Analgesia And Anesthesia For The Breastfeeding Mother

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Analgesia And Anesthesia For The Breastfeeding Mother

  1. 1. BREASTFEEDING MEDICINE Volume 1, Number 4, 2006 © Mary Ann Liebert, Inc. ABM Protocols ABM Clinical Protocol #15: Analgesia and Anesthesia for the Breastfeeding Mother ANNE MONTGOMERY, THOMAS W. HALE, and THE ACADEMY OF BREASTFEEDING MEDICINE PROTOCOL COMMITTEE A central goal of the Academy of Breastfeeding Medicine is the development of clinical proto- cols for managing common medical problems that may impact breastfeeding success. These pro- tocols serve only as guidelines for the care of breastfeeding mothers and infants and do not de- lineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient. PURPOSE examines the evidence currently available and makes recommendations for prudent practice. L ABOR, BIRTH, AND BREASTFEEDING INITIATION comprise a normal, continuous process. Oxytocin, endorphins, and adrenaline pro- There is even less information in the scien- tific literature about anesthesia for other sur- gery in breastfeeding mothers. Recommenda- duced in response to the normal pain of labor tions in this area focus on pharmacologic may play significant roles in maternal and properties of anesthetic agents and limited neonatal response to birth and early breast- studies of milk levels and infant effects. feeding.1 Use of pharmacologic agents for pain relief in labor and postpartum may improve outcomes by relieving suffering during labor ANALGESIA AND ANESTHESIA and allowing mothers to recover from birth, es- FOR LABOR pecially Cesarean birth, with minimal interfer- ence from pain. However, these methods also Maternity care providers should initiate an may affect the course of labor and the neu- informed consent discussion for pain manage- robehavioral state of the neonate, and have ad- ment in labor during the prenatal period before verse effects on breastfeeding initiation. Un- the onset of labor. Risk discussion should in- fortunately, the literature in this area has not clude what is known about the effects of vari- addressed the whole integrated process. Very ous modalities on the progress of labor, risk of few studies directly address breastfeeding out- instrumented and Cesarean delivery, effect on comes of various approaches to labor pain the newborn, and possible breastfeeding ef- management. Randomized controlled trials are fects. rare, and subject to a great deal of crossover, Unmedicated, spontaneous vaginal birth which confounds results. The technology of with immediate, uninterrupted skin-to-skin epidural analgesia in particular is evolving contact leads to the highest likelihood of baby- quickly, so studies that are even a few years old led breastfeeding initiation.2 Longer labors, in- may not reflect current practices. This protocol strumented deliveries, Cesarean section, and 271
  2. 2. 272 ABM PROTOCOLS separation of mother and baby after birth may greater incidence and duration of neonatal lead to higher risks of difficulty with breast- depression, cyanosis, and bradycardia. feeding initiation.3–5 Labor pain management 3. Nalbuphine, butorphanol, and pentazocine strategies may affect these labor outcomes and may be used for patients with certain opioid secondarily affect breastfeeding initiation in allergies or at increased risk of difficult air- addition to any direct effects of the medications way management or respiratory depression. themselves.6 However, these medications may interfere Women have differing levels of pain toler- with fetal heart rate monitoring interpreta- ance. Pain that exceeds a woman’s ability to tion. Observe the mother and infant for psy- cope, or pain magnified by fear and anxiety, chotomimetic reactions (3%). may produce suffering in labor. Suffering in la- 4. Multiple doses of intravenous analgesic, and bor may lead to dysfunctional labors, poorer their timing of administration may lead to psychologic outcomes, and increased risk of greater neonatal effects. For example, fen- postpartum depression, all of which may have tanyl administration within 1 hour of deliv- a negative effect on breastfeeding.7 ery or meperidine administration between 1 Continuous support in labor, ideally by a and 4 hours before delivery is associated trained doula, reduces the need for pharmaco- with more profound neonatal effects. logic pain management in labor, decreases in- 5. When a mother has received intravenous strumented delivery and Cesarean section, and narcotics for labor, mother and baby should leads to improved breastfeeding outcomes be given more skin-to-skin time to encour- both in the immediate postpartum period and age early breastfeeding.14 several weeks after birth.8 Nonpharmacologic methods for pain man- There is little evidence regarding the effects agement in