This is a paper that I started writing for a nursing journal, but decided I wanted to make this available for a broader audience.
If you type in epidural and breastfeeding into a search engine, you will probably chance upon a growing debate about how one affects the other. Many women find it confusing because much of the research has conflicting answers. Many are small studies and often have biases in either direction as well as being poorly designed. So where do we get the right answer and how does an epidural really effect breastfeeding? We also should ask, as providers who support women in labor and help with breastfeeding, what can we do to help support the woman who has chosen to get the epidural, but still needs help breastfeeding?
The thought among researchers is that epidural medication may affect the infants ability to suck and thus decrease their ability to nurse effectively after birth. Research has shown both a negative and a neutral affect of the epidural on breastfeeding. Another interesting study showed that the lower the dose of fentyl, the more success there is with breastfeeding. So we can see that the evidence for a link between these two things is unclear, but what we do know is that epidural medications do enter the baby. Fentanyl, a drug used often in epidurals, quickly crosses the placenta is metabolized slower in the infant than an adult. Because of this, and the effects of the epidural on the mom, there may be a more indirect impact of epidurals on the baby.
Epidurals have been linked with a greater chance of maternal fever, a longer second stage, a greater chance of forceps or a birth, and increased use of Pitocin. All of these things may affect the initial breastfeeding experience between the mother and the baby, and the initial experiences are indicators of early weaning.
A fever will often lead to the need for a separation between mom and baby soon after birth. This is due, in part, because blood tests may be required to make sure the baby does not have an infection. A longer second stage labor could possibly cause the mother to be more tired, and thus not be able to nurse or be as attentive to nursing. Both forceps and vaccuum have the potential for harm that could cause a baby to be separated from the mom. And Pitocin is associated with an increase in abnormal heart rates which may or may not affect how well the infant is doing after birth.
Because of this, those who are assisting with the initial breastfeeding experience should be able to support a woman who is considering using the epidural. We can do this is numerous ways. Providing information is one of the first things we should do to help a woman understand what the implications of having an epidural are, but also understand that the research is still limited. We should also be prepared to support her regardless of her decision.
For a woman that truly desires to have a medication free birth, adequate labor support should be the mainstay. Any woman who is working for a natural labor should have access to adequate non-pharmacologic labor support. More and more research is showing the benefit of having trained labor support, sometimes called a doula, to help a woman in labor. Women who have had continuous uninterrupted support, have fewer c-sections, use less Pitocin, and have less infants admitted to the NICU. Less of all three of these things could lead to better bonding and breastfeeding after birth.
If an epidural becomes medically necessary or the woman decides that she would like one, there are a few things we can do to help increase the chance of breastfeeding success. One is to encourage the lowest dose possible of fentanyl added to the epidural. At least one study has shown an association between the amount of fentanyl added and the rate of breastfeeding success. If we could even provide non medicated means of labor support along with low dose fentanyl, it might do something to increase the success of breastfeeding. Interventions like counter pressure, relaxation, and visualization might work well along with low dose epidural to provide the greatest amount of comfort with the least amount of side effects.
Women also need access to adequate breastfeedomg support, along with baby-friendly practices. Hospitals should provide access to a lactation consulant, and nurses should be trained to help support breastfeeding. A list of the 10 steps for a baby friendly hospital can be found at http://www.unicef.org/programme/breastfeeding/baby.htm#10 .
This protocol includes support such as rooming-in, unrestricted mother-infant contact, and encouraging skin-to-skin. If these steps are followed, breastfeeding continuation rates for women who use epidurals have been found to be similar to those who are unmedicated.
Another important factor in increasing breastfeeding rates is helping the mom herself to feel competent. A woman's personal perception of how she is doing with breastfeeding is a greater indicator of how long she will breastfeed than the perception of a lactation consultant regarding how she is doing. Therefore, if a woman is feeling frustrated with her experience, even if a nurse or lactation consultant feels she is doing fine, the mother is less likely to continue breastfeeding without additional support that builds her confidence. This can be done by education beforehand or during their hospital stay, as well as showing videos of successful breastfeeding attempts.
After birth, there needs to be some effort to reduce the pain and anxiety a mother feels as this may lead to difficultities breastfeeding immediately afterwards. Often times the pressure and intesity of the pushing stage of labor is difficult for a woman to work through, even with an epidural. Again, good labor support practices can help during this stage. Part of this may include allowing the woman to push in a more upright postion, even with an epidural. A side position can also be useful. The side position can also help to reduce the amount of truama to the perineum. Things such as ice packs and adequate pain control also help during this time.
The bottom line is, research has shown that epidurals may be linked to lower breastfeeding success in some instances, but that there are things we can do to help support a woman with any of her decisions. Labor support professionals can create a balance between controlling a woman's pain and decreasing the effects of the epidural.
References:
Courtney, K. (2007). Maternal Anesthesia: What Are the Effects on Neonates. Nursing for Women's Health. 5, 499-502.
Arnold, I., Beilin, Y., Bodian, C.A., Feierman, D.E., Holzman, I.,Hossain, S., Martin, G., Weuser, J. (2005). Effect of Labor Epidural Analgesia with and without Fentanyl on Infant Breast-feeding. Anesthesiology. 103, 1211-1217.
Baumgarder, D.J., Ficsher, M., Muehl, P., Pribbenow, B. (2003). Effect of Labor Epicural Anesthesia on Breast-Feeding of Healthy Full-Term Newborns Delivered Vaginally. Journal of the Amercian Board of Family Medicine. 1, 7-13.
Jordan, Sue. (2006). Infant feeding and analgesia in labour: the evidence is accumulating. International Breastfeeding Journal. 1:25.
Bassett, Vicki., Cragg, Betty., Noel-Weiss, Joy.(2006). Developing a Prenatal Breastfeeding Workshop to Support Maternal Breastfeeding Self-Efficacy. Journal of Obstetric, Gynecologic, & Neonatal Nursing. 35 , 349-357.
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