Connecting the Dots
From New Beginnings, Vol. 28 No. 3, 2009, pp. 42-43
"Giving Birth" features stories about how birth affects breastfeeding. Please send in your birth stories reflecting upon the impact on your breastfeeding experience. Articles focused on specific issues relating to birth and lactation are also welcome. Here is an overview of some of the issues we would like to develop in the future with an account of my first child's birth.
After my first baby was born, we struggled to breastfeed. Each time I put her to my breast, she would latch on for a few seconds and then pull off, uncertain what to do. Sometimes it would take up to an hour to get her comfortable and actually nursing at the breast. She lost weight and we were both a mess. She would cry and I would get more and more stressed, wondering why this wasn't working out for us.
At the time it didn't occur to me that it might have been our birth experience that was the root cause of our nursing problems. After all, I'd had a natural, unassisted, vaginal birth with no pain medication. But as breastfeeding gradually improved, and I became inspired to find out more about it, I realized that it wasn't the case that mom gives birth, period. Then she feeds the baby. I discovered instead that birth and breastfeeding are intricately linked, and how we give birth can have an impact on our breastfeeding experience. Pregnancy, labor, birth, and lactation are all part of the same continuum.
ne of the first changes mothers may notice in pregnancy is that their breasts enlarge and may feel tender and tingly -- they are already preparing for breastfeeding. Some of the weight gained during pregnancy is fat that is used for energy to make milk after the baby is born. Mothers' bodies expect to be nurturing and nourishing the baby at the breast after birth.
The human female body is amazing. It produces a hormone called relaxin during pregnancy, which softens tissues and joints, making them more flexible in preparation for birth. When the woman who is giving birth is in an upright position the space in her pelvis can then expand by up to 28 percent to allow the baby to move through it. During birth, other hormones are released that affect breastfeeding as well as labor. For example, oxytocin causes contractions and plays a big part in breastfeeding; beta-endorphins act as a natural painkiller and help the mother cope with stress (Buckley).
However, many medical interventions can inhibit the release of these hormones and interfere with the birth process. The "fight-or-flight'" hormones, adrenaline and noradrenaline, are naturally released during labor, but when a mother is afraid, high levels of these hormones can inhibit oxytocin release, stopping contractions -- or interfering with their effectiveness. When a woman's body senses danger, it won't let the baby be born in what it perceives to be an unsafe environment. Some uterine muscles stop contracting, others continue, creating a painful "tug-of-war" situation (Robertson) that may keep the cervix from opening up. When the mother's labor is not "progressing" because her cervix is not dilating, she becomes vulnerable to medical intervention. Odds are high that, at this stage, if she hasn't already done so, she will ask for pain relief medication. This, in turn, will inhibit the release of beta-endorphins. Both mother and baby will miss out on the feelings of well-being produced by these natural stress-relievers. Unmedicated births result in less drowsy babies and happier, even euphoric mothers. Fewer stress hormones are released in both mother and baby. Oxytocin flowing freely in a mother's system during and after labor will help her to breastfeed and respond to her new baby. Mary Kroeger writes in Impact of Birthing Practices on Breastfeeding "that the initiation of lactation will be most successful if the entire reproductive process is preserved in a setting of emotional and social support, free from anxiety, fear and danger" (Kroeger 2004).
In retrospect, my "natural" birth was, in fact, a highly managed one in a medical setting. Giving birth in an American hospital with an obstetrician in attendance, I was subject to constant fetal monitoring. Most mothers giving birth in this setting received epidural anesthesia and were confined to bed. I was given vaginal exams by at least four different people. My progress was monitored against a labor curve that stipulated dilation be at a rate of 1 cm an hour. When my labor fell short, I was given an amniotomy -- the amniotic membrances (the "bag" of waters) was broken to speed things along. I would have been given Pitocin (a synthetic form of oxytocin) if had continued to "fail to progress." I pushed my daughter out while lying flat on my back, attached to an IV that was giving me fluids. My pushing was directed by the medical team. When my baby emerged after 45 minutes of pushing, and a "necessary" episiotomy, she was put on my chest only momentarily before being taken away for cleaning and weighing.
There were no feelings of euphoria. Although my body had managed to give birth, my overriding thought was "I can never go through that again." Although I had my husband to support me, I had had my privacy disturbed by various nursing personnel coming in and out of my room throughout my labor, including someone who wanted to draw blood while I was having a contraction! There was nothing empowering about pushing a baby out in the restrictive position of lying on my back while being shouted at to push. And afterwards the pain of the episiotomy was considerable. Although the members of staff congratulated me on managing to give birth without an epidural, my obstetrician's final comment was that she would recommend a cesarean section next time!
Our first attempt at breastfeeding was hurried along by hovering nurses who wanted to take my baby away to the nursery and a health care assistant who was waiting to clean me up before I could be wheeled away to my room. I was exhausted, a little traumatized, and happy to have a break, but I lost a golden opportunity to nourish and get to know my baby at my breast.
The next day, when my daughter was examined, the pediatrician discovered she had a broken collarbone. A common birth injury, we were told. My husband wasn't surprised, having seen the way our obstetrician pulled Rebecca out by the neck. As the bones in a newborn are very soft, it doesn't take too long for them to heal but she must have been in some discomfort, especially when lying on her right side to nurse.
Mary Kroeger has carried out research on how maternal position in labor, fear and stress in childbirth, and episiotomies can affect breastfeeding, as well as the importance of not separating mother and baby after birth. She quotes lactation specialist Linda Smith who says we must begin to "connect the dots" between labor, birth, and breastfeeding experiences. The problems I experienced with breastfeeding after my "natural" unmedicated birth give credence to the viewpoint that even minor interventions -- let alone surgical delivery and epidural anesthesia -- can affect breastfeeding. This is not to say that breastfeeding can only take place after a natural birth, or that breastfeeding is guaranteed to go smoothly after a natural birth. But an undisturbed birth keeps mothers on the natural continuum so that lactation is more likely to follow smoothly. Interference with the birth process may lead to an uphill struggle to breastfeed, as it did for me. How many breastfeeding relationships are lost because of this?
Through growing awareness of how our birth choices may impact our desire to breastfeed our babies, I hope that mothers will be empowered to seek out care that respects their wishes. When necessary interventions take place during birth, understanding how they may affect breastfeeding efforts will make any problems easier to deal with.
My reluctant first nursling, whom I felt would never breastfeed, went on to nurse for several years. When planning the births of my following babies, there was no full stop between birth and breastfeeding. I was able to make choices that improved my birthing experiences of birthing. I had begun to connect the dots.
Further Reading and References
Buckley, S. J. Gentle Birth, Gentle Mothering. One Moon Press, 2005.
Enkin, M., et al. A Guide to Effective Care in Pregnancy and Childbirth. 3rd edition. Oxford University Press, 2000.
Gaskin, I. M. Ina May's Guide to Childbirth. Bantam Dell, 2003.
Kroeger, M. Impact of Birthing Practices on Breastfeeding. Jones and Bartlett, 2004.
Smith, L. J. Impact of Birthing Practices on Breastfeeding. 2nd edition. Jones and Bartlett, 2009 October.
Robertson, A. Empowering Women. Birth International,1994.