Linda J. Smith, MPH, IBCLC, Ohio, United States of America
Extracted and edited from: Smith, L. J., & Kroeger, M. (2010). Impact of birthing practices on breastfeeding (2nd ed.). Sudbury, Mass.: Jones and Bartlett.
Though it might seem obvious, for breastfeeding to happen the baby must be able to feed, the mother must be able and willing to let her baby feed, breastfeeding must be comfortable for both and the surroundings must support the dyad (mother and baby). All of these factors are impacted by interventions during labor and birth. La Leche League has recognized this from its inception, recognizing that childbirth practices affect breastfeeding for both the mother and the baby.
The chief labor and birth influences on breastfeeding are (1) mechanical forces that can disrupt body parts, (2) chemicals (drugs), (3) injuries to the mother and baby, and (4) psychological impacts. Unfortunately, there are few studies documenting how these issues affect breastfeeding, since lack of breastfeeding is rarely seen as an outcome that is studied or reported by researchers.
Even though maternal confidence has a significant impact on the initiation and continuation of breastfeeding, confidence and knowledge of birth are only part of the picture. Hospital routines and interventions can undermine even the most confident and well-prepared mother. A companion of the mother’s choice (doula) who stays with the mother throughout labor and birth is one of the most important factors contributing to a smoother birth and an easier start to breastfeeding.
Other interventions that can affect breastfeeding include epidural anesthesia and narcotic pain relief, induction/augmentation of labor, Cesarean (surgical) delivery, forceps delivery, vacuum extraction, and a long difficult labor, especially with a posterior presentation (baby is facing the mother’s front). In addition to the factors outlined below, these interventions can cause additional or excess pain and injuries to mother and/or baby, which also affects breastfeeding.
There are twelve cranial nerves involved in the suck, swallow, breathe coordination needed for babies to nurse effectively. These nerves can be pinched or otherwise affected by the movement of the baby’s cranial bones during the birth process. It is normal for some bone shifting to occur during labor and birth. A newborn’s breathing, breastfeeding, crying and other movements help the bones return to normal alignment within one to two weeks.
If additional or unusual forces are applied to an infant’s head during birth, those forces can result in additional and abnormal molding of the skull, causing facial and jaw asymmetry, and possibly torticollis (tightening of neck muscles on one side). If the baby’s head and body are in an abnormal position at the start of labor, the malpresentation may also have an effect.
Forceps use can cause nerve damage to an infant’s head and face, and vacuum extraction can result in a cephalohematoma (deep bruise under the scalp), which may contribute to jaundice, itself a risk factor for difficulty in initiating breastfeeding., 
In addition to the use of forceps, vacuum extraction or Cesarean surgery (in which the physician lifts the baby’s head and neck out of the abdominal incision), other mechanical factors that put more or abnormal force on the baby’s head and body include:
- Induction or augmentation of labor
- A long pushing (second) stage of labor
- A birth attendant pushing on the fundus (top or highest part of the uterus)
- The mother lying supine (on her back) and immobile for long periods can contribute to abnormal alignment of the baby’s head bones.
Cesarean section (Cesarean surgery)
Cesarean section has been associated with poorer infant outcomes, including more formula supplementation and reduced milk transfer on days two to five. According to the World Health Organization, 10-15% of Cesarean surgeries are probably medically justified; however, rates are substantially higher than this in many places. While many Cesareans are performed because of “failure to progress,” in 2014 the American College of Obstetricians and Gynecologists stated
“…it may be necessary to revisit the definition of labor dystocia [a slow/difficult labor] because recent data show that contemporary labor progresses at a rate substantially slower than what was historically taught.”
For mothers who have had at least one previous surgical abdominal birth, the National Institutes of Health (NIH) in the USA states that a trial of labor is a reasonable option for many pregnant women with a prior low transverse uterine incision.
A surgical birth requires a longer recovery and may result in delayed onset of lactogenesis (milk “coming in”.) Because of this, it may be useful to suggest that mothers at risk for Cesarean hand express and store colostrum prenatally starting at 36 weeks of pregnancy. This can help supplement the baby until the mother’s milk has transitioned from colostrum to full milk production. Mothers should also be aware that extended pain relief may be necessary after Cesarean surgery, and that most pain medications are compatible with breastfeeding. In addition, many mothers may not be aware that antibiotics are routinely given during surgery, so informing them of the possibility of nipple thrush (fungal infection) may enable them to seek treatment sooner if nipple pain (from thrush) occurs.
Epidural anesthesia is often used for Cesarean surgery, and epidural rates around the world continue to rise, even for uncomplicated vaginal births. The medications used in epidurals have pediatric half-lives of between 8 and 18 hours, which means the drugs affect the baby longer than they affect the mother. It takes about 5 half-lives to clear most of any medications from the infant’s system, resulting in groggy newborns who have difficulty latching properly and sucking effectively. Fentanyl administered via epidural is turning out to be especially problematic. A prospective, randomized, double-blind study done in 2005 concluded that
“Among women who breast-fed previously, those who were randomly assigned to receive high-dose labor epidural fentanyl were more likely to have stopped breast-feeding 6 weeks postpartum than women who were randomly assigned to receive less fentanyl or no fentanyl.” 
