27 Sep Birth and breastfeeding: the domino effect

(This article is also available in an audio format)

By Christine Klynhans – BCurI et A, SACLC – SA certified lactation consultant

Most new mothers plan to breastfeed their babies and, according to the South African Demographic and Health Survey of 1998, approximately 88% of mothers initiated breastfeeding at birth. However, only 10% of babies were breastfed exclusively in the first three months of life, with less than 8% reaching the 6 month mark. This makes South Africa one of the countries with the lowest breastfeeding rates in the world.

Increasingly research is showing that the birth option a woman chooses and the way births are conducted influence breastfeeding. Many women don’t realise this; in fact, many do not prepare for breastfeeding at all, assuming that it is something that will come naturally. Let’s take a closer look at what this means in practice.

Natural birth

Before examining the role of all the various interventions, it’s important to recognise the important positive contribution that a good, natural birth makes to breastfeeding.

Birth is a complex process that is extremely sensitive to outside influences, of which the fundamentals are still poorly understood. In her book ‘Gentle Birth, Gentle Mothering’, Dr Sarah J. Buckley describes the hormonal orchestra accompanying undisturbed birth, and how these hormones not only support the birth process, but also suffuse the brains of a new mother and her baby, catalysing profound neurological changes. These changes give the new mother the personal empowerment, physical strength and an intuitive sense of what her baby needs. It also kick-starts breastfeeding and breast milk production.

Two of the labour hormones that may specifically influence breastfeeding are Oxytocin and Beta-Endorphin.

Oxytocin – the hormone of love

In labour oxytocin is released in pulses by the posterior pituitary gland in the brain, and it is reckoned to be the prime mediator of rhythmic contractions. Oxytocin is also produced by the baby’s pituitary gland, as well as by the placenta and membranes. After birth skin-to-skin contact and the baby’s movements at the breast also stimulates oxytocin release.

Maternal blood oxytocin levels peak at one hour after birth, and then subside. Brain levels stay high for much longer, where it is involved in switching on maternal instinctive behaviour. Newborn babies have elevated oxytocin levels for at least four days after birth. Oxytocin is then also excreted while breastfeeding and causes the milk ducts to contract and excrete breast milk.

Another role that oxytocin plays in the olfactory system, which plays an important role in the establishment of mothering behaviour. One study found that monkeys who delivered by Caesarean section rejected their babies unless these babies were swabbed by secretions from the mother’s vagina. Newborn babies use their sense of smell to find and latch to the breast.

An elective Caesarean section (where the mother does not go through labour at all) or even an induction of labour where synthetic oxytocin is administered at a steady dose (instead of pulses), will have some influence on maternal and newborn oxytocin levels after birth. The true effect of this on bonding and breastfeeding is not known. However, one can speculate that it may play at least some role in why so many mothers seem to lack the confidence and persistence needed to persevere until breastfeeding is established.

Beta-endorphin – the hormone of pleasure and transcendence

This naturally occurring opiate is excreted by the posterior pituitary gland under conditions of stress and pain. During labour this hormone provides pain relief for women. In the hours after birth, beta-endorphin rewards and reinforces mother-baby interactions, including physical contact and breastfeeding, and contributes to feelings of pleasure and ecstasy for both.

One study found higher levels of Beta-endorphin four days postpartum in the breastmilk of mothers who gave normal birth compared to caesarean birth. This may help the newborn baby to adapt to the stressful environment outside the womb. Higher stress levels in babies may contribute to breastfeeding and latching difficulties.

The influence of birth interventions on breastfeeding

Disturbing birth

There is a difference between ‘normal vaginal deliveries’ as they are routinely done in most hospital set-ups, and ‘natural undisturbed birth’. Routine practices like brightly lit birthing rooms, the display of medical equipment, hospital noises in the back-ground, inserting IV lines and care by strangers are often the first spanners in the works, inhibiting a woman’s normal hormonal workings and leading to a cascade of interventions that could have been prevented. Simple changes like dimming lights or drawing curtains and playing soft music to drown out background noises can go a long way towards positively influencing birth and, indirectly, breastfeeding.

Induction of labour

First-time mothers have twice the likelihood of ending up with a caesarean section after an induction of labour compared to natural onset of labour. This increase is linked to the induction processes, not to the conditions for which the procedure was performed in the first place. All induction agents can cause uterine hyper stimulation, which in turn can lead to foetal distress. Inductions increase the need for other interventions like the insertion of IV-lines, continuous foetal monitoring and confinement to bed. Induced labours are more painful, and more women will require pharmacological pain relief and epidural anaesthesia. All of the above factors can negatively influence breastfeeding.

