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    <meta name="author" content="Denise Fisher" />
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    <title>The Birth Experience</title>
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      <h1 id="top">4.0 The Birth Experience</h1>
      <div>
    <p> The benchmark outcome of pregnancy is the normal vaginal birth of the baby, without any medical or pharmacological intervention and without complication for either mother or baby, followed by the baby being able to latch and breastfeed well. This may not be achievable for some women for whom the availability of skilled medical, nursing and pharmacological assistance is essential, but it is possible for the majority of women in the World.</p>
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      <blockquote>
    <div>Normal labor is a fragile entity. Once intervention occurs then a cascade of interventions inevitably follow.<sup><a href="#note1">1</a></sup></div>
  <p class="cite">Kroeger, 2004</p></blockquote>
      <div>
    <p>Health care professionals have a responsibility to support and facilitate normal birthing. What happens to the mother during birthing has far-reaching effects on her relationship with her baby, her ability to breastfeed and the health of the mother and her child. </p>
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        <img width="500" height="345" src="images/NHS_poster.jpg" alt="Poster available for purchase from NHS, UK" />
        <p>Poster available for purchase from NHS, UK</p>
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      <div class="section" id="Lactation_physiology"><h2>Lactation physiology</h2>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><h3></h3>
      <div>
        <p class="listTitle">Lactogenesis is the making of breastmilk. There are three distinct phases.</p>
        <ol>
          <li><strong style="font-weight: normal;">Lactogenesis I</strong> (LI) commences during pregnancy. Most women will see some evidence of a milky secretion (colostrum) from their breasts during their pregnancy.<br /><br /></li>
          <li><strong style="font-weight: normal;">Lactogenesis II</strong> (LII) begins biochemically around 30 - 40 hours after birth, and is felt as the milk 'coming in' around 70 hours after birthing. This is an <span style="font-weight: bold;">endocrine function</span>, entirely dependent on the right mix of hormones.<br /><br /></li>
          <li><strong style="font-weight: normal;">Lactogenesis III</strong> (LIII) is the maintenance of ongoing lactation. This is an <span style="font-weight: bold;">autocrine function</span>, dependent on frequent, effective removal of milk from the breasts.</li>
        </ol>
        <span class="aside">Lactogenesis I is scientifically referred to as Secretory Differentiation and Lactogenesis II is scientifically referred to as Secretory Activation.</span>
        <br />
      </div>
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    <div class="section" id="Lactogenesis_II"><h3>Lactogenesis II</h3>
      <div>
        <p class="listTitle">Lactogenesis II will occur when:</p>
        <ul foot="You will be aware that lactogenesis II occurs even in women who never put the baby to the breast or remove milk by other means.">
          <li><span style="font-style: italic;">progesterone levels drop</span> as a result of the removal of the placenta, AND</li>
          <li><span style="font-style: italic;">prolactin levels are high</span> as they are at the time of birthing, in the presence of</li>
          <li>normal insulin, thyroid hormones and glucocorticoids.</li>
          <li>Also, following birth, lactose secretion into colostrum increases, osmotically drawing water with it and increasing the volume of milk.</li>
        </ul>
      </div>
    </div>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/books.png" class="icon" alt="" /><h3>Workbook Activity 4.1</h3><p>Complete Activity 4.1 in your workbook.</p></td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
    <div class="section" id="What_could_delay_or_inhibit_lactogenesis_II_"><h3>What could delay or inhibit lactogenesis II?</h3>
      <div>
        <p> Hint: <span class="aside">Remember it's an endocrine function, therefore consider hormonal causes.</span> </p>
        <p> Accidents at birthing may cause endocrine disruption. For example, retention of a functional portion of the placenta that continues to secrete progesterone, or a haemorrhage severe enough to cause Sheehan's syndrome (pituitary gland necrosis). </p>
        <p> A delay in lactogenesis II occurs after assisted deliveries.<sup><a href="#note2">2</a></sup> Finding the cause of this delay and relating it to the physiology of lactogenesis has led researchers to look at the effect of stress. </p>
      </div>
      <div class="section" id="Stress_and_breastfeeding"><h4>Stress and breastfeeding</h4>
        <div>
          <p> High stress levels are correlated with high cortisol levels. Cortisol, in normal concentrations, is also necessary to initiate lactogenesis II successfully, though what its role is isn't fully understood yet. </p>
          <ul>
            <li>Markers of both fetal and maternal stress during labor and delivery are associated with delayed breast fullness.<sup><a href="#note3">3</a></sup></li>
            <li>Maternal stress seems to interfere with the release of oxytocin causing poor milk removal, and a newborn who experienced stress during labor and delivery may be too weak or too sleepy to latch on and suckle effectively.<sup><a href="#note4">4</a></sup></li>
            <li>Onset of lactation occurred later in women who had higher cortisol levels. Primiparous women had higher levels than multiparous women. Stress during labor and/or delivery is likely to be a significant risk factor for delayed onset of lactation.<sup><a href="#note5">5</a></sup></li>
          </ul>
