Janriordan.net

J et al.
16(1), 16(1),
The Effect of Labor Pain Relief Medication on Neonatal Suckling
and Breastfeeding Duration
Jan Riordan, EdD, RN, FAAN, Aimee Gross, RN, MSN, Judy Angeron, RN, BA, Becky Krumwiede, RN,
and Jeri Melin, RN, BSN
Abstract
We examined the relationship of labor pain relief medications with neonatal suckling andbreastfeeding duration in 129 mothers delivering vaginally. Suckling was measured using theInfant Breastfeeding Assessment Tool (IBFAT). Controlling for infant age, birthweight, andgender, infants of unmedicated mothers had higher IBFAT suckling scores than those ofmedicated mothers (xµ = 11.1 vs. xµ = 8.2 respectively, P=.001). IBFAT suckling scores forintravenous and epidural groups were similar (xµ = 8.5) while those who received acombination of both intravenous and epidural medications were lower (xµ = 6.4 ± 2.96,P=.001). Mothers evaluated their breastfeeds similarly to nurse evaluators (Z = 9.39, P=.001).
Breastfeeding duration did not differ between unmedicated and medicated groups; however,dyads with low IBFAT scores weaned earlier than those with medium or high scores. Laborpain relief medications diminish early suckling but are not associated with duration ofbreastfeeding through 6 weeks postpartum. J Hum Lact 2000; 16(1) 7-12.
Keywords: epidurals, intravenous, breastfeeding, labor, childbirth, pain relief
The use of labor pain relief medication is a controversial nates to exhibit disorganized, ineffective suckling at the issue that has engendered heated discussions among breast. In some cases, breastfeeding difficulties may health care professionals about safety, interference with labor, and birthing. Lactation consultants have also ex- Epidural analgesia during labor, administered in the pressed concerns that there may be a negative impact of epidural space between the dura and the ligamentum analgesia during labor on breastfeeding outcomes.
flavum, allows for pain relief while minimizing the level Many believe that use of labor analgesia causes neo- of medication into the maternal bloodstream as com-pared with intravenous administration.2 It is common tocombine a regional anesthetic (bupivicaine, xylocaine) Received for review, August 21, 1998; revised manuscript accepted for pub- with a narcotic (fentanyl, sufentanil, morphine) to potentiate the action so that a lower dose of narcotic and Jan Riordan is an Associate Professor at Wichita State University. Aimee
anesthetic is needed.3 Bupivacaine is the most com- Gross is a Clinical Nurse Specialist at St. Francis Hospital, Topeka, KS.
Judy Angeron is a Lactation Consultant at Via Christi Health Systems,
monly used epidural analgesia during labor, in part Wichita, KS. Becky Krumwiede is a Lactation Consultant at Appleton
because of its long duration of action and low incidence Medical Center, Appleton, WI. Jeri Melin is a Lactation Consultant at Via
of side effects. However, bupivacaine enters the mater- Christi Health Systems, Wichita, KS. Address correspondence to Jan Rior- nal blood stream rapidly from the epidural space and dan EdD, RN, FAAN, School of Nursing, Wichita State University, 1845 N.
Fairmount, Box 41, Wichita, KS 67260-0041.
crosses the placenta. Thus, measurable concentrations This study was supported by the Kansas Health Foundation and Wichita are present in the fetal circulation within 10 minutes of State University, School of Nursing, Wichita, Kansas.
the injection.4 The concentration of epidural analgesiatypically used for pain relief has progressively lowered J Hum Lact 16(1), 2000
 Copyright 2000 International Lactation Consultant Association
over the years as it has become evident that lower doses J Hum Lact 16(1), 2000
are as effective as higher concentrations and result in general anesthesia for delivery were also excluded. No eligible mothers refused to participate. Dyads were fol- Studies examining the effect of epidural analgesia during labor on breastfeeding outcomes typically com-pare birth outcomes among women who receive various types and dosages of labor medications; few include The Infant Breastfeeding Assessment Tool (IBFAT) women who received no analgesia during labor. For was used to assess neonatal suckling effectiveness dur- instance, Scanlon7 compared neonatal neurobehavior ing a quiet time in the mother’s hospital room. The responses between an epidural analgesia group and a IBFAT measures four components of infant breastfeed- nonepidural group. However, the nonepidural group ing effectiveness: readiness to feed, rooting, fixing, and received either low spinal or local anesthesia or intrave- suckling. The range of scores for each of the four com- nous narcotics during labor. In a frequently cited study ponents is 0 to 3; thus, the total score can range from 0 to of the effect of intravenous meperidine on neonatal 12, with a higher score representing more vigorous, suckling, the control group of mothers received either effective suckling.15 The IBFAT also measures the nitrous oxide or epidural analgesia during labor.8 mother’s perception of and satisfaction with the feed- A number of studies have documented that narcotics ing. Interrater reliability was found to be satisfactory in given parenterally (intravenously [IV], intramuscularly one study16 but unsatisfactory in another.17 [IM]) for pain relief during the intrapartum period The four evaluators were nurses certified as lactation decrease neonatal alertness,9 inhibit suckling,10 lower consultants who had a minimum of 3 years experience neurobehavioral scores,11 and delay effective feed- working with breastfeeding dyads. By analysis of ing.12,13 Meperidine (Demerol), when given parenterally covariance controlling for infant age, there were no sig- during labor, especially diminishes and delays neo- nificant differences in mean IBFAT scores among the nates’ suckling.8,9,10,14 Typically, assessments of breast- nurse evaluators (P=.262). The evaluators generally did feeding behaviors have not been included in these stud- not know the anesthetic or analgesic management at the ies. The most common infant assessments used, the time of the breastfeeding assessments.
