The benefits of breastfeeding is well researched, mothers benefit from a reduction in risk from many health concerns, protection from pregnancy related complications with ongoing health ramifications ie Pre-eclampsia and ongoing hypertension (Louis-Jacques & Stuebe, 2018; Stuebe, 2009; Victoria, et al., 2016). Families benefit from cost and resource saving benefits, no washing, preparation and reduced cost of family health care.
Breastfeeding has numerous benefits for babies with reduced risks of many health concerns including chronic disorders. Breastmilk is known to contain growth factors, anti-inflammatory agents and factors, none of which can be replicated artificially, vaccine effectiveness is enhanced and breastmilk is specialised to individual needs including sex (Spencer & Francis, 2021). Breastmilk changes throughout the day to the needs of the baby, including supplying additional antibodies if unwell, building children’s immunity, microbiome and providing ongoing developmental benefits (Toscano, et al., 2017; Victoria, et al., 2016).
Lactogenesis is the process of milk production, ejection and maintenance commencing in pregnancy and into the postpartum breastfeeding journey (Wambach & Genna, 2019). The process is divided into three parts plus mammogenesis (breast development) prior and involution (when breastfeeding has finished). Lactogenesis I commences in pregnancy up to day two post birth, it is an endocrine function controlled by hypothalamus (Wambach & Genna, 2019). Physiologically, prolactin increases steadily throughout pregnancy, milk synthesis commencing, but is largely inhibited by progesterone and oestrogen hormones, required to maintain pregnancy. Human placental lactogen (HPL) and prolactin compete for breast receptor sites further inhibiting prolactin movement into the milk secreting cells. After birth progesterone, oestrogen and HPL drop, with the anterior pituitary release larger amounts of prolactin in pulses to increase milk synthesis (increasing milk available within the breast). Oxytocin is released in response to suckling, which in turn causes contraction of myoepithelial cells, surrounding the alveoli (where milk is stored), allowing for milk release, this is particularly the case in lactogenesis II and III (galactopoieis) (Watson & Genna, 2019).
Lactogenesis II is the second step in the lactation process, this phase is identified through large increases in milk volume before a plateau; milk composition changes from colostrum to transition milk then to mature milk and cellular changes finalise in preparation for copious regular milk transfers (Wambach & Genna, 2019). Control of this phase changes from endocrine to autocrine control, prolactin assists, increasing nipple sensitivity required for further prolactin increase, when not felt, prolactin levels remain stable (Wambach & Genna, 2019). Infants suck and remove milk via subatmospheric pressure, requiring the combination of the top of their tongue wedging between nipple and areola, lower lips moving in a cycling action, while bottom of tongue moves in peristaltic waves (Elad, et al., 2014). Prolactin receptor theory states that early frequent feeds lead to faster, increased milk supply as early suckling stimulate the development of more receptors to prolactin at the breast (Wambach & Genna, 2019).
Prolactin requires the assistance of cortisol and insulin as these glucocorticoids are responsible for assisting transport across cell membranes during lactation (Watson & Genna, 2019).
Lactogenesis III/galactopoiesis is the final phase in commencing breastfeeding whereby the process becomes completely infant led. Oxytocin is released in pulses, responsible for milk ejection reflex but also promoting release of prolactin to continue milk production for ongoing feeds (Watson & Genna, 2019).
An epidural is defined by Macquarie Dictionary (2020), “an agent injected into the epidural space of the spinal cord to produce regional anaesthesia, especially in childbirth.” Epidural’s remove sensation associated with labour from birthing women, associated with this is (usually) a paralysing effect on the lower half of the body. Epidural analgesia are generally provided as described above – a catheter inserted into epidural space in the back with continued administration. Sometimes a spinal, a single injection into the nerves surrounding the spinal column can be included/referred to as epidural, especially as epidurals increasingly use a combination. Varied medications are used, high concentrations of local anaesthetics (minimum 0.25% bupivacaine), low dose local anesthetics (less .25% bupivacaine, ropivacaine) and/or opiods (fentanyl, sufentanil, morphine). With each administration method and drug choice, there are varied side effects to mothers and babies (Simmon, et al., 2012).
