Linda J. Smith, BSE, FACCE, IBCLC, FILCA Presentation to WHO BFHI Coordinators Network October 13,...

Linda J. Smith, BSE, FACCE, IBCLC, FILCA

Presentation to WHO BFHI Coordinators NetworkOctober 13, 2010 Istituto degli Innocenti, Florence Italy

Grand Rounds Sept 7, 2011 – Dayton Children’s Hospital

Wright State University School of Medicine

Impact of Birthing Practices on Breastfeeding

Disclosure

04/21/23© Copyright 2011 Linda J. Smith / BFLRC2

I am the sole author of Impact of Birthing Practices on Breastfeeding, Second Edition and receive partial royalties on sales of this book. Mary Kroeger, CNM, MPH was the co-author for the

first edition; her estate receives royalties on sales of this book.

I am the liaison from the International Lactation Consultant Association (ILCA) to the World Health Organization’s Baby-Friendly Hospital Initiative and receive reimbursement from ILCA for my travel expenses when representing ILCA to WHO.

For Breastfeeding to Succeed


The baby is able to feed: able to cue, suck, swallow, and breathe smoothly

The mother is producing milk and willing to bring her baby to breast many times a day

Breastfeeding is comfortable for both

Surroundings support the dyad

Research gaps


Few studies of birth practices address breastfeeding outcomes Lieberman, E., & O'Donoghue, C. (2002). Unintended effects of epidural analgesia

during labor: a systematic review. Am J Obstet Gynecol, 186(5 Suppl Nature), S31-68.

hundreds of studies; only 2 had BF outcomes

Few studies of breastfeeding & lactation investigate birth-related factors Dewey, K. G. (2001). Maternal and fetal stress are associated with impaired

lactogenesis in humans. J Nutr, 131(11), 3012S-3015S. reported oxytocin responses, no information on infant suck

Politics & Funding of Research Brown LP, Bair AH, Meier PP. Does federal funding for breastfeeding research target

our national health objectives? Pediatrics. Apr 2003;111(4 Pt 1):e360-364. “Out of 362 abstracts… awarded ~40.4 million dollars…only 13.7% (5.6 million

dollars) was awarded to projects determined to have either a direct or indirect impact on achieving the Healthy People 2000 goals for increasing the incidence and duration of breastfeeding”

“We measure what we value”


“Because ‘failure to breastfeed’ is not recognized as a possible harmful effect of medication, there are few methodological precedents in this area.

“This is the first report of a dose–response relationship between intrapartum neuraxial opioid analgesia and infant feeding.

“When well-established determinants of infant feeding are accounted for, intrapartum fentanyl may impede breastfeeding, particularly at higher doses.” Jordan S, Emery S, Bradshaw C, Watkins A, Friswell W. The impact of

intrapartum analgesia on infant feeding. BJOG. Jul 2005;112(7):927-934.

Failure to breastfeed IS harmful

04/21/23© Copyright 2011 Linda J. Smith / BFLRC

6

Failure to breastfeed MEANS formula feeding Formula fed children are more likely to die - everywhere

“[USA} excess 911 deaths, nearly all of which would be in infants ($10.5 billion and 741 deaths at 80% compliance” (Bartick & Reinhold, Pediatrics 2010)

~doubles the risk of SIDS throughout infancy (Venneman, Pediatrics 2009)

Mothers who do not lactate after birth are at higher risk of illness

Increased rates of Acute Otitis Media Gastrointestinal Infections Atopic Dermatitis Lower Respiratory Tract Diseases Asthma Cardiovascular Diseases

Poorer cognitive development

Obesity (mother and baby) Type I and II Diabetes Childhood Leukemia Osteoporosis Postpartum Depression Breast & Ovarian Cancer

• (AHRQ 2007)

Appendix 2. Excess Health Risks Associated with Not Breastfeeding*


Outcome Excess Risk* (%)(95% CI†) Comparison Among full-term infants

Acute ear infections (otitis media)2 100 (56, 233) EFF‡ vs. EBF§ for 3 or 6 mos Eczema (atopic dermatitis)11 47 (14, 92) EBF <3 mos vs. EBF ≥3 mos Diarrhea and vomiting (GI infection) 3 178 (144, 213) Never BF vs. ever BF Hospitalization for LRI, 1st yr 257 (85, 614) Never BF vs. EBF ≥4

mos Asthma, with family history2 67 (22, 133) BF <3 mos vs. ≥3 mos Asthma, no family history2 35 (9, 67) BF <3 mos vs. ≥3 mos Childhood obesity7 32 (16, 49) Never BF vs. ever BF Type 2 diabetes mellitus6 64 (18, 127) Never BF vs. ever BF

Acute lymphocytic leukemia2 23 (10, 41) Never BF vs. >6 mos Acute myelogenous leukemia5 18 (2, 37) Never BF vs. >6 mos Sudden infant death syndrome2 56 (23, 96) Never BF vs. ever BF Among preterm infants Necrotizing enterocolitis2 138 (22, 2400) Never BF vs. ever BF

