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Fetal monitoring
The aim of fetal monitoring is to ensure the well-being of the baby, for example that the baby is getting enough oxygen.
  • Fetal monitoring can be carried out by intermittent listening with a fetoscope (a stethoscope-like device for use during pregnancy and labor) or with a Doppler (ultrasound) device.

  • Electronic fetal monitoring (EFM) involves attaching the mother to a machine, either with two receivers held in place by belts around the hips (external monitoring), or by an electrode attached to baby’s scalp and a pressure catheter inserted alongside baby’s head (internal monitoring).

  • EFM usually involves lying down, the most painful and least effective position for labor progression. Even if the mother is not lying down, movement is restricted.

  • Routine EFM can make doctors and nurses believe that something is wrong when it is not, sometimes due to misinterpretation of the data from the machine.




  • EFM has not been proven to improve outcomes for mothers or babies, and does increase the risk of interventions such as cesarean birth or assisted delivery.

  • Laboring women being monitored by EFM sometimes feel that the machine becomes the center of attention during labor, instead of the mother and baby.

Assisted delivery
Instrument delivery with forceps causes compression of the baby’s head. Forceps can cause bruising and nerve damage to the sides of the cranium, causing the jaw to deviate. This can lead to jaw asymmetry, which can affect the baby’s suck. Use of a vacuum extractor can substantially increase the amount of force applied to the infant’s skull, causing compression of the baby’s head and increasing the risk of postpartum complications. Vacuum-assisted vaginal delivery may be a significant factor in the cessation of breastfeeding within the first two weeks of life.

The use of forceps or vacuum extraction may cause head pain and inhibit movement of the baby’s head and neck. Treating the baby as if he has a severe headache and reducing noise, light, touch (especially to the back of the baby’s head), and motion, can be effective comfort measures. “Kangaroo-style care” can also help, by holding the baby upright on his mother’s chest in a quiet, darkened place. Mothers might also seek help from practitioners trained in treating infants with gentle, noninvasive manual techniques. Chiropractors, osteopaths, physical therapists, occupational therapists, and massage therapists are some of the professionals who practice manual therapies.

Instrument delivery can cause the mother pain from an episiotomy (the surgical cut to enlarge the vaginal opening), which is sometimes performed in order to place/insert the instruments. The instruments themselves can sometimes injure the mother internally, causing pain. Being in pain can affect a mother trying to care for a newborn baby and may make it difficult to get breastfeeding off to a good start.

Cesarean birth
Cesarean birth is a major abdominal operation and carries well-documented risks for both mother and baby. A mother is likely to stay in hospital longer than she would otherwise, with a longer recovery time after the birth, which can have an impact on establishing breastfeeding. When a mother goes into labor and gives birth without intervention, her body releases hormones that help with breastfeeding (oxytocin and prolactin). A cesarean birth may interfere with the natural release of hormones in both mother and baby, making it more of a challenge to establish breastfeeding. Some experts describe earlier and more abundant lactation if the mother is allowed to experience labor before a cesarean delivery.

A Leader can encourage the mother to begin breastfeeding as soon as possible. The mother may need support to position her baby comfortably and avoid the area of her incision and stitches.Many mothers can go on later to have vaginal births after a cesarean (VBAC), thus avoiding the breastfeeding complications which might be caused by a cesarean birth. If a mother who has had a previous cesarean delivery talks with you about VBAC, you can encourage her to discuss it with her health care provider.

Medication for pain relief
There are several different types of medication used for pain relief during labor and delivery. Below is a summary of the range of typical options and some of their effects on mothers and babies; the list is not comprehensive.

  • Tranquilizers are given to reduce anxiety and tension. However, they can cross the placenta and interfere with the baby's ability to breathe, to suck, and to maintain a healthy muscle tension (tranquilized newborns tend to be limp).

  • Narcotics (e.g., Demerol, pethidine) in doses high enough to lower pain may not be safe for mother or baby, so they are given in lesser amounts. Given intravenously or by injection, a relatively safe dose
can cause sleepiness in the baby or mother, and often causes nausea, vomiting, and a drop in blood pressure in the mother. If narcotics cause nausea in the mother, the use of additional medications may




be necessary. These anti-nausea drugs can cause dizziness and drowsiness in the mother. Narcotics can affect the baby’s ability to suck, swallow, and breathe in a coordinated manner, lasting from several hours to several weeks after birth.

  • Inhaled pain medications are used in some locations. Mothers inhale the gas through a mask attached with tubing to a gas cylinder. Nitrous oxide gas is used to dull labor pain, both in hospital and in home births. The effects are immediate and short-lived; some sources report that no obvious side effects have been found in babies or mothers.

