I am often asked by my colleagues “why do we need Lactation Consultants?” “There seems to be so many more breastfeeding problems these days. It was never this difficult 20 years ago.” The answer is simple enough; birth intervention.
The World Health Organisation advises that all babies should be exclusively breastfed for the first six months of life. Complementary foods should only be introduced from six months onwards, continuing breastfeeding in baby’s diet for up to two years of age and beyond. Despite these recommendations and active work from National and State governments to implement BFHI as well as continuing education of staff in almost every health service, a continual decline in the figures is seen month to month in Australia.
WHO is focusing on these main topics to prolong breastfeeding durations:
1. Nutritional status of mothers who are breastfeeding
2. Nutrition of infants living in areas with deficiencies, such as in iron, zinc, and vitamin A.
3. Routine primary healthcare of infants.
Where are the recommendations to look further into the effects of medicalization of birth on the breastfeeding initiation and continuation rates?
It is well documented that initial declines in exclusive breastfeeding in the first month are due to problems with painful nipples and latching problems, a mother’s perceived inadequate breast milk supply and early introduction of formula milk. These problems are often exacerbated when mothers have had a medicalised birth.
In the last few years we have seen many advances in obstetric medicine (whether for the greater good or further problem inducing for the majority; I shall leave for you to decide). We have enabled pregnancy to occur for women who only a decade ago would not have had this opportunity due to age, illness or disability. With such pregnancies often comes high risk obstetric management during labour; continuous CTG monitoring, induced labour, enforced epidurals which often progresses to inactivity, directed pushing and an increased chance of instrumental or caesarean birth. Of course labour does not have to be considered ‘high risk’ to end up following a medicalised pathway. Even the seemingly innocuous impact of such ‘normal’ pain relieving actions as a shot of pethidine can have unwanted effects on how baby responds once born. For many of us these are considered within the realms of normal birth and non-interventionist. A regular occurrence in many birth suites all over the world and considered to be a part of everyday labour. For those babies who have had a combination of several interventions throughout the birth process; induction and augmentation of labour, pethidine, epidural, vacuum delivery or forceps this frequently leads to maternal and neonatal pain, stress and exhaustion. Babies are often separated from their mothers for resuscitation or 24 hours in special care nurseries which in turn can lead to delayed first and subsequent breastfeeds and often to “just one bottle”. We know how this small ‘gesture’ can have confounding effects on maternal confidence, interruption with milk production and promotes a change from normal newborn behaviours. Intervention whether from birth processes or subsequently due to poor initial neonatal responses, has a great potential to impact significantly on the baby’s ability to breastfeed and respond appropriately.
Jan Riordan found that babies born to mothers who had un-medicated labours had significantly better sucking skills compared to those babies with a medicalised birth. There are some early suggestions that epidural’s can predict lower neurological behaviour scores of newborns, but exposure to epidural analgesia alone was not found to be sufficient to affect breastfeeding ability. It does show that even in normal, healthy newborns, slight differences in central nervous system functioning was sufficient to affect breastfeeding on the 1st day of life. The majority of other findings, though, are not yet conclusive on whether epidurals specifically affect breastfeeding success rates.
During an epidural continuous IV fluid will be given throughout the course of labour and if over several hours this could be several litres. A pregnant women already carries an increased fluid volume and add to that the antidiuretic hormone, vasopressin, which exacerbates the fluid retention further and we can see how this is often responsible for breast and areola oedema we see at 2-4 days postpartum. This oedema and engorgement can last for up to 14 days. It makes the breasts very painful due to the increasing tightness surrounding the areola, babies can find it increasingly difficult to latch on to the breast and effectively drain the milk. This can be very uncomfortable and upsetting for mothers making it hard for her to breastfeed unaided. Reverse Pressure Softening (RPS) technique is recommended prior to every feed to relieve the oedema. Expressing the milk out prior to feeds will exacerbate this condition further if RPS has not pushed back the oedema first. See Jean Cotterman’s explanation here.
Birth trauma must not be only looked at in terms of the medical intervention involved but also the potentially disturbing psychological effects thereafter. A very good qualitative account following mothers from the US, UK, Australia and NZ found several recurring themes that either impeded or enhanced a new mother’s ability to breastfeed. The 5 themes women reported that had disrupted and intervened with their ability to continue breastfeeding were:
- Intrusive flashbacks of the birth
- Enduring pain
- Feeling violated
- Detachment from their baby
- Perceived low milk supply.
