It's probably fair to say that most women who decide to have an epidural during labor don't consider its possible impact on breastfeeding. Perhaps this is because no thought is given generally to any possible links between drugs and breastfeeding success (or otherwise). Instead, both pregnant (or laboring) women and caregivers usually assume that breastfeeding is a separate issue. Evidence from early research certainly doesn't seem to support that view and a little common sense would also lead us to challenge it further & considering drugs used in labor generally, Jordan, et al (2009) provide some evidence that drug use in labor and birth has an impact on breastfeeding rates at 48 hours postpartum.

(Of course, when women have already given up on breastfeeding two days after giving birth, it's unlikely that they will re-establish breastfeeding later, even though this might be possible.) However, although Jordan et al's conclusions are fairly clear, we also need to take into account the fact that many anesthesiologists wouldn't accept these researchers conclusions simply because their data is retrospective (i.e. it looks back at what happened in the past, and tries to establish causal links); anesthesiologists (like many other specialists) consider prospective randomized studies to be more reliable. In any study, cause-effect relationships are difficult to prove and epidural usage and its impact on breastfeeding success is no different in this respect.

Nevertheless, there are also prospective studies which have reported fairly clear problems with narcotics used in labor (Beilin, et al, 2005; Camann, et al, 2007; Torvaldsen, et al, 2006). In the study by Beilin, et al researchers concluded: Among women who breastfed previously, those who were randomly assigned to receive high-dose labor epidural fentanyl were more likely to have stopped breastfeeding 6 weeks postpartum than women who were randomly assigned to receive less fentanyl or no fentanyl. (Most women nowadays receive fentanyl as part of the epidural cocktail. Bupivicain, the drug it partly replaces in the epidural cocktail, causes paralysis in the lower part of the body so substituting part of this with fentanyl reduces this effect. However, some research suggests that problems with breastfeeding develop as a result of using fentanyl in the epidural cocktail.

The study by Torvaldsen, et al concluded: Women in this cohort who had epidurals were less likely to fully breastfeed their infant in the few days after birth and more likely to stop breast-feeding in the first 24 weeks. Despite making this statement, the researchers felt they were unable to say whether there was a causal link between epidural anesthesia and breastfeeding difficulties. This was despite the fact that Intrapartum analgesia and type of birth were associated with partial breastfeeding and breastfeeding difficulties in the first postpartum week and the fact that women who had epidurals were more likely to stop breastfeeding than women who used non-pharmacologic methods of pain relief.

Having said all that, an article by Pandya (from a Department of Anaesthesia in India) in 2010 claims that any impact on breastfeeding is not statistically significant. A study conducted on a small number of women (87) in Toronto, Canada, by Wieczorek et al (2010) also concludes that breastfeeding is unaffected by epidural use. An editorial by Camann (see references below) provides a good overview of research done up to and including 2007 and an article by Loubert et al (2011) summarises research up to the present day. A study by Lin et al (2011) somewhat less clearly but nevertheless significantly, indicates a possible link between the use of narcotic analgesia in the epidural mix and later actual or perceived breastfeeding problems. Another study by Reynolds at St Thomas Hospital in London (2009) concludes: Successful breastfeeding is dependent on many factors, therefore randomized trials are required to elucidate the effect of labour analgesia. Wilson et al's randomized controlled trial did take place after this recommendation (2010) and the conclusion was, in fact, that epidurals had no impact on breastfeeding. Devroe et al (2009) came to a similar conclusion. Common sense might lead us to view even these studies which find no link between epidurals and breastfeeding with some caution. After all, the following need to be taken into account as well:

• Epidurals are associated with a general medicalization of birth (since they usually and/or frequently involve IV lines and urinary catheters, as well as electronic fetal monitoring and ongoing monitoring of blood pressure) and this may contribute to greater maternal discomfort postnatally, meaning that breastfeeding could be affected.
• Epidurals are known to be associated with a higher rate of instrumental delivery and caesarean. Postpartum perineal discomfort, or pain as a result of abdominal surgery, will also inevitably make breastfeeding less comfortable, and therefore less likely to occur.
• Epidurals can influence the fluctuation of hormone levels that play an important role in breastfeeding. A study conducted by Handlin et al (2009) found that medical interventions in connection with birth influence the activity of the hypothalamic-pituitary-adrenal axis 2 days after birth. (Adrenal gland activity, which is dependent on pituitary gland activity, which in turn is dependent on the activity of the hypothalamus is affected.) As a result of this influence, hormonal production is likely to be compromised, which will of course affect the success of breastfeeding, which depends on the release of the hormones oxytocin and prolactin.

