Associations of drugs routinely given in labour with breastfeeding at 48 hours: analysis of the Cardiff Births Survey

The Association of Prenatal Diagnoses with Mortality and Long-Term Morbidity in Children with Specific Isolated Congenital Anomalies: A European Register-Based Cohort Study

OBJECTIVES

To compare 5-year survival rate and morbidity in children with spina bifida, transposition of great arteries (TGA), congenital diaphragmatic hernia (CDH) or gastroschisis diagnosed prenatally with those diagnosed postnatally.

METHODS

Population-based registers' data were linked to hospital and mortality databases.

RESULTS

Children whose anomaly was diagnosed prenatally (n = 1088) had a lower mean gestational age than those diagnosed postnatally (n = 1698) ranging from 8 days for CDH to 4 days for TGA. Children with CDH had the highest infant mortality rate with a significant difference (p < 0.001) between those prenatally (359/1,000 births) and postnatally (116/1,000) diagnosed. For all four anomalies, the median length of hospital stay was significantly greater in children with a prenatal diagnosis than those postnatally diagnosed. Children with prenatally diagnosed spina bifida (79% vs 60%; p = 0.002) were more likely to have surgery in the first week of life, with an indication that this also occurred in children with CDH (79% vs 69%; p = 0.06).

CONCLUSIONS

Our findings do not show improved outcomes for prenatally diagnosed infants. For conditions where prenatal diagnoses were associated with greater mortality and morbidity, the findings might be attributed to increased detection of more severe anomalies. The increased mortality and morbidity in those diagnosed prenatally may be related to the lower mean gestational age (GA) at birth, leading to insufficient surfactant for respiratory effort. This is especially important for these four groups of children as they have to undergo anaesthesia and surgery shortly after birth. Appropriate prenatal counselling about the time and mode of delivery is needed.

Impact of intrapartum oxytocin administration on neonatal sucking behavior and breastfeeding

This study aimed to examine the effect of intrapartum oxytocin administration on neonatal sucking behavior and breastfeeding. A total of 64 pairs (29 in the group treated with intrapartum oxytocin and 35 in the control group) of normal infants within 24-48 h of birth and their mothers were recruited. Sucking ability was evaluated by measuring Non-Nutritive Sucking (NNS) for 5 min. Data on the rate of exclusive breastfeeding at 1 month postpartum were collected. In the adjusted multiple regression models, intrapartum oxytocin exposure was significantly associated with fewer total NNS bursts (95% confidence interval (CI), -7.02 to -0.22), longer pause times (95% CI, 1.33 to 10.21), and greater pause-time variability (95% CI, 3.63 to 63.92). Effects estimated using structural equation modeling revealed that intrapartum oxytocin exposure had a significant negative and direct effect on the practice of exclusive breastfeeding 1 month postpartum (β = -0.238, p = 0.047). However, no NNS-mediated indirect effects were observed. This report demonstrates that infants born to mothers who receive intrapartum oxytocin may have impaired sucking ability for at least the first 48 h after birth, and breastfeeding support should be provided.

Trends and regional variations in prescriptions dispensed to stimulate uterine contractions at the end of pregnancy in Belgium: A community-based study from 2003 to 2018

PURPOSE

To investigate trends and regional variations in uterotonics dispensed around birth between 2003 and 2018 in Belgium.

METHODS

Data, including outpatient and inpatient prescriptions were extracted from a nationally representative prescription database. The prevalence of uterotonics dispensed during a period including the 7 days before birth, the delivery day and the 7 days after birth was computed over three 4-year-long study periods from 2003 to 2018. The trends between periods and associations between the use of at least one uterotonic and maternal age, region of residence, delivery type and social status were assessed using logistic regression.

RESULTS

In total, 31 675 pregnancies were included in the study. The proportion of pregnancies exposed to at least one uterotonic decreased significantly from 92.9% (95%CI, 92.3-93.4) in 2003-2006 to 91.4% (95%CI, 90.7-92.0) in 2015-2018 for vaginal births and from 95.5% (95%CI, 94.5-96.4) to 93.7% (95%CI, 92.6-94.7) for caesarean sections. However, for vaginal births, the proportion of oxytocin increased from 84.5% (95%CI, 83.7-85.2) to 89% (95%CI 88.3-89.7). A significant association was found between uterotonic agent use and maternal age, region of residence, and delivery type. The dispensation of some uterotonic agents differed significantly between the regions.

CONCLUSIONS

The proportion of pregnancies exposed to at least one uterotonic was high across the study period but decreased slightly between 2003 and 2018. Important variations in uterotonic use between regions highlight the need for improved national guidance.

