8/18/2019 Examining the Effects of Labor Epidural
2/3
10.1177/0890334403258003 ARTICLE Nommsen-Rivers
Research Spotlight
Research Spotlight
Examining the Effects of Labor Epidural
Analgesia on Newborn Breastfeeding Behaviors
Laurie Nommsen-Rivers, MS, RD, IBCLC
Baumgarder DJ, Muehl P, Fischer M, Pribbenow B. Ef-
fect of labor epidural anesthesia on breast-feeding of
healthy full-term newborns delivered vaginally. J Am
Board Fam Pract . 2002;16:7-13.
Radzyminiski S. The effect of ultra low dose epidural
analgesia on newborn breastfeeding behaviors.
JOGNN . 2003;32:322-331.
The unintended effects of labor epidural analgesia on
the mother, labor, delivery, and newborn continue to be
debated and receive much attention.1
The impact of
epidural analgesia on the establishment of lactation has
been difficult to assess, as few studies have specifically
included newborn breastfeeding behavior when exam-
ining outcomes related to epidural administration.2,3
Unfortunately, the opposing conclusions of 2 recently
published studies maintain the lack of consensus on the
issue.
The first of these 2 studies to appear in the literaturewas that
by Baumgarder et al. The “cases” in this study
consisted of consecutively enrolled breastfeeding
mother-infant pairs in which the mother received
epidural anesthesia and delivered vaginally a healthy,
full-term infant, without complications. The next
breastfeeding mother-infant pair that followed each
case and met the selection criteria but had not been
exposed to epidural anesthesia was included in the con-
trol group. After excluding those with incomplete data
or postnatal complications, 115 cases and 116 control
subjects comprisedthedata set. While most characteris-
tics were similar between groups (maternal age, ethnic-
ity, length of stay, gestational age, birth weight, and
infant status at birth), there were a higher percentage
of
primiparous mothers in the epidural group (49% vs
34%, P =.02). The primary outcome was 2 successful
breastfeeding encounters by 24 hours of age, as defined
by a LATCHbreastfeeding assessment score of ≥ 7
(out
of 10) and a latch score of 2 (out of 2). The primary out-
come of 2 successful breastfeeds within the first 24
hours was achieved by 69.6% of mother-baby dyads
exposed toepidural analgesiaversus 81%of those in thecontrol
group (crude odds ratio [OR]
1= 0.53; 95% con-
fidence interval [CI] = 0.28-1.03, chi-square
test, P =
.044). The OR changed little when weighted based on
parity (OR = 0.58, 95% CI = 0.31-1.08) but was
strengthened when narcotics use was considered (OR =
0.49, 95% CI = 0.26-0.91). A secondary outcome was
bottle supplementation while in the hospital. Infants
exposed to epidural anesthesia were significantly more
likely to receive a bottle supplement while hospitalized
(OR = 2.63, 95% CI = 1.43-4.85, P < .001). The
OR
remained significant when weighted based on parity,
age, narcotics use, and early breastfeeding.The second study, by
Radzyminski, examined the
effects of “ultra low dose” epidural analgesia on new-
born breastfeeding behaviors. The authors defined
“ultra low dose” as being a bolus of 0.125%
bupivacaine, 50 mcg fentanyl followed by a continuous
infusion of 0.044% bupivacaine and 0.000125%
fentanyl, at 14 ml per hour through an epidural catheter.
Study subjects consisted of mother-infant pairs in
which themothers were multiparous with a normalvag-
inal delivery and no postpartum complications. Among
those meeting the selection criteria, 28 mother-infant
pairs exposed to labor epidural analgesia and 28 not
exposed were recruited. Thestudy authors didnot spec-
ify how many mother-infant pairs were screened from
each group before the target sample size was reached.
Subjects in both groups were similar in parity, labor
duration, and previous breastfeeding experience. All
infants were placed skin-to-skin on their mother’s chest
438
J Hum Lact 19(4), 2003
DOI: 10.1177/0890334403258003
© Copyright 2003 International Lactation Consultant
Association
at UKM Medical Centre on June 30,
2014 jhl.sagepub.comDownloaded from
http://jhl.sagepub.com/http://jhl.sagepub.com/http://jhl.sagepub.com/http://jhl.sagepub.com/
8/18/2019 Examining the Effects of Labor Epidural
3/3
for 1 full hour immediately following delivery. During
this hour, an observer blind to epidural use assessed
infant breastfeeding behavior using the Preterm Infant
Breastfeeding BehaviorScale (PIBBS). At about 1 hour
after birth,neurobehavior of thenewborn was measured
with the Neurologic and Adaptive Capacity Score
(NACS). All newborns remained with their mothers,breastfeeding
on demand, for the duration of their hos-
pital stay, and none received supplemental formula or
pacifier during this time. At approximately 24 hours
of
age, the PIBBS and NACS assessments were repeated.
