Breastfeeding Initiation and Birth Setting Practices: A Review of the Literature

Della A. Forster, RN, RM, PhD; Helen L. McLachlan, RN, RM, PhD


J Midwifery Womens Health. 2007;52(3):273-280. 

In This Article

The First Stage of Labour

Although many of the practices that occur during labour and birth care may affect breastfeeding initiation, some may not be amenable to alteration; for example, procedures that are required to optimise the health of the mother or baby, such as a clinically indicated caesarean section. It is important to be aware of the evidence in these instances, to ensure that women who have increased risk factors for not initiating breastfeeding receive appropriate support. Additionally, a stressful birth experience has been associated with poorer breastfeeding outcomes[25] and delayed onset of lactation,[26,27,28] so it is important that providers ensure that as far as possible, intrapartum care is provided in a manner that minimises stress for the woman. Satisfaction with the care provided by midwives during labour and birth may also contribute to breastfeeding success.[29]

There have been few adequately-powered prospective studies exploring the effect of intrapartum analgesia on breastfeeding.[30] Although inhalational analgesics are eliminated rapidly from mother and infant and appear not to affect infant feeding behaviour,[31] other analgesics (e.g., opiates) cross the placenta and are also found in colostrum, and so may potentially affect breastfeeding initiation.[30] In an in-depth video study, epidural and opiate analgesia were both shown to interfere with newborns' spontaneous breast-seeking and breastfeeding behaviours in the first few hours after birth.[32] The use of intramuscular opiate analgesia during labour is relatively common in many countries, with meperidine or pethidine (Demerol; Sanofi-Aventis, Bridgewater, NJ) being the most commonly used. Several small studies have demonstrated the effects of maternal intramuscular opiate analgesia during labour on the newborn, with newborns less likely to be alert and attach to the breast and suck effectively[33,34] or to establish effective feeding later.[35,36] This effect may be more marked if the opiate is administered one[35,36] or two[33] hours before birth, although a larger study found the opposite: that an opiate administered within the hour before birth had the greatest negative effect on breastfeeding.[31] Clinicians could consider avoiding the use of intramuscular opiate analgesia if they believe that the end of first-stage labour is approaching,[31] and women should be informed of the possible effects of an intramuscular opiate on their infants' breastfeeding responses, a view that women themselves have reported.[29] Those who do have this type of analgesia may benefit from extra breastfeeding support.

Some studies have shown no difference in breastfeeding initiation for infants of mothers who received epidural analgesia in labour[31,37,38]; however, a retrospective case note review found a dose-response relationship between epidural opiate analgesia and infant feeding, concluding that the use of fentanyl intrapartum may impede breastfeeding at the time of hospital discharge following birth.[30] Another prospective study found that regional anesthesia was associated with suboptimal breastfeeding behaviour on the day of birth.[25] A recent randomized trial compared breastfeeding success in women who had breastfed previously and who received epidurals with either: no fentanyl, an intermediate dose of fentanyl, or a high dose of fentanyl. They found that women who received the high dose of epidural fentanyl were more likely to have stopped breastfeeding at 6 weeks (12%) when compared to the women who had an intermediate dose (5%) or no fentanyl (2%; P = .005).[39] A 2002 systematic review of the unintended effects of epidural analgesia in labour concluded there was insufficient good quality data to make any sound conclusions regarding the effect of epidural analgesia on breastfeeding initiation, and suggested further research was needed.[40] There is some evidence that women who have a general anaesthetic for caesarean section have lower rates of breastfeeding initiation.[31] It is important that intrapartum care providers be aware of current and further research in this area, and that if there is an association, be aware of the potential need for additional breastfeeding support.

A recent Cochrane review found that women who gave birth in a home-like setting were more likely to initiate and continue breastfeeding (two trials; N = 1431; RR, 1.06; 95% CI, 1.02, 1.10).[41] Other factors during the first stage of labour that may have an impact on breastfeeding initiation are support during labour and bladder "care." Frequency of micturition following birth can disrupt early breastfeeding, so it is important that potential damage, such as oedema or bruising caused by the foetal head pushing on a distended bladder, is prevented as much as possible by encouraging frequent emptying of the bladder during the first stage of labour.[31]

Continuous support during labour and birth appears to have a positive effect on breastfeeding success. Although it is not necessarily clear what type of person is the best to provide this support, there is increasing evidence that continuous support by a lay woman or someone who is not a member of the hospital staff may be most effective.[42] A number of studies and reviews demonstrated that continuous support provided by a trained laywoman (doula) leads to increased breastfeeding initiation.[43] One randomized controlled trial showed that continuous psychosocial support provided by a doula in labour had a positive effect on breastfeeding, although the intervention was not confined to intrapartum care; doulas also had an extended visit with women in the postnatal ward.[44] Care in labour by a known midwife positively affects many pregnancy outcomes as well as women's satisfaction, but does not appear to affect rates of breastfeeding initiation.[45] Continuous support in labour should be provided to all women, and women encouraged and "allowed" to have this support.[42]


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