by Cuidiu breastfeeding counsellor Carmen Stara
Claire has 3 beautiful girls all delivered by Caesarean section in UCHG. Her first was an emergency section, her second was performed as she was 10 days overdue and having had a previous section, the obstetrician wouldn’t induce her and the birth of her third daughter, Grace, was an elective section performed at 38.5 weeks. She had hoped to have a VBAC on her second pregnancy, but scans showed that her pelvic cavity wouldn’t have been able to accommodate a vaginal delivery with the girls’ heads all measuring on the 97% percentile. So in Claire’s case, caesarean was the only option. Claire went on to feed all three of her girls until they were 1 year old. When asked what she attributes her breastfeeding success to, she highlighted the following:
a) Being very motivated to breastfeed, particularly after finding out that her eldest daughter had a congenital condition diagnosed when she was 9 days old.
b) Having excellent support from one particular Australian midwife in the hospital and a very supportive public health nurse who helped with any breastfeeding issues during her home visits in the early weeks.
c) Having the support of her husband who is very pro-breastfeeding
d) Having a good supply and found it very reassuring that the girls all gained weight very quickly.
Fortunately Claire was able to breastfeed almost immediately after the delivery and all 3 girls latched well from the outset. She didn’t notice any lethargy or difficulty latching as a result of the spinal anesthesia or pain relief she received. Claire fed on demand, and this encouraged her milk to come in at the end of day three, which is quite early for a Caesarean birth. As with all Caesarean deliveries, she had to position the babies away from the scar. One such position, shown to her by one of the midwives, was to place the baby on its side on the bed, while Claire pulled up a chair to the bedside, facing the baby and latched her on. This allowed her to feed without having to hold the baby constantly. She also used a breastfeeding cushion to cover the scar. Fortunately, in her case, her scar healed very quickly, so it didn’t prove to be a barrier when feeding or cause her any undue discomfort.
Claire overcame surgery, postpartum hemorrhaging, jaundice and still fed very successfully, which shows that regardless of the mode of delivery, the mother’s motivation to breastfeed is the main determining factor in whether they persist and go on to enjoy a happy breastfeeding relationship with their baby.
In many ways, Claire’s story is quite unique. With some 27% of Irish births being performed by Caesarean section, the repercussions of surgical delivery and its impact on breastfeeding, is something that thousands of women have to deal with each year. Unfortunately, research indicates that after a caesarean, fewer women initiate breastfeeding at all or give up with the first month. Di Matteo (1996) Perez-Escamilla (1996) Weiderpass (1998) and Dewey (2001) all show that women who had a caesarean had lower breastfeeding rates. Although many women may plan to “try” breastfeeding, they often feel physically and emotionally exhausted after a Caesarean, or groggy from medication and change their minds.
While there are certainly a few additional challenges to getting breastfeeding established after a section, it is absolutely possible and indeed preferable for these mums to breastfeed their babies. In fact there are some specific advantages to breastfeeding after a Caesarean.
i. The babies’ sucking stimulates the mother’s uterus to contract more quickly and speeds healing.
ii. Breastfeeding will create a bond between mother and baby
iii. It can help the mother feel competent and whole, especially in the case of an emergency Caesarean section, where she may feel like she wasn’t in control of the birth.
The uterine contractions that accompany breastfeeding help accelerate healing. A study by Negishi (1999) found that caesarean mothers tended to have larger uteri at one month postpartum than mothers who had had a vaginal birth. So uterine involution may be of special concern to women who have had Caesareans. Furthermore they also found that by 3 months postpartum, mothers who were breastfeeding 80% or more per day, had smaller uteri that those who breastfed 2% or less per day. So breastfeeding strongly aids uterine involution.
Breastfeeding can bring mother and her baby emotionally closer and help with the bonding process. This can be of particular benefit following a traumatic birth or if the mother and baby were separated after the delivery. If the mother isn’t able to hold her baby due to medical interventions, then the partner / father can provide some valuable skin to skin until the mother is well enough. Research from Sweden show that a father can soothe his newborn as effectively as a mother and more effectively than if just placed in a crib during the first two hours after birth. Father – baby skin to skin also facilitates the newborn’s “pre-feeding” behavior of seeking the breast. The development of nursing reflexes such as mouth movements and rooting is similar to that of infants who have skin to skin contact with the mother. This makes the child fully prepared for the first breastfeeding when reunited with the mother.
Caesareans births have been associated with delayed lactogenisis with many women’s milk only coming in between days 4 – 6. Breastfeeding the baby as soon as possible after the birth ensures that all the hormonal processes involved in milk supply are activated. Research indicates that the optimal timeframe is within the first hour after birth. Early and frequent feeding, positively impacts on the production of oxytocin and prolactin, which are needed as part of the milk ejection process. Babies who were fed early and often had longer periods of milk ejection than those who were started later. Establishing early feeding also increases the probability of Caesarean born infants of being breast fed for longer. (Sozmen).
Having a Caesarean can affect how a mother feels about herself and her baby. She may feel upset or cheated out of the birth experience she wanted, particularly with unplanned sections. The mother can also feel emotionally detached from the baby if she was unconscious during the delivery and if the labour was curtailed, so too are the hormones that are produced to help with that bonding. Having time to do lots of skin to skin contact and just get to know the baby, what the smell and feel like, having a bath together or caressing them will help build a nurturing bond. It will help with getting them to latch, which they may have difficulty doing especially after a traumatic birth. The sense of empowerment that comes from being able to breastfeed and sustain your baby will help make the mother feel competent and will build her confidence.
Medications given to the mother during labour or during the Caesaeren can have implications for breastfeeding. For example several studies have found that breastfeeding rates are significantly higher after regional anaesthesia i.e. epidural or spinal than after a general anaesthetic. This could be due to a number of causes, but one reason could be faster bonding because the mother is alert and awake. Under general anaesthetic the mother often feels groggy and out of it and not inclined to feed or may delay feeding. General anaesthesia also affects the baby by depressing their responses and rooting reflexes for some time and by making them more lethargic. It could mean that they are more disinterested in feeding or that they’re less efficient at emptying the breast. There is even some evidence to suggest that regional anaesthetic like epidurals affect the newborn by making their movements more disorganized. In a recent study, 100% of babies of non-medicated mothers initiated instinctive breastfeeding behaviours and successfully self-attached and suckled. In the group whose mothers received the epidurals less than 33% of them self-attached and fed. Even IV fluids can make both the mother and babies glucose levels abnormally high and can lead to hypoglycemia in the baby. In the mother, all the additional fluids can lead to an overload and cause engorgement. This is turn can make it more challenging for the baby to latch. Even antibiotics which are sometimes prescribed if the mother is recovering from a post-op infection can leave her and consequentially the baby, prone to thrush.
After a Caesarean, most mothers find it difficult to find a comfortable feeding position. As well as the scar, they may have an IV line in their arm which can make movement awkward and uncomfortable. There are a few positions that are helpful for the C-section mum:
i. The football or clutch hold – where the mother sits upright with the baby facing her breast and with his body along the mother’s side. A pillow is useful to support the baby so they’re almost sitting up. One advantage of this hold is the baby approaches the breast from underneath and so is more likely to get a more of the areola and a deep latch.
ii. Side lying – where both mum and baby lie on their sides facing each other.
iii. The cradle hold with the support of a pillow so the scar is protected. The baby lies horizontally chest to chest to with the mother.
iv. The position used by Claire, where baby is lying on its side on a bed and the mother sits in a chair facing the bed. The bed should be at the height of the mother’s chest. This way the mother doesn’t have to hold the baby and in this position, is more likely to sit upright and have good posture, rather than hunched over the baby putting strain on the shoulders and neck. There are endless variations and holds but the important thing is that the baby gets a good latch for efficient milk transfer and that both mum and baby are comfortable.
Caesareans are an increasing trend worldwide despite the WHO recommendation that it should not account for more than 10% – 15% of all births. Therefore mums need to be aware of how a section will impact them and their babies, particularly if they hope to breastfeed. Despite some challenges, if the mother is informed and determined then there is no reason why they won’t be able to successfully nurse their babies. Peer support groups and breastfeeding counselors can play an important role. If the mother attends such a group during pregnancy, she can get information and share anecdotal information with other mums that may have attended the same hospitals about what the local practices and procedures in their maternity units are. Once the baby arrives, Caesarean section mums, do need some extra help and support from lactation consultants and the midwives in the hospital. As C-section mums tend to be hospitalized on average 4 -5 days for recovery, they are even more dependent on the hospital staff to provide practical assistance with positioning; lifting the baby and even the mother’s general mobility is affected. But just as importantly, they need to provide the environment and the encouragement, which will ensure that they are still breastfeeding upon discharge and for months or years beyond.