Category: Birth

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From Labor to Latch: How Interventions Affect Early Breastfeeding

A guest post by Donna Walls, RN, BSN, CLC,ANLC

I have heard this more times than I can count- “So, what’s labor got to do with breastfeeding?”. We tend to think of pregnancy, birthing and breastfeeding as all very separate parts of bringing a baby into the world. But, in reality it is just one connected, seamless, flowing process. Breastfeeding begins about halfway through the pregnancy as colostrum, or newborn milk, starts production. Our bodies know that growing a baby means eventually feeding that baby. So, we know that pregnancy affects breastfeeding but does what happens during the labor process affect breastfeeding? The answer is YES!

Intrapartum interventions are relatively new in the history of birthing and sadly, many of the early interventions began long before we studied the effects of these interventions on lactation, rather, focusing on the effects on the fetus and the labor progress. But the good news is that we now have great research on the concerns regarding many birth interventions on the initiation and continuation of milk production.

Specific interventions like epidurals, forceps, vacuum extraction, and pain medicines have been associated with negative effects on breastfeeding and here are some of these concerns.

The use of  Oxytocin

Cadwell and Brimdyr presented the disadvantages of using synthetic oxytocin for breastfeeding and these include:

-reduced maternal endogenous oxytocin with increased risk of breast edema and engorgement

-reduced neonatal rest in the first hour

-suckling reflexes may also be reduced resulting in newborns being less likely to initiate suckling in the first hour of life and delayed lactogenesis 2.

-“High doses of oxytocin can potentially weaken the milk-ejection reflex and may reduce the expression of primitive breastfeeding reflexes in the newborn.”

Research (Seyedi, R, et al.) also demonstrates a dose related association of Pitocin with increased risk of neonatal jaundice on day 2.

 Pain medications in labor

A Cochrane review confirms increased neonatal sleepiness, reduced early suckling reflexes, and fewer early effective breastfeeding attempts with the use of maternal pain medications. Opioids have been shown to suppress newborn breastfeeding behaviors and may lead to more irritability in newborns babies who then have difficulty breastfeeding effectively. These concerns are more profound with larger doses and longer exposures to the drugs.

Research by Lind also shows a relationship between the use of pain medications and a delayed onset of lactogenesis 2.

Higher doses are also associated with lower neurobehavioral scores in babies, less breast-seeking behaviors and less successful breastfeeding sessions and less stimulation for optimal breastfeeding production.

Newborns of mothers who received obstetric analgesia had a higher rate of complementary formula feeding while newborns born unmedicated had a higher rate of breastfeeding in the delivery room and less formula feeding in the hospital.

Use of epidural anesthesia

It is generally recognized that negative effects are more highly associated with receiving antenatal pain medications than the use of epidural anesthesia. That being said, medications used in the epidural can pass into the placenta resulting in newborn’s lowered ability to initiate the breast crawl and complete the 9 Stages. Other studies have noted increased newborn sleepiness in the first hours after birth which delays initiation of breastfeeding.  These factors too often result in early formula supplementation impacting the establishment of a healthy newborn microbiome.

On postpartum day 1, the women who were randomly assigned to receive high-dose fentanyl reported difficulties (ineffective, uncoordinated suckling) with breastfeeding and at 6 weeks postpartum, more women who were randomly assigned to high-dose fentanyl epidural were not breastfeeding. Effects can vary with the type of medication used in the epidural and the length of exposure to the fetus.

A few studies have linked epidural use to lower breastfeeding rates at six weeks postpartum and some studies have concluded that breastfeeding success was much lower in women who underwent epidurals during labor.

Use of intravenous (IV) fluids

IV fluids, especially in larger amounts (large amounts are considered a total of >2 litres) can cause breast edema in the mother, potentially leading to breast pain, congestion and engorgement. This early breast edema interferes with correct latching and optimal breast stimulation and emptying as well as a delayed onset of lactogenesis 2.

Maternal  IV fluids intake are shown to increase the newborn’s  urine output in the first days and this output is mistaken for weight loss, sometimes  leading to early formula supplementation. Although the AAP recommends assessment when weigh loss exceeds 7%, too often this step is skipped and formula supplementation is ordered. Waiting to perform the initial weight can help reduce this unnecessary supplementation.

