Breastfeeding After a Cesarean

Kelly Schwend had a plan. Even if the vaginal birth after cesarean (VBAC) that she hoped for did not occur, she was determined to put her newborn to breast within minutes after birth. Prior to going into the hospital in labor, Kelly had contacted the newborn nursery to tell them she preferred that her soon-to-be-born baby receive no artificial nipples while in the hospital. She contacted the labor/delivery staff to tell them she wanted to put her baby to breast in the first hour after birth regardless of the mode of delivery.

Kelly was unable to give birth vaginally, but was able to establish a deeply satisfying breastfeeding relationship with her child. Robert Parker Schwend joined his family on January 18, 1993. He remained with Kelly and her husband through the entire recovery period and the majority of her three day hospital stay.

After being assessed by the neonatologist, Parker was given to his father Bob, who held him as Kelly was stitched up and moved to the recovery room. A nurse placed the radiant heater over Kelly's bed and assisted her in holding Parker, skin-to-skin, in her arms. Parker began to nurse within minutes.

When Kelly was transferred to her room on the postpartum unit, she carried Parker with her on the cart rather than sending him to the nursery for bathing and weighing. He remained with the Schwends until several hours later. Like most newborns, Parker remained alert and eager to nurse for the first three or four hours after birth, then settled into a deep sleep. After arriving on the postpartum unit, he was dressed in a shirt and diaper and wrapped in a blanket. Parker's body temperature remained warm from being in close contact with his mother's body after birth.

He received no supplements or pacifiers during his hospital stay or in the early weeks at home. Later Kelly was delighted to report that he gained 21 ounces at his two week weight check at the pediatrician's office.

Parker is now six months old and still completely breastfed, even though Kelly has undergone another surgery and has returned to work part-time. Kelly attributes her positive breastfeeding experience to prenatal education about the benefits of breastfeeding, the support she received immediately after birth from the hospital staff, her husband, and her labor support person. She further credits her continued success with breastfeeding to the positive reinforcement she receives from her pediatrician, lactation consultant, family members and friends.

Breastfeeding in the hospital
Although the management of breastfeeding women after a cesarean birth varies in hospitals around the world, one aspect of care can be universal. Healthy, full-term babies can and should be put to breast in the first hour or so after birth and frequently thereafter (WHO/UNICEF 1989). Childbirth instructors may encourage couples in their classes to include this strategy for breastfeeding success in their birth plans.

Especially if a cesarean birth is unplanned, a mother may feel profoundly disappointed in her birth experience (Reichert et al. 1993). The mother may need a listening ear and emotional support as she comes to terms with the birth (Kearney et al. 1990). Hospital policies that promote mother/baby togetherness not only help women establish a copious milk supply (Janke 1988), but time spent holding and cuddling her baby can comfort a new mother, especially if she is grieving over the surgical birth (Mohrbacher and Stock 1991).

A woman recovering from major abdominal surgery will need skilled and sensitive assistance from the obstetrical staff and her mate regarding the care of the baby and positioning the baby at her breast. There are many ways a new mother's support people can help her conserve energy and enjoy nursing her infant. In the delivery or recovery room, especially if a regional anesthetic has been used so that the mother is alert and comfortable, the labor/delivery nurse may be able to slowly raise the head of her bed and help the mother assume a comfortable position for nursing. The baby may be positioned across the mother's chest using rolled blankets or a pillow to support her arm holding the baby. If there is a concern about the baby's body temperature, the nurse may position a radiant heater over the mother/baby couple and a warm blanket may be draped over the baby's body. Many newborns are eager to nurse about thirty minutes or so after birth. Some babies may only nuzzle the breast at this time. Mothers need to be reassured that the closeness is beneficial even if the baby isn't hungry right away.

If the baby does latch on and suckle, it will help the mother's uterus contract more quickly and decrease the chance of postpartum hemorrhage. Early and frequent breastfeedings will stabilize the baby's blood sugar levels, preventing hypoglycemia (Orr and Crase 1993; Riordan and Auerbach 1993). Focusing on the baby rather than on her own body may help allay some of the mother's anxiety (Mohrbacher and Stock 1991).

