Impact of Birthing Practices
on Breastfeeding
Linda J. Smith, BSE, FACCE, IBCLC, FILCA
Presentation toWHO BFHI Coordinators Network
October 13, 2010 Istituto degli Innocenti, Florence Italy
Grand Rounds Sept 7, 2011 – Dayton Children’s Hospital
Wright State University School of Medicine
Disclosure
 I am the sole author of Impact of Birthing Practices on Breastfeeding,
Second Edition and receive partial royalties on sales of this book.
 Mary Kroeger, CNM, MPH was the co-author for the first edition;
her estate receives royalties on sales of this book.
 I am the liaison from the International Lactation Consultant
Association (ILCA) to the World Health Organization’s BabyFriendly Hospital Initiative and receive reimbursement from ILCA
for my travel expenses when representing ILCA to WHO.
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© Copyright 2011 Linda J. Smith / BFLRC
4/8/2015
For Breastfeeding to Succeed
 The baby is able to feed: able to cue, suck, swallow, and
breathe smoothly
 The mother is producing milk and willing to bring her baby
to breast many times a day
 Breastfeeding is comfortable for both
 Surroundings support the dyad
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© Copyright 2011 Linda J. Smith / BFLRC
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Research gaps
 Few studies of birth practices address breastfeeding outcomes
 Lieberman, E., & O'Donoghue, C. (2002). Unintended effects of epidural analgesia during labor: a systematic
review. Am J Obstet Gynecol, 186(5 Suppl Nature), S31-68.
 hundreds of studies; only 2 had BF outcomes
 Few studies of breastfeeding & lactation investigate birth-related factors
 Dewey, K. G. (2001). Maternal and fetal stress are associated with impaired lactogenesis in humans. J Nutr,
131(11), 3012S-3015S.
 reported oxytocin responses, no information on infant suck
 Politics & Funding of Research
 Brown LP, Bair AH, Meier PP. Does federal funding for breastfeeding research target our national health
objectives? Pediatrics. Apr 2003;111(4 Pt 1):e360-364.
 “Out of 362 abstracts… awarded ~40.4 million dollars…only 13.7% (5.6 million dollars) was awarded to
projects determined to have either a direct or indirect impact on achieving the Healthy People 2000 goals for
increasing the incidence and duration of breastfeeding”
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© Copyright 2011 Linda J. Smith / BFLRC
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“We measure what we value”
 “Because ‘failure to breastfeed’ is not recognized as a
possible harmful effect of medication, there are few
methodological precedents in this area.
 “This is the first report of a dose–response relationship between
intrapartum neuraxial opioid analgesia and infant feeding.
 “When well-established determinants of infant feeding are
accounted for, intrapartum fentanyl may impede breastfeeding,
particularly at higher doses.”
 Jordan S, Emery S, Bradshaw C, Watkins A, Friswell W. The impact of intrapartum analgesia on
infant feeding. BJOG. Jul 2005;112(7):927-934.
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© Copyright 2011 Linda J. Smith / BFLRC
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Failure to breastfeed IS harmful
Failure to breastfeed MEANS formula feeding
Formula fed children are more likely to die - everywhere

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“[USA} excess 911 deaths, nearly all of which would be in infants ($10.5 billion and 741 deaths at 80%
compliance” (Bartick & Reinhold, Pediatrics 2010)
~doubles the risk of SIDS throughout infancy (Venneman, Pediatrics 2009)

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Mothers who do not lactate after birth are at higher risk of illness

Increased rates of
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Acute Otitis Media
Gastrointestinal Infections
Atopic Dermatitis
Lower Respiratory Tract Diseases
Asthma
Cardiovascular Diseases
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Poorer cognitive development
Obesity (mother and baby)
Type I and II Diabetes
Childhood Leukemia
Osteoporosis
Postpartum Depression
Breast & Ovarian Cancer
•
(AHRQ 2007)
© Copyright 2011 Linda J. Smith / BFLRC
4/8/2015
Appendix 2. Excess Health Risks Associated
with Not Breastfeeding*

Outcome
Excess Risk* (%)(95% CI†) Comparison Among full-term infants

Acute ear infections (otitis media)2
100 (56, 233)
EFF‡ vs. EBF§ for 3 or 6 mos

Eczema (atopic dermatitis)11
47 (14, 92)
EBF <3 mos vs. EBF ≥3 mos

Diarrhea and vomiting (GI infection) 3
178 (144, 213)
Never BF vs. ever BF

Hospitalization for LRI, 1st yr
257 (85, 614)
Never BF vs. EBF ≥4 mos

Asthma, with family history2
67 (22, 133)
BF <3 mos vs. ≥3 mos

Asthma, no family history2
35 (9, 67)
BF <3 mos vs. ≥3 mos

Childhood obesity7
32 (16, 49)
Never BF vs. ever BF

Type 2 diabetes mellitus6
64 (18, 127)
Never BF vs. ever BF

Acute lymphocytic leukemia2
23 (10, 41)
Never BF vs. >6 mos

Acute myelogenous leukemia5
18 (2, 37)
Never BF vs. >6 mos

Sudden infant death syndrome2
56 (23, 96)
Never BF vs. ever BF

Among preterm infants

Necrotizing enterocolitis2
138 (22, 2400)
Never BF vs. ever BF

Among mothers

Breast cancer8
4 (3, 6)
Never BF vs. ever BF (per year of BF)

