The effect of ultra low dose epidural analgesia on newborn breastfeeding behaviors

A prolonged latent phase: An early career in oxytocin during birth

•The author, a nurse-midwife scientist, shares her path to the study of the causes and consequences of clinical oxytocin use.•This paper highlights mentors and key research that informed new thinking about the role of oxytocin during parturition.•Future directions for improving maternal care during childbirth are presented, including genetic and epigenetic perspectives.

KMC by surrogate can have an effect equal to KMC by mother in improving the nutritional behavior and arterial oxygen saturation of the preterm infant: results of a controlled randomized clinical trial

BACKGROUND

The aim of this study was to investigate the effect of kangaroo mother care (KMC) by mother and her surrogate on nutritional behavior and physiological function of preterm neonates.

METHOD

This study was a randomized, controlled clinical trial conducted on 70 preterm infants admitted to the NICU. For the neonates of the intervention group, KMC was performed (by mother and surrogate) 3 times a day and the neonates of the control group received KMC by the mother 3 times a day for up to 4 days and 60 minutes each time. The primary outcome was to compare the effect of KMC by mother and surrogate on the feeding behavior measured by preterm infant breastfeeding behavior scale (PIBBS), and the secondary outcome was to compare the effect of KMC by mother and surrogate on physiological outcomes.

RESULT

The score of the PIBBS in both groups increased significantly during 4 days, this difference was not significant between the groups. [Adjusted mean difference (95% Confidence interval), 0.66 (- 2.36 to 1.03), P = 0.438]. Within the group, among the physiological functions, only O2 saturation had significantly increased during the study. This increase, however, was not statistically different between the two groups. [Adjusted mean difference (95% Confidence interval), 0.102 (- 0.68 to 0.88), P = 0.761].

CONCLUSION

When the mother is unable to provide this type of care, it can be provided by the surrogate that is as effective as the mother in improving arterial oxygen saturation and the feeding behavior of the preterm neonates.

TRIAL REGISTRATION

IRCT20150424021917N10 . Registered 22/04/ 2020.

Breastfeeding skills of full-term newborns and associated factors in a low-and-middle-income setting

BACKGROUND

Normative information on the breastfeeding of term newborns may guide clinicians in early identification of breastfeeding difficulties and oro-pharyngeal dysphagia (OPD), and may support optimal breastfeeding practices.

OBJECTIVE

To describe breastfeeding skills of term newborn infants in a South African hospital, a lower-middle-income setting, and investigate associations between infants' feeding and other factors.

METHOD

One breastfeeding session of each of the 71 healthy newborn full-term infants (mean chronological age=1.9 days; mean gestation=39.1 weeks) was evaluated using the Preterm Infant Breastfeeding Behavior Scale (PIBBS), suitable for use with term newborns.

RESULTS

All participants were exclusively breastfed. Thirteen participants (18%) were HIV-exposed. There was no significant difference in the findings of the PIBBS between HIV-exposed and unexposed participants. Most newborns had obvious rooting, latched deeply onto the nipple and some of the areola, had repeated long sucking bursts (mean length=16.82 sucks/burst), and swallowed repeatedly. Most participants were in either the drowsy or quiet-alert state, which are optimal behavioural states for breastfeeding. One to two-hourly on-demand feeds was significantly associated with mothers who had normal births and did not use galactogogues to promote lactation.

CONCLUSION

Results may be used for early identification of OPD in newborns. The findings may be useful to primary care clinicians.

Cutaneous Surgery in Patients Who Are Pregnant or Breastfeeding

Dermatologic surgery in pregnant/postpartum patients requires deliberate consideration. Although surgery can be safely performed during any trimester, the second trimester and immediate postpartum period is optimal. Surgery should not be delayed for melanoma/high-risk skin cancers. Perioperative positioning, analgesic, antiseptic, and antibiotic selection should be deliberate to avoid risk to the patient/fetus/infant. The left lateral tilt position reduces aortocaval compression syndrome. Lidocaine and epinephrine can be used safely. Alcohol and chlorhexidine are considered safe. Antibiotics commonly used in skin surgery are safe in pregnancy and lactation. Acetaminophen is first line for pain management. Nonsteroidal antiinflammatory drugs should be avoided.

