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Abm clinical protocol #15: analgesia and anesthesia for the breastfeeding mother, revised 2012

Volume 7, Number 6, 2012ª Mary Ann Liebert, Inc.
DOI: 10.1089/bfm.2012.9977 ABM Clinical Protocol #15: Analgesia and Anesthesia for the Breastfeeding Mother, Revised 2012 Anne Montgomery, Thomas W. Hale, and The Academy of Breastfeeding Medicine A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing commonmedical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breast-feeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care.
Variations in treatment may be appropriate according to the needs of an individual patient.
amine the evidence currently available and make recom-mendations for prudent practice.
Labor, birth, and breastfeeding initiation compose a There is even less information in the scientific literature normal, continuous process. Oxytocin, endorphins, and about anesthesia for surgery in breastfeeding mothers. Re- adrenaline produced in response to the normal pain of labor commendations in this area focus on pharmacologic proper- may play significant roles in maternal and neonatal responses ties of anesthetic agents and limited studies of milk levels and to birth and early breastfeeding.1 Use of pharmacologic agents for pain relief in labor and postpartum may improve Quality of evidence for each recommendation, as defined outcomes by relieving suffering during labor and allowing by the U.S. Preventive Task Force, is noted in parentheses (I, mothers to recover from birth, especially cesarean birth, with minimal interference from pain. However, these methodsmay also affect the course of labor and the neurobehavioral state of the neonate and have adverse effects on breastfeedinginitiation. Unfortunately, the literature in this area has not 1. Maternity care providers should initiate an informed addressed this issue as a whole, integrated process.
consent discussion for pain management in labor In the setting of labor and childbirth, we will use the fol- during the prenatal period, well before the onset of lowing definitions throughout this protocol: labor. Risk discussion should include what is knownabout the effects of various modalities on the progress  Analgesia: modification of painful stimuli so that they, of labor, risk of instrumented and cesarean delivery, while still experienced, are not painful.
effects on the newborn, and possible breastfeeding  Anesthesia: total loss of sensation.
 Epidural analgesia: use of epidural anesthetics and 2. Unmedicated, spontaneous vaginal birth with imme- opioids to reduce the painful experience of labor.
diate, uninterrupted skin-to-skin contact leads to the  Epidural anesthesia: use of epidural anesthetics to highest likelihood of baby-led breastfeeding initia- eliminate sensation, as for cesarean section.
tion.2,3 Longer labors, instrumented deliveries, cesarean Very few studies directly address the impact of various section, and separation of mother and infant after birth approaches to labor pain management on breastfeeding out- may lead to higher risk of difficulty with breastfeeding comes. Although there are some older trials in which women initiation.4–6 Labor pain management strategies may were randomized to analgesia versus no analgesia in labor, affect these birth outcomes and secondarily affect these studies are limited by both crossover and confounding.
