Interventions During Labor & Delivery
IABLE
Medications Interventions During Labor & Delivery

Interventions During Labor & Delivery

In general, there is no absolute indication to pump and dump with interventions commonly used during labor and delivery. Known or theoretical risks to milk production and effective infant feeding should be made clear during shared decision making when using these medications as noted below.

For detailed more information and references on specific medications, please refer to LactMed, e-lactancia, Infant Risk, or Mother to Baby.

Synthetic Oxytocin

Synthetic oxytocin/Pitocin is commonly used during and after labor and delivery. There are concerns that intrapartum synthetic oxytocin could negatively impact breastfeeding outcomes by impacting newborn reflexes and suckling behaviors and by reducing postpartum endogenous oxytocin in the lactating/birthing parent per the LactMed Database entry. In one study, infants exposed to synthetic oxytocin during labor and delivery were found to have inhibition of primitive reflexes important to latching and initiation of breastfeeding (1). Another recently published study found that oxytocin with epidural analgesia decreased breastfeeding rates (2). Stronger data is needed to further explore these risks, but the risks to lactation should be discussed with patients when the decision to initiate synthetic oxytocin to augment labor is considered. There is no absolute indication to pump and dump.

Magnesium Sulfate

This intervention is commonly used during labor for pre-eclampsia or eclampsia. There is a slight increase in milk magnesium content (this was still within the normal range with IV magnesium sulfate administration) and oral absorption of magnesium by infants is poor so this is unlikely to significantly affect the infant’s serum magnesium. Postpartum IV magnesium may delay initiation of breastfeeding (3) per available studies with greater delays noted with longer duration of IV magnesium administration postpartum (4), but this may also be related to the effects of disease severity on the intention to breastfeed (5). There is no absolute indication to pump and dump.

Corticosteroids

While high doses of glucocorticoids can cause transient decrease in milk production, there is no absolute indication to pump and dump.

  • Betamethasone and Dexamethasone: These are the most commonly used corticosteroids prior to delivery to help lung development in premature infants. While there is no absolute indication to pump and dump, steroid use may affect milk production and lactogenesis II. Dyads should be offered lactation support and be followed closely if antenatal corticosteroids are given.
      • Betamethasone given 3-9 days before delivery can has been shown to delay milk transition (6).
      • Dexamethasone has not been studied in this population with regards to breastfeeding outcomes in the perinatal period, but it may interfere with milk production as well.

IV Fluids

IV fluids are frequently used during labor with more fluids associated with Pitocin (or synthetic oxytocin) use, epidurals, cesarean sections, and other interventions. A recent study in 2020 noted greater early-postpartum infant weight loss with IV fluid use, which may result in unnecessary formula use (7). There are also greater risks of breast engorgement and associated symptoms and issues in the birthing parent (8). While laboring patients who plan to lactate should be informed of these risks to lactation during shared decision making, there is no absolute indication to pump and dump.

Intrapartum Analgesia & Anesthesia

Lactating parents may directly feed their baby after delivery if the parent is alert enough to do so. An in-depth discussion of the risks associated with peripartum neuraxial analgesia and anesthesia in breastfeeding dyads can be found in ABM Clinical Protocol 28 on Peripartum Analgesia and Anesthesia for the Breastfeeding Mother (9). There is no absolute indication to pump and dump. For more information about various types of analgesia and anesthesia, see the section on Anesthesia.

