Obstetric Practices and their
Possible Effects on the Initiation and Duration
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 complications.
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)
Breastfeeding Your Baby
One of the most special times in a mother's life is when she is breastfeeding her baby. Experts agree that breastfeeding is best.
Facts About Breastfeeding
Once feeding is established, the first milk that flows out of your breasts is watery and sweet. This quenches the baby's thirst and provides sugar, proteins, minerals and fluid. As the feeding goes on, the milk becomes thick and creamy. This milk will give your baby the nutrients he or she needs to grow.
To help give you a good start, during pregnancy tell your doctor that you plan to breastfeed.
During labor, remind the doctor and nurses that you plan to breastfeed. They can help you get started right after delivery.
How to Breastfeed
Cup your breast in your hand and stroke your baby's lower lip with your nipple. The baby will open his or her mouth wide (like a yawn). Quickly center your nipple in the baby's mouth, making sure the tongue is down, and pull the baby close to you. Bring your baby to your breast — not your breast to your baby.
Let your baby set his or her own nursing pattern. Many newborns nurse for 10 to 15 minutes on each breast.
Nurse on demand. When babies are hungry, they will nuzzle against your breast, make sucking motions, or put their hands to their mouth. Crying is a late sign of hunger.
When your baby empties one breast, offer the other. Don't worry if your baby doesn't continue to nurse, though.
Sex and Birth Control
Barrier methods such as latex condoms or a copper intrauterine device (IUD) are good options because they do not affect your milk supply.
Any breast milk is better than no breast milk. Try to breastfeed without supplementation for at least the first 6 months of your baby's life if you can.
Most often problems are easy to treat. If you have any of these signs of a problem, contact your doctor:
To keep your breasts healthy and to increase the chances of breastfeeding success, try these tips:
This excerpt from ACOG's Patient Education Pamphlet is provided for your information. It is not medical advice and should not be relied upon as a substitute for visiting your doctor. If you need medical care, have any questions, or wish to receive the full text of this Patient Education Pamphlet, please contact your obstetrician-gynecologist.
Copyright © July 2001 The American College of Obstetricians and Gynecologists
More Information about Breastfeeding:
Breast Feeding Book, The: Everything You Need to Know About Nursing Your Child
by William and Martha Sears (Author)