Use of Forceps/Vacuum Extraction

These methods have been implicated in possible trauma to the infant’s head and mouth and can lead to difficulty with suck-swallow-breathe coordination, compromising efficient suckling and milk transfer. The use of these instruments can also lead to longer vaginal repairs and delayed initiation skin to skin care.

Separation of mother and baby

One of the first and greatest concerns post birth is the delay or denial of immediate, uninterrupted and continuous skin to skin care. No other mammals separate themselves from their newborns- think about that!!!

Separation of the mother and newborn results in increased cortisol levels in both while immediate skin-to-skin contact stabilizes the newborn’s respiration, heartbeat and temperature while stimulating maternal oxytocin necessary for bonding and flow of colostrum.

“Separating mothers and newborns at birth, or delaying or disrupting skin to skin care, has adverse consequences on newborns’ transition to life outside the uterus; their innate protective behaviors; and, breastfeeding initiation, duration, and exclusivity and a mother’s sensitivity and attachment to her newborn”. (WHO & UNICEF, 2018).

Also, post partum rooming-in reduces newborn stress. Morgan  et al compared sleep cycles of 2-day-old newborns while having skin to skin care for 1 hour to sleeping alone (separated) for 1 hour. Separated infants had an 86% reduction in quiet sleep, a 176% increase in autonomic nervous system activity, and higher levels of cortisol. They concluded that maternal separation stresses newborns and that this stress may not be benign.

“Withholding skin-to-skin contact would now be considered unethical, as there is enough evidence to show that the practice improves newborn health and survival,” says Karin Cadwell, senior author and Executive Director and Lead Faculty of Healthy Children Project’s Center for Breastfeeding.

Cascading events can lead to early cessation of breastfeeding

In most “modern” western hospitals we see interventions as normal and routine. In fact it is not unusual to see more than 1 intervention used. Usually, one intervention requires another eg; epidurals require IV fluids to prevent hypotension in the mother which in turn leads to breast edema and engorgement.

These cascading interventions often interfere with the infant’s ability to initiate suckling, which in turn delays stimulation of milk production, which in turn can lead to  jaundice, which in turn often requires introduction of artificial formula supplementation, which in turn increases the infant’s risk of dysbiosis in the gut and diminishes breast stimulation, which in turn may, far too often, lead to abandonment of breastfeeding. There does appear to be a dose-response effect between number of interventions received and odds of each unfavourable breastfeeding outcome.

What we can do to optimize breastfeeding success in the hospital setting?

-Encourage prenatal education which emphasizes a risk-benefit-alternative focus for all interventions in labor.

-Offer evidence-based resources for education for both families and hospital and office staff.

-Encourage families to work with their caregiver to make a plan which minimizes labor interventions whenever possible or opt for birth centers that offer labor support with minimal interventions.

-Work with local and national maternal-child health focused groups and organizations to assure that non-separation and skin to skin care is the standard of care for all mothers and newborns.

-Work with local hospitals and birth centers to offer classes that include alternative pain reduction techniques including simple breathing techniques, mindfulness, water therapies, positional comforting, massage and companions and doula care.

-If analgesia is used- opt for the smallest dose whenever possible.

-Encourage parents and hospital staff to wait 24 hours for the initial newborn weight.

-Educate and encourage families to room in with the newborn.

As breastfeeding advocates we sometimes are called to expand our own “lactation world” and take a look at all the factors that might help or hinder families in the early hours, days and weeks of breastfeeding. Developing a program of education and care that encompasses then pre-breastfeeding influences might be a good place to start that journey.

References

 Hulman, A., et al. Impact of different obstetric interventions and types of delivery on breastfeeding: a nationwide cross-sectional survey of Hungarian women. BMC. 2024 Jul 11;24:473. doi: 10.1186/s12884-024-06666-x

CDC, Strategies for Continuity of Care in Breastfeeding, https://www.cdc.gov/breastfeeding/php/strategies/public-health-strategies-for-continuity-of-care-in-breastfeeding.html

 Takahata, K. et al. November 2023. A longitudinal study of the association of epidural anesthesia and low-dose synthetic oxytocin regimens with breast milk supply and breastfeeding rates. Scientific Reports volume 13, Article number: 21146 (2023)

