by KMom
Copyright © 1998-2002 KMom@Vireday.Com. All rights reserved.
Last updated: October-2002DISCLAIMER: The information on this website is not intended and should not be construed as medical advice. Consult your health provider.
CONTENTS
The cesarean rate in the United States skyrocketed in the 1980s until more than 1 in 5 births took place via cesarean. After dropping somewhat in the 1990s, it has started to rise again. It now is about 1 in 4 births, and will probably continue to have a very significant increase in the next few years. Therefore, many women are having to cope with having a cesarean (and all the problems associated with it) just as they are also trying to care for their newborn children.
One area which cesareans affect significantly is breastfeeding. Research shows fewer women breastfeed their babies after having had a cesarean. Stress tends to delay lactogenesis (the mature milk coming in), and routine protocols and medicines that surround cesareans tend to interfere with breastfeeding initiation and decrease supply.
Breastfeeding advocates have long promoted the idea that women who have had a cesarean need EXTRA support and help to establish breastfeeding. However, few hospitals routinely offer extra breastfeeding support to women who have had a difficult birth or who have had a cesarean. In fact, many hospitals have protocols that actively interfere with breastfeeding under these conditions.
This particular FAQ, therefore, is about breastfeeding after a c-section. It examines the benefits of breastfeeding after a cesarean, how a cesarean can interfere with breastfeeding, strategies for increasing breastfeeding success, bonding issues after a difficult birth, and issues of grieving in women for whom breastfeeding does not work out.
Too often, women who have had a long difficult labor and/or a cesarean encounter breastfeeding difficulties. Many of these difficulties could have been avoided or fixed much sooner had the women had better or more timely help. For most women, breastfeeding difficulties are resolvable with timely help, emotional support, patience, and diligence. Unfortunately, not all women receive timely help or emotional support after birth, and so breastfeeding does not last long for some. For a few women, hormonal, genetic, or infant conditions may prevent them from breastfeeding their babies fully. Try as we might, breastfeeding does not always work out, and this can be a very difficult and painful situation.
Women who have had an undesired cesarean and then encountered breastfeeding difficulties on top of that have a great deal of grief to deal with. Yet problems breastfeeding after a cesarean do not have to be a life-long wound on their hearts. Learning more information about this situation and hearing other women's stories can help women come to terms with their own grief and start the healing process.
This FAQ has several goals. First, it offers help to women who are presently struggling with breastfeeding problems after a cesarean, with information, links, and resources to help them overcome the difficulties they might be having. It discusses how common hospital protocols can affect breastfeeding, ways to work with hospital staff to minimize problems like these, other factors that might be affecting breastfeeding or supply, and resources they can call on for further help.
Second, this FAQ offers help to women planning to breastfeed in future pregnancies, whether those births are by Vaginal Birth After Cesarean (VBAC), unplanned cesarean, or planned repeat cesarean. If they know ahead of time the problems to watch for, they can develop a plan of action to prevent these problems from occurring, or a plan of action to get help if problems do occur. Many women have found that they are able to breastfeed much more easily the second (or even third) time around with good resources and planning.
And third, this FAQ offers reassurance to women who have had trouble breastfeeding after past births. It is important that women come to terms with past breastfeeding difficulties so that they can grieve the experience and find a measure of peace about it. They need to read other women's stories so that they know they are not alone in this experience, and that many other women have walked this path before them. They need to understand the breastfeeding problems they may have encountered and why they may have occurred, to understand that they made the best decisions they could at the time with the information they had, and that past difficulties with breastfeeding does not have to mean future difficulties with it. They also need to know that although breastfeeding is very important, breastfeeding alone does not define themselves or their relationship with their babies, whatever happens. The first and most important thing is mother love.
*Special Note: This FAQ is long, and many people will not read it in a continuous fashion, or in one sitting. Therefore, some information is repeated between sections, with apologies for the redundancy.
Benefits of Breastfeeding After a CesareanBreastfeeding offers many benefits to both infant and mother, but it is not within the scope of this FAQ to adequately cover all of the many benefits of breastfeeding in detail. For further information about the benefits of breastfeeding, see www.promom.org, www.breastfeeding.com, or www.lalecheleague.org.
Briefly, mothers who breastfeed lower their risk for reproductive cancers like breast cancer, ovarian cancer, etc., and may have less osteoporosis. Infants receive superior nutrition and immunological protection that strongly lowers their rate of ear infections, gastrointestinal problems, allergies, and many other illnesses. The longer the breastfeeding, the stronger the benefits to both mother and baby.
In addition, breastfeeding offers many benefits to the cesarean mother in particular. These include faster uterine involution and quicker weight loss after birth. Cesarean babies who are breastfed also receive significant benefits such as immunological protections, and prevention/minimization of hypoglycemia and jaundice problems. Finally, the cesarean mother/baby duo often finds that breastfeeding is extremely healing emotionally after a difficult birth and can do much to help the pair bond under trying circumstances. Many cesarean moms report that being able to breastfeed their child afterwards was one of the most healing things they were able to do for themselves.
Faster Uterine Involution
After the baby is born, the uterus needs to start shrinking down in order to return to its normal size and state. Breastfeeding stimulates uterine contractions and helps the uterus start shrinking more quickly and efficiently. Although the drugs most hospitals give will start this process, breastfeeding helps continue the process more naturally and efficiently.
Negishi (1999) found that cesarean mothers tended to have larger uteri at one month postpartum than mothers who had had a vaginal birth, so uterine involution may be of special concern to women who have had cesareans. They further found that by 3 months postpartum, mothers who were breastfeeding 80% or more per day had smaller uteri than those who were breastfeeding 2% or less per day. So breastfeeding helps uterine involution strongly. Since cesarean mothers may have more trouble with uterine involution, breastfeeding may be especially helpful in this group.
Weight Loss
Many mothers find it difficult to return to the pre-pregnancy weight after birth, and anecdotally, this may be particularly true after a cesarean. Restrictions on mobility, pain from the incision, anemia from blood loss, adhesions from the surgery, etc. may all combine to make a cesarean mother less active than one who has given birth vaginally, sometimes for significant lengths of time, which may affect postpartum weight loss.
Research shows that breastfeeding helps women return to their pre-pregnancy weight levels faster than those who do not breastfeed. Therefore, breastfeeding may be particularly helpful for losing pregnancy weight if a woman is having difficulty resuming her activity level after a cesarean.
Immunological Protections for the Baby
Cesarean babies may be more at risk for infection for several reasons. Babies born after the mother's waters had been broken for a long time are more at risk for infection. Cesarean mothers also have higher rates of infection than moms who have had vaginal births, thus potentially exposing their babies to this infection as well. Invasive procedures and equipment for the breathing problems common to cesarean babies may also further the risk for infection. And since cesarean babies stay in the hospital longer as their mothers recover, they are exposed to more germs and risk for infection, since recent research has shown that neonatal and maternity units are often home to some of the most virulent germs in the hospital.
Colostrum (the 'first milk') is extremely high in protective antibodies that help coat the baby's gastrointestinal system and protect it from harmful bacteria, and it also contains substances that help 'kickstart' the baby's own immune system. This helps protect the baby faster and more effectively than if the baby has to start its own immune systems without the mother's help. Research has shown that colostrum is extremely important in reducing a child's risk for infections.
As one doctor put it, "Breastfeeding is nature's first vaccine." Considering the possible infection risk many cesareans babies face, breastfeeding's immunological protections become especially important.
Hypoglycemia
Because of the possibility of low blood sugar after a difficult birth, many hospitals routinely give a bottle of glucose water to cesarean babies, 'just in case.' Unfortunately, this tends to cause a quick spike in blood sugar followed by a crash, and this unstable blood sugar can be a problem for the baby, causing a vicious cycle of treatment and re-treatment.
Unless the hypoglycemia is really severe, a better treatment is nursing frequently. The first milk a mother produces ('colostrum') has plenty of lactose to help raise the baby's blood sugar, but unlike glucose water, it also has a high amount of protein to help stabilize the blood sugar. The long-term treatment for adults with low blood sugar is frequent doses of protein to help slow and stabilize the rise in blood sugar. Nursing is the most like the usual treatment for adult hypoglycemia, plus it has the added benefits of all those immunological protections.
Barring illness or extreme prematurity, babies who are nursed early and frequently generally have a more stable blood sugar than those given glucose water. The Womanly Art of Breastfeeding states, "Nursing at least ten to twelve times per day is the best way to stabilize a baby's glucose levels."
Jaundice
Another common complication for newborns is physiological jaundice. This is a normal process that occurs when the body breaks down extra red blood cells that are not needed for life outside of the womb. One of the byproducts of this is bilirubin, which can make the baby appear yellowish-orange if his liver does not process it efficiently. In low levels, bilirubin is not harmful, but high levels may potentially be harmful.
Jaundice is most common in premature babies, sick babies, babies of diabetic mothers, and when labor was induced or augmented artificially with pitocin. Many of these babies end up with cesareans. Thus jaundice is not an unusual finding in cesarean babies, not because of the cesarean itself but because of the conditions and drugs that tend to cause a higher cesarean rate.
Frequent nursing causes the baby to stool more frequently, and much of the bilirubin in the first days is eliminated through the baby's meconium (stool). If the baby does not stool enough, the bilirubin is reabsorbed through the intestines. Because the colostrum acts as a laxative, it helps the body process and excrete the extra bilirubin instead of re-absorbing it. Thus breastfeeding frequently is one of the best ways to minimize jaundice. Research clearly shows that nursing 7 or more times a day significantly decreases the occurrence of jaundice (Yamauchi and Yamanouchi, 1990).
Although in the past jaundice was often treated by giving bottles of glucose water to help "flush" out the jaundice, research has shown that this does not help and may actually increase jaundice. Nursing early and frequently and exposing the baby to indirect sunlight are the best treatments for normal physiological jaundice. If extra help is needed, treatment with 'phototherapy' lights can also help lower bilirubin levels.
Many babies that end up with cesareans may be at more risk for physiological jaundice. Nursing is one of the best treatments for mild jaundice, and in conjunction with other therapies, can help even in more serious cases. But the benefits are strongest when the baby is able to nurse as soon as possible after birth, and as frequently as possible in the first few days.