labor such as hypnosis, psy- of epidural analgesia on breastfeeding and the choprophylaxis (e.g., Lamaze), intradermal or available data are inconclusive. Early studies of subcutaneous water injections for back pain, epidural analgesia for labor showed neonatal and so on, appear to be safe, have no known neurobehavioral effects and labor effects that adverse neonatal effects, and may reduce the may have had a significant impact on breast- need for pharmacologic pain management. feeding. The few studies that have looked di- More study of breastfeeding outcomes is rectly at breastfeeding outcomes have sug- needed for these modalities.9,10 gested poorer outcomes in women who had Evidence suggests that breastfeeding success epidural analgesia.15–18 These results must be is affected by the behavior of the newborn. De- interpreted with caution, however, as most of pressed or delayed suckling, which can be these studies have been problematic with poor caused by medications given to mothers, can control groups and much crossover between lead to delayed or suppressed lactogenesis and study groups. Furthermore, it is difficult to as- risk of excess infant weight loss.11,12 certain whether the effects were caused by the Intravenous opiates for labor may block the epidural per se, or epidural use was a marker newborn’s normal reflexes to seek the breast, for abnormal labor with adverse effects not di- root, and suckle within the first hour after rectly attributable to the epidural. Epidural birth.13,14 analgesia also may affect labor outcomes, for example, increasing instrumented delivery, 1. Shorter-acting opiates such as fentanyl are which may secondarily affect breastfeeding preferred. Remifentanil is potent and has outcomes.4,5 One study has suggested that rapid onset and offset but can be associated when epidural analgesia is commonplace in a with a high incidence of maternal apnea, re- hospital supportive of breastfeeding, longer- quiring increased monitoring. Its transfer in term breastfeeding outcomes are not adversely utero to the fetus is minimal. affected by epidural analgesia.19 A recent ran- 2. Meperidine/pethidine generally should not domized, double-blind study showed that be used except in small doses less than 1 epidural analgesia with fentanyl in low-to- hour before anticipated delivery because of moderate doses, along with bupivacaine, did
  3. 3. ABM PROTOCOLS 273 not have any effect on breastfeeding outcomes for labor. However, their use is limited by sev- compared to epidural analgesia using bupiva- eral factors, including lack of efficacy, techni- caine alone. Higher doses of fentanyl ( 150 g cal difficulties, and a high rate of complications. total dose) may have had a small negative ef- fect on maternal perception of breastfeeding at 24 hours and breastfeeding continuation at 6 ANESTHESIA FOR CESAREAN SECTION weeks.20 Regional anesthesia (epidural or intrathe- 1. If epidural anesthesia is chosen, methods cal/spinal) is preferred over general anesthe- that minimize the dose of medication and sia.26,27 minimize motor block should be used. Separation of the mother and baby should be Longer durations of epidural analgesia minimized and breastfeeding initiated as soon should be avoided if possible,21 and admin- as feasible. In fact, the baby may go to the breast istration should be delayed until necessary in the operating room during abdominal clo- to minimize effect on labor outcomes that sure with assistance to support the infant on may secondarily affect breastfeeding. Com- the mother’s chest. If breastfeeding is initiated bined spinal-epidural analgesia and patient- in the recovery room, there is the added ad- controlled epidural analgesia may be prefer- vantage that the incision is often still under the able. influence of the anesthetic. 2. Infants lose more weight in the first post- A mother may breastfeed postoperatively as partum days when labor medications are soon as she is alert enough to hold the baby. used.12 Some of this weight loss may be a result of mothers receiving an intravenous (IV) fluid load for epidural analgesia. One POSTPARTUM ANESTHESIA report notes babies are slightly heavier on average and lose more weight in the first Nonopioid analgesics days postpartum when epidural analgesia is Nonopioid analgesics generally should be used.22 In addition, the use of large volumes the first choice for pain management in breast- of intrapartum IV fluids has been associated feeding postpartum women, as they do not im- with a decrease in plasma oncotic pres- pact maternal or infant alertness. sure,23 which may then increase breast en- gorgement and interfere with subsequent 1. Acetaminophen and ibuprofen are safe and milk production and/or transfer. Conserva- effective for analgesia in postpartum moth- tive use of fluids may mitigate this effect. ers. Definitive