Do labor medications affect breastfeeding?

Knowledge and Attitudes towards Epidural Analgesia among Women of Childbearing Age in Jazan, Saudi Arabia: A Community-Based Cross-Sectional Study to Identify Predictors through Multivariate Modeling

Epidural analgesia (EA) is a central nerve blockade technique. It is linked to a significant reduction of labor pain and side effects. This study was designed to investigate the knowledge and attitudes towards EA among women of childbearing age (18-45 years) in Jazan, Saudi Arabia, and identify predictors through multivariate modeling. A random sampling technique (n = 680) was used for this cross-sectional, self-administered survey. A previously validated online questionnaire was distributed. After establishing a P value of less than 0.05 to denote statistical significance, SPSS was used to examine the data using descriptive analysis, the chi-square test of homogeneity, and multivariate logistic regression. Six hundred and eighty women were studied. Over 75% of the participants were university educated; less than half (46.3%) were 21-30 years old, students (42.2%), and had never been pregnant (49%). The previous mothers who had never had EA labor accounted for 64.6% (n = 347, 51.0%). "Family/friends" (39%), followed by "internet" (32%), were the most common sources of EA information. Those who correctly defined the EA accounted for 61.8%. Those who reported weak or no contractions after EA accounted for 32.2%. Those who said EA insertion hurt more than labor did accounted for 56.3%. Those women who said one should give consent to EA accounted for 83.1%. Those who believe EA is safe for the baby accounted for 50.1%. Those who knew about EA complications accounted for 24.34%. According to multivariate modeling, attitude score plays a significant role in determining the participant's knowledge level. This study found that childbearing women know a little about EA. Attitudes affected this knowledge level, and demographics did not. Cognitive intervention is needed to change these attitudes and spread EA-related knowledge.

Should maternal anesthesia delay breastfeeding? A systematic review of the literature

Introduction

The importance and benefits of breastfeeding for the babies and mothers are well established and documented in the literature. However, it is frequent that lactating mothers need to undergo general or spinal anesthesia and, due to the lack of information, many of them interrupt breastfeeding after anesthesia. There are limited data available regarding anesthetics transfer to breast milk. This review aims to develop some considerations and recommendations based on available literature.

Methods

A systematic search of the literature was conducted by using the following health science databases: Embase, Lilacs, Pubmed, Scopus, and Web of Science. The latest literature search was performed on April 6^th, 2018. Additional literature search was made via the World Health Organization's website. We used the following terms for the search strategy: “Anesthesia” and “Breastfeeding”, and their derivatives.

Results

In this research, 599 registers were found, and 549 had been excluded by different reasons. Fifty manuscripts have been included, with different designs of studies: prospective trials, retrospective observational studies, reviews, case reports, randomized clinical trials, case–control, and website access. Small concentrations of the most anesthetic agents, are transferred to the breast milk; however, their administration seem to be safe for lactating mothers when administered as a single dose during anesthesia and this should not contraindicate the breastfeeding. On the other hand, high-doses, continuous or repeated administration of drugs increase the risk of adverse effects on neonates, and should be avoided. Few drugs, such as diazepam and meperidine, produce adverse effects on breastfed babies even in single doses. Dexmedetomidine seems to be safe if breastfeeding starts 24 h after discontinuation of the drug.

Conclusions

Most of the anesthetic drugs are safe for nursing mothers and offer low risk to the breastfed neonates when administered in single-dose. However, high-dose and repeated administration of drugs significantly increase the risk of adverse effects on neonates. Moreover, diazepam and meperidine should be avoided in nursing women. Finally, anesthesiologists and pediatricians should consider individual risk/benefit, with special attention to premature neonates or babies with concurrent diseases since they are more susceptible to adverse effects.

[Should maternal anesthesia delay breastfeeding? A systematic review of the literature]

INTRODUCTION

The importance and benefits of breastfeeding for the babies and mothers are well established and documented in the literature. However, it is frequent that lactating mothers need to undergo general or spinal anesthesia and, due to the lack of information, many of them interrupt breastfeeding after anesthesia. There are limited data available regarding anesthetics transfer to breast milk. This review aims to develop some considerations and recommendations based on available literature.

METHODS

A systematic search of the literature was conducted by using the following health science databases: Embase, Lilacs, Pubmed, Scopus, and Web of Science. The latest literature search was performed on April 6th, 2018. Additional literature search was made via the World Health Organization's website. We used the following terms for the search strategy: "Anesthesia" and "Breastfeeding", and their derivatives.

