Birth Setting and Its Impact on Breastfeeding Initiation and Success (Part 1)

While you may already be aware that women who birth with midwife support have higher breastfeeding initiation rates and greater long-term success, you may not know that women who birth in the hospital without the support of a midwife may have their breastfeeding relationship undermined -- often before the baby is even born.

Management of Labor and Birth
Let's take a look at some of the ways breastfeeding may be undermined in a medically managed childbirth. Any of the following factors in isolation can hinder breastfeeding; in combination, they may prove to be extremely tricky for any but the most determined mother.

Drugs for Pain Relief
Narcotics, nitrous, epidural, oh my! The potential cocktail of drugs that may make their way into a laboring woman's body (and, crossing the placental barrier, the infant) is staggering. Narcotics can make both mother and baby sleepy and uncoordinated, and they run the (rare) risk of infant respiratory distress and/or unresponsiveness, which can last several days. Every anesthesiologist has his/her own blend of drugs for epidural anesthesia, so the effects of epidural vary. However, epidural pain relief is associated with fetal distress, drowsiness, poor sucking reflexes, and other newborn complications such as jaundice, which may impact the breastfeeding relationship.

Pharmaceutical pain relief of any stripe increases the potential need for interventions such as vacuum extraction, forceps, or cesarean delivery, all of which have their own associated breastfeeding impact. Other drugs during labor that can affect breastfeeding include pitocin, diuretics, anti-histamines, and magnesium sulfate.

Drugs ingested by the mother post-delivery also affect the breastfed baby. In fact, the FDA recently warned post-op mothers taking codeine (which the body converts to morphine) to watch for sleepiness and other side effects in their infants. A significant portion of the population metabolizes this drug so quickly that high levels of morphine will be present in their breast milk. In addition to the overall worry about overdose, a sleepy baby can be difficult to interest in nursing. Less suckling leads to lowered milk supply, as the supply/demand cycle of milk production relies on regular stimulation by the baby of the mother's breast.

IV Fluids
Bag after bag of IV fluids overload the body, causing edema (swelling). This can be problematic for the new mother because it can make the tissue under and around the areola too firm, even having a somewhat flattening effect on the nipple; it can also add to existing engorgement after her milk comes in. Babies need and expect a soft, pliable nipple and areola, so the swelling can make latching on painful or difficult.

IV fluids also pose the risk of artificially excessive weight loss in the infant in the first few days after birth. Because fluid overload can affect the baby as well, its birth weight may be inflated; when he or she processes and eliminates these extra fluids in the days following birth, that weight loss may prompt a misdiagnosis of breastfeeding difficulties, leading to more interventions.

Suctioning
Although it is occasionally indicated to help clear the airway, routine suctioning of the newborn's mouth and nose has been proven unnecessary, many doctors continue the practice vigorously during every delivery. This can traumatize the baby, especially if suctioning is roughly done or causes the baby pain, and lead an aversion to anything touching or entering the mouth. In extreme cases, the infant will attempt to reject any contact with its mouth or lips following this experience. In addition to the obvious mechanical difficulties suctioning can cause for breastfeeding initiation, feelings of rejection by her infant can undermine a mother's confidence in her ability to nourish him/her at the breast. A mother who states that her baby "didn't like" the breast likely had a traumatic suctioning experience or received early supplementation from a bottle.

Maternal Discomfort
A mother who receives an episiotomy during vaginal birth, or who delivers via cesarean, is likely to be in some pain (perhaps necessitating more drugs... see above). Just finding a comfortable position in which to nurse can be a barrier. New mothers should, ideally, be able to maneuver themselves and their nurslings into different positions to alleviate sore nipples and accommodate personal positional preferences for both mother and baby. Not being able to do so can aggravate problems and frustrate the mother.

Supplementation
According to Dr. Ruth Lawrence, "comfort sucking and formation of nipple preference are genetically determined behaviors for imprinting to the mother's nipple." Though some dispute the phenomenon of "nipple preference" in babies whose first feeding comes from a bottle, research clearly indicates that these babies have to be reprogrammed for the breast. Even a pacifier can disrupt early breastfeeding efforts.

Babies considered high risk for hypoglycemia (cesarean deliveries, large babies, those born to mothers with diabetes) may be supplemented with glucose water or formula even without a diagnosis of any blood sugar issues. Unfortunately, this can make the babies' blood sugar rise and then crash later. Colostrum has plenty of lactose to help elevate baby's blood sugar, and it also has plenty of protein to stabilize it. Breastfeeding every two hours is almost always the best treatment for hypoglycemia; even just skin-to-skin contact between mother and baby helps regular infant blood sugar.

Separation of Mother and Baby
Breastfeeding early and often is the most basic and effective way to ensure success. The first nursing should take place within at hour at most; delaying that first feeding disrupts hormone levels, impacts the milk supply, and even delays mature milk's arrival. The baby may be at risk of dehydration or excessive weight loss, which can lead to formula supplementation.

Babies also need as many feedings of the first milk, colostrum, as possible to receive its full immunological benefits and protect them from hypoglycemia and jaundice. When the nursing dyad's first feeding is delayed by hours, the baby will likely receive supplementation with formula (causing nipple confusion issues as addressed above, and often resulting in many supplemental feedings in those first critical days).

Unfortunately, constant mother-baby togetherness is the exception rather than the rule in the hospital environment. Even with a normal, healthy delivery, babies are usually removed from mothers' arms for assessments. Check-ups by the on-call pediatricians, baths, weighing, and administering medication are usually performed in the hospital nursery for convenience's sake -- at the expense of bonding and breastfeeding. And despite the increasing ubiquitousness of rooming-in, many L&D nurses will still offer to take newborns to the nursery for an overnight stretch to "let mother rest."

Cesarean
With a c-section delivery, you and your baby will likely experience all of the above, and more. We've covered how pain, drugs, separation from the baby, and (likely) supplementation can affect breastfeeding. Cesarean delivery also poses an increased likelihood of long separation (sometimes several hours, making supplementation more likely). Women also lose about twice as much blood during c-section as during vaginal delivery. It is normal for a mother's milk to take an additional 1-2 days to come in following c-section. More worryingly, however, is the increased likelihood of anemia for these mothers, putting them at high risk of insufficient milk supply.

Lactation "Support" (Or Lack Thereof)
In the medical model, the language and protocols surrounding pregnancy and birth undermine women’s confidence. Women who want a natural birth are warned not to be disappointed if it doesn’t happen. They’re told that breastfeeding is best, “if it works out,” and if it’s not going well, they’re told to “stop banging their heads against the wall." Unfortunately, having this negative language surrounding these normal physiological processes leads many women to doubt their ability to perform them. And if they do encounter difficulties, they are more likely to give up.

Most doctors don’t receive any training in supporting breastfeeding mothers and some aren’t even aware of all the benefits. The “help” moms get with their first breastfeeding in the hospital from a doctor or nurse may not be all that helpful; it’s frequently very high-pressure and ignores the baby’s cues. Lactation specialists, if a hospital has them on staff, often only work 9-5 on weekdays. Sadly many women never receive any specialized assistance with breastfeeding and are left to figure out solutions on their own -- or not.

And On That Happy Note...
Obviously, many nursing dyads overcome all these obstacles and more -- or never even experience them as being obstacles to a satisfying nursing relationship. However, it's important to be aware that everything we do to a woman in labor, even if it seems innocuous, or even if it's just hospital policy, can have an impact on her ability to breastfeed her baby.

In upcoming posts, I'll address how midwifery care differs in its support for breastfeeding, and also cover some tips for overcoming the breastfeeding hurdles posed by routine hospital interventions.