When we think about birth choices we rarely think about the effects that these can have on breastfeeding outcomes or on long-term breastfeeding success. In general our choices surrounding birth tend to be made in order to get us through the phase of birthing our baby which many health care professionals and hospital units see as separate from the immediate bonding and feeding that happens directly after birth. Certain birth practices and interventions are known to have effects on breastfeeding in the early days. This doesn’t mean that if you experience these interventions, you will not breastfeed, but knowing that there are issues associated with certain practices can prepare you in advance should they arise.
Birth and breastfeeding as part of a continuum.
In today’s maternity care settings, breastfeeding is often viewed as an adjunct to birth. It can be seen as something to be engaged in based on maternal choice and is usually viewed by women and health care professionals as something separate from the birth itself. Yet nurturing your baby through breastfeeding is very much part of the birthing continuum. It is an innate process that your baby is hardwired to do and that your body is designed to carry out. Therefore any intervention in the process of labour and birthing can affect the breastfeeding relationship especially if it alters your baby’s neurological behaviour or your hormonal responsiveness.
What is an intervention?
Michel Odent looks at what we define as intervention in the birthing process and ultimately defines it as “everything” that we “do” to a mother, including talking to her, asking her questions, asking her to move rooms, asking her to travel to hospital and even making suggestions as to what she should do and feel. All these “interventions” will affect her oxytocic responses that will in turn affect how she and her baby respond once her baby is born (Odent, 2008).
Baby’s innate capacity to breastfeed
In 1997 Swedish researchers noted that if a baby was placed on its tummy on the mother’s abdomen he would make his way to the breast. In a study in 1990, however researchers noted that two interventions would impede the baby’s natural journey to the breast. These were:
- the use of pethidine during labour; and
- separating the baby from the mother for 20 minutes following birth for washing and measurements.
When both of these happened, babies were unable to find their way to the breast and when one of these happened about half of the babies were unable to find their way to the breast (Righarde and Alade 1990). Whilst this study drew attention to the interventions of separation and pethidine, it also left an impression that these behaviours disappeared after the first day of life. However, this has subsequently been shown not to be true, most notably by Christina Smilie (2008) and then by Suzanne Colson in 2008.
Colson (2008), identified 20 innate neonate behaviours that exist to help the baby find the breast and/or to promote milk transfer.
Birthing practices that isolate women from their innate capacity to birth can interfere with these behaviours because women then focus on breastfeeding as a left brained activity when actually research has shown us it is more of a right brained activity (Smilie 2008).
Put another way if we constantly tell women that they need to LEARN to birth or that they CAN’T birth without help it’s a tall order to expect women to physiologically and physically immediately engage with the innate nature of breastfeeding.
Breastfeeding and birth trauma
Research has found that there is an association between stressful birth either physically or psychologically and a delay in milk production. This may be due to elevated levels of cortisol in the mother’s bloodstream after a long stressful or difficult birth, but research has also found that women who have a traumatic birth experience can become the most determined breastfeeders.
“The impact of birth trauma on mothers’ breast-feeding experiences can lead women down two strikingly different paths. One path can propel women into persevering in breast-feeding, whereas the other path can lead to distressing impediments that curtailed women’s breast-feeding attempts.”
Beck et al (2008)
The role of care models and carers
A medical model is more likely to have interventions built into it as the norm than physiological birth models. Who cares for you is also likely to determine the number and degree of interventions you have during your labour. Obstetric-led care is more associated with higher rates of interventions and midwifery-led care is associated with fewer interventions. Self employed community midwives or home birth midwives tend to have the lowest rate of interventions associated with their care. Most women in Ireland have obstetric-led medicalised hospital care as there are no other choices available to them. So most women are likely to have interventions that may have an impact on early breastfeeding experiences.
Location location location!
Where you have you baby will also determine breastfeeding success. For example in recently released figures for 2011, The Midlands Regional Hospital had a breastfeeding rate of 32.5% whilst the Rotunda hospital had a rate of 57.9%. In another regional variation, figures from 2012 show that the breastfeeding rate for home births were 96.6% and the cumulative hospital rate was 46.9% (ESRI, NPEC).
What interventions can adversely affect breastfeeding?
