4.2 Labor interventions
The care a mother experiences during labor and birthing can affect breastfeeding and how she cares for her baby. Birth practices that help the mother to feel competent, in control, supported and ready to interact with her baby include:
- Emotional support during labor
- Freedom of movement during labor
- Offering light foods and fluids during labor
- Avoidance of unnecessary caesarean section
- Early mother-infant contact
- Facilitating the first feed
Consideration of the following facts is important when labor interventions are considered:
Analgesia during labor
The most commonly used intrapartum analgesics are potent narcotics which have the potential to block the newborn's normal reflexes to suckle at the breast within the first hour after birth. When opiates must be used shorter-acting opiates are preferred.
- Fentanyl, sufentanil and remifentanil are all short-acting.
- Morphine has a short half-life (1.5 - 2 hrs) and does not have an active metabolite.
- Meperidine (Pethidine/Demerol) is associated with a greater incidence and duration of respiratory depression, cyanosis and bradycardia in neonates. It is metabolized to the active metabolite normeperidine (norpethidine) which has a long half-life (63 hours in the neonate). Meperidine/Pethidine reaches its highest levels in the fetus 2 to 3 hours after administration, however normeperidine/norpethidine levels continue to rise the longer it is until birth. Normeperidine/norpethidine still has half the pharmacological activity of meperidine/pethidine.
- Butorphanol (Stadol) and Nalbuphine (Nubain) interfere with fetal heart rate monitoring. Observe mother and baby for psychotomimetic reactions.

How long will the effects of meperidine/pethidine be experienced by the newborn baby?
It takes approximately 5 half-lives for a substance to reach insignificant serum (blood) concentration. How long will it take the newborn baby to clear normeperidine and its effects from his system?
Multiply 63 hours by 5 times; then divide by 24 to have your answer in days.
Other forms of analgesia such as inhaled nitrous oxide, paracervical block, pudendal block and local perineal anaesthesia expose the infant to minimal quantities of medication and may be an alternative to intravenous narcotics or epidural analgesia.
Neuraxial pain relief (epidural/spinal)
Anesthetics such as lignocaine and bupivacaine are commonly administered via the epidural route to mothers in labor to provide pain-free birthing. This local anesthetic is almost always combined with narcotics such as morphine, fentanyl or sufentanil, providing a rapid onset of pain relief while reducing the intensity of immobility for the mother.
While epidurals in labor provide greater pain relief than non-epidural methods, they are also associated with:1
- longer first and second stages of labor,
- maternal fever
- followed by septic work-up of infant, and maternal/infant separation, and possibly antibiotic therapy
- a drop in blood pressure
- fluid 'loading' used routinely; commonly associated with postnatal breast engorgement and additional weight loss in the infant during the first two days
- fluid 'loading' used routinely; commonly associated with postnatal breast engorgement and additional weight loss in the infant during the first two days
- problems passing urine
- decrease in oxytocin levels during labor, necessitating an increased use of oxytocin augmentation
- an increased incidence of fetal malposition,
- an increased need for instrumental vaginal delivery
- the mother being unable to move for a period of time after the birth, and
- the possibility of a postdural puncture headache2 palliatively treated by horizontal bed rest, and usually further medical intervention.
- decreased oxytocin and prolactin levels on Day 2 postpartum.3
Is breastfeeding affected?
The risk of associated interventions (eg assisted delivery, etc) make breastfeeding more challenging.
Infant behavior is adversely affected when high doses of analgesia, or repeated doses over a longer duration, are used. This is minimised when
- the dose used is low (eg less than 150mcg Fentanyl)
- motor block is minimized
- longer duration and repeated dosing are avoided.

Did you know?
- levels increase throughout pregnancy; high levels at the end of pregnancy are associated with a decreased need for intrapartum analgesia.7 Such high levels help the laboring woman to transmute pain and enter the altered state of consciousness that characterizes an undisturbed birth.8
- Beta-endorphins are found in colostrum; it is thought they contribute to postnatal fetal adaptation, to overcoming birth stress, to the postnatal development of several related biologic functions of breastfed infants and may persist for up to 3 days.9,5,10,11
Cesarean (caesarean) section
How it was ...
Cesarean birth is often associated with delayed skin-to-skin contact between mother and baby and longer time to first breastfeed.
- Rowe-Murray et al (2002)12 reported a significant delay in initiating breastfeeding compared with women giving birth vaginally, with or without instrumental assistance.
- Shawky & Abalkhail (2003)13 found caesarean section delivery to be significantly related to earlier cessation of breastfeeding.
- Leung et al (2002)14 identified caesarean delivery was a risk factor for not initiating breastfeeding, for breastfeeding less than 1 month, and it remained a significant hazard against breastfeeding duration.
Don't forget the effects of the operation itself: an abdominal incision, pain, restricted movement, intravenous therapy, a urinary catheter, analgesics for several days, restricted oral intake and any complications arising from these interventions. Rooming-in is more difficult, at least initially.
The baby has an increased risk of respiratory problems, and is subjected to suctioning of mouth and oropharynx. Some units purposely separate the post-cesarean delivered baby from its mother for "observation" for several hours and may perform routine heel prick blood tests. Due to separation and the desire of the staff to let the mother 'rest', the baby may be given formula supplements.
All of these factors have the potential to limit the frequency, effectiveness and, ultimately, duration of breastfeeding.

Interesting research
How it should be ...
Many hospitals support the newly delivered infant being dried and placed directly on the mother's chest for skin-to-skin contact while the obstetrician completes the surgery. The infant will remain here throughout the recovery and mother's transfer to the ward.
The ideal cesarean
The Natural Caesarean. A wonderful way to support the mother and respect the baby when birth is by caesarean. This 12 minute video is from Youtube. (Some hospitals block youtube - view from a home computer)

Pregnancy classes
What is included about birthing interventions in the curriculum of the pregnancy classes where you work? Do all pregnant women know the effects of interventions on themselves and their baby? Do they have to give consent prior to any of these procedures? How well informed is this consent?
Form a group to review the pregnancy class curriculum.
Assisting a mother following an assisted delivery
- Initiate skin-to-skin contact as soon as possible
- immediately following vaginal delivery if baby does not require advanced life support.
- as soon as possible if caesarean section under epidural or spinal analgesia. Many hospitals facilitate this while the surgeon closes the wound.
- as soon as the mother is responsive if caesarean section under general anaesthetic. Place baby in skin-to-skin contact with father or other close family until mother available.
- If contact must be delayed initiate skin-to-skin contact at the earliest opportunity.
- Facilitate breastfeeding as soon as possible.
- The mother does not need to be able to sit up, to hold her baby, or meet other mobility criteria in order to breastfeed.
- It is the baby that is finding the breast and suckling.
- As long as there is a support person with them, the baby can be in skin-to-skin contact in preparation for breastfeeding even if the mother is drowsy from anesthesia.
- Help the mother find a comfortable position.
- The 'biological nurturing' position (mother semi-reclined) is comfortable for mothers, best for skin-to-skin contact and facilitates infant self-attachment to the breast.
- Side-lying in bed. This position helps to avoid pain in the first hours and allows breastfeeding even if the mother must lie flat after spinal anesthesia.
- Sitting up with a pillow over the incision or with the baby held along the side of her body with the arm closest to the breast.
- Lying flat with the baby lying on top of the mother.
- The 'biological nurturing' position (mother semi-reclined) is comfortable for mothers, best for skin-to-skin contact and facilitates infant self-attachment to the breast.
- Facilitate rooming-in with assistance, until mother is able to care for baby.

Workbook Activity 4.3
Complete Activity 4.3 in your workbook.

What can you do?
- Prenatal parent preparation. Discuss ways to cope with pain and discomfort of labor, and the risks and benefits of interventions.
- Provide a supportive environment for birthing - lessens need for analgesia and assisted delivery.
- Be prepared to allow extra time and assistance to establish breastfeeding and bonding following intrapartum medications and assisted delivery.
What should I remember?

- all interventions in labor carry a risk for both mother and infant which must be weighed against the need for the intervention
- how intrapartum drugs affect the infant
- measures you can take to limit the deleterious effects of intrapartum interventions
Self-test quiz
Notes
- # Anim-Somuah M et al. (2005) Epidural versus non-epidural or no analgesia in labour.
- # Vincent RD et al. (1998) Epidural Analgesia During Labor
- # Jonas K et al. (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.
- # Rosenblatt DB et al. (1981) The influence of maternal analgesia on neonatal behaviour: II. Epidural bupivacaine
- # Sepkoski CM et al. (1992) The effects of maternal epidural anesthesia on neonatal behavior during the first month
- # Raisanen I et al. (1984) Pain and plasma beta-endorphin level during labor
- # Dabo F et al. (2010) Plasma levels of beta-endorphin during pregnancy and use of labor analgesia.
- # Buckley S (2002) Ecstatic Birth: The Hormonal Blueprint of Labor
- # Ombra MN et al. (2008) beta-Endorphin concentration in colostrums of Burkinabe and Sicilian women.
- # Zanardo V et al. (2001) Labor Pain Effects on Colostral Milk Beta-Endorphin Concentrations of Lactating Mothers
- # Zanardo V et al. (2001) Beta Endorphin Concentrations in Human Milk
- # Rowe-Murray HJ et al. (2002) Baby Friendly Hospital Practices: Cesarean Section is a Persistent Barrier to Early Initiation of Breastfeeding
- # Shawky S et al. (2003) Maternal factors associated with the duration of breast feeding in Jeddah, Saudi Arabia
- # Leung GM et al. (2002) Breast-feeding and its relation to smoking and mode of delivery
- # Nissen E et al. (1996) Different patterns of oxytocin, prolactin but not cortisol release during breastfeeding in women delivered by caesarean section or by the vaginal route
- # Smith J et al. (2008) The natural caesarean: a woman-centred technique.