        </div>
      </div>
    </div>
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      <div class="section" id="What_should_I_remember_"><h2>What should I remember?</h2>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/remember.png" class="icon" alt="" /><h3></h3>
      <div>
        <ul>
          <li>that interventions in labor have far-reaching effects on mother and infant</li>
          <li>the 3 stages of lactation<ul><li>when each commences</li><li>what controls their initiation or, in the case of LIII, what maintains it</li><li>the timing of their occurrence</li></ul></li>
          <li>the factors during or as a result of labor and birthing that can interfere with LII<br /></li>
        </ul>
      </div>
    </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
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      <div class="section" id="Self-test_quiz"><h2>Self-test quiz</h2>
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      <div></div><div class="activity" id="activity_f">
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	new Matching('Lactogenesis II', 'is felt by mothers at around 70 hours postpartum.'),
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      <div id="footnotes">
        <h3>Notes</h3>
        <ol>
          <li id="note1"><a href="references.html#kroe04" title="See full details">#</a> Kroeger M et al. (2004) Impact of Birthing Practices on Breastfeeding: Protecting the Mother and Baby Continuum</li>
          <li id="note2"><a href="references.html#dewe03b" title="See full details">#</a> Dewey KG et al. (2003) Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss</li>
          <li id="note3"><a href="references.html#chen98" title="See full details">#</a> Chen DC et al. (1998) Stress during labor and delivery and early lactation performance</li>
          <li id="note4"><a href="references.html#dewe01a" title="See full details">#</a> Dewey KG (2001) Maternal and fetal stress are associated with impaired lactogenesis in humans</li>
          <li id="note5"><a href="references.html#graj02" title="See full details">#</a> Grajeda R et al. (2002) Stress during labor and delivery is associated with delayed onset of lactation among urban Guatemalan women</li>
        </ol>
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      <h1>Breastfeeding Essentials</h1>
      <ol>
        <li>1.0 <a href="topic_1-0.html">Why Breastfeeding is Important</a><ol><li>1.1 <a href="topic_1-1.html">Biochemistry</a></li><li>1.2 <a href="topic_1-2.html">Immunology</a></li><li>1.3 <a href="topic_1-3.html">Relative risks</a></li></ol></li>
        <li>2.0 <a href="topic_2-0.html">Communication Skills</a><ol><li>2.1 <a href="topic_2-1.html">Non-verbal</a></li><li>2.2 <a href="topic_2-2.html">Listening skills</a></li><li>2.3 <a href="topic_2-3.html">Building confidence</a></li><li>2.4 <a href="topic_2-4.html">An example</a></li></ol></li>
        <li>3.0 <a href="topic_3-0.html">Pregnancy Care</a><ol><li>3.1 <a href="topic_3-1.html">The feeding decision</a></li><li>3.2 <a href="topic_3-2.html">The barriers</a></li><li>3.3 <a href="topic_3-3.html">Physical preparation</a></li></ol></li>
        <li class="current">4.0 <img src="design/bullet_arrow_right.png" alt="*" title="You are here" /><a href="topic_4-0.html">The Birth Experience</a><ol><li>4.1 <a href="topic_4-1.html">The first hours</a></li><li>4.2 <a href="topic_4-2.html">Labor interventions</a></li><li>4.3 <a href="topic_4-3.html">Postnatal interventions</a></li></ol></li>
        <li>5.0 <a href="topic_5-0.html">Breastfeeding the Baby</a><ol><li>5.1 <a href="topic_5-1.html">Positioning Principles</a></li><li>5.2 <a href="topic_5-2.html">Breastmilk transfer</a></li><li>5.3 <a href="topic_5-3.html">Assessing breastfeeding</a></li></ol></li>
        <li>6.0 <a href="topic_6-0.html">A time to learn</a><ol><li>6.1 <a href="topic_6-1.html">Practical skills</a></li><li>6.2 <a href="topic_6-2.html">Breastfeeding messages</a></li><li>6.3 <a href="topic_6-3.html">Normal growth</a></li><li>6.4 <a href="topic_6-4.html">Sleep</a></li><li>6.5 <a href="topic_6-5.html">Psychological support</a></li><li>6.6 <a href="topic_6-6.html">Discharge planning</a></li></ol></li>
        <li>7.0 <a href="topic_7-0.html">Infant Challenges</a><ol><li>7.1 <a href="topic_7-1.html">Late preterm infant; Non-latching</a></li><li>7.2 <a href="topic_7-2.html">Hypoglycemia; Jaundice</a></li><li>7.3 <a href="topic_7-3.html">Supplementation</a></li><li>7.4 <a href="topic_7-4.html">Crying baby</a></li><li>7.5 <a href="topic_7-5.html">Inadequate weight gain</a><ol><li>7.5.1 <a href="topic_7-5-1.html">Feeding-line device at the breast</a></li><li>7.5.2 <a href="topic_7-5-2.html">Cup feeding</a></li><li>7.5.3 <a href="topic_7-5-3.html">Finger Feeding</a></li><li>7.5.4 <a href="topic_7-5-4.html">Bottle feeding</a></li></ol></li></ol></li>
        <li>8.0 <a href="topic_8-0.html">Maternal Challenges</a><ol><li>8.1 <a href="topic_8-1.html">Engorgement</a></li><li>8.2 <a href="topic_8-2.html">Nipple Pain</a></li><li>8.3 <a href="topic_8-3.html">Breast Problems</a></li><li>8.4 <a href="topic_8-4.html">Insufficient breastmilk</a></li><li>8.5 <a href="topic_8-5.html">Medical, Surgical Issues</a></li></ol></li>
        <li>9.0 <a href="topic_9-0.html">Promotion, Protection and Support</a><ol><li>9.1 <a href="topic_9-1.html">The International Code of Marketing of Breastmilk Substitutes</a></li><li>9.2 <a href="topic_9-2.html">The Baby Friendly Initiative</a></li><li>9.3 <a href="topic_9-3.html">Young Child Feeding</a></li><li>9.4 <a href="topic_9-4.html">Local initiatives</a></li><li>9.5 <a href="topic_9-5.html">Infant feeding in emergencies</a></li></ol></li>
        <li>10.0 <a href="topic_10-0.html">Closing session</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>
        <li class="appendix"> <a href="full.html">Print version</a></li>
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