Does Mode of Birthing Have Any Effect on Breastfeeding?

Assalamualaikum/Greetings.
It's been quite a long hiatus since I wrote. Truly I love writing and I find it a source of therapy for myself while I share whatever little knowledge I gained during studying and consultation sessions with my clients.

As a Childbirth Educator and also a Lactation Counselor, this is a topic close to my heart. Does MODE OF BIRTHING actually has any impact on breastfeeding success? Let's have a little insight on this topic.

Firstly, I will briefly enlighten on the lactation physiology for a better understanding.

Very briefly focusing on lactogenesis, it is divided into 3 stages.

Stage 1: Begins during the second trimester of pregnancy & continues until about day 2-3 postpartum. During this period, the breast undergoes changes to prepare for lactation while the constituents of milk are already being manufactured and ready to be released under stimulation of prolactin after childbirth.

Stage 2: Begins during postpartum day 2 or 3. This is when a mother might feel a sensation of breast fullness or also known as "milk coming in".

Stage 3: This is the phase of maintainence of breastmilk secretion. This occurs during days 14 to day 30 of post partum. This is when mature milk is established. Prolactin and Oxytocin is essential for effective maintainence of milk supply, therefore frequent nursing and milk expression (if necessary) is essential during this period of time to ensure sufficient supply.

Note the changes in breastmilk with time

Onset of secretory activation (lactogenesis II) is an endocrine@hormonal function, while maintenance of lactation, lactogenesis III, is an autocrine@local function with the control located in each breast. 

With this in mind you will understand that mode of delivery will not affect the physiological onset of lactation. 

Type of Birth	Delayed Milk Onset
Spontaneous vaginal	16%
Assisted vaginal	42%
Scheduled cesarean	27%
Emergency cesarean	56%

                                         (Adapted from Dewey, 2003)1 



Note that the mode of delivery (vaginal vs cesarean) was not the cause of delayed lactogenesis. Only something that interferes with the proper functioning of the endocrine system will delay or inhibit secretory activation such as accidents at birthing for example, retention of a functional portion of the placenta that continues to secrete progesterone, or a hemorrhage severe enough to cause Sheehan's syndrome (pituitary gland necrosis). And so might stress.

   Below are some studies associating stress & delayed milk onset. 

High stress levels are correlated with high cortisol levels. Cortisol, in normal concentrations, is also necessary to initiate secretory activation (lactogenesis II) successfully, though what its role is isn't fully understood yet.

• The relationship between the birth experience and lactation performance of 40 women was explored. Stress hormones were measured in serum or plasma during pregnancy, parturition (cord and maternal blood), and lactation. The researchers found that markers of both fetal and maternal stress during labor and delivery were associated with delayed breast fullness.2


• Salivary cortisol levels were studied in women intrapartum and postpartum, to ascertain any link between them and the onset of lactation. Onset of lactation occurred later in women who had higher cortisol levels. Primiparous women had higher levels than multiparous women. They concluded that stress during labor and/or delivery is likely to be a significant risk factor for delayed onset of lactation.3


• Two mechanisms have been suggested to explain the link between delayed lactation and stress. Firstly, maternal stress seems to interfere with the release of oxytocin causing poor milk removal. Although milk removal is not necessary to trigger secretory activation, it may be related to the timing of onset of full milk production or the volume of milk produced. And secondly, a newborn who experienced stress during labor and delivery may be too weak or too sleepy to latch on and suckle effectively at the breast.4


• Cortisol levels were measured in the fetus and correlated with birthing circumstances. Umbilical vein cortisol was significantly elevated in association with spontaneous normal birthing, but highest for infants experiencing an instrumental delivery and lowest in infants delivered by elective cesarean section.5


• Cortisol levels fell significantly during the breastfeeding sessions on Day 2 postpartum and correlated with the duration of skin-to-skin contact before the onset of sucking. However, between mothers having received epidural analgesia, with and without oxytocin, cortisol levels differed significantly. The researchers noted that medical interventions in connection with birth influence the activity of the hypothalamic-pituitary-adrenal axis 2 days after birth.6

What about Caesarian Sections & Instrumental Vaginal Deliveries?

