Obstetric Practices 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
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
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
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
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,
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,
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
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
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!
One of the most special times
in a mother's life is when she
is breastfeeding her baby. Experts
agree that breastfeeding is
Benefits Breast milk is nature's
perfect baby food. Your milk
has just the right nutrients,
in just the right amounts, to
nourish your baby fully.
There are many reasons why breastfeeding
is best for your baby:
The colostrums — a
yellow, watery pre-milk
— that your breasts
make for the first few
days after birth helps
your newborn's digestive
system grow and function.
Breast milk has antibodies
that help your baby's immune
system fight off sickness.
The protein and fat in breast
milk are better used by
the baby's body than the
protein and fat in formula.
Babies who are breastfed
have less gas, fewer feeding
problems, and often less
constipation than those
Breastfed babies are at
lower risk for sudden infant
death syndrome (SIDS).
Breastfeeding isn't just good
for babies. It's good for mothers,
Releases the hormone oxytocin.
This makes the uterus contract
and helps it return to
its normal size more quickly.
May lower your risk of osteoporosis
and some forms of cancer.
Is cheaper than bottle feeding.
Creates a special bond between
you and your baby.
Facts About Breastfeeding
During pregnancy, your nipples
may start to drip a little colostrum.
After you give birth, your body
sends a signal to your breasts
to start making milk. Within
a few days, colostrum is replaced
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.
Although breastfeeding is a
natural process, it may take
some practice and patience to
master. Mothers and babies have
to learn together.
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
Babies are born with the instincts
they need to nurse, such as
the rooting reflex.
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
Let your baby set his or her own
nursing pattern. Many newborns
nurse for 10 to 15 minutes on
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
When your baby empties one breast,
offer the other. Don't worry
if your baby doesn't continue
to nurse, though.
When you are pregnant, your
body stores extra nutrients
and fat to prepare you for breastfeeding.
When you are nursing:
Eat a well-balanced diet.
Make sure you get 1,000
mg of calcium a day.
Avoid foods that bother
Drink at least eight glasses
of liquid a day.
Sex and Birth Control
When you are ready to resume
having sex, think about birth
control. Even though you may
not have menstrual periods while
you are breastfeeding, you can
still get pregnant. Talk with
your doctor about what form
of birth control is right for
Barrier methods such as latex
condoms or a copper intrauterine
device (IUD) are good options
because they do not affect your
Many mothers keep nursing their
babies after they return to
work. If you want to breastfeed
when you go back to work, you
may want to look into buying
or renting a breast pump.
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.
As they start to breastfeed,
some women may have a few minor
problems. Problems that may
- Sore nipples
- Blocked ducts
- Mastitis (an infection of
the breast caused by bacteria
in the milk ducts)
Most often problems are easy to
treat. If you have any of these
signs of a problem, contact
To keep your breasts healthy and
to increase the chances of breastfeeding
success, try these tips:
Learn proper nursing technique.
Use your finger to break
the suction before you
remove your breast from
your baby's mouth.
Gently pat your nipples
dry with a clean cloth
Use only cotton bra pads.
Apply 100 percent pure lanolin
to your nipples after feeding.
Don't wash your nipples
with harsh soaps or use
If one nipple is tender,
offer the other breast
Breastfeeding is a special gift
of love and health only you
can give your baby. Breastfeeding
is natural, but it takes practice.
You and your baby can learn
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.