PUERPERIUM AND AFTER

Section 3 – Puerperium and after 149 DRUGS AND BREASTFEEDING Mothers often ask their anaesthetist for information about breastfeeding after anaesthetic and surgical interventions. The majority of drugs administered to the mother enter her breast milk but many are present in pharmacologically insignif- icant amounts and do not therefore pose a risk to the baby. The amount of drug that a breastfed baby receives is dependent on the concentration of drug in the milk and the volume of milk taken by the baby. In the first few days following delivery, the baby receives colostrum and then very small volumes of milk, so that any drug exposure is likely to be minimal. It is, however, common sense to administer drugs to the breastfeeding mother only if they are considered essential. The British National Formulary (BNF) contains a comprehensive list of drugs that are known to be present in breast milk following maternal administration, but also points out that in many cases there are insufficient data to enable accurate information to be provided. Breastfeeding and anaesthesia Production of breast milk is dependent on adequate maternal hydration and regular stimulation (either by the baby feeding or by the mother expressing her milk). A mother scheduled for anaesthesia and surgery should be encouraged to feed her baby as near as possible to the planned time of surgery and also as soon as she feels able to postoperatively. In some cases it may be more appropriate for her to express milk in the early postoperative period. Intravenous agents Both thiopental and propofol are found in breast milk in insignificant amounts following maternal administration. Levels of volatile agent excreted into breast milk are also negligible (most information relates to halothane, but extrapolation of data based on pharmacokinetic information suggests that isoflurane, sevoflurane and desflurane would be present in breast milk in even lower concentrations). Neuromuscular blocking agents are large, water-soluble, ionised quaternary Analgesia, Anaesthesia and Pregnancy: A Practical Guide Second Edition, ed. Steve Yentis, Anne May and Surbhi Malhotra. Published by Cambridge University Press. ß Cambridge University Press 2007. ammonium compounds and therefore are not excreted into breast milk in any measurable quantity. Analgesics Transfer of non-steroidal anti-inflammatory drugs and opioids into breast milk has been extensively studied, and neither type of analgesic is present in clinically important quantities. Therapeutic doses of morphine and diamorphine given for postoperative analgesia (either following Caesarean section or other surgical intervention) can be given to the mother as required. The BNF states that breast- feeding is not recommended for mothers who are addicted to opioids, although this may be controversial since the American Academy of Pediatrics considers that up to 20 mg methadone daily is compatible with breastfeeding. Antiemetics All the commonly used antiemetics carry a manufacturers ‘use with caution’ or ‘use only if essential’ warning. Benzodiazepines Prolonged administration of benzodiazepines should be avoided. Diazepam is found in clinically significant quantities in breast milk and may cause hypotonia and impaired suckling in the baby. However, use of a single dose of temazepam or lorazepam as a premedicant drug is not contraindicated. Similarly, use of midazo- lam for intravenous sedation or during general anaesthesia is considered safe. Other drugs Anticoagulants Warfarin is now considered to be safe in breastfeeding mothers; there are currently insufficient data about low molecular weight heparins, which the manufacturers therefore advise should be avoided. Antidepressants The most recent Report on Confidential Enquiries into Maternal Deaths/Maternal and Child Health has highlighted the risk of postnatal depression and its potential to lead to postnatal psychosis and suicide. There are numerous case reports offering conflicting advice about the use of psychotropic drugs in lactating women. The tricyclic antidepressants amitriptyline, nortriptyline and desipramine are all excreted into breast milk, with the baby being exposed to approximately 1% of the maternal dose. This poses a theoretical risk for the infant, but there are no case reports of adverse effects, and the balance of risks is generally believed to favour continuing treatment of the mother and allowing breastfeeding. Information about the selective serotonin reuptake inhibitors (SSRIs) in lactation is limited. The drugs are excreted into breast milk, but there are no controlled 338 Section 3 – Puerperium and after studies investigating effects on the infant. The manufacturer’s data sheet states that fluoxetine should not be given to nursing mothers. Anticonvulsants Epileptic mothers can be allowed to breastfeed; although the commonly used anticonvulsants are excreted into breast milk, there have not been any reported adverse effects in babies. Antihypertensives It is common for pre-eclamptic women to receive b-blocking drugs for several weeks following delivery. Atenolol is excreted in breast milk in measurable amounts, but there is no evidence that this is harmful to the infant. Key points • Most drugs are excreted into breast milk; information about the effect on the neonate is scarce. • Commonly used anaesthetic and analgesic drugs can be safely used in breastfeeding mothers. FURTHER READING American Academy of Pediatrics Committee on Drugs. The transfer of drugs and other chemicals into human milk. Pediatrics 2001; 108: 776–89. Hale TW. Maternal medications during breast-feeding. Clin Obstet Gynecol 2004; 47: 696–711. 