OBSTETRIC INTERVENTIONS & THEIR POSSIBLE EFFECTS ON THE INITIATION & DURATION OF LACTATION
Gentle Birth Alternatives®
© 1997-2000 by Andrea Eastman, MA, CCE, IBCLC
As I was preparing for a meeting last month, I decided that I wanted to focus on childbirth and breastfeeding. My goal was to list as many obstetric interventions as possible and then discuss how each and every one could directly or indirectly influence the initiation and duration of breastfeeding.
At the top of the list was MIDWIFE or DOCTOR. We discussed how important it is for the caregiver's philosophy of birth to match our own. We also talked about the difference between seeing birth and breastfeeding as normal life events, and seeing birth as an illness, and breastfeeding as fraught with complications.
PREP, SHAVE, and ENEMA were next on my list. The important one here is the enema. An enema taken during labor stimulates the bowels. In addition, it may also make the contractions during labor stronger. Stronger contractions may make a mother choose medication to deal with the pain, and every type of maternal medication gets to the baby, and can affect the baby's ability to stay awake and suck properly.
Next on my list was LABORING IN BED. Women who labor in bed often experience more pain and a slower labor. More pain means that she may ask for drugs. A slower labor means that she is at risk for "failure to progress", which may mean pitocin augmentation, the accompanying IV drip, etc. Pitocin will mean stronger, more painful contractions. Laboring in bed, possibly flat on her back, the woman's uterus is compressing the blood vessels that supply the placenta and the baby with oxygen. Too little oxygen and stronger contractions may mean that the electronic monitor could show fetal distress. Failure to progress, incoordinate uterine contractions, and fetal distress are all reasons to have the doctors do cesarean surgery. Cesareans and the accompanying medications can affect breastfeeding.
Next was FASTING (NO FOOD OR DRINK) except for the occasional ice chips. Studies have shown that allowing women to eat and drink during labor can reduce the length of the labor by as much as 90 minutes. Labor is hard work, and the body needs the energy to work effectively. Dehydration means more painful contractions and slower labor. Fatigue combined with a slower labor may make a woman feel that she needs medications. And we all know that medications get to the baby and can affect breastfeeding.
INTRAVENOUS FLUIDS (IV) given to women in labor (such as glucose) can keep the glucose levels in mom's and baby's blood abnormally high. The body compensates by making extra insulin. Suddenly the baby is born, it's glucose supply is cut off, and it has all that extra insulin. This could lead to neonatal hypoglycemia, which may mean a trip to the Neonatal Intensive Care Unit (NICU), which means separation from mom. Dr. Righard's studies have shown that separation from mother after the birth can have almost as dramatic effect on the baby's ability to latch on as maternal medications. Some women on IVs experience fluid overload. Extra fluids in the woman's body means perhaps worse engorgement, which can affect a baby's ability to latch on properly. Engorgement can lead to the death of the cells responsible for secreting milk, thus having an impact upon the mother's milk supply.
PITOCIN, in addition to causing stronger, more painful contractions, is also an anti-diuretic, which means that it makes the body retain more fluids which means more engorgement, which can have a negative effect on breastfeeding. Pitocin use also increased the likelihood of jaundice in the baby.
ANALGESIA - demerol, stadol, nubain - affects the perception of pain. Some women experience relief, some women hallucinate. All of these drugs cross the placenta and can affect the baby. Narcotics such as these can lead to what nurses call "blue baby syndrome". Lower APGAR scores can affect the care required by the baby, and thus may mean separation from mother to monitor its breathing, etc. These drugs can also affect the baby's desire and ability to breastfeed. A sleepy baby combined with fluid-overload engorgement is a serious threat to breastfeeding. If the sleepy baby gets jaundiced, then the pediatrician may order supplements, etc. And we all know what supplementation can do to the mother's confidence and her milk supply.
ANESTHESIA - epidural, spinal, intrathecal - removes the sensation of pain, as well as stop the production of endorphins in the mother's body (the natural painkillers). Yes, epidurals can affect the baby. The degree to which the baby is affected depends upon the particular "cocktail" used by the anesthesiologist. There are many studies that show the effects of this type of medication can be longer lasting. Epidurals mean that the mother will have to have the whole host of accompanying interventions: IV; internal electronic fetal monitor; urinary catheter; automatic blood pressure cuff; possibly pitocin augmentation, etc. Her labor may slow down, her uterus may contract ineffectively. She won't be able to feel the contractions to push her baby out, which may mean forceps or vacuum extraction, and an episiotomy. It may affect her labor so dramatically that the doctor orders a cesarean. If they let the medication wear off so she can push, she will be deprived of the endorphins that would have helped her deal with the intense sensations, and will be left to deal with the fresh, new pain of transition on her own. This may make her request a "top-off", which can mean a prolonged second stage. Doctors rarely let a woman push for more than two hours, which may mean a cesarean, even if she has dilated to 10 cms. And cesareans can affect breastfeeding. Epidural use, whether for vaginal birth or cesarean birth, can increase the likelihood of jaundice in the baby. All drugs must be broken down by the infant's immature liver. The liver is also responsible for processing the bilirubin (making it water soluble) so that it can be excreted by the baby.
