Impact of Neuraxial Preservative-Free Morphine in Vaginal Delivery on Opiate Consumption and Recovery: A Randomized Control Trial.

BACKGROUND: Neuraxial opioids are commonly used after cesarean delivery (CD). However, they are not commonly used after vaginal delivery (VD) though some studies have suggested they may be beneficial from a pain perspective. However, they did not evaluate other potential benefits including patient satisfaction, impact on postpartum depression and breastfeeding (BF) success, or side effects such as pruritus. METHODS: Parturients who delivered vaginally with epidural analgesia were randomized to receive either 2 mg of preservative-free morphine (4 mL) or saline (4 mL) via the epidural catheter within 1 hour of VD. Routine analgesics were unchanged and included q 6-hour dosing of acetaminophen 975 mg orally and ketorolac 30 mg intravenous (IV). Hydromorphone 2 mg or oxycodone 10 mg were offered for breakthrough pain. Our primary outcome was opiate consumption in the first 24 hours after drug administration. Secondary outcomes included pain scores at 24 hours and 1 week postpartum as well as opiate consumption up to 1 week postpartum. Additional end points such as obstetric quality of recovery score (OBS-QOR10) breast feeding success, and an Edinburgh Postnatal Depression Score (EPDS) were also obtained. RESULTS: Data were analyzed for 157 parturients, 80 in the morphine group and 77 in the saline group. No difference was observed in the EDPS score predelivery or intention to BF. We found a statistically significant difference in the use of opioids in the first 24 hours, 3.8% (95% confidence interval [CI], 0.9%-11.3%) vs 14.3% (7.7%-24.5%) in the morphine and saline groups, respectively; and in total opioid dose, median (interquartile range, IQR [range]) of morphine milligram equivalent vs 0 (0-0 [0-47.5]) vs 0 (0-0 [0-72]), P = .023, in the morphine and saline groups, respectively. Verbal pain scores (0-10) at 24 hours were lower in the morphine group (median (IQR [range): 2.0 (1-4 [0-10]) vs 3.0 (1.5-5.0 [0-10]), P = .043. There was a greater incidence of pruritus in the morphine group versus saline group, 37.5% (95% CI, 27.1%-49.1%) vs 18.2% (95% CI, 10.6%-29.0%), P = .008. We did not find any differences in the OBS-QOR10, BF success, or EPDS at 6 weeks PP (P < .05). CONCLUSIONS: A single epidural dose of 2 mg preservative-free morphine after VD was effective at decreasing pain and opioid use at 24 hours after VD but came at the cost of increased pruritus. We did not detect any differences in BF, recovery scores, or PPD. Future studies should focus on elucidating the role of neuraxial preservative-free morphine after VD.

Is There an Association between Platelet Count and Blood Loss in the Parturient? A Retrospective Study.

OBJECTIVE: The influence of thrombocytopenia on blood loss and postpartum hemorrhage (PPH) has been conflicting. Our aim was to determine if there is an association between predelivery platelet count and quantitative blood loss (QBL) and PPH in both vaginal (VD) and cesarean deliveries (CD). STUDY DESIGN: We conducted a retrospective database study at a single institution from April 1, 2017 to September 9, 2020. The platelet count closest to time of delivery and the QBL was assessed separately for VD and CD. RESULTS: A total of 22,479 records were reviewed, of which 16,822 (75%) were VD and 5,657 (25%) were CD. A total of 2,600 (12%) patients had thrombocytopenia, defined as a platelet count <150,000/mm3. Of these, 1,980 (76%) had a VD and 620 (24%) had CD. We found a statistically significant difference in QBL between parturients with thrombocytopenia compared with those without, with a median estimated difference in QBL of 25 (95% confidence interval [CI]: 16-32) and 57 mL (95% CI: 31-87) in VD and CD patients, respectively. We also found a statistically significant difference in QBL when comparing patients among all the platelet count ranges except in the lowest platelet count range of 50,000 to 69,999/mm3 with a mean difference of 52 (95% CI: 25-81) and 107 mL (95% CI: 39-180) in the VD and CD patients, respectively in the platelet count range of 70,000 to 99,999/mm3 . We also found the incidence of PPH was greater in those with thrombocytopenia, p < 0.001, but the median difference in QBL in all platelet groups was small. CONCLUSION: We found a statistically significant association between lower predelivery platelet counts and QBL and PPH. The clinical significance of these results is debatable, because at all platelet count ranges, differences in blood loss were small. KEY POINTS: · Hemorrhage is etiology of morbidity and mortality in obstetric parturients.. · We found a small increase in blood loss in those with thrombocytopenia.. · The clinical relevance of these findings is debatable since the increased blood loss was small..

