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Session 5 birth practices and breastfeeding 2016
- 1. Birth Practices andBreastfeeding Session 5 Larry Hogan, Governor Boyd Rutherford, Lt. Governor Van Mitchell, Secretary, DHMH
- 2. Identify laborand birth practices that support breastfeeding Recognize birth practices that can interfere with breastfeeding Discuss the importance of early skin-to-skin contact Discuss ways to foster early initiation of breastfeeding Identify ways to support breastfeeding after a Cesarean birth 2
- 3. Support personor doula during labor Encourage comfortable birthing positions and ambulation Food or drink during labor Encourage non-medicated births Keep mother and baby together Source: United States Breastfeeding Committee
- 4. Pitocin use ◦Lower Apgar scores ◦ Increased anxiety and pain ◦ Inhibits oxytocin release ◦ Fluid retention Overhydration with IV fluids ◦ Breast edema ◦ Difficulty latching ◦ Increased newborn weight loss Source: University of Maryland Upper Chesapeake Medical Center
- 5. All painrelief medications cross the placenta ◦ Peripheral IV ◦ Epidurals Timing of analgesia is important Complications Non-medicated pain relief
- 6. Forceps andvacuum extraction Episiotomy Gastric and vigorous suctioning Eye prophylaxis before the first hour Separating mother and baby ◦ Bathing newborn at delivery ◦ Swaddling and wrapping newborn ◦ Taking newborn to nursery for assessments or procedures Source: United States Breastfeeding Committee
- 7. Place babiesskin-to-skin ◦ Immediately following birth ◦ Uninterrupted for first hour ◦ No clothing between mother and baby ◦ Dry infant while on mother’s chest ◦ Until first breastfeeding completed ◦ All infants, regardless of feeding plan Source: United States Breastfeeding Committee
- 8. Source: United StatesBreastfeeding Committee
- 9. Assisting withthe first feeding ◦ Pre-feeding behaviors Short rest periods Feeding cues Hands to mouth Licking Sucking motions Touching nipple Moving towards the breast Finding the nipple Source: B. Wilson-Clay / K. Hoover
- 11. Source: University ofMaryland Upper Chesapeake Medical Center. Used with permission.
- 12. Increases durationof breastfeeding Warms and colonizes baby More quickly stabilizes vital signs Provides antibody protection through colostrum Babies learn to suckle more effectively Improves developmental outcomes
- 13. Concerns ofcold stress Baby needs ◦ Exam ◦ Bath Insufficient staff Mother needs ◦ Tired ◦ Perineum repair Source: United States Breastfeeding Committee
- 14. Maternal disappointmentin birthing process ◦ Unexpected or unplanned ◦ Separation from newborn Impact on breastfeeding o Delay in Lactogenesis II o Newborn lethargic o Suctioning of infant o Delay in early contact o Separation
- 15. Assist motherwith skin-to-skin as soon after the delivery as possible Assist mother to find positions that are comfortable ◦ Laid-back (biological nurturing) ◦ Side lying ◦ Clutch/football Source: B. Wilson-Clay / K. Hoover
- 16. Observe infantsclosely for feeding cues Routine interval Assessment of infant by physician Limit visitors Source: United States Breastfeeding Committee
- 17. Baby-friendly practicessupport women whether or not they are breastfeeding ◦ Support during labor ◦ Skin-to-skin ◦ Respect a mother wishes ◦ Replacement feedings, if applicable Source: United States Breastfeeding Committee
- 18. American Academyof Pediatrics Policy Statement. (2012). Breastfeeding and the use of human milk. Pediatrics, 129, e827-e841. Berlin, Y. (2005). "Effect of labor epidural analgesia with and without fentanyl on infant breast-feeding: a prospective, randomized, double-blind study." Anesthesiology, 103(6), 1211-7. Crenshaw, J. T., Cadwell, K., et al. (2012). Use of a video-ethnographic intervention (PRECESS Immersion Method) to improve skin-to-skin care and breastfeeding rates. Breastfeed Med, 7(2), 69-78. Erlandsson, K., Dsilna, A., et al. (2007). Skin-to-skin care with the father after cesarean birth and its effect on newborn crying and prefeeding behavior. Birth, 34(2), 105-114. Gouchon, S., Gregori, D., et al. (2010). Skin-to-skin contact after cesarean delivery: an experimental study. Nurs Res, 59(2), 78-84. Hung, K. J., & Berg, O. (2011). Early skin-to-skin after Cesarean to improve breastfeeding. The American Journal of Maternal Child Nursing, 36(5), 318-326.
