Is Ropivacaine Safe in Breastfeeding

I am a breastfeeding mother and i want to know if it is safe to use Ropivacaine? Is Ropivacaine safe for nursing mother and child? Does Ropivacaine extracts into breast milk? Does Ropivacaine has any long term or short term side effects on infants? Can Ropivacaine influence milk supply or can Ropivacaine decrease milk supply in lactating mothers?

Local anesthetic agent which is used for infiltration and nerve-blocking procedures included Epidural anesthesia. It is excreted into breast milk in non-significant amount, with no side-effect observed on breastfed infants of treated mothers. Plasma levels in those infant were undetectable. There is controversy about the effect of drug-mediated analgesia used during the child birth (e.g. epidural injection of local anesthetics plus Fentanyl or alone) on the mature milk coming in, whether by delaying the onset of Lactogenesis phase II, or, by affecting the ability of the child for sucking. Some studies have shown a higher risk for delay of initiation of Lactogenesis phase II (milk coming in) longer than 3 post-natal days, but without effect on loss of initial weight. On other studies, the newborn infant appears to have higher risk for delay on first latch-on, higher body temperature and irritability or somnolence. Because of the latter, it is argued that those mothers would be in need of more support on breastfeeding when they have received ante or intra partum analgesia. However, some studies that have used Ropivacaine did not get such findings. There is consensus on the achievement of higher milk production and higher body weight increase in the neonate with an adequate pharmacological control of pain after C-section or vaginal childbirth.

Ropivacaine passes into milk poorly and is not orally absorbed by breastfed infants. Infants appear not to be affected by the small amounts of drug in breastmilk. Local anesthetics administered during labor and delivery with other anesthetics and analgesics have been reported by some to interfere with breastfeeding. However, this assessment is controversial and complex because of the many different combinations of drugs, dosages and patient populations studied as well as the variety of techniques used. Published data on the use of ropivacaine and fentanyl used during labor and delivery in a small number of women found little or no adverse effect on breastfeeding.[1] Labor pain medication may delay the onset of lactation.

Twenty-five infants whose mothers received a combination of ropivacaine and fentanyl for patient-controlled epidural analgesia for pain associated with cesarean section had normal Apgar and Neurological and Adaptive Capacity scores. No adverse effects were noted in any of the infants.[2]

A prospective cohort study compared women who received no analgesia (n = 63) to women who received continuous epidural analgesia with fentanyl and either 0.08 or 0.2% ropivacaine (n = 13) or bupivacaine (n = 39) during labor and delivery. The total dosage of ropivacaine was 50 to 124 mg and the average total infusion time from start to delivery was 219 minutes. The study found no differences between the groups in breastfeeding effectiveness or infant neurobehavioral status at 8 to 12 hours postpartum or the number exclusively or partially breastfeeding at 4 weeks postpartum.[3] A randomized, prospective study compared mothers who received epidural labor analgesia with ropivacaine (n = 75) to mothers who did not receive labor analgesia (n = 49). In the treatment group, 3 mL of ropivacaine 0.125% was injected epidurally, followed in some mothers by an additional 12 mL. In all treated mothers, 5 mL per hour was then given as a continuous epidural infusion. Although serum prolactin concentrations were somewhat lower in the group who received ropivacaine, no difference was seen between the groups in time of lactation onset, number of women with extensive lactation, and the decrease in infant weight reduction.[4] A nonrandomized study at one Italian hospital compared primaparous mothers undergoing vaginal delivery who received epidural analgesia (n = 64) to those who did not (n = 64). Mothers who requested the epidural analgesia received an initial dose of 100 mcg of fentanyl diluted to 10 mL with saline. After the initial fentanyl, doses of 15 to 20 mL of 0.1% ropivacaine were administered, if needed; however, the number of women who received ropivacaine was not reported. The only difference between the groups of mothers was a longer duration of labor among the treated mothers. The quality of infant nursing was equal between the 2 groups of infants on several measures; however, more infants in the treated group breastfed for less than 30 minutes at the first feeding.[5] A national survey of women and their infants from late pregnancy through 12 months postpartum compared the time of lactogenesis II in mothers who did and did not receive pain medication during labor. Categories of medication were spinal or epidural only, spinal or epidural plus another medication, and other pain medication only. Women who received medications from any of the categories had about twice the risk of having delayed lactogenesis II (>72 hours) compared to women who received no labor pain medication.[6] A nonrandomized convenience sample of women who did (n = 209) or did not (n = 157) receive epidural analgesia during labor was analyzed to determine whether epidurals affected the onset of lactation. Although not standardized, the typical procedure used sufentanil 10 to 15 mg together with either ropivacaine 0.1% or levobupivacaine 0.0625% epidurally, supplemented by epidural boluses of ropivacaine 0.1% or levobupivacaine 0.0625% about every 2 hours. No difference was found in the time of lactation onset between the two groups. Although women in both groups stated they wished to breastfeed prior to delivery, exclusive breastfeeding at 20 days postpartum was less frequent in the women who received an epidural (43%) than in women who did not (57%).[7] A retrospective study in a Spanish public hospital compared the infants of mothers who received an epidural during labor that contained fentanyl and either bupivacaine or ropivacaine. Infants of mothers who received an epidural had a lower frequency of early breastfeeding.[8]