Ovarian cancer2
27 (10, 47)
Never BF vs. ever BF
*U.S. Department of Health and Human Services. The Surgeon General’s Call to Action to Support Breastfeeding.
Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General; 2011.
www.surgeongeneral.gov.
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Disparities are disturbing
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Table 2. Provisional Breastfeeding Rates Among Children Born in 2007*
Sociodemographic Factor
Ever
BF @ 6 Mos. (%)
United States
75.0
43.0
Race/ethnicity
American Indian or Alaska Native
73.8
42.4
Asian or Pacific Islander
83.0
56.4
Hispanic or Latino
80.6
46.0
Non-Hispanic Black or African American
58.1
27.5
Non-Hispanic White
76.2
44.7
Receiving WIC†
Yes
67.5
33.7
No, but eligible
77.5
48.2
Ineligible
84.6
54.2
Maternal education
Not a high school graduate
67.0
37.0
High school graduate
66.1
31.4
Some college
76.5
41.0
College graduate
88.3
59.9
BF @12 Mos.(%)
22.4
20.7
32.8
24.7
12.5
23.3
17.5
30.7
27.6
21.9
15.1
20.5
31.1
*U.S. Department of Health and Human Services. The Surgeon General’s Call to Action to Support Breastfeeding. Washington,
DC: U.S. Department of Health and Human Services, Office of the Surgeon General; 2011. www.surgeongeneral.gov.
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© Copyright 2011 Linda J. Smith / BFLRC
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Preventive action
Breastfeeding
Insecticide-treated materials
Complementary feeding
Clean delivery
H. influenzae type b vaccination
Zinc supplementation
Clean water
Vitamin A supplementation
Tetanus toxoid vaccination
Nevirapine and replacement feeding
Measles vaccination
Antimalarial treatment in pregnancy
Newborn temperature management
Antibiotics for PROM
Estimated deaths prevented* %
1,301
691
587
411
403
351
326
176
61
150
103
22
0
0
13
7
6
4
4
4
3
2
2
2
1
1
0
0
Lancet Infant Survival Series, 2003
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© Copyright 2011 Linda J. Smith / BFLRC
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Global Recommendations
 Exclusive Breastfeeding for 6 months, followed by continued
breastfeeding with complementary family foods for 2+ years
 Recommended by World Health Organization and UNICEF 2003
 American Academy of Family Physicians
 American Academy of Pediatrics
 American College of Nurse-Midwives [PDF-76k]
 American College of Obstetricians and Gynecologists [PDF-17k]
 American Dietetic Association
 Association of Women's Health, Obstetric and Neonatal Nurses
 National Association of Pediatric Nurse Practitioners [PDF-72k]
 Every major organized religion
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US government supports BF
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Joint Commission Speak Up August 2011: What you need to know about breastfeeding
CDC Vital Signs August 2011: Preventing Obesity begins in Hospitals
CDC: mPINC surveys 2007 & 2009; 2011 in preparation
Nat’l Library of Medicine: LactMed online database
FDA: Breast pump information; IRS ruling
Office on Women’s Health: Business Case for Breastfeeding
Affordable Care Act 2010: mandated BF breaks at work
Healthy People 2020 Goals: 7 objectives
USBC www.usbreastfeeding.org
The Joint Commission Perinatal Core Measures 2010 on exclusive BF
First Lady’s “Let’s Move” campaign
Surgeon General’s Call to Action to Support Breastfeeding 2011
BFHI is in CTA and a line item in President Obama’s 2012 Budget
© Copyright 2011 Linda J. Smith / BFLRC
4/8/2015
USA: a decade of progress in BF
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Surgeon General’s Blueprint for Action, 2001
The Academy of Breastfeeding Medicine; journal, protocols
Federal & state legislation protecting the right to BF openly
WIC: $7 million in 1989, now $80+ million; peer counselors
CDC tracks BF rates instead of a formula company
OWH 2004-2006 Media campaign with “Risks of Not BF”
13 Donor Milk Banks, many started by neonatologists
National Business Group on Health: model reimbursement package
CDC / USBC Bi-Monthly Teleconferences; mPINC surveys
AAP Breastfeeding curriculum in medical schools 2009
AAP endorses the Ten Steps to Successful Breastfeeding 2009
3 National Conferences of State Breastfeeding Coalitions
CDC adopts WHO 2007 Growth Standards Sept 2010
© Copyright 2011 Linda J. Smith / BFLRC
4/8/2015
First, do no harm
 If the newborn is unable to breastfeed, AND/OR
 If lactogenesis is delayed or impaired, AND/OR
 If the mother is unwilling to breastfeed many times a day AND/OR
 Banked donor milk is not an option,
 The baby will be fed formula, which
 increases risk of sickness and death, and
 undermines the mother’s goals and
 The mother is at increased risk of illness
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© Copyright 2011 Linda J. Smith / BFLRC
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Increased risks of NOT lactating to the
mother (short list…)
 Breast cancer (pre & post menopause)
 Ovarian and endometrial cancer
 Higher stress hormones
 More postpartum depression
 More cardiovascular disease
 Altered metabolism: osteoporosis, obesity
 Early return of fertility
 Reduced ability to multitask
 Lower oxytocin – less trust
2006-09: Mother-Friendly Childbirth in BFHI
 Companion of the mother’s choice
 Freely move about, adopt positions of choice
 Eat and drink freely during labor
 Avoid unnecessary (routine) interventions
 Non-drug pain relief
 Required in educational Steps (2 & 3) now
 National BFHI Authorities to add assessment process on a country-by-
country basis
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© 2011 BFLRC / Linda J. Smith
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Companion(s) of the Mother’s Choice
No study has confirmed the safety and efficacy
of laboring alone
Continuous Companion(s) of choice
Strongly supports breastfeeding
 Better Breastfeeding Outcomes
 Hofmeyr,et al, 1991; Langer et al , 1998)
 Better Birth Outcomes
 25% shorter labor; 40% less oxytocin use; 30% less pain
medication; 40% less forceps; 60% fewer epidurals
(Hodnett,1994 & 2001; Scott et al,1999; Zhang et al,
1996)
 Less Surgical Intervention
 50% reduction in Cesarean rate (Hodnett,1994 & 2001;
Scott et al, 1999; Zhang et al, 1996; Nommsen-Rivers
2009)
 Empowered Mother
 (Campero, et al, 1998)
 Hodnett E, Gates S, Hofmeyr G, Sakala C. Continuous
support for women during childbirth. Cochrane Database
Syst Rev. 2007(3):CD003766.
4/8/2015
© Copyright 2011 Linda J. Smith /
BFLRC
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Criteria for companion(s)
 #1: Mother’s choice
 Continuous presence with mother
 Female who has given birth
 Short training is helpful
 Does not replace the father; supports both
 If payment is involved, mother pays
 Not hospital employee
 Provides no medical care nor interferes
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Freely move about in labor and birth
“Gravity works”
No study has confirmed the safety and
efficacy of horizontal and/or immobile
positions for labor or birth
Breastfeeding outcomes
 Horizontal position = longer 1st stage, poorer fetal oxygenation
 Horizontal position = longer 2nd stage, excess molding, more
fetal distress, more instruments & surgery
 Long labors = delayed lactogenesis (Chen)
 No direct research on BF outcomes
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© Copyright 2011 Linda J. Smith / BFLRC
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Eat and Drink Freely
“Labor is work”
No study has confirmed the safety and efficacy of
withholding food and drink during labor and birth
Light eating & drinking in labor
No direct research re: breastfeeding
 Labor is vigorous exercise / work
 Fasting & starvation slows, complicates
labor
 “Most obstetric anesthesiologists agree
that a rigid NPO policy in labor is no
longer appropriate”
◦ O'Sullivan, Anesthesiol Clin North America
2003
 “Consumption of a light diet during
labour did not influence obstetric or
neonatal outcomes in participants, nor
did it increase the incidence of
vomiting.”
◦ O'Sullivan, BMJ 2009
4/8/2015
Cambodia 2001- Offering oral fluids
was “new” policy for these midwives
(MK)
© Copyright 2011 Linda J. Smith /
BFLRC
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Breastfeeding outcomes
 When liquids are withheld, IV hydration is given
 60% of mothers with pitting edema had delayed onset of lactogenesis II
 IV fluids, induction, Cesarean, and other interventions were associated with
edema