RESULTS

In this research, 599 registers were found, and 549 had been excluded by different reasons. Fifty manuscripts have been included, with different designs of studies: prospective trials, retrospective observational studies, reviews, case reports, randomized clinical trials, case-control, and website access. Small concentrations of the most anesthetic agents, are transferred to the breast milk; however, their administration seem to be safe for lactating mothers when administered as a single dose during anesthesia and this should not contraindicate the breastfeeding. On the other hand, high-doses, continuous or repeated administration of drugs increase the risk of adverse effects on neonates, and should be avoided. Few drugs, such as diazepam and meperidine, produce adverse effects on breastfed babies even in single doses. Dexmedetomidine seems to be safe if breastfeeding starts 24h after discontinuation of the drug.

CONCLUSIONS

Most of the anesthetic drugs are safe for nursing mothers and offer low risk to the breastfed neonates when administered in single-dose. However, high-dose and repeated administration of drugs significantly increase the risk of adverse effects on neonates. Moreover, diazepam and meperidine should be avoided in nursing women. Finally, anesthesiologists and pediatricians should consider individual risk/benefit, with special attention to premature neonates or babies with concurrent diseases since they are more susceptible to adverse effects.

Epidural versus non-epidural or no analgesia for pain management in labour

BACKGROUND

Epidural analgesia is a central nerve block technique achieved by injection of a local anaesthetic close to the nerves that transmit pain, and is widely used as a form of pain relief in labour. However, there are concerns about unintended adverse effects on the mother and infant. This is an update of an existing Cochrane Review (Epidural versus non-epidural or no analgesia in labour), last published in 2011.

OBJECTIVES

To assess the effectiveness and safety of all types of epidural analgesia, including combined-spinal-epidural (CSE) on the mother and the baby, when compared with non-epidural or no pain relief during labour.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (ClinicalTrials.gov), the WHO International Clinical Trials Registry Platform (ICTRP) (30 April 2017), and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials comparing all types of epidural with any form of pain relief not involving regional blockade, or no pain relief in labour. We have not included cluster-randomised or quasi-randomised trials in this update.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risks of bias, extracted data and checked them for accuracy. We assessed selected outcomes using the GRADE approach.

MAIN RESULTS

Fifty-two trials met the inclusion criteria and we have included data from 40 trials, involving over 11,000 women. Four trials included more than two arms. Thirty-four trials compared epidural with opioids, seven compared epidural with no analgesia, one trial compared epidural with acu-stimulation, one trial compared epidural with inhaled analgesia, and one trial compared epidural with continuous midwifery support and other analgesia. Risks of bias varied throughout the included studies; six out of 40 studies were at high or unclear risk of bias for every bias domain, while most studies were at high or unclear risk of detection bias. Quality of the evidence assessed using GRADE ranged from moderate to low quality.Pain intensity as measured using pain scores was lower in women with epidural analgesia when compared to women who received opioids (standardised mean difference -2.64, 95% confidence interval (CI) -4.56 to -0.73; 1133 women; studies = 5; I2 = 98%; low-quality evidence) and a higher proportion were satisfied with their pain relief, reporting it to be "excellent or very good" (average risk ratio (RR) 1.47, 95% CI 1.03 to 2.08; 1911 women; studies = 7; I2 = 97%; low-quality evidence). There was substantial statistical heterogeneity in both these outcomes. There was a substantial decrease in the need for additional pain relief in women receiving epidural analgesia compared with opioid analgesia (average RR 0.10, 95% CI 0.04 to 0.25; 5099 women; studies = 16; I2 = 73%; Tau2 = 1.89; Chi2 = 52.07 (P < 0.00001)). More women in the epidural group experienced assisted vaginal birth (RR 1.44, 95% CI 1.29 to 1.60; 9948 women; studies = 30; low-quality evidence). A post hoc subgroup analysis of trials conducted after 2005 showed that this effect is negated when trials before 2005 are excluded from this analysis (RR 1.19, 95% CI 0.97 to 1.46). There was no difference between caesarean section rates (RR 1.07, 95% CI 0.96 to 1.18; 10,350 women; studies = 33; moderate-quality evidence), and maternal long-term backache (RR 1.00, 95% CI 0.89 to 1.12; 814 women; studies = 2; moderate-quality evidence). There were also no clear differences between groups for the neonatal outcomes, admission to neonatal intensive care unit (RR 1.03, 95% CI 0.95 to 1.12; 4488 babies; studies = 8; moderate-quality evidence) and Apgar score less than seven at five minutes (RR 0.73, 95% CI 0.52 to 1.02; 8752 babies; studies = 22; low-quality evidence). We downgraded the evidence for study design limitations, inconsistency, imprecision in effect estimates, and possible publication bias.Side effects were reported in both epidural and opioid groups. Women with epidural experienced more hypotension, motor blockade, fever, and urinary retention. They also had longer first and second stages of labour, and were more likely to have oxytocin augmentation than the women in the opioid group. Women receiving epidurals had less risk of respiratory depression requiring oxygen, and were less likely to experience nausea and vomiting than women receiving opioids. Babies born to women in the epidural group were less likely to have received naloxone. There was no clear difference between groups for postnatal depression, headache, itching, shivering, or drowsiness. Maternal morbidity and long-term neonatal outcomes were not reported.Epidural analgesia resulted in less reported pain when compared with placebo or no treatment, and with acu-stimulation. Pain intensity was not reported in the trials that compared epidural with inhaled analgesia, or continuous support. Few trials reported on serious maternal side effects.

