Getting off to a good start breastfeeding: advice for labor assistants.

The first hour after birth is special due to enormous physiologic changes taking place for mother and baby. Because of these changes, mother and baby should remain together without disturbance if at all possible. Since early breastfeeding leads to successful breastfeeding later, and because initial bonding is important, separation is something to be discouraged (Odent).

For the mother, birth and breastfeeding involve a complex interaction of hormones. Oxytocin plays a huge role in the birth and postpartum. The milk ejection reflex is triggered by oxytocin and the placenta is delivered by oxytocin release (Odent). The hormone causes uterine contractions during labor, releases the placenta and contracts the uterus after birth to slow down bleeding from the uterine blood vessels (Rice). Thus, the danger of postpartum hemorrhage is minimized and the uterus returns to its normal size.

Sometimes medical personnel don't trust this process and give routine injections of pitocin, which is artificial oxytocin, to prevent hemorrhage. Obstetricians don't always stop to consider what might increase the mother's oxytocin levels naturally (Odent). For instance, the experience of privacy for the mother is more likely to release oxytocin as it does in other settings such as during sexual relations. Privacy is also important after birth, before and right after the placenta delivers, and during breastfeeding. Michel Odent cites not disturbing the mother as most important. Cutting the cord, the phone ringing, voices of strangers, people being anxious, or the mother feeling observed or guided can all inhibit her and her mothering hormones (Odent).

Noradrenaline hormones have a role in the third stage, too. Noradrenaline creates the maternal behavior of caretaking. Adrenaline is released, too. The mother is wide awake with a surge of energy that would allow her to protect her young with maternal aggression, if necessary. The baby gets the surge of adrenaline in the last few contractions, and is alert right after being born (Odent). Mother and child make eye-to-eye contact, beginning a lifelong relationship.

The maternal hormone prolactin releases in the mother's bloodstream when the baby suckles. This facilitates the establishment of lactation and also serves to promote a state of equilibrium and physiological well being in the mother (Rice).

What Is Happening for the Baby?

Breathing

The first breath fills the lungs with oxygen for the first time and the fetal circulatory system closes. The baby's system switches to an independent pulmonary circulatory system which now includes the lungs.

Metabolic Adaptation

Inside the womb, the baby is accustomed to constant feeding. After birth, no more constant glucose is available via the umbilical cord. Perhaps this explains why new babies need to nurse so often, as they are used to constant feeding.

Bacteria

The newborn is getting used to millions of microbes after being in a germ-free environment. Mother and baby share the same antibodies. Thus mother and child should be together at this time (Odent). The intestinal flora is assisted by colostrum (the first breastmilk) that helps immunize the body naturally and adapt to a world of germs.

Thermoregulation 

Mechanisms to deal with heating and cooling of the body are immature, so it is good to keep the baby warm and dry. Skin-to-skin contact is desirable. A warm room for birthing is healthy for babies because of thermoregulation. Oxytocin releases in the mother's body in a warm, safe environment.

Initiation of Lactation

"Today most midwives know that the human baby is naturally programmed to find the breast during the hour following birth," said Michel Odent.

Renowned physician Michel Odent describes the mother as being capable of acting instinctually, of knowing how to hold and nurse her baby. Odent says that later is the time for education, imitation, and technique (Odent).

Unicef, the World Health Organization (WHO), Coalition for Improving Maternity Services (CIMS) (motherfriendly.org), La Leche League (Riordan), Michel Odent (Odent) and others advocate breastfeeding initiation in the first hour of life. Because the newborn is very active and alert during first hour of life and then goes to sleep, mothers should be encouraged to put the baby to the breast during this period of activity. The baby has a very strong sucking reflex at this time. After a cesarean birth, a baby may start to suckle within a few hours or as soon as the mother is no longer effected by the anesthesia.

Advice for Labor Assistants Supporting Breastfeeding

The mother should hold the baby close to her breast for skin-to-skin contact and start feeding by touching the baby around his mouth with the tip of her nipple. Touching the breast to the baby's lips stimulates the baby to open his mouth widely. This is called the "rooting reflex."