The IV in the mother's hand or forearm may be uncomfortable. The nurse or the mother's support person can assist the mother in holding the baby in a position that feels best to her, ensuring that the baby remains close to her breast. If the hospital, however, will not allow the mother to nurse in the recovery room after a cesarean birth, the mother may request that the baby be brought to her as soon as she is in her postpartum room. She may further request that her infant receive no artificial nipples while in the nursery. Commitment to breastfeeding can overcome the negative effects of a delayed first feeding (Janke 1988; Kearney et al. 1990; Riordan and Auerbach 1993).

Proper positioning of the baby at the breast is important in preventing nipple soreness. Mothers coping with a tender abdomen need help in assisting the baby to latch on correctly. You may want to encourage clients to attend breastfeeding classes prior to their babies' birth to learn the various comfortable positions for nursing.

In the early days of breastfeeding, newborns tend to latch on better when the mother gently supports the weight of her breast for him in the "C" hold, with all four fingers under the breast and her thumb above it, with all digits behind her areola. The tip of the baby's nose should touch the mother's breast through each feeding. Both of the baby's lips should be everted on her areola to prevent sore nipples.

If the mother was given a general anesthetic for the birth, she may feel too groggy to breastfeed in the early hours after birth. As she becomes more alert, the nurse or the mother's support person can assist the mother in putting the baby to the breast (Riordan and Auerbach 1993). Ideally, no artificial nipples will be used in the interim (WHO/UNICEF 1989). The baby's suck reflex may be diminished in the first few days after birth because of the general anesthesia. Consequently, the mother may require extra emotional support as she works to establish her milk supply (Janke 1988).

You may wish to encourage your clients to bring pillows from home when they enter the hospital to give birth. Especially if a woman has a cesarean birth, she'll appreciate the use of pillows to support her abdomen and her arm holding the baby. Many women sleep better when using their favorite pillow while in the hospital. You may further wish to encourage your clients to request a private room and room-in with their baby as much as possible after birth (WHO/UNICEF 1989). Many hospitals provide a cot or reclining chair on which a partner can sleep. The partner can change the baby's diapers, bring the baby to Mom to nurse, help her position the baby at breast, burp the baby etc. Mom can rest and the partner can feel more competent with baby care by the time the family leaves the hospital. If the baby's partner is unable to room-in with the mother and baby, encourage your client to request and expect extra help from the nursing or lactation consultant staff.

Another way in which childbirth educators may empower women is to encourage their clients to hire, prior to the baby's birth, a pediatrician or family practitioner who will truly support breastfeeding. Many women who are determined to breastfeed will ask the baby's doctor to write orders prohibiting the use of artificial nipples in the nursery. If the baby is full-term and healthy, there is no need for fluids other than the mother's colostrum in the early days after birth (WHO/UNICEF 1989). If the baby has a true medical need for additional fluids, encourage the mother to begin nursing at least every two to three hours around the clock (Mohrbacher and Stock 1991). If the baby is not nursing effectively, it is especially important that the mother express colostrum from her breasts. She may request the assistance of the lactation consultant or a supportive nurse on staff to learn how to manually express or pump colostrum for her baby. She may use a dropper, spoon, cup, or syringe to feed it to the baby so that nipple confusion does not develop.

Most babies are very sleepy the day after birth, then begin nursing about every two to three hours or more often for the next several weeks. Mature milk usually begins to replace the colostrum about three to five days after birth, or earlier with a multiparous woman. Early and frequent suckling will increase the mother's milk production (Sozmen 1992; Riordan and Auerbach 1993), help prevent severe engorgement, and minimize the baby's bilirubin.

Postpartum pain control
Pain control after a cesarean is still another concern for the new mother. In many hospitals, women continue to receive pain medication through their epidural catheter or an IV for the first twenty-four hours after birth before "graduating" to injections or oral pain medications. Because oxytocin, the hormone that causes the milk ejection reflex and uterine contractions, will course through the mother's bloodstream as she nurses, the new mother will experience cramping in the first few days after birth. If the epidural has been discontinued, she will benefit from requesting oral pain medication or using self-administered medication about thirty minutes before the baby will breastfeed. Hypos often make mothers sleepy. Pain medications are most effective when used before the pain becomes intolerable. As the mother becomes more mobile, she may be able to request nonnarcotic analgesics. Her baby will then become more alert and begin breastfeeding vigorously.

