Volume 1, Number 4, 2006
© Mary Ann Liebert, Inc.
ABM Clinical Protocol #15:
Analgesia and Anesthesia for the Breastfeeding Mother
ANNE MONTGOMERY, THOMAS W. HALE, and THE ACADEMY OF
BREASTFEEDING MEDICINE PROTOCOL COMMITTEE
A central goal of the Academy of Breastfeeding Medicine is the development of clinical proto-
cols for managing common medical problems that may impact breastfeeding success. These pro-
tocols serve only as guidelines for the care of breastfeeding mothers and infants and do not de-
lineate 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.
Oxytocin, endorphins, and adrenaline pro-
duced in response to the normal pain of labor
may play significant roles in maternal and
neonatal response to birth and early breast-
feeding.1Use of pharmacologic agents for pain
relief in labor and postpartum may improve
outcomes by relieving suffering during labor
and allowing mothers to recover from birth, es-
pecially Cesarean birth, with minimal interfer-
ence from pain. However, these methods also
may affect the course of labor and the neu-
robehavioral state of the neonate, and have ad-
verse effects on breastfeeding initiation. Un-
fortunately, the literature in this area has not
addressed the whole integrated process. Very
few studies directly address breastfeeding out-
comes of various approaches to labor pain
management. Randomized controlled trials are
rare, and subject to a great deal of crossover,
which confounds results. The technology of
epidural analgesia in particular is evolving
quickly, so studies that are even a few years old
may not reflect current practices. This protocol
ABOR, BIRTH, AND BREASTFEEDING INITIATION
comprise a normal, continuous process.
examines the evidence currently available and
makes recommendations for prudent practice.
There is even less information in the scien-
tific literature about anesthesia for other sur-
gery in breastfeeding mothers. Recommenda-
tions in this area focus on pharmacologic
properties of anesthetic agents and limited
studies of milk levels and infant effects.
ANALGESIA AND ANESTHESIA
Maternity care providers should initiate an
informed consent discussion for pain manage-
ment in labor during the prenatal period before
the onset of labor. Risk discussion should in-
clude what is known about the effects of vari-
ous modalities on the progress of labor, risk of
instrumented and Cesarean delivery, effect on
the newborn, and possible breastfeeding ef-
Unmedicated, spontaneous vaginal birth
with immediate, uninterrupted skin-to-skin
contact leads to the highest likelihood of baby-
led breastfeeding initiation.2Longer labors, in-
strumented deliveries, Cesarean section, and
separation of mother and baby after birth may
lead to higher risks of difficulty with breast-
feeding initiation.3–5Labor pain management
strategies may affect these labor outcomes and
secondarily affect breastfeeding initiation in
addition to any direct effects of the medications
Women have differing levels of pain toler-
ance. Pain that exceeds a woman’s ability to
cope, or pain magnified by fear and anxiety,
may produce suffering in labor. Suffering in la-
bor may lead to dysfunctional labors, poorer
psychologic outcomes, and increased risk of
postpartum depression, all of which may have
a negative effect on breastfeeding.7
Continuous support in labor, ideally by a
trained doula, reduces the need for pharmaco-
logic pain management in labor, decreases in-
strumented delivery and Cesarean section, and
leads to improved breastfeeding outcomes
both in the immediate postpartum period and
several weeks after birth.8
Nonpharmacologic methods for pain man-
agement in labor such as hypnosis, psy-
choprophylaxis (e.g., Lamaze), intradermal or
subcutaneous water injections for back pain,
and so on, appear to be safe, have no known
adverse neonatal effects, and may reduce the
need for pharmacologic pain management.
More study of breastfeeding outcomes is
needed for these modalities.9,10
Evidence suggests that breastfeeding success
is affected by the behavior of the newborn. De-
pressed or delayed suckling, which can be
caused by medications given to mothers, can
lead to delayed or suppressed lactogenesis and
risk of excess infant weight loss.11,12
Intravenous opiates for labor may block the
newborn’s normal reflexes to seek the breast,
root, and suckle within the first hour after
1. Shorter-acting opiates such as fentanyl are
preferred. Remifentanil is potent and has
rapid onset and offset but can be associated
with a high incidence of maternal apnea, re-
quiring increased monitoring. Its transfer in
utero to the fetus is minimal.
2. Meperidine/pethidine generally should not
be used except in small doses less than 1
hour before anticipated delivery because of
greater incidence and duration of neonatal
depression, cyanosis, and bradycardia.
3. Nalbuphine, butorphanol, and pentazocine
may be used for patients with certain opioid
allergies or at increased risk of difficult air-
way management or respiratory depression.