- 19. Moore, E.R., Anderson, G. C., et al. (2012). Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst, Rev 5, CD003519. Nolan, A., & Lawrence, C. (2009). A pilot study of a nursing intervention protocol to minimize maternal-infant separation after Cesarean birth. J Obstet Gynecol Neonatal Nurs, 38(4), 430-442. Romano, A.M., & Lothian J.A. (2008). Promoting, protecting, and supporting normal birth: a look at the evidence. J Obstet Gynecol Neonatal Nurs, 37(1), 94-104. Smith, J., Plaat, F., et al. (2008). The natural Cesarean: a woman-centered technique. BJOG, 115(8): 1037-1042. Smith, L. (2010). Impact of Birthing Practices on Breastfeeding. Sudbury, MA: Jones and Bartlett Learning.
- 20. Teich, A.S., et al. (2014). Women’s perceptions of breastfeeding barriers in early postpartum period: a qualitative analysis nested in two randomized controlled trials. Breastfeed Med, 9, 9-15. Thurman S. E., & Allen P.J. (2008). Integrating lactation consultants into primary health care services: are lactation consultants affecting breastfeeding success? Pediatr Nurs, 34, 419-425. Velandia, M., Uvnas-Moberg, K., et al. (2012). Sex differences in newborn interaction with mother or father during skin-to-skin contact after Cesarean section. Acta Paediatr, 101(4), 360-367. World Health Organization (2003). Kangaroo mother care: A practical guide. Geneva, Switzerland: Department of Reproductive Health and Research.
Editor's Notes
- #2 Read title and subtitle.
- #3 Labor and birth is a normal and healthy process. Instinctually and inherently women and infants have the ability to birth and breastfeed without much intervention. During this session we will identify birth practices that support as well as interfere with breastfeeding to better understand our role in providing evidence based care to the breastfeeding couplet. We will discuss the importance of skin-to-skin and early initiation of breastfeeding to improve exclusivity of breastfeeding and learn ways to help support mothers to be successful after medical interventions.
- #4 “The mother’s confidence in her ability to birth leads to confidence in her ability to breastfeed.” Research has shown that providing a mother with positive support and encouragement during labor builds confidence in her abilities, improves not only labor outcome, but also breastfeeding success . Research by Smith in 2010 showed positive, empowering attitudes from hospital staff support a mother’s confidence and ability to birth and breastfeed her newborn. Too often hospital practices , without meaning to, undermine and discourage breastfeeding. Research has shown that, when women labor without a chosen support person to help and comfort them during the birthing process, this leads to feelings of dissatisfaction with the delivery, increased use of medications for pain management, and increased labor and delivery interventions, such as augmentation and cesarean deliveries. Encouraging mothers to ambulate and labor in comfortable positions help a mother feel in control of her body and have been shown to aid in the birthing process. There is no evidence for the practices of restricting food, drink, or confining a woman to a bed in a supine position . The use of medications during labor and postpartum to control pain, may improve the mother’s comfort by providing relief during labor and aiding in her recovery process. But these medications also come with risks that may affect the course of labor and impact effective breastfeeding. These practices can undermine the mother’s ability and confidence to breastfeed, and also affect the infant’s ease of learning to breastfeed. Women need to be informed of the potential negative influence of anesthesia on their infants’ behavior and breastfeeding initiation, so they can make an informed decision about pain management. Encouraging and supporting women in having non-medicated births has been shown to improve breastfeeding outcomes. Massage, hypnotherapy, and hydrotherapy are all effective non-medicated methods for pain management, that have no negative consequences for the mother or the baby. Keeping mother and baby together after birth improves, not only breastfeeding, but the over all health of the infant. After birth, infants should immediately be placed skin-to-skin on their mothers’ chest and left there uninterrupted throughout the recovery period.
