Birth and Breastfeeding: Does it matter how baby is born?

If you’ve been pregnant for more than about five minutes, you’ve probably asked yourself (or been asked!) the following two questions:

1. What kind of birth will you have? And
2. Will you breastfeed your baby?

What many people fail to realize, however, is that these two things – birth and breastfeeding – are very closely linked. Everything that happens while you are in labour and giving birth affects how easy it will be to breastfeed. There’s a basic principle that’s always true:

The more you interfere with labour and birth, the more problems you are likely to have with breastfeeding. A natural, comfortable birth sets the stage for natural, comfortable breastfeeding.

Needless to say, I am an advocate of natural, unmedicated birth. Not because I want us to revert to a tree-hugging, cave dwelling existence, but because I’ve seen the profound effects that the type of birth can have on the mother, the baby and the breastfeeding relationship. I’ve also seen a lot of unnecessary interference with birth – interventions that are done with no good reason, usually for the convenience of the medical team – that can end the breastfeeding relationship before it has even started.

Important disclaimer: Sometimes interventions are really necessary for the sake your or your baby’s health. In those cases, don’t hesitate to do what’s necessary – we can always do damage control later. A necessary intervention may still make breastfeeding difficult, but we’ll deal with that – a healthy baby and healthy mom come first. What I have a problem with is all these unnecessary interventions that are performed without mom being informed of the risks or the alternatives.

Effect of various birth interventions on breastfeeding

Let’s look at a few of the more common routine interventions and why they may not be a good idea:

Induction of labour

An induction is when the doctor or nurse starts labour artificially. This is most often done by using certain medications that stimulate the uterus to contract. Some doctors also “break the waters” – they tear the membrane that surrounds the amniotic fluid so that the amniotic fluid drains out. There are many conditions where inductions are warranted, and if it is important to deliver the baby soon I would certainly go for an induction over a c-section if safely possible. But a lot of the times, the reasons are simply not valid:

• The baby is getting too big (using ultrasound or palpation to determine the weight of the baby is notoriously inaccurate – in the vast majority of babies I’ve seen , the actual birth weight was lower that the weight predicted by the sonar)
• I’m over 40 weeks (if the baby is still fine, there’s no rush – a normal pregnancy is 38-42 weeks!)
• The date will suit the parents or the doctor better (in my books, it’s not okay to place the baby at risk for the sake of someone else’s convenience)

An induction can cause breastfeeding complications for a number of reasons:

• If the induction was done early, there’s a good chance that baby is simply not ready to face the outside world yet. Babies born at 37-38 weeks often have poor suckling skills because they were not fully mature at the time of birth. Some babies simply need 40 (or 41, or 42!) weeks to be fully ready.
• The contractions caused by an induction are much more painful than those of a natural labour: during natural labour, the contraction always cuts out before it becomes unbearable. An artificially induced labour does not have such a fail-safe mechanism. This makes it difficult, if not impossible, to avoid using potent pain medications or an epidural (read on for why those are not a good idea)
• An induced birth is a medical birth from the outset. Because of all the interventions and monitoring, induced labour is much more likely to result in a c-section than natural, spontaneous labour. This has its own effects on breastfeeding (see below!)

If you need to or want to start labour, consider asking your care provider to do a “membrane sweep,” also known as a “stretch and sweep”. This simply involves disturbing (but not breaking) the membranes in the opening of the cervix. In most cases this will be enough to prompt labour to start naturally.

Cesarean Birth

In a high risk pregnancy or when complications arise, a cesarean birth, or c-section, is an important and often life-saving operation. But somewhere along the line we’ve made the mistake of thinking that it’s inherently a safer option that a normal birth. It’s not: in a healthy pregnancy, doing a c-section carries more risk for both mom and baby. And it can certainly create challenges for breastfeeding:

• Elective c-sections are routinely done at around 38 weeks – two weeks before baby was actually supposed to come! At 38 weeks the baby’s chance of survival is virtually 100%, but there is a significant risk that baby’s suckling and feeding skills are not fully mature. In practice, I’ve often noticed that there is a remarkable difference in the feeding skills of babies born via elective c-section and those born from a c-section that was performed after labour had already started. In the cases where labour started spontaneously, the babies are usually much more skilled at feeding from the outset – because their bodies and brains were ready to be born! If you do choose an elective c-section, do it as close to 40 weeks as possible – certainly not before 39 weeks.
• Unless you have a very supportive medical team, you will be separated from your baby for a period of time after the birth. The contact between mom and baby in the first hour or so after birth is one of the biggest keys to making breastfeeding easy. If you and your baby miss out on that special time, you will probably have to put in a lot more effort to figure out breastfeeding.
• C-section can lead to a delay in your milk increasing. This can cause doctors and nurses to panic and push you to start giving formula top-ups, which will further mess up your milk supply.
• Babies born via c-section are often very sleepy and don’t feed as actively as their vaginally-birthed counterparts. Less suckling in the first day or two leads to higher weight loss, and the decreased stimulation of the breast may be one of the reasons why the milk increases more slowly after a c-section. Again, you may be pushed to give unnecessary formula top-ups.
• A c-section is painful! Those who have experienced both tell me that the pain experienced during vaginal delivery is infinitely to be preferred over the pain after a c-section – because at least with a vaginal birth the pain is over by the time you need to pick up the baby. Recovering from major surgery makes it that much more difficult to pick up and handle your baby and position him for breastfeeding.

It’s not impossible to breastfeed after a c-section – not at all! – but you will be starting from a different place. The chances of having trouble is just so much greater. Avoid a c-section unless it is necessary for your or baby’s health.