Among mothers Breast cancer8 4 (3, 6) Never BF vs. ever BF (per year of BF) Ovarian cancer2 27 (10, 47) Never BF vs. ever BF

*U.S. Department of Health and Human Services. The Surgeon General’s Call to Action to Support Breastfeeding. Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General; 2011. www.surgeongeneral.gov.

http://www.surgeongeneral.gov/

Disparities are disturbing


Table 2. Provisional Breastfeeding Rates Among Children Born in 2007* Sociodemographic Factor Ever BF @ 6 Mos. (%) BF @12 Mos.(%) United States 75.0 43.0 22.4 Race/ethnicity American Indian or Alaska Native 73.8 42.4 20.7 Asian or Pacific Islander 83.0 56.4 32.8 Hispanic or Latino 80.6 46.0 24.7 Non-Hispanic Black or African American 58.1 27.5 12.5 Non-Hispanic White 76.2 44.7 23.3 Receiving WIC† Yes 67.5 33.7 17.5 No, but eligible 77.5 48.2 30.7 Ineligible 84.6 54.2 27.6 Maternal education Not a high school graduate 67.0 37.0 21.9 High school graduate 66.1 31.4 15.1 Some college 76.5 41.0 20.5 College graduate 88.3 59.9 31.1

*U.S. Department of Health and Human Services. The Surgeon General’s Call to Action to Support Breastfeeding. Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General; 2011. www.surgeongeneral.gov.


Preventive action Estimated deaths prevented* %

Breastfeeding 1,301 13

Insecticide-treated materials 691 7Complementary feeding 587 6Clean delivery 411 4H. influenzae type b vaccination 403 4Zinc supplementation 351 4Clean water 326 3Vitamin A supplementation 176 2Tetanus toxoid vaccination 61 2Nevirapine and replacement feeding 150 2Measles vaccination 103 1Antimalarial treatment in pregnancy 22 1Newborn temperature management 0 0Antibiotics for PROM 0 0

Lancet Infant Survival Series, 2003

Global Recommendations


Exclusive Breastfeeding for 6 months, followed by continued breastfeeding with complementary family foods for 2+ years

Recommended by World Health Organization and UNICEF 2003American Academy of Family PhysiciansAmerican Academy of PediatricsAmerican College of Nurse-Midwives [PDF-76k]American College of Obstetricians and Gynecologists [

PDF-17k]American Dietetic AssociationAssociation of Women's Health, Obstetric and Neonata

l NursesNational Association of Pediatric Nurse Practitioners [P

DF-72k]Every major organized religion

http://www.aafp.org/x6633.xml

http://aappolicy.aappublications.org/cgi/content/abstract/pediatrics;115/2/496

http://www.midwife.org/siteFiles/position/Breastfeeding_05.pdf

http://www.acog.org/departments/underserved/breastfeedingStatement.pdf

http://www.acog.org/departments/underserved/breastfeedingStatement.pdf

http://www.eatright.org/About/Content.aspx?id=8377

http://www.awhonn.org/awhonn/content.do?name=02_PracticeResources/2C1_Breastfeeding.htm

http://www.awhonn.org/awhonn/content.do?name=02_PracticeResources/2C1_Breastfeeding.htm

http://download.journals.elsevierhealth.com/pdfs/journals/0891-5245/PIIS0891524506007322.pdf

http://download.journals.elsevierhealth.com/pdfs/journals/0891-5245/PIIS0891524506007322.pdf

US government supports BF


Joint Commission Speak Up August 2011: What you need to know about breastfeeding

CDC Vital Signs August 2011: Preventing Obesity begins in Hospitals CDC: mPINC surveys 2007 & 2009; 2011 in preparation Nat’l Library of Medicine: LactMed online database FDA: Breast pump information; IRS ruling Office on Women’s Health: Business Case for Breastfeeding Affordable Care Act 2010: mandated BF breaks at work Healthy People 2020 Goals: 7 objectives USBC www.usbreastfeeding.org The Joint Commission Perinatal Core Measures 2010 on exclusive BF First Lady’s “Let’s Move” campaign Surgeon General’s Call to Action to Support Breastfeeding 2011 BFHI is in CTA and a line item in President Obama’s 2012 Budget

11

http://www.usbreastfeeding.org/

USA: a decade of progress in BF

Surgeon General’s Blueprint for Action, 2001The Academy of Breastfeeding Medicine; journal, protocolsFederal & state legislation protecting the right to BF openlyWIC: $7 million in 1989, now $80+ million; peer counselorsCDC tracks BF rates instead of a formula companyOWH 2004-2006 Media campaign with “Risks of Not BF” 13 Donor Milk Banks, many started by neonatologistsNational Business Group on Health: model reimbursement

packageCDC / USBC Bi-Monthly Teleconferences; mPINC surveysAAP Breastfeeding curriculum in medical schools 2009AAP endorses the Ten Steps to Successful Breastfeeding