- #5 Whenever possible, women should be encouraged to avoid unnecessary use of pitocin and IV fluids during labor. Research has shown inductions or augmentations of labor, before medically indicated, increase the risks of breastfeeding difficulties and the use of medical interventions, such as episiotomies, forceps use, and vacuum extractions. The use of pitocin and intravenous fluid during labor and delivery, can also have an impact on the mother’s body after the delivery, and negatively effect breastfeeding. Intravenous fluids for labor should only be used for clear medical indications. An association has been shown between low apgar scores with epidural use and infants with low apgar scores in turn exhibiting breastfeeding difficulties. A study done by Beebe in 2007 found that 1-minute Apgar scores of ≤3 were significantly more likely to occur after elective induction, than after spontaneous labor. A 2009 Global Survey by The World Health Organization (WHO) found that infants born to mothers whose labor was induced, had twice the risk of a 5-minute Apgar score of <7 compared to those who were not induced. Other studies have found that a 1-minute Apgar score of <7, was associated with increased risk of difficulties with breastfeeding at 3 days after birth, and a similar study by Matias in 2010 showed that a1-minute Apgar score of <8 was the main predictor of delayed onset of lactogenesis. Research suggests that induction of labor can also be related to hyperbilirubinemia, neonatal resuscitation, shoulder dystocia, admission to a neonatal special care unit, and abnormal heart rates. Induction of labor has also been associated with maternal increase levels of anxiety and pain during labor, and stronger and more painful contractions. When pitocin, otherwise known as synthetic oxytocin, is used, it occupies the body's oxytocin receptors. This process can inhibit the body’s natural oxytocin from being produced, thereby interfering with the milk making process and optimal milk production. Pitocin acts similar to an anti-diuretic, causing the body to retain fluids. Mothers given pitocin often experience increased edema, not only of the hands and feet, but also of the breast and areolar tissue. Edema in the areola and breast can flatten the nipples or decrease the elasticity of the nipple tissue, causing difficulties with latching. If a baby cannot latch effectively to drain the breast, risk of engorgement and edema increases, leading to decreased milk removal and sub-optimal milk production. Breast milk production is driven by supply and demand; when milk is removed, more milk is made. Over-hydration from IV fluids can also lead to breast and areolar edema, causing the same difficulties with breastfeeding that lead to inadequate milk removal and inhibited milk production. Research has shown that maternal over-hydration can result in excessive weight loss in the newborn, possibly as a result of diuresis and vasoactive hormones, leading to unnecessary supplementation. Any time difficulties with latching occur, this can lead to increased edema of the breast tissue, causing a decrease in milk removal and potentially a decrease in milk production, and sometimes lead to unnecessary supplementation.
