and their Possible Effects
on the Initiation and Duration of Lactation
by Andrea Eastman, MA, CCE, IBCLC
(Article appeared in "Keeping Abreast" , BMSG(S)
Newsletter, Jan-Mar 1999 Issue)
Did you know that some common obstetric practices, and the way
mothers birth can directly or indirectly influence breastfeeding?
Here we discuss some of them:
BIRTH ATTENDANT (MIDWIFE OR DOCTOR): It is important
for the caregiver's philosophy of birth to match our own. There is also
a difference between seeing birth and breastfeeding as normal life
events, and seeing birth as an illness, and breastfeeding as fraught with
PREP, SHAVE, and ENEMA: The important one here is the
enema. An enema taken during labour stimulates the bowels. In addition,
it may also make the contractions during labour stronger. Stronger contractions
may make a mother choose medication to deal with the pain, and every type
of maternal medication gets to the baby, and can affect the baby's ability
to stay awake and suck properly.
LABOURING IN BED: Women who labour in bed often experience
more pain and a slower labor. More pain means that she may ask for
drugs. A slower labour means that she is at risk for being classified as
"failure to progress", which may mean pitocin augmentation, the accompanying
IV drip, etc. Pitocin will mean stronger, more painful contractions.
Labouring in bed, possibly flat on
her back, the woman's uterus is compressing the blood vessels that
supply the placenta and the baby with oxygen. Too little oxygen and
stronger contractions may mean that the electronic monitor could show foetal
distress. Failure to progress, inco-ordinate uterine contractions, and
foetal distress are all reasons to have the doctors do caesarean surgery.
Caesareans and the accompanying medications
can affect breastfeeding.
FASTING (NO FOOD OR DRINK) except for the occasional ice
chips or sips of water. Studies have shown that allowing women
to eat and drink during labour can reduce the length of the labor by as
much as 90 minutes. Labour is hard work, and the body needs
the energy to work effectively. Dehydration means more painful contractions
and slower labour. Fatigue combined with a slower labour may
make a woman feel that she needs medications. All labour medications
get to the baby, and can affect the baby's ability to breastfeed.
INTRAVENOUS FLUIDS (IV): given to women in labour (such
as glucose) can keep the glucose levels in mom's and baby's blood abnormally
high. The body compensates by making extra insulin. Suddenly the baby is
born, it's glucose supply is cut off, and it has all that extra insulin.
This could lead to neonatal hypoglycemia, which may mean a trip to the
Neonatal Intensive Care Unit (NICU), which means separation from mom.
Studies have shown that separation from mother after the birth can have
almost as dramatic effect on the baby's ability to latch on as maternal
medications. Some women on IVs experience fluid overload. Extra fluids
in the woman's body means perhaps worse engorgement, which can affect a
baby's ability to latch on properly. Severe, protracted engorgement
can lead to the death of the cells responsible for secreting milk, and
therefore have an impact upon the mother's milk supply.
PITOCIN, given to speed up a labour, in addition to causing
stronger, more painful contractions, is also an anti-diuretic, which means
that it makes the body retain more fluids which means more engorgement,
which can have a negative effect on breastfeeding. Pitocin use also
increased the likelihood of jaundice in the baby.
ANAGLESIA - eg. pethidine, demerol, stadol, nubain - affects
the perception of pain. Some women experience relief, some women
hallucinate. All of these drugs cross the placenta and can affect the baby.
Narcotics such as these can lead to what nurses call "blue baby syndrome".
Lower APGAR scores can affect the care required by the baby, and thus may
mean separation from mother to monitor its breathing, etc. These drugs
can also affect the baby's desire and ability to breastfeed. A sleepy baby
combined with fluid-overload engorgement is a serious threat to breastfeeding.
If the sleepy baby gets jaundiced, then the pediatrician may order supplements,
etc. Unnecessary supplementation can have disastrous effects
on a mother's confidence and on her milk supply.
ANAESTHESIA - epidural, spinal, intrathecal - removes the sensation
of pain, as well as stop the production of endorphins in the mother's body
(the natural painkillers). Yes, epidurals can affect the baby. The
degree to which the baby is affected depends upon the particular "cocktail"
used by the anaesthesiologist. There are many studies that show the
effects of this type of medication can be longer lasting. Epidurals
mean that the mother will have to have the whole host of accompanying interventions:
IV; internal electronic foetal monitor; urinary catheter; automatic blood
pressure cuff; possibly pitocin augmentation, etc. Her labour
may slow down, her uterus may contract ineffectively. She won't
be able to feel the contractions to push her baby out, which may mean forceps
or vacuum extraction, and an episiotomy. It may affect her labor
so dramatically that the doctor orders a caesarean. If they let the
medication wear off so she can push, she will be deprived of the endorphins
that would have helped her deal ththe intense sensations, and will be left
to deal with the fresh, new pain of transition on her own. This may
make her request a "top-off", which can mean a prolonged second stage of
labour. Doctors rarely let a woman push for more than two hours
during the second stage, which may mean a caesarean, even if she has dilated
to 10 cm. And caesareans can affect breastfeeding. Epidural
use, whether for vaginal birth or caesarean birth, can increase the likelihood
of jaundice in the baby. All drugs must be broken down by the infant's
immature liver. The liver is also responsible for processing the
bilirubin (making it water soluble) so that it can be excreted by the baby.
