|
Breastfeeding and birthing
Do birthing practices affect breastfeeding?
Interventions and the use of pain medications
during birthing have always been controversial and no less so today as
mothers and birthing experts are rediscovering the profoundly
interrelated processes of birthing and breastfeeding. The classic
breastfeeding video Breast is Best,[1]
shows the tender and moving journey of a newborn to find her mother’s
breast. With umbilical cord attached and all senses alert the new baby
wriggles across her mother’s abdomen towards the breast, and finds the
nipple to begin the new mother-baby relationship of breastfeeding.
Another classic image is one produced by Lenard Righard[2] in
Delivery and Self-Attachment based on the 1990 Swedish study[3]
documenting the behaviours of 72 infants during the first two hours
following a normal birth. After about 50 minutes more than half the
infants were blissfully sucking at the breast. Infants who were left
uninterrupted (with no cleaning and dressing) ended up with the best
sucking technique. However 40 (56 per cent) of the 72 mothers had
received pethidine during labour. Subsequently their infants were also
sedated and most of those who were medicated (25/40) did not suck at
all. The authors recommended that contact between mother and infant
should be left uninterrupted during the first hour after birth or
until the first breastfeed has been accomplished, and that use of
drugs such as pethidine during labour should be restricted.
Since the production of these classic teaching
videos, some interesting and useful research data has emerged to give
us greater insight into the impact of birthing practices and labour
medications on breastfeeding behaviours. Recent Australian[4]
prospective research to determine the effect of epidural analgesia
containing fentanyl on breastfeeding initiation and duration warns us
of the effects of opioid drugs commonly used during labour and
delivery. The study, which included 1280 women, used surveys to
examine difficulties in breastfeeding during the first week
post-partum and cessation of breastfeeding during the first 24 weeks
of life. Results confirmed earlier research and
concluded that women who had received epidurals were less likely to
fully breastfeed their infants during the first few days after birth
and were also more likely to stop breastfeeding before their infants
were 24 weeks of age.
The relationship between different dosages of
epidural medications and breastfeeding outcomes has also been
explored. A UK-based retrospective study of 424 women,[5] 45 per cent of
whom were exclusively bottle feeding after hospital discharge, noted
that the dose of fentanyl adversely effected breastfeeding for each
microgram of fentanyl administered.
Although much more information is needed to
determine the effects and causal relationships associated with various
interventions, there is considerable information to help guide both
mothers and health care workers as to if and how interventions should
be practised and how breastfeeding — and subsequently infant
health — is impacted.
What is needed?
Just as mothers and babies form an inseparable
dyad, birthing and breastfeeding need to be recognized as a continuous
passage and not two separate events.
Babies must be placed on their mothers abdomen
skin-to-skin immediately after birth and left uninterrupted to
continue the passage to the breast (step 4 of the BFHI).
Interventions must stop. The common and still
routine procedures after birth are damaging to the mother-baby dyad
and interfere with the establishment of breastfeeding. Cord care,
weighing & measuring, dressing & ID tagging, wrapping/swaddling, eye
medications, vitamin K injection/drops, heel sticks, physical exam,
bathing, handling by many staff — none of these is as important as the
establishment of breastfeeding.
Pregnant women must be fully informed about
birthing procedures and their impact on infant behaviour and ability
to establish breastfeeding. This should include information about
maternal opioides and beta-endorphins,[6] which are developed naturally
as labour progresses and are depressed when epidural anesthesia is
administered.
Epidural rates
Epidural usage rates across Canada[7]
vary widely, from a low of 4.5 per cent in Nunavut to a high of 60.3
per cent in Quebec. The latest overall figures are from 2001 to 2002
and show a national average of 45.7 per cent. This is lower than the
national US average of 59 per cent and considerably higher than that
of England, which stands at 12 per cent. The high reliance on midwives
as the primary source for birthing services and the preference for
home settings explains the lower rate in England, whereas in Canada 99
per cent of births take place in hospital.
Protecting the mother-baby continuum[8]
cluding
humans, show that high levels of stress hormones interfere with oxcytocin and normal labour progress, and are linked to adverse
birth outcomes.
Mothers want security and safety in
labour and delivery.
Obstetrical interventions are
correlated with perceived traumatic birth events.
Newborns from vaginal delivery, with
high levels of catecholamines from the maternal circulation, are
better equipped to adapt to extrauterine life than those delivered
by caesearian section.
Growing evidence shows that stressful
labour events are associated with less frequent suckling and later
onset of lactogenesis, especially in first-time mothers.
Evidence shows that endogenous
opioids, beta-endorphins, are secreted in high concentrations during
labour, peak close to delivery, and play a role in blunting the
perceived pain in childbirth.
Labour medications, including epidural anesthesia,
block the normal secretions of maternal beta-endorphins during
labour.
References:
1. Nylander G. Breast is Best. Health-Info
Video Vital, Oslo, Norway.
2. Righard L. Delivery Self-attachment.
Geddes Productions, Los Angeles, USA.
3. Righard L, Alade MO. Effect of delivery room
routines on success of first breast-feed. Lancet 336:1105-1107,
1990.
4. Torvaldson S, Roberts CL, Simpson JM,
Thompson JF, Ellwood DA. Intrapartum epidural analgesia and
breastfeeding: a prospective cohort study. Int Breastfeeding J.
1:1-24, 2006.
5. Jordan S, Emery S, Bradshaw C, Watkins A, Friswell W. The impact of intrapartum analgesia on infant feeding.
BJOG 112: 927-934, 2005.
6. Hofman DI, Abboud TK, Haase HR. Plasma
beta-endorphin concentration prior to and during pregnancy, in labor
and delivery. Am J Obs Gyn 150: 492-496, 1984.
7. Giving Birth in Canada Today: A Regional
Profile. Canadian Institute for Health Information, September
2004.
8. Kroeger M with Smith LJ. Impact of Birthing
Practices on Breastfeeding. James and Bartlett, Sudbury, MA
2004. |