When the baby opens her mouth widely, offer the whole breast and she will take a mouthful. The mother should pull the baby straight forward onto the nipple and areola chin first. When a baby is correctly positioned, or latched-on, the nipple and a large part of the areola are sucked into the baby's mouth. The nipple should not be visible, and it should point in the same direction it does when a woman isn't nursing. Neither being pulled up or down, left or right is ideal. A wide-open mouth helps create proper latch-on.

Proper positioning, such as "tummy to tummy," helps encourage good latch-on. For this position, referred to as "The Cradle Hold," the baby is cradled close to the mother's body. The baby's head is supported in the bend of the mother's arm, and his mouth is lined up with her nipple. The baby's ear, shoulder and hip are in a straight line. The mother can support the baby's head in one hand (or the crook of her arm, as she prefers) and hold her breast with a "C" shape made by her thumb on top and forefinger on the bottom. While holding her breast tissue, not the areola, she can offer her breast. Holding the breast with two fingers in a "V" (like a peace sign) is not optimal.

A great way to support the mother is to help her get comfortable with lots of extra pillows. Pillows behind the mother's back and support beneath her arm and the baby can make a positive difference in positioning. Correct positioning helps prevent sore nipples, and helps them heal if they do get sore.

Let the baby start suckling when ready and don't rush. As a labor assistant, you might want to suggest unwrapping the front of the baby and putting blankets on top of mother and baby for the benefit of skin-to-skin contact. Skin-to-skin contact stimulates milk flow, helps with mother-child bonding and development of the baby. Ideally, according to Michel Odent, bonding and togetherness should not be interrupted in the first hour after birth and is instinctive for the mother (Odent).

Therefore, helping a woman get started breastfeeding can be non-verbal. Watch and see how you can assist. Help position pillows, and give verbal advice only if she seems to need or want it, but otherwise stay quiet and watch this beautiful process unfold. Labor assistants are "environment police" during labor, and we can continue in that role after birth. Low lights, a quiet environment, without disruption may someday be considered essential for human development instead of misunderstood as a romantic whim of the parents.

In cases where the baby is separated from the mother after birth, try to get them together as soon as possible. Bring the mother to the baby, or encourage the parents and the institution to get the baby brought back. Non-essential tasks done after birth could be put off until later for healthy babies. Weighing and measuring the baby, prophylactic eye treatment, and Vitamin K administration could be deferred until after the first hour when the baby is less alert and the initial period of reactivity has ended. Eye treatment sometimes stings (silver nitrate) or at least makes the vision blurry (ointment).

Some parents decline these treatments altogether. The Coalition for Improving Maternity Services (CIMS) suggests that the service providing obstetric care obtain informed consent from the mother for all non-emergency separation of mother and baby.

Other guidelines for early breastfeeding include ensuring that breast milk is the baby's first food. No foods such as sugar, formula, water, or anything else should be given as these inhibit the establishment of successful breastfeeding. Such feeding could interfere with production and supply of breastmilk, and possibly create "nipple confusion."

Mother's first milk, colostrum, is biologically designed with perfection. The intestinal flora needs colostrum in the first hours after birth for adjustment to the world of bacteria that the baby is experiencing for the first time.

A single bottle of formula changes the infant's gut flora for two to four weeks, upsetting the protective pH balance of exclusively breastfed babies. Giving formula at this time, either soy or milk-based, can trigger allergies for those in susceptible families (Shortridge). Another benefit of early breastfeeding is that colostrum has a laxative effect and will help the baby's bowels move as part of the physiological process.

Rooming-in, without separation of mother and baby, is ideal for breastfeeding. My personal experience as a homebirth midwife is that mother's milk comes in quickly with frequent breastfeeding for mothers that are constantly with their babies. Often I have seen this happen in the same day as when the baby was born. The American Academy of Pediatrics says that milk comes in on the "third or fourth day of breastfeeding" (AAP). Colostrum is more transparent, and milk is opaque.

When the milk comes in, a woman can experience breast engorgement. This is because her body makes more milk than she needs as it is unaware if she had a single baby or twins. The frequency and length of nursing will program the body to make the perfect amount of milk for baby.

If a woman experiences sore nipples and/or engorgement when her milk comes in there are several things she can do to be more comfortable. Getting through these days of learning and discomfort requires support and the reminder that the experience is temporary. For the engorgement, cold compresses may feel good. Some have put a white cabbage leaf in each bra cup for relief. Soaking the nipples in warm salt water can help them heal. Lanolin cream for breastfeeding is applied to sore nipples as is Bag Balm, a product originally made to heal cow's udders, yet safe on humans. Coconut oil has also been used with success. A mother should wash these things off before breastfeeding.

