Labor and Delivery Support
Hospitals are often frightening places for women in labor. The
birth of her baby may be her first experience with a hospital.
Support in labor has been shown to have positive effects on birth,
bonding and breastfeeding success (Langer et al; Kennell et al.
1991). In "Bonding: Recent Observations That Alter Perinatal Care,"
Kennell and Klaus state: " During labor and delivery, every mother
should have the possibility of continuous physical and emotional
support by a knowledgeable, caring woman (e.g.. Doula) in addition
to her partner as recommended by the Oxford Perinatal Study Group
in England and the Canadian Obstetric Society (11)." (emphasis
added)
The Role of the Doula
The term "Doula" came into popular use from Dana Raphael's classic
work, Breastfeeding: The Tender Gift. Raphael's definition of
doula is "One or more individuals, often female, who give psychological
encouragement and physical assistance to the newly delivered mother
(172)." Raphael believes that lack of doula support predisposes
a woman to breastfeeding failure (141-145).
The doula is a powerful force intrapartum, not only for breastfeeding
success but in medical care cost reduction. The laboring mother
receives one-to-one support from the doula throughout labor. The
result is shortened labors (averaging slightly less than six hours
for the first-time mother). In addition, there is little need
for medical interventions including pitocin, epidural anesthesia,
and cesarean sections. (Gordon et al; Klaus, Kennell and Klaus
106; Perez 3) It is the level of support that has the greatest
influence on successful outcomes. (Klaus, Kennell and Klaus 98)
Citing several studies, Klaus, Kennell and Klaus, enumerate the
multiple advantages in using doula support during labor. [Table]
| Outcome *all Statistically Significant | With Doula * |
WIthout Doula |
| Length of labor first time moms | 7.7 to 9 hours | 15.5 to 19 hrs |
| NSVD No medications used |
55% | 12% |
| Epidural Anesthesia | 8% | 55 to 85% |
| Oxytocin (Augmentation/Induction) | 2 to 17% | 17% |
| Forceps | 8 % | 26 % |
| Cesarean Sections | 7 to 8% | 17% to 27% |
"The doula gives a level of support different from that of a person
who is intimately related to the woman in labor (Klaus, Kennell
and Klaus 5)." Doulas are not involved in the medical management
of labor. Her role is one of continuous emotional support. Most
of the doula's time is spent in actual physical contact with the
laboring woman (holding, touching, cradling). Yet, she will not
intrude on intimate moments between the couple. The doula acknowledges
the woman's feelings, fear, anxiety and physical pain; and reassures
her.
What happens to the father (e.g., the coach, support persons)
when a doula is present? Lawrence and Lawrence state that calling
the father a coach "has negative connotations because a coach
is one who develops the players to work and try harder but always
to win (210)." The father is free to assume whatever role is most
comfortable for him. He can be a passive observer or an active
participant. Men often have very deep concerns for their wife's
safety in labor. The doula may need to support the father or if
needed, she may model supportive behaviors for him (Klaus, Kennell
and Klaus 19-24). The father is relieved of the responsibility
for primary labor support, a role that is often uncomfortable
for many men. Mother, in turn, is relieved of the burden of feeling
like she has to "perform" for her coach. She is also relieved
of any concerns she may have for his well-being, leaving her to
concentrate solely on her labor.
Postpartum outcomes are also significant. Once the baby is born,
mother is tucked peacefully into bed with her new baby beside
her. The doula protects the new mother and baby from stress and
intrusion. Where needed the doula gives expert advice on breastfeeding,
infant care and behavior. "The calm that can be experienced in
the presence of a confident caring person will relax the mother
. . . Breaking the cycle of panic that seizes a new mother . .
. requires someone to instill confidence (Lawrence and Lawrence
258). " The women in doula supported groups were breastfeeding
exclusively and for longer periods, and had positive feelings
about their infant's and partners.
Labor Medications
" . . . Many babies whose mothers receive labor analgesia, including
epidurals, have difficulty performing a cluster of behaviors necessary
for successfully initiating feedings at the breast (Walker 131)."
It is well known that the drugs commonly used in labor will effect
the fetus in utero. Only recently have studies shown that there
may be some long-term effects on the neonate after delivery. Difficult
medicated labors, appear to lower the rate of breastfeeding success
because of the effects on the infant [Table]. The infant may be less alert for several days. The ability of
the infant to suckle vigorously at the breast may be affected,
which delays or impairs lactation.
The Concern Over Epidural Anesthesia
Epidural anesthesia brings with it a host of medical interventions
into normal labor. The epidural rate in most U.S. Hospitals is
in excess of 85%. This resurgence in medicated deliveries raises
various concerns regarding epidural use and feeding problems.
