Bupivacaine

Topical anesthetic used for infiltrations and nerve blocks, including epidural.

It is excreted in breastmilk in clinically insignificant amounts (Bolat 2014, Ortega 1999, Baker 1989) and no problems have been observed in infants whose mothers were given it (Ortega 1999). The plasma levels of these infants were undetectable, even after intrapleural administration to the mother (Baker 1989).

In addition, its low oral bioavailability (due to minimal oral absorption) impedes transfer from breastmilk to infant plasma (Reece 2017).

According to the manufacturer, there is no risk for the infant due to the small amounts excreted in breastmilk (Pfizer 2018, AEMPS 2014).

There is controversy over whether drug analgesia during childbirth (epidural with local anesthetics with the addition or not of fentanyl) can affect the onset of breastfeeding, whether due to delayed lactogenesis II, or due to impairment of the infant's own competencies (French 2016, Herrera 2015, Howie 2006).

There are studies that show that with epidural anesthesia there is a greater risk of delaying the lactogenesis II period (stimulation of milk production) beyond 3 days (Herrera 2015, Lind 2014) and lower frequency and duration of breastfeeding (Thorvaldsen 2006), although they do not affect the initial weight loss of the newborn.
In some studies, the newborn appears to be at greater risk of delaying the first breastfeeding, due to having a higher body temperature and presenting irritability or drowsiness (Ransjö 2001). This being the case, more support will be needed for breastfeeding mothers who have received analgesia ante- and intra-partum (Zuppa 2014).

But other studies do not find significant problems in the initiation and maintenance of breastfeeding due to epidural anesthesia in childbirth or caesarean section (Mahomed 2019, Xu 2019, Grant 2019, Lee 2017, Mauri 2015, Shrestha 2014, Wilson 2010, Wieczorek 2010, Goma 2008, Chen 2008, Wang 2005, Chang 2005, Radzyminski 2003, Abouleish 1978).

The onset of breastfeeding was earlier and with more frequent feeds in vaginal delivery than after caesarean section and with epidural anesthesia than with general anesthesia (Kutlucan 2014, Sener 2003).
Regarding the epidural, general anesthesia was associated less frequently with breastfeeding and exclusive breastfeeding at 6 weeks (Orbach 2018) and at 6 months (Karasu 2018).

Prolactin levels decrease less with epidural anesthesia during childbirth (Jouppila 1980).

Postoperative pain control with continous epidural bupivacaine continues for 3 days after caesarean section improved breastmilk production and infant weight gain (Hirose 1996), but the opposite occurred when buprenorphine was associated (Hirose 1997).

The use of local anesthetics and regional anesthesia (spinal, epidural or peripheral block) decreases the need for opioids and other analgesics which can interfere with breastfeeding (Reece 2017).

There is consensus that there is greater milk production and greater neonate weight gain if pain is adequately controlled pharmacologically after delivery or cesarean section.

The manufacturer (Pfizer 2018, AEMPS 2014) and various medical associations and expert consensus consider the use of this medication to be safe during breastfeeding (Reece 2017, Cobb 2015, Lee 1993).

List of WHO essential medicines: compatible with breastfeeding (WHO / UNICEF 2002).

See below the information of this related product:

• Local and Epidural Anesthesia / Neuraxial analgesia (Safe substance and/or breastfeeding is the best option.)