A priori choice of neuraxial labour analgesia and breastfeeding initiation success: a community-based cohort study in an Italian baby-friendly hospital

OBJECTIVE

To investigate whether the nature of the decision about receiving neuraxial labour analgesia is associated with breastfeeding initiation success (BIS), defined as exclusive breastfeeding until discharge associated with postnatal weight loss <7% at 60 hours from birth.

DESIGN

Single-centre community-based cohort study.

SETTING

An Italian baby-friendly hospital, from 1 July 2011 to 22 September 2015.

PARTICIPANTS

Inclusion criteria: women vaginally delivering singleton cephalic newborns and willing to breastfeed.

EXCLUSION CRITERIA

women who delivered in uterus-dead fetuses, were single or requested but did not receive neuraxial analgesia. Overall, 775 out of the 3628 enrolled women received neuraxial analgesia.

RESULTS

Compared with women who tried to cope with labour pain, those who decided a priori to receive neuraxial analgesia had less BIS (planned vaginal birth: 2121/3421 (62.0%), vs 102/207 (49.3%; p<0.001; risk difference (RD), 12.7%); actual vaginal birth: 1924/2994 (64.3%), vs 93/189 (49.2%; p<0.001; RD, 15.1%)). Multivariable analyses with antelabour-only confounders confirmed both associations (planned vaginal birth: relative risk (RR), 0.65; 95% CI, 0.48 to 0.87; actual vaginal birth: RR, 0.59; 95% CI, 0.43 to 0.80). Although women who requested analgesia as a last resort had less BIS than did those successfully coping with labour pain in the bivariable analyses (planned vaginal birth: 1804/2853 (63.2%), vs 317/568 (55.8%; p=0.001; RD, 7.4%); actual vaginal birth: 1665/2546 (65.4%), vs 259/448 (57.8%; p=0.002; RD, 7.6%)), multivariable analyses with either antelabour-only or peripartum confounders did not confirm these associations (planned vaginal birth: RR, 0.99; 95% CI, 0.80 to 1.23; actual vaginal birth: RR, 0.90; 95% CI, 0.69 to 1.16).

CONCLUSIONS

Compared with trying to cope with labour pain, a priori choice of neuraxial analgesia is negatively associated with BIS. Conversely, compared with having successfully coped with pain, requesting neuraxial analgesia as a last resort is not negatively associated with BIS.

Initiation and continuation of breastfeeding among Jordanian first-time mothers: a prospective cohort study

Objective

This study aimed to examine the rates of initiation and continuation of breastfeeding (BF) and their relationship with mothers' sociodemographic, obstetric, neonatal, and medical interventions.

Methods

Data were collected from 199 first-time Jordanian mothers using medical records, face-to-face interviews within 24 hours of birth, and two telephone interviews at 6 weeks and 6 months after birth.

Results

The rate of BF initiation within the first 4 hours after birth was only 13%. The rate of exclusive BF at 6 weeks was 25.5%, and this rate dropped to 2.1% at 6 months. Mothers who initiated BF before discharge were older, were employed, had normal vaginal birth, and had undergone antenatal or after-birth BF education. Infants' birth weight or gender was not interrelated with BF initiation. There was no relationship between initiation and continuation of BF and use of medications for labor pain or for induction/augmentation. The only significant relationship was found between the dose of ergometrine and BF failure and painful BF at 6 weeks.

Conclusion

There is a need for increasing health care providers and public awareness about the role of intrapartum medications and procedures on the initiation and continuation of BF at 6 weeks and 6 months after birth.

