reviewed: Wednesday, September 15, 2010
Thus far we have been looking at the normal, uncomplicated vaginal delivery. For most mothers, nursing right after delivery isn't a problem. For the mother or infant with medical complications, some adjustments will be made.
Maternal Complications
Cesarean Section.
If the mother has a cesarean section under epidural or spinal
anesthesia, she can nurse the baby when the operative field is
cleared. She may not be able to sit up for a little while, but
the baby can be placed to her breast in a variety of positions;
almost face down or side-lying at the breast. Breastfeeding while
the anesthesia is still effective makes the first encounter a
pleasant one. After the anesthetic has worn off, mother will have
incisional pain. If mother has general anesthesia she can safely
nurse the infant once the anesthesia has worn off enough so that
she is alert and oriented.
If your hospital has a policy that the baby must go immediately to the nursery following cesarean section, the baby should be brought to mother in the recovery room or at the very least, when she has been released from recovery to the postpartum unit. This, of course, is providing that the infant is well. Unfortunately, many hospitals classify all cesarean section babies as "ill" for a period of hours after delivery, often assigning the infants to a special care nursery. Nursery personnel should be told that the mother intends to breastfeed and they should not offer bottles unless absolutely medically necessary (see: The Baby With Low Blood Sugar below). If needed, the first feeding can be delayed for four to six hours to allow for the average maternal recovery period.
It is important that the baby not be kept in the nursery at night for feedings. If the mother is well, it is unwise to offer to feed the baby for her in the nursery. Bottle feedings risk nipple confusion, flow preference, neonatal jaundice and maternal engorgement.
Cesarean mothers worry about the pain medication they need and breastfeeding. Some moms "do without" pain medication because they believe it will harm the infant. Maternal pain medications may make the baby a little sleepy, but the amount of pain medication the infant receives in the first one to two days is not believed harmful. However, it is important to note that if the mother is taking pain medication someone should be at the bedside (dad is a good choice) who is given the responsibility to keep the baby safe.
Maternal Diabetes.
Maternal insulin increases glucose uptake by the mammary cells.
The mother's glucose utilization may be increase by 30% when lactation
is established. Glucose is used for the production of lactose
and is critical to the volume of milk produced. (Lawrence and
Lawrence 83-84) The breast is a target organ for insulin where
rapid changes in insulin levels result in changes in the rate
of lipogenesis and the utilization of glucose. Lactation has an
insulin sparing effect. (Lawrence and Lawrence 515)
Women with insulin dependent (IDDM) and gestational diabetes should be encouraged to breastfeed. Several studies have shown that breastfeeding reduces the risk of the contracting childhood IDDM. Her blood glucose should be carefully monitored in the postpartum period. The diabetic mother may be prone to hypoglycemia and require her insulin dose adjusted appropriately. The renal threshold for glucose is lowered in pregnancy. During lactation any lactose reabsorbed from the breasts is excreted in the urine. Lactosuria may be misdiagnosed as glucosuria, so the use of urine test strips is inappropriate. (Lawrence and Lawrence 515).
Significant lactational problems arise for the diabetic mother when infants are kept in the nursery for observation and are bottle fed in the first few days. If breastfeeding is delayed due to an unstable infant, the mother should begin pumping shortly after delivery. (See: Early Pumping Paramount)
Severe Illness In The Mother
Occasionally, the mother is too ill to be concerned with breastfeeding.
She may be in the intensive care unit for several hours to several
days until her condition is stable. Primary lactogenesis will
occur without breast stimulation. As soon as mother is able she
should begin pumping her breasts or nursing the baby. Occasionally,
a severe hemorrhage for example; milk production is minimal for
a few days until the mother has recovered. All of her additional
reserves are being used to heal her body. Until the crisis is
past, the breasts may not produce milk.
Infant Complications
The Baby With Low Blood Sugar
Hypoglycemia is defined as a blood sugar level of 30 mg/dL in
the first day of life (Riordan and Auerbach 658). There is controversy
over the definition of a "normal range" for blood sugar. (WHO
Hypoglycaemia, 5, 27) In their position paper; "Hypoglycaemia
[sic] of the Newborn," the WHO states that "early and exclusive
breastfeeding is safe to meet the nutritional needs of term healthy
newborns (2)." For the normal, healthy infant breastmilk is all
he needs. Supplementation or "complimentary feeding" with D5W
or formula after breastfeeding is strongly discouraged. It can
put both the mother and the infant on a downward spiral toward
breastfeeding failure.
The neonate's blood sugar normally drops within an hour of delivery. Then gradually stabilizes by 6 hours after birth with unrestricted access to the breast. The infant has mechanisms that help in the transition from placental "feeding," to oral feeding. The baby with low blood sugar appears to do better on mother's milk as formula protein may interfere with ketogenesis (WHO Hypoglycaemia 37). "Symptoms of low blood sugar are vague: jitteriness, lethargy , a weak high-pitched cry and "are similar to those caused by many other conditions (Riordan and Auerbach 658)." "Term babies do not develop symptomatic hypoglycaemia [sic] as a result of simple underfeeding (WHO Hypoglycaemia 44) Persistent hypoglycemia can be caused by other factors such as sepsis.
In cases where the infant at risk; SGA, preterm, or LGA, supplemental feedings of expressed mother's milk or artificial baby milk may be required to maintain the infant's blood sugar. If breastfeeding is poorly tolerated and if hypoglycemia is continuing, intravenous glucose or formula should be given, but not glucose water. The use of glucose water to raise blood sugar is not recommended because it raises the blood sugar rapidly and contributes to neonatal jaundice. The sharp increase in the blood glucose level stimulates the infant to produce insulin and a rebound effect occurs. The increased insulin level lowers the blood sugar further (Auerbach and Riordan 659; Lawrence and Lawrence 285).
All staff should be educated in the how to obtain the sample for whole blood glucose levels and the proper use of glucose meters specifically designed for the neonatal period. Low blood sugar should be always documented by blood glucose levels and treatment begun as soon as possible. One or two supplementary feedings are usually all the infant needs to keep his blood sugar stable. Supplementation after every breastfeeding, without documentation of continued low blood sugar, can greatly affect maternal milk production and the infant's willingness to breastfeed.
Copyright 1999 Marie Davis, RN, IBCLC
reviewed:
Wednesday, September 15, 2010