How many parents have you met that experienced the following birth scenario: Labor began with an induction using Pitocin (aka Syntocinon), an epidural was requested for pain relief and a long pushing stage ensued.  The baby’s heart rate showed signs of distress and an unplanned cesarean resulted. Although exhausted, the parents felt overwhelming joy when the baby was born and relief that the labor was over.   

Then the next stage of parenting began - breast/chestfeeding a baby around the clock.  On Day 2, when the mother and baby were discharged home, the previously sleepy baby suddenly became more wakeful and began cluster feeding.  Day three became a bigger challenge: jaundice set in and the pediatrician recommended supplementation due to excessive weight loss.  The scenario ends with an emotionally drained parent blaming their milk supply, routinely supplementing with a bottle of formula and feeling like a failure 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 Workshop, I often see the light bulb moment for the 2nd time parents.   who gave up early or were unsuccessful at breast/chestfeeding previously.  Suddenly they realize that they hadn’t done anything wrong, their body hadn’t failed them and that the breastfeeding struggles they had with their first baby may have started with labor interventions.  By educating parents about how to counter breast/chestfeeding obstacles caused by labor and reviewing 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.   

Caesarean Section 

Of all the common interventions used during labor, a Caesarean Section is probably the one that gives researchers the most cause for concern for breastfeeding.  A mother who has had a C-Section may have a delay in initial skin to skin contact with her baby, a delay in the first (breast) feeding and/or separation from her baby contributing to a delay in milk coming in due to reduced breast stimulation.  The pain medications she receives both during the surgery and during recovery can also affect the baby’s latch and alertness.  Many births that end in C-Section started with labors where Pitocin was used to strengthen contractions.  One study suggests that the use of Pitocin (Syntocinon) during labor may reduce a baby’s ability to latch and suck well in the early hours due to the negative impact of stronger (Pitocin induced) contractions on the baby’s six cranial nerves (Fernandez et al, 2012, Abdoulahi, M., et al, 2017; Szabo et al, 2013).  With labor induction currently quoted at 34.5% (CDC, 2024), one would expect early breast/chestfeeding issues to be on the rise. 

Use of Pain Medications 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 less effective newborn sucking and feeding overall when pharmacological medications are used by the mother. In itself, pain medication in labor is a minor contributing factor to breastfeeding issues.  The bigger issue is a longer pushing stage which is a possible side effect of epidural use.   The potential knock on effects of a longer pushing stage include maternal stress and exhaustion, the increased need for an operative vaginal delivery (using suction), the use of pitocin to strengthen contractions and occasionally a C-Section if the baby shows signs of distress.  All of those confounding factors also increase breastfeeding difficulties. 

Fluid Load 

It is important for women to stay hydrated in labor.  The placement of an IV line for fluids is a normal admitting procedure in most hospitals – although women can usually opt to hydrate orally.  When women request an epidural, the rapid administration of 1000cc of fluid (referred to as a preload or bolus) helps stop a decline the blood pressure caused by the epidural and counteracts the widening of blood vessels. 

Useful as the fluid load may be, women can end up with a fluid ‘overload’.  This occurs when the intake of fluids reaches 2500+ mL – which would average 13 hours (1000mL +125mL per hour) - or sooner if the woman had an IV for hydration as soon as she was admitted and then received an epidural.  Water retention is a short term issue 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? 

The first line of defense to counter breastfeeding woes is skin to skin contact immediately after birth.  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 facilitates milk changing over from colostrum to transitional milk (secretory activation).  In class, I advocate feeding the baby at least eight times in the first 24 hours (“eight or more in 24”) from both breasts (or at least offering both) at each feed.  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 their infant’s weight loss and supplementing on day three, they almost always fed the baby 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 Video Link. 

Finally, supplementing with a few milliliters of artificial baby milk/formula or banked/donor 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 sometimes save the lactation relationship instead of destroying it.  Supplementation takes the early production pressure off the lactating parent and allows stress levels to decrease. However it is of utmost importance that the lactating parent feeds the baby from her own body first or hand expresses or pumps while their baby is receiving formula in order to stimulate her own 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 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: https://kellymom.com/bf/concerns/mother/rev_pressure_soft_cotterman/  

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, 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 IBCLC LCCE 

Mindy Cockeram is a Lamaze Certified Educator and Lactation Consultant.  She has been a guest contributor 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.  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. Last year she released a book solely about Breast Pumping: Pump It Up – A Practical Guide to Confident & Efficient Breast Pumping.  Her website is www.learn4birth.com. 

 

Published: October 06, 2026

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