Breastfeeding Outcomes After Oxytocin Use During Childbirth: An Integrative Review

INTRODUCTION

Despite widespread use of exogenous synthetic oxytocin during the birth process, few studies have examined the effect of this drug on breastfeeding. Based on neuroscience research, endogenous oxytocin may be altered or manipulated by exogenous administration or by blocking normal function of the hormone or receptor. Women commonly cite insufficient milk production as their reason for early supplementation, jeopardizing breastfeeding goals. Researchers need to consider the role of birth-related medications and interventions on the production of milk. This article examines the literature on the role of exogenous oxytocin on breastfeeding in humans.

METHODS

Using the method described by Whittemore and Knafl, this integrative review of literature included broad search criteria within the PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane, and Scopus databases. Studies published in English associating a breastfeeding outcome in relation to oxytocin use during the birth process were included. Twenty-six studies from 1978 to 2015 met the criteria.

RESULTS

Studies were analyzed according to the purpose of the research, measures and methods used, results, and confounding variables. The 26 studies reported 34 measures of breastfeeding. Outcomes included initiation and duration of breastfeeding, infant behavior, and physiologic markers of lactation. Timing of administration of oxytocin varied. Some studies reported on low-risk birth, while others included higher-risk experiences. Fifty percent of the results (17 of 34 measures) demonstrated an association between exogenous oxytocin and less optimal breastfeeding outcomes, while 8 of 34 measures (23%) reported no association. The remaining 9 measures (26%) had mixed findings. Breastfeeding intentions, parity, birth setting, obstetric risk, and indications for oxytocin use were inconsistently controlled among the studies.

DISCUSSION

Research on breastfeeding and lactation following exogenous oxytocin exposure is limited by few studies and heterogeneous methods. Despite the limitations, researchers and clinicians may benefit from awareness of this body of literature. Continued investigation is recommended given the prevalence of oxytocin use in clinical practice.

Labor Epidural Analgesia and Breastfeeding: A Systematic Review

Despite widespread use of epidural analgesia during labor, no consensus has been reached among obstetric and anesthesia providers regarding its effects on breastfeeding. The purpose of this review was to examine the relationship between labor epidural analgesia and breastfeeding in the immediate postpartum period. PubMed, Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature were searched for articles published in 1990 or thereafter, using the search term breastfeeding combined with epidural, labor epidural analgesia, labor analgesia, or epidural analgesia Of 117 articles, 23 described empirical studies specific to labor epidural analgesia and measured a breastfeeding outcome. Results were conflicting: 12 studies showed negative associations between epidural analgesia and breastfeeding success, 10 studies showed no effect, and 1 study showed a positive association. Most studies were observational. Of 3 randomized controlled studies, randomization methods were inadequate in 2 and not evaluable in 1. Other limitations were related to small sample size or inadequate study power; variation and lack of information regarding type and dosage of analgesia or use of other intrapartum interventions; differences in timing, definition, and method of assessing breastfeeding success; or failure to consider factors such as mothers' intention to breastfeed, social support, siblings, or the mother's need to return to work or school. It is also unclear to what extent results are mediated through effects on infant neurobehavior, maternal fever, oxytocin release, duration of labor, and need for instrumental delivery. Clinician awareness of factors affecting breastfeeding can help identify women at risk for breastfeeding difficulties in order to target support and resources effectively.

Physiological mechanisms, behavioral and psychological factors influencing the transfer of milk from mothers to their young

This article is part of a Special Issue "Parental Care".Producing milk to support the growth of their young is a central element of maternal care in mammals. In spite of the facts that ecological constraints influence nursing frequency, length of time until weaning and the composition of milk, there is considerable similarity in the anatomy and physiology of milk production and delivery across mammalian species. Here we provide an overview of cross species variation in nursing patterns and milk composition as well as the mechanisms underlying mammary gland development, milk production and letdown. Not all women breastfeed their infants, thus in later sections we review studies of factors that facilitate or impede the initiation and duration of breastfeeding. The results of these investigations suggest that the decisions to initiate and maintain breastfeeding are influenced by an array of personal, social and biological factors. Finally, studies comparing the development of breastfed and formula fed infants as well as those investigating associations between breastfeeding, maternal health and mother/infant interaction are reviewed. Leading health agencies including the World Health Organization and CDC advocate breastfeeding for at least the first 6months postpartum. To achieve these rates will require not only institutional support but also a focus on individual mother/infant dyads and their experience.