Bonding
Bonding is often an issue after a cesarean. Many mothers report feeling distant and detached from their cesarean babies. In part, this may be because the mother is not able to actually "see" the baby emerging from her body, and is usually one of the last people to get to hold and snuggle baby for any real time. Many women wonder if the baby handed to them is actually theirs. Others are so preoccupied with physical pain, grogginess from drugs, and exhaustion that they find it hard to care about their children the way they thought they would. Some women experience anger at the baby for being 'too big' or 'turned the wrong way' or for going into distress. After birth, some women report feeling like they were simply 'babysitting' their children for someone else, and this can cause real feelings of guilt.
Breastfeeding can help restore the bond between mother and baby, healing the separation that has occurred. Women often report that breastfeeding helped them reconnect with their babies in a way that nothing else did, helped them feel competent and whole again, and brought them emotionally closer to their babies. For many women, breastfeeding was the most healing thing in their lives after going through the cesarean.
Breastfeeding is important for cesarean mothers and babies not only for physiological reasons, but for emotional ones too. Unfortunately, too many hospitals do not place a priority on breastfeeding, or have routine protocols that actively interfere with breastfeeding.
How a Cesarean Can Interfere with Breastfeeding
Breastfeeding is more difficult after a cesarean for many reasons. These include maternal pain and fatigue, delayed access to baby, increased supplementary feedings, separation of mother and baby, blood loss causing anemia, mechanical problems in feeding, interference from medications, etc. Fortunately, although these can place significant barriers in front of the cesarean mom, many women manage to go on and breastfeed their child anyhow, in spite of the difficulties.
Maternal Pain, Stress, and Fatigue
Mothers who have had a cesarean tend to initiate breastfeeding less often than mothers who have had a vaginal birth. Most women plan to at least 'try' to breastfeed, but after a cesarean, many change their minds as the physical toll of the cesarean saps their physical and emotional resources. They may be groggy from drugs, woozy with pain, and exhausted from labor, surgery, and significant blood loss. Suddenly breastfeeding may seem overwhelming and too much trouble, or they may be too 'out of it' to try very effectively. In this situation, bottlefeeding often seems easier and more convenient.
Stress clearly can affect people strongly, and women who have had a difficult labor and then an unexpected cesarean (or women who have a bad cesarean experience) may be especially susceptible to stress-related breastfeeding problems. Dewey (2001) found that maternal stress interfered with the release of oxytocin, the hormone responsible for milk ejection reflex. It also found that stressed newborns were more likely to be weak or too sleepy to latch and suckle effectively.
Research clearly shows that after a cesarean, fewer women initiate breastfeeding at all, or give up within the first month. DiMatteo (1996), Perez-Escamilla (1996), Samuels (1985), Weiderpass (1998), Menghetti (1994), Ever-Hadani (1994), Mansbach (1991), and Dewey (2001) all show that women who had a cesarean had lower breastfeeding rates.
Nursing your baby as soon as possible after birth ensures the jumpstarting of hormonal processes designed to ensure milk supply, and aids in the physical recovery afterwards. Studies show that the most critical issue for breastfeeding success after any birth is early and frequent breastfeeding (Asselin and Lawrence 1987, Sozmen 1992, Samuels 1985). Research shows that breastfeeding works best if the first nursing takes place within the first hour after birth. Unfortunately, even in vaginal births many hospitals are hard-pressed to meet this standard, but delays tend to be especially long after a cesarean.
Although a few women are able to nurse their babies right on the table during surgery, most are told to wait until they are in the recovery room. This means a delay of almost an hour, and sometimes more. Although not ideal, this is not insurmountable. But a few misguided hospitals still have the outdated practice that forbids breastfeeding even in the recovery room, so their babies must wait even longer to nurse for the first time. In addition, many women are so groggy from drugs after the surgery that they are not able to nurse for many hours after that as well. All of these delays can add up.
Women who have a cesarean tend to receive their children much later than if they had had a vaginal birth, and in some places, the delay can be many hours. Dasgupta (1997) found that although their hospital had adopted guidelines stipulating that cesarean babies should be nursed for the first time within at least 4-6 hours, not a single baby in their hospital was nursed within this time period.
This delay in first nursing can cause critical differences in hormone levels (Nissen, 1996) and impact milk supply. It also helps delay the appearance of mature milk (Chapman and Perez-Escamilla 1999, Vestermark 1991), putting the baby at risk for dehydration or excessive weight loss after birth, which often leads to supplementary formula. All of this combines to undermine a woman's confidence and desire to breastfeed.
Because breastfeeding is very much a function of supply and demand, early and frequent breastfeeding is EXTREMELY important for establishing breastfeeding. Studies show that the more the first nursings are delayed, the higher the rate of problems (Mathur, 1993). Similarly, frequent breastfeeding (every 2-3 hours or so) in the first day is VERY important in helping the mature milk to come in more quickly.
The more feedings of colostrum (the early milk) that the baby receives, the more immunological protection the baby gets. In addition, early and frequent breastfeeding can help lessen or treat a baby's tendency towards hypoglycemia and jaundice, problems common after birth scenarios that lead to cesarean. So not only does early and frequent nursing promote earlier 'mature' milk and greater milk supply, it also is protective against many of the problems babies can face after difficult pregnancies or births.
Many cesarean babies are given bottles of formula routinely (Vestermark 1991), which research clearly shows also lowers the rate and duration of successful breastfeeding (Samuels 1985, Hill 1997). Blomquist (1994) found that, "Infants given a supplementary feeding had 4x the risk of not being breastfed at 3 months." Cronenwett (1992) found that "30% of mothers whose babies received bottles in the hospital reported severe breastfeeding problems, as compared with 14% of those whose babies did not."
Chapman and Perez-Escamilla (1999) also found that exclusive formula-feeding before onset of lactation was a strong risk factor for delayed onset of lactation (mature milk coming in late), which can lead mothers to think they 'don't have enough milk' and stop breastfeeding. Yet many hospitals still have policies requiring routine bottles, or nurses who aggressively insist that a postpartum bottle is necessary to 'prevent hypoglycemia' or 'test the baby's ability to suck and breathe at the same time.'
Even pediatricians rarely understand just how much supplementary feedings can interfere with breastfeeding. Freed (1995) studied over a thousand pediatricians and pediatric residents, and found that "Only 64% of practitioners and 52% of residents knew that supplementing during the first few weeks of life may cause breast-feeding failure." Thus the culture and traditions of hospitals and their personnel regularly promote supplementary feedings without recognition of just how harmful these can be.
When the mother's access to the baby is delayed, the baby is often given a pacifier to soothe it and keep it quiet in the meantime. Even when 'only' a pacifier and no supplementary bottles are given, research shows that breastfeeding can still be affected. Righard and Alade (1997) studied the effect of pacifier use on breastfeeding duration. They found that, "The breastfeeding rate at 4 months was 91% in the nonpacifier group and 44% in the pacifier group." The findings of Righard (1998) and Victora (1993) also support that pacifiers can interfere with breastfeeding. So not only should routine supplementation be abolished, but routine pacifier use should also be avoided whenever possible.
One circumstance that can sometimes necessitate supplementary feedings is when the baby loses a great deal of weight after birth and does not regain it quickly. In some cases, this is truly worrisome and indicative of problems, but in other cases, it can be caused by the policies of the hospitals themselves. Many women are given IV fluids during birth, sometimes excessively, and especially so before epidural or spinal anesthesia. Some of this may transfer into the baby and make him appear larger than normal at birth.
Henci Goer (The Thinking Woman's Guide to a Better Birth) documents that this overload of fluids "also result[s] in a transfer of water into the baby's tissues. This extra fluid inflates the baby's birth weight and the subsequent weight loss after birth. Doctors and others often gauge breastfeeding adequacy by how fast the baby regains her birth weight, so this misleading weight loss may lead a doctor or mother to mistakenly conclude that breastfeeding is inadequate" or that supplementary feedings are needed. Because of this, many babies are given supplementary feedings that seem necessary at the time but which are actually caused by the interventions used on the mother.
Although supplementary feedings should be avoided as much as possible, sometimes circumstances or medical conditions really do necessitate them. If they must be done, research shows that doing them by non-bottle means preserves breastfeeding more often than if the baby is given a bottle. Mathur (1993) found that 87% of babies who had 'prelacteal feeds' by spoon went on to total breastfeeding, while only 33% of babies who had prelacteal feeds by bottle went on to total breastfeeding. So why aren't hospitals avoiding bottles when supplementation truly is needed?
Many hospitals strongly resist non-bottle supplementation options because they are not aware of other options, are not trained or encouraged in other options, or are stuck in old, rigid protocols. Many different types of non-bottle options are available, including syringes, cup feeding, finger feeding, eyedroppers, spoon feeding, supplementary nursing systems, etc. Further information on these alternatives can be found below, and also online at www.breastfeeding.com, www.lalecheleague.org, and www.promom.org.
Research shows that rooming in (having baby stay in the room with you instead of staying in the nursery) also increases breastfeeding rates. This is probably because the baby nurses more often (stimulating milk supply) and gets less supplementation. Because some hospitals do not permit women who have had a cesarean to have their babies room in with them, this can negatively affect breastfeeding rates.
For example, Mathur (1993) found that 68% of women whose babies were not separated from them practiced total breastfeeding, versus only 35% of women whose babies were separated from them. Flores-Huerta and Cisneros-Silva (1997) found that 61% of those who had 'joint lodging' breastfed exclusively for the first month, while only 42% of those who did not room together breastfed exclusively in that time. Samuels (1985) also found that keeping the infant in the room during the hospital stay encouraged breastfeeding rates. Rooming in makes a difference!
Some nurses offer to take the baby to the nursery for the night in a well-meaning gesture to help the mother recover better. But Anderson (1989) found that women who roomed in with their babies used less pain medication and slept just as well as those whose babies went to the nursery. In addition, the babies' blood pressures were lower, they cried less, and their vital signs stabilized more quickly.
Anderson (1989) also noted that secretion of prolactin (an important hormone in milk supply) is 10x higher at night, and therefore nursing frequently at night "may be more important than daytime in the establishment of lactation." Frequent nursing at night is much more likely if the baby rooms in than if it goes to the nursery, where the nurses may or may not call the mother for a feeding, and sometimes give surreptitious bottles. Although well-meaning, taking the baby to the nursery for the night for "respite" care often exacerbates problems with low milk supply.
Many women also report that sleeping with their babies in the hospital bed (once they are aware and responsible after anesthesia) makes life after a cesarean much easier. It is easier to get the baby ready and into position when it's time to nurse, and they tend to nurse the baby more often and respond to its hunger cues more quickly when baby is right beside them. As long as safety precautions are followed and the mother is not too drugged, sleeping with the baby after a cesarean can work very well.