Brazelton Neonatal Behavior Assessment Scale Mothers in the study were called at about 6 weeks (BNBAS) and the Early Neonatal Neurobehavior Scale postpartum and asked about the length of breastfeeding.
(ENNS), do not assess breastfeeding behaviors directly.
The proportions of participants successfully contacted Because relatively few studies have included breast- in the unmedicated (68%) and medicated (77%) groups feeding outcomes when examining the effects of labor were similar. Breastfeeding duration was defined as the analgesia, this prospective, multisite study was under- postpartum week in which the mother had not breastfed taken to determine if the use of analgesia during labor is in the past 24 hours and did not intend to breastfeed the associated with poor infant suckling and a shorter dura- baby further. Breastfeeding duration was categorized as <2 weeks, >2 but <4 weeks, >4 but <6 weeks or 6 weekspostpartum.
The sample consisted of 129 mother-infant dyads Type of analgesia used and protocols for each of the delivered at one of three midwestern hospitals, either at medications were similar at all sites. Combined bupiva- a teaching hospital in a large city or one of two commu- caine and fentanyl were the most commonly used nity hospitals in mid-sized cities. Lactation consultants epidural medications. Administration concentrations of collected data during September 1995, May 1996, and bupivacaine ranged from 0.125% to 0.5%. Lidocaine June 1997. The sample consisted of newly delivered (2%) and chloroprocaine (2%) were used in a few mothers who were visited during their hospital stay by instances instead of bupivacaine. Although fentanyl lactation consultants conducting daily rounds on an as- dosages ranged from 25 to 200 µg, 50-100 µg was most they-come basis. The sample excluded infants born less commonly used. Sufentanil (25-50 µg) was used in one than 38 or more than 42 weeks gestation, and those hospital instead of fentanyl. Dosage ranges of intrave- admitted to the neonatal intensive care, or delivered by nous labor medications were 25-50 mg for meperidine cesarean section. Multiple births and mothers receiving (50-100 mg IM), 5-10 mg for nalbuphine, and 0.5-2 mg J Hum Lact 16(1), 2000
Figure 1. Adjusted mean IBFAT score by medicated group.
for butorphanol. Intravenous medications were given as the Kruskal-Wallis Tests for ordinal data were used to compare breastfeeding duration between medication As expected, dosages of labor medications given to groups and levels of LATCH scores, respectively.
individual mothers varied. Hospital records often omit- Descriptive statistics were used to determine means and ted the length of time the drug was administered; thus, it standard deviations of demographic and clinical vari- was not possible to calculate total dosage of analgesia ables. When probability values of P<.001 were found for each delivery from the patient anesthesia records.
for the main group effects, the Post-Hoc Fisher’s Pro- Therefore, mothers were categorized into groups that tected Least Significant Difference was used to deter- had received (1) no labor pain analgesia, (2) only epidural analgesia, (3) only intravenous narcotics, or (4)both epidural and intravenous analgesia.
Data were analyzed using StatView, Version 5.0.1 Mothers in the sample were an average of 28 ± 5 (SAS Institute, Inc.). ANCOVA was used to examine years old, and 45% were breastfeeding for the first time.
variables that might affect suckling scores. Birth weight Neonates were singleton, term babies weighing an aver- was used as a covariate owing to its established link to age of 3477 ± 479 g at birth. Half were males. Twenty- early suckling ability. Given empirical evidence that nine percent of the mothers had an unmedicated vaginal infant gender is related to a delay in suckling ability,12 delivery (NOMED group), and 71% had either epidural this was controlled in the analyses. In addition, the age or intravenous narcotic medication or both (MED (in hours) at which the assessment was performed was controlled because suckling improves with age as the Table 1 compares subject characteristics between infant develops and learns. The Mann-Whitney U and groups. Infant birth weight and gender did not differ sig- J Hum Lact 16(1), 2000
Table 1. Characteristics of subjects.
