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    <meta name="author" content="Denise Fisher" />
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    <title>Birthing Factors that Affect Breastfeeding</title>
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      <h1 id="top">2.2 Birthing Factors that Affect Breastfeeding</h1>
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            <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study B</h3>
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			Joanne asks you what she can do before the baby is born to help her successfully breastfeed.
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			The <cite>Ten Steps to Successful Breastfeeding</cite>, designed by the <img alt="External" src="design/external.gif" /><a href="http://www.who.int/en/" title="External link" target="_blank">WHO</a> and <img alt="External" src="design/external.gif" /><a href="http://www.unicef.org/" title="External link" target="_blank">UNICEF</a> summarise the maternity practices needed to support and encourage breastfeeding.
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		<dl><dt><a href="topic_2-1.html"><cite>Topic 2.1: Preparation Before Birth</cite></a></dt><dd class="topic-paragraph">Inform all pregnant women about the benefits and management of breastfeeding</dd></dl>
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			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?
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		<dl><dt><a href="topic_2-2.html"><cite>Topic 2.2: Birthing Factors that Affect Breastfeeding</cite></a></dt><dd class="topic-paragraph">Labour analgesia and near-term birth</dd></dl>
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			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?
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      <div class="section" id="Labour_Analgesia"><h2>Labour Analgesia</h2>
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			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<sup><a href="#note1">1</a></sup>. Early 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.
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			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<sup><a href="#note2">2</a></sup>. Additionally, its use has been associated with the infant being unable to effectively root, latch and feed soon after delivery<sup><a href="#note3">3</a>,</sup><sup><a href="#note4">4</a></sup> and to have a lower sucking frequency for as long as three days after birth<sup><a href="#note5">5</a></sup>. Other 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<sup><a href="#note2">2</a></sup>. Short acting opiates such as Fentanyl may be an effective alternative<sup><a href="#note6">6</a></sup>.
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			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<sup><a href="#note1">1</a></sup>. Some 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<sup><a href="#note7">7</a>,</sup><sup><a href="#note8">8</a></sup>, although others found no effect of epidurals on breastfeeding success<sup><a href="#note9">9</a></sup>.
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      <div class="section" id="Near-term_Birth"><h2>Near-term Birth</h2>
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			Although 37 weeks gestation is classified as term many infants born at this gestational age do not act in the same way as term infants. As well as having greater difficulty maintaining stable respirations, body temperature and blood glucose levels they 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 hypoglycaemia, jaundice, failure to thrive and readmission to hospital<sup><a href="#note10">10</a>,</sup><sup><a href="#note11">11</a></sup>.
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			Therefore Joanne and Rosie need careful monitoring during their hospital stay to ensure good breast drainage and adequate milk intake (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<sup><a href="#note10">10</a>,</sup><sup><a href="#note11">11</a></sup>.
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        <p>Factors affecting breastfeeding in the near-term infant</p>
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	{ c : '\n			<p>\n				<strong>James is delivered at term by emergency caesarean section following a long and difficult labour. His mother, Mary, had been given pethidine early in the labour and then an epidural. What factors may affect their early breastfeeding relationship and what steps could be taken to minimise these?</strong>\n			</p>\n		', r : '\n			<p>\n				James may be affected by the analgesia used during his mother\'s labour. He may be less able to effectively root, latch and feed after delivery and may be sleepy during the first postpartum days. Long and difficult labours and emergency caesarean sections have been associated with a delay in the onset of copious milk production. Early and frequent skin-to-skin contact and skilled assistance with breastfeeding in the postpartum period will help minimize these factors.\n			</p>\n		' }
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<p class="blurb">Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.</p></div><script type="text/javascript">renderActivity('t');</script>
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            <td class="body"><a href="http://www.bfmed.org/Resources/Download.aspx?filename=Protocol_10.pdf" target="_blank"><img src="design/article.png" class="icon" alt="" /></a><h3><a href="http://www.bfmed.org/Resources/Download.aspx?filename=Protocol_10.pdf" target="_blank">Academy of Breastfeeding Medicine Protocol</a></h3>