- #6 Women need to know about the potential effects that narcotic pain medication may have on them and their babies after delivery, and the negative impacts these effects can have on breastfeeding. All pain relief medications cross the placenta, and have the potential to cause infant sedation and depression of motor abilities in the first few hours after birth. When a fetus is exposed to large doses of pain medication, it greatly increases the risk of breastfeeding difficulties during hospitalization. Peripheral IV medications are used early in labor to help mothers relax and focus on birthing techniques. Often mothers choosing this option are intent on avoiding epidurals. Epidural pain medications, on the other hand, which is typically used throughout the labor process, are less likely to cause infant sedation. However, infants exposed to epidural narcotics during labor have decreased hand motions and sucking reflexes in the first hours after birth, and are more likely to be supplemented during the hospital stay. Recent research has found a dose-response relationship between the dose of fentanyl used and subsequent bottle feeding at time of discharge, with lower doses correlated with better breastfeeding outcomes, and a relationship between higher doses and weaning from the breast by six weeks. When using Patient Controlled Epidural Analgesia (PCEA), it is important to educate the mother to use as little as needed when giving self boluses, for better chances of easier breastfeeding outcomes during the early hospital period. Timing is important whether using peripheral or epidural pain relief. Peripheral medications are typically given during early labor to minimize occurrence of newborn sedation and potential respiratory depression. Peripheral IV pain management, if given too close to delivery, can cause sedation in a newborn, whereas too much epidural medication given close to delivery has been associated with decreased motor skills of the newborn. Both scenarios negatively affect breastfeeding. Epidural pain anesthesia has also been associated with other risk factors that can interfere with breastfeeding . Mothers are 16 times more likely to experience a fever after epidurals versus when no epidural pain medication was administered. Babies of mothers who received epidurals were 4 times more likely to have lower apgar scores at 1 minute, more likely to require bag and mask ventilation, receive oxygen in the nursery, and have a higher risk of seizures in the neonatal period. Further studies are needed to explain the exact nature of the association between epidural use and difficulties with breastfeeding. In order for infants to be successful with breastfeeding, they must be active and alert, with a coordinated suck and swallow. However negative outcomes from induction, IV’s, and epidural use impair the physiological functioning of infants, potentially interfering with successful breastfeeding. This is especially true of infants separated from their mothers. Keep in mind that non-medicated pain relief options exist! Offer women these first. Suggest that women walk and move around, use massage, warm water, frequent changing of labor positions, use of birthing balls, and most importantly have a support person help to reduce the use of pain medications in labor.
- #7 Studies show operative procedures, such as forceps and vacuum extractions, increase the odds of an infant having difficulties with breastfeeding after delivery. Deliveries using instruments such as forceps and vacuums can be traumatic, affecting head and neck nerve and muscle function, causing the baby to have difficulty attaching and breastfeeding. Episiotomies result in maternal pain, especially when sitting. Encourage the mother to hold her baby skin-to-skin during her episiotomy repair, to prevent separation of mother and baby and teach her to nurse in positions that will be comfortable. Gastric suctioning or vigorous suctioning of an infant’s mouth and nose after delivery has been associated with a delay of suckling and rooting reflexes. When suctioning is necessary, gentle use of a bulb syringe to suction the nose and the mouth is recommended. Delaying routine procedures, like eye care and bathing in the first hour of life, is recommended, along with delaying any unnecessary procedures that would remove the baby from the mother’s arms and interfere with initiation of early breastfeeding . Early breastfeeding within the first hour of life has been associated with continued breastfeeding after discharge. Mothers should be encouraged to breastfeed as soon as possible after delivery. Separation of newborns after delivery, including the barrier between mom and baby of the swaddled infant’s blanket, interferes with predictable behavior patterns of self-attachment and delays the start of effective suckling. An initial set of vital signs, assessment, and identification banding can be done while the infant is in skin-to-skin on the mother’s chest. Bathing, weighing, measuring, and obtaining foot prints can all be done after the first breastfeeding and /or after one hour of uninterrupted skin-to-skin has taken place. Remember, skin-to-skin is beneficial for all stable newborns, regardless of the mother’s feeding plan.