  • Epidural anesthesia numbs and weakens the lower part of the mother’s body. The mother remains conscious. A catheter remains in place for “topping up" of the anesthetic if required. For many women, it is an effective form of pain relief. However, epidurals don't always work, providing only partial pain relief (or none in 3% of cases).Possible side effects, such as maternal fever or a drop in maternal and/or infant blood pressure, may lead to further postpartum/postnatal intervention. Epidurals may be more likely to result in either cesarean birth or a forceps/vacuum-extractor delivery than an unmedicated labor. Research shows that after an epidural, babies are less alert, less able to orient themselves, and have less organized movements; these differences are measurable during the baby’s first month. After an epidural, the mother’s back may feel stiff, achy, or sore.

  • General anesthesia can be administered more quickly than an epidural, so it is still used when an emergency cesarean is required. It can cause nausea and vomiting in women after delivery and can produce breathing difficulties in babies.

  • Spinal anesthesia is similar to epidural anesthesia, with similarly effective pain relief. However, a catheter is not left in place, so the duration of anesthesia is limited. The possible side effects caused by spinals are similar to those for epidurals. Spinals can cause a sudden and drastic drop in blood pressure. Some women have a spinal headache after birth. This headache can last for days after the birth, interfere with daily activity and baby care (including breastfeeding), and may require further medical treatment. A mother in this situation may need extra practical help and emotional support. Mothers may be told to lie flat for several hours following a spinal to avoid a headache. Doing that can make breastfeeding difficult unless the mother has help from someone knowledgeable about positioning and latch.

Impact on breastfeeding from pain relief medication used during labor and delivery
The sucking reflex of a healthy, full-term newborn delivered without the use of pain medications or anesthesia usually peaks about twenty to thirty minutes after birth. If this optimal time to begin nursing is missed, the baby's sucking reflex may be less strong for about a day and a half.

Pain relievers or anesthesia can contribute to breastfeeding problems:
  • The baby and/or mother may be sleepy or less alert and thus delay the first nursing.
  • The baby's ability to suck, swallow, and breathe may be disorganized.
  • The baby’s rooting and sucking reflex may be delayed and depressed.
  • Pain medications (analgesia and anesthesia) do cross the placenta to the fetus, and the closer they are given to delivery, the more likely they are to remain in baby’s system after birth. While the fetus is in the uterus, the mother’s system and the placenta help the baby to eliminate toxins. Once the baby is born, his less mature liver will need to do this detoxification, hence it sometimes takes longer for babies to get rid of excess drugs.


OVERCOMING CHALLENGES AFTER BIRTH
Post-birth choices that can affect the start of breastfeeding
After a baby is born, the mother may have an expectation of what will happen next: the baby crawling up her abdomen to the breast or being gently lifted into her arms, in both cases enjoying maximum skin-to-skin contact and an early opportunity to breastfeed. However, the reality may be different, and it can be helpful for the mother to find out as much as she can before the birth so that she will be prepared for certain hospital/birth center procedures which may be thought necessary to determine and treat the condition of the baby.





Routine practice can include:
  • Newborn well-being assessments (barring medical complications, these measurements can be taken while the baby is skin-to-skin with the mother):
o ABC testing: Doneimmediately after birth, babies are assessed for Airways, Breathing, and Circulation to determine the need for resuscitation.
o Apgar score: This assessment of the baby's Appearance (skin color), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration is done after one minute and again at five minutes. This can be done quickly and need not disturb skin-to-skin contact time.
o How Ready Is This Child testing: This reformulation of Apgar testing checks Heart rate, Respiratory effort, Irritability, Tone, and Color.

  • Suctioning: Some hospitals remove mucus from the baby's airways by suctioning. It can be done more, or less, intrusively, depending on the baby's condition at birth. In some hospitals it is routine. Intrusive or deep suctioning (done for respiratory distress, or done routinely in some hospitals) can cause oral aversion in the baby, making him reject anything in or around his mouth, including the breast.

  • Postpartum routines such as washing and weighing the baby: These can be delayed until after an unhurried skin-to-skin time; the mother and her partner may need to be assertive about this. For instance, the baby can be dried as they snuggle together. Bathing the baby may include washing the baby’s hands. If this happens before offering the breast, it can confuse his sense of smell and make it harder for him to find his way to the breast.

