Grobman notes that, from a public health perspective too, women who fit the criteria should be encouraged to try for a VBAC — a successful vaginal birth is better for a mom's health and her future deliveries. But, he adds, it remains to be seen whether hospitals will change their policies.
Epidurals don't hinder breast-feeding
Around 70% of women in the U.S. receive epidural analgesia, an infusion of pain-blocking medicine directly to the spinal cord, during labor and delivery. A heavy dose of misinformation swirls around this common practice, handed down among women and on Internet forums. In part, this is due to the culture of childbirth education in the U.S., which largely favors natural or unmedicated birth as the best option for mother, baby and breast-feeding success.
Many women are wrongly advised that getting an epidural will slow down and prolong labor, leading to an increased chance of a forceps- or vacuum-assisted delivery or a caesarean. These and the epidural medicine itself, they are told, will make it harder to successfully establish breast-feeding in the hours and days after delivery because the newborn will be groggy, sluggish or sleepy from the medicines or experience of a "medicalized" birth.
Almost all of these ideas about epidurals have been debunked by research in the last decade (see related article), but the beliefs persist. That sets up many women to forego, or feel guilty about, what is arguably the most effective and safest form of pain relief for labor.
In 2006, an Australian study grabbed headlines when it seemed to confirm that the fentanyl medicine used in epidurals caused breast-feeding problems in newborns. But the study was extremely flawed, say researchers, in part because every woman who received an epidural also got a shot of pethidine (Demerol), a long-acting narcotic. Such narcotics are well-known to make babies groggy after delivery, so the breast-feeding troubles could easily have been caused by the pethidine alone.
Nonetheless, in the minds of natural childbirth advocates and the breast-feeding support community, fentanyl was the culprit.
There are medical reasons to suggest that probably isn't so. Although fentanyl, just like pethidine, is an opioid narcotic, the dose that goes into the spinal column during an epidural is small, and the amounts that get into the mother's bloodstream, across the placenta and into baby's bloodstream are tiny. What's more, fentanyl is a short-acting narcotic, meaning its effects are cleared in a matter of minutes to hours after the epidural catheter delivering the medicine is removed.
Dr. Matthew Wilson and other members of an epidural study group based in Britain realized they had the data to better test whether fentanyl was the bad guy.
In a study published last year in the journal Anaesthesia, they directly compared more than 1,000 women who had been randomly chosen to receive different types of epidurals — ones with and without fentanyl — and women who had no epidural at all. A day after delivery, the women were asked if they had established breast-feeding. One year later, they were asked how long they had breast-fed.
"There was really no difference between any of the groups" in terms of breast-feeding success, says Wilson, an obstetric anesthesiologist at Royal Hallamshire Hospital in Sheffield, England. "There was no evidence that fentanyl in an epidural has an effect on breast-feeding nor that having an epidural per se affects breast-feeding.
A woman considering an epidural "can be reassured that she's not reducing her chance of successful breast-feeding," he concludes.
Lactation experts remain unconvinced. "Different interventions at birth have a huge effect on breast-feeding down the road, because those first couple of weeks [are when] milk production is established and set," says Teresa Pitman, former executive director of La Leche League Canada, a breast-feeding support network, and co-author of "The Womanly Art of Breastfeeding."
Breast-feeding, she says, is the most complex behavior newborns must master: locating the nipple, latching on, sucking with the tongue placed properly and coordinating breathing with swallowing. Even a tiny amount of medicine might disrupt it, she argues. Higher rates of assisted deliveries could cause headaches in babies, overly swollen breasts from the intravenous fluids given along with epidurals, and post-epidural fevers that cause moms and babies to be separated.
Wilson and other anesthesiologists contend these ideas are based on speculation and not rigorous research. Dr. William Camann, head of obstetric anesthesiology at Brigham and Women's Hospital in Boston and co-author of "Easy Labor," calls the idea that epidural medications could affect a baby weeks later "completely ridiculous."
"If epidurals were dangerous or had downsides, three-fourths of women would not be getting them. The babies come out screaming, crying, and vigorous," he says.
Anesthesiologists and natural childbirth advocates do agree on some points, however:
Narcotic injections, delivered intravenously or into muscle, are riskier for a baby's health and successful breast-feeding than epidurals. "Narcotics are not good for baby and breast-feeding; they affect baby's initial alertness and ability to breast-feed," Camann says.
Adds Pitman: "With good help, most moms and babies can overcome any difficulties with breast-feeding and be successful."
Making personal decisions
Choices about sex, alcohol and labor pain relief are made within each woman's personal and cultural context. Kelly, Wilson and others say they hope their research has added valuable information that will enable women to make the best informed decisions during pregnancy.
Moore-Davis says that women should be asking their healthcare providers a series of questions about choices during pregnancy: "Can you tell me what the risk of that is? What are the benefits? What evidence supports your decisions in practice?"
And Kelly notes that a medically paternalistic view of pregnancy still exists that relies heavily on the precautionary principle, or the 'when in doubt, leave it out' approach. But, she says, "women are capable of making informed decisions based on the available evidence — it's fairly insulting to assume they cannot."