breastfeeding initiation in addition to any direct effects At present, such trials would not be considered ethical, so we of the medications themselves.7 (II-1; II-2) will not anticipate randomized controlled trials comparing 3. Women have differing levels of pain tolerance. Labor breastfeeding outcomes for analgesia versus no analgesia in pain may exceed a woman’s ability to cope or be labor. We do have a few recent trials looking at breastfeeding magnified by fear and anxiety. Suffering in labor may outcomes with different techniques and dosages for epidural lead to dysfunctional labors, poorer psychologic out- analgesia; these trials used a case-control design to compare comes, and increased risk of postpartum depression, all patients who received an epidural with those who had no of which may have a negative effect on breastfeeding.8,9 analgesia. The technology of epidural anesthesia, in particu- Severe maternal physiologic stress in labor also causes lar, is evolving quickly, so studies that are even a few years physiologic stress for babies, which may affect their old may not reflect current practices. This protocol will ex- readiness to breastfeed at birth.10 (III) 4. Continuous support in labor, ideally by a trained doula, e. When a mother has received intravenous or intra- reduces the need for pharmacologic pain management muscular narcotics for labor, mother and infant in labor and decreases the rates of instrumented deliv- should be given more skin-to-skin time to encourage ery and cesarean section. An earlier meta-analysis suggested that doulas also improve breastfeeding out- 9. Although many studies have shown that epidural an- comes both in the immediate postpartum period and algesia affects infant behavior,20 the effect of epidural several weeks after birth, but an update to this meta- analgesia on breastfeeding continues to be controver- analysis did not find statistical differences in breast- sial. Older case-control and cohort studies suggested that breastfeeding rates were lower after epidural an- 5. Nonpharmacologic methods for pain management in algesia, and another observational study found de- labor such as hypnosis and acupuncture have been creased breastfeeding rates with higher doses of found effective in reducing labor pain.12 (I) Other fentanyl.21 However, because these studies were not methods that are used in some but not all countries randomized, they also raise the question as to whether such as psychoprophylaxis (e.g., Lamaze), intrader- women who choose epidural analgesia may be less mal and/or subcutaneous water injections for back likely to continue breastfeeding.22 Hormonally, epidu- pain, etc., appear to be safe and have no known ad- ral analgesia has been shown to decrease oxytocin verse neonatal effects. These methods may reduce the levels during labor and to affect oxytocin and prolactin need for pharmacologic interventions. Additional levels on Day 2 postpartum.23 Practically, use of epi- study of breastfeeding outcomes is needed for these dural analgesia may affect labor outcomes such as an increased use of instrumented delivery and postpartum 6. Evidence suggests that breastfeeding success is affect- separation of mother and infant related to birth out- ed by the behavior of the newborn. Depressed or de- comes that may secondarily affect breastfeeding.
layed suckling, which can be caused by medications Several recent trials have shown no differences in given to mothers, can lead to delayed or suppressed breastfeeding rates in women with epidural analgesia.
lactogenesis and risk of excess infant weight loss.14,15 These trials randomized women to different techniques of epidural analgesia but used a case-control design to 7. Intrapartum intravenous fluids are often given in larger compare them with women who did not have any quantities when pharmacologic pain relief methods analgesia for labor. One trial done in New York ran- such as epidural analgesia or anesthesia are used. These domized 177 multiparas who had previously breastfed fluids can potentially lead to maternal engorgement, to different doses of epidural analgesia and compared affect birth weight and newborn weight loss,16 and them to a selected group of women with no analgesia.
cause neonatal hyperglycemia and rebound hyper- All of these women had vaginal births. There were no differences in breastfeeding rates except in the group 8. Parenteral (intravenous, intramuscular) opiates used for who received > 150 mcg of fentanyl.24 A larger trial labor may block the newborn’s normal reflexes to done in the United Kingdom randomized 1,054 pri- suckle at the breast within the first hour after birth.17,18 miparas to different techniques of epidural analgesia a. If opiates are used, shorter-acting opiates such as and compared them to a selected group. These groups fentanyl or sufentanil are preferred. Remifentanil is differed in that the epidural groups included more potent and has rapid onset and offset but can be women with cesarean and instrumented deliveries.
associated with a high incidence of maternal apnea, There was no statistically significant difference in requiring increased monitoring. Its transfer in utero breastfeeding initiation or continuation in these groups except that the ‘‘control’’ women who had received b. Meperidine/pethidine/morphine should generally intravenous pethidine had lower rates of breastfeeding not be used except in small doses less than 1 hour or initiation.25 Another well-designed prospective cohort more than 4 hours prior to anticipated delivery be- study also showed no differences in breastfeeding rates cause of greater incidence and duration of respira- after epidural analgesia in a population with high tory depression, cyanosis, and bradycardia in breastfeeding rates and good breastfeeding support.26 In summary, epidural analgesia has subtle effects on c. Nalbuphine, butorphanol, and pentazocine may be infant behavior. Women who choose epidural analgesia used for patients with certain opioid allergies or at may differ from women who do not with respect to increased risk of difficult airway management or re- breastfeeding plans. Higher or repeated doses of med- spiratory depression. These medications may, how- ication in the epidural space may make a difference.