The available studies reviewing the drug content of the epidural
conclude that the drug(s) do not pass to the infant. Thus, anesthesiologists
consider the epidural to be the ideal method of pain control during
labor (Cohen). "Much of the anesthesiology literature dismisses
early behavioral effects on infants as insignificant . . . inability
to latch and feed at the breast is a significant deviation from
normal Walker 131)." No study to date has looked at the effects
of the epidural itself on the ability breastfeed. Lactation Consultants
and hospital staff have noted that these babies are lethargic
and have uncoordinated suck-swallow patterns for days after birth
resulting in poor milk transfer leading to excessive neonatal
weight loss. Mothers exhibit problems secondary to poor latch
on and suckling difficulties: sore nipples, engorgement, low milk
supply, plugged ducts and mastitis. (Walker 131)
It appears that when a mother has epidural anesthesia she may be "setup" for a series of other medical interventions (Liberman 1, 2 et al) . When a mother receives epidural anesthesia, her labor may slow down. Consequently, the labor may require pitocin augmentation. Once the epidural is started, the mother is confined to bed and cannot turn or change positions easily. The epidural relaxes pelvic muscle tone. The mother lacks the normal bodily reflexes that turn the head into the optimal position for delivery. The normal decent of the baby's head is inhibited. The pushing phase may be prolonged, resulting in the need for vacuum extraction, forceps and/or cesarean delivery. When an epidural is used for any length of time, the mother's temperature begins to rise. If this fact is not recognized, the presence of maternal fever could lead to unnecessary tests for neonatal sepsis and costly antibiotic regimens for the mother (Liberman 1, 2 et al). The elevation in maternal temperature causes the baby's heart rate to increase and can mimic fetal distress. The incidence of cesarean section for fetal distress in these cases has not been studied. (Klaus, Kennell and Klaus 46-51)
Some hospitals require that a mother have some form of narcotic
pain relief before the epidural is started which further complicates
the picture. Anesthesiologists may require infusion of two or
more liters of I.V. fluids before the epidural and use further
I.V. fluids throughout the labor. This leads to generalized edema
in both the mother and the infant. Lactation consultants report
a type of maternal areolar edema peculiar to epidurals that makes
latch-on difficult, if not impossible. In addition, the infant's
birth weight may be "inflated." When diuresis begins in the baby,
weight loss may be more than allowable amounts. Formula supplementation
may be required based upon weight loss alone. Moreover, mothers
complain that epidural pain relief is not complete, is patchy
or fluctuates. Over 69% of women report back problems for more
than a year after having an epidural (Klaus, Kennell and Klaus
49).
Childbirth educators must again encourage "natural childbirth"
in their classes. They should provide their class with ALL the
potential risks of epidurals. Properly used childbirth techniques,
changing the mother's position frequently in labor, walking, squatting,
allowing nutritious clear liquids in labor (rather than ice chips)
may all assist in reducing and/or eliminating medicated births.
The need for medication in labor is not in question. Surely, many women benefit from its use. It is the routine use of medication at the first complaint or request that should be under scrutiny. Other comfort and coping measures should be tried first.
First Contact
Not enough can be said about the physiological and emotional impact
of the mother's first contact with her baby. New studies on neonatal
preference for amniotic fluid odor suggest that substances with
strong odors be avoided in the perinatal period and that leaving
some amniotic fluid, especially on the hands and arms may assist
the infant in locating the breast and ease the transition to extra-uterine
life (Verendi, Porter and Winberg; Winberg and Porter).
In the first two hours after birth, the baby is in a quiet, alert
state, and will be the most willing to nurse. The infant's suckling
reflex is strongest from 45 to 120 minutes following birth. "Delaying
gratification of this reflex can make it more difficult for the
infant to learn to suckle later on." (Riordan and Auerbach 283)
Following those first two hours the baby may be quite sleepy and
not very willing to nurse for as long as 24 hours (Riordan and
Auerbach 284).
The new mother receives an emotional boost from nursing an alert,
active, searching newborn. Her first attempt at parenting is successful
and her self confidence is vastly improved. Thus, it follows that
early feedings are equated with breastfeeding success. It has
some positive effects on the infant as well. The baby has come
from an entirely sterile environment. This first exposure to mother's
milk begins to line his respiratory and digestive tracts with
sIgA to protect him from the environment.
Following labor some babies may not be interested in nursing and may merely "nuzzle" or lick the breast. He may not nurse as vigorously as mom expected. Reassure the mother that this is normal positive behavior and not a "rejection" of her or her breast. (Riordan and Auerbach 284)
Newborn Procedures
Immediately following the birth, the baby may need to be gently
suctioned. Aggressive suctioning should be avoided. Routine emptying
of gastric contents by DeLee suctioning should be avoided. When
meconium is noted in the amniotic fluid, deep suctioning and visualization
of the vocal cords may be needed to prevent meconium aspiration.