Table 2. Di s tr ibu tio n o f r o u te o f la b o r p a in m e d i c a t i o n Assessment age, h, xµ ± SD *P<.05 chi-square analysis. **P<.05 Student’s t-test.
nificantly nor did the percentage of mothers who werebreastfeeding for the first time. Mothers in the NOMED Mothers who had no labor pain relief medication did group were significantly older, and their breastfeeding not breastfeed significantly longer than those who were was assessed significantly earlier than those in the MED medicated (Z=–0.71, P=.54). IBFAT scores were then group. The average suckling score was 9.0 and ranged divided into three groups: low (0-4), medium (5-8), and from 0 to 12. The age the assessment took place ranged high (9-12), and compared with duration of breastfeed- from 1 to 50 hours postpartum, the mean was 10.7 ing. Dyads with low scores breastfed for a significantly hours. Most of the mothers (72%) were still breastfeed- shorter period of time than those with medium or high ing at 6 weeks postpartum; however, 18% had weaned scores (H=107.7, P<.001).
Finally, a Spearman correlation was performed to The results of the ANCOVA model comparing determine if the mothers’ feeding assessment scores IBFAT scores between infants of medicated and non- were similar to those of the nurse observers. The IBFAT medicated mothers, including infant gender, age, and scores of these two groups were positively correlated birth weight as covariates, showed that gender and birth weight were not significant; thus, they were notincluded in further analyses. Mean suck scores were Discussion
significantly different between the MED and NOMED In almost all previous studies of the potential effects groups, and infant age was a significant covariate. Con- of the use of epidural analgesia during labor, assessment trolling for infant age, adjusted mean LATCH scores of the infant has been limited to a neurobehavioral or were 11.1 ± 0.9 and 8.2 ± 3.3 for the NOMED and MED Apgar score. These tools neither reflect the complex groups, respectively (P<.0001).
behaviors of feeding at the breast nor include maternal Further analysis examined mean IBFAT score by factors. In the present study, a valid tool developed spe- type of labor pain medication. Subjects were grouped cifically to measure suckling at the breast was used to into those who had received (1) no labor pain analgesia assess infant behavior. Furthermore, this assessment (n=37), (2) only epidural analgesia (n=27), (3) only included the mothers’ evaluation in addition to that of intravenous analgesia (n=52), or (4) both epidural and the nurse evaluators. Breastfeeding outcomes in groups intravenous analgesia (n=13). Suckling scores of each of infants whose mothers had received labor analgesia group were compared using an ANCOVA that con- were compared with those of infants whose mothers had trolled for infant age. By post hoc analysis, infants of not received analgesia. Although this study was limited women who had no labor pain analgesia had signifi- by the lack of detailed information regarding labor cantly higher suckling scores (11.1 ± 0.9) than any of medication dosages and intrapartum events, it is the first the other three groups (F=13.83, P<.0001). Adjusted study examining the effects of labor medication on the mean scores were the same for both the intravenous (8.5 infant to assess breastfeeding outcomes directly and ± 3.2) and epidural (8.5 ± 3.4) groups. The group who include unmedicated mothers as a control group.
had both intravenous and epidural labor pain medica- This study confirms previous studies8,10,11,13 that have tion had significantly lower suckling scores (6.4 ± 3.0) demonstrated intravenous analgesia diminishes neona- than the other three groups. (see Figure 1).
tal suckling. This study also found that the effect of J Hum Lact 16(1), 2000
epidural analgesia on suckling is similar to that of medi- rooting at both 2 and 24 hours postpartum. Although cations given intravenously. Although blood samples this is a counterintuitive finding, the women were given were not taken in this study, it is likely that infants of small doses of regional anesthesia (lidocaine, bupiva- women receiving both epidural and parenteral medica- caine, and 2-cholorporocaine) and did not receive the tions would have higher serum levels of labor medica- same narcotics, such as fentanyl, that are commonly tions and thus be at greater risk for poor suckling than given now. Abboud20 later repeated the study using a larger dose of lidocaine. Again, the percentage of neo- Mothers’ evaluations of the feedings were similar to nates with high suckling and rooting scores at 2 hours that of the lactation consultants. Matthews16 also found postpartum was higher in the lidocaine group than in the that mothers’ feeding scores were positively correlated unmedicated group. However, at 24 hours the situation with evaluators’ IBFAT feeding scores. These findings was reversed: The percentage of infants with high post- suggest that mothers, given specific guidelines, are partum suckling scores was higher in the unmedicated competent to evaluate how well breastfeeding is going.