Effects of maternal epidural analgesia on the neonate--a prospective cohort study

Background

Epidural analgesia is one of the most popular modes of analgesia for child birth. There are controversies regarding adverse effects and safety of epidural analgesia. This study was conducted to study the immediate effects of the maternal epidural analgesia on the neonate during early neonatal phase.

Methods

A prospective cohort study of 100 neonates born to mothers administered epidural analgesia were compared with 100 neonates born to mothers not administered epidural analgesia in terms of passage of urine, initiation of breast feeding, birth asphyxia and incidence of instrumentation.

Results

There was significant difference among the two groups in the passage of urine (P value 0.002) and incidence of instrumentation (P value 0.010) but there was no significant difference in regards to initiation of breast feeding and birth asphyxia.

Conclusions

Epidural analgesia does not have any effect on the newborns in regards to breast feeding and birth asphyxia but did have effects like delayed passage of urine and increased incidence of instrumentation.

Effects of different anesthesia protocols on lactation in the postpartum period

OBJECTIVE

Many factors can influence the secretion of breast milk. Cesarean section is a risk factor for late onset of breastfeeding.

MATERIAL AND METHODS

In our study, we compared the lactation process by mothers who underwent elective cesarean section under general anesthesia, spinal anesthesia, epidural anesthesia, and normal birth; 84 patients between 18-40 years of age with a risk of ASA I-II were included. Randomly patients were divided into four groups: group G (general anesthesia, n:21), group S (spinal anesthesia, n:21), group E (epidural anesthesia, n:21), and group V (vaginal birth, without anesthesia, n:21). Oxytocin and prolactin values of all patients before and after operation or birth were recorded. In addition the initiation time of lactation after delivery or cesarean section were recorded.

RESULTS

In all groups, there were no significant differences among hormone levels in the prepartum period (p=0.350). Prolactin levels in group G (p=0.011) and oxytocin levels in group V (p=0.012) in the postpartum period were significantly higher than in the other groups. The start of lactation was significantly delayed in group G (p=0.003).

CONCLUSION

We consider that the onset time of lactation is delayed in patients undergoing cesarean section with general anesthesia when compared with patients who undergo cesarean section with spinal and epidural anesthesia and with patients who undergo normal vaginal birth. Because of the delay of awakening and recovery of cognitive functions in general anesthesia, communication between the mother and the newborn is delayed and so is the lactation.

Epidural analgesia, neonatal care and breastfeeding

The objective of our study is to evaluate the correlation between epidural analgesia during labor, start of breastfeeding and type of maternal-neonatal care.Two different assistance models were considered: Partial and Full Rooming-in.In this cohort study, 2480 healthy infants were enrolled, 1519 in the Partial Rooming-in group and 1321 in the Full Rooming-in group; 1223 were born to women subjected to epidural analgesia in labor.In case of Partial Rooming-in the rate of exclusive or prevailing breastfeeding is significant more frequent in newborns born to mothers who didn't receive analgesia. Instead, in case of Full Rooming-in the rate of exclusive or prevailing breastfeeding is almost the same and there's no correlation between the use or not of epidural analgesia.The good start of lactation and the success of breastfeeding seems to be guaranteed by the type of care offered to the couple mother-infant, that reverses any possible adverse effects of the use of epidural analgesia in labor.

Relationship between use of labor pain medications and delayed onset of lactation

BACKGROUND

Despite estimates that 83% of mothers in the United States receive labor pain medications, little research has been done on how use of these medications affect onset of lactation.

OBJECTIVE

To investigate whether use of labor pain medications is associated with delayed onset of lactation (DOL).