AUTHORS' CONCLUSIONS

Low-quality evidence shows that epidural analgesia may be more effective in reducing pain during labour and increasing maternal satisfaction with pain relief than non-epidural methods. Although overall there appears to be an increase in assisted vaginal birth when women have epidural analgesia, a post hoc subgroup analysis showed this effect is not seen in recent studies (after 2005), suggesting that modern approaches to epidural analgesia in labour do not affect this outcome. Epidural analgesia had no impact on the risk of caesarean section or long-term backache, and did not appear to have an immediate effect on neonatal status as determined by Apgar scores or in admissions to neonatal intensive care. Further research may be helpful to evaluate rare but potentially severe adverse effects of epidural analgesia and non-epidural analgesia on women in labour and long-term neonatal outcomes.

Nitrous oxide labor analgesia and pain relief memory in breastfeeding women

OBJECTIVE

The use of labor pain relief medications is a controversial issue that has engendered heated discussions among health care professionals about safety, interference with birthing, and breastfeeding.

METHODS

This is a case-control study with 62 puerperae treated with nitrous oxide and 124 control women (ratio 1:2), matched for age, gestational age, parity, delivery route, labor augmentation, and spinal regional analgesia. We tested anhedonia, anxiety, and depression symptoms at hospital discharge by The Edinburgh Postnatal Depression Scale (EPDS), and the intensity of nitrous oxide labor pain relief and satisfaction memory by a retrospective Visual Analog Scale (VAS, 0-10 Numeric Rating Scale) at a set cut off time of 3 months of a child's age.

RESULTS

Nitrous oxide use did not influence EPDS subscales upon discharge. Its use was instead associated with a lasting positive labor pain relief experience (VAS, 7.3 ± 2.2) in 83.5% of women, and labor satisfaction memory (VAS, 8.9 ± 1.8) in 90% of women, respectively, and with a significantly higher breastfeeding rates from the seventh day after discharge (p < .031), to the 1st (p < .043), and the third month of life (p < .016).

CONCLUSIONS

Nitrous oxide labor analgesia is associated with favorable effects on both women's psychoemotional experience of labor and breastfeeding success.

Medications and Breast-Feeding: A Guide for Pharmacists, Pharmacy Technicians, and other Healthcare Professionals Part I

Objective:

To provide a guide for practicing pharmacists, pharmacy technicians, and other healthcare professionals so that they are able to counsel and advise breast-feeding mothers and fellow healthcare professionals on the safety and use of common ambulatory care, analgesic, and anesthetic medications during breast-feeding.

Data Sources:

Primary texts used by the breast-feeding community were searched, as well as Micromedex, MEDLINE, PubMed, Embase, and Embase2 (1984–July 2003).

Study Selection and Data Extraction:

Multiple sources were utilized whenever available to validate the data, and primary articles were used to verify all tertiary source information. Search terms included breast feeding, lactation, nursing, and medications, as well as specific drug names.

Data Synthesis:

Concerns regarding medication use during breast-feeding have caused mothers to either discontinue nursing or not take necessary medications. Complete avoidance of medications or cessation of breast-feeding is often unnecessary. Although there are medications that can be harmful to nursing infants, breast milk concentrations of most drugs are insufficient to cause any harm.

Conclusions:

Having objective and reliable information on medications enables pharmacists, pharmacy technicians, other healthcare providers, and mothers to make educated decisions regarding drug therapy and breast-feeding.

Nonpharmacologic approaches for pain management during labor compared with usual care: a meta-analysis

OBJECTIVES

To assess the effects of nonpharmacologic approaches to pain relief during labor, according to their endogenous mechanism of action, on obstetric interventions, maternal, and neonatal outcomes.