  • Neuraxial analgesics (epidural, spinal, combination spinal-epidural, and continuous spinal analgesia): Potential risks to the breastfeeding relationship, including disruption of normal newborn reflexes important to milk production, letdown, and removal, should be disclosed as outlined in ABM Protocol #28 (9). Meperidine should be avoided in laboring patients who plan to lactate and in postpartum patients due to the higher risk of infant sedation, respiratory depression, cyanosis, and bradycardia noted. Meperidine should be avoided due to higher risks associated with this medication and infants and lactating individuals should be closely monitored for sedation and respiratory depression with peripartum neuraxial analgesia use, but the use of neuraxial analgesia during labor do not absolutely preclude breastfeeding and is not an absolute indication to pump and dump.
  • Systemic opioids during labor: Infants and lactating individuals should be closely monitored for sedation and respiratory depression with peripartum opioid use, but the use of systemic opioids during labor do not  preclude absolutely breastfeeding and these medications are not an absolute indication to pump and dump except as noted below. An interruption in breastfeeding may be warranted if the infant develops signs of sedation while the lactating parent is on systemic opioids. For more information on specific agents, see the sections on Pain Medications and Anesthesia.
    • Generally, shorter acting agents are preferable to decrease the risks to the infant. Fentanyl may be preferred during the peripartum period if systemic opioids are needed as it is a shorter acting agent with a lower risk of these side effects.
    • Remifentanil is a shorter-acting agent that should be avoided during labor due to a higher risk of respiratory depression in the infant and maternal apnea.
    • Monitor infants closely if longer acting agents, including Meperidine (should be avoided) and morphine (should be used with caution), are used as there is a greater risk for respiratory depression, cyanosis, and bradycardia in the infant.
    • Data is lacking on partial agonists (nalbuphine, butorphanol, pentazocine).
  • General anesthesia: Small doses of IV ketamine, opioids, and midazolam used during cesarean delivery do not absolutely preclude breastfeeding once the parent is alert and stable. Birthing parents who plan to breastfeed should be advised that general anesthesia may delay secretory activation (9). The birthing/lactating parent can breastfeed as soon as they are alert enough to safely hold their infant and there is no absolute indication to pump and dump once the parent is alert. For more information, see the section on Anesthesia.
  • Local anesthesia: These are large, polarized molecules that do not easily enter milk and have low oral bioavailability. Transfer of epidural local anesthetics and their metabolites to breastmilk is low (9). There is no absolute indication to pump and dump with local anesthesia use during labor and delivery.
  • Nitrous Oxide: This molecule has a short half-life and is used in infants for certain indications. There is no absolute indication to pump and dump with inhaled nitrous oxide use by the birthing parent during labor.
  • Postpartum Analgesia: Generally, pain medications used in the peripartum period do not absolutely preclude breastfeeding and there is no absolute indication to pump and dump although some medications (such as opioid pain medications) should be used with caution and close monitoring of the infant for respiratory depression. For more information, see the section on Pain Medications.
    • Nonopioid analgesics: Acetaminophen and most non-steroidal anti-inflammatory medications (NSAIDs) have low levels in breastmilk. Ibuprofen has minimal to no milk transfer and is typically the NSAID of choice. Avoidance of NSAIDs may be warranted for parents with infants who have ductal dependent cardiac lesions. There is no absolute indication to pump and dump.
    • Opioid analgesics: Of note, opioids transfer easily into milk until tight junctions close around postpartum day (PPD) 7-10. The highest risk for opioid-related side effects is between PPD 3-10 after colostrum becomes transitional milk and before complete closure of the tight junctions (9). Infants and lactating individuals should be closely monitored for sedation and respiratory depression with postpartum opioid use especially between PPD 3-10 for infants once milk volumes start to increase, but the use of systemic opioids immediately postpartum do not absolutely preclude breastfeeding and these medications are not an absolute indication to pump and dump. For more information, see the section on Pain Medications.
      • Hydrocodone (<30 mg/day) and oxycodone (<30 mg/day) are commonly used postpartum and infants should be monitored for sedation while the lactating parent is taking either of these medications (9).
      • Codeine and tramadol should be avoided due to greater concerns about neonatal respiratory depression and a current black box warning against these medications by the FDA (9).
      • If IV or IM opioid pain medications are needed for adequate pain control, IV/IM morphine and fentanyl have lower milk transfer and oral bioavailability and may be preferable to other IV/IM opioids. Infants and lactating individuals should be monitored for side effects, but IV and IM opioid pain medications do not absolutely preclude breastfeeding and are generally not an absolute indication to pump and dump (9).
    • Epidural/spinal analgesia: There is no absolute indication to pump and dump as transfer of epidural local anesthetics to breast milk and oral bioavailability are low (9).

References

  1. Marín Gabriel MA, Olza Fernández I, Malalana Martínez AM, et al. Intrapartum synthetic oxytocin reduce the expression of primitive reflexes associated with breastfeeding. Breastfeed Med. 2015;10:209–13. DOI: https://doi.org/10.1089/bfm.2014.0156
  2. Takahashi Y, Uvnäs-Moberg K, Nissen E, et al. Epidural analgesia with or without oxytocin, but not oxytocin alone, administered during birth disturbs infant pre-feeding and sucking behaviors and maternal oxytocin levels in connection with a breastfeed two days later. Front Neurosci. 2021;15:673184. DOI: https://doi.org/10.3389/fnins.2021.673184
  3. Vigil-DeGracia P, Ludmir J, Ng J, et al. Is there benefit to continue magnesium sulfate post-partum in women receiving magnesium sulfate prior to delivery? A randomized controlled study. 2018;125:1304–11. DOI: https://doi.org/10.1111/1471-0528.15320
  4. Vigil-DeGracia P, Ramírez R, Duran Y, et al. Magnesium sulfate for 6 vs 24 hours post-delivery in patients who received magnesium sulfate for less than 8 hours before birth: A randomized clinical trial. BMC Pregnancy Childbirth. 2017;17:241. DOI: https://doi.org/10.1186/s12884-017-1424-3
  5. Burgess A, McDowell W, Ebersold S. Association between lactation and postpartum blood pressure in women with preeclampsia. MCN Am J Matern Child Nurs. 2019;44:86–93. DOI: https://doi.org/10.1097/nmc.0000000000000502
  6. Henderson JJ, Hartmann PE, Newnham JP, et al. Effect of preterm birth and antenatal corticosteroid treatment on lactogenesis II in women. 2008;121:e92–100. DOI: https://doi.org/10.1542/peds.2007-1107
  7. Margot Giudicelli, Michelle Hassler, Julie Blanc, Carole Zakarian & Barthélémy Tosello (2022) Influence of intrapartum maternal fluids on weight loss in breastfed newborns, The Journal of Maternal-Fetal & Neonatal Medicine, 35:4, 692-698, DOI: 1080/14767058.2020.1731453
  8. Kujawa-Myles, Sonya et al. “Maternal intravenous fluids and postpartum breast changes: a pilot observational study.” International breastfeeding journal 10 18. 2 Jun. 2015. DOI: https://doi.org/10.1186/s13006-015-0043-8
  9. E Martin, B Vickers, R Landau, S Reece-Stremtan. ABM Protocol #28: Peripartum Analgesia and Anesthesia for the Breastfeeding Mother. Breastfeeding Medicine 13.3 (2018). DOI: https://doi.org/10.1089/bfm.2018.29087.ejm