Since frequent feedings are an important part of establishing milk supply in a timely manner, rooming in is an important part of helping cesarean mothers breastfeed more easily, and sleeping with the baby in your arms can help even more.
Research shows that women having a cesarean lose about twice the amount of blood as women having a vaginal birth. If a woman experiences excessive blood loss during surgery, she may experience anemia afterwards, which can interfere with milk supply significantly (Willis and Livingstone, 1995). Yet few doctors are aware that anemia can affect milk supply, and few check for it or treat it aggressively afterwards.
More women may be anemic postpartum than doctors recognize. Bodnar et al. (2001) found that 27% of women were anemic postpartum, and that the rate of anemia rose to 43% among non-Hispanic black women. Yet much of this anemia goes unrecognized and untreated.
Henly (1995) studied the relationship between anemia and insufficient milk syndrome in 630 first-time mothers. They found that 22% of the mothers were anemic, and of the anemic women, about 20% reported symptoms of insufficient milk syndrome. These mothers breastfed fully for a shorter period of time and weaned earlier as well. The authors summarized their study by saying, "This study suggests that anemia is associated with the development of insufficient milk, which in turn, is related to duration of full breastfeeding and to age at weaning."
Women most at risk for anemia postpartum include those who were anemic prenatally; those whose babies were born by cesarean; those who experience a hemorrhage during or after birth; those with certain placental problems like placenta previa, accreta or abruption; women carrying multiples; those with a history of prior post-partum hemorrhage; those with uterine atony; and heavy women (because of extra blood vessels feeding extra tissue). Bodnar (2001) found that minority women and women from low socioeconomic groups may also be at greatly increased risk for anemia.
Although surgeons and nursing staff should be on alert for anemia in all women post-surgery, sadly this is a condition that is often missed. Even when it is caught, problems with breastfeeding are often not connected to it. If you experience dizziness, weakness, fainting, or extreme fatigue after your cesarean, strongly request that your iron levels be checked. Early treatment can prevent or minimize problems with milk supply and speed your recovery significantly. Iron supplements (herbal or traditional) and modifying food intake to include more iron and folic acid can usually take care of the problem if it is caught early enough.
Cesarean surgery also makes positioning the baby for nursing more painful. The usual 'cradle' nursing position can be painful after a cesarean, since this places baby against an abdomen that has just been traumatized. Placing a pillow over the incision may help cushion it sufficiently, but for some women even this places too much pressure on a tender area.
Many nurses tell women to nurse lying down instead, which some cesarean moms do find to be easier. However, others find this position quite difficult, especially when they have to turn over in bed in order to nurse on the other side. Well-endowed women often find nursing while lying down especially challenging.
The football hold is a great hold for post-cesarean nursing, as the baby is not against the incision at all, the mother can sit up (which makes controlling the baby's head and latch easier), and the mother can see to latch the baby on easier. For more information on the football hold or any other nursing position, see the "help" videos at www.breastfeeding.com.
However, some mothers even have difficulty using the football hold. Simply put, a cesarean presents yet another level of physical challenge to the new and unfamiliar task of breastfeeding, and the pain factor can be a significant deterrent for many women.
The type of anesthesia used for the cesarean can also influence breastfeeding rates. Several studies (Lie and Juul 1988, Mathur 1993, and Albania et al, 1999) have found that breastfeeding rates are significantly higher after regional anesthesia (epidural or spinal) than after general anesthesia.
This may due to a number of causes. Albania et al. speculated that the difference was probably due to faster mother-baby bonding after regional anesthesia. Since mothers who have general anesthesia tend to take longer to wake up and are often more groggy and 'out of it' afterwards, they may be less inclined to nurse, or to nurse right away. Many women who have experienced cesareans by general anesthesia also report feeling less connected to their babies, and may thus be less devoted to the idea of nursing. Also, because of the delay in access after a general, many of these babies also receive supplementary feedings in the nursery before the mother gets them.
There may also be physical influences on the baby and mother which may affect nursing. General anesthesia tends to reach the baby strongly, and may depress his/her responses after birth for some time. This may make the baby harder to rouse for nursing, resulting in baby getting nursed less often (creating less demand for the milk supply). Drugs may also result in the baby being less effective at suckling, which would make his nursing less efficient too. Regional anesthesia results in lower doses of the various drugs crossing the placenta to the baby, so although baby may still be affected, he may not be affected as strongly as after general anesthesia.
Whether the cesarean was scheduled or unplanned also may make a difference in 'delayed onset of lactogenesis.' Chapman and Perez-Escamilla (1999) found that women who had scheduled cesareans experienced delayed lactogenesis (mature milk coming in later) at a much lower rate than women who had unscheduled or emergency cesareans. This may reflect the type of anesthesia, the amount of medications the baby received, the amount of separation of mother and baby after the operation, or many other factors.
Inhibition of Newborn Suckling Responses by Medications
Although many women are told that pain medications (and particularly epidurals) do not reach or affect the baby, research shows that they do have some effect on babies, although authorities debate how significant these are. The weakness of much of this research is that they often do not include unmedicated control groups, and rarely do they consider feeding ability as an outcome. Thus, it is difficult to know how strongly babies really are affected by medications.
For years, lactation consultants have believed that pain medications affect the baby more than OBs and anesthesiologists believe they do. In particular, they find that babies of highly medicated labors tend to have trouble getting started with nursing. Walker (1997) states:
Staff nurses and lactation consultants have noted that many babies whose mothers receive labor analgesia, including epidurals, have difficulty performing a cluster of behaviors necessary for successfully initiating feedings at the breast. They have difficulty latching to the breast, are unable to sustain sucking once latched on, have inefficient or uncoordinated sucking leading to little milk transfer and low intake, have difficulty arousing or staying awake, and exhibit poor cueing to feed. Thus, these babies gain slowly or not at all, and many lose excessive amounts of weight during the first week following birth. Mothers of these babies may present with sore nipples, low milk supply, secondary engorgement, plugged milk ducts, and blocked areas of the breast.
Riordan et al. (2000) used a scoring system to evaluate the effect of medications on neonatal suckling in 129 vaginally-delivered babies. Babies of medicated mothers scored lower in suckling effectiveness than babies of unmedicated mothers, and the scores were lowest in the group that received both epidurals and IV drugs. The overall breastfeeding duration to 6 weeks postpartum was not significantly affected, but even so the authors concluded that:
Labor medications impair suckling in the early postpartum period. Therefore, lactation consultants should be concerned that breastfeeding mothers who have received labor medications may become discouraged, especially if they are discharged before effective breastfeeding is established. If mothers lack adequate support at home or did not receive follow-up care, babies with poor breastfeeding behaviors are at greater risk for dehydration, jaundice, and poor weight gain.
If these effects occur in babies that were born vaginally, what about the effects on babies who went through a long and highly medicated labor and then were exposed to even more drugs for a cesarean? Only further research will tell for sure, but it is likely these babies are affected even more strongly.
Righard and Alade (1990) found that sucking problems were more common in babies whose mothers had received Demerol. Walker (1997) reviewed a series of studies to determine the effect of labor medications on critical neonatal breastfeeding behaviors and time to first 'successful' breastfeed. She found that IV narcotic medications such as Demerol, Stadol, and Nubain did affect breastfeeding by depressing or delaying behaviors such as rooting and sucking. The longer the infants had been exposed to the medications, the more the feeding behaviors were affected, and generally speaking, the longer until the first 'successful' breastfeed. She noted that every single study reviewed "demonstrated that maternal medication had some effect on the breastfeeding behavior of the baby."
The effects of epidurals are harder to measure. We do know that epidurals affect newborn behavior, especially in alertness and in disorganized movements (Sepkoski 1992). However, Walker's review found NO studies on epidurals that specifically mentioned breastfeeding as an outcome. Of the studies that do measure behavioral effects of epidurals, designs of the studies do not permit adequate analysis of effect on components that might affect breastfeeding. The truth is no one has really studied the issue adequately, so no can say for sure that epidurals do or do not affect breastfeeding behaviors!
Instead, epidural studies examine the behavior of the newborn on behavioral assessment scales, but even these studies have major weaknesses, according to Walker. Most studies use dissimilar drugs and dosages and measure differing behaviors, so comparisons are difficult. Very few include a non-medicated control group, and even fewer include assessments of infant behavior after 24 hours postpartum, let alone assessment of breastfeeding behaviors. Walker urgently advocates for more well-controlled studies with these parameters.
Walker did find 2 studies (Murray 1981 and Sepkoski 1992) which had unmedicated control groups and behavioral assessments for longer than 24 hours postpartum:
[Both studies] showed clear depression in motor abilities of medicated babies. Both studies also showed medicated babies exhibited poor state control. The developmental agenda for healthy term infants is that of increasing differentiation and control of states. Medication may delay the process and interfere with the baby's ability to gain control over and modulate state changes in the first 24-48 hours. Drug induced interference may account for the anecdotal descriptions of 'sleepy' babies (babies unable to exhibit enough state control to breastfeed effectively) and further prolong the period of state disorganization.
Walker further notes that the most common drugs used in epidurals are known to cross the placenta. Bupivacaine "enters the maternal blood stream rapidly from the epidural space. It then crosses the placenta so that a measurable concentration is present in the fetal circulation within 10 minutes of administration." Narcotics (such as Fentanyl) that are commonly added also "show significant placental transfer." In a few studies reviewed for her article, some infants were affected by labor medications for as long as a month after birth (Sepkoski 1992).
A very recent article (published after the Walker article) compared the effect of 'caine family of drugs on newborn breastfeeding behaviors. 'Caine family drugs are the anesthetics typically used in epidurals; bupivacaine is the drug most frequently used. In this small study, 10/10 (100%) of the babies of non-medicated mothers initiated instinctive breastfeeding behaviors and successfully self-attached and suckled. The results were far different for the babies of the medicated mothers.
Only 2/6 (33%) of the babies who received a pudendal block (using mepivacaine) successfully self-attached and suckled, and only 3/12 (25%) of the group exposed to epidural bupivacaine, narcotic, or combo of these successfully self-attached and suckled. Although the study is extremely small, it certainly seems to indicate that medication can affect instinctive breastfeeding behaviors. (Read more about the study in the article by Henci Goer at www.parentsplace.com/expert/birthguru/articles/0,10335,243385_406529,00.html.)