  • Use of nurseries: Some hospitals have a special room where babies sleep and are cared for by the nursing staff. This system relies heavily on busy nurses to recognize feeding cues and get a baby to his mother in a timely manner. Rooming-in (baby in mother’s room) may or may not be an option. Rooming-in allows a mother to get to know her baby and to respond early to hunger cues, such as fist sucking and rooting, which facilitates the early breastfeeding relationship.

  • Artificial nipples: Routine baby care in the nursery may include dummies/pacifiers and supplementation, which can interfere with the establishment of breastfeeding.

  • Use of formula: The hospital may routinely provide artificial milk if the baby is not nursing well within hours of birth. Instead, mothers can express some colostrum by hand and give it to the baby by an alternative method, such as spoon, dropper, or cup. Some hospitals may assume that every baby over a certain weight has low blood sugar and needs supplementation with formula. If a baby does have relatively low blood sugar, the mother may be advised to give glucose water and/or formula. A mother can ask her health care provider what test results indicate that her baby might have a need for supplementation, and work with him/her to develop a plan of action that maintains and values breastfeeding.

  • Water/glucose water: The hospital may routinely provide water or glucose water if the baby shows signs of jaundice. Colostrum is more effective at flushing out meconium and preventing jaundice. Offering the baby water/glucose water can interfere with establishing the mother’s milk supply and increase the risk of jaundice.

  • Blood tests for newborn metabolic screening: These tests may be required by government health authorities. They are routinely done by pricking the baby's heel; this takes place no sooner than 24 hours after birth. Painful medical procedures can affect a baby’s ability and willingness to feed in the early days. However, breastfeeding during such procedures acts as a natural painkiller, alleviating the symptoms of pain, such as crying and grimacing.

  • Other painful medical procedures: These can include administration of vitamin K, vaccinations, and circumcision. Like blood tests, these procedures can affect a baby’s willingness to feed.







  • Test weighing: Test weighing before and after a feed is not usually necessary and may not be an accurate assessment tool in the first few days of life. It can result in babies receiving supplementary bottles, which in turn can interfere with the mother’s milk supply. Mothers can be supported to dialogue with their health care providers about other signs of infant growth and well-being and ways to support breastfeeding.

  • Special care babies: Some babies require additional care in a Special Care Baby Unit or Neonatal Intensive Care Unit. This can delay the start of breastfeeding; the mother can express her milk to establish her supply until her baby is well enough to be put to the breast. A mother in this situation may need the assistance of a knowledgeable LLL Leader or International Board Certified Lactation Consultant (IBCLC).

Getting started with breastfeeding after a challenging birth experience
When helping a mother, remember the basics of positioning and latch. After a challenging birth experience, a mother may have difficulty finding a comfortable position to breastfeed. She may feel disappointed, frustrated, or angry with herself or her body. She may be overwhelmed by the ordeal she has been through, exhausted and in pain or discomfort. She may also be afraid that the “window" for beginning breastfeeding has closed, or that breastfeeding will be another physical and emotional struggle. She may need support to gain confidence that she and her baby can breastfeed successfully. On the other hand, some mothers in this situation feel triumphant that they and their babies have survived the challenge; they look forward to breastfeeding.

Whatever her birth experience, a new mother is likely to benefit from feeling that she is being cared for and that she and her baby are safe and secure. She can then relax in the knowledge that all she has to do is look after her new baby. A mother who has had a challenging birth experience may need to share the story of her experience with you. She will value your listening ear and the support and information you can offer. If her situation is beyond the normal course of breastfeeding, you may need additional support from the Professional Liaison Department in order to help her effectively. You might also need to refer her to others for additional support, such as health care providers or a lactation consultant.

When the mother is in pain
The mother may be in pain from stitches in her abdomen (after a cesarean birth) or pelvic floor (after vaginal tearing or an episiotomy, the surgical cut to enlarge the vaginal opening), and struggling to cope. Many pain medications are compatible with breastfeeding. The mother can ask her health care provider about appropriate medications. A Leader can give the mother information about what to consider when the mother and her doctor evaluate a drug’s compatibility with breastfeeding (see the bullet points found in the LLLI FAQ online at http://www.llli.org/FAQ/medications.html and/or “Questions about Medications while Breastfeeding,” Leader’s Handbook). If a baby exhibits excessive sleepiness or other side effects while a mother is using pain medication, she should inform her doctor immediately.

A mother may find it more comfortable to lie down to breastfeed or to try a different way of holding her baby, such as an under-the-arm or ”clutch” hold. She may want to experiment using pillows to help support her arms and baby, or to protect her abdominal incision.