Special circumstances
If the baby born by cesarean is preterm or ill and cannot breastfeed effectively in the early days, the mother will need to be taught how to express her milk (WHO/UNICEF 1989). Ideally, she will have access to a hospital-sized electric breast pump. If the mother is discharged from the hospital before the baby is able to go home, encourage her to rent an electric breast pump. The newborn nursery or NICU will have a refrigerator or freezer in which breast milk may be stored.

Research indicates that babies in intensive care units fed human milk have shorter hospital stays than those babies fed formula (Barger 1994). If the mother develops a fever after her cesarean birth, there is no documented advantage to separating the mother and baby or for giving the baby bottles of artificial baby milk (Mohrbacher and Stock 1991). The mother will need to wash her hands thoroughly before touching the baby. Lactation consultants on staff can be advocates for the mother and baby who face special challenges.

Breastfeeding after leaving the hospital
Most new parents find the first night home from the hospital with a newborn to be a long one. Babies born by cesarean have often times slept through several feedings in the first few days, so will need to make up for those feedings when the family gets home three or four days after birth.

Many mothers find that nursing frequently and keeping the baby close will help the baby sleep better at night. The mother of a baby nursing very frequently needs to be reassured that her milk supply is adequate and be encouraged to begin waking the baby every two to three hours during the day to nurse. As the baby adjusts to his new environment and fills his tummy frequently during the day, the middle of the night "feeding frenzies" will soon end.

Physical help at home is vitally important to a woman recovering from a cesarean birth. Dad, grandma, doula or older children can attend to household chores, diaper changes, meal preparations, shopping, etc. as the mother and baby continue to recover from birth in the early weeks. Fluids, high protein snacks and rest will promote healing for the mother. Breast milk, naturally, is the perfect diet for the baby.

Conclusion
Of course, a mother can breastfeed her baby after a cesarean birth. With commitment, anticipatory guidance, physical assistance with child care and a supportive environment, breastfeeding can be a rewarding and esteem-building experience for all women, regardless of their mode of delivery (Kearney et al. 1990).

Childbirth educators can arm their clients with knowledge and motivation. Referring breastfeeding mothers to lactation consultants or breastfeeding support groups will help your clients have a positive breastfeeding experience.

(The author wishes to thank Kelly Schwend, RN, MS; Joan Arvin, RN; Shirley Jones, RN; Kay Kember, RN; Pam Koehler, RN; Mara Robbins, RN and Pam Whitaker, RN, for their input.)

PHOTO (BLACK & WHITE): Kelly Schwend and baby after a cesarean

References
Barger, J. (ed.) 1994. ILCA Globe 2 (February/ March) 1:5.

Janke, J.R. 1988. Breastfeeding duration following cesarean and vaginal births. Journal of Nurse-Midwifery 33 (July/August) 4:159-164.

Kearney, M.H., L.R. Cronenwett and R. Reinhardt. 1990. Cesarean delivery and breastfeeding outcomes. Birth 17, no. 2 (June): 97-105.

Mohrbacher, N. and J. Stock. 1991. The breastfeeding answer book. Franklin Park, IL: Le Leche League International.

Orr, E. and B. Crase. 1993. Neonatal hypoglycemia and breastfed babies. Leaven 28 (May-June): 36-37.

Reichert, J., M. Baron and Fawcett, J. 1993. Changes in attitudes toward cesarean birth. JOGNN 14, No. 2: 159-167.

Riordan, J. and K. Auerbach. 1993. Breastfeeding and human lactation. Boston: Jones and Bartlett.

Sozmen, M. 1992. Effects of early suckling on cesarean-born babies on lactation. Biol.- Neonate. 62, no. 1: 67-8.

Vestermark, V., C.K. Hogdall, M. Birch, G. Plenor and L.K. Toftager. 1991. Influence of the mode of delivery on initiation of breastfeeding. European Journal of Obstet. and Gynecol. and Reproductive Biology 38, no. 1: 33-8.

WHO/UNICEF. 1989. Ten Steps to successful breasffeeding. Protecting, promoting and supporting breastfeeding: The special role of maternity services.

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By Edie Orr

Edie J. Orr is the Lactation Consultant for Methodist Medical Center of Illinois in Peoria. She will complete her BSN in 1995.

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