Too often we separate birth from breastfeeding as if they are two separate entities. How many women are informed that the type of birth they have may impact on their baby’s ability to breastfeed? Do we even discuss the effects of perineal pain or surgical scarring and the mother’s ability to sit comfortably and feed her baby? Do we give enough support and time to mothers who have had a medicalised, if not traumatic, birth? Are we able to build self-esteem and confidence in the small amount of time allocated to women’s psychological needs in hospital postnatal wards? If the evidence and our own knowledge supports this, why is there often little value and respect given to the midwife who spends time listening and talking with a mother, instead of the midwife who completes her tick-list of physical maternal checks? Do we value productivity over holistic care?
So how can we best help those babies who are neurologically impaired and not yet interested to feed? The most helpful answer is to go back to basics. A mother who has had a medicalised birth does not need another ‘expert’ to help her get breastfeeding going. Long labours, drugs and intervention lead to exhausted mothers and babies. At this time it is difficult for new mums to absorb and process new information. Let her hormones do the thinking by keeping mother and baby together, preferably in skin to skin contact and for as long as possible. Allowing both to rest and recuperate.
Hopefully the parents have been taught antenatally about the benefits of establishing milk supply early and are able to initiate hand expression without having to take on board too much new information. By maintaining babies sugar levels with frequently (2-4hourly) expressed colostrum until baby is ready to establish breastfeeds will ensure mother and baby are left alone together. This ‘us’ time can enhance bonding, reduce cortisol levels in mother and baby and allow gentle recuperation. Once baby is ready she will crawl down from her comfy spot, in-between mother’s breasts, find the nipple and initiate an instinctive Biological Nurturing form of attachment; baby led and mother learnt.
In a nutshell:
- Skin to skin contact (prolonged)
- Keep baby close to the nipple. Smell, smell and more smell, important!
- Express some colostrum onto nipple and baby’s mouth
- No strong smells of perfume on mum (future post to come re baby’s sense of smell and the relevance to breastfeeding).
- If baby doesn’t want to feed yet, offer help to the mother to aid her hand expressing her colostrum every 2-3 hourly. Give all EBM to baby.
- Reassure, Reassure, Reassure! Mums need to be calm and relaxed to help milk to flow and provide a reassuring environment for her newborn. Loving partners can give a well needed shoulder massage which will enhance oxytocin and help milk to flow.
- Once baby wants to breastfeed try the laid back style of Biological Nurturing to keep mum and baby relaxed. See this link to watch clip on biological nurturing.
If we leave mothers without adequate lactation support in the first few days and weeks we will inevitably continue to see this rapid decline in breastfeeding rates. Government initiatives have introduced BFHI into many hospitals but yet we see the biggest decline in breastfeeding after the first week; once mother and baby have left the hospital. How are breastfeeding rates to increase if we discontinue our lactation support at a mother’s most vulnerable stage? I admit, in many community areas there is fantastic support services for mothers and babies; I have worked in breastfeeding and postnatal drop-ins in both in the UK and Australia with amazing results. I have also worked as a community midwife in the UK for many years, but looking back even though most mothers received 3-4 postnatal home visits I felt we often did not provide the time needed. Unfortunately drop-ins and home visits are still not universal and prolonged postnatal care and lactation support is not on a high agenda for local or national governments. If we are to make a change we need to stand up for the basic rights of new parents to all receive universal support and care in the first 4-8 weeks. Lobby your local government, make breastfeeding awareness week count, be heard, stay positive and give and seek the best care possible.
Beck, Cheryl, Tatano, Watson, Sue 2008, Impact of Birth Trauma on Breast-feeding: A Tale of Two Pathways Issue: vol. 57 (4), July/August , pp. 228-236
Colson S (2007) Non prescriptive recipe for breastfeeding. Available at: http://www.biologicalnurturing.com/pages/downloadarticles.html
Cotterman, KJ 2004 Reverse Pressure Softening: A simple tool to prepare areola for easier latching during engorgement . J Human Lactation, 20, 227-237.
Growing Up In Australia: Longitudinal Study of Australian Children (LSAC) – Annual Report 2006-07 – Breastfeeding. Available at: http://www.aifs.gov.au/growingup/pubs/ar/ar200607/breastfeeding.html viewed 01 October 2011
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New Zealand Ministry of Health, (2002). Breastfeeding: A guide to action
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Thompson, RE Kildea, SV Barclay, LM et al. 2011, An account of significant events influencing Australian breastfeeding practice over the last 40 years. Women and Birth: the Journal of the Australian College of Midwives, Vol. 24, no. 3, pp. 97-104
World Health Organization 2002, The optimal duration of exclusive breastfeeding: Report of an expert consultation. Geneva, Switzerland.