Epidurals have side effects including pyrexia, pruiritis, hypotension, and a list of inherent risks including urinary retention, motor blockade, prolonged labour, augmentation with synthetic oxytocins, instrumental and caesarean births and breastfeeding disruption (Anim-Somuah, et al., 2011; Djakovic, et al., 2017; Hasegawa, et al., 2013; Hincz, et al., 2014; Herrera-Gomez, et al., 2018; Munro, et al., 2017; Simmon, et al., 2012), the significance of risks vary depending on method and medication. Research on epidural impace on breastfeeding is contradictory and difficult to interpret because of common association with other interventions such as synthetic oxytocin and instrumental birth, also linked to breastfeeding disruption (French, et al., 2016).
As well as contradictory, many studies are flawed utilizing small numbers and not controlling/considering other labour factors in analysis (Dozier, et al., 2012; French, et al., 2016), reliance on maternal interviews is common which is impractical due to varied understanding of breastfeeding terms (Still, et al., 2017). Mahmoodi, et al. (2019) and Wilson, et al. (2010) site no impact of epidural in studies, both, however rely on limited checklist/survey responses, mention is made of induction and instrumentals, however accounting these in results is unclear. Studies also support negative epidural impact on breastfeeding, whether initiation (Hildebrandt, 1999; Lind, et al., 2014; Riordan, et al., 2000), continuation or early cessation (Dozier, et al., 2012; Orbach-Zinger, et al., 2019). These studies often included larger groups, interviews were correlated with medical records; labour and birth factors were considered when analysing results (Dozier, et al., 2012; Hildebrandt, 1999; Lind, et al., 2014; Orbach-Zinger, et al., 2019; Riordan, et al., 2000). French, et al. (2016) supports the contradictory and poor nature of this research in their systematic review where 23 articles were examined with 12 showing negative associations, 10 no impact, 1 a positive association and numerous limitations and methodological errors.
Epidurals have a hormonal impact on mothers during labour and birth processes, regardless of method/medications, the exact mechanism is unclear, but may be linked to lack of sensation felt by mothers (Buckley, 2015). Labour works as a positive feedback loop with mothers feeling contractions, brain registering and continuing to release hormones (including oxytocin) to maintain and build labour culminating in birth (Vidaeff & Ramin, 2008). When epidurals are administered this feedback loop is shut-down and hormones involved impacted, reflected in risks associated with epidurals. A mother’s natural oxytocin release is reduced during labour due to the lack of sensation, the peak that is expected at birth to assist with pushing and contraction efficacy is also reduced or absent (Anim-Somuah, et al., 2011; Buckley, 2015; Goodfellow, et al., 1983; Rahm, et al., 2002). Mother’s beta-endorphins are lower with an epidural with mother’s experiencing a rapid drop in epinephrine in labour and a reduction in rising norepinephrine through labour. Both hormones impact cortisol levels postnatally which is required for breastfeeding physiology (Buckley, 2015; Skull, et al., 1998). Prolactin is also impacted with the use of an epidural, with increasing levels in labour and dropping levels post birth, the opposite to what happens in physiological labour and birth (Buckley, 2015; Handlin, et al., 2009).
Local anesthetics and opioids cross the placenta and enter unborn babies blood steam at 80-100% maternal drug level. Babies have immature systems and therefore their ability to process and eliminate medication is limited resulting in these drugs remaining in their system up to 36hours post birth (Buckley, 2015). These drugs impact oxytocin and increase newborn stress response hormones, although the significance and impact is unknown (Buckley, 2015; La Camera, et al. 2020; Westgren, et al., 1986; Wynne-Edwards, et al., 2013). Research shows potential impacts of epidural analgesia on newborn ongoing autonomic nervous system function, differences in behaviour and thermoregulation post birth have been noted which may also contribute to breastfeeding disruption (Buckley, 2015).
The direct impact or extent of impact of epidurals on breastfeeding is essentially unknown (Buckley, 2015; French, et al., 2016), however, hormonal changes are acknowledged, theories can be formulated.
Oxytocin is the biggest shift with use of an epidural, it is unknown if this is the triggering factor for other hormone changes (Buckley, 2015). Oxytocin is significantly altered in labour, with a drop to almost none in labour, no peak at birth and continued reduction postnatally. As oxytocin plays a role in milk ejection and enhances prolactin release, it follows logically that initial milk ejection is disrupted and lower levels of prolactin are present (Anim-Somuah, et al., 2011; Buckley, 2015; Goodfellow, et al., 1983; Rahm, et al., 2002).
