Supporting Breastfeeding

La Leche League Canada

Epidurals and Breastfeeding

on February 24, 2014

 

In Canada the rate of epidural anesthesia use during labour and delivery sits at >50% and continues to climb.  The rate ranges from 90-100% in some American hospitals.  As breastfeeding rates also continue to increase, the lack of research of the effect of epidural medications on breastfeeding is striking. The majority of research that has been done looked either at maternal satisfaction, maternal and infant homeostasis or Apgar scores, not infant feeding behaviours. Given what we know about the importance of breastfeeding to lifelong health, it is important to understand the impact that birth interventions such as epidurals have on both initiation and duration of breastfeeding.

Epidural anesthesia was introduced in the early 1970s and considered to be a major improvement over general anesthesia and IV narcotic analgesia during delivery.   Over 80% of Canadian mothers who received an epidural rated it as “very helpful” for pain relief.   However, as Linda Smith says in the Womanly Art of Breastfeeding, “If your friend tells you how much she ‘loved her epidural’, ask her how her first month of motherhood went.”  What does the research tell us about that first month?

Newborn

 

A.   All medications cross the placenta. At one time it was believed that placing the anesthetic in the mother’s spine or epidural space meant that the drug remained local and could not possibly affect the fetus/baby. We now know that not to be true. Many of the medications have been isolated from cord and/or baby’s blood. Most are highly lipophilic and also cross into the baby’s central nervous system.

  • CNS effects can include sedation and difficulty organizing the suck-swallow-breath cycle required for effective breastfeeding.
  • These effects have been documented for up to 30 days postpartum.

B.  Epidurals increase the incidence of other birth interventions, from the need for IV fluids to avoid maternal hypotension through slower progression during both first and second stage of deliver, leading to augmentation (oxytocin), assisted (vacuum or forceps) delivery and/or surgical deliveries. All this adds to the trauma of the birth process. It also increases the fluid load in the mother’s body which is transferred to the baby.

  • This may lead to engorgement of the breasts making it difficult for the baby to latch on correctly, and
  • may artificially increase the baby’s birth weight, and subsequent weight loss,
  • resulting in a baby who is not feeding well and losing “too much” weight.

C.  Epidurals decrease endogenous endorphins in mother, baby and milk.

  • This means that there may be an increase in the perception of pain.
  • It also means that breastfeeding will not provide the infant with the same level of comfort if mother received an epidural.

D.  Epidurals affect temperature control.

  • Mothers and babies may spike fevers, which lead to sepsis work-ups and separations.
  • During breastfeeding and skin-to-skin contact researchers found less warming of the baby’s skin if the mother received an epidural.

E.  Epidurals do not decrease initiation (or attempts to breastfeed), but do decrease duration.

Birthnewborn

 

Any one of these effects can be detrimental to breastfeeding. The combination leads to a perceived need to supplement: a baby who is sleepy, unable to latch onto edematous breasts and losing “excessive” (fluid) weight.  For an otherwise healthy full-term baby, that supplement will be formula, despite its known risks for decreasing maternal milk supply, increased infections for baby, and increased risks for chronic diseases later in life. There may also be separation of mother and baby because of sepsis work-ups. There is some evidence to suggest that lower doses and shorter exposures (i.e. waiting until a mother is in active labour) to epidural medications might reduce their impact.

Two recent publications claim that the above evidence is not conclusive and that without double-blind randomized controlled studies we cannot draw conclusions.   But these studies would be unethical, as randomizing would take away patient choice in treatment. The research is further confounded by changing protocols and drug usage and the fact that many studies assessed breastfeeding as a side issue; very few are designed specifically to look at breastfeeding behaviours, initiation and duration and none look at the process of initiation of breastfeeding. “We measure what we value.”

A Canadian article describes how appropriate support can overcome many of the negative side-effects of epidurals, even those using opioids, at least for multiparae who have previously breastfed successfully.

Early and Often

 

However, “success at breastfeeding” as defined as still breastfeeding at 6 weeks does not capture the barriers that these dyads may have had to overcome. Although the authors claim a >95% breastfeeding rate, this is any breastfeeding, not exclusive breastfeeding. By one week almost 10% of the infants had already received some formula and by six weeks less than 82% were exclusively breastfed. More telling still is that 67% of the mothers accessed lactation support, almost half of whom needed support daily or at every feed. These were experienced breastfeeding mothers (selection criteria included having successfully breastfed for over 6 weeks and an intention to breastfeed this baby)! Is removal of the pain associated with childbirth worth the uphill struggle to establish breastfeeding?

Labor, birth, and breastfeeding initiation comprise a normal, continuous process. Oxytocin, endorphins, and adrenaline produced in response to the normal pain of labor may play significant roles in maternal and neonatal response to birth and early breastfeeding.

When we believe that removing that pain is the important goal, without considering the long-term consequences of interrupting the natural process of birth, we risk many unintended consequences, including breastfeeding difficulties.

By Nicola Aquino, Professional Liaison Administrator, La Leche League Canada  

http://s.lllc.ca/files/Keeping-in-the-LLLoop-Spring-2011.pdf for references

 

This is one of many articles from ‘Keeping in the LLLoop’, La Leche League Canada’s Newsletter for Health Professional members.  La Leche League Canada Health Professional Memberships are available here.

 

If you need more information or have a breastfeeding problem or concern, you are strongly encouraged to talk directly to a La Leche League Leader.  In Canada, Leaders can be located by clicking http://www.lllc.ca/find-group  or  Internationally http://www.llli.org/.  

 

 

 

 

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