METHODS

We analyzed data from the 2005-2007 Infant Feeding Practices Study II, a longitudinal study of women from late pregnancy through the entire first year after birth (n = 2366). In multivariable logistic regression analyses, we assessed the relationship between mothers' use of labor pain medication/method and DOL (milk coming in > 3 days after delivery).

RESULTS

Overall, 23.4% of women in our sample experienced DOL. Compared with women who delivered vaginally and received no labor pain medication, women who received labor pain medications had a higher odds of experiencing DOL: vaginal with spinal/epidural only (aOR 2.05; 95% CI, 1.43-2.95), vaginal with spinal/epidural plus another medication (aOR 1.79; 95% CI, 1.16-2.76), vaginal with other labor pain medications only ([not spinal/epidural]; aOR 1.84; 95% CI, 1.14-2.98), planned cesarean section with spinal/epidural only (aOR 2.13; 95% CI, 1.39-3.27), planned cesarean with spinal/epidural plus another medication (aOR 2.67; 95% CI, 1.35-5.29), emergency cesarean with spinal/epidural only (aOR 2.17; 95% CI, 1.34-3.51), and emergency cesarean with spinal/epidural plus another medication (aOR 3.03; 95% CI, 1.77-5.18).

CONCLUSION

Mothers who received labor pain medications were more likely to report DOL, regardless of delivery method. This information could help inform clinical decisions regarding labor/delivery.

Labor epidural anesthesia, obstetric factors and breastfeeding cessation

Breastfeeding benefits both infant and maternal health. Use of epidural anesthesia during labor is increasingly common and may interfere with breastfeeding. Studies analyzing epidural anesthesia's association with breastfeeding outcomes show mixed results; many have methodological flaws. We analyzed potential associations between epidural anesthesia and overall breast-feeding cessation within 30 days postpartum while adjusting for standard and novel covariates and uniquely accounting for labor induction. A pooled analysis using Kaplan-Meier curves and modified Cox Proportional Hazard models included 772 breastfeeding mothers from upstate New York who had vaginal term births of healthy singleton infants. Subjects were drawn from two cohort studies (recruited postpartum between 2005 and 2008) and included maternal self-report and maternal and infant medical record data. Analyses of potential associations between epidural anesthesia and overall breastfeeding cessation within 1 month included additional covariates and uniquely accounted for labor induction. After adjusting for standard demographics and intrapartum factors, epidural anesthesia significantly predicted breastfeeding cessation (hazard ratio 1.26 [95% confidence interval 1.10, 1.44], p < 0.01) as did hospital type, maternal age, income, education, planned breastfeeding goal, and breastfeeding confidence. In post hoc analyses stratified by Baby Friendly Hospital (BFH) status, epidural anesthesia significantly predicted breastfeeding cessation (BFH: 1.19 [1.01, 1.41], p < 0.04; non-BFH: 1.65 [1.31, 2.08], p < 0.01). A relationship between epidural anesthesia and breastfeeding was found but is complex and involves institutional, clinical, maternal and infant factors. These findings have implications for clinical care and hospital policies and point to the need for prospective studies.

Pregnancy, breast-feeding and drugs used in dentistry

BACKGROUND AND OVERVIEW

Despite advances in the study of birth defects related to drug exposures during pregnancy, medication use during pregnancy still causes anxiety and misunderstanding among both members of the public and health care professionals. This may result in a woman's unknowingly taking a medication that may harm the fetus or cause a birth defect or discontinuing medications necessary for treating chronic conditions. Using medications while breast-feeding also represents a challenge for patients and prescribers. Many mothers are told they must stop breast-feeding or "pump and discard" their breast milk if they are taking certain medications; however, in many cases, this advice-based on what may be limited education on the part of the health care provider about breast-feeding and medication use-may be incorrect. The authors review the current evidence regarding drugs that may be safe for pregnant or breast-feeding patients and medications that such patients should avoid.