Nommsen-Rivers, L. A., Chantry, C. J., Peerson, J. M., Cohen, R. J., & Dewey, K. G. (2010). Delayed onset of lactogenesis among first-time mothers is related to
maternal obesity and factors associated with ineffective breastfeeding. Am J Clin Nutr. (e-pub ahead of print)
 Indirect Maternal Risks
 Psychological risks
 Pain & stress
 Restriction of movement
 Indirect Newborn Risks
 Electrolyte imbalances
 Fluid overload, excess loss of birth weight
 Separation from mother
 Disruption in early breastfeeding
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Drugs for Pain Management
All drugs reach the fetus/baby within seconds
All drugs reach the fetus/baby
 “The lower NACS (Neurologic and Adaptive Capacity Score) at
24 hours in group B-F may reflect the continued
presence of fentanyl in the neonate.”
 Randomized; double-blind study of epidural sufentanil and fentanyl
infused with bupivacaine
 Loftus, J. R., Hill, H., & Cohen, S. E. (1995). Placental transfer and
neonatal effects of epidural sufentanil and fentanyl administered with
bupivacaine during labor. Anesthesiology, 83(2), 300-308.
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© Copyright 2011 Linda J. Smith / BFLRC
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All drugs reach the baby…
even local lidocaine
“It has not previously been reported that
the use of analgesia via pudendal block
has an adverse effect on the initiation of
developing breastfeeding behavior
including sucking.”
Ransjo-Arvidson, A., Matthiesen, A., Lilja, G.,
Nissen, E., Widstrom, A., & Uvnas-Moberg, K.
(2001). Maternal analgesia during labor disturbs
newborn behavior. Birth, 28, 5 - 12.
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© Copyright 2011 Linda J. Smith / BFLRC
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Strong evidence of consequences
 Sixty women were randomly assigned to receive no fentanyl, 59
were randomly assigned to receive an intermediate dose, and 58
were randomly assigned to receive high-dose fentanyl.
 At 6 weeks postpartum, more women who were randomly
assigned to high-dose epidural fentanyl were not breast-feeding (n
= 10, 17%) than women who were randomly assigned to receive
either an intermediate fentanyl dose (n = 3, 5%) or no fentanyl (n
= 1, 2%) (P = 0.005).
 Conclusion: Among women who breast-fed previously, those who
were randomly assigned to receive high-dose labor epidural
fentanyl were more likely to have stopped breast-feeding 6 weeks
postpartum than women who were randomly assigned to receive
less fentanyl or no fentanyl.
 BeilinY et al. Effect of labor epidural analgesia with and without fentanyl on infant breast-
feeding: A prospective, randomized, double-blind study. Anesthesiology 2005, 103(6),
1211-1217.
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© Copyright 2011 Linda J. Smith / BFLRC
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History of documented effects
 Cyanosis, unresponsive, visual skills, alertness, state, poor response to stress for 6
weeks
 Rosenblatt, D. B., Belsey, E. M., Lieberman, B. A., Redshaw, M., Caldwell, J., Notarianni, L., et al.
(1981). The influence of maternal analgesia on neonatal behaviour: II. Epidural bupivacaine. Br J Obstet
Gynaecol, 88(4), 407-413.
 Cueing, sucking, maternal attention
 N=60; 38 were products of epidural deliveries and 22 of non-medicated deliveries.
 Sepkoski, C. M., Lester, B. M., Ostheimer, G. W., & Brazelton, T. B. (1992). The effects of maternal
epidural anesthesia on neonatal behavior during the first month. Dev Med Child Neurol, 34(12),
1072-1080.
 Delayed feeding 2.5 hours, increased temperature, poor cueing, cried more
 N= 28; Group 1 mothers (n 4 10) had received no analgesia during labor, group 2 mothers (n 4 6) had
received mepivacaine via pudendal block, and group 3 mothers (n 4 12) had received pethidine or
bupivacaine or more than one type of analgesia during labor
 Ransjo-Arvidson, A., Matthiesen, A., Lilja, G., Nissen, E., Widstrom, A., & Uvnas-Moberg, K.
(2001). Maternal analgesia during labor disturbs newborn behavior. Birth, 28, 5 - 12
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Documented effects, cont.
 Poor suck on IBFAT, early weaning
 Riordan, J., Gross, A., Angeron, J., Krumwiede, B., & Melin, J. (2000). The effect of labor
pain relief medication on neonatal suckling and breastfeeding duration. J Hum Lact, 16(1),
7-12.
 More instruments, less spontaneous vaginal birth, longer labor, maternal
fever, septic workups
 Lieberman, E., & O'Donoghue, C. (2002). Unintended effects of epidural analgesia during
labor: a systematic review. Am J Obstet Gynecol, 186(5 Suppl Nature), S31-68.
 Ineffective feeds; more bottle supplements
 Baumgarder, D. J., Muehl, P., Fischer, M., & Pribbenow, B. (2003). Effect of
labor epidural anesthesia on breast-feeding of healthy full-term newborns
delivered vaginally. J Am Board Fam Pract, 16(1), 7-13
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Still more documented effects
 Breastfeed for shorter duration
 Henderson, J. J., Dickinson, J. E., Evans, S. F., McDonald, S. J., & Paech, M. J.
(2003). Impact of intrapartum epidural analgesia on breast-feeding duration. Aust N Z
J Obstet Gynaecol, 43(5), 372-377.
 “Not enough milk;” formula use
 Volmanen, P., Valanne, J., & Alahuhta, S. (2004). Breast-feeding problems after
epidural analgesia for labour: a retrospective cohort study of pain, obstetrical
procedures and breast-feeding practices. Int J Obstet Anesth, 13(1), 25-29.
 Breastfeeding difficulties, stop BF sooner
 Torvaldsen, S., Roberts, C. L., Simpson, J. M., Thompson, J. F., & Ellwood, D. A.
(2006). Intrapartum epidural analgesia and breastfeeding: a prospective cohort study.
Int Breastfeed J, 1, 24.
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© Copyright 2011 Linda J. Smith / BFLRC
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More and more effects
 Reduced warming effect of STS
 N=47 mother-infant pairs; 9 mothers had received OT stimulation during labour (OT group), 20 mothers had received
an EDA and OT during labour (EDA group), while 18 mothers had received neither EDA nor OT stimulation during
labour (control group).
 The temperature measured when the newborns were put skin-to-skin on their mothers' chest was significantly higher in
the infants of the EDA group (35.07 degrees C) when compared to the control group (34.19 degrees C, p=0.025).
 Skin temperature increased significantly (p=0.001) during the entire experimental period in the infants belonging to the
control group. The same response was observed in infants whose mothers received OT intravenously during labour
(p=0.008). No such rise was observed in infants whose mothers were given an EDA during labour.
 Jonas, W., Wiklund, I., Nissen, E., Ransjo-Arvidson, A. B., & Uvnas-Moberg, K. (2007). Newborn skin
temperature two days postpartum during breastfeeding related to different labour ward practices. Early
Hum Dev, 83(1), 55-62.
