EPIDURALS: THE EFFECTS EPIDURALS MAY HAVE ON BREASTFEEDING 2
Epidurals: The Effects Epidurals May Have on Breastfeeding The purpose of this paper is to summarize an evidence-based practice research project examining the use of epidurals during labor and delivery and whether or not the epidural affects a neonates ability to breastfeed. Practice Question The current management of feeding of neonates after delivery is breastfeeding first, then using formula, unless the mother requests formula be given in place of breast milk. This project will investigate what effects, if any, an epidural during labor and delivery have on a full-term neonates ability to breastfeed. P- Patient Population or Problem The patient population/problem is among babies born by vaginal birth, with gestational age of 36 to 42 weeks. I- Intervention The intervention of interest is epidural exposure. C- Comparison The comparison intervention is focused on natural child birth. O- Outcomes Identify if the use of an epidural affects the ability of babies to breastfeed. The Following Question was developed: Among babies born by vaginal birth with gestational age of 36 to 42 weeks, does an epidural exposure versus a natural child birth affect the ability of the baby to breast feed? Evidence EPIDURALS: THE EFFECTS EPIDURALS MAY HAVE ON BREASTFEEDING 3
The type of question is prognosis. Based on the type of question, the following databases and internet sites were searched: CINAHL (EBSCOhost), and JSTOR. Search Items and Results of Search Search terms developed from the PICO question included: full term, no abnormalities, no other meds given during labor and/or delivery, and vaginal delivery with no complications. Our group included the following types of studies in our search: cohort studies, descriptive studies, and systematic reviews. Our question was so specific that there was no need to change search terms or our question based on our search results; however, we later realized that we did not specify what type of epidural to include in our search, given that there are different kinds of medications in the epidurals and can demonstrate a variety of effects. Our group located five articles based on search terms and type of question. These include four observational cohort studies, and one study which encompassed retrospective, observational cohort, and prospective cohort studies. Study One This study was an observational cohort study. The purpose of this study was to find the effects of epidural anesthesia on women during their labor, and how this anesthesia affects the newborn babies. The population was full-term fetuses (37 to 42 weeks gestation) that were delivered vaginally in the vertex position to a neonate with no abnormalities. The subjects were chosen by convenience and included sixty full-term babies. The result of this study was as follows: babies that received oxytocin epidurals had greater depression of motor performance and had a tendency to be tense and hypertonic. The results of this study were highly applicable to the question we proposed and, through evidence, support our question. This study shows the elective use of medication should be minimized and other psychoprophylaxis techniques for pain EPIDURALS: THE EFFECTS EPIDURALS MAY HAVE ON BREASTFEEDING 4
relief should be used, thus reducing the depression of motor performance in neonates, namely a poor suckling reflex. Study Two This research included retrospective, observational cohort, and prospective cohort studies that analyzed the various adverse outcomes of labor and birth after the administration of epidural analgesia. The population of this study included full-term infants whose mothers requested epidural analgesia. They were chosen at random and included 1405 infants. This research question was answered by the findings of increased negative effects of breastfeeding, including a reduction in the rates of breastfeeding and the decreased likelihood that mothers would breastfeed after 24 weeks. Among these groups, women without pain relief proved to have the longest period of breastfeeding. Also, the researchers expressed the need for epidural analgesia to be reconsidered as a common choice for pain relief during labor. This research contained supporting evidence of the negative effects of epidural analgesia in relation to newborns and breastfeeding; therefore, the results proved to be highly applicable to our research question. Study Three This study was a cohort study to see if an epidural during labor is linked to breastfeeding problems within the first twelve weeks after being born. 164 new mothers who either had an epidural for labor pains or gave birth naturally were selected randomly for this study. Out of those 164 mothers, only 99 of them returned the finished questionnaire. These mothers reported that they had trouble breastfeeding within the first twelve weeks of the babys life. Other factors were also associated with breastfeeding problems, such as not producing enough milk and the age of the mother. The results of this study suggested that more research about this topic is needed before the hypothesis can be answered. I concluded that this article was relevant to our EPIDURALS: THE EFFECTS EPIDURALS MAY HAVE ON BREASTFEEDING 5