ever, interfere with fetal heart rate monitoring Like many other aspects of breastfeeding, epidural an- interpretation. Observe the mother and infant for algesia likely has almost no effect on women who are determined to breastfeed and have good support but d. Both the dosing (especially multiple doses) and the may be one more subtle challenge to women whose timing of parenteral analgesics may lead to greater intention to breastfeed is more vulnerable.
neonatal effects. For example, fentanyl administra- a. If epidural analgesia is chosen, methods that mini- tion within 1 hour of delivery or meperidine/pethi- mize the dose of medication and minimize motor dine administration between 1 and 4 hours prior to block should be used. Doses of fentanyl > 150 lg delivery is associated with more profound neonatal should be avoided.23 Longer durations and repeat- ed administration of epidural analgesia should be avoided if possible, to minimize effect on labor medication dose that is fully effective. Opioid analgesia outcomes that may secondarily affect breastfeed- postpartum may affect babies’ alertness and suckling ing. Combined spinal-epidural analgesia and vigor. However, when maternal pain is adequately patient-controlled epidural analgesia may be treated, breastfeeding outcomes improve.31,32 Mothers should be encouraged to adequately control their pain, b. When epidural analgesia has been used for labor, especially after cesarean birth or severe perineal trauma particular care to provide mothers with good breastfeeding support and close follow-up after a. Parenteral medications (may be intravenous or in- postpartum hospitalization should be taken. (II-2) 10. There are minimal data concerning the effects on the i. Meperidine/pethidine should be avoided due to neonate of other labor anesthesia, including inhaled reported neonatal sedation when given to breast- nitrous oxide, paracervical block, pudendal block, and feeding mothers postpartum,33 in addition to the local perineal anesthesia.28 These modalities do not concerns of cyanosis, bradycardia, and the risk of usually expose the infant to significant quantities of apnea that have been noted with intrapartum medication. In some situations, these may serve as al- ternatives to intravenous narcotics or epidural analgesia ii. The administration of moderate to low doses of in- for labor. Their use, however, is limited by several travenous or intramuscular morphine is preferred to factors. These include lack of efficacy, technical diffi- meperidine/pethidine as passage to milk and oral culties in performing, and a high rate of complications.
bioavailability are least with this agent.33,36 iii. When patient-controlled intravenous analgesia (PCA) is chosen after cesarean section, morphine orfentanyl is preferred over meperidine/pethidine.32,37 1. Regional anesthesia (epidural or intrathecal/spinal) is iv. Levels of butorphanol in human milk have been preferred over general anesthesia. Separation of a reported with approximately 0.5% of the weight- mother and her infant should be minimized, and adjusted maternal dose* transferred into human breastfeeding should be initiated as soon as feasible.29 milk. These appear minimal and probably are of In fact, the infant may go to the breast in the operating no concern to a breastfeeding neonate in the first room during abdominal closure with assistance to week postpartum. The use of butorphanol during support the infant on the mother’s chest. If breastfeed- labor has been reported to produce sinusoidal fetal ing is initiated in the recovery room, there is the added heart rate patterns and irritability in newborns.
advantage that the incision is often still under the in- v. Levels of nalbuphine in human milk are quite low.
In one study the levels of nalbuphine in milk av- 2. A mother who has had general anesthesia may breast- erage only 42 lg/L with an estimated weight- feed postoperatively as soon as she is alert enough to adjusted relative infant dose (RID) of 0.59%.38 hold the infant and is not overly sedated. (III) vi. Hydromorphone (approximately seven to 11 times as potent as morphine) is sometimes used forextreme pain in a PCA, intramuscularly, intrave- nously, or orally. Following a 2 mg intranasal 1. Non-opioid analgesics should generally be the first dose, levels in milk were quite low with a weight- choice for pain management in breastfeeding postpar- adjusted RID of about 0.67%.39 This correlates with tum women, as they do not impact maternal or infant about 2.2 lg/day via milk. This dose is probably too low to affect a breastfeeding infant, but this is a a. Acetaminophen/paracetamol and ibuprofen are safe strong opioid, and some caution is recommended.
