Wednesday, 16 October 2013

Epidural and breastfeeding: a call for better information

Image by ammateo - Creative Commons
Earlier this year a single line in Michel Odent's recently published book Childbirth and the Future of Homo Sapiens (Pinter and Martin, 2013) jumped out at me: 'The most common technique of epidural anaesthesia (with an opioid analgesic) has documented negative effects on the quality and the duration of breastfeeding.' It piqued my interest because I couldn't recall ever having come across a discussion of the effects of epidural on breastfeeding: intravenous pethidine, yes, but epidural? I started by looking up Odent's reference and reading the original research paper; Pubmed then led me to this study, and this one, and this one. While all the studies call for further research, they also all show demonstrable effects of epidural on breastfeeding behaviour in mothers and babies.

I was surprised not to have come across this information before, having had three babies in the last few years and having trained as a breastfeeding supporter. I did antenatal classes with the NCT, and while I clearly remember the discussion about pethidine making infants drowsy, and the impact this could have on breastfeeding, I don't remember breastfeeding problems being talked about as a possible side-effect of epidural, although the increased risk of instrumental delivery was certainly made clear. Indeed the NCTs page on pain relief in labour states clearly that pethidine may make the baby drowsy and thus make breastfeeding harder to establish, but does not make the same explicit link for epidural. When I was pregnant I was given this leaflet on pain relief in labour - which claims that with epidural 'Breast-feeding is not impaired, in fact it is often helped.'! (I'd be interested to know whether mothers are still being given this leaflet - let me know in the comments! - as I have numerous problems with it that might provoke a whole new blog post...) The NHS Choices page about the side-effects of epidural is brief, does not mention breastfeeding, and gives no indication of absolute risk (using figures such as 1 in 100) to enable women to make an informed choice. It seemed that accessible, up-to-date information about the potential side-effects of epidural, including on breastfeeding, was hard to come by.

I've never had an epidural - through luck, preparation, or most likely a combination of the two, I had three unmedicated home births. But I have had a spinal headache caused by a dural tap during a lumbar puncture (a complication that occurs in 1% of epidurals) - which was so awful that when faced with having the same procedure again years later, I collapsed in tears in front of the doctor, to his surprise and my own. A side-effect of that dural tap was a three-day separation from my older breastfeeding baby! So I was interested to find out more about the effects of epidural, particularly on breastfeeding. And when I started talking about it I found that women were quick to share their own experiences: from a very limited sample of just a few mothers I heard stories of a newborn whose sucking reflex was inhibited because of a reaction to the epidural, and of a mother who experienced such uncontrollable shaking as a result of the epidural that she could not hold or feed her baby for several hours after birth. Another mother described how the effects of the epidural (the need for a catheter, and the tingling in her legs) affected her movement for 12 hours after birth, leading to problems getting her baby out of the crib and into a good position for breastfeeding. A search of the Alpha Parent's Triumphant Tuesdays series of posts shows that many of the women, who have overcome considerable difficulties to breastfeed, gave birth with an epidural. But these were anecdotes, and I needed more data.

An internet search for articles led me to the La Leche League International page; their article is interesting, but dates from 1999. One of the best resources I found is Sarah Buckley's well-referenced article Epidurals: risks and concerns for mother and baby (2005), which specifically discusses breastfeeding. In addition to these I've also looked at The Impact of Birthing Practices on Breastfeeding by Mary Kroeger with Linda J. Smith, The Hormone of Closeness by Kerstin Uvnas Moberg, Birth Matters by Ina May Gaskin and Childbirth in the Age of Plastics by Michel Odent in terms of what they say about epidural and breastfeeding.

