Thursday, June 17, 2010

Healthy Birth Practices: Keep Baby With You

We've been discussing the Six Lamaze Healthy Birth Practices.

This is the last in a series on the Lamaze Healthy Birth Practices, why they are important in birth, and how they are less commonly "allowed" in women of size. The previous entries have been:

1. Let Labor Begin On Its Own
2. Walk, Move Around, and Change Positions During Birth
3. Bring a Loved One, Friend, or Doula for Continuous Support
4. Avoid Unnecessary Interventions
5. Get upright and follow urges to push

And the final Healthy Birth Practice is [drumrollllllllllll] :

6. Keep baby with you

Although you'd think that this one was a no-brainer, it's surprising how many women are kept from early and frequent contact with their babies after birth, which then can impact bonding and breastfeeding. 

And because of the incredibly high rate of interventions used with "obese" women, women of size often have even less contact with their babies after birth, which strongly contributes to lower rates of breastfeeding in this group.

Why Skin-To-Skin Contact and Rooming In Is Important

You wouldn't think you would have to fight for contact with your baby after birth, but sadly, mothers and babies are separated far too often postpartum and it can have long-lasting consequences on breastfeeding and bonding.

This separation seems to happen even more in high-tech, high-intervention births, especially cesareans.  Breastfeeding initiation rates are lower in women who have had cesareans, skin-to-skin contact is often not available (even though it could be), and contact is often delayed, sometimes for hours or even longer. In the meantime, babies are often given pacifiers and bottles of formula or glucose water, which decrease the baby's desire to nurse and which often interfere with a good latch. 

Even when the baby is born vaginally, the mother often gets only a few moments with baby before it is whisked off, cleaned up, weighed and measured, examined, given eye goop, and then bundled into a blanket.  When the mother gets the baby back, no skin-to-skin contact is available anymore and critical early moments together have been missed. In addition, many mothers are discouraged from having their babies "room in" with them at night, yet frequent nursing at night is very important in establishing a good milk supply.

Research shows that early skin-to-skin contact and continuous time (rooming in) with the mother improve outcomes.  Babies sustain their temperature better when skin-to-skin with their mothers, they maintain higher and better blood sugar, and have better cardio-respiratory function.  Skin-to-skin contact decreases crying behaviors, increases maternal gestures of affection, and long-term bonding seems improved after rooming in.  In addition, both short-term and long-term breastfeeding rates are improved with skin-to-skin contact and rooming in.Yet hospital routines often get in the way of this important time.

One study in Pediatrics in 2008 looked at six "Baby-Friendly" practices to see which were associated with less cessation of breastfeeding before 6 weeks. These "baby-friendly practices" included:
  • Breastfeeding initiation within 1 hour of birth
  • Giving only breast milk
  • Rooming in
  • Breastfeeding on demand
  • No pacifiers
  • Fostering breastfeeding support groups
Sounds pretty basic, right?  Not so.  Only 8.1% of the mothers in the study experienced all 6 "Baby-Friendly" practices.  According to the study (my emphasis):
The practices most consistently associated with breastfeeding beyond 6 weeks were initiation within 1 hour of birth, giving only breast milk, and not using pacifiers. Bringing the infant to the room for feeding at night if not rooming in and not giving pain medications to the mother during delivery were also protective against early breastfeeding termination. Compared with the mothers who experienced all 6 "Baby-Friendly" practices, mothers who experienced none were approximately 13 times more likely to stop breastfeeding early.
Interventions, Women of Size, and Impact On Breastfeeding

These practices may be even more important in women of size.  Research shows that there is a lower rate of breastfeeding among "obese" mothers. Some of this may be because of legitimate supply issues from PolyCystic Ovarian Syndrome (PCOS), a metabolic disease that many fat women have.  Other factors that may impede breastfeeding establishment include possible subclinical hypothyroidism, subtle or overt discouragement of breastfeeding in women with large breasts, more difficult mechanics with a larger body, or postpartum anemia.  [More on this in a future post.]