studies of these interrelationships 2. Parenteral ketorolac may be used in moth- are needed in order to better assess first- ers not subject to hemorrhage, and with no week weight loss in individual newborns. history of gastritis, aspirin allergy, or renal 3. When epidural analgesia has been used for insufficiency. labor, particular care to provide mothers 3. Diclofenac suppositories are available in with good breastfeeding support and close some countries and commonly used for follow-up after postpartum hospitalization postpartum analgesia. Milk levels are ex- should be taken. tremely low. 4. Cox-2 inhibitors such as celecoxib may have There are minimal data concerning the pedi- some theoretic advantages if maternal atric effects of other labor anesthesia, including bleeding is a concern. This must be balanced inhaled nitrous oxide, paracervical block, pu- with higher cost and possible cardiovascu- dendal block, and local perineal anesthesia.24,25 lar risks, which should be minimal with These modalities do not usually expose the in- short-term use in healthy young women. fant to significant quantities of medication. In some situations, these may serve as alternatives Both pain and opioid analgesia can have a to intravenous narcotics or epidural analgesia negative impact on breastfeeding outcomes;
  4. 4. 274 ABM PROTOCOLS thus, mothers should be encouraged to control use may lead to some sedation in the in- their pain with the lowest medication dose that fant. is fully effective. Opioid analgesia postpartum may affect babies’ alertness and suckling vigor. Epidural/spinal medications However, when maternal pain is adequately 1. Single-dose opioid medications (e.g., neu- treated, breastfeeding outcomes improve.28 Es- raxial morphine) should have minimal ef- pecially after Cesarean birth or severe perineal fects on breastfeeding because of negligible trauma requiring repair, mothers should be en- maternal plasma levels achieved. Extremely couraged to adequately control their pain. low doses of morphine are effective. 2. Continuous post-Cesarean epidural infu- Intravenous medications sion may be an effective form of pain relief 1. Meperidine should be avoided because of that minimizes opioid exposure. A random- reported neonatal sedation when given to ized study that compared spinal anesthesia breastfeeding mothers postpartum,29 in ad- for elective Cesarean with or without the use dition to the concerns of cyanosis, brady- of postoperative extradural continuous cardia, and risk of apnea, which have been bupivacaine found that the continuous noted with intrapartum administration.30,31 group had lower pain scores and a higher 2. The administration of moderate to low doses volume of milk fed to their infants.35 of IV or IM morphine is preferred as its pas- sage to milk and oral bioavailability in the infant are least with this agent.29,32 ANESTHESIA FOR SURGERY IN 3. When patient-controlled IV analgesia (PCA) BREASTFEEDING MOTHERS is chosen after Cesarean section, morphine The implications of drugs used in anesthesia or fentanyl is preferred to meperidine.33 in postpartum mothers depends on numerous 4. Although there are no data on the transfer of factors, including the age of the infant, stabil- nalbuphine, butorphanol, and pentazocine ity of the infant, stage of lactation (early or late into milk, there have been numerous anecdo- stage), and ability of the infant to handle the tal reports of a psychotomimetic effect when clearance of small quantities of anesthetic med- these agents are used in labor. They may be ications.36 Anesthetic agents will have little or suitable in individuals with certain opioid al- no effect on older infants, but could cause prob- lergies or other conditions described in the lems in newborn infants, particularly those preceding section on labor (see page 272 #3). who are premature or suffer from apnea. 5. Hydromorphone (approximately 7 to 11 The ability of the infant to clear small times as potent as morphine), is sometimes amounts of these medications is of primary used for extreme pain in a PCA, IM, IV, or concern before returning to breastfeeding. In- orally. Following a 2-mg intranasal dose, fants subject to apnea, hypotension, or weak- levels in milk were quite low with a relative ness probably should be protected by a few infant dose of about 0.67%.34 This correlates more hours of interruption from breastfeeding with about 2.2 g/day via milk. This dose before resuming (12 to 24 h) nursing. is probably too low to affect a breastfeeding Mothers with normal term or older infants infant, but this is a strong opioid and some generally can resume breastfeeding as soon as caution is recommended. they are awake, stable, and alert. Resumption of normal mentation is a hallmark that these Oral medications medications have left the plasma compartment 1. Hydrocodone and codeine have been used (and thus the milk compartment) and entered worldwide in millions of breastfeeding adipose and muscle tissue where they are mothers. This suggests they are suitable slowly released. A single pumping and dis- choices even though there are no data re- carding of the mother’s milk following surgery porting their transfer into milk. Higher will significantly eliminate any drug retained doses (10 mg hydrocodone) and frequent in milk fat, although this is seldom necessary