DATA SOURCE

Cochrane library, Medline, Embase, CINAHL and the MRCT databases were used to screen studies from January 1990 to December 2012.

STUDY SELECTION

According to Cochrane criteria, we selected randomized controlled trials that compared nonpharmacologic approaches for pain relief during labor to usual care, using intention-to-treat method.

RESULTS

Nonpharmacologic approaches, based on Gate Control (water immersion, massage, ambulation, positions) and Diffuse Noxious Inhibitory Control (acupressure, acupuncture, electrical stimulation, water injections), are associated with a reduction in epidural analgesia and a higher maternal satisfaction with childbirth. When compared with nonpharmacologic approaches based on Central Nervous System Control (education, attention deviation, support), usual care is associated with increased odds of epidural OR 1.13 (95% CI 1.05-1.23), cesarean delivery OR 1.60 (95% CI 1.18-2.18), instrumental delivery OR 1.21 (95% CI 1.03-1.44), use of oxytocin OR 1.20 (95% CI 1.01-1.43), labor duration (29.7 min, 95% CI 4.5-54.8), and a lesser satisfaction with childbirth. Tailored nonpharmacologic approaches, based on continuous support, were the most effective for reducing obstetric interventions.

CONCLUSION

Nonpharmacologic approaches to relieve pain during labor, when used as a part of hospital pain relief strategies, provide significant benefits to women and their infants without causing additional harm.

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.

Association between intrapartum interventions and breastfeeding duration

INTRODUCTION

Few women who reside in Hong Kong exclusively breastfeed, and one-half stop breastfeeding within the first few months. There is little research in this population on the association between intrapartum interventions and breastfeeding duration.

METHODS

A sample of 1280 mother-infant pairs were recruited from the obstetric units of 4 public hospitals in Hong Kong and followed prospectively for 12 months or until the infant was weaned. The outcome variables for this analysis were the duration of any and exclusive breastfeeding. Predictor variables were 4 intrapartum interventions: receipt of opioid pain medication, induction versus spontaneous labor, epidural administration, and mode of birth. We used Cox proportional hazards modeling to assess the impact of intrapartum interventions on the duration of any and exclusive breastfeeding, and we constructed Kaplan-Meier survival curves to evaluate the cumulative impact of multiple intrapartum interventions on breastfeeding outcomes.

RESULTS

Bivariate analysis showed that induction of labor (hazard ratio [HR], 1.24; 95% confidence interval [CI], 1.09-1.41), opioid pain medication (HR, 1.21; 95% CI, 1.06-1.37), and having an emergency cesarean birth (HR, 1.22; 95% CI, 1.01-1.48) were associated with a shorter duration of any breastfeeding. Induction of labor (HR, 1.23; 95% CI, 1.08-1.39) and having an emergency cesarean birth (HR, 1.25; 95% CI, 1.05-1.51) were associated with a shorter duration of exclusive breastfeeding. After controlling for known confounding variables, there was no longer any association between individual intrapartum interventions and the duration of any or exclusive breastfeeding. The median duration of breastfeeding for participants who experienced a natural birth with no intrapartum interventions was 9 weeks compared with 5 weeks for participants who experienced at least 3 intrapartum interventions.

DISCUSSION

Clinicians working with new breastfeeding mothers should focus on providing additional support to mothers who experience a difficult labor and birth with multiple interventions to improve their breastfeeding experiences.

Epidural versus non-epidural or no analgesia in labour

BACKGROUND

Epidural analgesia is a central nerve block technique achieved by injection of a local anaesthetic close to the nerves that transmit pain and is widely used as a form of pain relief in labour. However, there are concerns regarding unintended adverse effects on the mother and infant.

OBJECTIVES

To assess the effects of all modalities of epidural analgesia (including combined-spinal-epidural) on the mother and the baby, when compared with non-epidural or no pain relief during labour.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 March 2011).

SELECTION CRITERIA

Randomised controlled trials comparing all modalities of epidural with any form of pain relief not involving regional blockade, or no pain relief in labour.

DATA COLLECTION AND ANALYSIS

Two of the review authors independently assessed trials for eligibility, methodological quality and extracted all data. We entered data into RevMan and double checked it for accuracy. Primary analysis was by intention to treat; we conducted subgroup and sensitivity analyses where substantial heterogeneity was evident.

