Examining the Effects of Labor Epidural

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  • 8/18/2019 Examining the Effects of Labor Epidural

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     http://jhl.sagepub.com/ Journal of Human Lactation

     http://jhl.sagepub.com/content/19/4/438The online version of this article can be found at:

     DOI: 10.1177/0890334403258003 2003 19: 438J Hum Lact 

    Laurie Nommsen-RiversExamining the Effects of Labor Epidural Analgesia on Newborn Breastfeeding Behaviors

     

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    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

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    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

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