However, the role of aggressive birth interventions in the lower rate of breastfeeding among obese women typically goes conveniently unexamined in the research. Breastfeeding failure is blamed solely on fatness, when in fact, the high level of interventions in obese pregnancies and births may also play a significant role.

For example, "obese" women are induced at a higher rate than women of average size, with most induced women receiving pitocin at some point in labor.  Pitocin is an anti-diuretic, and when combined with aggressive IV fluids, can cause significant edema in the mother.  This can cause greater breast engorgement and make it difficult for the baby to latch on and nurse efficiently.

A high rate of inductions usually means a high rate of pain medication use in the mother, and some research indicates that more pain meds results in impaired breastfeeding behaviors in the baby, especially with IV narcotics. In particular, some research shows that the combination of pain meds and separation of mother and baby after birth significantly inhibits initial breastfeeding behaviors, while other research shows that avoiding pain medications in labor is protective against early breastfeeding cessation.

Because the rate of cesareans in women of size is so high, it also has strong impact on breastfeeding rates. Research shows that lactogenesis (the mother's milk "coming in") can be delayed after a cesarean compared to a vaginal birth.  This may be due to some inherent hormonal differences between vaginal birth and cesareans, or it may be due to decreased immediate contact after birth. Delayed initiation of breastfeeding may also be a factor; research shows that in women delivered by cesarean, aggressive early suckling leads to better breastfeeding rates than delayed suckling. 

Another possible reason for breastfeeding difficulties in fat women is the excessive intervention commonly seen with big babies, which are more common in women of size. Big babies have a higher risk of low blood sugar after birth, so there is often aggressive testing and formula supplementation of these babies after they are born, but all the separation, testing, and supplements can end up further sabotaging breastfeeding.

Research shows that most of the time routine testing and supplementing is not necessary in big babies if the baby is not symptomatic and is nursing well.  Furthermore, as noted above, skin-to-skin contact has been shown to improve blood sugar rates and stability of babies after birth, so the common interruption of time between women of size and their babies is usually unnecessary.

The high rate of interventions commonly used in the births of "obese" women often leads to a "perfect storm" of conditions that inhibit neonatal adaptations to life outside the womb, and interfere with bonding and breastfeeding in babies of women of size. 

Alas, my own first birth was a good demonstration of the negative effects of such interventions on breastfeeding. 

My Experience

Breastfeeding came very close to "failing" with my first child....for all the reasons cited above.

The doctor feared a big baby, so he induced labor. Labor was long and hard, high doses of pitocin and IV fluids were pushed, and pain meds were eventually needed. The induction failed, and we ended with an extremely traumatic cesarean. 

After the cesarean itself, there was no skin-to-skin contact, and only a brief moment of bonding in the post-op recovery room, after which I was separated from my baby for EIGHT HOURS. By the time we tried nursing, she had had many bottles of formula, glucose water, and had been regularly given a pacifier.

Even after I started breastfeeding her, the nurses pushed more bottles of glucose water to "flush out the jaundice" (jaundice is a common side-effect of pitocin). Never mind that glucose water doesn't flush anything and actually prolongs or worsens jaundice.

I experienced massive fluid overload postpartum because of the anti-diuretic properties of pitocin combined with an over-zealous IV protocol. I had severe edema everywhere, including my breasts. That made it very difficult for baby to latch on, and baby was very sleepy from the jaundice caused by all the pitocin. This made breastfeeding very inefficient even when it did happen.

I had a long, stressful labor and a horrible cesarean experience. A cesarean plus a stressful labor can cause real problems with lactogenesis. My milk didn't come in for a week....and when it did come in, the baby could hardly latch on because I was so severely engorged.  Add into that her sleepiness, all the formula and glucose water, all the resultant infrequent nursing....and you have a classic recipe for delayed lactogenesis and breastfeeding issues.

So was the problem here really my fatness? Or was it all the interventions that I experienced because of the way the doctors treated my fatness, interventions that snowballed into the classic cascade of complications?