 Andrew, M. et al. The association between intrapartum interventions and immediate and ongoing breastfeeding outcomes: an Australian retrospective population-based cohort study. International Breastfeeding Journal volume 17, Article number: 48 (July, 2022)

Crenshaw, J. Healthy Birth Practice #6: Keep Mother and Newborn Together—It’s Best for Mother, Newborn, and Breastfeeding. J Perinat Educ. 2019 Apr 1;28(2):108–115. doi: 10.1891/1058-1243.28.2.108

Kajsa Brimdyr PhD, CLC. 2015. Birth Issues in perinatal care. The Association Between Common Labor Drugs and Suckling When Skin-to-Skin During the First Hour After Birth. https://doi.org/10.1111/birt.12186

WHO.  Compendium on respectful maternal and newborn care. August, 2025.  https://www.who.int/publications/i/item/9789240110939

Seyedi, R. et al. 2017. The Effect of the Use of Oxytocin in Labor on Neonatal Jaundice: A Systematic Review and Meta-Analysis.  Department of Midwifery, Students Research Committee, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran.

Lind, J. et al. 2014 May. Relationship between Use of Labor Pain Medications and Delayed Onset of Lactation. Journal of Human Lactation. 167–173. doi:10.1177/0890334413520189

Dekker, R. Evidence on: IV Fluids During Labor. August, 2022. https://evidencebasedbirth.com/iv-fluids-during-labor/

Mahmoodi, F. et al. 2019. Breastfeeding and its outcome in Women Receiving Epidural Analgesia for Childbirth. https://pmc.ncbi.nlm.nih.gov/articles/PMC6714128

 

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Modifiable behaviors to improve breastfeeding

We all know breastfeeding is critical for both mothers and babies. Most of us are supporters, advocates, counselors, mothers, grandmothers and just generally breastfeeding cheerleaders! We want to help and sometimes it can be hard to know how to help. In a groundbreaking new article, nine unique elements have been identified as modifiable behaviors that can increase breastfeeding success. We always knew there were things we could do! Now we have clear definitions of what those things are. Truly incredible!

The article was recently published in Acta Paediatrica and you can find it here.  The research was an observational study conducted in Masaka, Uganda. It looks at 300 newborns in the postpartum unit as well as 166 infants attending the 6-week postpartum clinic. The research team utilized the Lactation Assessment & Comprehensive Intervention Tool (LAT). A tool chosen because it did not aggregate assessment items and has been validated.

What the research found was that there are nine elements that were significantly related to effective breastfeeding: the infant state and feeding cues pre-feeding, four postitioning elements including tummy-to-mummy, infants arms around the mothers breast, the breast not being held or shaped, and the baby’s head being free of restriction, and three latching elements which include the gape, the baby’s head tilt, and the baby’s lower lip reaching the breast first.

I was delighted to speak briefly with Dr. Anna Blair, the lead author on this remarkable paper to ask her few questions on the research and the findings.

Q: What would you say are the key takeaways from the research?

Dr. Blair: There are certain predicable, easily explained things that parents can do to help their baby breastfeeding effectively, before the baby even touches the breast. We found that having the baby tummy to mummy, for example, really matters. It’s best not to hold the breast. Watch that the head is free of restrictions. There’s been a lot of focus on assessing infants already at the breast, but the pre-feeding behaviors and attaching matter.

Q: Was there anything in the results that surprised you?

Dr Blair:  Many of these elements we’ve believed for years – written about in numerous texts by experts – but now we have clear findings from research.

I think it was interesting that the baby’s head being free of restrictions mattered more with the infants in post partum than at the 6 week checkup.

Breasts being held have become such a common practice and this research shows it is negatively associated with effective breastfeeding. I was not surprised by that because there has been some previous research on breast shaping having a negative impact on breastfeeding. But look at the images of people breastfeeding and the instructions from hospitals – they largely include breast holding and shaping , which is so unfortunate.

Q: What has you excited about this research?

Dr. Blair: What we found in this study has easy to follow, straightforward ways to improve breastfeeding effectiveness and feeding and I think that is very exciting.

I hope the article sparks as much excitement for you as it did for me and for the research team.  I also hope it sparks lots of conversations in your communities and workplaces around these specific, modifiable behaviors and how it might change our practice and the way we help moms and babies.

