Associations of drugs given in labour with breastfeeding
sue jordan, Swansea University
13 September 2009
Our recent work adds new data to the debate surrounding breastfeeding and medication administered in labour. We have no evidence of any causal inferences, but we found an association between drugs administered for prevention of post partum haemorrhage and formula feeding at 48 hours, which must be confirmed by further research [1] before recommending any change in practice.
We examined the Cardiff (Wales UK) Births Survey 1989-1999 to investigate potentially modifiable associations between drugs routinely administered in labour and breastfeeding in healthy women and infants. We reviewed data on 48,366 healthy women delivering healthy singleton babies at term and breastfeeding at 48 hours postpartum. At 48 hours, 43.3% (20,933/48,366) women were not breastfeeding. Multivariate logistic regression analysis confirmed previously reported associations of lower breast feeding rates with demographic indicators, epidural analgesia, intramuscular opioid analgesia and ergometrine. Novel associations were detected with oxytocin alone or in combination with ergometrine administered for prevention of post partum haemorrhage, which were associated with reductions of 6-8%, (intramuscular oxytocin OR 0.75, 95% CI 0.61-0.91, intravenous oxytocin OR 0.68, 95% CI 0.57-0.82, oxytocin/ ergometrine OR 0.77, 95%CI 0.65-0.91), and prostaglandins administered for induction of labour. The associations were maintained when subgroups, such as primiparous women, women whose labours were neither induced nor augmented, and women not receiving epidural analgesia were considered. Only a small number of women (806, 1.7%) in our study received no prophylaxis for post partum haemorrhage. We have no means of knowing if these women were more determined to breastfeed, but we found no difference in their socio-economic deprivation index score. These women were older, increasing chances of breastfeeding, but they were also more likely to have given birth before, decreasing their chances of breastfeeding [1].
The benefits of uterotonics (oxytocin and ergometrine) for prevention of post partum haemorrhage have been outlined in Cochrane reviews [2,3]. Existing RCTs found no links between uterotonics administered in third stage of labour and breastfeeding. These trials were published ten [4] and twenty [5] years ago, and, to our knowledge, more recent trials have not examined the impact of uterotonics on breastfeeding. In the absence of trial data, observation studies and biological mechanisms assume greater importance.
Older studies indicate an association between oxytocin, induction of labour and formula feeding [6-8]. This was confirmed in a more recent study [9]. The biological basis of the link between breastfeeding and exogenous (administered) oxytocin is discussed in the supplementary material for our article. It is possible that exogenous oxytocin may disrupt the normal pulsatile secretion of oxytocin and complex local feedbacks1. Most recently, a physiological study of 61 women who were successfully breastfeeding 48 hours after vaginal delivery found that epidurals and intramuscular oxytocin for prevention of PPH reduced the plasma concentration of prolactin [10].
We have no evidence to support a change in prescribing practice and no woman should be encouraged to refuse potentially life-saving medication on the basis of this study. Rather, we have highlighted a potential conflict of interest between the health of mother (prevention of post partum haemorrhage) and infant (breastfeeding). However, a reduction of 6-8% in breastfeeding rates is of considerable public health importance, and should be investigated. Funding support for prospective studies and a randomised controlled trial is urgently needed.
Sue Jordan 1.9.9
1. Jordan S, Emery S, Watkins A, Evans J, Storey M, Morgan G. Associations of drugs routinely given in labour with breastfeeding at 48 hours: analysis of the Cardiff Births Survey. BJOG 2009; DOI: 10.1111/j.1471-0528.2009.02256.x. http://www3.interscience.wiley.com/journal/120125883/issue
2. Prendiville WJ, Elbourne D, McDonald S. Active versus expectant management in the third stage of labour. Cochrane Database of Systematic Reviews 2000, Issue 3. Art. No.: CD000007. DOI: 10.1002/14651858.CD000007.
3. Cotter A, Ness A, Tolosa J. Prophylactic oxytocin for the third stage of labour. Cochrane Database of Systematic Reviews 2001 Issue 4. Art. No.: CD001808.DOI: 10.1002/14651858.CD001808.
4. Prendiville WJ, Harding JE, Elbourne DR, Stirrat GM. The Bristol third stage trial: active versus physiological management of third stage of labour. BMJ 1988; 297: 1295-1300.
5. Rogers J, Wood J, McCandlish R, Ayers S, Truesdale A, Elbourne D. Active versus expectant management of third stage of labour: the Hinchingbrooke randomised controlled trial. Lancet 1998; 351: 693-9.
6. Out JJ, Vierhout ME, Wallenburg HC. Breast-feeding following spontaneous and induced labour. Eur J Obstet Gynecol Reprod Biol 1988; 29: 275-9.
7. Ounsted MK, Hendrick M, Mutch LM, Calder AA, Good FJ. Induction of labour by different methods in primiparous women. I Some perinatal and postnatal problems. Early Hum Dev 1978; 2: 227-39.
8. Rajan L. The impact of obstetric procedures and analgesia/anaesthesia during labour and delivery on breast feeding. Midwifery 1994; 10: 87-103.
9. Wiklund I, Norman M, Uvnäs-Moberg K, Ransjö-Arvidson AB, Andolf E. Epidural analgesia: Breast-feeding success and related factors. Midwifery 2009; 25(2):e31-8.
10. Jonas W, Nissen E, Ransjö-Arvidson AB, Matthiesen AS, Uvnäs-Moberg K. Influence of oxytocin or epidural analgesia on personality profile in breastfeeding women: a comparative study. Arch Womens Ment Health 2008; 11(5-6):335-45.