20093 National Conferences of State Breastfeeding Coalitions CDC adopts WHO 2007 Growth Standards Sept 2010

04/21/2312 © Copyright 2011 Linda J. Smith / BFLRC

First, do no harm


If the newborn is unable to breastfeed, AND/ORIf lactogenesis is delayed or impaired, AND/ORIf the mother is unwilling to breastfeed many times a

day AND/ORBanked donor milk is not an option, The baby will be fed formula, which

increases risk of sickness and death, and undermines the mother’s goals and

The mother is at increased risk of illness

Increased risks of NOT lactating to the mother (short list…)

Breast cancer (pre & post menopause)Ovarian and endometrial cancerHigher stress hormonesMore postpartum depressionMore cardiovascular diseaseAltered metabolism: osteoporosis, obesityEarly return of fertilityReduced ability to multitaskLower oxytocin – less trust

04/21/23© 2011 BFLRC / Linda J. Smith15

2006-09: Mother-Friendly Childbirth in BFHI

Companion of the mother’s choiceFreely move about, adopt positions of choiceEat and drink freely during laborAvoid unnecessary (routine) interventionsNon-drug pain reliefRequired in educational Steps (2 & 3) nowNational BFHI Authorities to add assessment

process on a country-by-country basis

No study has confirmed the safety and efficacy of laboring

alone

Companion(s) of the Mother’s Choice

Continuous Companion(s) of choiceStrongly supports breastfeeding

Better Breastfeeding Outcomes Hofmeyr,et al, 1991; Langer et al , 1998)

Better Birth Outcomes 25% shorter labor; 40% less oxytocin

use; 30% less pain medication; 40% less forceps; 60% fewer epidurals (Hodnett,1994 & 2001; Scott et al,1999; Zhang et al, 1996)

Less Surgical Intervention 50% reduction in Cesarean rate

(Hodnett,1994 & 2001; Scott et al, 1999; Zhang et al, 1996; Nommsen-Rivers 2009)

Empowered Mother (Campero, et al, 1998) Hodnett E, Gates S, Hofmeyr G, Sakala

C. Continuous support for women during childbirth. Cochrane Database Syst Rev. 2007(3):CD003766.


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Criteria for companion(s)


#1: Mother’s choiceContinuous presence with mother

Female who has given birthShort training is helpfulDoes not replace the father; supports both

If payment is involved, mother paysNot hospital employee

Provides no medical care nor interferes

No study has confirmed the safety and efficacy of

horizontal and/or immobile positions for labor or birth

Freely move about in labor and birth

“Gravity works”

Breastfeeding outcomes


Horizontal position = longer 1st stage, poorer fetal oxygenation

Horizontal position = longer 2nd stage, excess molding, more fetal distress, more instruments & surgery

Long labors = delayed lactogenesis (Chen)

No direct research on BF outcomes

No study has confirmed the safety and efficacy of withholding food and drink during labor and birth

Eat and Drink Freely“Labor is work”

Light eating & drinking in laborNo direct research re: breastfeeding

Labor is vigorous exercise / work

Fasting & starvation slows, complicates labor

“Most obstetric anesthesiologists agree that a rigid NPO policy in labor is no longer appropriate”◦ O'Sullivan, Anesthesiol Clin

North America 2003 “Consumption of a light diet

during labour did not influence obstetric or neonatal outcomes in participants, nor did it increase the incidence of vomiting.”◦ O'Sullivan, BMJ 2009


22

Cambodia 2001- Offering oral fluids was “new” policy for these midwives (MK)

Breastfeeding outcomes


When liquids are withheld, IV hydration is given60% of mothers with pitting edema had delayed

onset of lactogenesis II IV fluids, induction, Cesarean, and other

interventions were associated with edema Nommsen-Rivers, L. A., Chantry, C. J., Peerson, J. M., Cohen, R. J., & Dewey, K. G. (2010). Delayed onset of lactogenesis

among first-time mothers is related to maternal obesity and factors associated with ineffective breastfeeding. Am J Clin Nutr. (e-pub ahead of print)

Indirect Maternal RisksPsychological risks Pain & stressRestriction of movement

Indirect Newborn RisksElectrolyte imbalancesFluid overload, excess loss of birth weightSeparation from motherDisruption in early breastfeeding

All drugs reach the fetus/baby within seconds

Drugs for Pain Management

All drugs reach the fetus/baby


“The lower NACS (Neurologic and Adaptive Capacity Score) at 24 hours in group B-F may reflect the continued presence of fentanyl in the neonate.”Randomized; double-blind study of epidural

sufentanil and fentanyl infused with bupivacaineLoftus, J. R., Hill, H., & Cohen, S. E. (1995).

Placental transfer and neonatal effects of epidural sufentanil and fentanyl administered with bupivacaine during labor. Anesthesiology, 83(2), 300-308.

All drugs reach the baby…even local lidocaine


Ransjo-Arvidson, A., Matthiesen, A., Lilja, G., Nissen, E., Widstrom, A., & Uvnas-Moberg, K. (2001). Maternal analgesia during labor disturbs newborn behavior. Birth, 28, 5 - 12.

“It has not previously been reported that the use of analgesia via pudendal block has an adverse effect on the initiation of developing breastfeeding behavior including sucking.”

Strong evidence of consequences


Sixty women were randomly assigned to receive no fentanyl, 59 were randomly assigned to receive an intermediate dose, and 58 were randomly assigned to receive high-dose fentanyl.