topic, even though the hypothesis wasnt answered; it helped us realize that there are many factors to consider before reaching a conclusion. Study Four The purpose of this study was to compare the early breastfeeding success of full-term newborns whose mothers received epidurals during an uncomplicated labor, with a group of newborns whose mothers had not received epidurals. The study sample consisted of 351 women chosen for convenience at the labor ward in Stockholm, Sweden. The study included only full- term newborns whose mothers had received epidural analgesia during an uncomplicated labor. For each epidural record, a control record was selected matching parity, age and gestational age at birth, excluding all C-section, vacuum extraction/forceps, twin pregnancy, breech presentation, or illness following birth. The study found that significantly fewer babies of mothers that received an epidural during labor suckled the breast within the first four hours of life. These babies were also more often given artificial milk during their hospital stay and fewer were breastfeeding at discharge. There were other factors that were positively associated with breastfeeding success such as multiparity, birth weight between three and four kilograms, and oxytocin administration (which was associated with an initial delay, but the baby was fully breastfeeding by discharge). The study directly applied to our research question. Although this study did show a connection between epidural use and a decrease in breastfeeding success, further studies are recommended. Study Five This observational cohort study evaluated if the use of an epidural agent in women who had a vaginal birth had any impact on whether or not breastfeeding was successful. The size of the study was 105 women and were chosen based on a stratified sample. This targeted population EPIDURALS: THE EFFECTS EPIDURALS MAY HAVE ON BREASTFEEDING 6
of the study was multiparous women who requested epidurals, who previously had breastfed successfully, and who intended to breastfeed their newborn children. The research question was answered based on the results of the study, which concluded that the success rate of breastfeeding among women who received an epidural agent was significantly higher than was previously reported in other research findings and literature. In conclusion, the level of evidence and findings of the research suggest that further studies need to be done because of the many variables that can affect breastfeeding success, such as post-natal support, time off of work, and age of the mother. The results of the study were relevant and applicable to our research question. Summary of Evidence and Practice Recommendation Evidence in these studies suggests that there are many other variables which may lead to the success or failure of breastfeeding. The scientific evidence confirms the negative effects of epidurals, including depressed motor performance in neonates, difficulty of the mothers to breastfeed, a reduction in breastfeeding rates, and a decreased suckling rate of the babies. The practice recommendations are to minimize the use of elective pain control medications during labor and delivery of full-term neonates. Conclusion In conclusion, there is more research that can be done regarding the effects of epidurals on newborn babies abilities to breastfeed, given that there are numerous other factors to consider. However, based on the research articles that we discovered, the articles support our hypothesis that epidurals have negative effects on neonates abilities to breastfeed. Three of our five articles seem to agree that women that were not given an epidural during labor and delivery seemed to breastfeed longer than women who had elected to receive an epidural. Undoubtedly, EPIDURALS: THE EFFECTS EPIDURALS MAY HAVE ON BREASTFEEDING 7
there is a significant correlation with the use of epidural analgesia and breastfeeding. This supports the idea of finding alternative controls for pain management during labor and delivery.
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References
Ann D. Murray, R. M. (1981, March). Effects of Epidural Anesthesia of Newborns and Their Mothers. Child Development Vol. 52, pp. 71-82. Ingela Wiklund, M. N.-M.-B.-A. (2009). Epidural analgesia: Breast-feeding success and related factors. Elsevier, Midwifery, pp. 25, e31-e38. Lapland Central Hospital. (2004). Epidural Analgesia for Labor May be Linked to Breast- feeding Problems. Biotech Week, pp. 282. Tamagawa, K. &. (2010). Analyzing adverse effects of epidural anesthesia during labour. British Journal of Midwifery, pp. 704-708. Wieczoreck, P. G. (2010). Breastfeeding success rate after vaginal delivery can be high despite the use of epidural fentanyl: an observational cohort study. International Journal of Obstetric Anesthesia, 19, pp. 273-277.