and effective for analgesia in postpartum mothers.
b. Ketorolac is commonly used for postpartum anal- i. Hydrocodone has been used frequently in breast- gesia, especially after cesarean section, despite a feeding mothers worldwide. Less than 3.7% of the Food and Drug Administration black box warning weight-adjusted maternal dose (RID) reaches the (in the United States) against the use of this medicine infant per day. Higher doses (10 mg of hydro- for breastfeeding women.30 Milk levels after oral codone) and/or more frequent administration may administration are quite low, but levels have not lead to neonatal sedation and should be used with been measured after parenteral administration.
c. Diclofenac suppositories are available in some ii. Recent cases have raised concern about the use of countries and commonly used for postpartum anal- codeine. Some mothers may rapidly metabolize gesia. Milk levels are extremely low.
d. Cyclooxygenase-2 inhibitors such as celecoxib may have some theoretical advantages if maternal bleeding *An important concept when discussing the risk of maternal is a concern; this must be balanced with higher cost and medications to the breastfeeding infant is that of the relative infant possible cardiovascular risks, which should be minimal dose. It is imperative to understand that this is a value that is cal- with short-term use in healthy young women.19 culated by dividing the infant’s dose from the milk in mg/kg/dayby the mother’s dose in mg/kg/day. In this manner of calculation, a 2. Both pain and opioid analgesia can have a negative weight-normalized dose is determined that the baby may receive, impact on breastfeeding outcomes; thus mothers should which is more accurate than when one does not take the weight of be encouraged to control their pain with the lowest the mother and the baby into account.
codeine to morphine, which can lead to toxic levels are low once mothers resume normal mentation. For of morphine in the infant. Codeine should be used maternal safety, regional anesthesia is recommended for with caution, although it is probably safe in the this procedure in preference to general anesthetic. (III) 3. Mothers who have undergone dental extractions or iii. Several studies now suggest that oxycodone may other procedures requiring the use of single doses of be useful in some patients postpartum. Less than medication for sedation and analgesia can breastfeed as 3.5% of the weight-adjusted maternal dose (RID) soon as they are awake and stable. Although shorter- transfers into human milk. Prolonged and frequent acting agents such as fentanyl and midazolam may be administration may lead to neonatal sedation.41 preferred, single doses of meperidine/pethidine or dia- There is also the rare mother who is an ultrarapid zepam are unlikely to affect the breastfeeding infant.42 (III) metabolizer, whose babies are at higher risk for 4. Mothers who have undergone plastic surgery, such as central nervous system depression [see Analgesics liposuction, where large doses of local anesthetics (lidocaine/xylocaine or lignocaine) have been used iv. Several recent studies of buprenorphine suggest should probably pump and discard their milk for 12 that approximately 1.9% of the weight-adjusted hours prior to resuming breastfeeding. (III) maternal dose is transferred to the infant daily.