- Epidural anesthesia
- Caesarean birth
- Instrumental birth
- Interference in general
Breastfeeding and labour medications
Establishing a definitive cause and effect relationship between birth practices and labour medications are difficult as most women are not going to want to take part in a research project that will randomly assign them to a medicated or unmedicated group! However, we know that all drugs reach the baby, even local lidocaine (used to numb the mouth during dental treatment). In 2001, Ranjsjo Arvidson looked at pethidine, bupivacaine, mepevacaine (via pudental block) and epidural anaesthesia . They concluded:
“It has not previously been reported that the use of analgesia via pudendal block has an adverse effect on the initiation of developing breastfeeding behavior including sucking.”
Ransjo-Arvidson et. al (2001).
The use of epidural analgesia
This is used in conjunction with IV fluids and often with synthetic oxytocin. IV fluids will more than likely exacerbate engorgement in the mother, and leave a baby bloated and with an exaggerated body weight. This in turn may lead a HCP to believe that the baby is loosing more weight than he should when he eliminates this fluid from his system. The use of epidurals can leave babies less responsive, with poorer co ordination, poorer cueing and sucking skills, and general lethargy. Epidural use has also been associated with shorter duration of breastfeeding. Some of the evidence is detailed below.
Epidurals – unresponsive babies, poorer coordination
Rosenblatt et al 1981 concluded that babies were more likely to be unresponsive, be less alert and have less co ordinated motor skills
“infants with greater exposure to bupivacaine in utero were more likely to be cyanotic and unresponsive to their surroundings.”
“Visual skills and alertness decreased significantly with increases in the cord blood concentration of bupivacaine, particularly on the first day of life but also throughout the next six weeks.”
“Adverse effects of bupivacaine levels on the infant’s motor organization, his ability to control his own state of consciousness and his physiological response to stress were also observed.”
Rosenblatt, D. B. et al.(1981). The influence of maternal analgesia on neonatal behaviour: II. Epidural bupivacaine. Obstet Gynaecol, 88(4), 407-413.
Epidural – cueing and sucking problems
Sepkoski et al (1992) observed babies for 30 days whose mothers had taken bupivicaine by epidural and concluded that these babies were more likely to have problems with cueing and sucking.
“The epidural group showed poorer performance on the orientation and motor clusters (cueing and sucking) during the first month of life.”
Sepkoski, C. M., Lester, B. M., Ostheimer, G. W., & Brazelton, T. B. (1992). The effects of maternal epidural anesthesia on neonatal behavior during the first month. Dev Med Child Neurol, 34(12),1072-1080.
Epidural – limited breastfeeding duration
Henderson, et al (2003) drew positive associations with epidural use and limited breastfeeding duration
“In the subgroup of women with spontaneous onset of labour and vaginal deliveries, after controlling for other obstetric and demographic factors, epidural analgesia but not narcotic analgesia was significantly associated with reduced breastfeeding duration (adjusted hazard ratio 1.44, 95% confidence interval 1.04-1.99).”
Henderson, J. J., Dickinson, J. E., Evans, S. F., McDonald, S. J., & Paech, M. J.(2003). Impact of intrapartum epidural analgesia on breast-feeding duration.Aust N Z J Obstet Gynaecol, 43(5), 372-377.
Dozier et al (2013) also identified the link between epidural use and limited breastfeeding duration, but their study was substantial in that they looked at all the contributing, or covariate, factors in the the relationship between epidural analgesia and breastfeeding including the associated use of IV fluid and synocinin.
“mothers receiving both epidural anesthesia and IV oxytocin represent the group most likely to cease breastfeeding within 1 month postpartum, while mothers receiving neither represent the lowest risk group”
(Dozier et al., 2013, p. 694-695).
Dozier, A.M., Howard, C.R., Brownell, E.A., Wissler, R.N., Glantz, C., Ternullo, S.R., Thevenet-Morrison, K.N., Childs, C.K. and Lawrence, R.A. (2013). Labour epidural anesthesia, obstetric factors and breastfeeding cessation. Maternal and Child Health, 17(4), pp 689-698.
Epidural – perceived insufficient milk supply
Volmanen et al (2004) identified an association between epidural use and the perception amongst mothers of not having enough milk and a propensity for mixed feeding
“67% of the mothers who had laboured with epidural analgesia and 29% of the mothers who laboured without epidural analgesia reported partial breast feeding or formula feeding (P= 0.003).”
