10 minute read
BREASTFEEDING CONNECTION
CAROL BARTLE POLICY ANALYST
BREASTFEEDING AFTER CAESAREAN BIRTH
Working with women who plan to breastfeed is a primary role for midwives, who support both the initiation and establishment of breastfeeding. Initiating breastfeeding after a caesarean birth can be challenging. In Aotearoa caesarean section rates increased to 29.1% of all births in 2019 - the highest ever recorded (Ministry of Health, 2021) - so challenges to breastfeeding continue to increase.
These are compounded further by the neglected state of support for midwifery and the maternity sector; primarily, issues with midwifery shortages, workload, recruitment and retention. Adding to these stressors is the continued catastrophe of the Covid-19 pandemic.
Once breastfeeding is established ongoing difficulties are reduced, so the importance of very early breastfeeding experiences cannot be overstated. The term ‘breastfeeding difficulties’ covers a range of influences including physical, psychological (can be linked to previous experiences), social (support for breastfeeding) and environmental. Environmental factors include situations now regularly experienced on postnatal wards, which are understaffed and/or have a reduced number of midwives. Provision of optimal midwifery support for breastfeeding initiation is challenging despite the positive influence of the Ten Steps to Successful Breastfeeding and the Baby Friendly Hospital Initiative. Babies who are born by caesarean should realistically be considered additional to their mothers in midwifery workload calculations, otherwise they represent an invisible midwifery activity in acuity assessments.
Caesarean birth is linked to delayed breastfeeding initiation and shorter breastfeeding durations (Chen et al, 2018; Hobbs, 2016). Women who have given birth via caesarean are less likely to breastfeed than those who have vaginal births (Arora et al, 2017; Zanardo et al, 2010) and there is an association with higher rates of non-exclusive breastfeeding (Sadkii et al, 2022). Hobbs et al (2016) also found that caesarean births are associated with more breastfeeding difficulties and a greater use of resources. Pain and lack of support negatively impact breastfeeding after caesarean birth (Fielder, 2016).
Breastfeeding obstacles after caesarean have been identified as including maternal mobility limitations, positioning difficulties, and frustration at the need for assistance to breastfeed (Tully & Ball, 2014). The women participants in the Tully & Ball research were also reported as being confused about infant night waking, which caused some women to have concerns about their milk supply. The researchers pointed out that publicised risks of caesarean birth do not necessarily include the potential disruption to breastfeeding, but the main breastfeeding problems which were identified in this study, including mobility issues, incision pain, maternal tiredness, mucousy infants, and latching difficulties can clearly be linked to mode of birth.
Women who have given birth by caesarean are one of the priority populations in the Australian National Breastfeeding Strategy, which notes that breastfeeding needs extra support after caesarean birth, or when obstetric or childbirth complications are present (COAG, 2019). Targeted approaches are recommended for women with health or medical risk factors, those with lactation difficulties and those who give birth by caesarean. The Academy of Breastfeeding Medicine also suggests additional support may be necessary for women who have had a caesarean birth (Holmes et al, 2013).
TARGETED APPROACHES TO SUPPORT BREASTFEEDING INITIATION Ways to ameliorate the identified breastfeeding issues are already employed by midwives, who work with recently birthed women in caesarean theatre, women with post-op mobility issues, pain, difficulties with latching and mucousy infants. Further points for discussion are outlined below, including the importance of early skin-toskin in theatre.
1 / Mother-infant skin-to-skin contact: Step 4 of the WHO Ten Steps to Successful Breastfeeding is about facilitation of immediate and uninterrupted skin-to-skin contact, as well as support for mothers to initiate breastfeeding as soon as possible after birth (WHO, 2018). Skin-to-skin contact after caesarean birth is an important part of Step 4 and the infant can be placed, with immediate and ongoing support, on the mother’s chest above the theatre
drape. On the mother’s chest the infant can progress through the nine instinctive, distinct, and observable stages including self-attachment and suckling (Brimdyr, et al, 2018). Mother-infant skin-to-skin contact has well-researched physiologic, social and psychological benefits for the infant and mother.
Guala et al (2017) examined skin-to-skin after caesarean birth in a cohort of 252 women with a follow up study period of six months. Skin-to-skin contact with the mother (57.5%), with the father (17.5%), and no skin-to-skin contact (25%) was evaluated, and there was a statistically positive association between skin-to-skin contact with the mother and the exclusive breastfeeding rates on discharge. This effect was statistically significant at three and six months, as compared to the other two groups. A quality improvement project looking at skin-to-skin contact in the operating theatre to increase the success of breastfeeding initiation found lower rates of formula supplementation in infants who had skin-to-skin in theatre (Hung & Berg, 2011). Two midwives were employed to support skin-to-skin contact for women who were having planned elective caesarean births in a public hospital in New South Wales with 4,000 births per year, and a caesarean rate of 39% (57.8% elective C/S) (Sheedy et al, 2022). In this study, women who had skin-to-skin contact at elective caesarean births were more likely to breastfeed earlier, to be successfully breastfeeding on leaving the maternity facility, and to report a positive birthing experience.