In summary, research clearly shows that IV narcotic pain meds can affect breastfeeding behaviors. While the effect of epidurals on breastfeeding cannot be conclusively analyzed, it is likely that there is reason for concern. This too, may be another reason why breastfeeding can be harder after a cesarean.
Lactation Supply Inhibition Due to Medication
Some medications may inhibit milk production. For example, if a woman has had her labor induced or augmented with Pitocin, its anti-diuretic properties may inhibit milk production. This tendency towards fluid retention may make the mother's milk tend to come in late, may make the mother excessively engorged or have difficulty resolving the engorgement, and the baby may have a harder time latching on because of this engorgement.
Certain specific labor or postpartum medications may also suppress breastfeeding. Hirose (1997) found that postoperative extradural buprenorphine decreased the amount of breastfeeding and infant weight gain for 11 days after a cesarean. Although this study needs to be replicated, the authors suggested that extradural buprenorphine suppressed breastfeeding after cesareans.
Many women are given Duramorph in their epidurals during the cesarean to help with post-operative pain. Duramorph and similar drugs are associated with a high incidence of itching (pruritis), and women are often given Benadryl or other antihistamines to lessen the itching. Unfortunately, antihistamines tend to "dry you out" and may interfere with milk supply if given in high amounts, or may make the baby drowsy and less responsive to nursing.
Many mothers report anecdotally that Magnesium Sulfate can interfere with establishment of breastfeeding. Mag Sulfate is a medication used to help women with pre-eclampsia prevent seizures and other problems. Most women report that its effects are most unpleasant, and the stress from being on this drug alone can probably interfere with breastfeeding.
Many women are given diuretics after birth to help deal with significant swelling/edema. Women who have had pre-eclampsia, women who have been induced with pitocin, and women who have had lots of extra IV fluids tend to have the worst problems with edema after the birth. To help women get rid of these extra fluids, some doctors prescribe diuretics. However, this can also interfere with breastfeeding supply.
Birth control pills can also decrease milk supply. Traditional estrogen-only pills are known to decrease milk supply significantly, yet many doctors remain unaware of this problem and prescribe them anyhow. Combined estrogen/progestin 'mini-pills' can be safely used during breastfeeding by most women, but few doctors know that if these are prescribed too early postpartum, they can also inhibit milk supply. Generally, it is safest to wait at least 6-8 weeks before starting the mini-pill, and even then a few women have noticed that it inhibits their milk supply (Breastfeeding Answer Book, 1997).
It's clear that medications given during labor and birth can affect the baby's suckling response and feeding behaviors (see above), and it's also clear that medications given to the mother can also affect her milk supply.
Breastfeeding Holds Useful After a Cesarean
As noted, positioning can be more difficult after a cesarean. There is no one hold that is best for everyone after a cesarean; each mother has to experiment to see what works best for her unique needs.
Many women can still use the 'cradle' position after a cesarean by putting a pillow over their incision and putting baby on top of that pillow. This position is the one most women use permanently for nursing, and although a bit awkward after a cesarean, can be done. If this position feels fine to you and will be the position you use for nursing later, don't feel that you have to use a different nursing hold just because you've had a cesarean! However, some women do find this position too difficult or painful after a cesarean and so choose other options.
Some women nurse in a side-lying or lying-down position after a cesarean, due to either discomfort or to prevent a 'spinal headache.' This is the position some breastfeeding books recommend first after a cesarean. A nurse or professional lactation consultant can help you use pillows to support your back and help position baby properly. Illustrations on breastfeeding positions can be found online at www.breastfeeding.com/helpme/helpme_video.html.
Women who are well-endowed or who find it difficult to nurse lying down usually find the football hold the best position for nursing after a cesarean. In this position, the baby's body is held to one side of the woman, under her arm and supported by pillows. Be sure your hospital bed is cranked up to a comfortable angle---higher is better than lower. Use LOTS of pillows wedged between you and the bed railing to bring baby up to your breast level; never lean in to baby. In Kmom's personal opinion, this is the most comfortable of the nursing positions for after a cesarean, and should be promoted more in breastfeeding resources.
The advantage of the 'football' hold is that it is easier to control the baby's head and latch, and easier to support a larger breast in this position. It also takes the weight of the baby off of your incision and allows you to sit up comfortably while nursing (many women find it difficult to lie down fully after a cesarean). It is also an excellent position for premature babies or when the mother is quite engorged. A video demonstrating the 'football' hold can be found at www.breastfeeding.com/aaavideo/footballhold.avi or at the 'helpme' videos on this site.
If you find these other positions impossible, some women have luck with the Aussie hold. In this unusual hold, the mother lies flat on her back or slightly tilted. She puts the baby on top of her body or with its legs slightly off to one side, with the baby's mouth at the mother's breast. Be sure baby is able to breathe around your breast tissue. If necessary, gently depress the breast around his nose slightly to ensure that baby has ventilation. Babies' noses are flared and made just for this situation so he won't need much help, but with very large breasts this is occasionally needed. Although it does not seem that this position would work very well from the description, some women find that this works better for them than the traditional 'lying down' position.
For more information on breastfeeding after a cesarean and illustrations of all these various nursing positions and others, read The Nursing Mother's Companion, The Womanly Art of Breastfeeding, or So That's What They're For! Breastfeeding Basics. You can also find more information and illustrations online at www.promom.org or www.lalecheleague.org.
Strategies for Increasing Breastfeeding Success
What if you must have a cesarean because it is medically necessary? Or if you are going for a vaginal birth but want to be prepared for a better breastfeeding experience in case a cesarean becomes necessary? Does breastfeeding after a cesarean HAVE to be difficult? What things can you do to help ensure breastfeeding goes well?
Even if you had a bad experience breastfeeding before, it doesn't have to happen that way again. Research shows that most women who have had problems breastfeeding a prior child have a better breastfeeding experience with a subsequent child (Ingram 2001). There are never any guarantees, of course, but chances are very good that things will be better this time. Remember, this is a DIFFERENT CHILD, a DIFFERENT BIRTH, and a DIFFERENT EXPERIENCE. Consciously choose to make as many things different this time as possible, and let those differences help you make a totally new experience this time.
Here are some ideas that may help facilitate a smoother transition to breastfeeding. The main thing is to be as informed as possible about breastfeeding, nurse early and frequently, have lots of expert resources, get help quickly if needed, and make the best decisions you can at the time. Then you can go forward, knowing that you did the very best you could do for your child and for yourself, whatever happens.
These ideas are drawn from the research cited above. Some of them may work for you; others may not be appropriate in your situation. As always, take what you need and leave the rest behind.
Summary of the Research: Hints for Breastfeeding SuccessIt is apparent from the literature that delayed lactogenesis is common with cesareans. In most cases, a VBAC is better for both mom and baby, and helps jumpstart the hormonal processes for lactation better than an elective cesarean. Thus, if at all possible, choose a VBAC for your next birth. However, if you do have a cesarean, it doesn't mean you cannot breastfeed! Simply emphasize nursing as early and as frequently as possible afterwards in order to help speed up the process of the mature milk coming in, and to lessen the chances of supplements being needed due to hypoglycemia or jaundice.
Utilize regional anesthesia instead of general anesthesia for the cesarean
As noted above, breastfeeding seems to go easier after regional anesthesia (epidural, spinal, or combined spinal epidural) rather than general anesthesia. This is probably because the mother is able to nurse sooner, with better pain control, and is less 'out of it' from the drugs. Also the baby is exposed to a lower dosage of drugs in regional anesthesia and thus may suckle more effectively than after general anesthesia. Unless there is a true emergency where every second counts, women should have regional anesthesia for their cesareans. If you had trouble with an epidural last time, a spinal or combined spinal epidural is often a good alternative and offers much better coverage. Discuss with your anesthesiologist your desire to sit up to breastfeed as soon as possible in recovery, and ask for ways to avoid a spinal headache or drug combinations that may cause problems. Working with your providers to express your concerns and desires ahead of time often helps women have a better experience and avoid the problems that occurred previously.
Nurse as early as possible after the baby is delivered, especially before regional anesthesia wears offNurse as early after birth as possible. Some women are able to breastfeed the baby right on the delivery table as the surgeons finish up their repairs, but most women nurse for the first time in the recovery room. Nursing within the first hour after birth and frequently thereafter helps bring the mature milk in sooner and increases supply. If possible, nurse the baby before the effects of the regional anesthesia wear off. You will be relatively alert and free of pain, which will help the first nursing go better than if you are worn out, in pain, or in need of sleep.
Take pain medication as needed in order to be comfortableAfter the regional anesthesia has worn off, don't hesitate to take enough pain medication to be comfortable. You cannot nurse well or enjoy your baby if you are in pain from the surgery. Take what pain relief that you need so that feeding and enjoying your baby will be your top priority. The pain medication that you are given will be safe for your baby and will only be passed on in small amounts that won't affect baby very much. Occasionally some women find that their babies are more affected by pain medication; these women must find a balance between getting enough pain relief to function yet easing off the amount in order to make baby less lethargic. But most women find that it is best to take pain medication as needed, and that adequate pain relief helps them be more able to nurse frequently.
Pursue regular, frequent feedings
Research shows that breastfeeding goes best if mother and baby nurse early and frequently in the first few days. Experts note that babies do best when nursed at least 8-12 times in the first days. Breastfeeding is very much a supply and demand process, and the best and simplest thing you can do is to nurse AT LEAST every 2-3 hours for the first several days to a week. After that, use your baby's cues to help you know how often to nurse; about every 3 hours works well for most babies.
Don't limit time on the breast
Many hospitals, even today, tell women that they do not need to breastfeed their babies more than about 5-10 minutes on each side. This is poor advice. Some babies nurse more efficiently than others, while some are sleepy at first and may take a long time to finish a feed. Limiting time on the breast does NOT eliminate sore nipples, and can lead to low weight gain in babies. Babies need to receive plenty of the fat-rich hindmilk (which comes in the last part of a nursing session) in order to regain their birth weight more easily; limiting time on the breast also limits baby's weight gain. Instead, be sure baby gets plenty of time nursing at each breast so that they get plenty of foremilk AND hindmilk. Babies don't need to nurse constantly, but neither should they be artificially limited to small amounts of time. Let your baby set its own feeding cues as long as it seems like they seem like they are getting enough. If there is any doubt about baby's weight gain or whether there is sufficient intake, nurse frequently and don't limit time on the breast.