IV fluids

It seems almost ridiculous to think that putting up a drip could affect breastfeeding. But apart from the pain and discomfort of trying to hold the baby with a needle in your arm, a drip has one significant problem: you can’t control how much fluid goes in. If the drip is running, it’s running – it doesn’t automatically shut off once you’ve had enough fluids. This creates two problems:

• You have an overload of fluid in your body. After birth, all that fluid tends to move to your breasts, causing swelling and engorgement, which in turn makes it much harder for baby to latch on to the breast.
• Your baby is also born with a lot of extra water, which he soon gets rid of once he starts urinating. However, as this water goes out, the baby’s weight drops – and pretty soon everyone is panicking that you don’t have milk, and pushing you to give unnecessary formula top-ups.

The bottom line is: if you can drink water, you don’t need a drip.

Staying in bed or birthing on your back

Being upright, as opposed to lying on your back, is a much more effective position for labour and birth: gravity helps to move baby down in the birth canal. When you’re lying on your back, your uterus is actually tilted in such a way that you’re pushing the baby uphill! Walking around while you’re in labour will guarantee a faster, less painful labour. This is important, because a long labour is very exhausting for both mom and baby. If the labour was long, and especially if the pushing stage was long, baby can be too tired to breastfeed effectively immediately after birth. So best to get out of bed and keep things moving!

Epidurals

An epidural has become so common in the labour ward that you are almost considered a bit strange if you don’t want to have one. After all, if you listen to most gynaecologists, an epidural gives you a pain-free labour with absolutely no side-effects. Well, not quite…

• A full (high dose) epidural will require you to stay in bed, as you won’t be able to move – we definitely don’t want this (see the previous point). And even if you have a walking (low dose) epidural, it requires you to be monitored a lot more. That means more time in bed, on your back – with all the effects that follow from that.
• Epidurals can slow down the progress of labour, which increases the risk of having additional interventions and even a c-section.
• The medications used in an epidural do cross over to the baby – if the dose is high, baby will often be noticeably “drugged” and sleepy at birth. This does not help breastfeeding get off to a good start!
• When you experience pain, your brain produces its own painkillers called endorphins. The endorphin rush you experience after an unmedicated birth is amazing – I’ve never experienced anything else like it. But with an epidural you do not experience the pain of labour, so you don’t get the endorphin rush. This can actually leave you feeling emotionally “flat” and as if you’re having trouble bonding with your baby. As my one friend put it: “After the birth, I remember thinking: I’m not as happy as I thought I’d be.”

All said, I would recommend avoiding an epidural if you can. However, if you cannot stand the pain of labour, a low-dose epidural is probably a better option than the other injectable pain medications that are usually used (see below), and a normal birth with an epidural is certainly better than an unnecessary c-section.

Pain medications

When you are using pain medication in labour, it is helpful to remember that your baby is getting the same dose of whatever you are getting – remember, you two are sharing a blood supply! It’s not such a big problem while you are still in labour, because your liver can process the medication so that baby doesn’t suffer any side effects. After the birth, though, it’s a different story: your baby will be born with a dose of the medicine still in his blood, and because he’s still a baby, his liver can’t get rid of it very quickly. This means that the effects of those medicines can last a long, long time – as long as two weeks in the case of pethidine (the medicine most commonly used for pain relief)

And what, you may ask, are these effects? In the worst case scenario, pethidine can cause your baby to be floppy at birth, or even not to breathe at all. This will result in baby being taken away from you to the high care unit, you will miss out on early skin-to-skin contact and your first breastfeed will be delayed. However, even if baby breathes just fine at birth, pethidine will almost certainly impair baby’s ability to breastfeed. A baby who was exposed to pethidine during labour is usually very sleepy, and the breastfeeding reflexes are very weak or completely absent. This makes it very difficult for baby to start breastfeeding, and baby may be reluctant to breastfeed for quite some time. The effects of pethidine are the worst when it is given in the last few hours of labour – and ironically, that’s exactly when the pain is at its worst!

There are a number of options that can help with labour pain without having an effect on baby: massage, hot water, air-and-gas (Entonox) and TENS are just a few examples. Do yourself and your baby a favour and research your options before you go in to the hospital, and stay away from the strong stuff. Most importantly: let your medical team know that you don’t want any pain meds unless you ask for it; pethidine is often prescribed routinely without even asking you if you want or need it.

Suctioning the baby

Suctioning the baby involves using a pipe attached to a vacuum pump to remove saliva and mucous from the baby’s mouth (very similar to the gadget that a dental assistant uses to suck up your saliva while the dentist is working). Some hospitals still routinely suction all babies, even though it is completely unnecessary in most cases. If there was meconium (i.e. poop) in the amniotic fluid or the baby doesn’t breathe at birth, suctioning is definitely necessary, but otherwise it does more harm than good.

The problem is that suctioning is an extremely unpleasant experience for the baby, especially if that’s the first thing that ever goes into his mouth. The suctioning can damage baby’s throat and tongue, making it very painful for baby to suckle for the first few days. It can also cause baby to be scared of anything going into his mouth – including the breast. If your baby is suctioned, you may need some help getting baby onto the breast.

The light at the end of the tunnel

I wrote this post to inform you of some of the ways that seemingly harmless birth practices can interfere with breastfeeding. The intention was certainly not to scare you, or to make you feel terrible about your birth choices. It was rather to help you know what you’re getting yourself in to. Remember, knowledge is power – the more you know, the better you can plan.

I intend to, in time, write separate about all the different interventions and what you can do to address their side-effects (watch this space!). In the meanwhile, make sure you have skilled, reliable breastfeeding help on standby in case things don’t go according to plan. Good luck, and remember: do the best you can, and always make sure you give the next step in the direction of your goal. And whatever happens at the birth, if you want to breastfeed, and you get the right help, you will do it!