However, these medications may interfere
with fetal heart rate monitoring interpreta-
tion. Observe the mother and infant for psy-
chotomimetic reactions (3%).
4. Multiple doses of intravenous analgesic, and
their timing of administration may lead to
greater neonatal effects. For example, fen-
tanyl administration within 1 hour of deliv-
ery or meperidine administration between 1
and 4 hours before delivery is associated
with more profound neonatal effects.
5. When a mother has received intravenous
narcotics for labor, mother and baby should
be given more skin-to-skin time to encour-
age early breastfeeding.14
There is little evidence regarding the effects
of epidural analgesia on breastfeeding and the
available data are inconclusive. Early studies of
epidural analgesia for labor showed neonatal
neurobehavioral effects and labor effects that
may have had a significant impact on breast-
feeding. The few studies that have looked di-
rectly at breastfeeding outcomes have sug-
gested poorer outcomes in women who had
epidural analgesia.15–18These results must be
interpreted with caution, however, as most of
these studies have been problematic with poor
control groups and much crossover between
study groups. Furthermore, it is difficult to as-
certain whether the effects were caused by the
epidural per se, or epidural use was a marker
for abnormal labor with adverse effects not di-
rectly attributable to the epidural. Epidural
analgesia also may affect labor outcomes, for
example, increasing instrumented delivery,
which may secondarily affect breastfeeding
outcomes.4,5One study has suggested that
when epidural analgesia is commonplace in a
hospital supportive of breastfeeding, longer-
term breastfeeding outcomes are not adversely
affected by epidural analgesia.19A recent ran-
domized, double-blind study showed that
epidural analgesia with fentanyl in low-to-
moderate doses, along with bupivacaine, did
ABM PROTOCOLS 272
not have any effect on breastfeeding outcomes
compared to epidural analgesia using bupiva-
caine alone. Higher doses of fentanyl (?150 ?g
total dose) may have had a small negative ef-
fect on maternal perception of breastfeeding at
24 hours and breastfeeding continuation at 6
1. If epidural anesthesia is chosen, methods
that minimize the dose of medication and
minimize motor block should be used.
Longer durations of epidural analgesia
should be avoided if possible,21and admin-
istration should be delayed until necessary
to minimize effect on labor outcomes that
may secondarily affect breastfeeding. Com-
bined spinal-epidural analgesia and patient-
controlled epidural analgesia may be prefer-
2. Infants lose more weight in the first post-
partum days when labor medications are
used.12Some of this weight loss may be a
result of mothers receiving an intravenous
(IV) fluid load for epidural analgesia. One
report notes babies are slightly heavier on
average and lose more weight in the first
days postpartum when epidural analgesia is
used.22In addition, the use of large volumes
of intrapartum IV fluids has been associated
with a decrease in plasma oncotic pres-
sure,23which may then increase breast en-
gorgement and interfere with subsequent
milk production and/or transfer. Conserva-
tive use of fluids may mitigate this effect.
Definitive studies of these interrelationships
are needed in order to better assess first-
week weight loss in individual newborns.
3. When epidural analgesia has been used for
labor, particular care to provide mothers
with good breastfeeding support and close
follow-up after postpartum hospitalization
should be taken.
There are minimal data concerning the pedi-
atric effects of other labor anesthesia, including
inhaled nitrous oxide, paracervical block, pu-
dendal block, and local perineal anesthesia.24,25
These modalities do not usually expose the in-
fant to significant quantities of medication. In
some situations, these may serve as alternatives
to intravenous narcotics or epidural analgesia
for labor. However, their use is limited by sev-
eral factors, including lack of efficacy, techni-
cal difficulties, and a high rate of complications.
ANESTHESIA FOR CESAREAN SECTION
Regional anesthesia (epidural or intrathe-
cal/spinal) is preferred over general anesthe-
Separation of the mother and baby should be
minimized and breastfeeding initiated as soon
as feasible. In fact, the baby may go to the breast
in the operating room during abdominal clo-
sure with assistance to support the infant on
the mother’s chest. If breastfeeding is initiated
in the recovery room, there is the added ad-
vantage that the incision is often still under the
influence of the anesthetic.
A mother may breastfeed postoperatively as
soon as she is alert enough to hold the baby.
Nonopioid analgesics generally should be
the first choice for pain management in breast-
feeding postpartum women, as they do not im-
pact maternal or infant alertness.