		<p>Click on the icon and read the Academy of Breastfeeding Medicine Protocol: Breastfeeding the Near-term Infant.</p>
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      <div id="footnotes">
        <h3>Notes</h3>
        <ol>
          <li id="note1"><a href="references.html#mont06" title="See full details">#</a> Montgomery A et al. (2006) ABM clinical protocol #15: analgesia and anesthesia for the breastfeeding mother.</li>
          <li id="note2"><a href="references.html#matt03" title="See full details">#</a> Mattingly JE et al. (2003) Effects of obstetric analgesics and anesthetics on the neonate : a review</li>
          <li id="note3"><a href="references.html#righ90" title="See full details">#</a> Righard L et al. (1990) Effect of delivery room routines on success of first breast-feed</li>
          <li id="note4"><a href="references.html#niss95" title="See full details">#</a> Nissen E et al. (1995) Effects of maternal pethidine on infants' developing breast feeding behaviours</li>
          <li id="note5"><a href="references.html#hafs00" title="See full details">#</a> Hafstrom M et al. (2000) Non-nutritive sucking by infants exposed to pethidine in utero</li>
          <li id="note6"><a href="references.html#hale07b" title="See full details">#</a> Hale TW (2007) Anesthetic and analgesic medications: Implications for breastfeeding</li>
          <li id="note7"><a href="references.html#beil05" title="See full details">#</a> Beilin Y et al. (2005) Effect of labor epidural analgesia with and without fentanyl on infant breast-feeding: a prospective, randomized, double-blind study</li>
          <li id="note8"><a href="references.html#jord05" title="See full details">#</a> Jordan S et al. (2005) The Impact of Intrapartum Analgesia on Infant Feeding</li>
          <li id="note9"><a href="references.html#halp99" title="See full details">#</a> Halpern SH et al. (1999) Effect of Labor Analgesia on Breastfeeding Success</li>
          <li id="note10"><a href="references.html#meie07" title="See full details">#</a> Meier PP et al. (2007) Increased lactation risk for late preterm infants and mothers: evidence and management strategies to protect breastfeeding</li>
          <li id="note11"><a href="references.html#wigh03" title="See full details">#</a> Wight NE (2003) Breastfeeding the borderline (near-term) preterm infant</li>
        </ol>
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      <h1>Breastfeeding Essentials</h1>
      <ol>
        <li>0.1 <a href="topic_0-1.html">Introduction</a></li>
        <li>1.0 <a href="topic_1-0.html">Case Study A (Joanne)</a><ol><li>1.1 <a href="topic_1-1.html">Discussing breastfeeding</a></li><li>1.2 <a href="topic_1-2.html">What information to give</a></li><li>1.3 <a href="topic_1-3.html">Effects of Breastfeeding alternatives</a></li><li>1.4 <a href="topic_1-4.html">Common breastfeeding concerns</a></li><li>1.5 <a href="topic_1-5.html">Breast examination</a></li><li>1.6 <a href="topic_1-6.html">Contraindications to breastfeeding</a></li><li>1.7 <a href="topic_1-7.html">Conditions related to lactation outcomes</a></li><li>1.8 <a href="topic_1-8.html">Medications</a></li></ol></li>
        <li>2.0 <a href="topic_2-0.html">Case Study B (Joanne)</a><ol><li>2.1 <a href="topic_2-1.html">Preparation Before Birth</a></li><li class="current">2.2 <img src="design/bullet_arrow_right.png" alt="*" title="You are here" /><a href="topic_2-2.html">Birthing Factors that Affect Breastfeeding</a></li><li>2.3 <a href="topic_2-3.html">Management After Birth</a></li><li>2.4 <a href="topic_2-4.html">Poor Attachment</a></li><li>2.5 <a href="topic_2-5.html">Hypoglycaemia</a></li><li>2.6 <a href="topic_2-6.html">Relationship between Jaundice and Breastfeeding</a></li></ol></li>
        <li>3.0 <a href="topic_3-0.html">Case Study C (Joanne)</a><ol><li>3.1 <a href="topic_3-1.html">Early problems</a></li><li>3.2 <a href="topic_3-2.html">Risk of SIDS</a></li><li>3.3 <a href="topic_3-3.html">Contraception</a></li><li>3.4 <a href="topic_3-4.html">Milk composition</a></li><li>3.5 <a href="topic_3-5.html">Slowing of growth</a></li><li>3.6 <a href="topic_3-6.html">Introducing solids</a></li><li>3.7 <a href="topic_3-7.html">Weaning</a></li></ol></li>
        <li>4.0 <a href="topic_4-0.html">Case Study D (Sally)</a><ol><li>4.1 <a href="topic_4-1.html">Initial assessment</a></li><li>4.2 <a href="topic_4-2.html">Milk production</a></li><li>4.3 <a href="topic_4-3.html">Causes of inadequate infant growth</a></li><li>4.4 <a href="topic_4-4.html">Increasing milk supply</a></li></ol></li>
        <li>5.0 <a href="topic_5-0.html">Case Study E (Anna)</a><ol><li>5.1 <a href="topic_5-1.html">Sore nipples</a></li><li>5.2 <a href="topic_5-2.html">Factors causing nipple damage</a></li><li>5.3 <a href="topic_5-3.html">General treatment for sore nipples</a></li><li>5.4 <a href="topic_5-4.html">Further causes of nipple pain</a></li><li>5.5 <a href="topic_5-5.html">Mastitis – diagnosis</a></li><li>5.6 <a href="topic_5-6.html">Mastitis – treatment and complications</a></li></ol></li>
        <li>6.0 <a href="topic_6-0.html">In conclusion</a><hr /></li>
        <li class="appendix"> <a href="references.html">List of references</a></li>
        <li class="appendix"> <a href="contents.html">Course contents</a></li>
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