  5. 5. ABM PROTOCOLS 275 and not generally recommended. For women its limited transport to milk, and poor oral who undergo postpartum tubal ligation, bioavailability in infants.29,33 breastfeeding interruption is not indicated, as 2. The transfer of meperidine into breast milk the volume of colostrum is small.37 In addition, is documented, although it is somewhat low the levels of medication in the maternal plasma (1.7% to 3.5% of maternal dose). However, and milk are low once mothers resume normal the administration of meperidine and its me- mentation. Regional anesthesia is recom- tabolite (normeperidine) is consistently as- mended for this procedure in preference to sociated with neonatal sedation, which is general anesthetic for maternal safety. dose related. Transfer into milk and neona- Mothers who have undergone dental extrac- tal sedation have been documented for up tions or other procedures requiring the use of to 36 hours after the dose.29 Meperidine single doses of medication for sedation and should be avoided during labor and in post- analgesia can breastfeed as soon as they are partum analgesia (except, perhaps, within 1 awake and stable. Although shorter-acting hour before delivery). Infants of mothers agents such as fentanyl and midazolam may be who have been exposed to repeated doses preferred, single doses of meperidine or di- of meperidine should be closely monitored azepam are unlikely to affect the breastfeeding for sedation, cyanosis, bradycardia, and pos- infant.36 sibly seizures. Mothers who have undergone plastic sur- 2. Although there are no published data on gery, such as liposuction, in which large doses remifentanil, this esterase-metabolized opi- of local anesthetics (lidocaine) have been used oid has a brief half-life even in infants ( 10 probably should pump and discard their milk minutes) and has been documented to pro- for 12 hours before resuming breastfeeding. duce no fetal sedation even in utero. Al- though its duration of action is limited, it could be used safely, and indeed may be SPECIFIC AGENTS USED FOR ideal in breastfeeding mothers for short ANESTHESIA AND ANALGESIA painful procedures. 3. Fentanyl levels in breast milk have been Anesthetics studied and are extremely low to below the limit of detection.42,43 Drugs used for induction such as propofol, 4. Sufentanil transfer into milk has not been midazolam, etomidate, or thiopental enter the published, but it should be similar to fen- milk compartment only minimally, as they tanyl. have extraordinarily brief plasma distribution 5. Nalbuphine, butorphanol, and penta- phases (only minutes) and hence their trans- zocine levels in breast milk have not been port to milk is low to nil.38–41 published. At this time they would only Little or nothing has been reported about the be indicated in the specific situations use of anesthetic gases in breastfeeding moth- mentioned previously (see page 272 #3). If ers. However, they too have brief plasma dis- these agents are used, observe the mother tribution phases and milk levels are likely nil. and infant for psychotomimetic reactions The use of ketamine in breastfeeding moth- (3%). ers is unreported. Because of its high rate of 6. Hydrocodone and codeine have been used psychotomimetic effect, including hallucina- in millions of breastfeeding mothers. Oc- tions and dissociative anesthesia (catalepsy, casional cases of neonatal sedation have nystagmus), ketamine is probably not an ideal been documented, but these are rare and anesthetic agent for breastfeeding mothers. generally dose related. Doses in breast- feeding mothers should be kept at the min- Analgesics imum necessary to control pain. Routine, Opioid analgesics. consistent dosing throughout the day may 1. Morphine is still considered an ideal anal- lead to sedative effects in the breastfed in- gesic for breastfeeding mothers because of fant.