- #8 Skin-to-Skin contact between mother and baby should be uninterrupted during the first hour after birth. The American Academy of Pediatrics (AAP) recommends “ avoiding procedures that may interfere with breastfeeding or may traumatize the infant, including unnecessary, excessive, and overly vigorous suctioning. Delaying of procedures such as weights, measurements, bath, needle sticks, and eye prophylaxis should wait to be done until after the first feeding.” Immediately after the baby is born, place the baby skin-to-skin on the mother’s chest, to facilitate imprinting of proper breastfeeding techniques. No clothing should be between the mother and the baby, other than baby’s hat and diaper. You may want to ask the mother to prepare while in labor, by removing her bra and other clothing that could interfere with achieving skin-to-skin. Once the baby is born, place the baby naked on the mother’s bare chest or abdomen, and dry the baby while on the mother. Make sure to remove wet towels, and dry between the mother and the baby to ensure that the baby does not become cold-stressed. After the baby has been dried, clamping of the cord can occur with the baby on the mother’s chest. Place a warm blanket over the mother and the baby. Assessing babies’ vital signs and placement of identification bands can be easily accomplished with baby on mother. Infants should remain skin-to-skin until the first feeding has occurred spontaneously for breastfed infants, and for at least the first hour after birth. The first spontaneous feeding may take longer to occur for the infant who was exposed to medications, or during deliveries which required other medical interventions. Skin-to-skin should be routine for all stable newborns, regardless of the mother’s feeding plans. Babies who are not stable and need medical intervention should be allowed to go skin-to-skin once stable.
- #9 Suckling and skin-to-skin contact within the first hour after delivery has a positive impact on breastfeeding at 3 months, and increases duration of breastfeeding.
- #10 When mother and baby are allowed to be skin-to-skin, uninterrupted after delivery, the baby moves through a series of pre-feeding steps in preparation for breastfeeding. Teaching a mother to recognize these behaviors will help her to learn and understand her baby's feeding cues, and recognize when he is ready to feed. The baby will start out with a short resting phase of alertness taking in his new surroundings. Shortly after, he will begin with feeding cues, moving his hands towards his mouth, making sucking motions, rooting, licking, moving his hands towards the mother’s nipples. In between these periods, one often observes stages of rest. Eventually the baby starts crawling and sliding towards the breast , focusing on the dark area around the nipple. Allow the baby to move towards the nipple. Try to let the baby spontaneously find the breast, yet assist and help the mother reposition him if needed. Babies are born with a natural instinct to find the nipple and open wide to attach. This first time at the breast should be for the mother and baby to bond, and become familiar with each other, and with the process of breastfeeding. Avoid any pressure for the mother to hurry and complete the first feeding. Help her into a comfortable position. Point out her baby’s positive behaviors, such as rooting and looking for the breast. Wait for the next feeding to work on correcting positioning and latch.
- #11 This video was developed to help the staff at a hospital going through the Baby Friendly journey learn how skin-to-skin could be accomplished in the hospital environment. With much reservation, the staff has now embraced the practice, and seen improvements in breastfeeding initiation and duration rates. Although concerned that mothers would reject wanting their babies place un-bathed on their chests, staff were surprised with the overwhelming acceptance from all mothers, regardless of education and socioeconomic status. Take a minute now to view the skin-to-skin video.
- #13 Babies placed skin-to-skin are kept warm by their mothers’ body temperature and are colonized by their mothers’ natural bacteria. This is associated with a decreased incidence of hospital-acquired infections. Babies kept skin-to-skin with mothers maintain and stabilize their vital signs-- temperatures, heart rate, blood pressure, respiratory rate, and even blood sugars quicker. During this early period, babies learn to suckle more effectively, and experience improved developmental outcomes.
- #14 Many real or perceived barriers exist in the implementation of skin-to-skin (STS) care. Often barriers are related to common and traditional practices among maternity staff, rather than medical needs. Changes in practices can better facilitate the desired outcome. It is important to keep current and change practices as the evidence dictates. Exams, routine vital signs, and treatments can safely be done while the baby is skin-to-skin on the mother, or postponed until after the first feeding. After delivery, babies can be wiped clean and dried with a towel while on the mother’s chest. The bath can wait several hours or become part of routine teaching of baby care at a later time during the hospitalization. Allowing the baby to remain skin-to-skin with the mother does not require additional staffing; rather, it allows the labor and delivery nurse time for routine documentation and post-birth nursing responsibilities. It is important that a mother not be left alone during that first hour she and baby are skin-to-skin. A staff member should always be close by, in case a mother or baby were to become unstable. Mother can rest while her baby is safe with her. Having the baby on her body is a welcome distraction for the mother who requires uncomfortable post-delivery perineum care. This also sets the stage for the mother to see the natural transition to 24 hour rooming-in. Research has shown that mothers receive more restful sleep when babies room-in with them.
