CESAREAN BIRTH AND BREASTFEEDING
Breastfeeding after cesarean birth is an important way for you and baby to get to know each other. It can also help heal any feelings of sadness or disappointment if birth did not go as planned. Breastfeeding can give you the satisfaction of knowing that you are giving your newborn the very best—something no one else can do—even though you are recovering from major surgery.
Whether you give birth vaginally or by cesarean surgery, family, friends, or a La Leche League Leader can be of great assistance and support when you are beginning the breastfeeding experience.
CHOOSING A HOSPITAL
Make every attempt to choose a health care facility with current, evidence-based policies on breastfeeding. Maternity hospitals that have achieved designation as Baby-Friendly Hospitals™ (BFHI) are especially understanding and supportive of breastfeeding. Any barriers to early contact and exclusive breastfeeding will have a greater negative effect if you have a cesarean birth, because your hospital stay is usually longer after surgery.
Current research strongly supports placing your baby on your chest, skin-to-skin, immediately after birth[i], even after Cesarean surgery – right in the operating room or in the recovery area. In most cases, your baby will move toward your breast and begin breastfeeding within the first hour or so after birth by himself[ii]. There should be no clothing or blankets between your baby’s body and your body because immediate and uninterrupted direct skin-to-skin contact is important for both of you. The baby will be dried and kept warm with a blanket over her back during this skin-to-skin time.
Talk to your care providers during pregnancy about keeping baby skin-to-skin until after the first nursing. If you have complications during after the surgery, a family member can hold the baby skin to skin until you feel more stable, then the baby can begin or resume skin-to-skin contact with you. The maternity staff should offer help as needed.
Most babies can move to the breast and begin nursing all by themselves within the first hour or so after birth. If the baby is ill or unstable, she can be returned to you for skin-skin-contact and breastfeeding as soon as medically feasible. If the facility does not support immediate skin-to-skin policies, talk to your care providers and request that a medical order be written for immediate and uninterrupted skin-to-skin contact for at least an hour, or until after the baby’s first nursing.[iii]
If the birth facility is BFHI-designated, the staff will be trained and able to help you achieve your goal of early and exclusive breast feeding. All routine procedures including the baby’s first bath can be postponed until after the baby’s first nursing, or sometimes longer. The baby’s health will be checked thoroughly by the medical or nursing staff, which can often be done while the baby is resting on your body or in your arms.
Rooming-in, or the baby staying in your room around the clock, is now standard procedure in BFHI-designated hospitals and in most maternity facilities worldwide. If the hospital still has a central nursery, ask to have your baby remain with you as continually as possible, and ask the reasons for any routine separation. You and your baby will both rest, sleep and recover better if you are in the same room most of the time. Many hospitals now have ‘side-car’ devices, or little cribs that attach to the side of the adult bed. Side-car devices allow easy breastfeeding, yet provide a safe place for the baby to rest if the mother needs to move away for a while.
You and your baby will be more relaxed and comfortable when you stay together.
Early and free access to nursing on your baby’s cues (BFHI Step 8) helps prevent breast and nipple problems, including engorgement and nipple pain.
Often a baby born by cesarean is groggy from medications used during the surgery (although babies born vaginally are sometimes groggy, too). A groggy baby especially needs lots of skin-to-skin contact and gentle massage. Try to make sure he nurses at least every two hours.
You are more aware of your baby’s sleeping and waking cycles, and can take advantage of his early feeding cues (eyes moving under his eyelids, hands coming to his face, alert and looking for you).
Holding baby skin to skin is often all that’s needed for him to begin nursing well. A baby sleeping on your chest or close to you lets you respond to his cues quickly.
When the baby is with you most of the time, you have more control over what happens to your baby and what the baby might be given. BFHI-designated hospitals have policies that prevent your baby being given a supplemental feed without a medical reason.
USE OF ARTIFICIAL NIPPLES (TEATS)
The early use of bottles with artificial nipples (teats) can interfere with baby’s ability to nurse effectively. Liquid tends to flow rapidly through a bottle nipple, whether baby sucks or not, which forces him to thrust his tongue forward to stop the flow of liquid to breathe. That’s the opposite motion of what happens in the baby’s mouth during breastfeeding. During nursing, the baby draws your nipple far back into his mouth and uses his tongue and jaw to wrap around your nipple and breast, and gather and swallow the milk. If supplemental fluids must be given, request use of a small cup instead of a bottle-and-teat system. None of the artificial nipples work like your breast.