150 FOLLOW-UP Follow-up of mothers after obstetric analgesia and anaesthesia is important for the individual anaesthetist, the hospital and obstetric anaesthesia as a whole. In an ideal world all anaesthetists would aim to follow up their own patients. This ideal is often not practical; therefore follow-up has to become part of the routine of an obstetric anaesthetic service. At national and international levels, data collection would enable anaesthetists to assess risk and monitor standards of care. At present there are very few data available at national or international level, and this is an area that comes more closely under the remit of audit. Problems/special considerations Follow-up of women who have had analgesia or anaesthesia administered by the anaesthetist should ideally be carried out within 24 hours. However, it may be dif- ficult to see all women before they are discharged from hospital. This early 150 Follow-up 339 discharge to the community means that anaesthetists must rely on midwifery, obstetric and general practitioner colleagues to refer back any problems. Areas that anaesthetists might wish to follow up can be divided into: • Anaesthetic interventions perceived to be uncomplicated • Anaesthetic interventions where there was a problem. Follow-up of the first group is important to ensure that women are satisfied with their treatment and, if not, why not. The follow-up interview gives the woman a chance to voice her opinion of the treatment she received. The anaesthetist should be responsive to criticisms of the service as a whole, since many women make their comments in order to help improve the service to others. Suggested list of questions that may be asked at follow-up: • Relating to analgesia in labour: Were you satisfied with the pain relief you received for the first and second stages of your labour? Were you able to mobilise during labour where appropriate? Has your sensation returned to normal? Have you a headache? Have you any comments about the care that you received? • Relating to regional anaesthesia: Were you satisfied with the anaesthesia that you received? Did you feel any discomfort or pain at any time during the Caesarean section? Have you had good postoperative pain relief? Are you up and about? Are you able to pass urine? Has your sensation returned to normal? Have you a headache? Have you any comments about the treatment that you received? • Relating to general anaesthesia: Did you have a good sleep? Do you remember going to sleep? Do you remember waking up? Do you remember dreaming or waking up during the operation? Do you have a sore throat, sore muscles or headache? Were you in pain when you woke up? Has the postoperative pain relief been adequate (at rest and on movement)? Have you had nausea or vomiting? Have you any comments about your treatment? The most common problems associated with an anaesthetic intervention are: • Difficulty in siting a regional analgesic • Accidental dural puncture • Paraesthesia during insertion of a spinal or epidural, and/or neurological symptoms afterwards • Poor analgesia in labour (especially in the second stage if the epidural was inadequately topped up) • Pain during Caesarean section or operative delivery. Patients with the above problems should always be followed up, ideally by a consultant obstetric anaesthetist. Continuity of care is important for these patients, and early involvement of other specialists, when appropriate, should occur at an early stage. For example, neurological consultation should be sought when there is any doubt as to the cause of a headache or neurological deficit. Early involvement of a clinical psychologist with a special interest in post-traumatic stress disorder following childbirth (if available) is often useful when there has been a painful experience during delivery. 340 Section 3 – Puerperium and after Communication with the women, their partners and the midwifery and obstetric staff is essential to ensure that any problems, however small, are dealt with quickly and comprehensively. All women who have had a problem should have the oppor- tunity to see the consultant obstetric anaesthetist after discharge from hospital. A follow-up visit at around 6–8 weeks post-delivery is useful for both the women and the obstetric anaesthetist. This consultation allows the lines of communication to remain open and offers the opportunity for a frank and open dialogue about any problems. Key points • Follow-up is important in both straightforward and complicated cases. • Follow-up does not end when the woman leaves hospital. • Consultant anaesthetic involvement is important. • Communication is vital between all the professional groups involved. FURTHER READING Peach M, Godkin R, Webster S. Complications of obstetric epidural analgesia and anaesthesia: a prospective analysis of 10 995 cases. Int J Obstet Anesth 1998; 7: 5–11. 