 Delayed spontaneous breastfeeding 4+ hrs; increased formula supplementation
 n=585 mothers with EDA matched with 585 controls
 Significantly fewer babies of mothers with EDA during labour suckled the breast within
the first 4 hours of life [odds ratio (OR) 3.79]. These babies were also more often given artificial
milk during their hospital stay (OR 2.19) and fewer were fully breast fed at discharge (OR 1.79).
 Delayed initiation of breast feeding was also associated with a prolonged first (OR 2.81) and second stage
(OR 2.49) and with the administration of oxytocin (OR 3.28).
 Wiklund, I., Norman, M., Uvnas-Moberg, K., Ransjo-Arvidson, A. B., & Andolf, E. (2009). Epidural
analgesia: breast-feeding success and related factors. Midwifery, 25(2), e31-38
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Hormone effects
 Reduced oxytocin
 Rahm, V. A., Hallgren, A., Hogberg, H., Hurtig, I., & Odlind, V. (2002). Plasma oxytocin levels in women
during labor with or without epidural analgesia: a prospective study. Acta Obstet Gynecol Scand, 81(11),
1033-1039.
 Reduced pulsatile oxytocin
 Nissen, E., Uvnas-Moberg, K., Svensson, K., Stock, S., Widstrom, A. M., & Winberg, J. (1996).
Different patterns of oxytocin, prolactin but not cortisol release during breastfeeding in women
delivered by caesarean section or by the vaginal route. Early Hum Dev, 45(1-2), 103-118.
 Reduced maternal socialization; increased anxiety and aggression
 Jonas, W., Nissen, E., Ransjo-Arvidson, A. B., Matthiesen, A. S., & Uvnas-Moberg, K. (2008). Influence
of oxytocin or epidural analgesia on personality profile in breastfeeding women: a comparative study. Arch
Womens Ment Health, 11(5-6), 335-345.
 Lowered endogenous oxytocin with epidural + oxytocin infusion
 Jonas, W., Johansson, L. M., Nissen, E., Ejdeback, M., Ransjo-Arvidson, A. B., & Uvnas-Moberg, K.
(2009). Effects of Intrapartum Oxytocin Administration and Epidural Analgesia on the Concentration of
Plasma Oxytocin and Prolactin, in Response to Suckling During the Second Day Postpartum. Breastfeed
Med, 4(2), 71-82
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© Copyright 2011 Linda J. Smith / BFLRC
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Natural pain relief: endorphins
 “beta-endorphin is 18 to 33 times more potent than morphine”
 Loh, Proc Natl Acad Sci USA 1976
 Epidurals reduce maternal endorphins
 Abboud, T. K., Khoo, S. S., Miller, F., Doan, T., & Henriksen, E. H. (1982). Maternal, fetal, and
neonatal responses after epidural anesthesia with bupivacaine, 2-chloroprocaine, or lidocaine.
Anesth Analg, 61(8), 638-644.
 Cesarean without labor reduces endorphins in milk
 Zanardo, V., Nicolussi, S., Giacomin, C., Faggian, D., Favaro, F., & Plebani, M. (2001). Labor pain
effects on colostral milk beta-endorphin concentrations of lactating mothers. Biol Neonate, 79(2),
87-90
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© Copyright 2011 Linda J. Smith / BFLRC
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Clinical implications
 Babies with altered neurobehavior do not feed effectively,
causing…
 Inadequate nutrition for infant
 Risk of formula supplementation
 Milk retention in breast
 Suppressed onset of lactation / lactogenesis
 Maternal pain
 Undermining of mothers’ confidence
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© Copyright 2011 Linda J. Smith / BFLRC
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Clinical implications, cont.
 Epidurals reduce / block maternal endorphins released in labor
 unrelieved maternal pain
 Epidurals & birth without labor reduce endorphin
concentrations in milk
 Unrelieved infant pain?
 Inability to access pain-relieving effect of breastfeeding
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© Copyright 2011 Linda J. Smith / BFLRC
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Clinical implications, cont.
 Non-pulsatile oxytocin: reduced milk release
 Milk retention; compromised lactogenesis
 Inadequate infant nutrition
 Increased risk of formula supplementation
 Altered oxytocin: behavioral & biological effects
 Reduced uterine contractions
 Reduced digestion, slower healing
 Reduced maternal socialization
 Increased anxiety and aggression
 Reduced trust; reduced facial recognition
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© Copyright 2011 Linda J. Smith / BFLRC
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Non-drug pain relief
Strongly supports breastfeeding
•Before
•In addition to
•Instead of
Drug methods
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© Copyright 2011 Linda J. Smith / BFLRC
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Routine interventions
Elective Induction of Labor
Routine Suctioning
Routine Episiotomy
Cesarean Surgery
Risks of inducing labor
 2X the risk of Cesarean in primiparas
 Synthetic oxytocin = stronger contractions
 ↑ pressure on baby’s head
 ↑ maternal pain
 ↑ infant pain ??
 Less-mature baby (?)
 WHO: 10% induction medically justified
39
© Copyright 2011 Linda J. Smith / BFLRC
4/8/2015
Increased forces to baby’s head
 Induction & augmentation
 Pushing on fundus
 Supine position
 Immobility
 Instruments and Cesarean
 Result: more molding / abnormal molding
40
© Copyright 2011 Linda J. Smith / BFLRC
4/8/2015
Research Evidence
 “Vacuum vaginal delivery was a strong predictor of early cessation of
breastfeeding”
 N=1075; 8 variables identified as significant.
 Hall RT, Mercer AM, Teasley SL, et al. 2002. A breastfeeding assessment score to evaluate
the risk for cessation of breastfeeding by 7 to 10 days of age. J Ped 141:659–664.
 Poor feeding is one sign of intercranial bleeding
 58term newborns with Apgars of 9-10 were referred for repeat CT examination of the
brain with symptoms, such as apnea, disturbances of swallowing or sucking,
impaired muscular tonus, tremor and jerks.
 Avrahami E, Amzel S, Katz R, et al. 1996. CT demonstration of intracranial bleeding in
term newborns with mild clinical symptoms. Clin Radiol 51:31–34.
41
© Copyright 2011 Linda J. Smith / BFLRC
4/8/2015
Research Evidence (cont.)
 Wall & Glass: 11 mother-infant pairs had breastfeeding
problems related to the infants' mandibular asymmetry
 2 received septic workups for poor feeding and weight loss but had negative culture results.
Five lost more than 8% of their birth weight. Nine received supplementation (by tube at
breast, finger-feeding, or bottle) secondary to difficulty breastfeeding in the first week of life.
 Labor was prolonged in at least 6 and resulted in cesarean section in 4 of the 11 cases. One
birth was forceps-assisted. Three infants were large for gestational age.
 Wall, V., & Glass, R. (2006). Mandibular Asymmetry and Breastfeeding Problems: Experience From 11 Cases. J Hum
Lact, 22(3), 328-334.
 Evans: “The volume of milk transferred to infants born by
caesarean section was significantly less than that transferred to
infants born by normal vaginal delivery on days 2 -5 (p<0.05).”

