Tova Ovits, Brooklyn, New York, USA
Originally printed in Leaven Issue 2, 2014.
“Hello? Yes, this is La Leche League. How can I . . . ? Mmm hmmm. Yes. Wow. Sounds really painful! Let’s start from the beginning. Can you tell me a little about your labor and delivery?”
This seemingly unrelated question does more than let a mother share her birth story and build rapport. It may also give a Leader the information she needs to help a mother figure out where her troubles started and options for how to proceed. Simple questions can confirm which birth interventions may have impacted—and perhaps continue to impact—early breastfeeding.
The “normal” birth
La Leche League has always believed that alert and active participation by the mother in childbirth helps to get breastfeeding off to a good start. However, popular opinion promotes a perception that inductions and interventions are part of a “normal” birth as long as the baby is born vaginally. Also, one in three American mothers will leave the hospital with an abdominal incision [CDC Birth data 2013]. Because of these factors, helping calls from mothers who had natural, unmedicated births seem rare in the United States.
Birth interventions interfere with breastfeeding
In the United States, many laboring mothers today enter the hospital expecting unbearable pain and immediately request an epidural. Numbing a mother from her waist down requires that she stay in bed, immobile, and fight gravity when told “it’s time” to push. If labor slows or contractions weaken because gravity is no longer moving the baby down, pitocin (a synthetic oxytocin) is often given intravenously to speed up the contractions. Pitocin requires internal monitoring to ensure that the baby can tolerate the unnaturally strong contractions. If labor doesn’t progress along the doctor’s anticipated time frame, a cesarean section or forceps/vacuum extraction, along with an episiotomy, often appear in the birth story.
Breastfeeding helps prevent hemorrhaging due to the natural oxytocin produced when the baby suckles which both helps trigger the let-down reflex and helps the uterus contract. However, whether they plan to breastfeed or not, most mothers receive more Pitocin by intravenous drip (IV) to prevent hemorrhaging after delivery.
Each intervention can interfere with early breastfeeding. Asking specific questions about her birth experience can guide the Leader’s suggestions for each mother who calls.
Can you tell me more details about the induction?
The World Health Organization (WHO) recommends limiting inductions to those that are medically necessary, less than ten percent of all births (The Womanly Art of Breastfeeding Eighth edition, 2010, page 55). Inductions based on estimated due dates can result in premature births. Babies who aren’t ready to be born may not suck well. In addition, the drugs used during an induction can disorient babies after birth. See Bell et al, 2012 and Handlin et al, 2009.
Keeping mother and baby skin-to-skin can help as the drugs leave their systems. Induced babies may need more guidance, including breast shaping (such as tilting the nipple, narrowing the “breast sandwich,” etc., The Womanly Art, page 75) and breast compressions (The Womanly Art, pages 112–113) before they are able to self-latch and breastfeed well.
Did you have an epidural? For how many hours was the catheter in?
The 2009 Leader Accreditation Department booklet, Childbirth and Breastfeeding, can be used by Leader Applicants to meet the childbirth learning requirement. The booklet states:
“Possible side effects [of an epidural], such as maternal fever or a drop in maternal and/ or infant blood pressure, may lead to further postpartum/postnatal intervention. Epidurals may be more likely to result in either cesarean birth or a forceps/vacuum-extractor delivery than an unmedicated labor. Research shows that after an epidural, babies are less alert, less able to orient themselves, and have less organized movements; these differences are measurable during the baby’s first month. After an epidural, the mother’s back may feel stiff, achy, or sore.”—page 8.
If the epidural was in place for hours before the birth, it can take hours, days, or weeks for the baby to “wake up” to nurse easily. The instinctual latching and bonding are further delayed if babies are not kept skin to skin with their mothers and are whisked away to be weighed and bathed, or if the baby was sent to the nursery overnight.
If a mother says she had an epidural, we can suggest that she keep her baby skin to skin at home, whenever possible for as long as possible. This constant access to mother’s breast can help the baby orient himself and awaken his natural feeding instincts.
The injection site on the mother’s back may be sore where the epidural catheter was inserted. She may be uncomfortable sitting to nurse for the long, frequent periods that a newborn often requires. Using a laid-back (The Womanly Art, pages 63–66) or side-lying position (The Womanly Art, pages 72–73) when nursing can make mother comfortable enough to look at the baby’s feeding cues instead of the clock to start and end feeds.
Did you have an intravenous line during or after labor? Are your ankles swollen?
Many mothers who call about being engorged when their mature milk comes in are actually experiencing edema caused by IV fluids. Their ankles are often swollen because of the fluids or pitocin given by IV during labor or after birth. Those fluids can also go into the interstitial spaces [small, narrow spaces between tissues] of the breasts, between the milk ducts. The edema can make the areola too hard and firm for a baby to latch well and transfer milk efficiently.