5. The maternal dose and the ability of the infant to clear Buprenorphine has a long half-life and should be small amounts of medications that can cause cardiore- used with some caution in infants who have not spiratory effects is of primary concern before returning been previously exposed to the drug. Mothers to breastfeeding. Infants subject to apnea, hypotension, treated continually for addiction may continue to or hypotonia should probably be protected by a few breastfeed using this medication as long as the more hours of interruption from breastfeeding (12–24 infant is tolerant to the current dose.42 i. Single-dose opioid medications (e.g., neuraxial morphine) should have minimal effects on breast- feeding because of negligible maternal plasmalevels achieved. Extremely low doses of morphine 1. Drugs used for anesthetic induction such as propofol, ii. Continuous post-cesarean epidural infusion may midazolam, etomidate, or thiopental enter the milk be an effective form of pain relief that minimizes compartment only minimally, as they have extraordi- opioid exposure. A randomized study that com- narily brief plasma distribution phases (only minutes), pared spinal anesthesia for elective cesarean with and hence their transport to milk is low to nil.45–48 or without the use of postoperative extradural 2. Little or nothing has been reported about the use of continuous bupivacaine found that the continuous anesthetic gases in breastfeeding mothers. However, group had lower pain scores and a higher volume they too have brief plasma distribution phases, and milk levels are likely nil. A recent series of case reportssuggests that xenon maintenance after propofol induction allows for breastfeeding immediately after surgery.49 3. The use of ketamine in breastfeeding mothers is unre- ported. Following the use of ketamine, many adult 1. The implications of drugs used in anesthesia in post- patients may exhibit dissociative anesthetic effects. This partum mothers depend on numerous factors, including is often suppressed with the addition of midazolam or the age of the infant, the stability of the infant, the length other benzodiazepines. The emergent reactions are ap- of lactation, and the ability of the infant to clear small parently age-dependent and appear to occur more fre- quantities of anesthetic medications.43 Anesthetic agents quently in adults (30–50%) and less frequently in will have little or no effect on older infants but could potentially cause problems in newborn infants, particu- 4. For specific local anesthetics for epidural use (such as larly those who are premature or suffer from apnea. (III) bupivacaine and ropivacaine), see general comments 2. Mothers with normal term or older infants can gener- about epidural analgesia/anesthesia. These and other ally resume breastfeeding as soon as they are awake, local anesthetics are poorly absorbed orally so should be stable, and alert. Resumption of normal mentation is a safe in postpartum breastfeeding mothers. Milk levels of hallmark that these medications have redistributed bupivacaine and ropivacaine51 are exceedingly low.
from the plasma compartment (and thus generally themilk compartment) and entered adipose and muscletissue where they are slowly released. The exception could be a drug that is highly lipid soluble, in which breast tissue may function as a fat compartment, actingas a drug reservoir. For women who undergo post- a. Morphine is still considered an ideal analgesic for partum tubal ligation, interruption of breastfeeding is breastfeeding mothers due to its limited transport to not indicated as the volume of colostrum is small; hence milk and its poor oral bioavailability in infants.33,37 the dose to the infant is low as well.44 In addition, the b. The transfer of meperidine/pethidine into breast- levels of medication in the maternal plasma and milk milk is low (1.7–3.5% of maternal weight-adjusted dose). However, meperidine/pethidine and its 2. Non-steroidal anti-inflammatory drug analgesics metabolite (normeperidine) are consistently associ- Use of non-steroidal anti-inflammatory drugs (NSAIDs) ated with dose-related neonatal sedation. Transfer alone after vaginal birth or in combination with opioids into milk and neonatal sedation have been docu- after cesarean birth can improve pain control by as- mented for even up to 36 hours after a single dose.33 sisting with some of the pain due to uterine cramping.
Meperidine/pethidine should be avoided during NSAIDs are generally safe for breastfeeding and can labor and in postpartum analgesia (except, perhaps, help minimize the total dose of opioid needed to control within 1 hour prior to delivery). Infants of mothers who have been exposed to repeated doses of meper- a. Ibuprofen is considered an ideal, moderately effec- idine/pethidine should be closely monitored for se- tive analgesic. Its transfer to milk is low to nil.56 dation, cyanosis, bradycardia, and possibly seizures.
b. Ketorolac is a potent analgesic in breastfeeding c. Although there are no published data on re- mothers and is increasingly popular when used mifentanil, this esterase-metabolized opioid has a postpartum. Its primary benefit is excellent analge- brief half-life even in infants ( < 10 minutes) and has sia, with no sedative properties. In addition, the been documented to produce no fetal sedation even transfer of ketorolac into milk is extremely low.57 in utero. Although its duration of action is limited, it However, its use in postsurgical patients with hem- could be used safely and indeed may be ideal in orrhage may be somewhat risky as it inhibits platelet breastfeeding mothers for short painful procedures.