42
Evans, K. C., Evans, R. G., Royal, R., Esterman, A. J., & James, S. L. (2003). Effect of caesarean section on breast milk transfer to
the normal term newborn over the first week of life. Arch Dis Child Fetal Neonatal Ed, 88(5), F380-382.
© Copyright 2011 Linda J. Smith / BFLRC
4/8/2015
Chance or Choice? Induction
 This isn’t new!
 The U.S. Food and Drug Administration disapproved of elective inductions in the
1970s due to iatrogenic prematurity, overcrowded neonatal intensive care units, and
huge unnecessary costs
 Increased risk of infant death
 Kramer, M. S., Demissie, K.,Yang, H., Platt, R. W., Sauve, R., & Liston, R. (2000).
The contribution of mild and moderate preterm birth to infant mortality. Fetal and
Infant Health Study Group of the Canadian Perinatal Surveillance System. JAMA,
284(7), 843-849.
 Doubled risk of Cesarean
 Crosby, W. (2008). Elective induction of labor: part 2. J Okla State Med Assoc, 101(12),
369-373.
43
© Copyright 2011 Linda J. Smith / BFLRC
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“Insufficient evidence”
 “The evidence regarding elective induction of labor prior
to 41 weeks of gestation is insufficient to draw any
conclusion.
 There is a paucity of information from prospective RCTs
examining other maternal or neonatal outcomes in the
setting of elective induction of labor.”
 Caughey, A. B., Sundaram, V., Kaimal, A. J., Cheng,Y. W., Gienger, A.,
Little, S. E., et al. (2009). Maternal and neonatal outcomes of elective
induction of labor. Evid Rep Technol Assess (Full Rep)(176), 1-257.
44
© Copyright 2011 Linda J. Smith / BFLRC
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No information on BF outcomes
 As of August 3, 2011, to the best of my
knowledge:
 No studies of induction have investigated
breastfeeding outcomes
45
© Copyright 2011 Linda J. Smith / BFLRC
4/8/2015
Suctioning & airway management
 Oral aversion ?
 Superstimulus, vagal response ?
 Triggers poor tongue movements?
 Injury to oropharanyx (L. Black,
MD)
 Mucus has a purpose (M. Klaus)
 Unmedicated: babies handle mucus
 Artifact from heavily medicated
births??
4/8/2015
© Copyright 2011 Linda J. Smith /
BFLRC
46
No direct research on suctioning
 Lack of benefit
 RCT; N=2514; 11 hospitals in US and Argentina
 No significant difference between treatment groups was seen in the incidence of MAS (52
[4%] suction vs 47 [4%] no suction; relative risk 0.9, 95% CI 0.6-1.3), need for mechanical
ventilation for MAS (24 [2%] vs 18 [1%]; 0.8, 0.4-1.4), mortality (9 [1%] vs 4 [0.3%]; 0.4,
0.1-1.5), or in the duration of ventilation, oxygen treatment, and hospital care
 Routine intrapartum oropharyngeal and nasopharyngeal suctioning of term-gestation infants
born through meconium stained amniotic fluid does not prevent meconium aspiration
syndrome. Consideration should be given to revision of present recommendations.