- #15 Cesarean deliveries, while common in the United States, are not without consequences. Unexpected or unplanned cesarean delivery can cause disappointment and grief from the loss of not experiencing a vaginal birth and feeling of inadequacy or failure. If the cesarean was an emergency, the infant may need to be stabilized or even taken to the nursery for medical treatment. This often adds to the disappointment in the birthing process. As soon as possible when the mother can respond to her baby, the mother and infant should be allowed to have uninterrupted skin-to-skin. Whenever there is a need for a Cesarean delivery or medical intervention, breastfeeding can be negatively impacted. Knowing how various delivery events affect breastfeeding helps hospital staff be able to intervene to protect and support breastfeeding. Whenever a mother has a Cesarean or a medical delivery, the trauma of surgery and the resulting pain can delay Lactogenesis II. This is one strike against breastfeeding. The increase in milk volume after delivery takes longer than expected. In addition, babies born by C-section delivery often are lethargic or slow to begin breastfeeding, due to anesthesia. Overly aggressive suctioning of the oral cavity after delivery can result in oral defensiveness, making the baby resistant to having anything in its mouth. Babies that are born via C-section are more likely to be taken to the nursery and to be separated from their mothers, delaying early contact and increasing the potential for supplementation.
- #16 It may take a little longer for the mother who has had a cesarean birth to be able to hold her baby skin-to-skin due to surgery. Assist the mother with skin-to-skin as soon as it is safe and possible, when both are in stable condition. The mother may feel uncomfortable with the baby directly on her abdomen, so help her position the baby across her chest or in the football hold, to reduce pressure on her incision. Laid back, side-lying, and football hold positions, or having a pillow on the mother’s lap, all are techniques that women who deliver via cesarean find helpful. The added assistance of the father or other support person may also be effective.
- #17 If infants do not self-attach and breastfeed in the first hour after delivery, more skin-to-skin may be necessary. Encourage the mother to practice skin-to-skin often in the first few days. Teach the mother to watch for early feeding cues and help her to initiate breastfeeding. Nurses should monitor these infants on routine intervals to assess and watch for feeding cues. Babies who do not self-attach in the first few hours should be given a comprehensive assessment by a pediatrician. A referral to the lactation consultant should also be implemented. Lactation consultants can anticipate and manage when unexpected breastfeeding issues occur. Consider having the mother limit visitors in the first few hours, so she and baby can have a chance to learn how to breastfeed without interruptions. Sometimes babies may not be breastfeeding because they are getting attention from other family members, or visitors are distracting the mother from focusing on her new baby and the infant care she needs to learn..
- #18 Most hospital birthing practices that impact breastfeeding also affect those mothers who choose not to breastfeed. If your hospital is following the Baby Friendly Hospital Initiative, you will not only support breastfeeding mothers, but also those mothers that cannot or choice not to breastfeed. The mother-baby dyad that experiences any level of medical intervention during the delivery process, can potentially experience added challenges with healing and learning new tasks. Teaching all mothers what to expect regarding their recovery and ability to care for their newborns. Mothers should have continuous support during labor, allowing for early and uninterrupted skin-to-skin regardless of their feeding choice. Unless there is a known medical reason not to breastfeed, all mothers should be encouraged to breastfeed. If a mother plans to formula feed, proper formula preparation and bottle-feeding techniques should be taught shortly after delivery. Normal newborn behavior teaching will help new families understand their new babies and the ways to best care for them once home.