Use relaxation tapes and guided imagery to help decrease stress and increase milk output
Dewey (2001) discusses a study where the use of of relaxation and guided imagery audiotapes before nursing helped nearly double the milk output of a group of pumping mothers of premature babies. Holding preemies skin to skin also helps increase the mother's milk supply. If you are having trouble with milk supply, take time to do relaxation exercises, get relaxation and guided imagery tapes if you can (some are available through www.lalecheleague.org), and hold your baby skin to skin as much as possible. You can also ask a lactation consultant about herbs and/or medications to help increase milk supply.
Utilize the support of a professional lactation consultant to help with positioning and latch-on concernsIf you are having trouble getting the baby latched on properly, finding a comfortable nursing position, or are experiencing lots of soreness, don't hesitate to call in a PROFESSIONAL lactation consultant. They are experts at assessing the latch of a baby, the suck of a baby, and helping mothers find the best way possible to help their babies breastfeed. Nurses on the hospital staff may say that they are trained in breastfeeding issues (and some genuinely are), but so much misinformation about breastfeeding is passed on in the medical and nursing professions that you never know if they really have been well-trained. Many give out well-intentioned but incorrect information. A professional lactation consultant with the initials "IBCLC" after their name has taken a standardized and carefully prepared course of learning, and has passed a rigorous exam in order to become board-certified. If in doubt, call the true experts, the IBCLCs.
Avoid artificial nipples and unnecessary supplements as much as possibleAbove all, avoid bottles if at all possible. Bottles are a quick way to breastfeeding problems, especially if used in the first few weeks of life. If you need to use them for working, they can be introduced later, but they can greatly complicate breastfeeding during the initial weeks. If supplementation becomes medically necessary, there are other methods that pose less interference with a baby's sucking mechanism, such as syringe, finger-feeding, flexible cups, etc. Although some babies can successfully switch from bottles to breast and back, many have difficulties with it. Unfortunately, you cannot predict ahead of time which babies will have problems with nipple confusion and which will not. Therefore, it's best to try to avoid bottles if at all possible, and to use alternative methods should supplementation become necessary.
The ' football' or 'clutch' hold is often more comfortable after a c-sectionAlthough most breastfeeding guides suggest that women nurse lying down after a cesarean, many women find this quite uncomfortable or difficult to manage. It can be an especially hard position for the well-endowed woman. Although women should use whatever position they find most comfortable, many women do find that the 'football' hold ('clutch' hold )is the most position to nurse in immediately after a cesarean. The key to using the football hold is to raise the head of the bed somewhat, and to put plenty of pillows beside you so that the level of the baby's mouth will be at your breast. It is very important to bring the baby to YOU, instead of you leaning over to the baby. Don't be afraid to use LOTS of pillows.
Room in with the baby to increase the breastfeeding success rateAs noted above, rooming in has been found to strongly increase the breastfeeding success rate. When the baby rooms in with its mother, it gets more frequent nursing (and therefore more milk), and the mother's supply is stimulated more. It is also less likely to receive a bottle if it is rooming in with the mother. Most hospitals today recognize that rooming in is a good thing, but a few still discourage cesarean mothers from doing this. Families may have to be assertive about keeping the baby in the room with them.
Have a family member (father or other relative) room in too
Having the father (or other family member) stay in the hospital room overnight can greatly ease the process of rooming in. If the staff is resistant to the idea of a cesarean mother rooming in with her baby, then the presence of another adult can help reassure them that baby will be well taken care of. In addition, the cesarean mother often needs a little extra help with the baby when it is time to get out of bed to go to the bathroom or walk around, and the father can help with diaper changes too. When a woman has had major surgery and is taking care of a baby too, an extra pair of hands are important. Having another family member room in should be done whenever possible.Sleep with the baby, which can greatly ease regular feedings
As long as the mother is not too groggy from drugs, she can keep the baby in bed with her as much as possible. This makes feedings much easier, probably helps ensure more frequent feedings and better weight gain, and can help the mother and baby bond better. Naturally, the mother should pay careful attention to safety concerns with the baby in bed with her, using the railings and the pillows as needed to keep a barrier to the edge, and keeping the baby in her arms as much as possible so she is always sure where the baby is. If the mother is not feeling well enough or alert enough to have the baby in bed with her, the father (or other relative) can take the baby between nursings, and the baby can sleep with the father on the pullout couch. However, most women find that they are able to sleep with the baby very safely, and that it makes things much easier after a cesarean. Best of all, many women report that it speeds their emotional healing to have baby so close.
Be sure your nutrition is excellent and that you are getting plenty of extra fluids
If you are breastfeeding, you will need to be sure that you are getting enough extra calories and fluids and such, so continuing to follow a pregnancy diet is generally a good idea. Do not try to diet right away (if at all, see discussion in Dieting and Pregnancy). You will probably find that breastfeeding, on its own, will promote some weight loss with very little effort, although this is not a sure thing for all women. However, restricting your food intake can affect your milk supply or make you run down, so you will want to be sure to continue to eat well and healthily. Emphasize iron and folic acid foods to help build back up your blood supply, and drink plenty of fluids so you are well-hydrated. Some sources also recommend extra vitamin C in order to help tissue healing.
Watch carefully for thrush (a yeast infection) after a c-sectionThrush (a yeast infection of the baby's mouth and/or the mother's nipples) is a special concern after a c-section, due to the high amounts of antibiotics often given during and after surgery. If the mother tends towards glucose intolerance/insulin resistance and she consumes a lot of carbs, she may be particularly prone to developing thrush. Any pain, redness, burning/itching of the mother's nipples, or white patches seen in baby's mouth may indicate that thrush has developed and needs to be treated. Often, significant nipple soreness in the early weeks of nursing is actually due to undiagnosed thrush. There are a number of options for treatment of the baby's mouth and the mother's nipples, but it is critical that both mother and baby be treated simultaneously, since it is very common for one to reinfect the other, making the process an ongoing and stubborn battle. The mother's bras should be laundered daily to prevent re-infection from that source as well. For more information on treating thrush/yeast, see www.laleacheleague.org, www.promom.org, or www.breastfeeding.com.
Also watch for infections in the "fold" under the belly near the incision, as a yeast infection there can easily transfer to the breasts through cross-contamination. Use a blow-dryer on "cool" to help decrease the likelihood of infection, and be sure to stay away from simple carbs for a while. Taking "acidophilus" in your diet may also help. Consult your doctor about other possible treatment options if yeast becomes a chronic problem. For really stubborn and recurring yeast problems, some women report that a careful consultation with a naturopath can help.
If experiencing problems, get expert help from a professional lactation consultant as soon as possible
If you have ANY problems with breastfeeding, be sure to consult a professional lactation consultant as soon as possible. Given the high occurrence of breastfeeding problems, women who have had cesareans should be receiving automatic consultations from lactation consultants, but unfortunately they often do not get this extra help. Breastfeeding presents so many benefits that it should be strongly promoted for all moms, but the reality is that help is often neglected, and many cesarean moms fall through the cracks. If you have problems at ALL, get to a professional IBCLC as SOON as possible. Quick support is often the difference in whether breastfeeding works out or not.
Leave The Free Formula at the Hospital
Many doctors and hospitals routinely send free formula samples home with mom, which can be a difficult temptation to resist, especially in the mother's vulnerable postpartum state. Cesarean mothers may be even more vulnerable to these samples. Well-meaning family members may give the baby a bottle 'to give mom a break,' or the mom may be so exhausted and groggy from the surgery that she gives in to the temptation to use the formula. Or if the baby has experienced jaundice or low weight gain, the hospital may tell her to take the formula to help finish 'flushing out the jaundice' (see above) or to bolster the baby's weight gain. But these extra bottles can be a road straight to breastfeeding 'failure.'
Even pediatricians and new mom support groups often have free formula samples prominently on display. These free samples are unethical and a violation of World Health Organization Code, but they are still quite common. This kind of sabotage from health professionals is an outrage, but it does exist, and is insidious in its influence on breastfeeding. Giving free samples to mothers who intend to breastfeed shortens the breastfeeding period markedly. This affects babies' health long-term, and so is unethical and unconscionable.
Even simply having formula advertising in infant feeding information packs can lower the rate of breastfeeding. One randomized, controlled trial (Howard 2000) found that the group exposed to formula advertisements had greater breastfeeding cessation rates in the first 2 weeks. In particular, women with uncertain or short-term breastfeeding goals were the most affected. The authors state unequivocally that "Formula promotion products should be eliminated from prenatal settings."
Formula companies also routinely send unsolicited cases of free formula in the mail to pregnant women, especially if you sign up for one of their 'free' teddy bears or diaper bags (even when you note on the sign-up form that you plan to exclusively breastfeed). This isn't altruism! They know that a breastfeeding child who has formula in the house is likely to wean more quickly, thus making the company more money in the long run. Although it may seem like a gift to have these free formula samples 'just in case,' formula companies are good at marketing. They know that a little product sample up front will mean greater profits later. And it's your baby's health that potentially pays the price.
New mothers who intend to breastfeed have to be very careful to avoid falling into these seductive marketing traps. The best strategy is to not sign up for promotional gifts, avoid formula promotional materials, and to leave the formula at the hospital so you are not even tempted to use it at home. If you prefer, you can take the formula to your local food closet/shelter, or donate it to a friend who is already bottle-feeding.
Of course, if you are truly struggling with nursing issues and a professional lactation consultant has recommended supplementing the baby, there is no reason to feel guilty about taking home the free samples of formula. Although most cases of 'low milk supply' are iatrogenic (caused by medical mismanagement) and can be resolved through nursing alone, this is not always true. Sometimes supplementation really is necessary and there are women who must combine nursing with supplementation.
If you need to do this, then of course, formula can be a wonderful and life-saving product. That is a different situation than deliberately sabotaging breastfeeding because of corporate greed. When supplementation is truly necessary, free samples can be very helpful, judiciously used, and mothers should never be made to feel bad for taking advantage of them.
But for the majority of women who are breastfeeding, it is best to leave the free formula samples at the hospital or give them away immediately. They are a specific marketing tool designed to sabotage breastfeeding, and this strategy is all too successful. If you have had breastfeeding difficulties in the past, you should be particularly careful to avoid taking these home with your next baby.
It is important to continue to pay attention to proper eating post-partum. It is vital that a woman be well-fed and well-hydrated while her body goes through the difficult hormonal and physical changes postpartum, and while her body is attending to the amazing physical task of starting to breastfeed.
Yet between the time period before and after a cesarean, most hospitals strongly restrict a woman's intake for several days. This can further interfere with the body's ability to cope with postpartum changes and to start the lactation process efficiently. Many women complain of feeling starved, yet still being deprived of food their body desperately needs to start recovering well.