“The problem of “not having enough milk” was more often reported by those who had had epidural analgesia”
Volmanen, P., Valanne, J., & Alahuhta, S. (2004). Breast-feeding problems afterepidural analgesia for labour: a retrospective cohort study of pain, obstetrical procedure
Epidural – delayed breastfeeding
Wiklund et al (2009) found that epidural administration was associated with delayed breastfeeding
Key conclusions: “the study shows that EDA is associated with impaired spontaneous breastfeeding including breastfeeding at discharge from the hospital.”
Wiklund, I., Norman, M., Uvnas-Moberg, K., Ransjo-Arvidson, A. B., & Andolf, E.(2009). Epidural analgesia: breast-feeding success and related factors. Midwifery, 25(2),e31-38.
Epidural – lack of skin to skin warming
Meanwhile Jonas et al (2007) identified that the warming effect of skin to skin was hampered by epidural use
“Skin temperature increased significantly (p=0.001) during the entire experimental period in the infants belonging to the control group.
“No such rise was observed in infants whose mothers were given an epidural during labour.”
“CONCLUSION: The results show that the skin temperature in newborns rises when newborns are put skin-to-skin to breastfeed two days postpartum. This effect on temperature may be hampered by medical interventions during labour such as EDA.”
Jonas, W., Wiklund, I., Nissen, E., Ransjo-Arvidson, A. B., & Uvnas-Moberg, K. (2007). Newborn skin temperature two days postpartum during breastfeeding related to different labour ward practices. Early Hum Dev, 83(1), 55-62
Many of the studies above indicate that babies who are born following the use of epidural and syntocinon may well have altered neurobehaviour as a result of exposure to these medications during the birthing process. Babies with such altered behaviour do not feed effectively, and this in turn causes:
- Inadequate nutrition for baby
- Risk of formula supplementation
- Milk retention in breast
- Suppressed onset of lactation / lactogenesis
- Maternal pain
- Undermining of mothers’ confidence
Seven out of ten women in Ireland will take an epidural,and six out of ten women will receive syntocinon either in the first or second stage of labour. The majority of women birthing in hospital will receive syntocinon intramuscularly during the third stage of labour to help expel the placenta.
Induction – association with cascade of interventions
There is no research to show that induction does not cause breastfeeding issues in mother or baby per se, However, the cascade of interventions associated with induction can have an affect. For example, induction doubles the risk of Caesarean birth, and increases the use of syntocinon. It is also associated with a higher use of epidural. Induction also carries risks to the baby. These risks in turn may affect the baby’s natural innate capacity to breastfeed. For example, it can result in immaturity in the baby and increased respiratory problems in the baby. All of which in combination can contribute to breastfeeding challenges. More or less one out of three women will be induced in Ireland (current rate 31%).
Planned Caesarean birth is associated with respiratory problems (especially if done before 39 weeks) and this in turn has impacts on the breastfeeding baby as babies may be more likely to have NICU admissions. As most Caesarean births are carried out via epidural, the epidural issues all apply, but in addition there is the position and pain associated with the scar, delayed lactogenesis (production of milk) and a perception amongst women and HCPs that Caesarean birth is a barrier to breastfeeding. In 2012, 28.9% of women had a Caesarean birth in Ireland. In some hospitals this rate was as high as 40% for first time mothers.
Instrumental deliveries – physical issues
More and more babies are being delivered by instrumental delivery in Ireland; either by forceps or by vacuum extraction. Whilst this process is not a surgical event as such, the additional pressures put on the baby’s head and jaw can result in tortollis and sometimes in uneven jaw structures that make breastfeeding more difficult. Very little research has been done in this area so evidence is mainly clinical reporting and anecdotal.
Separation in the first few hours
When a baby is separated from his mother he is taken out of his natural habitat and this limits his innate breastfeeding behaviours. Research shows us that newborn babies who are separated from their mother demonstrate the following physiological changes
- Lower infant body temperature
- Lower blood glucose levels
- Agitated states with more crying, higher levels of stress hormones and less sleep
- More breastfeeding problems
- Decreased intake of mother’s milk Mohrbacher (2010)
This is the practice of wrapping up a baby tightly in a blanket. The practice of swaddling has used in many parts of the world, but research now shows that swaddled babies arouse less frequently and sleep longer (Franco et al 2005). In the early days and hours this can mean that swaddled babies breastfeed less. In a comparative study of babies that were placed skin to skin for two hours and babies that were swaddled with hands free and given to the mother, the skin to skin group of babies showed earlier feeding behaviours, more competent suckling during their first breastfeeding and established breastfeeding earlier. Furthermore, research has also shown that several newborn stressors had a more profound negative effect when newborns were also swaddled.