I did eventually manage to preserve the breastfeeding relationship, but mostly through sheer luck and stubborness. But it took about 2-3 months before things really started to work, and I almost gave up any number of times.

I should also note that I never had problems again with breastfeeding in my subsequent pregnancies. If fatness was really to blame, the problems with breastfeeding would have been consistent.  Instead, the difference was in the interventions used and my insistence on early and frequent nursing, rooming in, and constant contact with my babies.  For me, that made all the difference in the world.

What Can You Do To Avoid This?

While there may definitely be something to the idea of hormonal imbalances like PCOS causing breastfeeding issues, it is important not to overlook the negative influence of the aggressive interventions commonly used in women of size. These can also affect breastfeeding, but are rarely controlled for in most research.

For fat women to have the best possible chance to succeed at breastfeeding, the best approach is to:
  • promote a vaginal birth with spontaneous labor
  • not use routine birth interventions unless truly medically indicated, especially IV fluids and pitocin
  • encourage early contact and breastfeeding as soon as possible after birth
  • avoid separations between mother and baby
  • promote skin-to-skin contact as much as possible and as early as possible
  • have the baby "room in" after the birth, and especially at night
  • avoid routine neonatal testing for low blood sugar unless baby is symptomatic
  • strongly discourage formula and sugar-water supplementations unless necessary
  • encourage frequent breastfeeding (every 2 hours or more)
  • give help and information about positioning to women with very large breasts
  • provide strong encouragement for breastfeeding to women of size
Of all these recommendations, I think the most important are to breastfeed early as possible, as often as possible, and to avoid separations whenever possible.

Some women of size may still experience breastfeeding problems--even when they do everything "right"--because of the hormonal imbalances that PCOS can cause. However, that doesn't mean that breastfeeding should be discontinued or discouraged, because any amount of breastmilk a baby receives is extremely beneficial immunologically.

Instead, these women should be given information and support for increasing milk supply through the use of herbs and medications if needed, they should be given emotional support while working on breastfeeding issues, they should be given information and support for improving baby's latch (craniosacral therapy can work wonders in some babies), and they should be provided information about supplementation alternatives like Lact-Aid or the Supplemental Nursing System if the addition of formula is needed.

Of course, sometimes weaning is the only sane thing to do under certain circumstances, and it deserves to be grieved and accepted if that becomes necessary.  But too often, women are not told that breastfeeding does not have to be an all-or-nothing proposition. Many women who experience problems can breastfeed at least partially, short-term or long-term, thereby giving baby much-needed immunological protections while still providing formula supplements if necessary.

But most of the time, most women can breastfeed, and more would probably breastfeed successfully if there were fewer interventions routinely used around labor and birth, if early skin-to-skin contact were uniformly utilized, if early and frequent breastfeeding was encouraged, if better breastfeeding support were given after birth, and if rooming-in became the standard of care. 

Question: How many of the "Baby-Friendly" practices (breastfeeding initiation within 1 hour of birth, giving only breast milk, rooming in, breastfeeding on demand, no pacifiers, breastfeeding support groups) did you experience with your babies?


Piffle said...

I got rooming in, with no problem, even with the C that took a couple of hours to sew up for all three births. For two of the three I got breastmilk only, my first and largest baby (10lb 9oz) got one supplement of glucose water for low blood sugar. I got lots of help lactating for all of them, which was good because I had flat nipples and a tendency towards mastitis (do not ever decide on your own not to nurse on one side to let a crack heal--my breast swelled to twice the nursing size! It hurt!) For my first they took him away to check his breathing and decided unilaterally to keep him for a couple hours; the nurse was shocked to come back into my room and find me reading my book, asked what I was doing, and I said waiting for my baby. Apparently they expected my to blithley go to sleep without him. No way!

The other things I didn't get, didn't even know I should. And I was determined to breastfeed.

Ashley said...