Furthermore, most studies conducted so far are unlikely to have compared physiological, unmedicated active labor with epidural labors. Comparing breastfeeding success after epidural birth to opiate-medicated birth (or birth with other forms of analgesia, such as Entonox) is not the same as comparing physiological birth to epidural birth. Of import are the sizes of the associated studies which inform our understanding of epidural analgesia and its impact on breastfeeding. While the studies by Belin, et al, Wieczorek, et al and some of the studies cited in Loubert's review are all modest in size (Belin, n=66; Wieczorek, n=87) others boast larger numbers (Wilson via Loubert, n=1054; Torvaldson, n=1280; Jordan, n=48,366).

Our overall conclusions then are clearly not only based on incomplete evidence, but also on research which is perhaps comparing two scenarios which are both unconducive to successful breastfeeding: birth with opiate analgesia (e.g. Demerol) and birth with epidural analgesia. Clearly, too, many people involved in the debate have vested interests in continuing to promote epidurals. Caregivers who are unfamiliar (and therefore uncomfortable) supporting "noisy", mobile and "demanding" women (who are laboring without an epidural) are perhaps unlikely to want to change their more convenient practice; anesthetists have their livelihood to think about; drug companies which manufacture drugs such as fentanyl also have enormous profits to lose should women decide that epidural is, after all, not ideally conducive to breastfeeding success.

Posted by: Sylvie Donna, author of Birth: Countdown to Optimal published by Fresh Heart Publishing. Available from www.freshheartpublishing.com or from any other online shop (e.g. Amazon). Read the Science & Sensibility review of Birth: Countdown to Optimal by Christine Hurst Praeger.

References

1. Beilin Y, Bodian C, Weiser J, et al. Effect of labor epidural analgesia with and without fentanyl on infant breast-feeding: a prospective, randomized, double blind study.
2. Anesthesiology, 2005, Dec;103(6):1211-7Camann W. Labor analgesia and breast feeding: avoid parenteral narcotics and provide lactation support. International Journal of Obstetric Anesthesia, 2007, Jul; 16(3):199-201Cardiff Births Survey.
3. BJOG: International Journal of Obstetrics & Gynaecology, 2009, online publication on 1 SeptDevroe S, De Coster J, Van de Velde M. Breastfeeding and epidural analgesia during labour.
4. Curr Opin Anaesthesiol. 2009 Jun; 22(3):327-9.Handlin L, Jonas W, Petersson M, Ejdeback M, Ransjo-Arvidson AB, Nissen E, Uvnas-Moberg K. Effects of sucking and skin-to-skin contact on maternal ACTH and cortisol levels during the second day postpartum-influence of epidural analgesia and oxytocin in the perinatal period.
5. Breastfeed Med. 2009 Dec;4(4):207-20.Jordan S, Emery, S, Watkins A, Evans JD, Storey M, Morgan G. Associations of drugs routinely given in labour with breastfeeding at 48 hours: analysis of theLin SY, Lee JT, Yang CC, Gau ML.
6. Factors related to milk supply perception in women who underwent cesarean section. J Nurs Res. 2011 Jun;19(2):94-101.Loubert C, Hinova A, Fernando R.
7. Update on modern neuraxial analgesia in labour: a review of the literature of the last 5 years. Anaesthesia 2011 Mar;66(3):191-212. doi: 10.1111/j.1365-2044.2010.06616.x.
8. Pandya ST. Labour analgesia: Recent advances. Indian J Anaesth. 2010 Sep;54(5):400-8.
9. Reynolds F. The effects of maternal labour analgesia on the fetus. Best Pract Res Clin Obstet Gynaecol. 2010 Jun;24(3):289-302. Epub 2009 Dec 11.
10. Torvaldsen S, Roberts CL, Simpson JM, et al. Intrapartum epidural analgesia and breastfeeding: a prospective cohort study. International Breastfeeding Journal, 2006,Dec11;1:24
11. Wieczorek PM, Guest S, Balki M, Shah V, Carvalho JC. Breastfeeding success rate after vaginal delivery can be high despite the use of epidural fentanyl: an observational cohort study. Int J Obstet Anesth. 2010 Jul;19(3):273-7. Epub 2010 Jun 2.
12. Wilson MJ, MacArthur C, Cooper GM, Bick D, Moore PA, Shennan A, COMET Study Group UK. Epidural analgesia and breastfeeding: a randomised controlled trial of epidural techniques with and without fentanyl and a non-epidural comparison group. Anaesthesia. 2010 Feb;65(2):145-53. Epub 2009 Nov 12.

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