The hospitals do have a legitimate concern for using this protocol. Surgical anesthesia can affect the function of nearby organs, and the intestines tend to slow down (and can even be affected permanently sometimes). To make sure a woman's intestines have started re-functioning properly after the surgery, hospitals often refuse to let a woman eat real food again until she has started to pass gas. The problem with this protocol is that if the woman has been in labor a long time at a hospital that forbids food during labor, there is no food to help make the gas. Or the woman may have plenty of gas but the intestines are moving slowly from the surgery and with no new food the gas becomes trapped and painful.
Some hospitals are beginning to question this protocol now. A recent study (Patolia 2001) found that women who ate earlier than traditional protocols did just as well as women who ate later. They reported feeling better and less weak. They also were ready to leave the hospital sooner. Although breastfeeding was not a measured outcome in this study, it would be interesting to see if the delay in food intake plays a part in the delayed lactogenesis that many cesarean mothers experience, or if it negatively affects milk supply. At the very least, most cesarean moms would feel better to be able to eat normally again sooner instead of later.
A woman who is breastfeeding needs as many or more calories in the first few weeks as she did when she was pregnant. In addition, some sources feel that women who have had a c-section need a slight increase in calories as well in order to help with recovery and healing. So be careful to be sure that your intake in the first weeks after birth is really adequate; sometimes women are so worn out from the surgery and new parenthood that they neglect their nutrition. And this can definitely affect milk supply and slow down healing.
As during pregnancy, QUALITY is more important than quantity; keep your emphasis on plenty of fruits and veggies, plenty of protein, and other foods in moderation. It is also important to up your consumption of fluids (preferably WATER) during this time to help flush out any edema and keep up your fluid levels for breastfeeding. You may also want to consider adding a vitamin C supplement to help promote tissue healing.
If you have been on a somewhat restricted-calorie regimen in the past (either before or during pregnancy), you need to be sure you are getting adequate intake for this post-partum period, even if you feel like you need to emphasize weight loss. La Leche League recommends that a woman who is breastfeeding consume at least 1800 calories minimum, and most women immediately post-partum need more like 2000+. So it is vitally important not to diet or to let others pressure you into limiting your intake during this very important period.
Although research shows that women can start cutting back their calories modestly once their milk supply is well-established, this process should not begin until at least 4 (and preferably 6) weeks postpartum. Milk supply in the first 2 months can be a delicate balance, so it's best not to throw in too many variables too early. Increasing your exercise level won't hurt the baby and may help with weight loss, so if you are wanting to start working off that pregnancy weight gain, start with increased exercise first. After 6-8 weeks or so, you can also start modestly cutting back on calories if you do it carefully. Keep your emphasis on quality foods. For more guidance on this subject, see the La Leche League book, Eat Well, Lose Weight While Breastfeeding.
Even if you did not lose a lot of blood or experience significant anemia, you should emphasize iron foods in your diet, since you did have surgery and blood loss is involved. Foods that are great sources of iron include legumes, beef, dried fruit, eggs, liver, and particularly seeds such as pumpkin and sesame (try tahini butter). Sea vegetables are also an excellent source, if you have access to them. Iron absorption is decreased if you eat your iron foods with milk or other sources of calcium; iron absorption is increased if you eat your iron foods with vitamin C foods such as oranges, strawberries, or broccoli. So pay attention to how you schedule your foods together as well as what you eat.
Excellent nutrition is an important part of every woman's postpartum journey; it is even more important for the cesarean mother. Make sure you continue to emphasize great nutrition just as strongly as you did in pregnancy. Remember that you are recovering from major surgery, nourishing another little human being, and helping your body adjust to huge postpartum hormonal changes. Nutrition is VERY important for this transition.
Lactation Consultants and Peer Support Groups
As noted, one of the best things that mothers who are having breastfeeding difficulties can do is to get expert help. Sometimes this help is available right in the hospital, but oftentimes women must look elsewhere for it.
Support for breastfeeding in hospitals tends to be inconsistent, and expert training in lactation issues incomplete at best. Even nurses that have taken extra training in lactation issues often are misinformed and can do more harm than good, especially if there are special concerns like a premature baby, an extremely well-endowed mother, flat or inverted nipples, etc. Research also shows that even pediatricians (who ought to be experts in lactation) are woefully lacking in breastfeeding knowledge and give advice that leads to breastfeeding difficulties (Freed 1995). That's why, whenever possible, it is best to bring in the true experts, professional lactation consultants.
But how can you know that the person you are consulting is really a breastfeeding expert? Many hospitals have people who claim to be lactation experts and may even carry that title, but who are not fully trained in lactation issues and intervention techniques. That's why it's important to look for a lactation consultant with the title, "Internationally Board Certified Lactation Consultant." Lactation consultants with this extra training can be identified by the initials "IBCLC" after their names. Some hospital LCs are board-certified (IBCLCs) and can be very helpful; sometimes women need to go outside the hospital to find an IBCLC. Whomever you find, it is important that they be truly well-trained in lactation issues.
It is especially critical to enlist the help of an IBCLC when there are supply issues. If you think you don't have enough milk, be sure to see an IBCLC right away as there are many things to be done to help with this problem but quick intervention is critical to success. An LC will evaluate your baby's latch and suck, your positioning, and help evaluate the baby's hydration and weight gain patterns. If supplementation is necessary, the LC will guide you so that it interferes as little as possible with breastfeeding and supply. Interventions may include pumping to increase your milk supply, medications or herbal supplements to increase your milk supply, retraining your baby's suck, or help correcting the baby's latch and/or positioning. (See below for more details.)
Another time it is important to see a lactation consultant right away is when you are experiencing significant soreness. A bit of tenderness is not unusual at first, but should not be much nor last long. Real soreness usually indicates a poor latch, a problem with the baby's suck, a plugged duct, mastitis, or thrush. Again, a professional LC is needed to diagnose and evaluate the problem, and then to decide upon the proper treatment.
Although these are the most common reasons women need to see LCs, a consultation may be helpful in any situation where you experience difficulty with breastfeeding. Although it is disconcerting to consider exposing your breasts and breastfeeding in front of a stranger, professional LCs can help eliminate so many of the common problems that derail many breastfeeding relationships that it is worth pursuing, even if you are particularly modest. And really, after prenatal care and childbirth, modesty about breastfeeding in front of a professional LC seems redundant!
Many moms have reported delaying seeing an LC due to embarrassment, modesty, or reluctance to seek help, yet regretted delaying so long once they saw how much help they received. It is normal to feel strange about breastfeeding in front of a stranger, but don't let that stop you from getting needed help. Your baby is depending on you, and you deserve to have a better nursing experience.
Also remember that sometimes you may need to see more than one lactation consultant to get the right help, a new perspective, or to find the right mesh of personality styles. Don't be afraid to try more than one LC if needed. Another option for help is peer support through a breastfeeding support group. If a professional lactation consultant is not available right away, then volunteer leaders from La Leche League or Nursing Mother's Counsel can fill in the gaps. The advantage of these resources is that they are completely free and sometimes peer support from another mother is less threatening than going to yet another healthcare professional.
However, do remember that these peer support organizations are staffed by volunteers, so the skills may vary from leader to leader, and the women are mothers themselves and may be too busy to offer the amount of support you need. Usually there is more than one chapter in an urban area so if you don't get the help and support you need from one leader, try calling another chapter. Chances are one of them will suit you and be able to help. Also take full advantage of their library of breastfeeding and parenting books that can be checked out for free; many of these are extremely helpful.
Some people are hesitant about these organizations because they are afraid of 'breastfeeding militants,' but generally most mothers find that these groups really are invaluable. What you have to do is find a group that suits your attitudes and situation, then take the advice you need for yourself and leave the rest behind. Don't deny yourself the benefits of these groups because you might not necessarily agree with all that they say. Because these are volunteer groups, their quality and leadership will vary greatly. If you do not find one to your liking at first, keep looking. All points in the breastfeeding spectrum are represented sooner or later in these groups, and eventually you will find one that suits your needs.
In summary, do not rely on your doctor to help diagnose or rectify breastfeeding problems; they are often too unaggressive in their approach and they usually have little training in lactation. Hospital nurses can sometimes be very helpful, but on the other hand, sometimes perpetuate breastfeeding myths and may not be adequately trained either.
You need a lactation specialist (preferably an IBCLC), and you need it as EARLY as possible. You need the eye of an experienced professional to identify potential problems that a less-trained person might misdiagnose, to detect the subtle and very technical problems that hospital nurses and doctors are not qualified to identify or treat, to evaluate whether your baby truly needs supplementation or not, and to help you work out a plan of treatment that meets the baby's needs for nourishment while still doing everything possible to preserve breastfeeding. Don't let problems escalate by delaying treatment.
Finally, peer support groups can be invaluable as well, especially for the breastfeeding mother experiencing problems. The one-to-one support from other mothers who have 'been there, done that' can help women work through the difficult emotional issues that can accompany breastfeeding problems, and put into perspective the everyday ups and downs of a breastfeeding relationship. Although these are volunteer groups and can vary in quality at times, most women find them an extremely valuable source of support and comfort during their breastfeeding years.
Dealing with Special Situations
Cesarean moms can encounter a number of special situations that may complicate breastfeeding. These can include hypoglycemia, jaundice, a sleepy baby, prematurity, need for supplementation, and 'failure to thrive' syndrome. Also, although most mothers who have Poly Cystic Ovarian Syndrome (PCOS) breastfeed without problems, there is a small but significant percentage who have major breastfeeding supply problems.
Because these situations can complicate breastfeeding after any birth (but especially after a cesarean), more information on these issues is presented here. However, this is just general information about these situations; more thorough information on these subjects can be found on various breastfeeding websites online. And as always, consult a medical professional (preferably one well-educated about lactation issues) about your own specific situation.
As noted previously, the conditions that lead to cesareans can sometimes cause cesarean babies to have hypoglycemia issues. Because of this, it is routine in many hospitals to automatically give a cesarean baby a bottle of glucose water or formula, usually before the mother is even out of surgery, and before discovering whether or not baby even has hypoglycemia issues. Although sometimes supplementation truly is needed, most of the time routine supplementation is not necessary, and can even be harmful. It is often the first step on the way to breastfeeding 'failure.'