So what did I learn from all this research? There is now a growing body of work focussing on the critical importance of a woman's natural oxytocin (synthetic oxytocin, used in induction and to augment labour, acts differently) in promoting behaviours in mother and infant that help to establish breastfeeding and attachment, with a woman's oxytocin levels reaching a lifetime peak just after she gives birth - unless she has an epidural. As Uvnas Moberg explains:
"An epidural anaesthetic not only blocks the activity in the nerves in the spinal cord that transmit pain, but also in the nerves that lead to the release of oxytocin normally triggered when the baby's head is pushing against the cervix. Consequently, mothers who receive an epidural also have lower levels of oxytocin during labour." (p.64)
A potential side-effect of epidural is a drop in blood pressure (natural oxytocin acts to increase a woman's blood pressure slightly during labour); this may mean that the mother is given fluids via a drip (IV). A baby born to a mother given additional IV fluids may lose more weight than expected in the first few days, leading to concerns about breastfeeding, but this weight loss is is due to the infant excreting the excess fluids. (See this article by Nancy Mohrbacher for more.) If a new mother's confidence in breastfeeding is dented, it can be hard to repair.

Kroeger and Smith's chapter on pain relief concludes:
"Strong evidence exists from randomized controlled clinical trials that epidural anesthesia can lead to poor progress of labor...need for oxytocin augmentation, a longer second stage, a lower rate of spontaneous vaginal delivery, increased maternal fever, and increased evaluation and treatment of newborns for suspected sepsis...Observational evidence shows that epidural and narcotic analgesia affects inborn feeding behaviours and adversely affects breastfeeding." (p.114)
Cochrane Intervention Review was carried out in 2011:
"The review identified 38 randomised controlled studies involving 9658 women. All but five studies compared epidural analgesia with opiates. Epidurals relieved labour pain better than other types of pain medication but led to more use of instruments to assist with the birth. Caesarean delivery rates did not differ overall and nor were there effects of the epidural on the baby soon after birth; fewer babies needed a drug (naloxone) to counter opiate use by the mother for pain relief. The risk of caesarean section for fetal distress was increased. Women who used epidurals were more likely to have a longer delivery (second stage of labour), needed their labour contractions stimulated with oxytocin, experienced very low blood pressure, were unable to move for a period of time after the birth (motor blockage), had problems passing urine (fluid retention) and suffered fever. Long-term backache was no different. Further research on reducing the adverse outcomes with epidurals would be helpful."
To draw together a few threads: epidural is often associated with synthetic oxytocin (synthetic oxytocin induction provokes painful labour, epidural slows labour progress, synthetic oxytocin augments labour...); this hormonal disruption can interfere with feeding behaviour. An increased risk of instrumental delivery after epidural means pain, stitches and a higher incidence of birth trauma for mothers, and the risk of bruising, swelling and trauma for the infant, which can interfere with early establishment of breastfeeding. IV fluids can distort assessments of baby's weight and dent confidence in breastfeeding. There's an increased risk of post-partum haemorrhage (PPH) after an instrumental delivery; this can lead to breastfeeding problems too, as described in this paper.

There are obvious problems, in our birth culture in the UK, with raising the issue of epidural as a contributing factor in breastfeeding problems. Epidural is common and widely regarded as easy and safe; indeed, there's a cultural perception of it as the 'ultimate' in labour pain relief. (The Lindo Wing, where the Duchess of Cambridge gave birth, reportedly has an epidural rate of 100%). Its efficacy (at relieving pain, although more than 10% of recipients report inadequate pain relief) is seen to outweigh the potential side-effects, although, as this post aims to point out, the true scope of these potential side-effects may be poorly understood, even among health professionals. There's also the (I think) separate issue of women's access to epidural: to be clear, I believe women should have access to the pain relief they need, when they need it - although I want them (and their care providers) to be as armed with the facts as they possibly can. There was a fascinating and in-depth discussion on Mumsnet with consultant obstetric anaesthetist David Bogod about epidural that covers many important points (although I disagree with him about breastfeeding!).

Good information empowers everyone. If midwives, maternity support workers, peer supporters and health visitors were more informed about some of the issues I've raised above, it might mean that more women who want to breastfeed, but are considering epidural or through circumstances have ended up with one they didn't plan for, are well supported. All breastfeeding supporters know that women having breastfeeding problems often need to talk through their births, and that this often gives many clues that shed light on their current difficulties: better information about the effects of epidural on breastfeeding can improve how we support these mothers.

