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ABM Clinical Protocol #28: Peripartum Analgesia and Anesthesia for the Breastfeeding Mother *


Abstract

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols, free from commercial interest or influence, for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient .

Background

THE WORLD HEALTH ORGANIZATION recommends exclusive breastfeeding for 6 months followed by a continuation of breastfeeding with the introduction of complementary foods for 2 years or longer as mutually desired by mother and infant. This recommendation is supported by a growing body of evidence for both the short- and long-term health benefits to infants and mothers. Despite its large public health impact, the study of breastfeeding initiation and continuation beginning in the peripartum phase is methodologically complex, lacking in scientific rigor, and sparse. There are several external factors such as maternal intention to breastfeed, community traditions and support, level of education, maternal age, race, and social class that influence breastfeeding outcomes. Many intrapartum interventions also have the potential to impact breastfeeding outcomes. Oxytocin, endorphins, and adrenaline produced in response to the physiological pain of labor may play significant roles in maternal and neonatal responses to birth and early breastfeeding. The use of pharmacologic and nonpharmacologic agents for pain relief in labor and postpartum may improve outcomes by relieving suffering during labor; however, some of these methods may affect the course of labor and the neurobehavioral state of the neonate.

Few studies directly address the impact of various approaches to peripartum anesthesia and analgesia on breastfeeding outcomes. While a Cochrane review evaluated 38 studies published before 2011 on epidural analgesia compared with other pain management options, it is notable that only one assessed breastfeeding outcomes.

This protocol will examine the evidence currently available, make recommendations for prudent practice regarding peripartum analgesia and anesthesia for the breastfeeding mother and offer suggestions for future research. Quality of evidence (levels of evidence: IA, IB, IIA, IIB, III, and IV) is based on levels of evidence used for the National Guidelines Clearinghouse and is noted in parentheses. The first part of the protocol will discuss the use of analgesia during labor and anesthesia for operative deliveries, and the second half will discuss specific medications used for postpartum pain relief. Note that some medications will be mentioned in both situations as infant effects may be different with medication through placental transfer versus colostrum and milk intake.

Recommendations

Analgesia for labor pain

Women experience labor pain in different ways and have differing levels of pain tolerance. Labor pain may exceed a woman’s ability to cope or be magnified by fear and anxiety. Suffering in labor may lead to dysfunctional labors, poorer psychological outcomes, delayed secretory activation, and increased risk of postpartum depression, all of which may have negative effects on breastfeeding. In addition, severe maternal physiologic stress in labor also causes in utero fetal stress as well as increased physiologic stress for infants, which may affect their readiness to breastfeed at birth (III).

Maternity care providers should discuss labor pain management options during the prenatal period, before the onset of labor. This discussion should include what is known about the association of various modalities on the progress of labor, risk of instrumented and cesarean delivery, effects on the newborn, and possible breastfeeding effects (IV).

Regardless of the modality used for labor analgesia, comprehensive patient and provider education, early and uninterrupted initiation of maternal–infant skin-to-skin contact, continuing lactation support in the postpartum phase, and identifying and actively addressing barriers to breastfeeding improve outcomes (IIA-IV).

Neuraxial labor analgesia

  • Neuraxial analgesia continues to be the most commonly used modality in many countries and the most effective pain management option available to parturients. There are no studies comparing breastfeeding outcomes according to neuraxial technique (i.e., epidural, combined spinal-epidural, spinal, and continuous spinal), therefore these will all be discussed together under the method of neuraxial analgesia.

  • The effect of neuraxial analgesia on breastfeeding outcomes continues to be inconclusive due to inconsistent reporting, differences in study design and end points, and mixed results. A 2016 systematic review found 23 studies examining the association between neuraxial analgesia and breastfeeding outcomes. These were mostly observational studies. Twelve found negative associations, 10 found no effect, and 1 found positive association between neuraxial analgesia and breastfeeding success (IIA-III). In addition, Lee et al. in 2017 reported no association between the cumulative fentanyl dose and rate of breastfeeding at 3 months postpartum (IB).

  • Opioids are commonly used in combination with local anesthetics in neuraxial solutions for labor analgesia. There are three prospective randomized studies evaluating the effect of epidural fentanyl dose on breastfeeding success, and the results differ. Beilin et al. reported that in mothers who had previously breastfed a child, those randomized to receive a high dose of epidural fentanyl (cumulative dose greater than or equal to 150 mcg) were more likely to stop breastfeeding 6 weeks postpartum when compared with mothers receiving no fentanyl or low dose of fentanyl (cumulative dose less than 150 mcg) (IB). Wilson et al. reported that neuraxial analgesia, with or without epidural fentanyl, did not impact breastfeeding up to 12 months postpartum (IIA). The third study was that by Lee et al., a randomized controlled trial (RCT) with objective measures of maternal and umbilical cord venous fentanyl and bupivacaine concentrations in multiparous mothers with previous breastfeeding experience. Of note, only 19% of participants in this trial received greater than or equal to 150 mcg cumulative dose of epidural fentanyl, which has been the suggested cutoff for breastfeeding effects (IB).

  • The association between neuraxial analgesia and neonatal neurobehavioral organization is also controversial and inconclusive in its long-term effects on breastfeeding outcomes. There may be depressed hand massage and suckling behavior in neonates exposed to neuraxial analgesia, but some of the neonates studied were also exposed to oxytocin and/or meperidine/pethidine during the course of labor, which were not accounted for in statistical analysis. There were no long-term differences in breastfeeding outcomes or these outcomes were not reported (III).

  • Like many other aspects of breastfeeding, neuraxial labor analgesia likely has minimal effects on women who strongly intend to breastfeed and have good support but may present one more subtle challenge to women whose intention to breastfeed is more vulnerable.

    • When neuraxial labor analgesia has been used, particular care should be taken to provide mothers with good breastfeeding support and close postpartum follow-up. Zuppa et al., in a retrospective cohort study, reported that in the case of partial rooming-in, the rate of exclusive or predominant breastfeeding was higher in mothers who did not receive epidural analgesia, although this may be a casual association rather than a causal one; in the case of full rooming-in, there was no difference in breastfeeding rates between mothers who did or did not receive neuraxial labor analgesia (III).

    • While there is currently no recommendation to encourage intrapartum fluid administration before neuraxial analgesia placement, intravenous fluids are still often provided as a bolus to mothers receiving epidural analgesia as a way to increase the intravascular volume and offset sympathetic blockade. Excessive fluid can potentially lead to maternal engorgement and affect birth weight and newborn weight loss (IIA).

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