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Just the Beginning: An Early Stage Career Interview

I thought it might be interesting to speak with folks working in the field of lactation who are all at different points in their careers; someone in the beginning, middle and end of their careers. I was curious to hear their thoughts on the work and if there were any similarities at different stages of the path.

 

The first person I spoke with is Calliope. They are in the very beginning of their career. Calliope became a doula and a CLC in 2022. They have attended four births.  They are primarily a birth doula but have had a few post-partum clients. However, since they are a CLC they say they stay on longer than maybe some other doulas might. They consider themselves a full spectrum doula. While they do not do doula work full time, they try to do it as much as their schedule allows.

What is the process like for you as you are helping these birthing people?

I love taking a doula client any time I can. This most recent one was extra special because she was a friend so we had a jump start on all of the “getting to know you” stuff. But also, it was a totally different challenge to get to know someone in this other way from what our relationship had been up to this point. But the thing I am struck by every time I do it is how do people do this without support? And like beyond that, how am I supposed to ask someone to pay me for this? If you want it, it should just be free flowing from the tap.

And then I am also really amazed and I learn a lot every time. I learn about how different people want to be interacted with both in a doula client relationship and just in life. I get a lot of good practice listening to people. I think it is also really important to be living in a community of support so that if I need a net, hopefully someone will be there to catch me. I think that is quite beautiful.

 

If you could change something in the healthcare system around birth and caring for mothers, what would you like to see?

I think more midwives would be really helpful. No shade to OB’s but I have noticed that sometimes doctors don’t really have the time to sit with a mother and help through what can be a stressful time. It feels a little like we are doing emotional clean-up from that lack of care. Especially first-time parents in a high-risk pregnancy which has been the clients I have had so far. Also, lower cost of care across the board.

Tell me about your work in Texas

I worked through an organization called GALS in Austin, which stands for Giving Austin Labor Support. They are an amazing organization! They pair every birthing person who walks into the hospital with a free doula. The client never pays anything, its state funded so I was paid through the state not from the parents. And I think more programs like that, all over would be amazing.

How do you think that could happen?

I don’t know. But my friend Juju, who is also a doula, and I are making grand plans for someday in the future to start one of here in New York. The success rates at GALS were amazing and they also provided lots of outside support with prisons which I thought was very cool.

When you say success rates, what does that mean to you?

When I think of success rates as a doula I’m talking ideally of a healthy everyone at the end. And luckily for everyone so far that has been my experience. And for the client, I think success is a sense of satisfaction on their part and a job well done. For the birthing person, that this event that is so personal and can really feel isolating is actually a massive empowering success. Empowering is a weird word but the idea that they feel really proud of themselves and they see themselves as incredibly capable.

And tell me about breastfeeding. How has it been helping these folks with breastfeeding?

That has also been great! All four of my clients have been able to exclusively breastfeed. For some of them, I didn’t keep up with after six months but they were all planning on nursing until either they or the baby were done. One of the families I worked with had three kids under five and then the father broke both his wrists so I stayed on a long time with them. I think I stayed for three months. That mother had breastfed all of her kids and had only just recently weaned the eldest. She found breastfeeding to be a huge way to bond with her kids. All of my clients so far have all really wanted to breastfeed and didn’t need much education on the benefits. So, they were all eager to troubleshoot if something wasn’t right. Like the latch or oversupply. Oversupply is the thing that I’ve come across most, which is interesting.

Why do you think breastfeeding was so successful for the folks you’ve helped?

I think for all four of them it was something that they were excited to do and I think that helps tremendously. For two of my clients it was the first baby. And for two it was the second or third and they had varying rates of success the first times around. I think for them it was about getting some external validation that they were doing a good job. Just someone telling them that is really important.

Validation is so important.

Yes. And skin to skin! They were all skin to skin for I think the entire first week! As much time spent skin to skin is key! My third client had a really rough road starting breastfeeding with her previous birth and we talked a lot about spending as much time as possible skin to skin and how helpful it is.

I also make it my practice to make sure we get a good latch before I leave on that first day. I also like to point out feeding cues and particularly rooting. I like to include the partner in this too. It gives them a little game to play, to look for the cues!

What are your goals for the future with regards to birth and breastfeeding work?

I am actually thinking about midwifery school. But I’m on the fence because it seems like you don’t really get as much time with a client and I think that’s the part that I love the most. But I definitely want to keep this work as part of my life. Especially as my friends have kids, I want to be able to support them.