International Breastfeeding Journal
Associations of drugs given in labour with breastfeeding
13 September 2009
Our recent work adds new data to the debate surrounding breastfeeding and medication administered in labour. We have no evidence of any causal inferences, but we found an association between drugs administered for prevention of post partum haemorrhage and formula feeding at 48 hours, which must be confirmed by further research [1] before recommending any change in practice.
We examined the Cardiff (Wales UK) Births Survey 1989-1999 to investigate potentially modifiable associations between drugs routinely administered in labour and breastfeeding in healthy women and infants. We reviewed data on 48,366 healthy women delivering healthy singleton babies at term and breastfeeding at 48 hours postpartum. At 48 hours, 43.3% (20,933/48,366) women were not breastfeeding. Multivariate logistic regression analysis confirmed previously reported associations of lower breast feeding rates with demographic indicators, epidural analgesia, intramuscular opioid analgesia and ergometrine. Novel associations were detected with oxytocin alone or in combination with ergometrine administered for prevention of post partum haemorrhage, which were associated with reductions of 6-8%, (intramuscular oxytocin OR 0.75, 95% CI 0.61-0.91, intravenous oxytocin OR 0.68, 95% CI 0.57-0.82, oxytocin/ ergometrine OR 0.77, 95%CI 0.65-0.91), and prostaglandins administered for induction of labour. The associations were maintained when subgroups, such as primiparous women, women whose labours were neither induced nor augmented, and women not receiving epidural analgesia were considered. Only a small number of women (806, 1.7%) in our study received no prophylaxis for post partum haemorrhage. We have no means of knowing if these women were more determined to breastfeed, but we found no difference in their socio-economic deprivation index score. These women were older, increasing chances of breastfeeding, but they were also more likely to have given birth before, decreasing their chances of breastfeeding [1].
The benefits of uterotonics (oxytocin and ergometrine) for prevention of post partum haemorrhage have been outlined in Cochrane reviews [2,3]. Existing RCTs found no links between uterotonics administered in third stage of labour and breastfeeding. These trials were published ten [4] and twenty [5] years ago, and, to our knowledge, more recent trials have not examined the impact of uterotonics on breastfeeding. In the absence of trial data, observation studies and biological mechanisms assume greater importance.
Older studies indicate an association between oxytocin, induction of labour and formula feeding [6-8]. This was confirmed in a more recent study [9]. The biological basis of the link between breastfeeding and exogenous (administered) oxytocin is discussed in the supplementary material for our article. It is possible that exogenous oxytocin may disrupt the normal pulsatile secretion of oxytocin and complex local feedbacks1. Most recently, a physiological study of 61 women who were successfully breastfeeding 48 hours after vaginal delivery found that epidurals and intramuscular oxytocin for prevention of PPH reduced the plasma concentration of prolactin [10].
We have no evidence to support a change in prescribing practice and no woman should be encouraged to refuse potentially life-saving medication on the basis of this study. Rather, we have highlighted a potential conflict of interest between the health of mother (prevention of post partum haemorrhage) and infant (breastfeeding). However, a reduction of 6-8% in breastfeeding rates is of considerable public health importance, and should be investigated. Funding support for prospective studies and a randomised controlled trial is urgently needed.
Sue Jordan 1.9.9
1. Jordan S, Emery S, Watkins A, Evans J, Storey M, Morgan G. Associations of drugs routinely given in labour with breastfeeding at 48 hours: analysis of the Cardiff Births Survey. BJOG 2009; DOI: 10.1111/j.1471-0528.2009.02256.x. http://www3.interscience.wiley.com/journal/120125883/issue
2. Prendiville WJ, Elbourne D, McDonald S. Active versus expectant management in the third stage of labour. Cochrane Database of Systematic Reviews 2000, Issue 3. Art. No.: CD000007. DOI: 10.1002/14651858.CD000007.
3. Cotter A, Ness A, Tolosa J. Prophylactic oxytocin for the third stage of labour. Cochrane Database of Systematic Reviews 2001 Issue 4. Art. No.: CD001808.DOI: 10.1002/14651858.CD001808.
4. Prendiville WJ, Harding JE, Elbourne DR, Stirrat GM. The Bristol third stage trial: active versus physiological management of third stage of labour. BMJ 1988; 297: 1295-1300.
5. Rogers J, Wood J, McCandlish R, Ayers S, Truesdale A, Elbourne D. Active versus expectant management of third stage of labour: the Hinchingbrooke randomised controlled trial. Lancet 1998; 351: 693-9.
6. Out JJ, Vierhout ME, Wallenburg HC. Breast-feeding following spontaneous and induced labour. Eur J Obstet Gynecol Reprod Biol 1988; 29: 275-9.
7. Ounsted MK, Hendrick M, Mutch LM, Calder AA, Good FJ. Induction of labour by different methods in primiparous women. I Some perinatal and postnatal problems. Early Hum Dev 1978; 2: 227-39.
8. Rajan L. The impact of obstetric procedures and analgesia/anaesthesia during labour and delivery on breast feeding. Midwifery 1994; 10: 87-103.
9. Wiklund I, Norman M, Uvnäs-Moberg K, Ransjö-Arvidson AB, Andolf E. Epidural analgesia: Breast-feeding success and related factors. Midwifery 2009; 25(2):e31-8.
10. Jonas W, Nissen E, Ransjö-Arvidson AB, Matthiesen AS, Uvnäs-Moberg K. Influence of oxytocin or epidural analgesia on personality profile in breastfeeding women: a comparative study. Arch Womens Ment Health 2008; 11(5-6):335-45.
Competing interests
None declared