How many parents have you met that experienced the following birth scenario: Labor began with an induced labor using Pitocin (UK-Syntocinon), an epidural for pain relief and a long pushing stage or even an unplanned cesarean? The parents felt overwhelmed with joy when the baby was born and relief that the labor was over.  As the new emotions settled in, the next stage of parenting began - breast/chestfeeding a baby on cue around the clock.  Discharged home, the sleepy baby suddenly became more wakeful and eager to cluster feed.  Day three became a challenge: jaundice set in and the pediatrician recommended supplementation due to excessive weight loss.  The scenario ends with an emotionally drained parent worrying about their milk supply, supplementing with bottles of formula daily and potentially giving up on breast/chestfeeding before the mature milk even has a chance to arrive!  Did their body really let them down?  Did they really not have enough milk?

When I teach about labor interventions and their possible effect on early latching, delayed onset of transitional/mature milk and infant weight loss (and gain) in our “Breastfeeding with Success” class, I often see the light bulb moment for the 2nd time parents who were unsuccessful at breast/chestfeeding previously.  Suddenly they realize that they weren’t doing anything wrong, their body hadn’t failed and that the decisions made and interventions used during labor were probably the initial cause of their lactation problems. By educating them about how to counter breast/chestfeeding obstacles caused by labor (should they occur) and an overview of normal newborn weight gain (or loss) goals, my hope is that families leave the class prepared for the common challenges that lay ahead.  

One of the first topics we discuss in class is the effect of various medications and procedures during the labor.  Last year I began showing this video clip which summarizes a study (Brimdyr, K., et al, 2015) of the potential effects of labor medications on latching and the nine newborn behaviors associated with the golden hour: Important Findings Published about Common Labor Medications and Breastfeeding Success - YouTube.  The average baby does not latch for roughly 45 minutes but most new parents have expectations of the baby latching within the first few minutes after birth.  The “Golden Hour” should really be called the “Golden Hours.”

Pitocin is the ‘Pits’ for Breast/chestfeeding

Of all the common drugs used during labor, Pitocin is probably the one that gives researchers the most cause for concern because its use is associated with reduced newborn sucking in the first two hours (Fernandez et al, 2012, Abdoulahi, M., et al, 2017) - probably due to the negative impact on six cranial nerves from stronger contractions, higher likelihood of jaundice and delayed onset of mature milk production (Szabo et al, 2013) .  With induction quoted at anywhere between 25%-50% of primiparous labors, one would expect early breast/chestfeeding issues to be on the rise.

 Use of Narcotics in Labor

More than 75% of pregnant people will request pain medication in labor – usually either a narcotic (like Nubain, Stadol, Fentanyl or Demerol) or more likely an epidural (containing Fentanyl).  Pain medication in labor can be a positive choice for many reasons but studies suggest some medications used for pain management can create a hurdle to successful breast/chestfeeding and that the longer the laboring person had pain medication on board, the greater the potential impact.

Manufacturers’ guidelines warn that people who use opioid analgesics for pain relief in labor should not breast/chestfeed for four hours after receiving them.  This is usually not a problem since opioid analgesics are rarely given after 4cm dilation and labor usually has at least four hours left to go at that point.  However if labor moved quickly and the baby was born with opioids in their system, one could expect breathing problems, decreased alertness, a weak suck or a poor latch.  In addition, the parent could encounter delayed onset of their mature milk.

Worry About the Fluid Load – Not the Epidural

While the Fentanyl in an epidural can inhibit the nine newborn behaviors and ability to latch in the first 60 minutes of life (Brimdyr, K., et al. 2015), the main hurdle to successful breast/chestfeeding after an epidural seems to be fluid overload.  A person who requests an epidural will have a mandatory 1000 mL IV of Ringer’s Lactate to help maintain their blood pressure (which occasionally drops with epidural administration), keep them hydrated and keep the labor progressing.  After the epidural is placed, the parent will continue to receive roughly 125mL of fluid every hour thereafter and may be denied hydrating ‘by mouth’ (NPO).

Fluid overload occurs when the intake of fluids reaches 2500+ mL – which would average 13 hours (1000mL +125mL per hour) - or sooner if they had an IV for fluids as soon as they were admitted and then received an epidural.  Water retention is acute because the parent’s body releases the excess over the next 24-48 hours after birth through urination.  However the excess retention can cause several distinct lactation issues.  A large fluid load has the potential to thin out colostrum, reduce or negate engorgement and delay transitional milk replacing colostrum for several days.  In turn, these side effects can result in a very hungry baby who may lose an excessive amount of weight in the first 72 hours and need supplementing with formula (Watson et al, 2012).  In some cases, people who receive more than 2500 mL of fluid during labor may suffer from third spacing fluid retention. Third spacing fluid retention is when excess fluid gathers in anything that hangs down (i.e. the breast, ankles, etc) and can temporarily cause edematous, flat or inverted nipples that make latching a newborn particularly difficult.

What Can Parents Do to Counter the Effects of Labor Interventions?

As a childbirth educator, you are no doubt aware of the first line of defense - “skin to skin to bring milk in” which  is my mantra.  Continuous skin to skin time with the baby in the first three days and encouraging the baby to feed from both breasts at each feed often facilitates the move from colostrum to transitional milk.  In class, I advocate feeding the baby at least eight times in the first 24 hours from both breasts (or at least offering both) at each session and then “10 or more in 24” until the baby is consistently gaining weight.  It is also paramount that new parents don’t rely on waiting for a baby to wake them for a feed – especially in those first 24 hours when babies are so sleepy, but rather plan to set an alarm to make sure that they get the feeds in.  When I talk to people who are upset about weight loss and supplementing on day three, they almost always fed less than eight times in the first 24 hours.