CONCLUSIONS

When considering prescribing in pregnancy, the dentist must weigh the risk to the fetus versus the benefit to the mother, and the appropriate conclusion should reflect current evidence. In some cases medication dosing should be avoided or altered; however, there are times when it is unnecessary to stop the use of medications. Breast-feeding also represents a clinical challenge, the risks and benefits of which need to be understood by both the patient and practitioner before any medication is administered.

PRACTICE IMPLICATIONS

Dentists should be familiar with the risks and benefits for pregnant or breast-feeding patients posed by five types of medications: analgesics and anti-inflammatories, antibiotics, local anesthetics, sedatives and emergency medications.

Neonatal neurobehavioral organization after exposure to maternal epidural analgesia in labor

OBJECTIVE

To explore relationships between maternal epidural analgesia and two measures of neurobehavioral organization in infants at the initial feeding 1 hour after birth.

DESIGN

Prospective comparative design.

SETTING

Inner-city community hospital, Chicago, Illinois.

PARTICIPANTS

Convenience sample of 52 low-risk, mainly Black and Latino, mother/infant dyads.

METHODS

Mothers self-selected to labor with epidural or no labor pain medication. Neonatal neurobehavioral organization was measured in term infants at the initial feeding 1 hour after birth. A nutritive sucking apparatus generated data on total number of sucks and sucking pressure. Video recordings of infants (before and after the initial feeding) were coded for behavioral states, with analysis on frequency of alertness.

RESULTS

Total number of sucks and sucking pressure were not related to epidural exposure, although an epidural drug dosage effect on total number of sucks was evident when gender was a factor. Unmedicated girls demonstrated more sucks than girls in the high-dosage epidural group (p=.027). Overall, girls exhibited stronger sucking pressure than boys (p=.042). Frequency of alertness was not related to epidural exposure, although longer labor was related to greater alertness (p=.003), and Latino infants were more alert than Black infants (p=.002).

CONCLUSIONS

Results suggest attenuated neonatal nutritive sucking organization in girls after exposure to high maternal epidural dosages. In comparison to boys, girls may have enhanced neurobehavioral organization at birth. Race/ethnicity and alertness may have spurious associations in which hidden factors drive the relationship.

Effect of maternity-care practices on breastfeeding

OBJECTIVE

Our goal was to assess the impact of "Baby-Friendly" hospital practices and other maternity-care practices experienced by mothers on breastfeeding duration.

METHODS

This analysis of the Infant Feeding Practices Study II focused on mothers who initiated breastfeeding and intended prenatally to breastfeed for >2 months, with complete data on all variables (n = 1907). Predictor variables included indicators of 6 "Baby-Friendly" practices (breastfeeding initiation within 1 hour of birth, giving only breast milk, rooming in, breastfeeding on demand, no pacifiers, fostering breastfeeding support groups) along with several other maternity-care practices. The main outcome measure was breastfeeding termination before 6 weeks.

RESULTS

Only 8.1% of the mothers experienced all 6 "Baby-Friendly" practices. The practices most consistently associated with breastfeeding beyond 6 weeks were initiation within 1 hour of birth, giving only breast milk, and not using pacifiers. Bringing the infant to the room for feeding at night if not rooming in and not giving pain medications to the mother during delivery were also protective against early breastfeeding termination. Compared with the mothers who experienced all 6 "Baby-Friendly" practices, mothers who experienced none were approximately 13 times more likely to stop breastfeeding early. Additional practices decreased the risk for early termination.

CONCLUSIONS

Increased "Baby-Friendly" hospital practices, along with several other maternity-care practices, improve the chances of breastfeeding beyond 6 weeks. The need to work with hospitals to implement these practices continues to exist, as illustrated by the small proportion of mothers who reported experiencing all 6 of the "Baby-Friendly" hospital practices measured in this study.