Prolactin is the major hormone involved with breastfeeding. It increases throughout pregnancy in preparation for milk production, peaking after birth, increasing nipple sensitivity (essential for ongoing prolactin increase, supporting initiation of breastfeeding) and is release in pulses attaching to breast receptor sites as human placental lactogen drops off (Buckley, 2015). Prolactin is responsible for milk synthesis in the cells, the more prolactin that is present, the more milk that is produced in preparation for baby feeding (Watson & Genna, 2019). When an epidural is administered the levels of prolactin increase significantly in labour, while after birth they drop (Buckley, 2015; Handlin, et al., 2009). This means that unlike physiological labour, epidurals produce lower levels of prolactin, impacting sensitivity of nipples, this may be further impacted in cases of high level epidurals. This interruption has been shown to impact prolactin increases postnatally (Buckley, 2015; Handlin, et al., 2009), and can be theorized that initiation and lactogenesis II are delayed due to low levels of initial prolactin, lower levels of increase, impacting the amount of milk synthesized.
Prolactin works in partnership with cortisol, which is impacted by changes in epinephrine and norepinephrine levels (both much lower) in labour and postnatally. Cortisol levels are lower postnatally as a result, cortisol’s role in breastfeeding is to promote development of prolactin receptors in the breast, much like oxytocin, lower levels result in longer time frames to achieve the same levels of prolactin receptors. Less receptors in the breast results in lower levels of prolactin uptake in the breast which results in reduced milk synthesis (Buckley, 2015).
Beta-endorphins are impacted by epidural use with drops in labour and postpartum (Buckley, 2015; Skull, et al., 1998). Postnatally beta-endorphins are responsible for reward centre and priming, whereby mothers feel good when breastfeeding. When reduced, reward feelings are reduced, limiting maternal motivation towards breastfeeding, with initiation and lactogenesis already delayed, lowered motivation can make it harder to continue. With lactogenesis dependent on autocrine function, breastfeeding motivation and response to infant feeding cues is vital for continued success (Buckley, 2015; Watson & Genna, 2019).
Recommendations for families in pregnancy include:
- Continuity of care models shown to increase rates of physiological birth, decrease inductions, cesarean sections and need for pain relief (Buckley, 2015; Sandall et al., 2016)
- Clinic appointments and early access to lactation consultants where more likely to require epidural anesthesia in labour (maternal cardiac issues, twin pregnancy etc.) (Louis-Jacques & Stuebe, 2018)
- Group prenatal education classes, discussing physiological birth, importance of breastfeeding, impact of common interventions such as epidurals and medication education to improve understanding, implications and ensure consent is informed (Buckley, 2015; Louis-Jacques & Stuebe, 2018; National Partnership for Women & Families, 2015; WHO & UNICEF, 2018)
Recommendations for labour and birth include:
- Non-judgemental support for informed decision making in labour – a woman who feels judged, unsupported or unsafe, will have altered hormone release, impacting physiological labour (Buckley, 2015)
- Early uninterrupted skin to skin – hormones are altered during epidural use in labour, early often and uninterrupted skin to skin may begin to counter the hormonal impact (Buckley, 2015)
- Hands-off approach to breastfeeding support – babies born after epidural have opioid and/or local anaesthetic affects, their initial feeding is more likely to require support, allowing them to breast crawl and self-attach for as long as possible are known to have benefits for infant neurodevelopment and positively impact mother’s breastfeeding confidence (Raising Children, 2016; QLD Health, 2020; Widstrom, et al., 2011).
Recommendations for postpartum
- Access to breast pumps – babies can be impacted by medication (particularly opioids) and hormones already impacted, stimulation of breasts is vital for initiation and activation of lactogenesis II. Avoiding the need for artificial formula where not medically necessary (Buckley, 2015; Louis-Jacques & Stuebe, 2018; Scott, et al., 2017)
- Early, frequent, and ongoing breastfeeding – assist in countering hormonal impacts of epidural analgesia, with ongoing guided support and encouragement where required (Buckley, 2015; WHO & UNICEF, 2018)
- 24 hour rooming in – combat hormonal impact and encourage maternal behaviour and confidence regarding feeding and infant cues (Buckley, 2015; WHO & UNICEF, 2018)
- Peer counselling and support – in hospital and after discharge – normalizing breastfeeding through support from other women and trained health professionals has been shown to improve breastfeeding continuation and confidence (Louis-Jacques & Stuebe, 2018; Scott, et al., 2017)
For all women – ask questions every step of the way, ask for research, get independent birth education and make the best informed decision for you.
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