MAIN RESULTS

We included 38 studies involving 9658 women; all but five studies compared epidural analgesia with opiates. Epidural analgesia was found to offer better pain relief (mean difference (MD) -3.36, 95% confidence interval (CI) -5.41 to -1.31, three trials, 1166 women); a reduction in the need for additional pain relief (risk ratio (RR) 0.05, 95% CI 0.02 to 0.17, 15 trials, 6019 women); a reduced risk of acidosis (RR 0.80, 95% CI 0.68 to 0.94, seven trials, 3643 women); and a reduced risk of naloxone administration (RR 0.15, 95% CI 0.10 to 0.23, 10 trials, 2645 women). However, epidural analgesia was associated with an increased risk of assisted vaginal birth (RR 1.42, 95% CI 1.28 to 1.57, 23 trials, 7935 women), maternal hypotension (RR 18.23, 95% CI 5.09 to 65.35, eight trials, 2789 women), motor-blockade (RR 31.67, 95% CI 4.33 to 231.51, three trials, 322 women), maternal fever (RR 3.34, 95% CI 2.63 to 4.23, six trials, 2741 women), urinary retention (RR 17.05, 95% CI 4.82 to 60.39, three trials, 283 women), longer second stage of labour (MD 13.66 minutes, 95% CI 6.67 to 20.66, 13 trials, 4233 women), oxytocin administration (RR 1.19, 95% CI 1.03 to 1.39, 13 trials, 5815 women) and an increased risk of caesarean section for fetal distress (RR 1.43, 95% CI 1.03 to 1.97, 11 trials, 4816 women). There was no evidence of a significant difference in the risk of caesarean section overall (RR 1.10, 95% CI 0.97 to 1.25, 27 trials, 8417 women), long-term backache (RR 0.96, 95% CI 0.86 to 1.07, three trials, 1806 women), Apgar score less than seven at five minutes (RR 0.80, 95% CI 0.54 to 1.20, 18 trials, 6898 women), and maternal satisfaction with pain relief (RR 1.31, 95% CI 0.84 to 2.05, seven trials, 2929 women). We found substantial heterogeneity for the following outcomes: pain relief; maternal satisfaction; need for additional means of pain relief; length of second stage of labour; and oxytocin augmentation. This could not be explained by subgroup or sensitivity analyses, where data allowed analysis. No studies reported on rare but potentially serious adverse effects of epidural analgesia.

AUTHORS' CONCLUSIONS

Epidural analgesia appears to be effective in reducing pain during labour. However, women who use this form of pain relief are at increased risk of having an instrumental delivery. Epidural analgesia had no statistically significant impact on the risk of caesarean section, maternal satisfaction with pain relief and long-term backache and did not appear to have an immediate effect on neonatal status as determined by Apgar scores. Further research may be helpful to evaluate rare but potentially severe adverse effects of epidural analgesia on women in labour and long-term neonatal outcomes.

Epidural versus non-epidural or no analgesia in labour

BACKGROUND

Epidural analgesia is a central nerve block technique achieved by injection of a local anaesthetic close to the nerves that transmit pain and is widely used as a form of pain relief in labour. However, there are concerns regarding unintended adverse effects on the mother and infant.

OBJECTIVES

To assess the effects of all modalities of epidural analgesia (including combined -spinal-epidural) on the mother and the baby, when compared with non-epidural or no pain relief during labour.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (June 2005).

SELECTION CRITERIA

Randomised controlled trials comparing all modalities of epidural with any form of pain relief not involving regional blockade, or no pain relief in labour.

DATA COLLECTION AND ANALYSIS

Two of the review authors independently assessed trials for eligibility, methodological quality and extracted all data. Data were entered into RevMan and double checked. Primary analysis was by intention-to-treat; sensitivity analyses excluded trials with > 30% of women receiving un-allocated treatment.

MAIN RESULTS

Twenty-one studies involving 6664 women were included, all but one study compared epidural analgesia with opiates. For technical reasons, data on women's perception of pain relief in labour could only be included from one study which found epidural analgesia to offer better pain relief than non-epidural analgesia (weighted mean difference (WMD) -2.60, 95% confidence interval (CI) -3.82 to -1.38, 1 trial, 105 women). However, epidural analgesia was associated with an increased risk of instrumental vaginal birth (relative risk (RR) 1.38, 95% CI 1.24 to 1.53, 17 trials, 6162 women). There was no evidence of a significant difference in the risk of caesarean delivery (RR 1.07, 95% CI 0.93 to 1.23, 20 trials, 6534 women), long-term backache (RR 1.00, 95% CI 0.89 to 1.12, 2 trials, 814 women), low neonatal Apgar scores at five minutes (RR 0.70, 95% CI 0.44 to 1.10, 14 trials, 5363 women), and maternal satisfaction with pain relief (RR 1.18 95% CI 0.92 to 1.50, 5 trials, 1940 women). No studies reported on rare but potentially serious adverse effects of epidural analgesia.