Breastfeeding is most successful when all supplementation is avoided so the woman's body can make the perfect quantity of milk. Supplemental formula feeding reduces the mother's milk supply, possibly leading to problems later. If supplements are deemed necessary, using a breast pump can help keep the supply up for the mother. Nighttime nursing can be considered valuable practice time and is disturbed by supplementation (Shortridge).

During the time when breastfeeding is being established, mothers need to learn the hunger cues of the baby (Shortridge).

Rooting is a sign of being interested in nursing. Sleepy babies may root in their sleep, and that would be a good time to unwrap the baby, but leave it in the sleeping spot. Waking up is more likely if the baby isn't held at this time. The advice applies to sleepy babies who aren't nursing frequently (every 3-4 hours). Doing this helps establish good early breastfeeding. Co-sleeping helps mothers and babies get in sync with sleep cycles and assists in mother's learning cues from the baby as to what he seems to need.

As a labor assistant, you should encourage breastfeeding on demand. By observing hunger cues such as rooting, the mother can detect early hunger signs, instead of waiting until the baby is crying hard. The quiet alert state is a wonderful time to feed the baby, if possible (Chamblin). When a new baby is at the point of needing to cry loudly, the baby is more likely to have disorganized nursing behavior, and is more difficult to feed.

The birth itself can have an effect on early breastfeeding. Epidurals are one of several childbirth interventions that may affect breastfeeding. Procedures such as maternal intravenous fluids, vacuum extraction, cesarean deliveries, and infant oral suctioning may also alter suckling. Researchers are studying what factors impact early breastfeeding the most (Riordan).

As labor assistants focused on helping women during labor and birth, we need to consider the hour after birth as well. We can create a quiet environment conducive to positive bonding and good breastfeeding, thus preventing breastfeeding problems before they start. We can respect the huge physiological changes for mother and baby. We can collaborate with professional staff in this crucial time, with a goal of a mother-friendly and baby-friendly environment. We can educate women about this part of birthing, which will help the family get off to a good start.

Suggested Reading

Small, Meridith. 1998. Our Babies Ourselves: How Biology and Culture Shape the Way We Parent, Anchor Books, New York.

Bibliography

AAP. "A Woman's Guide to Breastfeeding." www.aap.org/family/brstguid.htm>.

Chamblin, Carol, RN, MS. "Infant Feeding Cues During the Early Days of Life: The Period of Reactivity"; www.breastbabyproducts.com/firstdays.html>.

CIMS. "Mother-Friendly Childbirth Initiative Self-Assessment Tool: Ten Steps of the Mother-Friendly Childbirth Initiative"; www.motherfriendly.org/Downloads/SAT.pdf>.

Odent, Michel. "The First Hour Following Birth: Don't Wake the Mother!" Midwifery Today, Issue 61, Spring 2002; www.midwiferytoday.com/articles/firsthour.asp>.

Rice, Ruth D., PHD. 1977. In "21st Century Obstetrics Now!" NAPSAC. Quoted in Midwifery Today E-News, 3:8 February 21, 2001; www.midwiferytoday.com/enews/enews0308.asp?e=1&q=Ruth+D.+Rice>.

Riordan, Jan, RN, EDD, IBCLC, FAAN. 1999. "Epidurals and Breastfeeding." Breastfeeding Abstracts, Volume 19, Number 2, pp. 11-12, November; www.lalecheleague.org/ba/Nov99.html> which quotes King, T. "Epidural anesthesia in labor." J Nurs-Midw. 1997. 42:377-88.

Shortridge, Beth, MD, "Keeping Abreast: Breastfeeding Newsletter"; http://articles.shortridgemd.org/article.php3?124>.

WHO. "The Ten Steps to Successful Breastfeeding." A Joint WHO/Unicef Statement published by the World Health Organization; www.gov.mb.ca/health/nutrition/10steps.ppt>.

--Shannon Brophy is a former homebirth midwife and doula who practiced in Cambridge, MA for many years. She is passionate about natural healing, empowered birth, yoga, creative pursuits, and homeschooling.