Vain, N. E., Szyld, E. G., Prudent, L. M., Wiswell, T. E., Aguilar, A. M., & Vivas, N. I. (2004). Oropharyngeal and nasopharyngeal suctioning of
meconium-stained neonates before delivery of their shoulders: multicentre, randomised controlled trial. Lancet, 364(9434), 597-602.
 Long term negative consequences
 “Noxious stimulation caused by gastric suction at birth may promote the development of
long-term visceral hypersensitivity and cognitive hypervigilance, leading to an increased
prevalence of functional intestinal disorders in later life.”
 Anand, K. J., Runeson, B., & Jacobson, B. (2004). Gastric suction at birth associated with long-term risk for functional
intestinal disorders in later life. J Pediatr, 144(4), 449-454
47
© Copyright 2011 Linda J. Smith / BFLRC
4/8/2015
Episiotomy – one study
Pain in Perineum Distracted Woman When Breastfeeding
Not at all
A bit/
occasionally
A lot, often,
always
Total
Tear
234 (68%)
79 (23%)
31 (9%)
344
Episiotomy
409 (43%)
381 (40%)
167 (17%)
957
Episiotomy & Tear
55 (37%)
62 (42%)
31 (21%)
148
Intact
154 (92%)
9 (5%)
5 (3%)
168
Total
852 (53%)
531 (33%)
234 (14%)
1617
Kitzinger, S. (1981). Some Women's Experiences of Episiotomy. In N. C. Trust (Ed.) (Vol.
Pamphlet NLM # 05304054-6). London: National Childbirth Trust.
4/8/2015
© Copyright 2011 Linda J. Smith /
BFLRC
48
Cesarean Surgery
Emergent Cesarean
Scheduled (elective) Cesarean
Elective Cesarean:
Infant respiratory problems
 Conclusions Elective repeat cesarean
delivery before 39 weeks of gestation is
common and is associated with
respiratory and other adverse neonatal
outcomes.
 Tita, A. T. N., Landon, M. B., Spong, C.Y., Lai,Y., Leveno, K. J.,
Varner, M. W., et al. (2009). Timing of Elective Repeat Cesarean
Delivery at Term and Neonatal Outcomes. N Engl J Med, 360(2), 111120.
50
© Copyright 2011 Linda J. Smith / BFLRC
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Elective Cesarean:
Infant respiratory problems, NICU
 CONCLUSION: In comparison with vaginal birth
after cesarean, neonates born after elective
repeat cesarean delivery have significantly
higher rates of respiratory morbidity and
NICU-admission and longer length of hospital
stay.
 Kamath, B. D., Todd, J. K., Glazner, J. E., Lezotte, D., & Lynch, A. M.
(2009). Neonatal outcomes after elective cesarean delivery. Obstet
Gynecol, 113(6), 1231-1238.
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© Copyright 2011 Linda J. Smith / BFLRC
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Elective Cesarean:
BF to a lesser extent at 3 months
 In a prospective cohort study 357 healthy primiparas from two
different groups, "cesarean section on maternal request" (n=91) and
"controls planning a vaginal delivery" (n=266) completed three selfassessment questionnaires in late pregnancy, two days after delivery
and 3 months after birth.
 RESULTS: Women requesting cesarean section experienced their
health as less good (p<0.001) and were more often planning for one
child only (p<0.001). They more often reported anxiety for lack of
support during labor (p<0.001), for loss of control (p<0.001), and
concern for fetal injury/death (p<0.001).
 They were breastfeeding to a lesser extent three months after birth
(p<0.001). There were no differences in signs of postpartum
depression between the groups three months after birth (p=0.878).
 Wiklund, I., Edman, G., & Andolf, E. (2007). Cesarean section on maternal request: reasons
for the request, self-estimated health, expectations, experience of birth and signs of
depression among first-time mothers. Acta Obstet Gynecol Scand, 86(4), 451-456.
52
© Copyright 2011 Linda J. Smith / BFLRC
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Any Cesarean:
Delayed onset of lactogenesis
 Risk factors for delayed lactation were being primiparous
(adjusted OR 3.16, 95% CI 1.58-6.33) and having delivered by
caesarean section (adjusted OR 2.40, 95% CI 1.28-4.51).
 Scott, J. A., Binns, C. W., & Oddy, W. H. (2007). Predictors of
delayed onset of lactation. Matern Child Nutr, 3(3), 186-193.
 Delayed onset of lactation (>72 hours) occurred in 22% of
women and was associated with primiparity, cesarean section,
stage II labor >1 hour, maternal body mass index >27
kg/m(2), flat or inverted nipples, and birth weight >3600 g (in
primiparas).
 Dewey, K. G., Nommsen-Rivers, L. A., Heinig, M. J., & Cohen, R. J. (2003).
Risk factors for suboptimal infant breastfeeding behavior, delayed onset of
lactation, and excess neonatal weight loss. Pediatrics, 112(3 Pt 1), 607-619.
53
© Copyright 2011 Linda J. Smith / BFLRC
4/8/2015
Ecologic analysis of delayed onset of lactogenesis by birth setting
% Delayed Onset of Lactogenesis
Nommsen-Rivers, L. A., Mastergeorge, A. M., Hansen, R. L., Cullum, A. S., & Dewey, K. G. (2009). Doula care, early breastfeeding outcomes,
and breastfeeding status at 6 weeks postpartum among low-income primiparae. J Obstet Gynecol Neonatal Nurs, 38(2), 157-173.
40
y=0.97x + 5.44; R-squared = .85
35
From L to R:
30
Lusaka, Zambia
Kasonka, 2002
25
Rural Guatemala
20
Hruschka, 2003
15
Davis, California
Dewey, 2003
10
Rural Ghana, BabyFriendly Hospital Otoo, 2009
5
Urban Guatemala
Grajeda, 2002
Urban Connecticut
0
0
5
10
15
20
25
30
35
Chapman,
1999
40
% Cesarean delivery
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© Copyright 2011 Linda J. Smith / BFLRC
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Who is at risk for delayed OL?