AUTHORS' CONCLUSIONS

Epidural analgesia appears to be effective in reducing pain during labour. However, women who use this form of pain relief are at increased risk of having an instrumental delivery. Epidural analgesia had no statistically significant impact on the risk of caesarean section, maternal satisfaction with pain relief and long-term backache and did not appear to have an immediate effect on neonatal status as determined by Apgar scores. Further research may be helpful to evaluate rare but potentially severe adverse effects of epidural analgesia on women in labour and long-term neonatal outcomes.

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.

Epidural analgesia for childbirth: effects of newer techniques on neonatal outcome

New low-dose, local anesthetic-opioid combinations, combined spinal epidural analgesia, and new anesthetic drugs, such as ropivacaine and levobupivacaine, have modified the anesthetic practice in obstetric labor analgesia. These new analgesic techniques have less or no neonatal effects when compared with traditional epidural labor analgesia. They also have less effect on mode of delivery, which may in turn affect neonatal outcome. The use of very diluted or low concentrations of local anesthetic solutions may reduce their placental passage and thus the possible subtle neonatal effects. Small doses of epidural or spinal opioids alone or combined with low doses of local anesthetics does not affect the well-being of the neonate at birth. When considering the neonatal outcome, combined spinal epidural analgesia is as well tolerated as low-dose epidural analgesia. Transient fetal heart rate changes have been described immediately after the administration of intrathecal or epidural opioids. Maternal hypotension may also occur at the onset of epidural analgesia. Whether the occurrence of transient fetal heart rate changes or maternal hypotension immediately after the epidural block may influence the neonatal outcome at birth needs verification.

The neuromatrix theory of pain: implications for selected nonpharmacologic methods of pain relief for labor

Women experience the pain of labor differently, with many factors contributing to their overall perception of pain. The neuromatrix theory of pain provides a framework that may explain why selected nonpharmacologic methods of pain relief can be quite effective for the relief of pain for the laboring woman. The concept of a pain "neuromatrix" suggests that perception of pain is simultaneously modulated by multiple influences. The theory was developed by Ronald Melzack and represents an expansion beyond his original "gate theory" of pain, first proposed in 1965 with P. D. Wall. This article reviews several nonpharmacologic methods of pain relief with implications for the practicing clinician. Providing adequate pain relief during labor and birth is an important component of caring for women during labor and birth.

Epidural analgesia for pain relief in labour and childbirth - a review with a systematic approach

BACKGROUND

Clinical ambiguity concerning effects of epidural analgesia for pain relief in labour seems to reflect a need for evidence-based knowledge for midwives.

AIMS

This study aimed to review, with a systematic approach, the literature about effects and risks associated with the use of epidural analgesia for pain relief in labour and childbirth.

DESIGN

A structured question was formulated and used for deriving search terms, establishing the inclusion of certain criteria and retrieving articles, i.e. what are the effects of epidural analgesia for pain relief in labour and childbirth? References were obtained through searches using MeSH-terms in Medline and Subheadings (SH) in CINAHL (e.g. Obstetrical Analgesia combined either with psychology or adverse effects and together with, Dystocia, Caesarean Section, Infant Newborn and Breastfeeding). The articles were divided into prospective randomized trials (C), non-randomized prospective studies (P) and retrospective studies (R). Scientific quality of the studies was assessed on a three-grade scale: high scientific quality (I), moderate scientific quality (II) or low scientific quality (III).

RESULTS

Twenty-four articles were retrieved and systematically assessed. Seven studies were judged as high quality, 15 as moderate quality and two as low quality. The majority of studies appraised in this review failed to obtain or establish a cause and effect relationship. According to the data, it seems clear that the use of epidural analgesia is considered to be an effective method of pain relief during labour and childbirth from the perspective of women giving birth.

RELEVANCE TO CLINICAL PRACTICE

Midwives and doctors can recommend this form of pain relief. However, information about possible associations with adverse effects in mothers and infants must be provided to expectant couples.

Impact of intrapartum epidural analgesia on breast-feeding duration

BACKGROUND

Although the labour and delivery outcomes of epidural analgesia have been investigated extensively, the effects on breast-feeding success are not clearly identified.

AIM

To investigate the effects of intrapartum epidural analgesia on breast-feeding duration.

METHODS

Nulliparous women enrolled in a randomised trial investigating labour and delivery outcomes of intrapartum epidural analgesia were asked about breast-feeding outcomes. Breast-feeding duration was ascertained by a self-report at 2 and 6 months post-partum. Breast-feeding outcomes were analysed as a prospective observational study because of high cross-over rates (43.4%) in the original randomised controlled trial.