Pacifiers used in the early days also interfere with baby’s ability to learn how to breastfeed. There is no food in a pacifier – your baby’s need to suck is actually a need for food. In the early days, if your baby seems to ‘need to suck,’ it’s time to nurse again.
TYPES OF ANAESTHETIC
The type of anaesthetic used during cesarean surgery can directly affect breastfeeding. Except in the case when cesarean surgery in a true emergency, most mothers are given a regional anaesthetic so that she is awake and aware during the birth. If there is any time to discuss your options, ask that your hospital gown, the IV tubing, blood pressure cuff and any other monitoring equipment be arranged so that your baby can be placed on your bare chest immediately after birth.
During the surgery, you will be lying on your back, and a drape is placed above your belly so that your hands (and nothing else) touches your abdomen. Some hospitals will agree to lower the drape briefly as your baby is lifted out of your body, so you can see most of the birth. After the baby’s umbilical cord is cut and he is dried gently, he can be brought around the drape and placed directly on your bare chest. The nurses will be monitoring you and your baby closely for safety. Your partner is usually allowed to be near you, and can also help watch your baby’s natural instincts emerge.
Newborns go through nine distinct stages [iv]after birth within the first hour or so:
Birth cry: Intense crying just after birth
Relaxation phase: Infant resting and recovering. No activity of mouth, head, arms, legs or body
Awakening phase: Infant begins to show signs of activity. Small thrusts of head: up, down, from side-to-side. Small movements of limbs and shoulders
Active phase: Infant moves limbs and head, is more determined in movements. Rooting activity, ‘pushing’ with limbs without shifting body
Crawling phase: ‘Pushing’ which results in shifting body
Resting phase: Infant rests, with some activity, such as mouth activity, sucks on hand
Familiarisation: Infant has reached areola ⁄nipple with mouth positioned to brush and lick areola ⁄nipple
Suckling phase: Infant has taken nipple in mouth and commences suckling
Sleeping phase: The baby has closed its eyes. Mother may also fall asleep.
If you are too shaky or ill to start skin-to-skin in the operating room, your partner may be able to hold your baby skin-to-skin until you feel better or in the recovery area. If a general anaesthetic is used, you can start skin-to-skin when you are awake and responding normally. If your baby is premature or ill, she may be taken to an intensive care area (NICU) for advanced care. Your partner should be able to stay with your baby. Once you have recovered enough, you can reconnect with your baby.
Immediate and uninterrupted skin-to-skin contact allows your baby’s instinctive behaviour to emerge. You can help and support your baby through the 9 stages, but don’t try to force the baby to the breast before she begins nursing on her own. When babies are allowed to move to the breast and self-attach, the chances of poor feeding on your baby’s part, and breast or nipple pain on your part, are drastically reduced. The first few nursing sessions are as important for immune protection and sensory stimulation as they are for nutrition. Your baby’s stomach is small at first, and your colostrum is made in just the right amount. Your baby doesn’t need any other fluids or supplements, as long as he is nursing well and often (8-12 times a day).
BREASTFEED EARLY AND OFTEN
Early and frequent skin-to-skin contact and breastfeeding t brings you and your baby emotionally closer.
Early and frequent skin-to-skin and nursing releases hormones to contract the uterus to prevent or limit blood loss. You may find the contractions to be painful at first. If you need pain relief for incision pain or uterine cramping, those medications are compatible with breastfeeding. (see below)
IF YOUR BABY IS SEPARATED
Ask the hospital staff for help in hand-expressing your milk, and ask for electric breast pump. If the baby can’t nurse right away, start hand-expressing within an hour or two after you give birth. Hand-expressing is better than pumping in the first 2 days. If the baby hasn’t nursed by about 6 hours, also ask for an electric breastpump.
Pumping soon after birth and every couple of hours thereafter will normalise your milk production, prevent engorgement, and collect valuable colostrum and milk which can be given to your baby when he’s able to eat.