Even when hypoglycemia is present, the best treatment is usually nursing. As noted above, colostrum has plenty of lactose to help raise the baby's blood sugar, but more importantly it has lots of protein to help stabilize those blood sugars as well. Protein and lactose together are important to help slow and stabilize the rise in blood sugar. With lactose or glucose alone, the baby's blood sugars tend to rise and then crash later, a fluctuation that can also be harmful.
Unless hypoglycemia is severe, frequent nursing is usually sufficient to treat most cases, plus it has the added benefits of immunological protections. The Womanly Art of Breastfeeding states, "Nursing at least ten to twelve times per day is the best way to stabilize a baby's glucose levels."
On the other hand, while it is clear that routine supplementation of cesarean babies is unnecessary, sometimes treatment for hypoglycemia can become necessary. However, just how aggressive surveillance and treatment should be will depend on the cause and circumstances of the case.
Possible Causes of Hypoglycemia
Babies who have been through a long or stressful labor can sometimes have low blood sugar at birth, especially if they were deprived of oxygen at some point. Although all babies with hypoglycemia need to be watched, most cases that result from moderate stress respond well to treatment and stabilize quickly. For these babies, frequent nursings and close observation is sufficient treatment most of the time. If the baby is symptomatic, not nursing well, or does not respond to nursings, then supplementation may sometimes be necessary. Usually, however, aggressive testing and routine supplementation is not necessary unless the baby's stress has been severe.
Another baby that is often aggressively supplemented is the macrosomic ('big') baby. Although definitions vary, macrosomia is loosely defined as any baby at or over 9 lbs. Because a percentage of macrosomic babies do experience hypoglycemia, many hospitals routinely require automatic testing and/or supplementation of babies over 9 lbs. This is rarely necessary, as most of these cases respond well to early and frequent nursing, and simple observation is usually all that is required.
Extra-small babies ('Small for Gestational Age') may also experience higher rates of hypoglycemia, and often are supplemented too. These babies must be carefully watched because there is a potential for problems, and if the baby does not maintain a stable blood sugar level, supplementation may become necessary. However, most SGA babies stabilize well if they are nursed early and frequently.
Babies of diabetic mothers, on the other hand, need careful testing and observation because neonatal hypoglycemia is a real risk. Because these babies tend to receive higher levels of blood sugar in utero, they respond by producing high levels of insulin. After birth, the mother's blood sugar is taken away but the baby's insulin production takes a while to adjust, and thus unstable blood sugar is common. This is most prevalent in babies of poorly controlled diabetics but can sometimes also occur even with well-controlled diabetes.
In the past, most babies of diabetics were automatically given IV glucose and/or formula supplementation, but recent research has shown that many of these babies do very well on nursing alone, with careful monitoring. So while some babies of diabetic mothers are going to need supplementation, automatic supplementation should be replaced by a more selective approach (Cordero 1998). And even if a baby of a diabetic pregnancy needs supplementation, there is no reason it has to be given by bottle. Nursing and non-bottle supplementation methods should be combined to help these babies stabilize their blood sugar while also stimulating the mother's milk supply and giving the baby those all-important antibody protections.
Babies of mothers with gestational diabetes used to be treated exactly the same as those with overt diabetes, with extremely aggressive testing and supplementation protocols. However, it is questionable whether this is truly necessary in most cases. If the mother needed insulin, then careful testing is probably justified, and supplementation may sometimes become necessary. If the mother did not need insulin and had excellent control, then routine testing may not be needed at all; careful observation and promotion of early and frequent nursing may be sufficient. However, just how much testing and what protocols are important is subject to a great deal of debate, and standards will vary considerably from hospital to hospital. (For more information about this, see the FAQ on GD and Breastfeeding.)
Premature babies often struggle to regulate their blood sugar, and supplementation often becomes truly necessary here. A lot depends on just how premature the baby is, how well they are able to suckle (if at all), and whether there are other problems accompanying the prematurity. There are too many variables in prematurity for any strict guidelines; consulting a board-certified lactation specialist is the best way to sort through all the information and know more reliably when supplementation is truly needed and when it is not. Further resources on breastfeeding premature babies can be found at www.preemie-l.org.
Babies who have an infection (or who are otherwise sick) often have hypoglycemia problems, and may have particular difficulty keeping their blood sugar steady. Their blood sugar can shoot up and down like a roller coaster; keeping their levels steady can be very difficult. This type of hypoglycemia is much harder to treat and often does necessitate supplementation, but should not rule out breastfeeding either. Sick babies need the protective immunological elements in their mother's colostrum and milk the most, so supplements should never be used instead of breastmilk but in addition to it (preferably after nursing). However, as with premature babies, even if supplementation does become necessary, it does not mean that it has to be done by bottle. There are many other options that can help preserve breastfeeding (see below).
Finally, while it is clear that automatic bottles after cesareans should be abolished, some hospitals still cling to this outdated protocol under the assumption that any baby born by cesarean is going to be stressed and have low blood sugar. Parents need to assertively make it clear that NO routine bottles should be given to their babies, and frequently remind staff of this during and after the cesarean. The father or support person can request that the baby stay in the O.R. while the surgery is completed (where they can watch for supplements), or they can follow baby to the nursery and reinforce the message that no supplements are to be used unless hypoglycemia is shown to be a legitimate concern.
Diagnosis and Treatment Issues
If low blood sugar is suspected, then it is possible that the baby may indeed need supplementation. However, it is important that this be DOCUMENTED WITH LAB TESTS. Unless the baby is severely symptomatic or there is reason to suspect a serious problem, frequent nursing should be the only treatment to take place until lab results document that there is a problem. Although there are occasional exceptions, early and frequent nursing should be the treatment of choice before routine supplementation.
Lab tests are important to document blood sugar levels because most portable glucometers do NOT accurately measure blood sugar in a newborn. Unless the monitor has been specially calibrated for differences in neonatal blood, it consistently underestimates a newborn's blood sugar levels. Yet even though this is stated on the brochures of many glucometers, some hospitals still continue to use regular glucometers, leading to babies being diagnosed and treated for 'hypoglycemia' that doesn't exist. A regular glucometer can be used to rule out hypoglycemia, but it cannot be used to diagnose it.
On the other hand, if glucometer results are extremely low, then lab tests will undoubtedly confirm hypoglycemia, and treatment should proceed immediately without waiting for lab results. Even so, unless the hospital has a glucometer that is calibrated for neonatal blood, lab tests should still be run to find out the exact blood sugar levels of the baby. Continuing treatment needs to be based on valid data.
At what point hypoglycemia should be diagnosed is a difficult question. It depends on the circumstances. If the baby is ill, premature, or has some other special consideration, the guidelines used for diagnosis completely depend on the situation. No guidelines can be presented here for scenarios of illness or prematurity because the cutoffs are so dependent on the situation. Consult a lactation consultant for guidelines specific to your situation.
However, if baby is born at term, is healthy, and has no other special concerns, then hypoglycemia diagnosis guidelines range between 30-40 mg/dl (divide by 18 for non-USA readings). Some doctors use 40 mg/dl as a cutoff, most use 35 mg/dl as a cutoff, and a few use 30 mg/dl as a cutoff. At this time, research does not make clear which diagnostic cutoff is most advantageous.
How seriously these results are treated varies too; in some hospitals, a level of 37 mg/dl is considered normal or 'borderline,' yet in others is considered seriously hypoglycemic. One hospital may require automatic supplementation with formula or glucose water at 37 mg/dl, yet another hospital may require nothing more than frequent breastfeeding, observation, and retesting in an hour or two. Because opinions and requirements vary so much, no absolute guidelines can be set out, and each mother should consult a board-certified lactation consultant to discuss the implications of any specific situation they encounter.
Hypoglycemia Summary
Hypoglycemia is a potentially serious problem for a newborn if it is severe or if the blood sugar is unstable. If untreated, it can result in brain damage and other problems, and it is totally understandable that hospital personnel are concerned about it. However, it is clear that routine supplementation protocols of the past are outdated and should be abandoned.
In the normal term baby with no symptoms of hypoglycemia, automatic supplementation is not needed. Nursing about every 2 hours is usually enough to prevent hypoglycemia. In the baby at increased risk for hypoglycemia, more frequent nursing is indicated. Supplementation is usually not necessary for most of these babies; careful observation and periodic testing is usually all that is needed. However, babies that are symptomatic or born with special concerns like prematurity, illness, or maternal diabetes may need closer observation and more aggressive treatment.
If treatment is needed, it should be based on valid data (instead of on assumptions about risks, or on data from invalid sources), should take into account the specific circumstances of each unique situation, and should be based on the latest research instead of on tradition. If supplementation does become necessary, preserving breastfeeding should still be an important priority, alternative methods should be used whenever possible, and frequent nursing should be among the treatment options utilized. Whenever there are concerns about hypoglycemia, consultation with a PROFESSIONAL lactation consultant for treatment decisions is vital.
Jaundice is another potential complication that can accompany difficult labors and cesareans. Like hypoglycemia, the traditional treatment protocols for jaundice can interfere with establishment of breastfeeding, and sometimes even increase the jaundice. Again, treatment should be based on the specifics of the case and recent research findings, not on traditional and outdated protocols.
Cause and Types of Jaundice
Jaundice occurs when the extra red blood cells baby uses in utero are broken down after birth. A by-product of this process is bilirubin, which must be processed by the baby's liver. If the baby's liver is a bit immature or there are a lot of extra red blood cells to be broken down, then this processing may not be very efficient. Extra bilirubin that remains in the baby's body tends to make him turn yellowish. Although usually not serious, it has the potential to be dangerous if bilirubin reaches very high levels.
There is more than one type of jaundice. Abnormal jaundice begins the first day or so after birth, and often is the result of incompatible blood types or other serious problems. In this type of jaundice, the baby is seriously sick and will need many treatments, perhaps including blood transfusions. This is not the kind of jaundice this FAQ discusses. Consult your provider for specifics on this situation.
Normal, physiological jaundice is the type of jaundice this FAQ is concerned with. In this type, jaundice is a result of normal physiological processes, and treatment means simply helping the baby to get rid of the extra bilirubin in its system. This is best accomplished by having the baby nurse early and frequently and by exposing it to light.
Some babies are particularly prone to physiological jaundice and this may make them sicker than most jaundiced babies. Premature babies often have immature livers and so can have trouble clearing the bilirubin from their systems. Sick babies may also have trouble because their systems are so overwhelmed that they have difficulty coping with normal processes. Multiples often have a greater tendency towards jaundice, as do babies who have bruises resulting from the birth process. Babies of diabetic moms are more prone to jaundice because hyperinsulinemia tends to result in the production of lots of extra red blood cells, which present a difficult load for the baby's liver to handle.