Swaddling on a continuous basis has also been associated with:
- Greater risk of respiratory disease
- Greater risk of hip dysplasia
- Greater risk of SIDS in prone sleeping positions
- Greater risk of over heating
Top ups with artificial milk
Health care professionals are obliged to ensure that when a mother is discharged back into the community her baby is feeding well and receiving adequate nutrition. If breastfeeding babies are perceived to not be breastfeeding well, to be jaundiced or to have low blood sugars then routine practice in many Irish maternity units is to suggest that the mother give artificial milk to “top up” the baby’s breast-feeds. Top ups may also be given routinely when full term babies are in the special baby unit for observation directly after birth. Sometimes top ups are given without the mother’s consent.
Newborn babies are born with more fluids in their tissues than they need, which is one of the reasons that most babies lose weight in the early days. The advantage of this extra birth fluid is that it gives babies practice time to learn to breastfeed before their need for fluids is genuine. Giving top ups for this “weight loss” is an unnecessary intervention.
One of the best ways of eliminating newborn jaundice is to breastfeed. Research shows that babies that were breastfed for nine or more times in the first day had very limited chances of being jaundiced on day 6.
In healthy newborns blood sugars are usually at their lowest at about 1- 2 hours after birth. They begin to rise after 2 – 4 hours and continue to do so until 96 hours after birth. No long or short-term benefits have been found in testing or treating the baby for this very normal dip in blood sugar during the first few hours after the baby is born. After 12 hours postpartum the baby’s glycogen stores are spent and milk feedings and fat stores will start to provide the baby with the glucose his brain needs. Research shows us that breast feedings within the first two hours have no effect on a baby’s blood sugar level, therefore if the mother is unable to feed her baby in this time there is no benefit to giving the baby artificial milk. Research indicates that giving a baby artificial milk at this time can actually worsen his blood sugar problem as it stops him using alternative brain fuels such as ketone bodies and lactate. Research recommends that for a healthy full term baby who has no symptoms of low blood sugar it is safe to wait 8 hours without a breastfeed.
Giving newborns artificial milk is not recommended, as their gut junctions are more open and permeable than they will be later, and introducing foreign proteins at this time increases the risk of allergy sensitisation. These junctions close as the baby grows. Artificial milk can also change gut flora of a baby to more resemble that of an adult, which gives the newborn a greater risk of infection.
Giving large amounts of artificial milk at each feeding can lead to breastfeeding problems later as babies become accustomed to large fast flowing quantities at long intervals which is quite different to the feeding experience at the breast. Overfeeding with artificial milk in the first week of life is also associated with obesity in later life (Stettler et al 2005).
What interventions during the birth can help breastfeeding?
Interventions that can promote and support breastfeeding in the birth tend to focus around the “lack of doing” or just mimicking what would happen if there was not a “system” imposed on the birthing mother and her immediate birthing and postpartum environment. It’s strange that we have now come through observation and evidenced based research to accept what mothers and babies have done naturally for millennia.
Emotional support, in labour.
Research exists to show that women who receive emotional support during their pregnancy, labour and the immediate postpartum period, have a shorter time to the first breastfeed after birth than women who did not receive such support. (Morhasen- Bello, 2009). This shorter duration before the first feed has been associated with longer duration of breastfeeding.
Skin to Skin immediately after birth and during the first days postpartum
Skin to skin contact between mother and baby promotes oxytocin release in the mother’s system, which in turn promotes milk production. Research shows us that where a baby can see or hear his mother but not feel her body against his torso, he can become disorientated and his innate feeding behaviours can become inhibited (Smilie 2008). Based on a review of 30 studies and 1925 babies a Cochrane Review concluded that skin to skin contact after birth enabled babies to interact more with their mothers, stay warmer, cry less are more likely to breastfeed and to breastfeed for longer (Moore et al 2007).
This is when mothers and babies are kept together after the birth in the postnatal ward. Historically, mothers and babies were separate in maternity settings so that mothers could get their rest after delivering the baby. However, now research shows us that prolonged contact between mother and baby leads to more feedings, better weight gain and longer duration of breastfeeding.