When the baby can’t or won’t breastfeed
Different factors can contribute to difficulties starting breastfeeding. For instance, a premature baby may have a weak suck due to an immature nervous system. A newborn baby can be very sleepy, especially after a medicated delivery. In these instances, getting started with breastfeeding can take some perseverance on the mother's part. There may be other concerns or specific breastfeeding challenges unconnected to the birth experience. It is important for the mother to know that, even though breastfeeding may be delayed, she and her baby can still breastfeed.

A delay in establishing breastfeeding may require support for the mother to express her milk, and she will benefit from information about alternative feeding methods such as spoon, dropper, or cup if she wants to avoid bottle use. If the mother opts to use bottles, mimicking breastfeeding as much as possible can make the





eventual transition to breastfeeding go more smoothly. This might include holding the baby in a nursing position, using a “slow-flow” nipple that is soft and long enough for the baby to draw to the back of his mouth, touching the baby’s lips with the bottle nipple and waiting for him to open wide, letting him draw the nipple in himself, and keeping the bottle in a nearly horizontal position so that the baby has to work to get the milk from the nipple. Your support will be important while the mother works to get the baby to the breast and especially if her breastfeeding experience continues to be challenging.


BABY CARE
Skin-to-skin contact
Skin-to-skin contact can help the mother and baby learn about each other through touch, warmth, and smell, until the baby starts to breastfeed. This is the basis of “kangaroo care" for premature babies. The mother carries her baby against her body, skin-to-skin, building a bond of love and trust. The effect seems magical: the baby is better able to maintain body temperature; heart and breathing rates become more regular; the baby makes eye contact with his mother and may explore her nipple and perhaps attempt a few tentative sucks, which is especially gratifying to the mother. The principles of kangaroo care can be helpful for any mother and her breastfeeding baby.

Mother and baby can enjoy skin-to-skin contact at any stage; the mother's chest is the normal habitat for a newborn baby. He will calm down and rest well whenever he is close to his mother in this way. If he bobs and slides down to a breast, the mother keeps his bottom close to her so that he feels secure. She can help him gently to latch on well. This method (sometimes called “biological nurturing”) is especially helpful if a baby has a sore head or has been pushed onto the breast by an overenthusiastic helper.

Mothers can find out if the hospital/birth center supports skin-to-skin contact and initiation of breastfeeding within the first hour. A healthy, unmedicated baby will generally show interest and initiate breastfeeding when he is ready and does not need to be rushed, especially if he has been skin-to-skin with his mother since birth. If the baby is too irritable or overwhelmed to take an interest in breastfeeding, skin-to-skin contact is sometimes enough to restore normal behavior within 15-30 minutes.

If skin-to-skin contact is delayed for any reason, the mother and her birth partner can advocate for this to begin as soon as the mother and her baby are ready. The mother will need to recline, with her chest area uncovered (she can wear a big shirt or pajama top, open at the front), and a cool drink nearby. The baby wears just a nappy/diaper and lies on the mother’s chest, between her breasts or slightly above, his whole body facing her and his head turned to one side. He has a blanket over his back and tucked round his feet, or he may be covered by the mother's clothing. If there are concerns about the baby's temperature, he can wear a hat. If the mother is very tired or is affected by medications that make her sleepy, she will need someone to stay with her so that she does not worry about the baby slipping off the bed if she falls asleep.

Co-bathing
Taking a bath together can be relaxing for both mother and baby and provide an opportunity for skin-to-skin contact and easy access to the breast. It may be wise to remind mothers of commonsense precautions regarding water temperature (warm to the mother’s elbow, not hot), with most of baby’s body submerged to retain body heat. It is also a good idea to have another adult present to hold the baby as the mother gets in and out of the bathtub.

Baby carriers
Various kinds of baby carriers worn by the mother can provide a way of keeping the baby close and within easy reach of the breast. Wearing the baby in a soft carrier or sling facilitates breastfeeding in many ways: it’s convenient; movement can help calm the baby and help a baby having problems sucking to “organize” himself and nurse more effectively; the mother’s arms are free to care for older siblings. Babies who are slow weight gainers tend to nurse more and gain more when worn in a sling. Research shows that meeting a baby’s need for closeness will lead to more independence as the baby grows. Other research shows that “babywearing” reduces crying and provides the sensory stimulation that babies need to figure out the world around them. Keeping her baby close allows a mother to notice early hunger cues rather than waiting to be alerted by the late signal of crying. This early response helps maintain the mother’s milk supply, keeps the baby happy and secure, and helps the mother’s postpartum moods adjust more smoothly.