When the baby suddenly becomes ravenous on day two, the new parent can easily doubt their supply.  “All the baby wants to do is feed!” the parent says.  My lactation instructor used to compare intensely long periods of sucking on day 2-3 as ‘placing an order’ and then waiting a day or two for it to arrive.  I call that period of cluster feeding the ‘all you can eat buffet at the breastaurant’.  It seems to normalize the experience and assure parents that the baby is doing exactly what it should be doing at that time.

Another wise way to combat a slow transition to mature milk is to encourage the parent to hand express or hand pump colostrum several times a day in the first 48 hours – especially if the baby cannot be woken for a feed.  According to Stanford Medical Center’s Professor of Pediatrics Dr Jane Morton, it is the “early, frequent and effective removal of colostrum which determines future production potential” (2016).  In a 2012 study (Parker, L., et al, 2012) of the effect of hand expression after birth of a preterm infant that could not latch, parents who hand expressed in the first sixty minutes after birth boosted supply by up to 130% by week six versus people who waited 2-6 hours to begin milk removal. Hand expressed milk can be stored and fed to the baby with a dropper or supplemental nursing system (SNS).  Hand expression can be a daunting concept so I’ve now started to show the first few minutes of Stanford School of Medicine’s video by Dr. Jane Morton to normalize it: Hand Expressing Milk | Newborn Nursery | Stanford Medicine

Finally, supplementing with a few ounces of artificial baby milk/formula or banked breast milk may seem counterproductive to breast/chestfeeding but if weight loss is severe, it can solve the immediate problem while the parent’s body equalizes.  Although there are downsides to early formula, it can often save the lactation relationship instead of destroying it by taking the production pressure off the lactating parent.  There are no studies I can find (yet) that show any short or long term harm from supplementing with formula for 24-48 hours.  However I always encourage the parent to feed the baby from their own body first to stimulate the milk supply.

Parents should also be educated in recognizing the difference between breasts engorged with milk versus a breast swollen with fluids.  A waterlogged breast often inverts the nipple and feels similar to the fleshy part of your arm.  An engorged breast has firmness comparable to your wrist.  Also, a person who has received a large fluid load during labor may not be engorged (overproduce) with milk at all.  If a new parent is trying to latch a baby onto a breast swollen with excess fluids, urge them to try a technique called Reverse Pressure Softening.  It is similar to making a sandwich with the breast but sandwiches the areola instead to evert the nipple so it protrudes out of the areola before latching.  The research and writing of J Kean Cotterman educates and promotes the technique: Engorgement Help: Reverse Pressure Softening • KellyMom.com

 Do you know anyone who has struggled to breast/chestfeed or has given up in the early days because they did not realize the impact that well-intended labor interventions might have on latching, milk supply and newborn weight loss?  In the second part of the series, found here,  we discuss newborn procedures that could skew weight loss assessment, pediatric goals for newborn weight gain and look at a tool for determining if weight loss really falls into the supplementation zone.

References:

Abdoulahi M, Hemati Z, Mousavi Asl FS, Delaram M, Namnabati M. Association of Using Oxytocin during Labor and Breastfeeding Behaviors of Infants within Two Hours after Birth. Iranian Journal of Neonatology. 2017 Sep: 8(3).

Brimdyr, K., Cadwell, K., Widström, A. M., Svensson, K., Neumann, M., Hart, E. A., ... & Phillips, R. (2015). The association between common labor drugs and suckling when skin‐to‐skin during the first hour after birth. Birth, 42(4), 319-328.

Cotterman KJ. Reverse Pressure Softening: A Simple Tool to Prepare Areola for Easier Latching During Engorgement. J Hum Lact 2004 20: 227-237.

Healthy Children Project Inc. – Center For Breastfeeding.  The Association Between Common Labor Drugs and Suckling When Skin-to-Skin During the First Hour After Birth – Healthy Children Project, Inc. (centerforbreastfeeding.org).  Accessed 2.15.21.

Fernandez O, Marín G, Malalana M, Fernández-Cañadas M, López S, Costarelli V. Newborn feeding behavior depressed by intrapartum oxytocin: a pilot study. Acta Paediatr. 2012; 101(7):749-54.

Lind JN, Perrine CG, Li R. Relationship between use of labor pain medications and delayed onset of lactation. J Hum Lact. 2014;30(2):167–173.

Parker LA, Sullivan S, Krueger C, Kelechi T, Mueller M. Effect of early breast milk expression on milk volume and timing of lactogenesis stage II among mothers of very low birth weight infants: a pilot study. J Perinatol. 2012.32(3):205-9.

Szabo AL. Intrapartum neuraxial analgesia and breastfeeding outcomes: limitations of current knowledge. Anesth Analg. 2013; 116(2):399-405

Watson, J., et al. (2012). A randomized controlled trial of the effect of intrapartum intravenous fluid management on breastfed newborn weight loss. J Obstet Gynecol Neonatal Nurs 41 (1): 24-32

About Mindy Cockeram

Mindy Cockeram has been a guest contributor for Connecting the Dots and an LCCE since 2011.  She initially trained with the United Kingdom’s National Childbirth Trust (NCT), teaching both private classes and for the National Health Service at St Georges Hospital, London from 2004.  Graduating from Villanova University in 1986, she earned a bachelor's degree in Communications and a minor in Business Studies. Currently, she teaches childbirth and breastfeeding for a large non-profit hospital in Southern California. She released Cut Your Labor in Half: 19 Secrets to a Faster & Easier Birth in 2017.  Two years later, she published Breastfeeding Doesn’t Have to Suck: Tips, Tricks and Knowledge for a Great Experience. She is currently writing her third book Pregnant Again? A Refresher for Childbirth & Breastfeeding due out in summer 2021.

Tags