THE USE OF PAIN MEDICATION
Medications used for pain relief after cesarean birth are usually compatible with breastfeeding. So are antibiotics and other medications which may be prescribed. If there is any question about a particular medication, a doctor can almost always prescribe a substitute that has been found safe to use while breastfeeding. Less than 1% of most medications passed into a mother’s milk, although there are variations to this. Most medications are compatible with breastfeeding, even during the newborn period.[v]
COMFORTABLE BREASTFEEDING POSITIONS
At first, it may be difficult to find a comfortable position that allows baby to breastfeed without hurting your incision. Have your partner or other helper stay nearby to help move and position your baby during the early days.
Many mothers find breastfeeding while lying on their side the most comfortable during the first day or so. It’s also an easy way to nurse and rest at the same time.
You and baby lie on your sides facing each other. Use pillows under your head, behind your back, and behind or between your knees to help get comfortable.
Baby’s feet should be close to your body with your nipple mouth clear of the surface you’re lying on and at the height of baby’s mouth.
Guide baby onto the breast using the hand of your upper arm on the baby’s upper back. Avoid pushing on the back of his head.
Another position that mothers find comfortable to use after a cesarean birth is called the underarm, football or clutch hold.
Tuck baby’s body along your side under your arm.
Support the breast with the other hand. If you’re nursing on the right breast, your left hand will be supporting the breast with the thumb above and well back from the nipple and the fingers below.
Support baby’s head with your palm on baby’s upper back (not head), thumb behind one ear and index and other fingers behind the other ear.
Baby’s body should be supported so that he is high enough and his nose is aligned with your nipple. He shouldn’t have to bend his neck forward to latch on—his head, neck, and hips should be in a straight line.
Let the baby ‘finish the first breast first.” Sometimes she will want the second side right away, or a bit later, or may only nurse on one breast at a time. It’s good to offer both breasts at each feeding, realising some babies only take one breast per nursing. Let the baby finish at her own pace and do not limit baby’s time at the breast. Many babies nurse for about 10-30 minutes for a feed. Breastfed babies cannot overfeed. She will let go of the breast or fall asleep when satisfied. If you hold the baby after a nursing for about as long as the nursing session, she may move into a deeper sleep state. If you need to move away from the baby for a while, make sure she’s lying face-up on a firm, flat surface in a safe place within sight and sound of a responsible adult.
WHILE YOU RECOVER
It is important for your loved ones to realise that you need time to recover from childbirth and surgery, and to learn to breastfeed
While in the hospital, ask the nurse for a sign to put on your door several times a day to tell visitors that you are resting so that you do not have to entertain guests in your room all day long.
In the early weeks after arriving home, feel free to ask for and accept help from family and friends. They want to help, so ask them to do some of the usual household chores or bring prepared, healthy food. You don’t need a special diet to recover from surgery and birth. Continue to drink to thirst and eat nutritious foods to help regain your strength.
Breastfeeding should be comfortable. Learning a new skill often takes time, no matter how your baby arrived! If for any reason breastfeeding is not going smoothly or you find it painful to breastfeed, ask a La Leche League Leader for help.
[i] BFHI Step 4: “Help mothers initiate breastfeeding within one hour of birth.” World Health Organization, & United Nations Childrens Fund. (2009). Baby-Friendly Hospital Initiative: Revised, Updated and Expanded for Integrated Care. Geneva: World Health Organization.
[ii] Male and female pronouns referring to the baby are used randomly in this document.
[iii] Feldman-Winter, L., & Goldsmith, J. P. (2016). Safe Sleep and Skin-to-Skin Care in the Neonatal Period for Healthy Term Newborns. Pediatrics, 138(3). doi: 10.1542/peds.2016-1889
[iv] Widstrom, A. M., Lilja, G., Aaltomaa-Michalias, P., Dahllof, A., Lintula, M., & Nissen, E. (2011). Newborn behaviour to locate the breast when skin-to-skin: a possible method for enabling early self-regulation. Acta Paediatr, 100(1), 79-85.
[v] Sachs, H. C., & DRUGS, C. O. (2013). The Transfer of Drugs and Therapeutics Into Human Breast Milk: An Update on Selected Topics. Pediatrics. doi: 10.1542/peds.2013-1985