1. Acetaminophen and ibuprofen are safe and
effective for analgesia in postpartum moth-
2. Parenteral ketorolac may be used in moth-
ers not subject to hemorrhage, and with no
history of gastritis, aspirin allergy, or renal
3. Diclofenac suppositories are available in
some countries and commonly used for
postpartum analgesia. Milk levels are ex-
4. Cox-2 inhibitors such as celecoxib may have
some theoretic advantages if maternal
bleeding is a concern. This must be balanced
with higher cost and possible cardiovascu-
lar risks, which should be minimal with
short-term use in healthy young women.
Both pain and opioid analgesia can have a
negative impact on breastfeeding outcomes;
thus, mothers should be encouraged to control
their pain with the lowest medication dose that
is fully effective. Opioid analgesia postpartum
may affect babies’ alertness and suckling vigor.
However, when maternal pain is adequately
treated, breastfeeding outcomes improve.28Es-
pecially after Cesarean birth or severe perineal
trauma requiring repair, mothers should be en-
couraged to adequately control their pain.
1. Meperidine should be avoided because of
reported neonatal sedation when given to
breastfeeding mothers postpartum,29in ad-
dition to the concerns of cyanosis, brady-
cardia, and risk of apnea, which have been
noted with intrapartum administration.30,31
2. The administration of moderate to low doses
of IV or IM morphine is preferred as its pas-
sage to milk and oral bioavailability in the
infant are least with this agent.29,32
3. When patient-controlled IV analgesia (PCA)
is chosen after Cesarean section, morphine
or fentanyl is preferred to meperidine.33
4. Although there are no data on the transfer of
nalbuphine, butorphanol, and pentazocine
into milk, there have been numerous anecdo-
tal reports of a psychotomimetic effect when
these agents are used in labor. They may be
suitable in individuals with certain opioid al-
lergies or other conditions described in the
preceding section on labor (see page 272 #3).
5. Hydromorphone (approximately 7 to 11
times as potent as morphine), is sometimes
used for extreme pain in a PCA, IM, IV, or
orally. Following a 2-mg intranasal dose,
levels in milk were quite low with a relative
infant dose of about 0.67%.34This correlates
with about 2.2 ?g/day via milk. This dose
is probably too low to affect a breastfeeding
infant, but this is a strong opioid and some
caution is recommended.
1. Hydrocodone and codeine have been used
worldwide in millions of breastfeeding
mothers. This suggests they are suitable
choices even though there are no data re-
porting their transfer into milk. Higher
doses (10 mg hydrocodone) and frequent
use may lead to some sedation in the in-
1. Single-dose opioid medications (e.g., neu-
raxial morphine) should have minimal ef-
fects on breastfeeding because of negligible
maternal plasma levels achieved. Extremely
low doses of morphine are effective.
2. Continuous post-Cesarean epidural infu-
sion may be an effective form of pain relief
that minimizes opioid exposure. A random-
ized study that compared spinal anesthesia
for elective Cesarean with or without the use
of postoperative extradural continuous
bupivacaine found that the continuous
group had lower pain scores and a higher
volume of milk fed to their infants.35
ANESTHESIA FOR SURGERY IN
The implications of drugs used in anesthesia
in postpartum mothers depends on numerous
factors, including the age of the infant, stabil-
ity of the infant, stage of lactation (early or late
stage), and ability of the infant to handle the
clearance of small quantities of anesthetic med-
ications.36Anesthetic agents will have little or
no effect on older infants, but could cause prob-
lems in newborn infants, particularly those
who are premature or suffer from apnea.
The ability of the infant to clear small
amounts of these medications is of primary
concern before returning to breastfeeding. In-
fants subject to apnea, hypotension, or weak-
ness probably should be protected by a few
more hours of interruption from breastfeeding
before resuming (12 to 24 h) nursing.
Mothers with normal term or older infants
generally can resume breastfeeding as soon as
they are awake, stable, and alert. Resumption
of normal mentation is a hallmark that these
medications have left the plasma compartment
(and thus the milk compartment) and entered
adipose and muscle tissue where they are
slowly released. A single pumping and dis-
carding of the mother’s milk following surgery
will significantly eliminate any drug retained
in milk fat, although this is seldom necessary
and not generally recommended. For women
who undergo postpartum tubal ligation,
breastfeeding interruption is not indicated, as
the volume of colostrum is small.37In addition,
the levels of medication in the maternal plasma
and milk are low once mothers resume normal
mentation. Regional anesthesia is recom-
mended for this procedure in preference to
general anesthetic for maternal safety.
Mothers who have undergone dental extrac-
tions or other procedures requiring the use of
single doses of medication for sedation and
analgesia can breastfeed as soon as they are
awake and stable. Although shorter-acting
agents such as fentanyl and midazolam may be
preferred, single doses of meperidine or di-
azepam are unlikely to affect the breastfeeding
Mothers who have undergone plastic sur-
gery, such as liposuction, in which large doses
of local anesthetics (lidocaine) have been used
probably should pump and discard their milk
for 12 hours before resuming breastfeeding.
