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2.2 Birthing Factors that Affect Breastfeeding

Key Points - Case Study B

Joanne asks you what she can do before the baby is born to help her successfully breastfeed.

The Ten Steps to Successful Breastfeeding, designed by the ExternalWHO and ExternalUNICEF summarise the maternity practices needed to support and encourage breastfeeding.
Topic 2.1: Preparation Before Birth
Inform all pregnant women about the benefits and management of breastfeeding
Joanne's baby Rosie is born by spontaneous vaginal delivery at 37 weeks following a 15-hour labour. She had been given pethidine (meperidine) and an epidural for pain relief during labour. Are there any features of her birthing experience that may affect breastfeeding?
Topic 2.2: Birthing Factors that Affect Breastfeeding
Labour analgesia and near-term birth
Joanne's baby Rosie is born by spontaneous vaginal delivery at 37 weeks following a 15-hour labour. She had been given pethidine (meperidine) and an epidural for pain relief during labour. Are there any features of her birthing experience that may affect breastfeeding?

Labour Analgesia

Infants, whose mothers are given analgesia during labour, are at greater risk of a delay in appropriate breastfeeding behaviours and some studies suggest poorer long-term breastfeeding outcomes.1Early and prolonged skin-to-skin contact as well as consistent and skilled assistance throughout the postpartum period facilitates breastfeeding and negates some of these negative effects.

Pethidine (meperidine), the opiate most widely used for obstetric analgesia in Australia, and its metabolite norpethidine accumulate and are excreted slowly in the infant. Given during labour, especially 2-3 hours prior to delivery, pethidine is known to cause neonatal sedation and respiratory depression.2Additionally, its use has been associated with the infant being unable to effectively root, latch and feed soon after delivery3,4 and to have a lower sucking frequency for as long as three days after birth.5Other opiates, such as Morphine, do not have an active metabolite and their effect on breastfeeding behaviours, when used during labour, are not as well documented. However, their impact on maternal and neonatal sedation and respiratory depression remains a concern.2Short acting opiates such as Fentanyl may be an effective alternative.6

Studies investigating the effects of epidural analgesia on breastfeeding do not give a clear cut answer in part because there is a wide variation in the doses and drugs used. Additionally, the effects may be confounded by the addition of other analgesia during labour (such as pethidine), the length of the labour and the reason for the epidural.1Some studies indicate that adding opiates, such as high doses of epidural fentanyl, to local anaesthetic agents may affect breastfeeding in the short and long term,7,8although others found no effect of epidurals on breastfeeding success.9

Late Preterm Birth

A late preterm birth occurs between 34+0 and 36+6 weeks gestation. Many infants born at this gestational age do not act in the same way as term infants10and a proportion of infants born at 37 or 38 weeks also have problems. As well as having greater difficulty maintaining stable respiration, body temperature and blood glucose levels these infants also have higher metabolic needs and lower energy stores. Immature sucking and rooting reflexes as well as a lack of awake/alert periods may result in poor milk transfer, ineffective breast stimulation and incomplete breast emptying leading to poor weight gain and an insufficient milk supply. These factors may result in hypoglycemia, jaundice, failure to thrive and readmission to hospital11,10,12

Therefore Joanne and Rosie need careful monitoring during their hospital stay to ensure good breast drainage (15 minutes effective sucking either to 12 times in 24 hours) and adequate milk intake (monitor urine and stool output, weight and development of jaundice). Joanne may need to express after feeds, and the colostrum or milk fed to Rosie by syringe, dropper, cup or spoon. They also need early follow-up (48 hours) after hospital discharge to ensure problems have not developed.11,12

Factors affecting breastfeeding in the near-term infant

Factors affecting breastfeeding in the near-term infant

Case Study Activity

Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.

Notes

  1. # Montgomery A et al. (2006) ABM clinical protocol #15: analgesia and anesthesia for the breastfeeding mother.
  2. # Mattingly JE et al. (2003) Effects of obstetric analgesics and anesthetics on the neonate : a review
  3. # Righard L et al. (1990) Effect of delivery room routines on success of first breast-feed
  4. # Nissen E et al. (1995) Effects of maternal pethidine on infants' developing breast feeding behaviours
  5. # Hafstrom M et al. (2000) Non-nutritive sucking by infants exposed to pethidine in utero
  6. # Hale TW (2007) Anesthetic and analgesic medications: Implications for breastfeeding
  7. # Beilin Y et al. (2005) Effect of labor epidural analgesia with and without fentanyl on infant breast-feeding: a prospective, randomized, double-blind study
  8. # Jordan S et al. (2005) The Impact of Intrapartum Analgesia on Infant Feeding
  9. # Halpern SH et al. (1999) Effect of Labor Analgesia on Breastfeeding Success
  10. # Melamed N et al. (2009) Short-term neonatal outcome in low-risk, spontaneous, singleton, late preterm deliveries.
  11. # Academy of Breastfeeding Medicine (2011) Breastfeeding the late preterm infant.
  12. # Meier PP et al. (2007) Increased lactation risk for late preterm infants and mothers: evidence and management strategies to protect breastfeeding