The other side of the coin, of course, is providing women with genuine alternatives to epidural if they want to avoid the risks discussed. Some suggestions:

- continuous support in labour - shown to reduce need for epidural and thus reduce likelihood of instrumental birth.

- consider a home birth - research shows that home birth is safe, particularly for second or subsequent babies, and there are no epidurals at home deliveries (although of course you can transfer in if you do decide you want one). Booking a home birth can keep all options open for low-risk mothers. Information from the Infant Feeding Survey 2010 showed the highest rates of successful breastfeeding initiation and continuation in mothers who birthed at home; at least part of this could be down to the fact that these mothers have neither synthetic oxytocin nor epidural.

- avoid induction if possible.

- hospitals should increase access to water for labour, if not birth itself, for a greater proportion of mothers, not just those at lowest risk. Continuous foetal monitoring (CFM) has been shown to have no benefit over the midwife listening to the baby's heart at intervals, so why can't more women labour in water? Michel Odent (in Childbirth in the Age of Plastics) describes how labour immersion provides pain relief and also an increase in oxytocin...

- Finally, I've just read a case-study, in Birthrights' new Projects and Perspectives, published to coincide with their Dignity Forum on 16 October, of an Ayrshire maternity unit that has begun offering free Hypnobirthing courses to, among others, women who can't have opiate medication or epidural. I'd love to see this programme extended.

What do you think of this post? Too long, too technical? Let me know in the comments - I'd love to hear from you.


  1. I've had two babies and in a month I'll be having my third. With my first, an emergency situation led to a (failed) spinal and then an epidural, into a c-section. Second, problems arose again and I needed the c-section: epidural again.

    Both my boys were breastfed, though I noticed that both were drowsy and not very hungry in the first 24 hours after birth. Bad advice from Health Visitors was more likely as a cause for me, of my eldest getting formula 'alongside' breastmilk as a baby - they told me he was just 'too hungry' and I 'needed a break' from his demands?

    That said, he was breastfed to 1 year old, my second breastfed to 20 months. I am, out of lack of confidence in my own ability to dilate after those two births, booking a caesarian again, for my third... I suspect that the only problem I'll see from the epidural, may be a drowsiness and not too hungry baby, for the first 24 hours...

    But that's just my experience, talking.

    1. Thanks so much for commenting Christiane, and sharing your experiences and I am glad that breastfeeding worked out for you. I'm sure it will again, particularly as you know what you might see in terms of the drowsiness/lack of hunger in the first 24 hours. Good luck with it all!

  2. Having read through your post i am even more interested in the subject. My first birth was a home birtg wannebe turned syntocin and epidural labour followed by emergency csec. I agree with all the points raised now but i didnt until my then new born was much older. We had 4 months of struggling to breastfeed which i of course blamed myself. If there is a link and i had known this at the time, i would have hopefully not beaten myself up for it quite so much. Thank you.

    1. Thank you Michaela - you make a very good point that mothers who have explanations for the difficulties they faced feel better about their experiences. I'd love for there to be fewer women beating themselves up when they have probably done the best they could with the support they had (or didn't have!)

  3. Thank you for your very timely and thorough review of this topic!
    I would encourage everyone who works with pregnant and new mothers to read Linda Smith's chapter "Why Johnny Can't Suck" in Cathy Genna Watson's "Supporting Sucking Skills in Breastfeeding Babies" (you might be able to find this on Google Scholar). This provides a very useful review of the extensive work available in her book "Impact of Birthing Practices on Breastfeeding" 2nd ed 2010.
    I wish all doctors, OBs, anaesthetists, and midwives would read it as well as breastfeeding supporters!
    I just wanted to say that in La Leche League Leader training, there is a module on birth which does cover the effects of epidurals and other birth interventions, and these are also mentioned in the LLLGB leaflet for mothers on "Birth and Breastfeeding"
    And of course it would be covered in the education to become an IBCLC as well.
    Thanks for another very clearly argued and well researched blog, as always!

    1. Thanks for commenting and glad you liked the piece. Thanks also for those references (and yes, it would be great if doctors, OBs and anaesthetists and mws read up on the topic too!) Interesting that there is more discussion of this subject in LLL Leader training and IBCLC education; one of my interests is in how much, and in what way, knowledge should (and does) filter down to those of us who support women without bf qualifications, and how we manage the boundaries of our roles. I think everyone needs some level of awareness, because then we can signpost women to the level of support that's most appropriate. Thanks again for joining the discussion.

    2. Just noticed this very good summary article on Birth and Breastfeeding written for mothers, in LLL's international online mag "Breastfeeding Today":

  4. I delivered my now two-year old without any medication. I managed to convince my OB-Gyn to let me do it as I wished even if she wasn't used to patients doing it naturally, and got much-needed support from my husband. I am not going to lie. I didn't expect that kind of pain and screamed like a banshee (mostly because I was taken by surprise and my doula couldn't make it on my delivery date). After an hour of transition, though, the pushing period went very quickly -- just three pushes and he was out! We were both alert, my baby was able to latch right away, and I was able to stay calm and remember all the tips on proper latching that I had learned from my birthing instructor. My baby and I were both calm and alert right after delivery, and I really think that made us so successful in our breastfeeding journey. Even his pediatrician and my OB-Gyn, both of whom had not witnessed a lot of unmedicated births in the past, were impressed by the very quick recovery period and how easy it was for us to connect. Now that we are expecting another baby in a few months, my husband and I know this is the only way we are going to do it, unless serious medical considerations prevent us, of course.

    1. Thank you for sharing your story Noelle, and great to know that you had such a successful breastfeeding journey :)

  5. I started googling about breastfeeding in my 2nd trimester of pregnancy and learned that the best option was to go natural or at least unmedicated bec of the risks that you mention in your article (drowsy baby, difficulty latching, etc). This started me on a whole journey to make sure i had an unmedicated birth including bradley method class and hypnobirthing. Thankfully,my birth was unmedicated (in a hospital) but i had to fight for it every step of the way. At the hospital, it seemed that they were pushing every known intervention at me: from asking if i wanted a "painless" birth as if from a menu, to insisting to hook me up to an IV for no real reason, threatening to induce my labor bec of so-called slow progress after only 3-4 hours, and so on. All this WHILE i was in labor. And this was supposed to be a breastfeeding friendly hospital. I had great help from my husband but i wonder how it would have been if i had not been better informed and did not have as strong a commitment to birthing naturally. I gave birth 5 hours after being admitted, baby latched immediately, to the admiration of my OB, pedia and the nurses. I dont think they have witnessed an unmedicated birth before. Breastfeeding support is already hard to come by, but there definitely should also be support/ information/ awareness for pregnancy/birthing practices that will aid breastfeeding.

    1. Thanks for commenting Nadia. And glad you helped to show your care providers an unmedicated birth, maybe they will learn not to push the interventions too soon! Lovely to hear everyone's birth and breastfeeding experiences.

  6. I'm loving this increased flow of research supporting what many midwives like myself have seen: nothing beats naturally released Oxytocin. For far too long, we have discounted its vital importance, thinking the synthetic Syntocinon/Pictocin is an adequate equivalent.
    Angela (Australia)
    While Epidurals are great for pain, they disrupt the natural release of supportive hormones. They do have side-effects; not just on Mums but babies too. Thanks for formalising this.

  7. Yes!!!! I knew I was right...I had my first son 17 years ago and then my second boy last year. I had a natural birth first time around but this time I was forced into a c-section. They took so long to bring him to me afterwards and the midwife (who didn't seem to want to be there) asked if I wanted skin to skin with him. I said that my arms were still a bit numb from the epidural and was worried I'd drop him. She shrugged and walked off. (later she wrote 'mother declined skin to skin) so by the time I actually got him it was 7 hours later and although they denied it I am sure they'd given him a bottle. Having breastfed my older boy with no issues for 18 months, I struggled with my younger boy and the midwife insisted that I gave him a bottle at three days as he had dropped a couple of ounces. I made it to 5 months BF and it broke my heart to stop and I always blamed the epidural, I felt as though my milk never really came in properly.

  8. Such a great and informative article! I am part of a team of women who are constantly updating a blog in Ireland at where we are trying to provide the most current, robust and up-to-date evidence-based research to women and their families about their choices in maternity care (with an Irish focus, as we are facing serious restrictions to women's choices in childbirth, here). I wrote this piece on the link between epidurals and breastfeeding for our blog as I was struck, like you, at the lack of scrutiny of other medications that are often used along with epidural anesthesia and their relationship with breastfeeding. A very interesting and well-designed study by Dozier et al. (2013) - linked on the 42weeks blog - shows a very significant correlation between the combination of epidural and oxytocic agents and the cessation of breastfeeding. I am in full agreement with you that this link must be researched further and women must be told of the results. Thank you, again, for a great well-researched article on this important topic. Barbara W.

  9. Hi, I don't agree with this entirely. You put forward a really one sided argument which isn't particularly helpful. You are clearly pro-breast feeding and want women to have the best shot at success which is GREAT, but this provides one more reason for women to feel guilty and completely at fault if they have a hard time and give up. I've not had chance to read all the studies you cite in full, but what I can glean from a quick look is this:

    The first study cited doesn't say how long mothers had breast fed a previous child for. It might have been only one day, or even one month. Perhaps that's why they didn't feed for so long in this study? You might argue that women who are fundamentally opposed to epidurals might be more inclined to breast feed for longer too, given their leaning towards more natural approaches to pregnancy, birth and parenting.

    Second study tells us that women experiencing labour for the first time are more likely to have an epidural - not surprising then that they haven't breast fed before, and therefore that they are more likely to find it hard in the beginning and consequently give up sooner.

    I am a midwife, and have looked after women who have declined most forms of pain relief and have then been so absolutely exhausted after delivery, that they have then been unable to feed their babies. Every labour is unique, sometimes an epidural can allow someone who has has a three day latent phase or loooong induction to get some sleep. It's irresponsible to tell women 'you can have the epidural, but it might mean you can't breast feed very well' (especially when based of weak research findings). It will only bring about feelings of guilt and anxiety for those who run into feeding problems... and to be honest, who doesn't have feeding problems?

    In my own experience, I have had two epidurals, I was BEYOND tired after those two labours and I think if I hadn't been able to doze albeit intermittently in labour, there is a good chance I would have been way way too tired to breastfeed. In my experience, that is when women start to run into feeding problems (top up feeds interfering with supply and demand.... mastitis... thrush - it just spirals).

    Sorry for the rant, I just have a real issue with people making epidurals out to be a bad choice - they are really helpful in the right circumstances.

  10. Hi Viv, thanks for joining the discussion and interesting points that you make - I think I'm primarily trying to make the case that there is a need for more information, I certainly don't want to see an end to epidurals, as you say, they are valuable in some circumstances. However, I do think the newest research (as Barbara Weston mentioned above) about the interaction between synthetic oxytocics and epidural and the impact on maternal/fetal instinctive behaviour is an important one and something that we don't yet fully understand. I also think that the reasons that women have breastfeeding problems are varied; being 'too tired' after delivery is not one that comes up much in the literature (not saying it never happens in real life though). Interestingly some of the biological nurturing literature is helpful in this regard, it may be that mum doesn't have to do anything much to start breastfeeding off, if she and baby are given unrestricted skin-to-skin in a laid back position then nature may take its course regardless of how tired the mother is. I don't think it's irresponsible to give women the risks of epidural, and I think a risk to a potential breastfeeding relationship is a real risk that different women will feel differently about. But if they don't know, they can't make an informed decision, hence this research/article.