At 6 weeks postpartum, more women who were randomly assigned to high-dose epidural fentanyl were not breast-feeding (n = 10, 17%) than women who were randomly assigned to receive either an intermediate fentanyl dose (n = 3, 5%) or no fentanyl (n = 1, 2%) (P = 0.005).

Conclusion: Among women who breast-fed previously, those who were randomly assigned to receive high-dose labor epidural fentanyl were more likely to have stopped breast-feeding 6 weeks postpartum than women who were randomly assigned to receive less fentanyl or no fentanyl. Beilin Y et al. Effect of labor epidural analgesia with and without fentanyl on

infant breast-feeding: A prospective, randomized, double-blind study. Anesthesiology 2005, 103(6), 1211-1217.

History of documented effects


Cyanosis, unresponsive, visual skills, alertness, state, poor response to stress for 6 weeks Rosenblatt, D. B., Belsey, E. M., Lieberman, B. A., Redshaw, M., Caldwell, J.,

Notarianni, L., et al. (1981). The influence of maternal analgesia on neonatal behaviour: II. Epidural bupivacaine. Br J Obstet Gynaecol, 88(4), 407-413.

Cueing, sucking, maternal attention N=60; 38 were products of epidural deliveries and 22 of non-medicated deliveries. Sepkoski, C. M., Lester, B. M., Ostheimer, G. W., & Brazelton, T. B. (1992). The

effects of maternal epidural anesthesia on neonatal behavior during the first month. Dev Med Child Neurol, 34(12), 1072-1080.

Delayed feeding 2.5 hours, increased temperature, poor cueing, cried more N= 28; Group 1 mothers (n 4 10) had received no analgesia during labor,

group 2 mothers (n 4 6) had received mepivacaine via pudendal block, and group 3 mothers (n 4 12) had received pethidine or bupivacaine or more than one type of analgesia during labor

Ransjo-Arvidson, A., Matthiesen, A., Lilja, G., Nissen, E., Widstrom, A., & Uvnas-Moberg, K. (2001). Maternal analgesia during labor disturbs newborn behavior. Birth, 28, 5 - 12

Documented effects, cont.


Poor suck on IBFAT, early weaning Riordan, J., Gross, A., Angeron, J., Krumwiede, B., & Melin, J.

(2000). The effect of labor pain relief medication on neonatal suckling and breastfeeding duration. J Hum Lact, 16(1), 7-12.

More instruments, less spontaneous vaginal birth, longer labor, maternal fever, septic workups Lieberman, E., & O'Donoghue, C. (2002). Unintended effects of

epidural analgesia during labor: a systematic review. Am J Obstet Gynecol, 186(5 Suppl Nature), S31-68.

Ineffective feeds; more bottle supplementsBaumgarder, D. J., Muehl, P., Fischer, M., & Pribbenow, B.

(2003). Effect of labor epidural anesthesia on breast-feeding of healthy full-term newborns delivered vaginally. J Am Board Fam Pract, 16(1), 7-13

Still more documented effects


Breastfeed for shorter durationHenderson, J. J., Dickinson, J. E., Evans, S. F., McDonald, S. J.,

& Paech, M. J. (2003). Impact of intrapartum epidural analgesia on breast-feeding duration. Aust N Z J Obstet Gynaecol, 43(5), 372-377.

“Not enough milk;” formula useVolmanen, P., Valanne, J., & Alahuhta, S. (2004). Breast-

feeding problems after epidural analgesia for labour: a retrospective cohort study of pain, obstetrical procedures and breast-feeding practices. Int J Obstet Anesth, 13(1), 25-29.

Breastfeeding difficulties, stop BF soonerTorvaldsen, S., Roberts, C. L., Simpson, J. M., Thompson, J. F.,

& Ellwood, D. A. (2006). Intrapartum epidural analgesia and breastfeeding: a prospective cohort study. Int Breastfeed J, 1, 24.

More and more effects


Reduced warming effect of STS N=47 mother-infant pairs; 9 mothers had received OT stimulation during labour (OT group), 20

mothers had received an EDA and OT during labour (EDA group), while 18 mothers had received neither EDA nor OT stimulation during labour (control group).

The temperature measured when the newborns were put skin-to-skin on their mothers' chest was significantly higher in the infants of the EDA group (35.07 degrees C) when compared to the control group (34.19 degrees C, p=0.025).

Skin temperature increased significantly (p=0.001) during the entire experimental period in the infants belonging to the control group. The same response was observed in infants whose mothers received OT intravenously during labour (p=0.008). No such rise was observed in infants whose mothers were given an EDA during labour.

Jonas, W., Wiklund, I., Nissen, E., Ransjo-Arvidson, A. B., & Uvnas-Moberg, K. (2007). Newborn skin temperature two days postpartum during breastfeeding related to different labour ward practices. Early Hum Dev, 83(1), 55-62.

Delayed spontaneous breastfeeding 4+ hrs; increased formula supplementation n=585 mothers with EDA matched with 585 controls Significantly fewer babies of mothers with EDA during labour suckled the

breast within the first 4 hours of life [odds ratio (OR) 3.79]. These babies were also more often given artificial milk during their hospital stay (OR 2.19) and fewer were fully breast fed at discharge (OR 1.79).