Sacramento Cohort, Maternal Factors
< 25.0
25-29.9
> 30.0
Body
Mass
Index
P=.002
31
45
54
10 20 30 40 50 60 70 80
A-B
44
C-D
43
DD-H
Bra cup
size
P=.86
48
10 20 30 40 50 60 70 80
55
© Copyright 2011 Linda J. Smith / BFLRC
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Who is at risk for delayed OL?
Sacramento Cohort, peri-partum factors
none
35
mild
49
pitting
Postpartum
edema
P<.001
65
20
30
40
50
60
70
80
none
mild
42
pitting
© Copyright 2011 Linda J. Smith / BFLRC
78
(7/9)
20
56
PP edema
BMI < 27,
P=.01
31
30
40
50
60
70
80
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Elective Cesarean:
Less sensitive to baby’s cries
 We conducted functional magnetic resonance imaging, 2-4 weeks after
delivery, of the brains of six mothers who delivered vaginally and six who
had an elective CSD. VD mothers' brains were significantly more
responsive than CSD mothers' brains to their own baby-cry in the superior
and middle temporal gyri, superior frontal gyrus, medial fusiform gyrus,
superior parietal lobe, as well as regions of the caudate, thalamus,
hypothalamus, amygdala and pons.
 Also, within preferentially active regions of VD brains, there were
correlations across all 12 mothers with out-of-magnet variables. These
include correlations between own baby-cry responses in the left and right
lenticular nuclei and parental preoccupations (r = .64, p < .05 and .67, p
< .05 respectively), as well as in the superior frontal cortex and Beck
depression inventory (r = .78, p < .01).
 this suggests that VD mothers are more sensitive to own baby-cry than
CSD mothers in the early postpartum in sensory processing, empathy,
arousal, motivation, reward and habit-regulation circuits.
 Swain, J. E., Tasgin, E., Mayes, L. C., Feldman, R., Constable, R. T., & Leckman, J. F. (2008). Maternal brain
response to own baby-cry is affected by cesarean section delivery. J Child Psychol Psychiatry, 49(10), 1042-1052.
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© Copyright 2011 Linda J. Smith / BFLRC
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Any Cesarean:
Barrier to BF initiation
 N=1696 over 6 years
 Overall, 36% of all births were performed by cesarean
section, while initiation of breastfeeding was achieved by
61.5% of the women.
 Cesarean section was negatively related to breastfeeding
initiation in multivariable logistic regression models (odds
ratio=.64; 95% CI=0.51-0.81) after controlling for
confounding variables.
 Perez-Rios, N., Ramos-Valencia, G., & Ortiz, A. P. (2008).
Cesarean delivery as a barrier for breastfeeding initiation: the
Puerto Rican experience. J Hum Lact, 24(3), 293-302.
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© Copyright 2011 Linda J. Smith / BFLRC
4/8/2015
Clinical Implications
 WHO: 10 – 15% probably medically justified
 NIH: Trial of Labor is a reasonable
option for many pregnant women with a
prior low transverse uterine incision. NIH Consensus Development Conference:
Vaginal Birth After Cesarean: New Insights March 8–10, 2010
 US Cesarean rate, August 2011: 34%
 Risk of infant respiratory and suck problems
 Risk of delayed onset of lactation
 Risk of extended maternal pain
 Most pain relievers are compatible with BF
 Assure close and extended skilled follow up
59
© Copyright 2011 Linda J. Smith / BFLRC
4/8/2015
Immediate Skin-to-Skin after Cesarean
From a nurse at Wentworth Douglass, responding to a grateful mother as her
second baby was immediately placed STS after her 2nd Cesarean: “This is
what we do.”
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© Copyright 2011 Linda J. Smith / BFLRC
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Cumulative effect of interventions
 N=753,895 low-risk women who gave birth in Australia during
2000-2002.
 RESULTS: We observed increased rates of operative birth in association
with each of the interventions offered during the labour process. For first
time mothers the association was particularly strong.
 At a population level it demonstrates the magnitude of the fall in rates of
unassisted vaginal birth in association with a cascade of interventions in
labour and interventions at birth particularly amongst women with no
identified risk markers and having their first baby.
 Tracy, S. K., Sullivan, E., Wang,Y. A., Black, D., & Tracy, M. (2007). Birth outcomes
associated with interventions in labour amongst low risk women: a population-based study.
Women Birth, 20(2), 41-48.
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© Copyright 2011 Linda J. Smith / BFLRC
4/8/2015
Rate of unassisted vaginal birth in association with instrumental and
caesarean births amongst ‘low risk’ first time mothers, Australia,
2000—2002.
Tracy, S. K., Sullivan, E., Wang, Y. A., Black, D., & Tracy, M. (2007). Birth outcomes associated with
interventions in labour amongst low risk women: a population-based study. Women Birth, 20(2), 41-48.
62
© Copyright 2011 Linda J. Smith / BFLRC
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Tracy, S. K., Sullivan, E., Wang, Y. A., Black, D., & Tracy, M. (2007). Birth outcomes associated with
interventions in labour amongst low risk women: a population-based study. Women Birth, 20(2), 41-48.
63
© Copyright 2011 Linda J. Smith / BFLRC
4/8/2015
Traumatic birth impedes BF
 RESULTS: n= 52; Eight themes emerged about whether mothers' breast-feeding
attempts were promoted or impeded. These themes included