Women who have a cesarean section experience a significant delay in initiating breastfeeding compared with women giving birth vaginally, with or without instrumental assistance.7,8 One study showed that breastfeeding rates at 8 months weren't significantly different7 while another8 showed that cesarean delivery was associated with a lower breastfeeding rate at discharge and at follow-up at 7 days, 3 and 6 months of life. In a further population that has a high breastfeeding initiation and duration rate, cesarean section delivery was significantly related to earlier cessation of breastfeeding.9

A Hong Kong study followed a very large cohort and identified cesarean delivery as a risk factor for:10

• not initiating breastfeeding
• for breastfeeding for less than 1 month, and
• a significant hazard against breastfeeding duration.
• Assisted delivery with forceps or vacuum, although not associated with breastfeeding initiation, was a significant risk for reduced breastfeeding duration.

An interesting study investigated differences in the hormonal patterns of oxytocin, prolactin and cortisol between women delivered by emergency cesarean section or vaginally, and their relationship to the duration of breastfeeding. The researchers found that the mothers birthing vaginally had significantly more oxytocin pulses on Day 2 than the cesarean section mothers. Furthermore, the cesarean section women lacked a significant rise in prolactin levels at 20-30 min after the onset of breastfeeding. They were able to link the oxytocin pulsatility on Day 2 to the duration of exclusive breastfeeding.11

I have not touched on the intrapartum factors like ability to eat, drink, IV fluids commencement, mobility, analgesia with regards to breastfeeding; which I will do so in future posts, hopefully :-)

Maternal Commitment? In the end, this is the most important key to breastfeeding success!

Several authors(7,9,12) have demonstrated that maternal commitment and support by health care professionals are significant factors in the mother reaching her breastfeeding goal when obstetric factors are against it. Intervention is sometimes lifesaving, and sometimes we are in no position to prevent unnecessary intervention. Giving the neonate and mother as much skin-to-skin contact as possible, being patient and continuing to support the mother for as long as it takes are all important to assisting her to follow through with her commitment to breastfeeding. 

Of course, early preparation like attending breastfeeding and birthing classes during the antenatal period would help mothers be well prepared on birthing and breastfeeding, empower themselves with knowledge and ensure that they understand what is happening during the time of labour to avoid stress on themselves should anything unplanned happen along they way.

So, moral of the story, be it spontaneous vaginal delivery or caesarian section..empower yourselves with knowledge, understand what is going on with your body and should you need necessary interventions, understand the situation, think rationally, avoid grudge or holding on to emotional baggage..please avoid stress...and believe that you can breastfeed your baby!


References:

1. # Dewey KG et al. (2003) Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss
2. # Chen DC et al. (1998) Stress during labor and delivery and early lactation performance
3. # Grajeda R et al. (2002) Stress during labor and delivery is associated with delayed onset of lactation among urban Guatemalan women
4. # Dewey KG (2001) Maternal and fetal stress are associated with impaired lactogenesis in humans
5. # Mears K et al. (2004) Fetal cortisol in relation to labour, intrapartum events and mode of delivery
6. # Handlin L et al. (2009) Effects of sucking and skin-to-skin contact on maternal ACTH and cortisol levels during the second day postpartum-influence of epidural analgesia and oxytocin in the perinatal period.
7. # Rowe-Murray HJ et al. (2002) Baby Friendly Hospital Practices: Cesarean Section is a Persistent Barrier to Early Initiation of Breastfeeding
8. # Zanardo V et al. (2010) Elective cesarean delivery: does it have a negative effect on breastfeeding?
9. # Shawky S et al. (2003) Maternal factors associated with the duration of breast feeding in Jeddah, Saudi Arabia
10. # Leung GM et al. (2002) Breast-feeding and its relation to smoking and mode of delivery
11. # Nissen E et al. (1996) Different patterns of oxytocin, prolactin but not cortisol release during breastfeeding in women delivered by caesarean section or by the vaginal route
12. # Janke JR (1988) Breastfeeding duration following cesarean and vaginal births