The Society for Obstetric Anesthesia and Perinatology Interdisciplinary Consensus Statement on Neuraxial Procedures in Obstetric Patients With Thrombocytopenia.

Because up to 12% of obstetric patients meet criteria for the diagnosis of thrombocytopenia in pregnancy, it is not infrequent that the anesthesiologist must decide whether to proceed with a neuraxial procedure in an affected patient. Given the potential morbidity associated with general anesthesia for cesarean delivery, thoughtful consideration of which patients with thrombocytopenia are likely to have an increased risk of spinal epidural hematoma with neuraxial procedures, and when these risks outweigh the relative benefits is important to consider and to inform shared decision making with patients. Because there are substantial risks associated with withholding a neuraxial analgesic/anesthetic procedure in obstetric patients, every effort should be made to perform a bleeding history assessment and determine the thrombocytopenia etiology before admission for delivery. Whereas multiple other professional societies (obstetric, interventional pain, and hematologic) have published guidelines addressing platelet thresholds for safe neuraxial procedures, the US anesthesia professional societies have been silent on this topic. Despite a paucity of high-quality data, there are now meta-analyses that provide better estimations of risks. An interdisciplinary taskforce was convened to unite the relevant professional societies, synthesize the data, and provide a practical decision algorithm to help inform risk-benefit discussions and shared decision making with patients. Through a systematic review and modified Delphi process, the taskforce concluded that the best available evidence indicates the risk of spinal epidural hematoma associated with a platelet count ≥70,000 × 106/L is likely to be very low in obstetric patients with thrombocytopenia secondary to gestational thrombocytopenia, immune thrombocytopenia (ITP), and hypertensive disorders of pregnancy in the absence of other risk factors. Ultimately, the decision of whether to proceed with a neuraxial procedure in an obstetric patient with thrombocytopenia occurs within a clinical context. Potentially relevant factors include, but are not limited to, patient comorbidities, obstetric risk factors, airway examination, available airway equipment, risk of general anesthesia, and patient preference.

The Society for Obstetric Anesthesia and Perinatology Coronavirus Disease 2019 Registry: An Analysis of Outcomes Among Pregnant Women Delivering During the Initial Severe Acute Respiratory Syndrome Coronavirus-2 Outbreak in the United States.

BACKGROUND: Early reports associating severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection with adverse pregnancy outcomes were biased by including only women with severe disease without controls. The Society for Obstetric Anesthesia and Perinatology (SOAP) coronavirus disease 2019 (COVID-19) registry was created to compare peripartum outcomes and anesthetic utilization in women with and without SARS-CoV-2 infection delivering at institutions with widespread testing. METHODS: Deliveries from 14 US medical centers, from March 19 to May 31, 2020, were included. Peripartum infection was defined as a positive SARS-CoV-2 polymerase chain reaction test within 14 days of delivery. Consecutive SARS-CoV-2-infected patients with randomly selected control patients were sampled (1:2 ratio) with controls delivering during the same day without a positive test. Outcomes were obstetric (eg, delivery mode, hypertensive disorders of pregnancy, and delivery <37 weeks), an adverse neonatal outcome composite measure (primary), and anesthetic utilization (eg, neuraxial labor analgesia and anesthesia). Outcomes were analyzed using generalized estimating equations to account for clustering within centers. Sensitivity analyses compared symptomatic and asymptomatic patients to controls. RESULTS: One thousand four hundred fifty four peripartum women were included: 490 with SARS-CoV-2 infection (176 [35.9%] symptomatic) and 964 were controls. SARS-CoV-2 patients were slightly younger, more likely nonnulliparous, nonwhite, and Hispanic than controls. They were more likely to have diabetes, obesity, or cardiac disease and less likely to have autoimmune disease. After adjustment for confounders, individuals experiencing SARS-CoV-2 infection exhibited an increased risk for delivery <37 weeks of gestation compared to controls, 73 (14.8%) vs 98 (10.2%) (adjusted odds ratio [aOR], 1.47; 95% confidence interval [CI], 1.03-2.09). Effect estimates for other obstetric outcomes and the neonatal composite outcome measure were not meaningfully different between SARS-CoV-2 patients versus controls. In sensitivity analyses, compared to controls, symptomatic SARS-CoV-2 patients exhibited increases in cesarean delivery (aOR, 1.57; 95% CI, 1.09-2.27), postpartum length of stay (aOR, 1.89; 95% CI, 1.18-2.60), and delivery <37 weeks of gestation (aOR, 2.08; 95% CI, 1.29-3.36). These adverse outcomes were not found in asymptomatic women versus controls. SARS-CoV-2 patients (asymptomatic and symptomatic) were less likely to receive neuraxial labor analgesia (aOR, 0.52; 95% CI, 0.35-0.75) and more likely to receive general anesthesia for cesarean delivery (aOR, 3.69; 95% CI, 1.40-9.74) due to maternal respiratory failure. CONCLUSIONS: In this large, multicenter US cohort study of women with and without peripartum SARS-CoV-2 infection, differences in obstetric and neonatal outcomes seem to be mostly driven by symptomatic patients. Lower utilization of neuraxial analgesia in laboring patients with asymptomatic or symptomatic infection compared to patients without infection requires further investigation.