Delayed initiation of breast feeding was also associated with a prolonged first (OR 2.81) and second stage (OR 2.49) and with the administration of oxytocin (OR 3.28).

Wiklund, I., Norman, M., Uvnas-Moberg, K., Ransjo-Arvidson, A. B., & Andolf, E. (2009). Epidural analgesia: breast-feeding success and related factors. Midwifery, 25(2), e31-38

Hormone effects


Reduced oxytocin Rahm, V. A., Hallgren, A., Hogberg, H., Hurtig, I., & Odlind, V. (2002). Plasma oxytocin

levels in women during labor with or without epidural analgesia: a prospective study. Acta Obstet Gynecol Scand, 81(11), 1033-1039.

Reduced pulsatile oxytocin Nissen, E., Uvnas-Moberg, K., Svensson, K., Stock, S., Widstrom, A. M., & Winberg, J.

(1996). Different patterns of oxytocin, prolactin but not cortisol release during breastfeeding in women delivered by caesarean section or by the vaginal route. Early Hum Dev, 45(1-2), 103-118.

Reduced maternal socialization; increased anxiety and aggression Jonas, W., Nissen, E., Ransjo-Arvidson, A. B., Matthiesen, A. S., & Uvnas-Moberg, K.

(2008). Influence of oxytocin or epidural analgesia on personality profile in breastfeeding women: a comparative study. Arch Womens Ment Health, 11(5-6), 335-345.

Lowered endogenous oxytocin with epidural + oxytocin infusion Jonas, W., Johansson, L. M., Nissen, E., Ejdeback, M., Ransjo-Arvidson, A. B., & Uvnas-

Moberg, K. (2009). Effects of Intrapartum Oxytocin Administration and Epidural Analgesia on the Concentration of Plasma Oxytocin and Prolactin, in Response to Suckling During the Second Day Postpartum. Breastfeed Med, 4(2), 71-82

Natural pain relief: endorphins


“beta-endorphin is 18 to 33 times more potent than morphine”Loh, Proc Natl Acad Sci USA 1976

Epidurals reduce maternal endorphins Abboud, T. K., Khoo, S. S., Miller, F., Doan, T., & Henriksen, E. H.

(1982). Maternal, fetal, and neonatal responses after epidural anesthesia with bupivacaine, 2-chloroprocaine, or lidocaine. Anesth Analg, 61(8), 638-644.

Cesarean without labor reduces endorphins in milk Zanardo, V., Nicolussi, S., Giacomin, C., Faggian, D., Favaro, F., &

Plebani, M. (2001). Labor pain effects on colostral milk beta-endorphin concentrations of lactating mothers. Biol Neonate, 79(2), 87-90

Clinical implications


Babies with altered neurobehavior do not feed effectively, causing…

Inadequate nutrition for infant Risk of formula supplementation

Milk retention in breastSuppressed onset of lactation / lactogenesisMaternal pain

Undermining of mothers’ confidence

Clinical implications, cont.


Epidurals reduce / block maternal endorphins released in laborunrelieved maternal pain

Epidurals & birth without labor reduce endorphin concentrations in milkUnrelieved infant pain?Inability to access pain-relieving effect of

breastfeeding

Clinical implications, cont.


Non-pulsatile oxytocin: reduced milk releaseMilk retention; compromised lactogenesisInadequate infant nutritionIncreased risk of formula supplementation

Altered oxytocin: behavioral & biological effectsReduced uterine contractionsReduced digestion, slower healingReduced maternal socializationIncreased anxiety and aggressionReduced trust; reduced facial recognition

Non-drug pain reliefStrongly supports breastfeeding


•Before

•In addition to

•Instead of

Drug methods

Elective Induction of LaborRoutine SuctioningRoutine EpisiotomyCesarean Surgery

Routine interventions

Risks of inducing labor


2X the risk of Cesarean in primiparasSynthetic oxytocin = stronger contractions

↑ pressure on baby’s head ↑ maternal pain ↑ infant pain ??

Less-mature baby (?)WHO: 10% induction medically justified

Increased forces to baby’s head


Induction & augmentationPushing on fundusSupine positionImmobilityInstruments and CesareanResult: more molding / abnormal molding

Research Evidence


“Vacuum vaginal delivery was a strong predictor of early cessation of breastfeeding” N=1075; 8 variables identified as significant. Hall RT, Mercer AM, Teasley SL, et al. 2002. A breastfeeding assessment

score to evaluate the risk for cessation of breastfeeding by 7 to 10 days of age. J Ped 141:659–664.

Poor feeding is one sign of intercranial bleeding 58term newborns with Apgars of 9-10 were referred for repeat CT

examination of the brain with symptoms, such as apnea, disturbances of swallowing or sucking, impaired muscular tonus, tremor and jerks.

Avrahami E, Amzel S, Katz R, et al. 1996. CT demonstration of intracranial bleeding in term newborns with mild clinical symptoms. Clin Radiol 51:31–34.