function, although this is somewhat controversial. It d. Fentanyl levels in breastmilk have been studied and should not be used in patients with a history of are extremely low after 2 hours and generally below gastritis, aspirin allergy, or renal insufficiency. If there is no risk of hemorrhage, it carries few com- e. Sufentanil transfer into milk has not been published, plications for breastfeeding mothers and their in- but it should be similar to that of fentanyl.
fants. However, the Food and Drug Administration f. Nalbuphine and butorphanol levels in breastmilk are now has a black box warning against use of ketorolac very low. At this time they would only be indicated in the specific situations mentioned previously. If c. Celecoxib transfer into milk is extraordinarily low these agents are used, observe the mother and infant ( < 0.3% of the weight-adjusted maternal dose).58 Its g. Hydrocodone has been used frequently in breast- d. Naproxen transfer into milk is low, but gastrointes- feeding mothers. Occasional cases of neonatal seda- tinal disturbances have been reported in some in- tion have been documented, but these are rare and fants following prolonged therapy. Short-term use (1 generally dose related. Doses in breastfeeding mothers should be kept at the minimum necessary tocontrol pain. Frequent dosing throughout the day may lead to sedative effects in the breastfed infant.
h. A recent report of a neonatal death following the use 1. Studies of labor analgesia and anesthesia for cesarean of codeine suggests that the use of codeine in breast- section should specifically study breastfeeding outcomes.
feeding mothers should be monitored closely.54 Al- Although randomization of analgesia versus no analgesia though rare, rapid metabolizers of codeine are known, is not possible, good prospective study designs should and levels of morphine following the use of codeine allow appropriate comparisons and should help describe may be significantly elevated thus putting the infant at appropriate support for breastfeeding mothers and in- risk. Use caution with codeine in breastfeeding mothers.
fants who have been exposed to labor analgesia.
i. Oxycodone levels in milk are known and average ap- 2. More study of specific breastfeeding outcomes after proximately 58 lg/L (range, 7–130 lg/L) (RID = 1.5– surgical anesthesia in breastfeeding mothers is needed.
3.5%). Oxycodone may not be significantly safer for the 3. More data on the use of ketorolac as it has gained in rare mother who is an ultrarapid metabolizer, as it is popularity in the postpartum period are needed.
also a substrate for CYP2D6. A recent retrospective 4. More study is required of the special needs of prema- study showed that one in five breastfed infants with ture and unstable babies including how their ability to mothers medicated with oxycodone experienced cen- clear maternal anesthetic and analgesic drugs may dif- tral nervous system depression. The strong concor- dance between maternal and infant symptoms may beused to identify babies at higher risk. It is important to follow these infants carefully for drowsiness.55 j. Regardless of the opioid, always consider the dose This work was supported in part by a grant from the Ma- used. Many mothers undergoing chronic pain thera- ternal and Child Health Bureau, U.S. Department of Health py in various pain clinics may use exceedingly high doses of hydrocodone, oxycodone, methadone, andother opioid analgesics. Those infants of mothers with exceedingly high doses should be closely monitored 1. Smith L. Impact of Birthing Practices on Breastfeeding, 2nd for sedation and apnea. If the infants are exposed in ed. Jones and Bartlett Publishers, Sudbury, MA, 2010.
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LEAVING CERTIFICATE BIOLOGY HIGHER LEVEL EXAM PAPER SOLUTIONS Sample Paper 4 Section A Question 1 a) D: Zone of Differentiation/C: Zone of Elongation/A: Root Cap/B: Meristem 4(1)New Tissues: Zone of Differentiation/Mitosis: Meristem/Growth Regulators: Zone ofElongation/Absorbtion of water: Zone of Differentiation 4(1)(i) A: Vascular bundle/B: Air Spaces/C: Guard Cells/D: Stoma 4(1).

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DAILY BIBLE READING SCHEDULE YEAR 2009 Holy Cross Lutheran Church Indianapolis Indiana YEAR 2009 DAILY BIBLE READINGS The Holy Bible is a great treasure through which God Himself speaks to us! This schedule is one year of a program to read the entire Bible in 2 years, while including all the major teachings of the Bible each year. The following Bible books coveri

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