The PIBBS includes 9 areas of assessment: time new-
born held, time to latch on, longest sucking burst, and
scores for environment, newborn behavior, areolar
grasp, rooting, sucking, and swallowing. The data for
environment, areolar grasp, and rooting were too
skewed to include in the analysis. Mean values for the
other 6 assessment areas were notsignificantly different
between groups, either in the immediate postpartum orat 24 hours
of age. The NACS includes 4 areas of mea-
surement: adaptation, passive tone, active tone, and pri-
mary reflexes. In the immediate postpartum, scores
were significantly lowerforprimary reflex (P = .03)and
adaptation (P = .02) in the epidural group. At 24 hours
of age, the primary reflex score remained significantly
lower in the epidural group (P = .02).
What could account for the different results reported
in these 2 studies? Somewhat different tools were used
to assess breastfeeding behavior, although both tools
have similar components. The study populations were
quite different. In the second study, only multiparous
mothers, most with previous breastfeeding experience,
were included, and breastfeeding policies at the study
site appear very supportive of breastfeeding. There was
a considerable sample size difference between the 2
studies. With only 28 subjects per group, the second
study does not have the statistical power to detect mod-
est differences between groups. For example, the mean
for “longest sucking burst length” was 16.8 versus 12.9
in the no epidural versus epidural groups, respectively.
Even though this represents a 23% difference, there
would need to be 64 subjects per group for this differ-ence to
be statistically significant. In contrast, the first
study was designed to have adequate power to detect a
15% difference between groups. A shortcoming of the
first study is the lack of data on type or dosage of
epidural analgesia or duration of labor. The latter may
be an important bias between those who ultimately ask
for pharmacological pain relief and those who donot. A
longer labor, which is more likely among primiparous
mothers (and primiparous mothers were more repre-
sented in the epidural group), rather than epidural use,
may be the underlying factor affecting infant breast-
feeding behavior. Obviously, one cannot randomly
assignmothers to receiveanepidural or not, but control-ling for
other factors that may affect newborn breast-
feeding behavior, such as a long, difficult labor, is
important for establishing the unbiased risk of epidural
analgesia on the establishment of lactation.
These data suggest that epidural analgesia may have
only a modest direct effect on breastfeeding behavior.
However, it is also important to consider the potential
indirect effects of labor analgesia on the establishment
of breastfeeding. In both studies, only those experienc-
ingan uncomplicated vaginal deliverywith no newborn
or maternal postpartum complications met study selec-
tion criteria. It is possible that those receiving
epiduralanalgesia were overrepresented among those excluded
fromthestudy. Recentmeta-analyses4,5
clearly establish
that epidural analgesiaprolongs stage II labor, increases
the likelihood of instrumental delivery, and increases
the risk of maternal fever, all of which may interfere
with the establishment of breastfeeding. These unin-
tended effects of epidural analgesia may explain the
increased risk of bottle supplements observed among
those in the epidural group in the Baumgarder study.
Thus, in addition to any possible direct effects of
epidural use on breastfeeding behavior, it is important
toconsider theindirect effect that epidural usemayhave
on the breastfeeding relationship.
References
1. Caton D, Corry MP, Frigoletto FD, et al. The nature and
management
of labor pain: peer-reviewed papers from an evidence-based
sympo-
sium. Am J Obstet Gynecol. 2002;186(5 Suppl Nature).
2. Ransjo-Arvidson AB, Matthiesen AS, Lilja G, Nissen E,
Widstrom
AM, Uvnas-Moberg K. Maternal analgesia during labor disturbs
new-
born behavior: effects on breastfeeding, temperature, and
crying.
Birth. 2001;28:5-12.
3. Riordan J, Gross A, Angerson J, Krumwiede B, Melin J. The
effect of
laborpain reliefmedicationonneonatalsucklingand
breastfeedingdu-ration. J Hum Lact . 2000;16:7-12.
4. Lieberman E, O’Donoghue C. Unintended effects of epidural
analge-
sia during labor: a systematic review. Am J Obstet
Gynecol.
2002;186(5 Suppl Nature):S31-S68.
5. Leighton BL, Halpern SH. The effects of epidural analgesia on
labour,
maternal, and neonatal outcomes: a systematic review. Am J
Obstet
Gynecol. 2002;186:S69-S77.
J Hum Lact 19(4), 2003 Research Spotlight
439
at UKM Medical Centre on June 30,
2014 jhl.sagepub.comDownloaded from
http://jhl.sagepub.com/http://jhl.sagepub.com/http://jhl.sagepub.com/http://jhl.sagepub.com/
![Effects of Epidural Low Concentration Ropivacaine with ...cme.mc.fju.edu.tw/sites/default/files/輔仁醫學期刊第18卷第2期-1.pdf · for labor analgesia [2,11-13]. Epidural](https://img.dokumen.tips/doc/110x75/5fe4cf4a95f99e6f6b7ec774/effects-of-epidural-low-concentration-ropivacaine-with-cmemcfjuedutwsitesdefaultfileseeoec18c2oe-1pdf.jpg)