Any other thoughts on the work in the birthing and breastfeeding space?

Yes, I feel very lucky that I know that if I had a scenario with a client as a CLC and I needed more support, like I needed help troubleshooting, I would have you all to call. I think in general, the birth work world could use a bit more community support. I know a lot of doulas and we all think that more community support for the practitioner would be awesome.

Next week, I’ll speak with someone in the middle stages of their career. Let’s see if there are similarities! Have a great week, and may all your ways be milky ways!

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Newest Research on Skin-to-Skin contact in the first hour

As you may know, here at The Healthy Children Project, Center for Breastfeeding, our focus has 4 main points;

  • Education: Offering lactation training programs for novices and professionals
  • Collaboration: Working together to create meaningful change in the field of maternal and child health care delivery
  • Research: Designing and implementing collaborative inquiry to solve practical dilemmas incorporating evidence-based protocols and solutions
  • Consulting: Developing and implementing community-specific strategies to promote, protect and support breastfeeding

Last year, several of our faculty and staff traveled to Uganda for a project that embodied all four of these focus points. Research based on the work they did was recently published in Scientific Reports. The impact of implementing and sustaining the international guidelines for skin-to-skin contact in the first hour after birth in Uganda.

I was able to sit down with one of the authors of the paper, Dr. Kajsa Brimdyr, to talk about the work and the experiences of the team while in Uganda.

Dr Brimdyr, can you tell us a little about the project?

While the project began in January 2023, planning began a year earlier. We’ve known Scovia Nalugo Mbalinda for many years. She and I worked together in Gulu, Uganda on a skin-to-skin project that resulted in several papers (you can find one here) and the beautiful video Kristin Svensson and I created to educate about skin-to-skin in Gulu. (You can watch it here). Mike was a member of the International Guideline Project workshop that we conducted in Iceland in 2023 (read the guideline here) and it was thrilling to work together again. Our team was interdisciplinary, from the US, Sweden and Uganda, consisting of PhD researchers, an MD, midwives, and breastfeeding specialists along with two Ugandan research assistants. We worked collaboratively with the leadership team at the hospital, including midwives, nursing students and physicians.

When we arrived at the hospital, our team started out by observing births and the newborn behavior. We video recorded newborn behavior starting from birth and continuing for the first hour. This was to get a baseline of what was happening at the facility.

Then, we began to implement the research methodology, PRECESS, which we have used and published about in the past in Egypt (read about it here) and Texas (and here). We began with a training program for staff based on the supplementary material in the International Guideline for Skin to Skin (you can find a copy of the supplementary material here).

True skin-to-skin contact begins immediately after birth and is uninterrupted and continuous, for at least an hour after birth. We also offered guidance for potential challenges. Then, the staff began implementing the guideline: immediate, continuous, uninterrupted skin-to-skin contact for at least an hour after birth for all of the deliveries – every staff member, every shift. It was a change in practice, not just a change for those who were part of the study. The hospital made the decision to change care for all. Then, our research team came back 6 weeks later. Not only were the staff continuing to implement the guideline, but they had also improved their skill with skin to skin.

When staff first see how capable newborns are, as they see the 9 stages for the first time, it’s just so special to me. They can see how much these new babies can do.

There are still challenges ahead. For example, the beds in the labor and delivery are narrow and don’t have side rails, and mothers are worried that the baby might fall off…. and it would be helpful if the unit had beds that are more conducive to skin to skin in the first hour.

 What do you think the key take-aways are from the project?

I love that this intervention is quick and easy to implement, and that it is sustainable. It’s possible to make significant change in a short period of time.

Was there anything that surprised you while you were there?

We were not surprised by this, but we were impressed by the collaborative spirit of the team at the hospital. Our research team was at the hospital 24 hours a day and we worked long shifts to cover the time. It was important for us not to just be there for births of only one shift of staff or another, but covering nights, days and weekends. The staff were so warm and welcoming, teaching us their process, and embracing the changes.

Do you have any favorite stories about your time there?

We loved so many parts of our experience doing this research. One thing that was extra fun was the storks. They have these enormous, 5-foot-tall storks, with a wing span of 12 feet! the storks live in that part of Uganda. The maternity hospital had a tree just outside of it filled with these storks. In many parts of the world, storks are a symbol for babies being born. Our team thought it was so special that the storks like to hang out at the maternity unit!