Gerard W. Ostheimer Lecture 2006: What’s New in Obstetric Anaesthesia? Contributions from the 2005 literature

The Gerard W. Ostheimer lecture is given every year at the annual meeting of the Society for Obstetric Anesthesia and Perinatology by an obstetric anaesthesiologist who has reviewed the scientific literature for the previous calendar year. This article is based on the 2006 Ostheimer lecture and reviews three areas of interest in neonatology: resuscitation of the newborn, neonatal encephalopathy and the influence of epidural analgesia on breastfeeding.

Evidence-based practices for the fetal to newborn transition

Many common care practices during labor, birth, and the immediate postpartum period impact the fetal to neonatal transition, including medication used during labor, suctioning protocols, strategies to prevent heat loss, umbilical cord clamping, and use of 100% oxygen for resuscitation. Many of the care practices used to assess and manage a newborn immediately after birth have not proven efficacious. No definitive outcomes have been obtained from studies on maternal analgesia effects on the newborn. Although immediate cord clamping is common practice, recent evidence from large randomized, controlled trials suggests that delayed cord clamping may protect the infant against anemia. Skin-to-skin care of the newborn after birth is recommended as the mainstay of newborn thermoregulation and care. Routine suctioning of infants at birth was not been found to be beneficial. Neither amnioinfusion, suctioning of meconium-stained babies after the birth of the head, nor intubation and suctioning of vigorous infants prevents meconium aspiration syndrome. The use of 100% oxygen at birth to resuscitate a newborn causes increased oxidative stress and does not appear to offer benefits over room air. This review of evidence on newborn care practices reveals that more often than not, less intervention is better. The recommendations support a gentle, physiologic birth and family-centered care of the newborn.

Care practice #4: no routine interventions

This updated edition of Care Practice Paper #4 presents the evidence for risks of routinely intervening in normal physiologic labor and birth. The authors review evidence related to the routine use of restrictions on oral intake, intravenous lines, continuous electronic fetal monitoring, artificial rupture of membranes, pharmacologic augmentation of labor, epidural analgesia, and episiotomy. Medical indications for each intervention are listed. Women are encouraged to avoid routine interventions in labor unless interventions are medically indicated.

Intrapartum epidural analgesia and breastfeeding: a prospective cohort study

Background

Anecdotal reports suggest that the addition of fentanyl (an opioid) to epidural analgesia for women during childbirth results in difficulty establishing breastfeeding. The aim of this paper is to determine any association between epidural analgesia and 1) breastfeeding in the first week postpartum and 2) breastfeeding cessation during the first 24 weeks postpartum.

Methods

A prospective cohort study of 1280 women aged ≥ 16 years, who gave birth to a single live infant in the Australian Capital Territory in 1997 was conducted. Women completed questionnaires at weeks 1, 8, 16 and 24 postpartum. Breastfeeding information was collected in each of the four surveys and women were categorised as either fully breastfeeding, partially breastfeeding or not breastfeeding at all. Women who had stopped breastfeeding since the previous survey were asked when they stopped.

Results

In the first week postpartum, 93% of women were either fully or partially breastfeeding their baby and 60% were continuing to breastfeed at 24 weeks. Intrapartum analgesia and type of birth were associated with partial breastfeeding and breastfeeding difficulties in the first postpartum week (p < 0.0001). Analgesia, maternal age and education were associated with breastfeeding cessation in the first 24 weeks (p < 0.0001), with women who had epidurals being more likely to stop breastfeeding than women who used non-pharmacological methods of pain relief (adjusted hazard ratio 2.02, 95% CI 1.53, 2.67).

Conclusion

Women in this cohort who had epidurals were less likely to fully breastfeed their infant in the few days after birth and more likely to stop breastfeeding in the first 24 weeks. Although this relationship may not be causal, it is important that women at higher risk of breastfeeding cessation are provided with adequate breastfeeding assistance and support.