The significant associations between low IBFAT scores and Corke21 found that neonates in the United Kingdom breastfeeding duration and between maternal and nurse whose mothers had no epidural analgesia during labor evaluator scores support the validity of the IBFAT tool.
tended to have lower scores in rooting and suckling abil- Three studies have examined the effects of the use of ity at 4 hours postpartum than infants whose mothers labor epidurals on neonatal neurobehavior using a con- had received epidural medications; however, these dif- trol group of mothers who received minimal or no medi- ferences were not statistically significant and the study cation. Murray et al.18 studied the effects of epidural included only a small sample of infants.
analgesia on neonates. Infants were grouped according Lack of a positive relationship between the use of any to whether their mothers received (1) continuous infu- epidural analgesia during labor and the duration of sion of 0.25% bupivacaine epidurally (n=20), (2) the breastfeeding is puzzling since it is thought that mothers same medication as group 1 in combination with oxyto- who have unmedicated births breastfeed for a longer cin to stimulate labor (n=20), or (3) no medication dur- period of time than those who choose to have epidural ing childbirth (n=15). Nine of the 15 mothers in the no analgesia during labor. However, breastfeeding dura- medication group briefly inhaled nitrous oxide, and 11 tion was measured only at 6 weeks, and therefore any received lidocaine for perineal infiltration. The BNBAS relationship between epidural medication and extended was used to measure neonatal neurobehavior. After breastfeeding could not be examined.
excluding five infants from the no medication group This study was limited in that other perinatal events because of extremely high levels of lidocaine in the that may play an important role in neonatal suckling, maternal serum, the authors found that infants in both such as the use of oxytocin, vacuum extraction, forceps, epidural groups performed significantly less well on the and oral suctioning were not included in the study. Ran- BNBAS motor, state control, and physiologic response dom assignment of study participants to labor pain clusters than those in the NOMED group. By the fifth medication groups was not possible. The lack of informa- day, infants in the epidural groups continued to show tion regarding timing of administration and total dos- ages of the analgesics also limited the scope of this study.
In 1982, Abboud et al.19 compared fetal, maternal, The results of this study indicate that labor medica- and neonatal responses following epidural administra- tions impair suckling in the early postpartum period.
tion of one of three regional anesthetics (lidocaine, Therefore, lactation consultants should be concerned bupivacaine, or 2-chloroprocaine; n=50 mother infant that breastfeeding mothers who have received labor pairs in each group) and in an umedicated control group medications may become discouraged, especially if (n=20). No narcotic, such as fentanyl, was used for the they are discharged before effective breastfeeding is epidurals. Neonatal behavior was evaluated using the established. If mothers lack adequate support at home or Early Neonatal Neurobehavior Scale (EENS) at 2 and did not receive follow-up care, babies with poor breast- 24 hours of life. Data analysis consisted of calculating feeding behaviors are at greater risk for dehydration, the percentage of neonates with high scores and com- paring each group with chi-square analysis. Compared Nonpharmacological methods of pain control for with those in the epidural groups, infants in the unmedi- labor such as paced breathing, position change, mas- cated groups generally scored lower in suckling and sage, therapeutic touch, visualization, relaxation, and J Hum Lact 16(1), 2000
hydrotherapy are effective23 and do not compromise 15. Matthews MK. Developing an instrument to assess infant breastfeed- ing behaviour in the early neonatal period. Midwifery. 1988;4:154- early neonatal suckling and breastfeeding. If epidural analgesia is given, it appears that the best choice is a 16. Matthews MK. Mothers’ satisfaction with their neonates’ breastfeed- local anesthetic that does not include a narcotic.19,20 ing behaviors. J Obstet Gynecol Neonatal Nurs. 1991;20:49-55.
17. Riordan J, Koehn M. Reliability and validity testing of three breast- Informed consent constitutes knowing all the conse- feeding assessment tools. J Obstet Gynecol Neonatal Nurs.
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19. Abboud TK, Khoo SS, Miller F, Doan T, Henriksen EH. Maternal, fe- at the expense of the infant is a difficult balance of tal, and neonatal responses after epidural anesthesia with bupivacaine, choice, health professionals are the guardians of health, 2-chloroprocaine, or lidocaine. Anesth Analg. 1982;61:638-644.
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Lack of adverse neonatal neurobehavioral effects of lidocaine. Anesth health professionals to tell them the truth about possible consequences of medical treatments. Therefore, infor- 21. Corke BC. Neurobehavioural responses of the newborn. Anaesthesia.
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cussion of pregnancy, labor, delivery, and breastfeeding 23. CNM Data Group, 1996. Midwifery management of pain in labor. J Nurse Midwifery. 1998;43:77-82.
24. Mann DH, Albers LL. Informed consent for epidural analgesia in la- bor. J Nurse Midwifery. 1997;42:389-392.
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