Especially concerning is the use of synthetic oxytocin during an induction, a drug linked to uterine hyper stimulation and postpartum haemorrhage. Postpartum haemorrhage may delay the initiation of breastfeeding. It is a common cause of delayed ‘coming in’ of milk. Maternal fatigue may also necessitate formula supplementation.

Pethidine for pain relief

In South African hospitals the opioid Pethidine is offered to labouring women for pain relief almost routinely. Pethidine during labour has been linked to delayed and depressed sucking and rooting behaviour in infants. Another study found that Pethidine also increases infants’ body temperatures and crying after birth. Through these effects Pethidine affects the baby’s ability to latch at the breast at a time when it is best programmed to learn how to do this.

Another well-known effect of Pethidine is the suppressing effect on the newborn infants’ respiratory system. This may cause low Apgar scores, may necessitate a traumatic and painful Narcan injection and can even lead to baby’s admission to NICU.

A literature review done in 2012 on the efectiveness of pain relief options for labour women found insufficient evidence that opioids are more effective than placebo for pain management in labour. It does, however lead to side-effects like nausea and drowsiness in the labouring women, disturbing the birth process and the precious first hours between mom and baby. Another concerning matter identified is that, despite concerns for more than 30 years about the effects of maternal opioid administration on subsequent baby behaviour and breastfeeding, only two out of the 57 studies reviewed reported on breastfeeding as an outcome. The fact is that the effects are probably far more severe than we currently know.

Epidural anaesthesia

Epidural anaesthesia is currently the most effective method of pain relief in labouring women. However, epidurals disrupt birth processes in major ways, and are linked to very serious side-effects, many which are still poorly studied. Most women who receive epidurals are not informed of these possible effects on them and their babies.

Many of the maternal side-effects of epidural anaesthesia impact on breastfeeding. Epidurals drastically reduce oxytocin and beta-endorphin release, interfering with the normal hormonal symphony in labour and beyond. It is linked to longer labours, and a higher incidence of instrument deliveries.

The effects of epidural anaesthesia on breastfeeding are not well studied. It’s also difficult to study. Many mothers with epidurals have also been exposed to opioid drugs like Pethidine, with its well-known effects on breastfeeding, or underwent an induction. Different drugs and different dosages are used for epidurals, which may have different effects. How the fourth stage is managed will also still affect breastfeeding.

Lastly there are concerns over the neuro-behavioural, hormonal and autonomic effects of epidural anaesthesia during mom’s labour on babies. There seems to be a link between epidural anaesthesia and disorganized pre-feeding behaviour (finding the breast, licking, nipple massage and hand sucking), to more feeding difficulties in the early days and to shorter duration of breastfeeding.

Instrument deliveries

Instrument deliveries usually follow complicated labours, and many of these women have already been exposed to opioid drugs, synthetic oxytocin and epidural anaesthesia. Another indication is foetal distress in the second stage of labour. All of the above already impacts negatively on breastfeeding, making it difficult to determine the exact role that the instrument delivery plays.

Instrument deliveries have been linked to short term risks for baby like bruising, facial injuries, displacement of the skull bones and cephalohaematoma.

In more serious cases, facial nerve and muscle damage, and intracranial haemorrhage will most certainly seriously affect breastfeeding. However, even babies with much milder injuries will still experience pain and discomfort, especially as the head may be touched or may press against bedding or mom’s body during breastfeeding. And of course there is the increased risk of jaundice with cephalohematoma, linked to separation between mom and baby and to sleepy babies, further impacting on breastfeeding. These little ones will need extra care and attention.

Caesarean section

The majority of mothers delivering their babies in private sector hospitals in South Africa will do so via Caesarean section. While a proportion of these Caesars are medically justifiable, the majority are not.

Various breastfeeding difficulties are linked to birth by caesarean section. Even when a supposedly accurate due date has been estimated by sonography, an elective caesar holds the risk of medically caused prematurity, with all the implications of a premature birth for a baby. Various studies link caesarean birth to breathing difficulties after birth, often leading to separation between mom and baby and to admission in NICU. Babies born via caesarean section also miss out on the hormonal support that natural birth offers both mom and baby in the hours after birth, with physical and emotional consequences.

Due to all of the above, successful breastfeeding is less likely after a caesarean section. It has also been shown that abnormalities in the release of prolactin in the early days after caesarean section, negatively influence milk supply.

There is hope

It’s important to know that, no matter how bad the start, from the very first moment after birth we have the power to make a difference. Most babies hampered by difficult birth experiences will still be able to successfully breastfeed, with perseverance from the mother, continuous skin-to-skin contact and good breastfeeding support.