Infant feeding and analgesia in labour: the evidence is accumulating

The interesting and important paper by Torvaldsen and colleagues provides further circumstantial evidence of a positive association between intrapartum analgesia and feeding infant formula. Not all research supports this association. Before 'failure to breastfeed' can be adjudged an adverse effect of intrapartum analgesia, the research evidence needs to be considered in detail. Examination of the existing evidence against the Bradford-Hill criteria indicates that the evidence is not yet conclusive. However, the difficulties of obtaining funding and undertaking large trials to explore putative adverse drug reactions in pregnant women may mean that we shall never have conclusive evidence of harm. Therefore, reports of large cohort studies with regression models, as in the paper published today, assume a greater importance than in other areas of investigation. Meanwhile, women and their clinicians may feel that sufficient evidence has accumulated to justify offering extra support to establish breastfeeding if women have received high doses of analgesics in labour.

Epidural analgesia during labor and delivery: effects on the initiation and continuation of effective breastfeeding

This prospective cohort study examined the association between epidural analgesia during labor and delivery, infant neurobehavioral status, and the initiation and continuation of effective breastfeeding. Healthy, term infants delivered vaginally by mothers who received epidural analgesia (n = 52) or no analgesia (n = 63) during labor and delivery were assessed at 8 to 12 hours postpartum, followed by a telephone interview with the mothers at 4 weeks postpartum. There was no significant difference between the epidural analgesia and no-analgesia groups in breastfeeding effectiveness or infant neurobehavioral status at 8 to 12 hours or in the proportion of mothers continuing to breastfeed at 4 weeks. Therefore, epidural analgesia did not appear to inhibit effective breastfeeding. There was a positive correlation between infant neurobehavioral status and breastfeeding effectiveness (Spearman rho = 0.48, P = .01), suggesting that neurobehavioral assessment may prove beneficial in identifying infants at greater risk for breastfeeding difficulties.

Neurobehavioral functioning and breastfeeding behavior in the newborn

OBJECTIVE

To determine whether central nervous system functioning has an effect on the normal, term infant's ability to breastfeed in the first day following birth.

DESIGN

Breastfeeding behaviors and neurobehaviors were evaluated at birth and at 24 hrs of age in two groups of neonates. One group of neonates was born to mothers who received epidural analgesia during labor, and one group was born to mothers who received no pain medication. Breastfeeding behavior was evaluated using the Preterm Infant Breastfeeding Behavior Scale, and the infant's neurobehaviors were evaluated using the Neurologic and Adaptive Capacity Score.

PARTICIPANTS

Fifty-six breastfeeding mother-newborn dyads. All mothers were healthy multiparae who gave birth vaginally to normal, full-term, healthy newborns.

MAIN OUTCOME MEASURES

Newborns were observed for rooting, latch-on, sucking, swallowing, activity state, and neurobehavior.

RESULT

Analysis of the data indicated that the higher the infant scored in relation to neurobehavioral functioning, the higher the infant scored on breast-feeding behaviors.

CONCLUSION

When determining physiologically what is important for the infant to successfully latch on and feed, it appears that an intact and functioning central nervous system may be one of the crucial elements.

What’s new and novel in obstetric anesthesia? Contributions from the 2003 scientific literature

THE PREGNANT PATIENT: Age; maternal disease; prophylactic antibiotics; gastroesophageal reflux; obesity; starvation; genotyping; coagulopathy; infection; substance abuse; altered drug responses in pregnancy; physiological changes of pregnancy. THE FETUS: Fetal monitoring; intrauterine surgery. THE NEWBORN: Breastfeeding; maternal infection, fever, and neonatal sepsis evaluation. OBSTETRIC COMPLICATIONS: Embolic phenomena; hemorrhage; preeclampsia; preterm delivery. OBSTETRIC MANAGEMENT: External cephalic version and cervical cerclage; elective cesarean delivery; fetal malpresentation; vaginal birth after cesarean delivery; termination of pregnancy. OBSTETRIC ANESTHESIA: Analgesia for labor and delivery; anesthesia for cesarean delivery; anesthesia for short obstetric operations; complications of anesthesia. MISCELLANEOUS: Consent; ethics; history; labor support; websites/books/leaflets/journal announcements.