RESULTS

A total of 992 women were recruited to the trial with 690 (69.6%) receiving epidural analgesia in labour. Breast-feeding was initiated by 95% (n = 946). At 2 and 6 months, 625 (63.5%) and 401 (40.7%), respectively, were still breast-feeding. Intrapartum analgesia (trend P-value = 0.036), mode of delivery (P < 0.001), age (P < 0.001), education (P < 0.001), and smoking in pregnancy (P < 0.001) showed univariate associations with breast-feeding duration. In the subgroup of women with spontaneous onset of labour and vaginal deliveries, after controlling for other obstetric and demographic factors, epidural analgesia but not narcotic analgesia was significantly associated with reduced breast-feeding duration (adjusted hazard ratio 1.44, 95% confidence interval 1.04-1.99).

CONCLUSIONS

Nulliparous women have a high use of epidural analgesia in labour. Nulliparous women who choose epidural analgesia are more likely to breast-feed for shorter durations. Further exploration of the factors underlying this association should be undertaken.

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

OBJECTIVE

To determine whether a difference in breastfeeding behaviors could be observed between newborns whose mothers received epidural analgesia for labor pain relief and those newborns whose mothers received no pain medication in labor.

DESIGN

There were two groups of neonates in this study. One group was born to mothers who received epidural analgesia, and one group was born to mothers who received no pain medication for labor. Both groups were observed for initial breastfeeding behaviors using the Premature Infant Breastfeeding Behavior Scale following birth and at 24 hours. Central nervous system functioning in the newborn was measured with the Neurologic and Adaptive Capacity Score at 2 and 24 hours of age.

SETTING

A large tertiary hospital in northeast Ohio.

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.

RESULTS

There were no statistically significant differences in breastfeeding behaviors at birth or at 24 hours of age.

CONCLUSION

A possible cause for the lack of significant results may have been the ultra low dose of bupivacaine and fentanyl used in this sample.

Misconceptions about neuraxial analgesia

Neuraxial analgesia is the most effective treatment for labor pain. Although there are known risks and side effects, many problems are attributed to the technique without appropriate scientific assessment. Some observations, such as the increased use of forceps and prolonged second stage of labor, are associated with epidural analgesia, but there is not enough evidence to categorically state whether the technique caused the problems. These topics warrant continued investigation.

Breastfeeding initiation and duration: a 1990-2000 literature review

OBJECTIVE

To review the literature on breastfeeding initiation and duration and to delineate effective strategies for promoting positive breastfeeding behaviors.

DATA SOURCES

Computerized searches on MEDLINE, CINAHL, and the Cochrane Library.

STUDY SELECTION

Articles from indexed journals relevant to the objective and published after 1990 (except for classic findings) were reviewed. Although a myriad of pertinent articles was located, referenced citations were limited to three per point. When article selection was required for a specific point, preferences were given to (a) randomized controlled trials; (b) meta-analyses; (c) studies with the largest, most representative samples; and (d) investigations conducted in North America.

DATA EXTRACTION

Data were extracted and organized under the following headings: benefits of breastfeeding, breastfeeding initiation and duration, personal characteristics, attitudinal and intrapersonal characteristics, hospital policies and intrapartum experience, sources of support, breastfeeding interventions, and review implications.

DATA SYNTHESIS

Although the health benefits of breastfeeding are well documented and initiation rates have increased over the past 20 years, most mothers wean before the recommended 6-months postpartum because of perceived difficulties with breastfeeding rather than due to maternal choice. Women least likely to breastfeed are those who are young, have a low income, belong to an ethnic minority, are unsupported, are employed full-time, decided to breastfeed during or late in pregnancy, have negative attitudes toward breastfeeding, and have low confidence in their ability to breastfeed. Support from the mother's partner or a nonprofessional greatly increases the likelihood of positive breastfeeding behaviors. Health care professionals can be a negative source of support if their lack of knowledge results in inaccurate or inconsistent advice. Furthermore, a number of hospital routines are potentially detrimental to breastfeeding. Although professional interventions that enhance the usual care mothers receive increase breastfeeding duration to 2 months, these supportive strategies have limited long-term effects. Peer support interventions also promote positive breastfeeding behaviors and should be considered.

CONCLUSIONS

A promising intervention is the complementation of professional services with peer support from a mother experienced in breastfeeding. This lay support appears to be an effective intervention with socially disadvantaged women.