ARTIFICIAL RUPTURE OF MEMBRANES (AROM): Commonly
known as “breaking the water-bag” means that the cushioning forewaters
are gone. This can dramatically increase the pain felt with each
contraction. The baby's head is suddenly compressed more with each
contraction, which may cause the normal dip in the foetal heart tones to
dip a little further. The doctor may
interpret this as foetal distress and order a caesarean.
EXTERNAL AND INTERNAL ELECTRONIC FOETAL MONITORING (EFM):
was developed by physicians determined to detect foetal distress early
and therefore lower the incidence of cerebral palsy. However,
a study published in the New England Journal of Medicine in 1996 showed
that routine EFM has not lowered the incidence of cerebral palsy, and questioned
its value in predicting cerebral palsy. In fact, some doctors have
argued that routine EFM has increased the caesarean rate. Thus, EFM can
indirectly have a negative effect on breastfeeding because of the medications
used for the cesarean surgery, separation from mother, etc.
VAGINAL EXAMINATIONS are painful, require a woman to be flat
on her back, can lead to premature rupture of membranes, increased risk
of infection, and can be misleading if they are overdone, and if they are
done by different people. Imagine labouring for hours, and
you hit a plateau. You have continued har labour, but the vaginal
exam done to check your dilation every 30
minutes shows no progress. You will probably feel very discouraged.
They may put you on pitocin, if you aren't already on it. You may “run
out of time” according to the doctor. He will come in, check you
and declare that there is no way THIS baby is coming through THIS pelvis,
and order a caesarean for failure to progress, or cephalopelvic disproportion
(inadequate pelvis size), or inco-ordinate uterine function. We have
already discussed the negative effects that pitocin and caesareans can
have on breastfeeding.
DIRECTED, SUSTAINED PUSHING: - you know, the circle of people
standing around the woman flat on her back or propped up so she is sitting
on her tailbone, with her elbows in the air, holding her legs apart,
everyone shouting PUSH, PUSH, PUSH, and counting to 10 over and over again!
Holding your breath while closing your glottis (the opening between your
vocal cords) raises the pressure in your abdomen, which has a negative
effect on the blood going back to your heart and then to the lungs. This
means that the baby is getting no new oxygenated blood as long as you are
pushing this way. Granted, the baby is not getting any new oxygen
when the uterus is contracting, but many women push much longer than the
actual contraction. This lack of oxygen can negatively affect the
baby. The EFM may show foetal distress, and an emergency caesarean
may be performed. Interestingly, this type of pushing actually causes
the condition - foetal hypoxia (decrease in oxygen to the foetus) - that
it was intended to prevent! So you see how this can hav a indirect
effect on breastfeeding. In addition, foetal hypoxia is in one of
the general categories of causes of pathological jaundice.
LITHOTOMY POSITION: - pushing while flat on your back - in addition
to what has been discussed above, means pushing your baby uphill, against
gravity, and can lead to a prolonged second stage of labour.
This can lead to fatigue, which may mean the woman is unable to push her
baby out. The doctor may diagnose this as shoulder dystocia
(whereby shoulder is stuck inside the birth canal), and remove the baby
with forceps after doing a huge episiotomy. Next time, the
mother may be convinced that she can't push out her babies, that her pelvis
is inadequate, and she may be talked into a scheduled cesarean.
EPISIOTOMY:- yes, this can affect breastfeeding! This
cut at your perineum to enlarge the vaginal opening will make your bottom
sore! And if your bottom is sore, you sit further back on your tailbone.
This can affect your ability to properly position your baby, which may
lead to sore, cracked, bleeding nipples - as well as a slow growing baby
who cries all the time.
SUCTIONING of the baby's nose and mouth vigorously can create
oral aversions in sensitive newborns. The nose and mouth areas are
the baby's first "window to the world", and the focus of their sensory
input. Suctioning can scrape their delicate tissues, and give them
sore throats. Even worse, when placed at mother's breast, they may
vehemently refuse to nurse. Suctioning is a routine intervention
that often does more harm than good. Babies birthed over intact perineums
rarely need vigorous suctioning. Save this procedure for the rare
times when it is really needed.
WASHING THE BABY, EYE TREATMENT, SEPARATION FOR OBSERVATION, USE
OF A WARMER : - all of these things may mean separation from mom, which
can dramatically affect the newborn's ability and willingness to latch
on and suck effectively.
It is STILL possible to successfully breastfeed if you have every
intervention on this list (and many mothers have!), but it is important
for mothers to give birth where they feel most safe and to choose a birth
attendant with a philosophy of birth similar to their own. Women
need to learn to listen to their bodies and trust their intuition -- they
already KNOW how to birth their babies!
©1997, 1998 by Andrea Eastman, MA, CCE, IBCLC (Used with Permission)
Gentle Birth Alternatives®
BACK TO Index
of Breastfeeding Articles
Breastfeeding Mothers' Support
Group (S) Main Page
Copyright 1997-1998, BMSG