Kollman et al (2017) conducted a randomised clinical pilot study looking at early skin-to-skin contact after caesarean and did not find any significant disadvantages for neonatal transition. A feasibility study found that immediate and uninterrupted skin-to-skin during medically uncomplicated caesarean surgery was a feasible and low-cost intervention that can safely begin during surgery and continue, uninterrupted for extended durations (Crenshaw et al, 2019). Early skin-to-skin contact immediately, or soon after a caesarean section, has been associated with physiological stability and the emotional wellbeing of mothers and their newborns, potential reduction in maternal pain, increase in parent and newborn communication, and an improvement in breastfeeding outcomes (Stevens et al, 2014). 2 / Mobility: Infants being within easy reach of their mothers is an obvious consideration,
and Tully & Ball (2014) highlight the difficulties women experience manoeuvring themselves to access their infants and to breastfeed. The caesarean incision wound can make picking up an infant painful and difficult. Ideally, postnatal units would have side-car cots attached to beds, which would not totally eliminate pain issues, but as mothers have expressed overwhelming enthusiasm for this option, maternal wellbeing is likely to be increased (Tully & Ball, 2012). It has been suggested that stand-alone cots may present an unnecessary breastfeeding obstacle and pose a hazard for infants after caesarean birth because of the compromised mobility of postoperative women during the early postpartum period.
In an observational (video) study (Tully & Ball, 2012), participants (n=35) described the side-car bassinet as permitting visual and physical access to their infants, enabling emotional closeness, facilitating breastfeeding, and minimising the need to request midwifery assistance. A more frequent breastfeeding trend and total breastfeeding effort, more mother-infant sleep overlap, and less midwifery presence in the side-car group was noted, but this was not statistically different compared to the stand-alone cot group (Tully & Ball, 2012). Discussing side-car cots may seem pointless given their current lack of availability in Aotearoa, but future maternity unit planning could give this some consideration because of the obvious benefits.
Meanwhile, being aware of where the infant’s cot is placed in relation to the bed, and facilitating family/visitor input to support women post-caesarean is the best option available. Tully & Ball (2014) found that night was the most difficult time for these breastfeeding mothers due to visitors not being permitted to stay in the unit. This situation compounded maternal tiredness. 3 / Pain: Because maternal movement exacerbates the post-surgical pain after a caesarean, effective pain control plays a significant part in early breastfeeding establishment. A participant in the Tully & Ball study (2014) reported the pain as being restrictive. Women reported high levels of pain during the first 24 hours after caesarean birth (n = 60) and this pain negatively affected breastfeeding and infant care (Karlström et al, 2007).
Women are likely to be anxious about how to position the infant for breastfeeding to avoid pressure on the wound area. Women who have had caesarean births are reported to have more problems with latching, positioning, and more pain when compared to those who birthed vaginally (Hobbs et al, 2016; Brown & Jordan, 2013). Regular analgesia will support more comfortable experiences and using a feeding position that supports latching while avoiding pressure on the wound is important. The infant positioned under the mother’s arm (underarm/rugby hold), means that their legs are well away from any tender abdominal area. An adapted laid back/semi-reclined breastfeeding position or side lying position can also work well.
Nipple pain can also be an issue if caesarean pain and positioning difficulties result in latching problems. A clinical reasoning model was developed by Amir et al (2015) and the complexity of pain was divided into three categories: local stimulation, external influences and central modulation. Tissue pathology, damage or inflammation leads to local stimulation of nociceptors (nerve cells capable of sensing pain and transmitting a pain signal). Pain modulation can be affected through central mechanisms including maternal illness, lack of support, exhaustion, anxiety and depression. These categories are useful to consider and address in situations where multiple factors such as anxiety and exhaustion can complicate painful experiences and breastfeeding difficulties.
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4 / Latching difficulties: As discussed in previous Breastfeeding Connection articles, infants who are having initial latching difficulties are at significant risk of shortened duration of breastfeeding and loss of breastfeeding exclusivity. When an infant is not latching on the breast, lactation is fragile and a multi-pronged strategy is needed: feeding the infant; provision of the right support for the infant to move closer towards latching; protecting lactation; and avoidance of further complications from any
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intervention. Delayed lactation may be an issue for some women. Hand expression of breastmilk may remove larger volumes of colostrum than a breast pump in the first few days after birth, and gentle breast massage and hand compression may also increase the amounts of available milk (Academy of Breastfeeding Medicine, 2017).
5 / Newborn infants and mucous: There is limited research about this issue. Ingram et al (2013) collected information about factors during labour and around birth associated with excess mucous production in 160 breastfed infants (80 mucousy infants and 80 non-mucousy controls). Significant associated factors were induction, a long membrane rupture to birth interval, heavier birthweight, delay to the first breastfeed and skin-to-skin contact that was shorter than 30 minutes. Although caesarean birth was not directly associated with mucousy infants in the Ingram study, anecdotal reports indicate that infants in the first 24 hours after caesarean birth may be disinterested in feeding and vomit mucousy fluid. Infants do seem to clear mucous faster when colostrum feeding commences, so infants who are disinterested in feeding initially will likely benefit from early colostrum feeding, via breastfeeding wherever possible. Strategies for supporting the infant to feed include skin-to-skin contact as the first action.
CONCLUSION AND KEY POINTS
• Caesarean births are increasing and are linked to breastfeeding challenges • Mother-infant skin-to-skin contact is associated with positive breastfeeding outcomes
• Additional support for breastfeeding after caesarean birth is essential
• Initiation of, and early establishment of breastfeeding is linked to a reduction in ongoing breastfeeding difficulties
• Effective pain relief is protective of breastfeeding • Mobility restriction needs to be addressed to enable women to access their infants for breastfeeding easily • Providing targeted information and facilitating family/visitor support for the mother post-caesarean can support breastfeeding by reducing maternal tiredness and stress.
References available on request.