Baby friendly hospital initiative (BFHI)
This initiative accredits hospitals in full compliance with the BFHI’s 10 steps to encourage and promote breastfeeding The Ten Steps to Successful Breastfeeding are:
- Have a written breastfeeding policy that is routinely communicated to all health care staff.
- Train all health care staff in the skills necessary to implement this policy.
- Inform all pregnant women about the benefits and management of breastfeeding.
- Help mothers initiate breastfeeding within one hour of birth.
- Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.
- Give infants no food or drink other than breast-milk, unless medically indicated.
- Practice rooming in – allow mothers and infants to remain together 24 hours a day.
- Encourage breastfeeding on demand.
- Give no pacifiers or artificial nipples to breastfeeding infants.
- Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or birth centre.
Several units in Ireland have this designation, but they are not necessarily the units with the highest breastfeeding rates.
Hospitals that currently have Baby Friendly status in 2014 are The Rotunda in Dublin, Midlands Regional Hospital Mullingar, Portiuncula Hospital, Ballinasloe, Limerick Regional Hospital, UCHG Galway, Cavan General Hospital, Midlands Regional Hospital Portlaoise and Our Lady of Lourdes Hospital, Drogheda. As hospitals have to renew their BFHI status please check to see if your local hospital is on the current list. http://www.ihph.ie/babyfriendlyinitiative/participatinghospitals.htm
Breastfeeding beyond the immediate postpartum
Whilst early breastfeeding experiences can be heavily dominated by birth experiences and birth practices within maternity settings, they are not the sole contributer to long-term breastfeeding success. In the early days mothers rely heavily on the advice and support of hospital midwives and obstetric staff, but after moving into the community other factors come into play that will determine breastfeeding success. These include support in the community and self-belief. Remember even if breastfeeding challenges arise for you, there is usually a breastfeeding solution to the problem and the most important thing to do is to seek help form a credible source. It is a good idea to research the local breastfeeding support groups in your area during your pregnancy and even attend them so that you have the names and numbers of breastfeeding support counsellors in your area. Visit Cuidiu, La Leche League Ireland and Friends of Breastfeeding to find your local group. Private lactation consultants are also available. Visit ALC Ireland to find a certified lactation consultant in your area.
Beck, C. T., & Watson, S. (2008). Impact of birth trauma on breast-feeding: a tale of two pathways. Nurs Res, 57(4), 228-236.
Colson, S. (2008), Biological nurturing, laid back breastfeeding. Hythe Kent UK the Nurturing Project
Franco, P, Seret, N., Van Hees, J.N., Scaillet, S., Groswawser, J. and Kahn, A et al (2005). Influence of swaddling on sleep and arousal characteristics of healthy infants, Paediatrics, 115 (5), 1307-1311
Mohrbacher, N. (2010) Breastfeeding answers made simple a guide for helping mothers. Hale Amarillo TX
Moore, E. R., Anderson, G. C. and Bergman, N. (2007) Early skin to skin contact for mothers and their healthy newborn infants. Cochrane Database of systematic reviews (3) CD003519
Morhasen- Bello, I. O., Adedokun, B, O, and Ojengbede, O. A (2009) Social support during childbirth as a catalyst for early breastfeeding initiation for first time Nigerian mothers. International breastfeeding journal 4 p16
Odent, M. (2008).Birth and breastfeeding: Rediscovering the needs of women during pregnancy and childbirth. London: Rudoplh Steiner Press
Ransjo-Arvidson, A., Matthiesen, A., Lilja, G., Nissen, E., Widstrom, A., & Uvnas-Moberg, K. (2001). Maternal analgesia during labor disturbs newborn behavior. Birth, 28, 5 – 12.
Righarde, L. and Alade, M. O. (1990) Effective delivery room routines on success of first breastfeed. Lancet, 336 (8723) pp 1105-1107
Smilie, C. (2008) How infants learn to feed; a neurobehavioural model in C, W Genna (ed) Supporting sucking skills in breastfeeding infants pp79-95 Boston: Jones and Bartlett
Stettler, N. Stallings, V. A. Troxel, A. B. Zhao, J. Schinnar, R. Nelson, S.E. et al (2005) Weight gain in the first week of life and overweight in adult hood: a cohort study of European American subjects fed infant formula. Circulation 111(15) pp1897-1903