Reverse pressure softening
If a mother received IV fluid and complains of engorgement during the first two weeks, we can tell her how to do Reverse Pressure Softening (RPS), as explained in The Womanly Art on page 387 and in the Leaven article by K. Jean Cotterman, “Too Swollen to Latch On? Try Reverse Pressure Softening First” 2003.
Using RPS pushes fluids away from where the baby’s mouth needs to be, softening a “landing platform” for him so that he can attach deeply and remove milk effectively. Encouraging a mother to relieve the pressure by using hand expression instead of pumping can also help resolve the painful engorgement caused by IV fluids without exacerbating the swelling. Sometimes a mother’s breasts are so full of fluid that they are like shiny, plastic breasts that stand up like a fashion doll’s breasts, even if the mother is lying on her back. Gently massaging the fluid up toward the lymph nodes in her armpit can relieve the pressure of engorgement as well. For more engorgement cautions and suggestions, see pages 385–388 in The Womanly Art of Breastfeeding.
Did the doctor perform an episiotomy?
Many mothers who have a perineal incision and closure with stitches are more uncomfortable when they sit to feed than mothers who gave birth without perineal injury. If mother and baby were separated during the suturing, the interruption or delayed skin-to-skin time can also inhibit early breastfeeding, according to Linda J. Smith and Mary Kroeger in their book, Impact of Birthing Practices on Breastfeeding: Protecting the Mother and Baby Continuum. We can suggest that the mother consider breastfeeding in the side-lying or the laid-back positions to take pressure off the sore area. She might try sitting on a breastfeeding pillow to become more comfortable.
Did the doctor use forceps or a vacuum extractor?
Sometimes the answer is obvious if you see the baby because the vacuum extractor can leave a golf-ball size lump on the baby’s head, and forceps can leave long bruises down his cheeks. Babies are normally pushed out of the birth canal. Being pulled out can hurt a baby’s head, neck, and nerves, making it difficult for the baby to latch well. Tilting baby’s head for the typical asymmetrical latch may bring discomfort to his head. Instead, using the clutch or “football” hold (described in The Womanly Art on page 72) while supporting his neck helps make the baby comfortable enough to latch.
How long were you in labor before your cesarean?
In the United States, one in three mothers gives birth by cesarean section: about 33%, far above the WHO-suggested maximum of 10 to 15%. At one local LLL Group’s recent Topic 2 Series Meetings, five of the six new mothers in the room had had a cesarean; the mother who birthed naturally had attended LLL meetings while pregnant, while the others had not.
Cesarean section births include many of the aforementioned interventions: drugs, edema-causing IVs, separation, and pulling the baby out by his head. Babies born via scheduled cesareans may also be born before they are ready. Babies are often separated from mothers after a cesarean and are sleepy or disoriented from the drugs. Skin-to-skin contact can help elicit baby’s instinct to breastfeed. The trauma of surgery can delay lactogenesis II (the onset of copious milk secretion, when the milk “comes in”), and a mother may fear that she doesn’t produce enough milk for her baby, even though a newborn’s stomach on Day 1 is only about the size of a small marble (1/2 inch or 1.3 cm in diameter).
If babies can’t be put to the breast and are bottle-fed instead of fed colostrum via spoon, syringe, or cup, these babies often find it harder to latch on. A silicone nipple shield (The Womanly Art, pages 405–407) can help trigger the baby’s sucking reflex if he is used to a bottle teat touching his palate. Expressing drops of colostrum before latching may give the baby the instant reward he is used to receiving from a bottle.
A mother’s incision site may make it hard to find a comfortable position to hold the baby to breastfeed. The Womanly Art (page 58) suggests that mothers try breastfeeding in the recovery room after a cesarean section, perhaps with someone else helping to position the baby. If you are helping a mother after she is home from cesarean surgery, you can suggest a number of possible nursing positions: baby at her side, across her chest or below the opposite breast, in mother’s armpit, or even along mother’s face with his feet near a bed’s headboard. For more about positioning after a cesarean, see page 74 in The Womanly Art.
Preparing for next time
As we help and support mothers and their babies as they learn to breastfeed, we also listen to their birth stories. Active listening helps women process their births. As they tell us about the interventions they experienced, we can offer information, and then they can help their friends and family members who may be having babies soon (and themselves, of course, when the next birth takes place) to avoid the cascade of interventions and get breastfeeding off to a better start.
Smith, L. J. and Kroeger, M Impact of Birthing Practices on Breastfeeding: Protecting the Mother and Baby Continuum, Second Edition, Jones & Bartlett Learning, 2010: 160–161.