Hi, my name’s Rebecca Dekker, and I’m a nurse with my PhD and the founder of Evidence Based Birth®. In this video we’re going to talk about the effect of epidurals on breastfeeding.

Concerns about the Effect of Epidurals on Breastfeeding

Some people have told me they have concerns about using epidurals or spinals, or combined spinal-epidurals during labor for pain management because they’re worried that perhaps the medications in the epidural might affect their breastfeeding relationship with their newborn. It is true that the medications in the epidural can cross the placenta and get into the newborn’s circulation. These medications have also been found in breast milk. That information comes from a statement from ACOG, the American Congress of Obstetricians and Gynecologists.

Researchers have theorized that there’s a couple different ways that epidurals could theoretically affect breastfeeding. First, the medications cross the placenta and could potentially affect the newborn’s ability to suck and latch onto the breast.

Second, the medications could lead to the mother developing a fever during labor. Fevers in the mother are linked to lower Apgar scores in the baby, and potentially more health problems in the newborn that could make breastfeeding more difficult for the baby.

Third, the medications could potentially influence the mother’s hormones, which may impact breastfeeding.

Fourth, epidurals are linked to higher rates of vacuum and forceps delivery, which could impact breastfeeding because often those mothers need to have more stitches done down there after the vacuum or forceps, and because they’re having to have that repair done of their perineum, that might delay breastfeeding or skin to skin contact in some cases. Or the baby may have head or neck bruising that makes it more difficult for them to breastfeed.

Another potential link are the longer second stages of labor- the longer pushing phases that we see with an epidural. This could potentially tire the mother and baby and make it more difficult for them to breastfeed. We’re going to talk more about longer second stages of labor with epidurals in a separate video.

Finally, IV fluids are given in higher amounts when you have an epidural. They give the IV fluids to help keep your blood pressure up because low blood pressure is a side effect of the epidural. Having excessive IV fluids during labor could lead to painful breast swelling after the birth, also known as engorgement, or edema, a more severe form where you have extremely swollen breasts. This can make it more difficult for you to breastfeed your baby.

Also, IV fluids given during labor mean that the baby’s going to be born with a little bit extra fluid onboard, and when the baby urinates off that fluid or pees off that fluid, healthcare professionals might think the baby is losing weight and they might recommend formula, which might then influence the breastfeeding relationship.

The Effect of Epidurals on Breastfeeding Could Be Positive in Some Cases

On the other hand, for people who don’t get epidurals, it is possible that if labor pain is severe and not managed appropriately, perhaps the mother’s labor pain is exceeding her ability to cope with the pain, leading to potential suffering- the suffering could lead to problems during labor and postpartum, which might make breastfeeding more difficult for the mother.

Those are some of researchers’ theories about how there might be a relationship.

What Have Studies Found About the Effect of Epidurals on Breastfeeding?

In 2016, a group of researchers led by someone named French pulled all of the studies that had ever been done on this topic to try and figure out if there is a relationship between epidurals during labor and breastfeeding. They found 23 studies examining this topic, and the results are conflicting.

12 studies showed that epidurals harmed breastfeeding, and 10 studies showed that there was no impact on breastfeeding. One study showed that epidurals benefited breastfeeding. The researchers said that there were so many differences between each individual study, every study had a different type of epidural- different doses and different drugs used in the epidural. Every researcher measured breastfeeding success differently, so they couldn’t really combine the results and it was just really hard to figure out what was going on because the research was all so different from study to study.

There have been, though, two high quality randomized controlled trials that actually looked at this topic- looked at the dose of medication that was given in epidurals to see if it had any impact on breastfeeding. One of those studies was led by a researcher named Lee. This study took place in Chicago and was published in the year 2017. They included 305 people who had already given birth before and were having a subsequent baby. They were all planning on having epidurals and they all intended to breastfeed. They’d all breastfed successfully before with the previous baby.

This was a double blind trial, meaning that both the people giving birth and the researchers didn’t know which group the people were in until well after the study was analyzed. They were randomly assigned into one of three groups. They could be in a group with Bupivacaine only, a numbing agent. Or they may have had a very, very tiny dose of fentanyl, which is an opiod. Opioids are morphine-like drugs. The second group included a low dose of opioid along with the numbing agent. The third group included a higher dose of opioid along with the numbing agent.

The researchers found no differences in breastfeeding at six weeks postpartum. The authors concluded that the opioid doses of fentanyl as high as two micrograms per milliliter did not harm breastfeeding in this study.

The next randomized trial did find an impact of epidural dose on breastfeeding success. This study was led by a researcher named Bellin and was published in the year 2005. The study was conducted in New York. There were 177 people in this study. They had all breastfed successfully with a previous infant and were planning on breastfeeding again. Just like the other study, they were randomly assigned into one of three groups: the numbing agent only, the numbing agent plus a low dose of fentanyl, or the numbing agent plus a high dose of fentanyl.

The high dose group in this study received a much higher dose on average than the previous study that I just talked about. The researchers looked at the babies’ neurobehavior scores, which basically looks at their behavior and their reflexes. They found that babies whose mothers received the high dose fentanyl had lower neurobehavior scores on average. Mothers in the high dose fentanyl group were more likely to stop breastfeeding at six weeks postpartum compared to the two other groups. 17% of mothers in the high dose group had stopped breastfeeding at six weeks postpartum compared to 5% and 2% in the other groups. Mothers in the high dose group were also more likely, immediately postpartum in the first few days, to state that their babies were fussy and had more difficulty with breastfeeding. 28% of them said that their babies were fussy and had difficulty breastfeeding compared to 13% and 19% in the other groups.

There were two other randomized trials on this topic but they were both very small and had major limitations and don’t really give us good quality information. In summary, the research evidence on this topic is very controversial. Epidurals are very effective pain management tools during labor, and there are many factors that can affect your breastfeeding success. It’s possible that epidurals might be one of those factors.

It’s possible from looking at those two randomized trials to assume that a very high dose of epidural medications may negatively influence breastfeeding even if you’ve already successfully breastfed in the past. However, low dose epidurals, at least so far, don’t seem to have that same problem.

Practice Considerations Concerning the Effect of Epidurals on Breastfeeding

At this time, an evidence-based approach would be to provide mothers who wish to avoid medication during labor with other alternatives for pain relief so that pain medication like epidurals are not the only option, but they have lots of options to use. Secondly, it’s also evidence-based for care providers to provide additional support for breastfeeding to mothers who received an epidural, especially if the mother received a high dose epidural. It’s probable that care providers could negate a potential negative effect of epidurals on breastfeeding by providing lots of support in other ways to the mother and baby.

For example, providing just really intensive lactation support, immediate skin to skin contact, undisturbed time for the first breastfeeding session, support from certified lactation consultants, rooming in and avoiding formula and pacifiers if possible.

I hope this helps answer your questions about the effect of epidurals on breastfeeding. Thanks so much for listening. Bye. To learn more and subscribe to our newsletters for useful information, please visit evidencebasedbirth.com.