Babies where the mother has been induced or augmented significantly with pitocin also tend towards jaundice; the drug labels on pitocin warn that jaundice is one of the possible complications frequently associated with pitocin. Babies whose mothers receive a great deal of fluid by IV (such as during induction or epidurals) may also have higher rates of jaundice. According to Henci Goer in The Thinking Woman's Guide to a Better Birth, high fluid rates by IV can cause the baby's red blood cells to swell and burst, thus increasing the load of bilirubin by-product for the baby's liver to deal with right away.
Diagnosis and Treatment
The best prevention/treatment for jaundice is early and extremely frequent nursing. The colostrum or 'pre-milk' of the first few days acts as a major laxative and helps the baby pass its meconium (first stool) faster. When the liver breaks down the extra red blood cells and processes the bilirubin, it is excreted into the meconium. If the baby's meconium is not passed quickly, the bilirubin in the stools may be reabsorbed by the intestines and into the bloodstream, exacerbating jaundice levels. Thus it is in the baby's best interest to pass meconium as quickly as possible, and the strong laxative effect of colostrum is one of the best ways to promote this.
Sometimes doctors and nurses recommend supplemental glucose water to help 'flush out' the bilirubin, but this treatment is outdated. The most recent research indicates that glucose water can actually make the problem worse by delaying stooling. Frequent nursing is the best remedy for normal 'physiological' jaundice.
Unfortunately, many doctors and nurses are unaware of this new information and may still recommend supplements when none are required. These tend to fill up baby and make him less interested in nursing, thereby making the problem worse. The American Academy of Pediatrics now states unequivocally that "Supplementing nursing with water or dextrose [glucose] water does not lower the bilirubin level in jaundiced, healthy, breastfeeding infants."
It is important that the mother nurse the baby as SOON as possible after birth and thereafter as often as possible in the first days in order to help the baby finish clearing the meconium from its system. One study cited by the Breastfeeding Answer Book showed that a minimum of at least NINE feedings every 24 hours prevented jaundice from becoming exaggerated, and noted that the number of the breastfeedings on the first day was especially critical. Another study (Yamauchi and Yamanouchi, 1990) found that the incidence of significant jaundice was 7.7% in babies nursed 7+ times in 24 hours, and 22.8% in babies nursed less than 7 times in 24 hours. Frequent nursing is very important in preventing jaundice.
A good rule of thumb is to nurse every 2-3 hours during the day, and every 3-4 hours or so at night in the first week. If the baby is sleepy (common with jaundice), it is important to rouse the baby for feeding anyhow. 'Switch nursing' (see below) or other techniques may help in this process. However, do be sure that the baby eventually gets plenty of uninterrupted time on each side in order to get enough of the rich 'hindmilk' as well, since this also helps stimulate bowel movements and get rid of bilirubin faster. Hindmilk also lessens baby gas, and increases the baby's weight regain after birth.
Normal physiologic jaundice usually resolves itself within a week or two and has no aftereffects, as long as bilirubin levels do not reach dangerous levels. If bilirubin levels are somewhat raised and your doctor is concerned, increase nursing frequency strongly. Also expose the baby to indirect sunlight frequently during the day. This is usually enough to resolve most cases of jaundice.
If levels are more strongly raised, however, phototherapy may also be needed in addition to frequent nursing and indirect sunlight. Sometimes hospitals will tell you that this means you cannot nurse much. But except for rare cases, breastfeeding should NOT be interrupted. An American Academy of Pediatrics bulletin states, "The AAP discourages the interruption of breastfeeding in healthy term newborns and encourages continued and frequent breastfeeding (at least eight to ten times every 24 hours)...if the baby receives phototherapy...there is no significant advantage in discontinuing nursing." Frequent nursing remains especially important during the phototherapy process, since dehydration is one of the potential side effects of this treatment.
Occasionally formula supplements are needed in addition to nursing when jaundice levels rise too high, the mother's access to the baby is limited, or milk supply is low or delayed. A need for formula supplements is unusual and should NOT be done routinely, but if it does become necessary, parents should not hesitate to do it. However, supplements should be given by alternative feeding methods instead of a bottle (see below).
The exact levels at which jaundice needs aggressive treatment are subject to great debate and sources differ; consult your provider. 'Hyperbilirubinemia' is generally diagnosed in healthy term babies at levels of >12 mg/dl; the most commonly seen recommendations in the past were to treat fairly aggressively at 15-20 mg/dl. At present the guidelines usually seen are a bit higher, depending on the age and condition of the baby. According to Kathleen Huggins in The Nursing Mother's Companion, "If the baby was born at term and is otherwise healthy, many doctors will not order treatment unless the bilirubin level is over 20 mg/dl. Frequent breastfeeding may be all that is necessary."
It must be strongly emphasized that any cutoffs are HIGHLY dependent on a number of complex factors, and a parent or other layperson is not familiar enough with all of the intermingling factors to make treatment decisions. Be SURE to consult a breastfeeding professional and medical professional for advice on your particular scenario.
For example, a premature or ill baby cannot tolerate bilirubin as well and needs treatment at much lower levels. A healthy term baby who is nursing well, getting indirect sunlight, and who is being watched carefully may be able to tolerate higher levels before further treatment is necessary. A great deal depends on the baby's age, its health, bilirubin levels, how fast the bilirubin level is going up, and whether it has peaked or is near peaking. In extremely rare cases, a blood transfusion may be needed to help bring down a baby's bilirubin count, but the advent of phototherapy and other proactive treatments has made this an extremely unusual last resort for normal physiological jaundice.
If your doctor is concerned about your baby's jaundice levels, it is important to clarify what the cause of the jaundice is (is it normal jaundice or abnormal jaundice?), what test results have been, the diagnostic criteria used for determining care decisions, and the factors influencing your doctor's concern (illness, prematurity, etc.). Then clarify what types of treatment are recommended and why. Remember that a lot also depends on the provider's philosophy of treatment. If in doubt, start the prescribed treatment and get a second opinion.
As noted, sometimes mothers whose babies are receiving phototherapy are told that they cannot nurse, or are kept from nursing frequently. Mothers must advocate strongly in this situation that nursing continue as frequently as possible; dehydration is a real risk of phototherapy, and the mother's milk supply depends on frequent stimulation in the early days. Interruption of nursing time and unnecessary nursing restrictions during phototherapy are often the first step to nursing difficulties and low supply down the line.
Express your strong desire to breastfeed your baby and request a consultation with a professional lactation consultant in order to work out a plan that will allow you to stay as close as possible to your baby and continue to breastfeed frequently during treatment. For an excellent in-depth discussion of jaundice and breastfeeding issues, see The Breastfeeding Answer Book (La Leche League, 1997).
Jaundice Summary
Early and frequent breastfeeding is the most effective way to prevent jaundice. Some babies may be more prone to jaundice than others, and in these babies frequent breastfeeding becomes especially important, along with close observation. If jaundice does develop, most cases do not need specialized treatment, just monitoring to be sure levels do not go too high. In some cases, phototherapy or formula supplements may be needed, but breastfeeding rarely needs to be interrupted.
In the vast majority of cases, early and frequent breastfeeding along with regular exposure to indirect sunlight can prevent or minimize physiologic jaundice. If a woman knows her baby is at particular risk for jaundice, she and her care provider should develop a plan beforehand to be as proactive as possible in order to prevent or minimize jaundice.
One problem encountered by many c-section moms is a sleepy baby from medications given during labor and surgery. IV drugs such as Demerol, Stadol, Fentanyl, etc. are known to affect the baby in utero. Epidural drugs also reach the baby but their effects on baby are less well understood (see above); in all likelihood, they affect baby temporarily too. Sometimes you have to keep aggressively nursing the baby until these drugs work their way out of the baby's system. Breastmilk is the best protection you can give baby in the meantime, but it may take some time for the drugs to clear the baby's system fully.
Jaundiced babies are also often sleepy. As noted above, the best treatment for jaundice is frequent nursing to help the baby pass its first stools, as well as exposure to indirect sunlight If necessary, phototherapy is also helpful. Sometimes mothers whose babies are receiving phototherapy are told that they cannot nurse, or are kept from nursing frequently. Interruption of nursing time and unnecessary nursing restrictions during treatment are often the first step to nursing difficulties and low supply down the line.
Babies can also be sleepy from birth trauma, from newborn trauma like circumcision, or simply being in an area with too much stimulation. Babies who are wrapped snugly in blankets also tend to sleep for longer periods of time, which is why nurses have learned to do this. In addition, sometimes nurses surreptitiously give babies bottles of formula or glucose water without the mother's knowledge, and this can make the baby appear 'too sleepy to nurse' when in reality the baby is sleepy because it's just been fed. Mothers must make it clear that NO bottles are to be given without their consent. Rooming in (and going with the baby for any 'procedures' that need to be done at the nursery) are an important way to avoid surreptitious bottles. It really does happen more than women think.
Sleepy babies often do not nurse as frequently or as efficiently, resulting in less milk supply stimulation for mom and perhaps delaying the arrival of mom's mature milk. In normal unmedicated births, the mature milk usually comes in within 2-4 days. In medicated births, this can be longer. In medicated, traumatic births like many c-sections (and especially those with general anesthesia), mature milk is often delayed until 4-6 days. A baby is usually fine on just colostrum during this time if he is nursed frequently and suckles well, but a sleepy baby may not be nursing efficiently enough or often enough to avoid dehydration. It is important to carefully monitor the sleepy baby for signs of dehydration (see below).
The most important thing to do if you have a sleepy baby is to nurse as frequently as possible (at least every 2 hours), waking baby up and stimulating him in order to get efficient sucking and longer nursing times. If he drowses during a feeding, keep waking him up and give him lots of time to complete the feeding. It is important to be sure that the baby receives plenty of fat-rich hindmilk from an extended feeding in order to help increase his weight gain and prevent gassy colic (see below).
Although it may seem unkind to wake a peacefully sleeping baby up every two hours, it is important to do so in the first days. Demand feeding is fine as the baby gets older, but the sleepy baby needs mother-led feeding schedules for the first few days. Don't hesitate to wake the baby up for feeding EVERY TWO HOURS. This is very important for the sleepy baby, especially if there are other medical concerns like jaundice.
Nursing books and websites have lots of hints for waking a sleepy baby to nurse, including: