daily rounds on an as-they-come basis. Scores ranged
from 0 to 12. Mothers were also asked to score the feeding at the same
time as the lactation consultant. Not surprisingly these women evaluated
the breastfeedings about the same as the LC.
Infants whose mothers had
no labor analgesia scored higher (x=11.1) on the breastfeeding scale
than mothers who had epidurals (x=8.5) or intravenous narcotics (x=8.5).
Despite higher breastfeeding scores in neonates of unmedicated women,
no difference in the duration of breastfeeding at six weeks was found
between the medicated and the unmedicated mothers. The lack of a positive
relationship between epidural labor analgesia and weaning before six
weeks postpartum was surprising but reassuring in that the use of epidurals
did not seem to be associated with early weaning.
Three other studies, all
conducted before 1982, examined labor epidurals and general neonatal
behavior with differing results. All used a control group of unmedicated
mothers but did not measure breastfeeding as an outcome. Murray et al.
(19) studied the effects of epidural analgesia on neonates whose mothers
had 1) epidurals with continuous infusion of 0.25% bupivacaine (n=20);
2) epidurals in combination with oxytocin to stimulate labor (n=20);
and 3) little or no medication during childbirth (n=15). Over half of
the 15 mothers in the little-or-no-medication group briefly inhaled
nitrous oxide and 11 received lidocaine for perineal infiltration. Infants
in both epidural groups performed less well on the motor, state control,
and physiologic response clusters of the Brazelton Neonatal Behavior
Assessment Scale than the little-or-no-medication group. On the fifth
day the babies in the epidural groups continued to show poor state organization.
Abboud et al. (1) compared
fetal, maternal, and neonatal responses following epidurals that infused
regional anesthetics (lidocaine, bupivacaine, or chloroprocaine). No
narcotic was used. Fifty infants were in each epidural group, and 20
were in an unmedicated control group. The Early Neonatal Neurobehavior
Scale was used at 2 and 24 hours of life to evaluate the babies' behaviors.
Compared with the epidural groups, more infants in the unmedicated group
scored lower in suckling and rooting at both 2 and 24 hours postpartum.
Abboud later repeated the study (2), this time using a larger dose of
lidocaine. Again, the average suckling and rooting scores were higher
for the neonates in the lidocaine group at 2 hours postpartum, but the
findings reversed at 24 hours postpartum and unmedicated neonates had
higher suckling scores. United Kingdom babies whose mothers had no labor
analgesia of any kind actually scored lower in rooting and suckling
ability than infants whose mothers had epidurals, (8) but the differences
were not statistically significant. Although these earlier studies are
instructive, it is difficult to compare studies that were done over
a decade ago with current investigations because of changes in epidural
techniques and medication dosages.
Epidural labor analgesia
is only one of the many intrapartum interventions that may affect breastfeeding.
Interventions such as maternal intravenous fluids, vacuum extraction,
operative deliveries, and infant oral suctioning may also alter suckling.(16)
Sorting out which intervention has the greatest impact on suckling is
the next step for researchers in this area.
Epidural labor analgesia
puts mothers and infants at risk for a variety of health problems that
are not encountered in an unmedicated labor. Added to these is evidence
that epidurals hinder early breastfeeding. Instead of incurring the
risks of labor epidurals, women may use non-pharmacological methods
of pain control that do not hinder suckling. Paced breathing, hydrotherapy,
changing position, massage, therapeutic touch, visualization, and relaxation
exercises all effectively reduce pain during labor. (6) The presence
of an experienced doula who remains with the laboring mother reduces
the likelihood that the mother will need epidural medication. La Leche
League meetings and expectant parents' classes are ideal situations
to discuss options for labor discomfort.
Jan Riordan is currently
an Associate Professor of Nursing at Wichita State University. She is
also an IBCLC, the President of the International Board of Lactation
Consultant Examiners, and the author of Breastfeeding and Human Lactation,
along with Kathleen Auerbach. Dr. Riordan also serves on the Health
Advisory Council of La Leche League International.
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Page last edited Sun Oct 14 09:32:42 UTC 2007.