When epidurals are given, intravenous (IV) fluids are also given to avoid maternal low blood pressure. Overhydration from IV fluids can result in a greater risk of edema (fluid retention) in the mother (including breast edema) and an artificially inflated birth weight in the infant. When epidurals are given, there is a greater risk of augmentation of labor, more risk of infant resuscitation, more frequent use of instruments and more risk of Cesarean surgery. The most recent study on this issue states,
“Results suggest that intrapartum exposure to the drugs fentanyl and synthetic oxytocin significantly decreased the likelihood of the baby suckling while skin-to-skin with its mother during the first hour after birth.”
Research confirms that all medications for pain relief given to the mother during labor and birth, even local lidocaine, quickly reach the baby via the placenta and all delay the onset of lactation.
Other research linking epidurals and breastfeeding outcomes includes a study reporting that epidural anesthesia is associated with impaired spontaneous breastfeeding and breastfeeding at discharge from the hospital. Another study related to skin temperature found that
“…the skin temperature in newborns rises when newborns are put skin-to-skin to breastfeed two days postpartum. This effect on temperature may be hampered by medical interventions during labour such as EDA (epidural analgesia).”
Lower skin temperature in a newborn can lead to separation from the mother because the infant is placed in an incubator or warmer instead of skin-to-skin on mother’s body. Any such separation is a risk factor for breastfeeding difficulties.
Preterm birth is also associated with problems breastfeeding. Both elective (scheduled) Cesarean (without labor) and induction of labor, especially without a compelling medical reason, increase the risk that a baby will be born early. Epidural medications, elective Cesarean surgery, and induction of labor all significantly lower endorphin (pain relieving hormones) levels that are normally elevated during the first ten days of life. This lack of natural pain relief for the newborn means the baby may be experiencing more-than-normal pain even from routine procedures. .
Suctioning mucus from baby’s nose and mouth is another common obstetrical practice that can disrupt breastfeeding. Routine suctioning may result in oral aversion, may trigger poor tongue movements, and can result in injury to the oropharanyx (part of the pharynx). Mucus in utero serves a purpose, so many birth providers now simply let mucus drain from the infant’s nose and mouth unless respiratory problems occur.  Research has shown that suctioning lacks benefits even in the presence of meconium stained amniotic fluid:
“Routine intrapartum oropharyngeal and nasopharyngeal suctioning of term-gestation infants born through MSAF (meconium-stained amniotic fluid) does not prevent MAS (meconium aspiration syndrome). Consideration should be given to revision of present recommendations.” 
Other birth practices
Several standard birth procedures can negatively affect a baby’s suck if done before the first breastfeeding session: separation from the mother for any reason including weighing or measuring; a vitamin K injection; heel sticks for metabolic tests; and elective surgical procedures. Infant hypothermia (low body temperature), often the result of a bath shortly after birth, can result in hypoglycemia (low blood sugar) and other newborn problems. A 2013 study showed that delaying an infant’s first bath resulted in both increased likelihood of breastfeeding initiation and increased in-hospital breastfeeding rates.
How Leaders can help
Injured, drugged and/or immature infants tend to feed poorly. This often leads to damaged nipples in the mother and a hungry, unhappy baby, which in turn undermines the mother’s confidence and affects their relationship. Poor feeding results in less milk removed from the breasts, which then leads to impaired milk production. LLL Leaders can provide mothers with basic breastfeeding information and refer to an International Board Certified Lactation Consultant (IBCLC) when the issues become too complex.
A Leader can also be an empathetic listener to a mother who needs to tell her birth story and provide other emotional support. Leaders can encourage a mother whose baby doesn’t latch right away to start hand-expressing colostrum into a spoon and giving it to her newborn starting within 1-2 hours of birth then every hour or so. This can continue until the infant is breastfeeding effectively or the mother has worked out a plan with a skilled lactation care provider/IBCLC. The Leader can also explain the importance of skin-to-skin contact and provide information on safe bed-sharing to keep mother and baby together.
For pregnant women or mothers looking to improve their breastfeeding experiences with the next child, Leaders can inform these parents of the research-based practices outlined by the Baby Friendly Hospital Initiative and the updated World Health Organization’s Intrapartum Care for a Positive Childbirth experience. Supportive practices during labor and birth include encouraging women to have companions of their choice during labor; eating and drinking lightly as desired; considering non-drug methods of pain relief; walking/moving around and assuming positions of their choice while giving birth; and seeking care providers and facilities that do not practice routine invasive procedures.
Not all birth interventions can be avoided, and some are life saving. Even necessary birth practices can have a profound impact on the ability of the newborn to latch and nurse effectively and on the mother’s ability and willingness to care for her baby many hours of the day and night. Leaders need to be aware of these issues and be prepared to support mothers as they work towards establishing a long and satisfying breastfeeding relationship.
