Our companion blog for childbirth professionals, Connecting the Dots, recently released a two-part article that all parents should read and understand. "The Impact of Common Labor Interventions on Newborn Weight Loss and Breast/Chestfeeding Cessation - Part I & Part II" by Mindy Cockeram, LCCE, discusses how specific, commonly used medical interventions, commonly used routinely during labor and birth, can impact a new baby's weight and continuation of breastfeeding/chestfeeding.
We encourage you to read the complete Part I and Part II of this article. Below, we highlight some of the most important points.
Many childbirth educators encounter scenarios like the following. Does it sound familiar to you?
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?
If this is familiar, you're not alone and it's not your fault. Often, it's the decisions made and interventions used during labor that cause initial problems with breast/chestfeeding. Learn more about 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."
What you should know:
Pitocin
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)
Narcotics
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.
IV Fluids
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).
How can you counteract these interventions?
"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."
Additionally, "feeding 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."
"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."
"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."
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."
For more details about what you can do to counteract interventions, be sure to read Part I of this article on Connecting the Dots.
Newborn Weight
In Part II of the article, the discussion centers on newborn weight and weight loss, including the significance of when baby's weight is first taken and follow-up weight measurements.
When, after birth, should a newborn’s baseline weight be established? Using a weight that may have been impacted by labor interventions can hinder maternal breastfeeding confidence and skew pediatric goals for normal newborn weight gain. We also look at an evidence based tool for determining if weight loss really falls into the supplementation zone.
Most babies are weighed after birth. This first weight is considered their "baseline weight" to determine, based on proceeding weight gain, if baby is gaining weight -- a measure for thriving. However:
In 2011, a study (Noel-Weiss, J., et al, 2011) suggested that the baby’s birth weight should be recorded at the 24 hour mark instead of at birth if the parent had received IV fluids during labor. In the study, there was a positive correlation between the baby’s output (wet diapers) in the first day of life, the amount of IV fluid the parent received in the two hours before birth and newborn weight loss at the 24 hour mark.
When to Weigh
Based on the evidence, the better suggestion is to have "baby re-weighed at the 24 hour mark (or at discharge if sooner) if the parent had received IV fluids in labor." It's also useful for parents to know "the potential variation in weight loss when using the birth weight versus the 24 hour weight since weight loss can cause parents a great deal of stress which can in turn affect milk production, Lactogenesis II and let-down."
Wet Diapers
To further determine impact from the IV on baby's fluids and weight, parents can "record the number of wet and dirty diapers in the first two weeks so that pediatricians can take all factors into consideration when deciding whether or not the baby has lost an excessive amount of weight. If the baby had more than one wet diaper in the first 24 hours, it is probable that the baby was offloading retained fluid from labor and may have an inflated birth weight."
Weight Loss - What's Normal?
It's also important for parents to know what is considered normal weight loss. The percentage of acceptable weight loss (some weight loss in the first few days after birth is normal) is debated:
Most current clinical practice guidelines suggest that a baby who has lost more than 7% of their birth weight by day three needs intervention (The Academy of Breastfeeding Medicine Protocol Committee, 2009). Weight loss of ≥10% is considered to be a sign of inadequate breast/chestfeeding (Manganaro, R., et al, 2001), and supplementing with pumped milk, donor milk, or formula immediately is the recommended course of action. Weight loss in both scenarios is defined as the percentage of weight lost from the first weight measured (i.e. birth weight).
New Assessments Being Used
Thankfully, a new tool is being used to determine if baby's weight loss is acceptable depending on the birth circumstances. This tool will help parents and care providers know more accurately when intervention is needed.
Penn State Health and Children’s Miracle Network created and released a handy tool called the Newt (newborn weight) nomogram which differentiates mode of birth for plotting and comparing weight fluctuation against the percent weight loss of other babies in the same situation.
For more details about newborn weight loss, be sure to read Part II of this article on Connecting the Dots.
Bottom Line
When assessing weight loss and the need for intervention with breastfeeding, parents should understand and look at three things to make the most informed and beneficial decision together with their care providers:
- true birth weight parameters,
- have the baby (re)weighed at the 24 hour mark
- accurately recording the times and number of breast/chestfeeding sessions and diaper counts
Published: April 26, 2021
Tags
BreastfeedingInterventionsEpiduralIV FluidsNewborn Weight LossNewborn Health