  6. 6. 276 ABM PROTOCOLS NSAID analgesics. 3. Rajan L. The impact of obstetric procedures and anal- 1. Ibuprofen is considered an ideal, moder- gesia/anaesthesia during labour and delivery on breast feeding. Midwifery 1994;10:87–103. ately effective analgesic. Its transfer to milk 4. Tamminen T, Verronen P, Saarikoski S, et al. The in- is low to nil.44,45 fluence of perinatal factors on breast feeding. Acta 2. Ketorolac is considered an ideal and potent Paediatr Scand 1983;72:9–12. analgesic in breastfeeding mothers. The 5. Patel RR, Liegling RE, Murphy DJ. Effect of operative transfer of ketorolac into milk is extremely delivery in the second stage of labor on breastfeeding low.46 However, its use in patients with success. Birth 2003;30:255–260. 6. Howell CJ. Epidural versus non-epidural analgesia hemorrhage is risky as it inhibits platelet for pain relief in labour. Cochrane Database Rev function. Other contraindications are noted 2006(4):CD003521. in the preceding section on postpartum 7. Ferber SG, Ganot M, Zimmer EZ. Catastrophizing la- anesthesia (see page 273 #2). bor pain compromised later maternity adjustments. 3. Celecoxib transfer into milk is extraordinar- Am J Obstet Gynecol 2005;192:826–831. 8. Hodnett ED, Gates S, Hofmeyr GJ, et al. Continuous ily low ( 0.3% of the maternal dose).47 Its support for women during childbirth. Cochrane Re- short-term use is safe. views 2003;3:CD003766. 4. Naproxen transfer into milk is low, but gas- 9. Simkin PP, O’Hara MA. Nonpharmacologic relief of trointestinal disturbances have been reported pain during labor: Systematic reviews of five meth- in some infants after prolonged therapy. ods. Am J Obstet Gynecol 2002;186:S131–159. Short-term use (1 week) probably is safe.48,49 10. Smith CA, Collins CT, Cyna AM, et al. Complemen- tary and alternative therapies for pain management in labour. Cochrane Reviews 2003;2:CD003521. 11. Mizuno K, Fujimaki K, Sawada M. Sucking behavior RECOMMENDATIONS FOR at breast during the early newborn period affects later FUTURE RESEARCH breast-feeding rate and duration of breast-feeding. Pe- diatr Intl 2004;46:15–20. Studies of labor analgesia and labor anes- 12. Dewey KG, Nommsen-Rivers LA, Heinig MJ, et al. thesia should specifically study breastfeeding Risk factors for suboptimal infant breastfeeding be- havior, delayed onset of lactation, and excess neona- outcomes. tal weight loss. Pediatrics 2003;112:607–618. Specific data is needed about the use of in- 13. Ransjo-Arvidson AB, Matthiesen, SA, Lilja G, et al. travenous fluid loading during labor, such as Maternal analgesia during labor disturbs newborn be- for epidural anesthesia, and its effects on infant havior: Effects on breastfeeding, temperature, and birthweight, breast engorgement, milk supply, crying. Birth 2001;28:5–12. and neonatal weight loss in order to more ap- 14. Nissen E, Lilja G, Matthiesen A-S, et al. Effects of ma- ternal pethidine on infants’ developing breast feed- propriately assess early infant feeding and ing behaviour. Acta Paediatr 1995;84:140–145. weight loss in these babies. 15. Volmanen P, Valanne J, Alahuhta S. Breast-feeding More study is required of the special needs of problems after epidural analgesia for labour: A ret- premature and unstable babies, including how rospective cohort study of pain, obstetrical proce- their ability to clear maternal anesthetic and anal- dures and breast-feeding practices. Int J Obstetr Anes- thesiol 2004;13:25–29. gesic drugs may differ from healthy, term babies. 16. Wiener PC, Hogg MI, Rosen M. Neonatal respiration, feeding and neurobehavioural state: Effects of intra- ACKNOWLEDGMENT partum bupivacaine, pethidine, and pethidine re- versed by naloxone. Anaesthesia 1979;34:996–1004. 17. Henderson J, Dickinson JE, Evans SF, et al. Impact of This work was supported in part by a grant intrapartum epidural analgesia on breast-feeding du- from the Maternal and Child Health Bureau, ration. Aust NZ J Obst Gynecol 2003;43:372–377. Department of Health and Human Services. 18. Baumgarder DJ, Muehl P, Fischer M, et al. Effect of labor epidural anesthesia on breast-feeding of healthy full-term newborns delivered vaginally. JABFP 2003; REFERENCES 16:7–13. 19. Halpern SH, Levine T, Wilson DB, et al. Effect of labor 1. Kroeger M, Smith L. Impact of Birthing Practices on analgesia on breastfeeding success. Birth 1999;26: Breastfeeding: Protecting the Mother and Baby Contin- 83–88. uum. Jones and Bartlett, Sudbury, MA, 2004. 20. Beilin Y, Boida CA, Weiser J, et al. Effect of labor 2. Righard L, Alade MO. Effect of delivery room routines epidural analgesia with and without fentanyl on infant on success of first breast-feed. Lancet 1990;336:1105–1107. breast-feeding. Anesthesiology 2005;103:1211–1217.
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Chantry, M.D., Co-Chairperson Analg 1996;82:1166–1169. Cynthia R. Howard, M.D., MPH, 36. Hale TW. Anesthetic medications in breastfeeding Co-Chairperson mothers. J Hum Lact 1999;15:185–194. 37. Rathmell JP, Viscomi CM, Ashburn MA. Management Ruth A. Lawrence, M.D. of nonobstetric pain during pregnancy and lactation. Nancy G. Powers, M.D. Anesthesiol Analg 1997;85:1074–1087. 38. Andersen LW, Qvist T, Hertz J, et al. Concentrations For reprint requests: abm@bfmed.org

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