Section 2: Maternity Care Practices
Influences of Birth Practices on Breastfeeding Outcomes
- Skin-to-Skin & Early Initiation
- Inductions & Labor Medications
- Rooming In and Evidence Base for the 10 Steps
Labor, delivery, and all maternity care practices can influence breastfeeding initiation and duration. The practices associated with supporting breastfeeding success include:
- Maintaining skin-to-skin contact between mother and baby immediately after birth until after the first breastfeeding
- Promoting early initiation of breastfeeding
- No supplementation with anything other than breastmilk unless medically indicated
Spontaneous, unmedicated vaginal birth, followed by immediate and uninterrupted skin-to-skin contact is associated with the highest likelihood of newborn-initiated breastfeeding. Anything that interrupts a spontaneous vaginal birth may impact the success of breastfeeding during the critical first hour after birth, as well as the long-term breastfeeding success of the mother/baby couplet. Minimizing unnecessary interventions and discussing risk/benefits of all interventions will go a long way towards promoting normal birth, which supports normal breastfeeding.
- Babies, like all mammals, are intended to be in close contact with the mother (or father). When removed from the natural habitat in the early hours after birth, physiologic signs of stress are demonstrated by the newborn. These signs include crying, disorganized behavior, and temperature and glucose instability.
- Babies who remain in skin-to-skin contact immediately after birth and for at least an hour are more likely to latch at the breast, maintain body temperature, maintain and stabilize heart rate, respiratory rate and glucose levels, cry less, and are more likely to breastfeed exclusively for a longer period of time.44
- Skin-to-skin is defined as placing the unclothed, diapered newborn against the bare chest of the mother (or father) as they are both covered with a blanket. The newborn should not be assisted to latch at the breast at this time, but allowed to transition and latch when ready.
- Skin-to-skin should begin as soon as possible, when mother and baby are able to respond to each other. This includes both vaginal birth and c-section births. Implementing skin-to-skin during c-sections is a multi-disciplinary process. It is important to involve all members of the team including obstetricians, pediatricians/neonatologists, anesthesiologists and nursing.44
- Safety is key when practicing skin-to –skin care. Mother and baby should be stable. There needs to be consistent observations and frequent assessments of newborn’s breathing, activity and color. The article, Safe Sleep and Skin-to-Skin Care in the Neonatal Period for Healthy Term Newborns in Pediatrics details procedures for immediate skin to skin after delivery and provides more information about safety considerations in skin-to-skin practice.24
Early Initiation of Breastfeeding
Breastfeeding should be initiated as soon after birth as possible. Ideally, the newborn is placed skin-to-skin and is left to begin to suckle and self-latch when ready. This practice is associated with improved breastfeeding outcomes. Breastfeeding in the first hour after birth is associated with higher initiation and duration rates of both exclusive breastmilk feeding and any breastmilk feeding.
Some newborns are too sleepy to breastfeed or are unable to latch. This may be due to maternal medications during labor. Intravenous opiate administration may interfere with the newborn’s ability to seek the breast, root, and suckle with the first hour after birth. When mothers are given IV narcotics during labor, more time for skin-to-skin and the first feeding should be provided. Depressed or delayed sucking by the newborn may lead to delayed lactogenesis.25 Additional information related to labor medications and breastfeeding is available later in the tutorial.
Counseling women about pain relief in labor is challenging because everyone has differing levels of pain tolerance. Providing insufficient pain relief may result in anxiety, an inability to cope with labor, dysfunctional labor patterns, and increased risk of postpartum depression – which may all negatively impact breastfeeding success.
To promote breastfeeding in the first hour after birth:
- Teach mother/family about normal newborn behaviors.
- Point out the nine instinctive stages (http://www.magicalhour.com/) as the newborn demonstrates the behaviors.
- Reinforce the normal observations and provide encouragement. Tell the mother that the touch of the newborn’s hand or face against her breast will stimulate oxytocin, a hormone that stimulates the flow of milk.
- Visitors during the first hour should be informed about the importance of not interrupting skin-to-skin and that there will be opportunities to hold the newborn after this very important mother-baby bonding time.
- Help the mother/family to see the cues that the baby demonstrates to indicate an interest in feeding:
- Teach the mother that her breasts produce colostrum which is the perfect first food for her baby and is easily digested.
- Colostrum is produced in the perfect volume for the size of her newborn’s stomach: approximately 5-7mL on Day 1. The newborn’s stomach capacity increases to approximately 22-27mL on Day 3. Small, frequent feedings will ensure that the mother makes enough milk to meet her baby’s needs. Mature milk is thinner, whiter and higher in volume. The transition to mature milk occurs as the newborn stimulates production of milk through frequent feedings (8-12 times in a 24 hour period). For suggestions on how to teach this to parents, see: CME1: Composition of Milk
- Colostrum is yellow-orange colored, thick and sticky. It is low in fat and high in carbohydrates, protein and antibodies – designed to keep the newborn healthy. It has a laxative effect to help the newborn pass stools which helps to excrete bilirubin and decrease the likelihood of jaundice.
- Allow the baby to seek the breast, do not force the feeding. The mother/father may stimulate the newborn with touch.
- Delay all routine hospital procedures such as the newborn weight, measurement, and preventative medications until after the first breastfeeding.
- All assessments and care should be performed while mother and newborn are skin-to-skin.