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INTRAPARTUM OBSTETRIC FACTORS

Caesarean section

Caesarean section is associated with delayed initiation of breastfeeding. This is likely due to separation of mother and baby and loss of immediate skin to skin contact because of recovery from general anaesthetic, because mother or baby is unwell or because of lack of proactive support while the caesarean is ongoing. This can impair the establishment of breastfeeding and milk supply.

Caesarean section is also associated with premature cessation of breastfeeding. In addition to the consequences of delayed initiation, this may be due to pain and reduced mobility, leading to increased challenges in responding to the baby's feeding cues and finding a comfortable and effective position for breastfeeding. Lactogenesis II is delayed after caesarean, with lower milk intake until day 6 of life - thus caesarean delivery is associated with higher rate of excessive weight loss leading to recommendations for formula supplements and loss of maternal confidence.

Planned caesarean is associated with lower intention to breastfeed, but this is not the case with emergency caesarean.

 

The maternity team can maximise breastfeeding success by:

  • Ensuring adequate analgesia

  • Helping the mother to try different feeding positions

  • Supporting the mother to have skin to skin contact within 30 minutes of delivery (high rates of on table skin to skin contact can be achieved and are associated with improved breastfeeding outcomes)

  • Education on feeding cues

  • Supporting a birth partner to stay on the postnatal ward

  • Urgent hand expression if mother and baby are separated (within 2 hours of birth), and proactive hand expressing if there are early feeding difficulties to support the establishment of supply. Regular expressing, in addition to directly breastfeeding, may decrease time to lactogenesis II

Effective breastfeeding support targeted at mothers after caesarean can improve early initiation and exclusive breastfeeding rates longer term. For elective caesareans, antenatal education is also effective. In countries with very high breastfeeding rates, caesarean section poses a much smaller risk of premature cessation of breastfeeding

Transfer to theatre

The mother may be transferred to theatre for instrumental delivery, manual removal of placenta or repair of obstetric anal sphincter injury. This will lead to separation from the baby and sometimes loss of immediate skin to skin contact. There is little guidance relating specifically to this context but it is likely that the advice listed above will also help these mothers.

Intrapartum medication

There is some research showing a link between epidural analgesia, delayed initiation of breastfeeding and shorter breastfeeding duration. This has been seen even in mothers with no intrapartum complications. A large cohort showed reduced breastfeeding at 48 hours with use of epidural, intramuscular opiates, oxytocin and ergometrine, even when controlling for complications and assisted delivery. These medications may be necessary, or mothers may make an informed decision to use them. However breastfeeding support should be intensified to counter the negative effects.

Birth Trauma

Intrapartum complications may have a significant impact on the mother’s mental health. Difficulties in breastfeeding can contribute to postnatal depression, which could exacerbate this. If the mother requires medication, check out the lactation in medication resources.