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Lactation Information and Discussion <[log in to unmask]>
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Thu, 4 Jan 2001 11:23:11 EST
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Marie has certainly hit a sensitive nerve, so to speak, with her web page on
epidural analgesia. I bore the brunt of this type of reaction when my
literature review article on epidurals and breastfeeding was published in JHL
in 1997. This resulted in an inflammatory article in an anesthesiology
newsletter blasting my work and myself as a "mere" lactation consultant. I
was raked over the coals and continue to be slammed for stating the side
effects of epidurals. I have a couple of comments on the information at
Marie's web site and the letter written to her by an angry anesthesiologist.

Marie, it is so good to see that you have the courage to help parents
understand that while epidurals have their uses, they also have their side
effects. These side effects also have their own side effects! The latest was
published in the November 2000 issue of Pediatrics, showing a four fold
increase in unexplained seizures in term babies whose mothers had epidurals
with intrapartum fevers. Epidural analgesia is the major cause of
non-infectious fever during labor. It is not only the drugs themselves that
have the potential for disrupting breastfeeding, but all the other baggage
that accompanies epidural use. He is actually incorrect in stating that no
study has looked at the effect of epidurals on breastfeeding. There are a few
studies that address breastfeeding as an outcome measure of epidural use.
Riordan found that early sucking was affected by epidurals. If the epidural
contains fentanyl, the possibility increases for a sleepy baby to be
discharged from the hospital who does not have good motor or state control.
The pediatric half life of fentanyl is 3-13 hours in neonates. It is possible
that the baby could be affected by this drug for up to 2 and a half days.

Epidurals are associated with a number of side effects that impact
breastfeeding but mothers are seldom informed about these. How many know that
epidural catheters can migrate, that inadvertent puncturing of the dura
results in a spinal headache that requires a patch and more pain to fix?
Vacuum extraction can have such nasty side effects that the FDA issued a
public health advisory notice regarding the brain injuries and deaths in
vacuum assisted deliveries. One of the signs of brain or cranial blood vessel
damage is poor feeding.

Anyway, I think a professional letter written to the anesthesiologist could
address his concerns and provide some needed education too. I think we are on
shaky ground saying that most hospitals have an 85% epidural rate. I would
rephrase this as saying that many hospitals have up to a 95% epidural rate.
There is a citation from 1994 that looked at a selected few hospitals showing
epidural rates from 58%-95%. (Biasella SM. Epidural anesthesia. Journal of
Perinatal Education 1994; 3:67-69) Epidurals were placed anytime in labor
including as early as 2 cm! Do we wonder why so much IV fluid is used? A
simple chart review shows the number of bags hung which can be three or more.

I would consider changing the text on confinement to bed as the lighter
epidurals or walking epidurals do exist. Areolar edema has not been
systematically studied but could be said to be associated anecdotally.
Explain to him what a lactation consultant is, sending him information from
IBLCE on the certifying requirements. Acknowledge that some of the effects we
see have not been subjected to randomized controlled trials, but between my
article, Jan Riordan's LC Series monograph on epidurals and a host of
citations that have occurred since, the case can be made that epidurals are
not without risks that parents should be made aware of. Offer to help him put
together his pamphlet on epidurals and see if we can win an ally and friend.
We need all we can get!

Marsha Walker, RN, IBCLC
Weston, MA

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