151 MATERNAL SATISFACTION Maternal satisfaction has become a major outcome measure, mentioned in several important documents and strategies concerned with childbirth. This means that providers of health care must pay attention to mothers’ expression of satisfaction with their care during and after pregnancy. Anaesthetists have an important role to play in maternal satisfaction, since for many women aspects of their analgesia and anaesthesia can have an enormous effect on how they view their overall experience, in some cases irrespective of what happened in other areas of their care. Conversely, mothers’ rating of their satisfaction with analgesia or anaesthesia in general, and different techniques in particular, may be affected by several factors unrelated to the anaesthetic itself. Despite this, studies comparing different techniques often quote measures of global satisfaction as evidence that one technique is superior to another. Similarly, obstetric anaesthetists are encouraged to assess and audit maternal satisfaction with the obstetric anaesthetic service as a marker of quality of performance. Problems/special considerations Apart from the confounding effects of various unrelated factors described above, another difficulty relates to the measuring tool used to assess satisfaction. 151 Maternal satisfaction 341 Methods used have varied from simple ‘satisfaction scales,’ e.g. visual analogue scale or verbal rating scale, to complex evaluations of different modalities that combine to produce a positive experience of childbirth such as fulfilment (e.g. happiness), lack of distress (e.g. pleasure) and physical wellbeing (e.g. lack of pain). The simpler systems will always be more attrac- tive to busy clinicians such as anaesthetists than the more complex and time- consuming ones, even though simple questions such as ‘Are you satisfied?’ or ‘Rate your satisfaction on a scale of 1–10’ are next to useless as objective outcome measures. Studies suggest that factors associated with dissatisfaction include being excluded from one’s care and decisions relating to it, poor communication and lack of information, bad outcome (although there may be strong satisfaction with the medical care if this is perceived to have been good) and being led to expect a particular event and then not experiencing it (e.g. receiving assurance that an epidural will be available but not receiving it because the anaesthetist is unavailable). Despite initial assumptions that effective analgesia in labour automatically guar- antees maternal satisfaction, this is not necessarily the case, and factors such as control and involvement in proceedings may be more important. This has led to the suggestion that satisfaction is increased when motor block is minimised by using low-dose epidural techniques. Management options Until more work is done on the interplay between specific factors that contribute to maternal satisfaction, obstetric anaesthetists have to fall back on the use of vague and non-specific methods of assessing it. It is probably more important to assess dissatisfaction, which may indicate deficiencies in service, but any single measure of satisfaction is only as good as the methods used to obtain it. It is also important to ensure that if a mother has had a bad experience in childbirth but the anaesthetic care has been good and appropriate, her adverse opinion should not extend to include the anaesthetist. Sometimes attempts to prevent this are futile, especially when the opinions of other professionals on the labour ward towards anaesthetists are themselves adverse. Attention meanwhile should be paid to those factors that have been shown to be important in promoting maternal satisfaction, such as involving the mother in decisions, keeping her informed, being prompt and courteous and other desirable general professional attitudes. Similarly, any expression of dissatisfaction should be taken seriously and an attempt made (and recorded in the notes) to discuss the particulars of the case, perhaps by offering an appointment at a later date. Medicolegal experience supports this approach as one of the most important factors in preventing subsequent legal action. 342 Section 3 – Puerperium and after Key points • Maternal satisfaction is an increasingly recognised but poorly defined measure of quality of care. • Involving women in their care, good communication and honesty are important factors in increasing maternal satisfaction. • Women expressing dissatisfaction should be identified and offered the opportunity to discuss their care further with a senior member of staff. FURTHER READING Hodnett ED. Pain and women’s satisfaction with the experience of childbirth: a systematic review. Am J Obstet Gynecol 2002; 186: S160–72. Hundley VA, Milne JM, Glazener CMA, Mollison J. Satisfaction and the three Cs: continuity, choice and control. Women’s views from a randomised controlled trial of midwife-led care. Br J Obstet Gynaecol 1997; 104: 1273–80. Morgan PJ, Halpern S, Lo J. The development of a maternal satisfaction scale for caesarean section. Int J Obstet Anesth 1999; 8: 165–70. Robinson PN, Salmon P, Yentis SM. Maternal satisfaction. Int J Obstet Anesth 1998; 7: 32–7. 151 Maternal satisfaction 343 . Section 3 – Puerperium and after 149 DRUGS AND BREASTFEEDING Mothers often ask their anaesthetist for information about breastfeeding after anaesthetic and surgical. during delivery. 340 Section 3 – Puerperium and after Communication with the women, their partners and the midwifery and obstetric staff is essential