Is there anything else you’d like us to know about your work in Uganda?

There’s more to come! We’ll let you know when the other articles are published!

Let us know what you think or if you have any questions about the newest research paper. And as always, may all your ways be Milky Ways.

 

 

 

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Allow me to introduce myself

Have you ever noticed that parents always have stories about breastfeeding? When you introduce yourself and they learn that you work in the field of lactation, it seems to me that there is always a story. And parents really want to tell you theirs. Upon reflection, this makes sense to me. Giving birth and the subsequent feeding of an infant is a life changing event. It’s right up there with…well, I think if I’m being honest, it stands alone as a monumental moment in a person’s life.

I love to hear the stories. I love to hear about a parent’s journey through breastfeeding; the struggles, the triumphs, the frustration, the elation. All of it! Bring on the stories!

And that is part of what I hope to do here, at Our Milky Way. My name is Kristin and I am honored to be taking over the blog from Jess. Jess has shepherded this blog from infancy to this point. Her work is incredible, the stories she has shared are inspiring. I hope to do her work justice and continue writing interesting, inspiring, thought provoking work.

The first story I would like to share with you is my own. For those of you that have been around awhile, you have probably heard us say “all roads lead to breastfeeding”. And around here, that is certainly true, though some of our roads were a little windier than others. As with a lot of lactation care providers, my story starts with my own breastfeeding journey.

Imagine, if you will, a bright eyed young 29 year old woman; well educated, strong willed, and dare I say it, over confident. I took the birthing class because…birth seemed well outside my scope of experience. But a breastfeeding class? Nope. Didn’t take that because…breastfeeding, how hard could it be? You put the baby’s mouth on your nipple and they feed, right? Well, the big day arrives and we go through labor, lots of labor, we end up with an emergency C-section and my daughter is whisked away to the NICU for observation. After 4 agonizing hours, they bring her to me, checked, poked, prodded and cleared for action. And she is very, very hungry. And quite frankly, more than a little pissed-off. So I put her mouth next to my nipple and….she’ll have none of it. She is so mad, so frustrated that she will not stop crying. So of course, I start crying, which in turn leads my husband to start crying. I think the only one not crying at this point is the nurse. So, she makes a helpful suggestion that we give the baby “just one bottle” of formula to calm her down and then we can try again.

I know, I know…hindsight is 20-20.

Now, I need to clarify that I do think the nurse was trying to be helpful, but as you can probably guess, after that “one bottle” there was no going back for my stubborn, strong willed (like her mamma) little girl. To make this long story a bit shorter, we wound up pumping for 5 weeks to give her breastmilk from a bottle and then finally threw in the cloth diaper and switched to formula.

Fast forward 2 years and I am pregnant again and this time I am bound and determined to breastfeed. We end up with another C-section after trying for a VBAC and this time they bring my son to me in the recovery room! At which point, my husband turns to the nurse, who happens to be a lactation care provider, and says:

“If we don’t get this baby to breastfeed my life will never be the same!”

While a little self-serving, it worked. The nurse helped me to breastfeed in the recovery room. And we went on to successfully breastfeed for a year. There is more in that story, and I will share more as we get to know each other here. A little peek into the deeper story; cracked nipples, phone help with a CLC, circus (yes, you read that right), community support and a lot of learning.

Fast forward again about 5 years and I am back here on Cape Cod, where I grew up. I meet an old friend who tells me she works for the Healthy Children Project, Center for Breastfeeding. And of course, I tell her my story (see first paragraph above). About a year later I am working for Healthy Children, I’ve taken the Lactation Counselor Training Course, I know everything that went wrong with my own stories and I realize that this! This is what I want to do! I want to help other parents avoid the pitfalls, the mistakes, the misinformation. And well, the rest is history. I am proud to say I have been working with Healthy Children for over 15 years now. I learn constantly. I am inspired often. I am lucky lucky lucky to work with this amazing group of women.

But enough about me! I want to hear about you. For real! I find blogs so much more interesting if folks comment and participate in conversation. Maybe you have or know a good story? Reach out, I’d love to hear it and maybe share it. In the meantime, may all your ways be milky ways!

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