This process is not atraumatic. It is important to realize that
the baby who has been deep suctioned may not be willing to nurse
for a while. The infant's mouth and throat may be tender and sore.
He may fear that anything coming near his mouth will cause pain.
Physical therapists and lactation consultants call this "oral
defensiveness." Deep suctioning should be done as gently as possible
and still be effective. (Riordan and Auerbach 284)
During the critical hours immediately postpartum, nurses should
try not to become task-oriented. The labor and delivery nurse
has a list of what must be done as necessary newborn procedures.
Weight and length measurements, footprints, Vitamin K injection
and eye treatment can wait for several hours if needed, without
any serious effect on the baby. Labor is not "over" yet. When
both the newborn and the mother are stable and healthy, the nurse
should learn to stand back and let this part of the birth process
continue uninterrupted. Assist the mother into a comfortable position
and allow the infant to make his way to the breast. The baby's
suckling and crawling reflexes will take over and he will self-attach
with little or no assistance. "The baby should be allowed to decide
when to start the first suckling (Kennell and Klaus 11)."
The primary concerns for the infant in the immediate neonatal period are: respiratory status and conservation of body heat. Conservation of body heat is of deep concern because cold stresses the infant more than heat. The baby can be placed at the mother's breast, skin to skin, and then a blanket can be wrapped around the couple in a way that leaves part of the breast and infant exposed for viewing. Mother makes an excellent incubator. The infant will absorb some of her body heat through convection. This technique is known as Kangaroo Care and is used effectively in places were radiant heaters and isolettes are not available. Water losses in the infant may be less with mother's natural warming than with radiant heaters and isolettes.
The only preparation ever needed before each breastfeeding is that mother wash her hands. This becomes important later on, especially if she changes the baby's diapers before each feeding. In the immediate post-delivery setting, give the mother a warm wash cloth (plain water, no soap) for her hands. She does not need to wash her breasts.
Nursery and Postpartum Routines
Breastfeeding can be innocently sabotaged by hospital routines.
Kennell and Klaus advocate the abolition of the central nursery
for normal healthy newborns and recommend that the couplet remain
together throughout the hospital stay (11). Newborn policies can
have serious effects on lactation and may contribute to maternal
engorgement and neonatal jaundice (see: Defining Neonatal Jaundice).
The most common offenders are: scheduled feedings, separation
from the mother, formula feeding at night so mother can rest,
and routine assignment of any cesarean section baby to the nursery
for several hours after birth.
The Problem with Bottles
Normal, healthy newborns do not need bottles of water, glucose
water or formula (Riordan 218; Lawrence and Lawrence 284-285).
Lactation consultants know that a few babies will have breastfeeding
difficulties from as little as one bottle. The difficulties these
infants exhibit are called nipple confusion (Riordan 47, 218;
Lawrence and Lawrence 284-285; Lauwers 225, 272, 387, Newman 60-61).
However, " . . . the existence of nipple confusion is not universally
accepted. Some health care professionals consider nipple confusion
to be a myth (Morhbacher and Stock 83)." Feeding is a learned
skill. Suckling is a reflex action.
Several theories try to explain the havoc (nipple confusion) caused
by artificial nipples:
Routine Supplementation
Routine supplementation after every feeding greatly undermines
the mother's self confidence. After nursing for up to forty-five
minutes, she dutifully gives the infant a bottle of water or formula
and watches as the infant takes up to four ounces. What can the
mother think, except that her milk is not enough? Because suckling
is a reflexive action, the baby will suck on anything that comes
near his mouth, hungry or not.
Baby Needs Access to the Breast Around the Clock
The breast should be viewed as an external placenta. The newborn
should have access to the breast around the clock. The baby will
need 10 to 12 breastfeedings per day during the first week of
life. Both mother and baby will get off to the best possible start
breastfeeding if the baby remains with the mother, rooming-in.
Breastfeeding mothers should be advised against skipping night
feedings.
Avoid Take Over Behavior
Individuals working in the caring fields may often have the need
to mother; to protect and guide, and to be the expert (Riordan
and Auerbach 549). The nurse will do well to remember that only
the mother is the expert where her baby is concerned. "One of
the most persistent feelings during role transition [from woman
to mother] is inadequacy and lack of self-confidence (Bocar and
Moore 4)." "Take over behavior" may make a new mother feel like
a child who must produce the behavior the "parent" figure desires,
reinforcing her personal feelings of inadequacy (Riordan and Auerbach
718). A mother's face will light up when she suddenly hears someone
tell her she is doing well.
Critical Discharge Instructions
Keep discharge instructions simple. These critical discharge instructions
should be reinforced throughout her hospital stay and given to
the mother in writing at discharge:
The mother should also be given the telephone numbers of her obstetrician, baby's pediatrician, the hospital's help line and a lactation consultant if one is available.
Copyright Marie Davis, RN, IBCLC 1999
Revised: