Nursing Through Pregnancy
By Sora Feldman
Victoria BC Canada
From NEW BEGINNINGS, Vol. 17 No. 4, July-August 2000, pp. 116-118, 145
We provide articles from our publications from previous years for reference for our Leaders and members. Readers are cautioned to remember that research and medical information change over time
Genevieve's first pregnancy was complicated with a medical condition that is likely to recur. She and her husband are eager to have a second child, but she is not ready to wean her toddler. Can she continue to nurse during a pregnancy that will require medication and possibly a hospital stay?
Lucy has just miscarried a much-wanted baby. She was nursing her 10-month-old daughter and wonders if her breastfeeding caused the miscarriage.
Fran's son is only five months old and she has just discovered she is pregnant again. Will she be able to continue to meet his nutritional needs through breastfeeding?
Women who come to LLL meetings tend to breastfeed for a longer time than average, so they may be more likely to become pregnant (or consider a subsequent pregnancy) while still breastfeeding. As an LLL Leader who has both nursed through a pregnancy and tandem nursed, I have fielded many questions from women like Genevieve, Lucy, and Fran. Because of my special interest, I have also corresponded with women who have nursed during pregnancy in a wide variety of situations. I know of mothers who have breastfed three consecutive siblings together, as well as several who have nursed through a twin pregnancy and then tandem nursed the twins with the older sibling. I have heard from mothers who nursed during pregnancies complicated by placenta previa, thyroid disease, threatened preterm labor, and severe nausea and vomiting. Their experiences (and the available research) suggest that weaning for the health of the pregnancy may be advisable for some women's individual situations. However, during most pregnancies, continuing to nurse or deciding how long to nurse is a parenting decision, not a medical question.
Health care providers may advise mothers to wean a baby or toddler immediately when a subsequent pregnancy is confirmed. They may fear that continuing to breastfeed during a pregnancy will slow the growth of the developing fetus or will contribute to a miscarriage or preterm labor. Cultural beliefs may also encourage weaning. Ruth Lawrence writes, "In some societies it is believed that a suckling infant will 'take the spirit' from the newly conceived fetus; thus weaning is mandated once the pregnancy is confirmed." However, much of the written information available falls under the category of educated guess or outright conjecture rather than scientific research.
One reason doctors may advise weaning is because of the effects of oxytocin on the uterus. Research shows that repeated, ongoing nipple stimulation through the use of a breast pump can bring on labor in a woman who is at term. Breastfeeding immediately after birth helps the uterus to contract and return to its pre-pregnancy state. Both of these effects occur because nipple stimulation triggers release of the hormone oxytocin, which causes milk "let-down" and also contractions of the uterus. However, there are several reasons why continued breastfeeding should not pose a problem for women with normal pregnancies.
The uterus is different during early pregnancy than it is at term or immediately postpartum. It contains far fewer oxytocin receptor sites - places where oxytocin can be absorbed. Between the first trimester and the third trimester of pregnancy, the number of sites in the uterus becomes 12 times greater (then doubles or triples before labor begins). The lower ability of the uterus to absorb oxytocin during early pregnancy suggests that oxytocin will not cause effective contractions during that time. This may be why inducing labor using intravenous oxytocin sometimes fails: the uterus is not ready.
For most of pregnancy, progesterone is the dominant hormone. Toward the end of pregnancy estrogen blood levels become higher than progesterone levels in preparation for labor. Progesterone relaxes smooth muscle cells. Since the walls of the gastrointestinal tract and veins have a smooth muscle layer, this effect of progesterone can contribute to pregnancy discomforts such as heartburn, varicose veins, and susceptibility to urinary tract infections. At the same time, the high progesterone levels of pregnancy are highly effective at keeping the smooth muscles of the uterus quiet until it is time for labor to begin.
In the first few days postpartum, when milk production is just beginning, women have very high levels of hormones related to milk production, which in turn have a strong effect on the uterus. When the baby suckles, those hormones affect the uterus. Over time, as the mother's body becomes accustomed to the stimulation of the suckling infant, much lower hormone levels are needed to maintain lactation. Once lactation is established, hormone blood levels are actually not very high. So, oxytocin levels are lower at a time when the uterus is less receptive to oxytocin. The kind of nipple stimulation that has been shown to induce labor at term involves using a hospital-grade breast pump for long periods of time. Even the most enthusiastic nursing toddler is unlikely to breastfeed that long.
What about preterm labor? This situation is less clear-cut than threatened first-trimester miscarriage, and it seems much more likely that a mother who is experiencing symptoms of preterm labor might potentially benefit from at least a temporary weaning. Prolonging pregnancy by a few days or even hours can make a great difference to the health and viability of a premature baby. Weaning may be advisable in a few cases when a woman is experiencing preterm labor. MOTHERING MULTIPLES discourages nursing through pregnancy if a twin pregnancy or higher order pregnancy is confirmed. But weaning is unnecessary for the vast majority of women who are not at risk of delivering a premature infant. Braxton-Hicks contractions, or "toning" contractions, are present from six weeks of pregnancy on. Particularly in second or subsequent pregnancies, it can be difficult to distinguish Braxton-Hicks contractions from those of labor. Breastfeeding can stimulate Braxton-Hicks contractions. If the contractions go away when you stop nursing, put your feet up, and drink a few glasses of water (dehydration can contribute to preterm labor), then it isn't labor. Braxton-Hicks contractions can be surprisingly strong and regular, which is why it can be hard to tell when "real" labor starts.
Overlap of breastfeeding and pregnancy may have been a fairly common occurrence until recent generations, and is still common in some cultures where extended breastfeeding is the norm. The few anthropological studies which address the subject have cited "overlap" of breastfeeding and pregnancy in 12 to 50 percent of pregnancies in countries such as Bangladesh (12%), Senegal (30%), Java (40%) and Guatemala (50%) (Lawrence 1994). Many of these mothers continue to breastfeed well into the second trimester of pregnancy or beyond. In an article on the subject, Ruth Lufkin pointed out, "the vast number of women in contact with LLL over many years constitute a large, informal study population. If the practice of continuing to nurse through pregnancy were responsible for significantly increased pregnancy problems, it would surely have become apparent in our LLL population" (Lufkin 1995).
Miscarriage occurs in an estimated 16 to 30 percent of all pregnancies, so it will sometimes happen coincidentally when a mother is nursing. If family members or medical professionals suggest that breastfeeding caused the miscarriage, it may reinforce any guilt that the mother already feels. One mother whose doctor advised her to wean at the first sign of threatened miscarriage felt that she was placed in a position of having to choose between two babies. Losing a baby is always painful, but having a doctor tell you that you are responsible for a miscarriage can be devastating.
How will a subsequent pregnancy affect your breastfeeding relationship? No two women experience it in exactly the same way. Your child's age, personality, and current nursing patterns will be factors, as will your physical and psychological reaction to the pregnancy and your feelings about continued breastfeeding (which often cannot be predicted before the event). Think about whether your child is breastfeeding primarily for nutrition or comfort and how he will respond to substitutions for nursing for some or all of these needs. Only you can find a balance that will work for you. Breastfeeding through a pregnancy can bring on very intense feelings for both you and your child. "My daughter would have kept nursing even if it had been motor oil coming out of my breast," one mother told me.
Most, but by no means all women, experience pain or discomfort in the breast or nipples or emotional discomfort related to being both pregnant and still nursing. One study listed pain as the most common reason for weaning during pregnancy followed by fatigue and irritability (Bumgarner 2000).
One mother said, "I had to wean him at night. I just couldn't stand it any more. It got to the point where I would rather walk the halls with him for two hours than let him touch my breasts again."
Hormonal levels are as unique as fingerprints, as can be seen in the wide variety of "normal" menstrual cycles. The extent to which you have tender breasts and nipples and discomfort nursing just before your menstrual period may predict the severity of these symptoms during pregnancy, since estrogen and progesterone may cause these symptoms. However, even women who do not find breastfeeding bothersome premenstrually may not be comfortable nursing while pregnant.
The nipple soreness of pregnancy is caused by the mother's hormone levels, so treatment may not help. It is also different from woman to woman. An LLL Leader can offer ideas about managing the pain.
Decreased milk supply
Most women also experience decreased milk supply when pregnant. Because many of the scientific studies of nursing during pregnancy have been done after the experience had ended, reports of decreased milk supply may not offer us an accurate picture of when and to what extent pregnancy changes breast milk. In MOTHERING YOUR NURSING TODDLER, Norma Jane Bumgarner writes about a study that tested the milk of three pregnant mothers over several months. "About the second month of pregnancy, the milk began to undergo changes similar to those observed during the course of weaning. Concentrations of sodium and protein gradually increased while milk volume, along with concentrations of glucose, lactose, and potassium, gradually fell. In weaning, these changes are brought on by decreased suckling, but they occurred in the pregnant women even when they continued nursing as much or even more than before the pregnancy." In Breastfeeding: A Guide for the Medical Profession author Ruth Lawrence suggests that it is usually not possible to increase the milk supply during pregnancy, "but milk usually returns toward the end of the pregnancy and is completely regenerated at delivery." However, some mothers have found that careful attention to nutrition, or using vitamin or herbal supplements, helped them maintain an adequate milk supply during pregnancy.
High levels of estrogens and progesterone are known to suppress milk production. At some point during pregnancy, probably during the second trimester, your milk will change to colostrum. (Some cultures believe that colostrum is unclean, which may contribute to taboos against breastfeeding during pregnancy.) Although some women produce colostrum in copious amounts, the quantity of milk will be much lower once the change occurs. In addition, the taste and composition change dramatically. Some babies and toddlers will wean themselves when the milk changes. Others are not bothered. One two-year-old nursling told her mother at the beginning of the mother's second trimester, "The milk tastes like cream and strawberries!" The change to colostrum is hormonally caused and cannot be delayed or affected by what or how much you eat or drink.
If your baby is less than six months of age and completely dependent on breast milk for sustenance when you conceive, your ability to nourish him during the next pregnancy may be of primary concern. Careful observation of his health and continued growth and weight gain is in order. Supplemental feedings of some sort may be needed. Older babies and toddlers who already eat a variety of other foods will demonstrate an increased appetite for these foods as your milk supply decreases.
Eating well and wisely helps assure that your own nutritional reserves are not exhausted. However, continuing to breastfeed will not deprive your unborn baby of needed nutrients. You may feel ravenously hungry while pregnant and nursing. It is important to eat healthful, wholesome foods whenever you are hungry and drink to thirst. Some sources advise that a pregnant women who is breastfeeding should eat "as if for a twin pregnancy."
Why is it that some little ones lose interest in the breast and wean themselves as the milk changes and is less abundant, while other children seem to show an increased attachment to breastfeeding when their mothers become pregnant? One mother said, "To nurse through a pregnancy requires a child who needs a great deal more than milk. My three-year-old daughter Elizabeth demonstrated a great need for oral satisfaction, physical contact, continuous mother-type affection, and constant reassurance that we would not desert her." Babies vary widely in the extent to which they are willing and able to have their needs met in ways other than nursing: The real and present need of the child in their arms motivates some mothers to persevere with nursing despite the doubts and discomforts brought on by a subsequent pregnancy.
Norma Jane Bumgarner writes: "We have been schooled to think of nursing as a bad habit that will go on forever if we do not somehow eliminate the opportunities for nursing and get the child to forget about it. But nursing is not a sneaky way little people have of dominating adults. Rather it is the manifestation of infantile needs in the growing child. When children wean spontaneously it is not because they forget about it, but because they outgrow the need."
At the same time, mothers should not discount their own feelings. Negative feelings are quite common while breastfeeding through a pregnancy and the physical discomfort can be considerable. It's possible that those negative feelings are a natural way of encouraging mothers to focus on the coming baby who is more vulnerable than the older child.
When breastfeeding and pregnancy overlap, the critical factors to consider in decision-making are feelings and relationships. Only the mother can decide how to proceed based on her own needs and feelings and those of her little ones. Mothers who become pregnant while breastfeeding need to know that most of the common objections to nursing during pregnancy are unfounded. In a culture where extended nursing is unusual, choosing to nurse during pregnancy will inevitably be questioned and challenged. It is important to lay to rest the myths and fears that undermine a mother's responsibility to determine the course of action that is right for her and her child.
Sora Feldman is an LLL Leader who has corresponded extensively with mothers who are breastfeeding though pregnancies. She is a full-time wife and mother, and part-time student midwife. She will soon be moving from Victoria, British Columbia, to Ithaca, New York, with her husband Matt and children Talia, 5, and Aedan, 3.
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