Peripartum effects of synthetic oxytocin: The good, the bad, and the unknown

The first clinical applications of oxytocin (OT) were in obstetrics as a hormone to start and speed up labor and to control postpartum hemorrhage. Discoveries in the 1960s and 1970s revealed that the effects of OT are not limited to its peripheral actions around birth and milk ejection. Indeed, OT also acts as a neuromodulator in the brain affecting fear memory, social attachment, and other forms of social behaviors. The peripheral and central effects of OT have been separately subject to extensive scrutiny. However, the effects of peripheral OT-particularly in the form of administration of synthetic OT (synOT) around birth-on the central nervous system are surprisingly understudied. Here, we provide a narrative review of the current evidence, suggest putative mechanisms of synOT action, and provide new directions and hypotheses for future studies to bridge the gaps between neuroscience, obstetrics, and psychiatry.

Effect of lullaby on volume, fat, total protein and albumin concentration of breast milk in premature infants' mothers admitted to NICU: a randomized controlled trial

Background

Listening to music can reduce or manage stress, fatigue, and accompanying symptoms in mothers. Music increases oxytocin secretion which affects breast milk. This study aimed to examine the effect of lullaby on volume, fat, total protein and albumin concentration of breast milk in mothers of premature infants admitted to the NICU.

Methods

This clinical trial was performed on 100 primiparous mothers whose premature infants were hospitalized in the NICU of Ayatollah Rouhani Hospital from January 2020 to December 2020. Using block randomization method, the participants were divided into three groups: control (A), playing lullaby for mother (B) and playing lullaby for a mother while holding a photo of her own baby (C). The mothers of the intervention groups listened to lullabies through headphones for 30 minutes every morning for 6 days. On the first and the sixth day of birth, the volume of breast milk (ml) and two milliliters of breast milk samples of all three groups were measured and compared in terms of fat, albumin concentration and total protein (mg/DL). ANOVA, Paired T-Test and ANCOVA model (the included variables were: basic value of dependent variable, group type, Maternal age, Birth weight, Gestational age and Maternal weight) was used for analytical statistics.

Results

The difference between the mean compositions of breast milk before and after the intervention in three groups of A, B and C: in terms of the breast milk volume were 66.33 ± 4.80, 71.30 ± 4.18 and 75.91 ± 6.80 ml; in terms of triglyceride level was 177.84 ± 50.57, 210.72 ± 34.55 and 224.17 ± 12.97 mg/DL, cholesterol level was 14.57 ± 3.70, 21.96 ± 3.82 and 26.26 ± 5.16 mg/DL, albumin concentration was 0.90 ± 0.30, 1.22 ± 0.19 and 1.46 ± 0.28 mg/DL and total protein level was 1.61 ± 0.61, 2.20 ± 0.57 and 2.72 ± 0.30 mg/DL. Finally, the results of ANCOVA analysis for the effects of the intervention, taking into account the baseline values, showed that the intervention was effective and had the greatest effect on cholesterol levels.

Conclusion

In this small trial, there was a statistically significant association between trial arm and biochemical composition of breastmilk though further studies are needed to see if these changes result in meaningful clinical outcomes to the infant.

Trial registration

IRCT, IRCT20191114045439N1. Registered 14 January 2020- prospective, https://en.irct.ir/trial/43671

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-022-00511-7.

Breastfeeding, pregnancy, medicines, neurodevelopment, and population databases: the information desert

Background

The pharmacoepidemiology of the long-term benefits and harms of medicines in pregnancy and breastfeeding has received little attention. The impact of maternal medicines on children is increasingly recognised as a source of avoidable harm. The focus of attention has expanded from congenital anomalies to include less visible, but equally important, outcomes, including cognition, neurodevelopmental disorders, educational performance, and childhood ill-health. Breastfeeding, whether as a source of medicine exposure, a mitigator of adverse effects or as an outcome, has been all but ignored in pharmacoepidemiology and pharmacovigilance: a significant ‘blind spot’.

Whole-population data on breastfeeding: why we need them

Optimal child development and maternal health necessitate breastfeeding, yet little information exists to guide families regarding the safety of medicine use during lactation. Breastfeeding initiation or success may be altered by medicine use, and breastfeeding may obscure the true relationship between medicine exposure during pregnancy and developmental outcomes. Absent or poorly standardised recording of breastfeeding in most population databases hampers analysis and understanding of the complex relationships between medicine, pregnancy, breastfeeding and infant and maternal health. The purpose of this paper is to present the arguments for breastfeeding to be included alongside medicine use and neurodevelopmental outcomes in whole-population database investigations of the harms and benefits of medicines during pregnancy, the puerperium and postnatal period. We review: 1) the current situation, 2) how these complexities might be accommodated in pharmacoepidemiological models, using antidepressants and antiepileptics as examples; 3) the challenges in obtaining comprehensive data.