Maternal analgesia during labor disturbs newborn behavior: effects on breastfeeding, temperature, and crying

BACKGROUND

Newborns not exposed to analgesia, when placed on the mother's chest, exhibit an inborn prefeeding behavior. This study was performed to assess the effects of different types of analgesia during labor on the development of spontaneous breastfeeding movements, crying behavior, and skin temperature during the first hours of life in healthy term newborns.

METHODS

Video recordings were made of 28 newborns who had been dried and placed in skin-to-skin contact between their mother's breasts immediately after delivery. The video recordings were analyzed blindly with respect to infant exposure to analgesia. Defined infant behaviors were assessed every 30 seconds. Group 1 mothers (n = 10) had received no analgesia during labor, group 2 mothers (n = 6) had received mepivacaine via pudendal block, and group 3 mothers (n = 12) had received pethidine or bupivacaine or more than one type of analgesia during labor.

RESULTS

All infants made finger and hand movements, but the infant's massagelike hand movements were less frequent in infants whose mothers had received labor analgesia. A significantly lower proportion of group 3 infants made hand-to-mouth movements (p < 0.001), and a significantly lower proportion of the infants in groups 2 and 3 touched the nipple with their hands before suckling (p < 0.01), made licking movements (p < 0.01), and sucked the breast (p < 0.01). Nearly one-half of the infants, all in groups 2 or 3, did not breastfeed within the first 2.5 hour of life. The infants whose mothers had received analgesia during labor had higher temperatures (p = 0.03) and they cried more (p = 0.05) than infants whose mothers had not received any analgesia.

CONCLUSIONS

The present data indicate that several types of analgesia given to the mother during labor may interfere with the newborn's spontaneous breast-seeking and breastfeeding behaviors and increase the newborn's temperature and crying.

The effect of labor pain relief medication on neonatal suckling and breastfeeding duration

We examined the relationship of labor pain relief medications with neonatal suckling and breastfeeding duration in 129 mothers delivering vaginally. Suckling was measured using the Infant Breastfeeding Assessment Tool (IBFAT). Controlling for infant age, birthweight, and gender, infants of unmedicated mothers had higher IBFAT suckling scores than those of medicated mothers (x = 11.1 vs. x = 8.2 respectively, P = .001). IBFAT suckling scores for intravenous and epidural groups were similar (x = 8.5) while those who received a combination of both intravenous and epidural medications were lower (x = 6.4 +/- 2.96, P = .001). Mothers evaluated their breastfeeding similarly to nurse evaluators (Z = 9.39, P = .001). Breastfeeding duration did not differ between unmedicated and medicated groups; however, dyads with low IBFAT scores weaned earlier than those with medium or high scores. Labor pain relief medications diminish early suckling but are not associated with duration of breastfeeding through 6 weeks postpartum.

Effect of labor analgesia on breastfeeding success

BACKGROUND

The effect of labor analgesia on breastfeeding success is not well defined. Some authors have hypothesized that labor analgesia may affect lactation success. The purpose of this observational study was to determine if intrapartum analgesia influenced breastfeeding success at 6 weeks postpartum in a setting that strongly supported breastfeeding.

METHODS

Healthy women with uncomplicated term pregnancies who planned to breastfeed consented to a telephone interview. We recorded demographic data, labor induction status, delivery mode, and analgesic medications. At between 6 and 8 weeks postpartum, patients were asked to describe breastfeeding use, problems encountered, solutions derived, sources of support and information, and satisfaction. We created a logistic regression model using intrapartum analgesia information and controlling for demographic factors previously correlated with lactation success.

RESULTS

We enrolled 189 women, contacted 177 women postpartum, and obtained complete data on 171 women. Of these, 59 percent received epidural analgesia, 72 percent breastfed fully, and 20 percent breastfed partially (> 50% of infant nutrition) at 6 weeks postpartum. After controlling for demographics and labor outcome, we could not demonstrate a correlation between breastfeeding success at 6 to 8 weeks and labor analgesia.

CONCLUSIONS

In a hospital that strongly promotes breastfeeding, epidural labor analgesia with local anesthetics and opioids does not impede breastfeeding success. We recommend that hospitals that find decreased lactation success in parturients receiving epidural analgesia reexamine their postdelivery care policies.

Does epidural analgesia during labour affect the neonate?

Focus has changed from the immediate postpartum condition to the more long-term outcome of the neonate with respect to the use of epidural analgesia in labour. Anaesthesiologists have been slow to respond to the demand for this information. Newer analgesic agents and techniques may offer some advantage to the neonate; however, extensive study is still needed.