(a) proving oneself as a mother: sheer determination to succeed,
(b) making up for an awful arrival: atonement to the baby,
(c) helping to heal mentally: time-out from the pain in one's head,
(d) just one more thing to be violated: mothers' breasts,
(e) enduring the physical pain: seeming at times an insurmountable ordeal,
(f) dangerous mix: birth trauma and insufficient milk supply,
(g) intruding flashbacks: stealing anticipated joy, and (h) disturbing detachment: an
empty affair.
 CONCLUSIONS: The impact of birth trauma on mothers' breast-feeding
experiences can lead women down two strikingly different paths. One path can
propel women into persevering in breast-feeding, whereas the other path can lead
to distressing impediments that curtailed women's breast-feeding attempts.
 Beck, C. T., & Watson, S. (2008). Impact of birth trauma on breast-feeding: a tale of two
pathways. Nurs Res, 57(4), 228-236.
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© Copyright 2011 Linda J. Smith / BFLRC
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For Breastfeeding to Succeed
 The baby is able to feed: able to cue, suck, swallow, and
breathe smoothly
 The mother is producing milk and willing to bring her baby
to breast many times a day
 Breastfeeding is comfortable for both
 Surroundings support the dyad
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© Copyright 2011 Linda J. Smith / BFLRC
4/8/2015
Summary
 Companion(s) of the mother’s choice: Strong positive effect on




breastfeeding
Movement & position: no direct evidence on BF
Eat & drink: no direct evidence on BF; new policies
Labor Drugs: Strong negative effect on BF, especially fentanyl
Routine Interventions
 Induction: no direct evidence on BF
 Episiotomy: one study, negative effect on BF
 Suctioning: no direct evidence on BF
 Cesarean: Strong negative effect on BF
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© Copyright 2011 Linda J. Smith / BFLRC
4/8/2015
Thank you!
 Linda J. Smith
Lindaj@bflrc.com
937-438-9458
 Impact of Birthing Practices on
Breastfeeding, 2nd Edition
 www.jblearning.com
4/8/2015
© Copyright 2011 Linda J. Smith /
BFLRC
67