ARTIFICIAL RUPTURE OF MEMBRANES (AROM) means that the cushioning forewaters are gone. This can dramatically increase the pain felt with each contraction. The baby's head is suddenly compressed more with each contraction, which may cause the normal dip in the fetal heart tones to dip a little farther. The doctor may interpret this as fetal distress and order a cesarean.
EXTERNAL AND INTERNAL ELECTRONIC FETAL MONITORING (EFM) was developed by physicians determined to detect fetal distress early and therefore lower the incidence of cerebral palsy. However, a study published in the New England Journal of Medicine last year showed that routine EFM has not lowered the incidence of cerebral palsy, and questioned its value in predicting cerebral palsy. In fact, some doctors have argued that routine EFM has increased the cesarean rate. Thus, EFM can indirectly have a negative effect on breastfeeding because of the medications used for the cesarean surgery, separation from mother, etc.
VAGINAL EXAMS are painful, require a woman to be flat on her back, can lead to premature rupture of membranes, increased risk of infection, and can be misleading if they are overdone, and if they are done by different people. Imagine laboring for hours, and you hit a plateau. You have continued hard labor, but the vaginal exam done to check your dilation every 30 minutes shows no progress. You will probably feel very discouraged. They may put you on pitocin, if you aren't already on it. You may run out of time, according to the doctor. He will come in, check you, declare that there is no way THIS baby is coming through THIS pelvis, and order a cesarean for failure to progress, or cephalopelvic disproportion, or incoordinate uterine function. We have already discussed the negative effects that pitocin and cesareans can have on breastfeeding.
DIRECTED, SUSTAINED PUSHING - you know, the circle of people standing around the woman flat on her back or propped up so she is sitting on her tailbone, with her elbows in the air, holding her legs apart, everyone shouting PUSH, PUSH, PUSH, and counting to 10 over and over again! Holding your breath while closing your glottis raises the pressure in your abdomen, which has a negative effect on the blood going back to your heart and then to the lungs. This means that the baby is getting no new oxygenated blood as long as you are pushing this way. Granted, the baby is not getting any new oxygen when the uterus is contracting, but many women push much longer than the actual contraction. This lack of oxygen can negatively affect the baby. The EFM may show fetal distress, and an emergency cesarean may be performed. Interestingly, this type of pushing actually causes the condition - fetal hypoxia - that it was intended to prevent! So you see how this can have an indirect effect on breastfeeding. In addition, fetal hypoxia is in one of three general categories of causes of pathological jaundice.
LITHOTOMY POSITION - flat on your back - in addition to what we discussed above, pushing your baby uphill, against gravity can lead to a prolonged second stage. This can lead to fatigue, which may mean the woman is unable to push her baby out. The doctor may diagnose this as shoulder dystocia, remove the baby with forceps after doing a huge episiotomy. Next time, she may be convinced that she can't push out her babies, that her pelvis is inadequate, and she may be talked into a scheduled cesarean.
EPISIOTOMY - yes, this can affect breastfeeding! If your bottom is sore, you sit back farther on your tailbone. This can affect your ability to properly position your baby, which may lead to sore, cracked, bleeding nipples - as well as a slow growing baby who cries all the time.
SUCTIONING of the baby's nose and mouth vigorously with a bulb syringe can create oral aversions in sensitive newborns. The nose and mouth areas are the baby's first "window to the world", and the focus of their sensory input. Suctioning can scrape their delicate tissues, and give them sore throats. Even worse, when placed at mother's breast, they may vehemently refuse to nurse. Suctioning is a routine intervention that often does more harm than good. Babies birthed over intact perineums rarely need vigorous suctioning. Save this procedure for the rare times when it is really needed.
WASHING THE BABY, EYE TREATMENT, SEPARATION FOR OBSERVATION, USE OF A WARMER - all of these things may mean separation from mom, which can dramatically affect the newborn's ability and willingness to latch on and suck effectively.
GLUCOSE WATER AND PACIFIERS - can satiate a baby with empty calories, and cause infrequent stooling in the newborn, and thus increase the likelihood of jaundice. This can also lead to nipple confusion, which means sore nipples for mom, a baby that cries alot, and grows slowly. Mom may be convinced she doesn't have enough milk and may decide to supplement with formula, which can reduce the mother's milk supply and lead to a vicious cycle that ends with the baby refusing the breast and the end of breastfeeding for this baby.
CIRCUMCISION can affect the baby's ability and desire to breastfeed. Pain disorganizes babies. Newborns feel pain more exquisitely. Parents who feel a need (cosmetic or religious) to have this procedure performed on their newborn sons should postpone it until the baby is nursing better, especially if he is having trouble latching on. Circumcision can have a detrimental effect on breastfeeding, since pain disorganizes babies and their sucking.
As you can guess, this was a highly charged meeting. The mothers seemed to NEED to talk about what happened to them. We discussed the fact that it is still possible to successfully breastfeed if you have every intervention on this list (and many of them had). I ended the meeting by telling them that they each need to give birth where they feel most safe and to choose a birth attendant with a philosophy of birth similar to their own. I also told them that if they listen to their bodies and trust their intuition, they already KNOW how to birth their babies!
Please use only with the permission of the author.
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