Research Evidence (cont.)


Wall & Glass: 11 mother-infant pairs had breastfeeding problems related to the infants' mandibular asymmetry2 received septic workups for poor feeding and weight loss but had negative

culture results. Five lost more than 8% of their birth weight. Nine received supplementation (by tube at breast, finger-feeding, or bottle) secondary to difficulty breastfeeding in the first week of life.

Labor was prolonged in at least 6 and resulted in cesarean section in 4 of the 11 cases. One birth was forceps-assisted. Three infants were large for gestational age.

Wall, V., & Glass, R. (2006). Mandibular Asymmetry and Breastfeeding Problems: Experience From 11 Cases. J Hum Lact, 22(3), 328-334.

Evans: “The volume of milk transferred to infants born by caesarean section was significantly less than that transferred to infants born by normal vaginal delivery on days 2 -5 (p<0.05).” Evans, K. C., Evans, R. G., Royal, R., Esterman, A. J., & James, S. L. (2003). Effect of caesarean section on breast

milk transfer to the normal term newborn over the first week of life. Arch Dis Child Fetal Neonatal Ed, 88(5), F380-382.

Chance or Choice? Induction


This isn’t new!The U.S. Food and Drug Administration disapproved of

elective inductions in the 1970s due to iatrogenic prematurity, overcrowded neonatal intensive care units, and huge unnecessary costs

Increased risk of infant deathKramer, M. S., Demissie, K., Yang, H., Platt, R. W., Sauve, R.,

& Liston, R. (2000). The contribution of mild and moderate preterm birth to infant mortality. Fetal and Infant Health Study Group of the Canadian Perinatal Surveillance System. JAMA, 284(7), 843-849.

Doubled risk of CesareanCrosby, W. (2008). Elective induction of labor: part 2. J Okla

State Med Assoc, 101(12), 369-373.

“Insufficient evidence”


“The evidence regarding elective induction of labor prior to 41 weeks of gestation is insufficient to draw any conclusion.

There is a paucity of information from prospective RCTs examining other maternal or neonatal outcomes in the setting of elective induction of labor.” Caughey, A. B., Sundaram, V., Kaimal, A. J., Cheng,

Y. W., Gienger, A., Little, S. E., et al. (2009). Maternal and neonatal outcomes of elective induction of labor. Evid Rep Technol Assess (Full Rep)(176), 1-257.

No information on BF outcomes


As of August 3, 2011, to the best of my knowledge:

No studies of induction have investigated breastfeeding outcomes

Suctioning & airway management

Oral aversion ?Superstimulus, vagal

response ?Triggers poor tongue

movements?Injury to oropharanyx (L. Black,

MD)Mucus has a purpose (M. Klaus)Unmedicated: babies handle

mucusArtifact from heavily medicated

births??


46

No direct research on suctioning


Lack of benefitRCT; N=2514; 11 hospitals in US and ArgentinaNo significant difference between treatment groups was seen in the

incidence of MAS (52 [4%] suction vs 47 [4%] no suction; relative risk 0.9, 95% CI 0.6-1.3), need for mechanical ventilation for MAS (24 [2%] vs 18 [1%]; 0.8, 0.4-1.4), mortality (9 [1%] vs 4 [0.3%]; 0.4, 0.1-1.5), or in the duration of ventilation, oxygen treatment, and hospital care

Routine intrapartum oropharyngeal and nasopharyngeal suctioning of term-gestation infants born through meconium stained amniotic fluid does not prevent meconium aspiration syndrome. Consideration should be given to revision of present recommendations.

Vain, N. E., Szyld, E. G., Prudent, L. M., Wiswell, T. E., Aguilar, A. M., & Vivas, N. I. (2004). Oropharyngeal and nasopharyngeal suctioning of meconium-stained neonates before delivery of their shoulders: multicentre, randomised controlled trial. Lancet, 364(9434), 597-602.

Long term negative consequences “Noxious stimulation caused by gastric suction at birth may promote the

development of long-term visceral hypersensitivity and cognitive hypervigilance, leading to an increased prevalence of functional intestinal disorders in later life.”

Anand, K. J., Runeson, B., & Jacobson, B. (2004). Gastric suction at birth associated with long-term risk for functional intestinal disorders in later life. J Pediatr, 144(4), 449-454

Episiotomy – one study


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Kitzinger, S. (1981). Some Women's Experiences of Episiotomy. In N. C. Trust (Ed.) (Vol. Pamphlet NLM # 05304054-6). London: National Childbirth Trust.

Pain in Perineum Distracted Woman When Breastfeeding Not at all A bit/

occasionallyA lot, often, always

Total

Tear

234 (68%) 79 (23%) 31 (9%) 344

Episiotomy

409 (43%) 381 (40%) 167 (17%) 957

Episiotomy & Tear 55 (37%) 62 (42%) 31 (21%) 148

Intact

154 (92%) 9 (5%) 5 (3%) 168

Total

852 (53%) 531 (33%) 234 (14%) 1617

Emergent CesareanScheduled (elective) Cesarean

Cesarean Surgery

Elective Cesarean:Infant respiratory problems


Conclusions Elective repeat cesarean delivery before 39 weeks of gestation is common and is associated with respiratory and other adverse neonatal outcomes.Tita, A. T. N., Landon, M. B., Spong, C. Y., Lai, Y.,

Leveno, K. J., Varner, M. W., et al. (2009). Timing of Elective Repeat Cesarean Delivery at Term and Neonatal Outcomes. N Engl J Med, 360(2), 111-120.