I know this is somewhat outside the scope of your blog, but I would love it if you wrote more on PCOS and early breastfeeding.

I have PCOS, attempted to homebirth but wound up tranfering and getting a c-section, didn't see my baby until 2 hours postpartum and had no skin to skin contact for awhile, but my milk came in after 2 days and I had some oversupply. Nursing was super easy. I mention this just so other women with PCOS do know that it's quite possible they'd have no problems with breastfeeding.

Selena said...

I've had a different breast feeding experience with all 4 of my children. My first baby was induced at 41 weeks and was over 10lbs born vag with forceps and I had and epidural. My milk took over 7 days to come in and she lost over a pound and was jaundiced. Her father was not bfing supportive and I was only able to see a LC once after we left the hospital. I never was able to catch up and ended up doing a combo of bfing and bottles for six months. My second baby was born by csection at 38 weeks with no labor(not my choice, I still feel forced and violated by this 8 years later). I did not see my baby for hours after and he developed jaundice and was supplemented with out my permission. He never caught on to breast feeding even though I had more milk this time. I had zero support from my then husband(now ex) and no access to a lactation consultant and ended up giving up after two months of constant struggle. With my 3rd I was induced again at 40wks and labored naturally for 16 hrs before another(unnecessary) csection. My baby was with me the entire time and never left my sight this time but my milk took forever to come in(2 weeks!). Luckily I had a supportive husband and lots of lactation consultant help that time. It was a huge struggle for months with low supply, mastitis, csection infection, jaundice etc. I was able to exclusively bf him though and we're still going almost 3 years later! With my 4th I had moved back to my home state of OR and was able to have access to CPMs and planned a home birth. My baby was born when he was ready all naturally at home. He breastfed right away and was pretty much latched on the first 24hours strait. My milk came right in with no problems at all and he had zero jaundice. He's two months old and bfing has been a dream with him. It's amazing what a difference the natural birth made. We defiantly experienced "baby friendly" practices this last time and they made a world of difference.

Mary and Eden Z said...

My first was born by emergency section due to eclampsia. As he was only 33 weeks BF had to wait a bit and in the mean time I became a real pro in the pumping room at the hospital. The nurses were very supportive both of trying to nurse and being with my guy as much as possible. The LC was kinda useless in the hospital but once I was out (a month later) my midwife hooked me up with a community LC who was AWESOME. She had him nursing and completely off bottles in a month and I was never SO happy not to see another bottle!

My second was an attempted VBAC that also ended in a section. (Hoping to change that this time around...but that's another story.) I lost enough blood at the end of surgery that I lost consciousness and so am not sure what the nurses did or didn't do with baby #2. The hospital fully supports rooming in and the nurses only look after your baby if you specifically ask them to for a short period of time. Other than that, your baby is with you. Nursing happened quickly, no problems there. Doctor vocally praised nursing success while nurses were in the room...and I felt a bit of

Wendy said...

I gave birth at a military hospital which was very breastfeeding-friendly. They had rooming-in. In fact there was only a NICU, they didn't have a regular nursery at all. They had me try to breast feed in the first hour, bf on demand, no pacifiers, no pressure to supplement with formula. They had lactation consultants available during the day. My daughter turned out to be a good nurser and my milk came in about 2 days after the birth. She barely lost any weight, only about 4% of her birth weight.

Mom2twins2008 said...

for PCOS women out there: my story. Due to PROM - Premature Rupture of Membraines - my twins were born one day shy of 34 weeks. My son - baby A - was frank breech so C-section was done. I didn't see the twins for 9 hours after my delivery. I had general anesthesia since my spinal didn't work, had a horrible spinal headache, didn't get to pump until 10 pm that night (delivered at 10 am) and didn't get to pump again for another 12 hours. I then started pumping 10 - 12 times a day (appox every 2 hours). I was then able to breastfeed my twins for 2 years and had a LARGE EXCESS of milk - I could have fed quads if I'd wanted to!! Don't give up! The odds were totally stacked against me and we succeeded!