Linda writes:

<Does anyone know of any current studies on the effects of epidurals on breastfeeding?  I know of some that are around 10 years old, but I am looking for something up-to-date.  I have checked the archives and didn't find what I was looking for.  I also checked JHL for any recent studies, but wasn't successful.  Our educators need current evidence-based back-up on what we are teaching, because we are getting complaints from the doctors and L & D RNs that their patients are resisting epidurals due to our teaching that there may be some effects on breastfeeding.  Thank you for any leads you could provide.>


The lead I am providing you comes from a whole different perspective.  It may be worth weaving into your philosophies and those of your staff. Or not.


Everyone caring for new mothers and babies feels dedicated to helping them in the best way their training, reading and experience has prepared them to do. They intend to do what they judge as the best for their patients, and are understandably insulted that someone else would try to persuade the patient otherwise. Not everything has yet, or may ever, be proven by research. And even then, there will be mothers with genuine emergencies whose lives and whose babies lives are going to need the expertise of these other kinds of practitioners. 


Trying to "go around the doctors directly to the patients" is a philosophy I once felt strongly, in my younger (40ish) CBE days, was the only way to give mothers a "fighting chance". I identified with them, having only finally achieved NCB with my 5th child. I can attest that it is a great way to make oneself a "personna non grata" to physicians from many specialties in one's institution, and yes, in one's whole community, for that matter. From a longer perspective 4 decades later I can clearly see my own fervor was closely connected to personal issues with authority figures very early in life, and in fact, often played out as part of my own personal "savior complex". I had to learn to rethink my personal role in the whole scheme of things as the years passed. I suspect there is still much that I can yet learn.


My very first experiences with caring for nursing mothers was as a student nurse in 1948. I did as I was told, and followed the routines. Mothers with vaginal deliveries stayed for at least 4-5 days, moms with CS, 7-10. Most mothers got "twilight sleep" (dry mouths) NPO in labor, sometimes 48 hour long labors, very few inductions, and then, not with pitocin. Most received general anesthetics(and probably were very dehydrated, because they got no IV's!). All moms received 1 cc. of pitocin IM after the placenta, as well as 1 cc. of ergotrate IM. Moms received ergotrate orally round the clock the first day and 3 times a day for the next two days as well! ((This was later found to be chemically related to bromcriptin and has a negative effect on milk production.)


All babies were NPO for 12 hours, then fed 5% glucose water with a rubber nipple every 4 hours and came out to mom, swaddled, for the first breastfeeding at 24 hours. Moms were told  to "keep the babies wrapped in order to avoid infections", given a moist pledget of boric acid(!!) to cleanse her fingers and the nipple, told to offer one breast only, and for only 3 minutes, and "get the whole circle in the baby's mouth"! (There was generous supplementation in the nursery!) Next day, 5 minutes, one side only each feeding, next day (4th PP day), 7-10 minutes on one side each feeding! (All this was "to avoid sore nipples!" Avoided long enough to show up after mom was discharged! By the end of my rotation, I was assigned a month of solo night duty on postpartum, with the L&D supervisor occasionally making a visit when free from responsibility, to "see how I was doing." I am here to tell you that the milk definitely did come in for what seemed to me, nearly all those mothers, even many of the ones who weren't nursing, and were getting stilbesterol 3 times daily! I became very experienced in applying breast binders to firm, swollen leaking breasts, since nursing bra's weren't on the market yet. The mothers felt much more comfortable, and probably had better lymphatic drainage of the breasts when the binders were on!


We all see the same mother and the same baby. But we see them in different rooms, on different days, at different stages in their childbirth experience. Many of them become overhydrated from IV fluids, (babies as well as moms) and some moms have hours and hours of pitocin, if not before delivery, then for several days after delivery, and pitocin has a secondary effect as an antidiuretic, adding to any overhydration the tendencey to edematous ankles, fingers, breasts, etc. Today's mothers seldom stay in the hospital more than 2-3 days. Occasionally mothers in my community may stay as long as the 4th day after C.S.  


It is wonderful that we are trying to change the rigid routines that used to surround breastfeeding in hospitals. But I recently saw a very troubled, abdominally uncomfortable CS mom at 4 days postpartum, at a WIC appointment. She said "no one had really helped her breastfeed in the hospital". No one had even told her about, or shown her the "laid back" position, or explained about the aroma of her areola and its appeal to her baby, as one example where an improvement could be made. Yet, it seems to me that many others have gotten the idea that only the "perfect start, according to the books they themselves have read" is going to successfully bring in the milk, etc. etc. 


Granted, seeing moms and babies make progress toward a good start in the hospital is a rewarding experience for those who work in hospitals. But there are so very many changes that continue to take place in the following 7-10 days in the mother's breasts, and therefore the baby's feedings, that many folks working in the hospital have seldom seen or begun to imagine! Giving moms anticipatory guidance about how to use their hands to assist in breast care (see Dr. Jane Morton's wonderful commentary on "The importance of hands" in the August 2012 JHL) would be such a wonderful help for these mothers, with their permission. I would like to encourage hospital LC's and nurses and childbirth educators to focus their attention on that area. They have the chance to empower mothers so very much, right where they are, without getting into a power struggle over what falls into someone else's area of practice.


And of course, I am prejudiced about teaching them all the skill of reverse pressure softening in case they should need it when (not really "if") areolar firmness and/or breast swelling interferes with latching. I feel persuaded that this is a much more effective expenditure of nurse and LC time and energy than to try to attempt to get moms to refuse an epidural because of any effects, proven or unproven, on the earliest stages of their breastfeeding. Believe me, it's all out there on the internet for mothers who really want to learn on their own and negotiate with their physicians in advance. Or choose to have a midwife help them birth;-)


I suppose I still "go round the doctors" by helping moms know to expect and how to cope with extra breast swelling from pre-L-2 edema that I have found happening so often. I would love to inspire someone to do formal research on extra breast swelling as a side effect of IV's > 2000 cc/24 hours and hours of pitocin. 


But realistically, I also hope to help a little in putting it all in perspective for the L&D, recovery room postpartum, nursery, home care and pediatric office nurses. The fact that mothers may have all the trappings of medical perinatal management is something that as nurses and LC's (and pediatricians) we have no real control over. What I think we lactation folk, and nurses need to learn is to give anticipatory guidance to every mother about how to use her hands to help manage any of the side effects that will occur, if they are going to occur, in the week after she leaves the hospital, with only, or mainly her support persons to help her round the clock. There are times when, with the permission of the mother, I have taught the support persons as well.


Perhaps just another way to consider looking at the situation.


K. Jean Cotterman RNC-E, IBCLC  
WIC Volunteer LC     Dayton OH

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