Elective Cesarean: Infant respiratory problems, NICU


CONCLUSION: In comparison with vaginal birth after cesarean, neonates born after elective repeat cesarean delivery have significantly higher rates of respiratory morbidity and NICU-admission and longer length of hospital stay. Kamath, B. D., Todd, J. K., Glazner, J. E., Lezotte,

D., & Lynch, A. M. (2009). Neonatal outcomes after elective cesarean delivery. Obstet Gynecol, 113(6), 1231-1238.

Elective Cesarean: BF to a lesser extent at 3 months


In a prospective cohort study 357 healthy primiparas from two different groups, "cesarean section on maternal request" (n=91) and "controls planning a vaginal delivery" (n=266) completed three self-assessment questionnaires in late pregnancy, two days after delivery and 3 months after birth.

RESULTS: Women requesting cesarean section experienced their health as less good (p<0.001) and were more often planning for one child only (p<0.001). They more often reported anxiety for lack of support during labor (p<0.001), for loss of control (p<0.001), and concern for fetal injury/death (p<0.001).

They were breastfeeding to a lesser extent three months after birth (p<0.001). There were no differences in signs of postpartum depression between the groups three months after birth (p=0.878). Wiklund, I., Edman, G., & Andolf, E. (2007). Cesarean section on maternal

request: reasons for the request, self-estimated health, expectations, experience of birth and signs of depression among first-time mothers. Acta Obstet Gynecol Scand, 86(4), 451-456.

Any Cesarean:Delayed onset of lactogenesis


Risk factors for delayed lactation were being primiparous (adjusted OR 3.16, 95% CI 1.58-6.33) and having delivered by caesarean section (adjusted OR 2.40, 95% CI 1.28-4.51). Scott, J. A., Binns, C. W., & Oddy, W. H. (2007). Predictors

of delayed onset of lactation. Matern Child Nutr, 3(3), 186-193.

Delayed onset of lactation (>72 hours) occurred in 22% of women and was associated with primiparity, cesarean section, stage II labor >1 hour, maternal body mass index >27 kg/m(2), flat or inverted nipples, and birth weight >3600 g (in primiparas). Dewey, K. G., Nommsen-Rivers, L. A., Heinig, M. J., & Cohen, R. J.

(2003). Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss. Pediatrics, 112(3 Pt 1), 607-619.

© Copyright 2011 Linda J. Smith / BFLRC

Ecologic analysis of delayed onset of lactogenesis by birth setting Nommsen-Rivers, L. A., Mastergeorge, A. M., Hansen, R. L., Cullum, A. S., & Dewey, K. G. (2009). Doula care, early breastfeeding outcomes, and breastfeeding status at 6 weeks postpartum among low-income primiparae. J Obstet Gynecol Neonatal Nurs, 38(2), 157-173.

0

5

10

15

20

25

30

35

40

0 5 10 15 20 25 30 35 40

% Cesarean delivery

% D

ela

ye

d O

ns

et

of

La

cto

ge

ne

sis

y=0.97x + 5.44; R-squared = .85

From L to R:

Lusaka, Zambia Kasonka, 2002

Rural Guatemala Hruschka, 2003

Davis, California

Dewey, 2003

Urban Guatemala Grajeda, 2002

Urban Connecticut Chapman, 1999

Rural Ghana, Baby-Friendly Hospital Otoo, 2009

04/21/2354


54

45

31

10 20 30 40 50 60 70 80

> 30.0

25-29.9

< 25.0

48

43

44

10 20 30 40 50 60 70 80

DD-H

C-D

A-B

Body Mass Index P=.002

Bra cup size P=.86

Who is at risk for delayed OL?Sacramento Cohort, Maternal Factors

04/21/2355


65

49

35

20 30 40 50 60 70 80

pitting

mild

none

78

42

31

20 30 40 50 60 70 80

pitting

mild

none

Postpartum edema P<.001

PP edema BMI < 27,P=.01

(7/9)

Who is at risk for delayed OL?Sacramento Cohort, peri-partum factors

04/21/2356

Elective Cesarean:Less sensitive to baby’s cries


We conducted functional magnetic resonance imaging, 2-4 weeks after delivery, of the brains of six mothers who delivered vaginally and six who had an elective CSD. VD mothers' brains were significantly more responsive than CSD mothers' brains to their own baby-cry in the superior and middle temporal gyri, superior frontal gyrus, medial fusiform gyrus, superior parietal lobe, as well as regions of the caudate, thalamus, hypothalamus, amygdala and pons.