For more in-depth information on how birth practices impact breastfeeding, see:
- Impact of Birthing Practices on Breastfeeding published by Jones & Bartlett or
- Register for Linda J. Smith’s LLLI webinar, Impact of Birth Practices on the Breastfeeding Mother-Baby Dyad. In this webinar Linda Smith shares an in-depth view of current birth practices and their impact on breastfeeding behaviors in newborn babies and their mothers. She discusses how medications used in childbirth may affect the sucking ability of infants, the response of the mother to the baby, and the long lasting—perhaps even lifelong—effects that birth has on behavior. Linda’s presentation is supported throughout by research showing that interventions during birth are not without consequence.
Linda J. Smith has been an LLL Leader since 1974 and lives in Ohio, United States of America. She has served on the LLLI Board of Directors and in the Professional Liaison Department and is the author of four professional textbooks on birth and breastfeeding and is co-author of Sweet Sleep, Nighttime and Naptime Strategies for the Breastfeeding Family.
 Smith, L. J. (2007). Impact of birthing practices on the breastfeeding dyad. J Midwifery Womens Health, 52(6), 621-630.
 Smith, L. J. (2017). Impact of Birth Practices on Infant Suck. In C. W. Genna (Ed.), Supporting Sucking Skills in Breastfeeding Infants (Third ed.). Boston, MA: Jones and Bartlett Publishers.
 Evans KC, Evans RG, Royal R, Esterman AJ, James SL. Effect of caesarean section on breast milk transfer to the normal term newborn over the first week of life. Arch Dis Child Fetal Neonatal Ed 2003;88:F380 –2.
 NIH Consensus Development Conference: Vaginal Birth After Cesarean: New Insights March 8–10, 2010
 Brisbane, J. M., & Giglia, R. C. (2015). Experiences of expressing and storing colostrum antenatally: A qualitative study of mothers in regional Western Australia. J Child Health Care, 19(2), 206-215.
 Sachs, H. C., & AAP Committee on Drugs. (2013). The Transfer of Drugs and Therapeutics Into Human Breast Milk: An Update on Selected Topics. Pediatrics.
 Moore, A., El-Bahrawy, A., Hatzakorzian, R., et al. (2016). Maternal Epidural Fentanyl Administered for Labor Analgesia Is Found in Neonatal Urine 24 Hours After Birth. Breastfeed Med, 11, 40-41.
 Beilin Y et al. Effect of labor epidural analgesia with and without fentanyl on infant breast-feeding: a prospective, randomized, double-blind study. Anesthesiology 2005, 103(6), 1211-1217.
 Brimdyr, K., Cadwell, K., Widström, A.-M., Svensson, K., Neumann, M., Hart, E. A., Phillips, R. (2015). The Association Between Common Labor Drugs and Suckling When Skin-to-Skin During the First Hour After Birth. Birth, n/a-n/a. doi: 10.1111/birt.12186
 Lind, J. N., Perrine, C. G., & Li, R. (2014). Relationship between Use of Labor Pain Medications and Delayed Onset of Lactation. Journal of Human Lactation, 30(2), 167-173
 Jonas, W., Wiklund, I., Norman, M., Uvnas-Moberg, K., Ransjo-Arvidson, A. B., & Andolf, E. (2009). Epidural analgesia: breast-feeding success and related factors. Midwifery, 25(2), e31-38.
 Jonas, W., Wiklund, I., Nissen, E., Ransjo-Arvidson, A. B., & Uvnas-Moberg, K. (2007). Newborn skin temperature two days postpartum during breastfeeding related to different labour ward practices. Early Hum Dev, 83(1), 55-62.
 Christensson K, Siles C, & L, M. (1992). Temperature, metabolic adaptation and crying in healthy full term newborns cared for skin-to-skin or in a cot. Acta Paediatr, 81, 488. .
 Zanardo V, Nicolussi S, Carlo G, Marzari F, Faggian D, Favaro F, et al. Beta endorphin concentrations in human milk. J Pediatr Gastroenterol Nutr 2001;33:160–4.
 Black, L. S. (2001). Incorporating breastfeeding care into daily newborn rounds and pediatric office practice. Pediatr Clin North Am, 48(2), 299-319.
 Foster, J. P., Dawson, J. A., Davis, P. G., et al. (2017). Routine oro/nasopharyngeal suction versus no suction at birth. Cochrane Database Syst Rev, 4, Cd010332.
 Vain et al, Lancet 2004;364 (9434):597-602
 Preer, G., Pisegna, J. M., Cook, J. T., Henri, A.-M., & Philipp, B. L. (2013). Delaying the Bath and In-Hospital Breastfeeding Rates. Breastfeeding Medicine, 8(6), 485-490.
 Baby-Friendly Hospital Initiative, World Health Organisation, 2009 https://www.ncbi.nlm.nih.gov/books/NBK153471/
 World Health Organization. (2018). WHO recommendations: intrapartum care for a positive childbirth experience. Retrieved from Geneva: http://www.who.int/reproductivehealth/publications/intrapartum-care.