Comparison of Nitroglycerin and Terbutaline for External Cephalic Version in Women Who Received Neuraxial Anesthesia: A Retrospective Analysis.

External cephalic version is a technique that decreases the need for cesarean delivery in patients with breech presentation. Several techniques exist to increase the success of external cephalic version; however, there are no studies comparing different tocolytics in patients who also received neuraxial anesthesia. We, therefore, performed a review of 198 patients who presented for external cephalic version and compared their success rates based on the tocolytic medication utilized. The external cephalic version success rate for patients who received terbutaline was significantly higher than for those who received nitroglycerin (N [%]: 57 [65.6] terbutaline group versus 40 [36.0] nitroglycerin group; P < .001).

Retrospective Analysis of Obstetric Intensive Care Unit Admissions Reveals Differences in Etiology for Admission Based on Mode of Conception.

BACKGROUND: The use of in vitro fertilization is increasing. The incidence of adverse outcomes is greater for women who undergo in vitro fertilization, potentially leading to intensive care unit admission. This study aimed to assess the etiology and course of intensive care unit admission in women who underwent in vitro fertilization compared to those who did not, with specific focus on intensive care unit admission due to postpartum hemorrhage. METHODS: In this retrospective study, medical records of patients admitted to the intensive care unit during pregnancy or the peripartum period at 2 medical centers (2005-2016 at Mount Sinai Hospital, New York, NY, and 2005-2013 at Shaare Zedek Medical Center, Jerusalem, Israel) were analyzed. Demographic, past medical and obstetric history, and details regarding delivery and intensive care unit stay were collected, as was information regarding mode of conception (in vitro fertilization versus non-in vitro fertilization) for the current pregnancy. The primary outcome measure was difference in etiology of intensive care unit admission between in vitro fertilization and non-in vitro fertilization groups. Secondary outcome measures included differences in prepregnancy characteristics, incidence, severity, and management of postpartum hemorrhage, as well as incidence of other clinical major morbidity events and delivery-related complications. Multivariable logistic regression was performed to study the relationship between in vitro fertilization and the odds of having been admitted to the intensive care unit due to hemorrhage. RESULTS: During the study period, there were nearly 192,000 deliveries, with 428 pregnant and peripartum women admitted to the intensive care unit. Of the 409 cases analyzed, 60 had conceived following in vitro fertilization and 349 had conceived without in vitro fertilization. The non-in vitro fertilization group was more likely to have multiple medical comorbidities, and the in vitro fertilization group was more likely to have multiple gestations. The groups also differed in etiology of intensive care unit admission; more women in the in vitro fertilization group were admitted due to a pregnancy-related complication. Intensive care unit admission for postpartum hemorrhage was more frequent in the in vitro fertilization group (60.0% vs 43.1%, P = .014), with a 2-fold increase in the incidence of hemorrhagic shock. Logistic regression analysis revealed a 2-fold increase in the odds that intensive care unit admission was due to hemorrhage in women undergoing in vitro fertilization, a finding that was not statistically significant when multiple gestation was added to the model. CONCLUSIONS: Among patients admitted to the intensive care unit, patients with different modes of conception had dissimilar etiologies for intensive care unit admission with intensive care unit admission due to hemorrhage greater in those with in vitro fertilization. Higher rates of multiple gestation pregnancies may explain this difference. Differences in pregnancies conceived via in vitro fertilization versus without in vitro fertilization may affect the obstetric intensive care unit case mix.

Point-of-Care Fibrinogen Testing in Pregnancy.

Agreement between estimated fibrinogen concentration via thromboelastography and traditional assays is not established in the parturient. We therefore recruited 56 parturients and performed Clauss and functional fibrinogen level (FLEV) tests. Mean difference of measurements was 36.8 mg/dL (95% CI, 21.8-51.9) with a standard deviation of 52.8 mg/dL. Calculated limits of agreement were 140.2 mg/dL (95% CI, 166.3-114.6) and -66.6 mg/dL (95% CI, -40.8 to -92.5), within the maximum allowable difference of 165 mg/dL. We therefore conclude that while most measurements fell within the limits of agreement, more work is needed to clearly define the role of this test in the obstetric population.

The Effect of Adding Subarachnoid Epinephrine to Hyperbaric Bupivacaine and Morphine for Repeat Cesarean Delivery: A Double-Blind Prospective Randomized Control Trial.

BACKGROUND: Spinal anesthesia has become the most common type of anesthetic for cesarean delivery. The major limitation to spinal anesthesia is that the duration of the anesthetic may not be adequate in the event of a prolonged surgery. Some practitioners add epinephrine to hyperbaric bupivacaine to increase the duration, although its effect has not been fully studied. We therefore aimed to evaluate whether adding epinephrine to the spinal medication prolongs the duration of action of the resultant block in women presenting for repeat cesarean delivery. METHODS: Sixty-eight patients were randomized to receive no epinephrine (NE group), epinephrine 100 µg (low-dose [LD] group), or epinephrine 200 µg (high-dose [HD] group) with a standardized spinal mixture (1.5 mL 0.75% hyperbaric bupivacaine with 0.25 mg morphine). Sixty-five patients were included for primary analysis. Our primary outcome was time to intraoperative activation of the epidural catheter or postoperative regression of sensory blockade to T-10 dermatome level as measured by pinprick sensation; motor recovery was a secondary outcome, and graded via a Modified Bromage scale. RESULTS: Block onset time, vital sign changes, and the incidence of hypotension; nausea, and vomiting were similar among groups. Median difference in time to T-10 regression was greatest in the HD group compared to the NE group (median difference [min] [95% confidence interval]: 40 [15-60]; P = .007), followed by the HD group to the LD group (30 [15-45]; P = .007). Comparisons of LD to NE were not significant, but trended to an increase in T-10 regression time (10 [-15 to 30]; P = .76). Median difference in time to knee extension (Bromage 3) was also greatest in the HD group when compared to both the LD and NE group (median difference [min] [95% confidence interval]: 30 [0-60]; P = .034, 60 [0-93]; P = .007). Median difference time to knee extension (min) between the LD and NE group was also significant (37.5 [15-60]; P = .001]. Pain scores during the procedure were higher in the NE group (median [interquartile range] HD: 0 [0-0], LD: 0 [0-0], NE: 0 [0-3]; P = .02) during uterine closure and were otherwise not significantly different from the other groups. CONCLUSIONS: In this single center, prospective, double-blind, randomized control trial, the addition of epinephrine 200 µg to hyperbaric bupivacaine and preservative-free morphine for repeat cesarean delivery prolonged the duration of the sensory blockade. Motor blockade was similarly prolonged and block quality may have been enhanced.

Preventable Anesthesia-Related Adverse Events at a Large Tertiary Care Center: A Nine-Year Retrospective Analysis.

BACKGROUND: Anesthesiologists have studied adverse events during anesthesia dating back to the original critical incident studies of the 1970s. Despite improvements, adverse events continue to occur. The purpose of this study was to characterize anesthesia-related adverse events within a single large tertiary care institution and to distinguish preventable adverse events from those that are not preventable. METHODS: A retrospective review of all cases referred to the Performance Improvement (PI) Committee at a large academic medical center from 2007 to 2015 was performed. The primary adverse event and underlying cause of the event were determined using a two-reviewer system for each case. Univariate analysis was performed to determine overall characteristics of cases, the underlying causes of adverse events, and whether the event was preventable; p < 0.05 was considered significant. RESULTS: A total of 1,424 records were referred to the PI Committee during the study period. After exclusions, 747 cases were included in the final analysis. Respiratory complications (n = 245) were the most frequently reported adverse event type. The most common respiratory events included unplanned reintubations, aspirations, and respiratory arrests. A large proportion of the adverse events (42.8%) may have been preventable. In particular, respiratory, trauma, and medication adverse events were often preventable. CONCLUSION: Anesthesia-related adverse events continue to occur even though the field is considered at the forefront of patient safety. Respiratory, trauma, and medication events were often preventable, and these represent areas to allocate resources to improve patient safety and perioperative outcomes.

Review of the Alternatives to Epidural Blood Patch for Treatment of Postdural Puncture Headache in the Parturient.

Labor neuraxial anesthesia is commonly used in the parturient, and postdural puncture headache is the most common complication of the technique. Although epidural blood patch is the best treatment, there are some patients in whom this treatment is refused or contraindicated. The goal of this article is to review the efficacy of the most studied alternate modalities to treat postdural puncture headache. This will include a discussion of the various oral or intravenous therapies and the non-blood-containing epidural injections. Last, the evidence behind interventional pain modalities and acupuncture will be examined.

Anesthetic management with labor epidural analgesia of the parturient with severe factor VII deficiency: a case report.

BACKGROUND: Factor VII deficiency is considered a contraindication to neuraxial anesthesia due to the risk of an epidural hematoma. CASE REPORT: A 32 year old G1P0 parturient with severe factor VII deficiency presented for an anesthesiology consultation at 32 weeks gestation. Initial coagulation studies were significant for an elevated INR (2.0) and a low factor VII level of 6%. After interdisciplinary discussion, it was decided that neuraxial analgesia could be offered if her coagulation studies corrected after administration of recombinant activated factor VII (rFVIIa). The patient presented at 36 weeks gestation for a rFVIIa challenge. She received 22 mcg/kg rFVIIa and coagulation studies were analyzed 20 minutes later which showed complete correction of the coagulopathy. The patient presented to the hospital at 39 weeks and 3 days for delivery, received 2 mg rFVIIa and 20 minutes later, successfully received an epidural catheter. Her INR was monitored every 3 hours during her labor course and rFVIIa was given if the INR was 1.3 or greater. She required three additional doses over 22 hours. No bleeding or thrombotic events occurred, and the patient was discharged home without complications. CONCLUSION: This case highlights the safe management of an epidural catheter in a parturient with severe factor VII deficiency.

Race and Intention to Breastfeed are the Strongest Predictors of Exclusive Breastfeeding: a Retrospective Study.

INTRODUCTION: Racial disparities exist in maternal and neonatal care including breastfeeding (BF). The purpose of this study is to assess factors associated with BF success by race with a specific focus on pre-birth BF plan and time duration from birth until initiation of skin-to-skin contact and from birth to the first feed or breastfeed. METHODS: A database query of our electronic medical records was performed for all patients who had a vaginal delivery that met our study criteria. Demographic information, pre-delivery feeding plan (exclusive BF, exclusive formula, or mixed), time to first feed and first breastfeed, and time to skin-to-skin were compared among different postpartum feeding practices (exclusive BF, exclusive formula, mixed), and compared across race/ethnic groups using ANOVA, Chi-square, and Fisher's exact statistical tests as appropriate. Logistic regression was used to investigate the independent effect of each variable on exclusive BF. RESULTS: The study analyzed 12,578 deliveries. There was a significant difference in intended feeding plans among the different racial groups. Approximately 61% of Black patients intended to exclusively BF as compared to 79% of the other groups. Overall, 3994 (32%) patients breastfed exclusively, 872 (7%) exclusively used formula, and 7712 (61%) used a mix of breast and formula. White patients were most likely to exclusively BF (35%) and Black patients were least likely (21%), p < 0.001. Our model found that self-identified race and pre-delivery feeding plan were the strongest predictors of exclusive BF. CONCLUSIONS: The main findings of this study are that self-identified race and intention to BF are the strongest predictors of exclusive BF. Black patients intend to BF at a significantly lower rate than other racial groups, for reasons not determined by this study, and this affects feeding practice. Our findings are notable because prehospital intention to BF can be modified by outreach, education, and changes to in-hospital practices.

Obstetric and perioperative management of patients with factor XI deficiency: a retrospective observational study.

Factor XI (FXI) deficiency is an autosomal inherited, milder bleeding disorder that may predispose to a potential risk of life-threatening bleeding during childbirth or surgery. Unfortunately, data regarding obstetric and perioperative management of this condition are scarce, with limited cases reviewed in the last decade. Therefore, the present study aimed to expand this database and identify factors associated with increased bleeding risk. We performed a retrospective chart review of patients with FXI deficiency who underwent childbirth or other surgical procedures between August 2011 and April 2021 within a single academic health system and identified 198 patients who underwent 252 procedures, including 143 vaginal deliveries, 63 cesarean deliveries, and 46 other surgical procedures. Thirty-three of the 252 procedures resulted in bleeding complications. On multivariable logistic regression analysis, personal history of bleeding was the strongest predictor of perioperative or obstetric bleeding (odds ratio [OR], 5.92; P = .001). Higher FXI levels were correlated with lower odds of bleeding (OR, 0.72 with every 10 U/dL increase in FXI level; P = .05). On receiver operative characteristic analysis, FXI level of >40 U/dL predicted a lower bleeding risk with reasonable specificity (75%) but lacked sensitivity (47%). A family history of bleeding, ethnicity, genotype, preprocedural partial thromboplastin time, and platelet levels were not associated with bleeding risk. There were no cases of epidural or spinal hematoma associated with neuraxial anesthesia. FXI levels remain stable during pregnancy and repeated measurements may not be necessary.

Management of post-partum hemorrhage and the role of the obstetric anesthesiologist.

PURPOSE OF REVIEW: The landscape of post-partum hemorrhage management is rapidly changing. Modifications to definitions, bundles, and care plans occur frequently with management strategies becoming more complex. It has become apparent that the management of these patients requires a multidisciplinary approach with the involvement of obstetricians, anesthesiologists, gynecologist/oncologists, nursing, and care associates. This review article is meant to be an evidence-based review of post-partum hemorrhage with practical recommendations and a look at future directions of the management of post-partum hemorrhage from the vantage point of the obstetric anesthesiologist in an effort to enhance the collaborative treatment of this at risk population.

Thromboelastometry-guided neuraxial anesthesia in a parturient with severe thrombocytopenia due to large granular lymphocytic leukemia.

Severe thrombocytopenia (platelet count <50 000/µl) in pregnancy is uncommon and is generally considered a contraindication to neuraxial anesthesia. We present a case of a parturient who presented with severe thrombocytopenia secondary to bone marrow failure. After receiving platelet and cryoprecipitate transfusions to correct coagulopathy as verified by thromboelastometry, neuraxial anesthesia was safely utilized.

Labor neuraxial analgesia and breastfeeding: An updated systematic review.

INTRODUCTION: There have been numerous reports studying the effect of neuraxial analgesia on breastfeeding success, but the results are inconsistent. METHODS: We performed a literature search in various databases for studies comparing neuraxial analgesia to non-neuraxial or no analgesia. Outcomes were the percentage of women breastfeeding fully or mixed with formula. Where possible, nulliparous parturients were analyzed separately. We conducted an analysis excluding studies of serious and critical risk of bias. Odds ratios and 95% confidence intervals were calculated. RESULTS: We included 15 studies (13 observational studies, 1 secondary analysis of a randomized controlled trial, 1 case-control study) with 16,112 participants. Overall, there were 6 studies that found no difference between groups, 6 studies that showed a significantly lower incidence of breastfeeding in the neuraxial group and 3 studies finding mixed results (at some time-points statistically significant and at some time-point statistically non-significant results). In nulliparous only studies, 2 found no difference between study groups, 1 found a lower breastfeeding rate in the neuraxial group and 3 studies showed mixed results. Excluding studies with a serious and critical risk of bias, 1 study found no difference between study groups, 3 studies found a decrease of breastfeeding rates in the neuraxial group, and 1 study showed mixed results. DISCUSSION: In our review we found a high disparity in results. One reason is probably the high potential of confounding (immediate skin to skin placement, maternity leave etc.). Education programs and breastfeeding support are likely more important in determining long term breastfeeding success.