Also, within preferentially active regions of VD brains, there were correlations across all 12 mothers with out-of-magnet variables. These include correlations between own baby-cry responses in the left and right lenticular nuclei and parental preoccupations (r = .64, p < .05 and .67, p < .05 respectively), as well as in the superior frontal cortex and Beck depression inventory (r = .78, p < .01).

this suggests that VD mothers are more sensitive to own baby-cry than CSD mothers in the early postpartum in sensory processing, empathy, arousal, motivation, reward and habit-regulation circuits. Swain, J. E., Tasgin, E., Mayes, L. C., Feldman, R., Constable, R. T., & Leckman, J. F. (2008).

Maternal brain response to own baby-cry is affected by cesarean section delivery. J Child Psychol Psychiatry, 49(10), 1042-1052.

Any Cesarean:Barrier to BF initiation


N=1696 over 6 years Overall, 36% of all births were performed by

cesarean section, while initiation of breastfeeding was achieved by 61.5% of the women.

Cesarean section was negatively related to breastfeeding initiation in multivariable logistic regression models (odds ratio=.64; 95% CI=0.51-0.81) after controlling for confounding variables.Perez-Rios, N., Ramos-Valencia, G., & Ortiz, A. P.

(2008). Cesarean delivery as a barrier for breastfeeding initiation: the Puerto Rican experience. J Hum Lact, 24(3), 293-302.

Clinical Implications


WHO: 10 – 15% probably medically justified NIH: Trial of Labor is a reasonable option for many

pregnant women with a prior low transverse uterine incision. NIH Consensus Development Conference: Vaginal Birth After Cesarean: New Insights March 8–10, 2010

US Cesarean rate, August 2011: 34%

Risk of infant respiratory and suck problemsRisk of delayed onset of lactationRisk of extended maternal pain

Most pain relievers are compatible with BFAssure close and extended skilled follow up

Immediate Skin-to-Skin after Cesarean


From a nurse at Wentworth Douglass, responding to a grateful mother as her second baby was immediately placed STS after her 2nd Cesarean: “This is what we do.”

Cumulative effect of interventions


N=753,895 low-risk women who gave birth in Australia during 2000-2002.

RESULTS: We observed increased rates of operative birth in association with each of the interventions offered during the labour process. For first time mothers the association was particularly strong.

At a population level it demonstrates the magnitude of the fall in rates of unassisted vaginal birth in association with a cascade of interventions in labour and interventions at birth particularly amongst women with no identified risk markers and having their first baby. Tracy, S. K., Sullivan, E., Wang, Y. A., Black, D., & Tracy, M. (2007).

Birth outcomes associated with interventions in labour amongst low risk women: a population-based study. Women Birth, 20(2), 41-48.

Tracy, S. K., Sullivan, E., Wang, Y. A., Black, D., & Tracy, M. (2007). Birth outcomes associated with interventions in labour amongst low risk women: a population-based study. Women Birth, 20(2), 41-48.


Rate of unassisted vaginal birth in association with instrumental and caesarean births amongst ‘low risk’ first time mothers, Australia, 2000—2002.


Tracy, S. K., Sullivan, E., Wang, Y. A., Black, D., & Tracy, M. (2007). Birth outcomes associated with interventions in labour amongst low risk women: a population-based study. Women Birth, 20(2), 41-48.

Traumatic birth impedes BF


RESULTS: n= 52; Eight themes emerged about whether mothers' breast-feeding attempts were promoted or impeded. These themes included (a) proving oneself as a mother: sheer determination to succeed, (b) making up for an awful arrival: atonement to the baby, (c) helping to heal mentally: time-out from the pain in one's head, (d) just one more thing to be violated: mothers' breasts, (e) enduring the physical pain: seeming at times an insurmountable

ordeal, (f) dangerous mix: birth trauma and insufficient milk supply, (g) intruding flashbacks: stealing anticipated joy, and (h) disturbing

detachment: an empty affair. CONCLUSIONS: The impact of birth trauma on mothers' breast-

feeding experiences can lead women down two strikingly different paths. One path can propel women into persevering in breast-feeding, whereas the other path can lead to distressing impediments that curtailed women's breast-feeding attempts. Beck, C. T., & Watson, S. (2008). Impact of birth trauma on breast-

feeding: a tale of two pathways. Nurs Res, 57(4), 228-236.

For Breastfeeding to Succeed


The baby is able to feed: able to cue, suck, swallow, and breathe smoothly

The mother is producing milk and willing to bring her baby to breast many times a day

Breastfeeding is comfortable for both

Surroundings support the dyad

Summary


Companion(s) of the mother’s choice: Strong positive effect on breastfeeding

Movement & position: no direct evidence on BFEat & drink: no direct evidence on BF; new policiesLabor Drugs: Strong negative effect on BF, especially

fentanylRoutine Interventions

Induction: no direct evidence on BFEpisiotomy: one study, negative effect on BFSuctioning: no direct evidence on BFCesarean: Strong negative effect on BF

Thank you!Linda J. Smith

[email protected]

Impact of Birthing Practices on Breastfeeding, 2nd Edition

www.jblearning.com


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mailto:[email protected]

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Linda J. Smith, BSE, FACCE, IBCLC, FILCA Presentation to WHO BFHI Coordinators Network October 13,...

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