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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.

REFERENCES

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2. Abboud, T.K., F. Sarkis, A. Blikian et al. Lack of adverse neonatal neurobehavioral effects of lidocaine. Anesth Analg 1983; 62:473-75.

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