SPECIFIC AGENTS USED FOR
ANESTHESIA AND ANALGESIA
Drugs used for induction such as propofol,
midazolam, etomidate, or thiopental enter the
milk compartment only minimally, as they
have extraordinarily brief plasma distribution
phases (only minutes) and hence their trans-
port to milk is low to nil.38–41
Little or nothing has been reported about the
use of anesthetic gases in breastfeeding moth-
ers. However, they too have brief plasma dis-
tribution phases and milk levels are likely nil.
The use of ketamine in breastfeeding moth-
ers is unreported. Because of its high rate of
psychotomimetic effect, including hallucina-
tions and dissociative anesthesia (catalepsy,
nystagmus), ketamine is probably not an ideal
anesthetic agent for breastfeeding mothers.
1. Morphine is still considered an ideal anal-
gesic for breastfeeding mothers because of
its limited transport to milk, and poor oral
bioavailability in infants.29,33
2. The transfer of meperidine into breast milk
is documented, although it is somewhat low
(1.7% to 3.5% of maternal dose). However,
the administration of meperidine and its me-
tabolite (normeperidine) is consistently as-
sociated with neonatal sedation, which is
dose related. Transfer into milk and neona-
tal sedation have been documented for up
to 36 hours after the dose.29Meperidine
should be avoided during labor and in post-
partum analgesia (except, perhaps, within 1
hour before delivery). Infants of mothers
who have been exposed to repeated doses
of meperidine should be closely monitored
for sedation, cyanosis, bradycardia, and pos-
2. Although there are no published data on
remifentanil, this esterase-metabolized opi-
oid has a brief half-life even in infants (?10
minutes) and has been documented to pro-
duce no fetal sedation even in utero. Al-
though its duration of action is limited, it
could be used safely, and indeed may be
ideal in breastfeeding mothers for short
3. Fentanyl levels in breast milk have been
studied and are extremely low to below the
limit of detection.42,43
4. Sufentanil transfer into milk has not been
published, but it should be similar to fen-
5. Nalbuphine, butorphanol, and penta-
zocine levels in breast milk have not been
published. At this time they would only
be indicated in the specific situations
mentioned previously (see page 272 #3). If
these agents are used, observe the mother
and infant for psychotomimetic reactions
6. Hydrocodone and codeine have been used
in millions of breastfeeding mothers. Oc-
casional cases of neonatal sedation have
been documented, but these are rare and
generally dose related. Doses in breast-
feeding mothers should be kept at the min-
imum necessary to control pain. Routine,
consistent dosing throughout the day may
lead to sedative effects in the breastfed in-
ABM PROTOCOLS 275
1. Ibuprofen is considered an ideal, moder-
ately effective analgesic. Its transfer to milk
is low to nil.44,45
2. Ketorolac is considered an ideal and potent
analgesic in breastfeeding mothers. The
transfer of ketorolac into milk is extremely
low.46However, its use in patients with
hemorrhage is risky as it inhibits platelet
function. Other contraindications are noted
in the preceding section on postpartum
anesthesia (see page 273 #2).
3. Celecoxib transfer into milk is extraordinar-
ily low (?0.3% of the maternal dose).47Its
short-term use is safe.
4. Naproxen transfer into milk is low, but gas-
trointestinal disturbances have been reported
in some infants after prolonged therapy.
Short-term use (1 week) probably is safe.48,49
Studies of labor analgesia and labor anes-
thesia should specifically study breastfeeding
Specific data is needed about the use of in-
travenous fluid loading during labor, such as
for epidural anesthesia, and its effects on infant
birthweight, breast engorgement, milk supply,
and neonatal weight loss in order to more ap-
propriately assess early infant feeding and
weight loss in these babies.
More study is required of the special needs of
premature and unstable babies, including how
their ability to clear maternal anesthetic and anal-
gesic drugs may differ from healthy, term babies.
This work was supported in part by a grant
from the Maternal and Child Health Bureau,
Department of Health and Human Services.
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Anne Montgomery, M.D.
Department of Family Medicine
University of Washington, Seattle, WA
Thomas W. Hale, Ph.D.
Texas Tech University School of Medicine
Caroline J. Chantry, M.D., Co-Chairperson
Cynthia R. Howard, M.D., MPH,
Ruth A. Lawrence, M.D.
Nancy G. Powers, M.D.
For reprint requests: firstname.lastname@example.org