Conclusions

The scarcity of whole-population data and the complexities of the inter-relationships between breastfeeding, medicines, co-exposures and infant outcomes are significant barriers to full characterisation of the benefits and harms of medicines during pregnancy and breastfeeding. This makes it difficult to answer the questions: ‘is it safe to breastfeed whilst taking this medicine’, and ‘will this medicine interfere with breastfeeding and/ or infants’ development’?

The Effects of Intrapartum Administration of Synthetic Oxytocin on Breastfeeding in the First 9 Months Postpartum: A Longitudinal Prospective Study

Background and Objective: Synthetic oxytocin (synOT) is a widely used drug to induce or accelerate labor and to prevent postpartum hemorrhage. Although some studies indicate there are associations between intrapartum synOT and impaired breastfeeding initiation or earlier cessation, the long-term effects of synOT on breastfeeding are largely understudied. The aim of this study was to examine the effects of synOT on breastfeeding status during the first 9 months postpartum. Materials and Methods: The women were recruited from five maternity hospitals during prenatal medical checkups or postpartum hospital stay. They reported their breastfeeding status on discharge from maternity hospital (mean 4.54 days postpartum) (N = 439), at 6 weeks (N = 439), and at 9 months postpartum (N = 274). The data related to synOT administration were extracted from the medical records. Results: In the analysis adjusted for maternal age, parity, educational level, marital status, child's sex, delivery mode, and labor analgesia/anesthesia, intrapartum administration of synOT predicted a lower probability of exclusive breastfeeding on discharge from maternity hospital (odds ratio = 0.37; p = 0.006), but we observed no effect on breastfeeding status at 6 weeks or 9 months postpartum. Conclusion: Our results suggest that adverse effects of synOT on breastfeeding do not persist beyond the first postpartum days.

Predictors of exclusive breastfeeding in the first six months: four consecutive surveys in a tertiary hospital in Lithuania

Background

There are little up-to-date data available on the duration of exclusive breastfeeding in Lithuania. The aim of our study was to examine the factors that could influence exclusive breastfeeding during the first 6 months of life.

Methods

In 2016, a survey was conducted at the Obstetrics and Gynecology Clinic of Vilnius University Hospital, Santaros Klinikos. Women in postnatal wards were opportunistically offered questionnaires and later followed up by telephone interviews at 6 weeks, 3 months, and 6 months postpartum. We used binary logistic regression to determine the factors that impacted exclusive breastfeeding during the first 6 months following childbirth.

Results

Of 475 eligible women that were approached, a total of 447 women were recruited, with response rates of 76.1, 71.4 and 67.0% at 6 weeks, 3 months, and 6 months postpartum, respectively. The prevalence of exclusive breastfeeding through the 6 month postpartum period was 39.8%. Exclusive breastfeeding during days 2 to 4 postpartum was positively influenced by factors such as a natural childbirth, the practice of breastfeeding on demand and maternal self-confidence in breastfeeding. Subsequently, exclusive breastfeeding on demand in the immediate postpartum period and exclusive breastfeeding for up to 3 months were associated with successful exclusive breastfeeding up to 6 months. However, the adverse factors that limited the success and duration of exclusive breastfeeding included free samples of human milk substitutes or advertising at primary healthcare centers 6 weeks after childbirth, pacifier use 6 months after childbirth, as well as amniotomy for labor induction.

Conclusions

Our research demonstrated that exclusive breastfeeding is impacted in both directions by a range of factors during particular periods after delivery. One of the novel findings was the adverse influence of amniotomy for labor induction on exclusive breastfeeding rates. Taking into account diverse factors influencing exclusive breastfeeding and the absence of a single way to promote it, there is a crucial need to increase the incidence of exclusive breastfeeding until infants reach the age of 6 months.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-021-00364-6.

Relationships Among Factors Related to Childbirth and Breastfeeding Outcomes in Primiparous Women

OBJECTIVES

To explore the relationships among potentially modifiable factors related to childbirth and effective breastfeeding initiation at approximately 36 hours after birth and duration and exclusivity at hospital discharge, 2 weeks, 2 months, and 6 months after birth in primiparous women and to explore whether modifiable and nonmodifiable secondary factors and covariates influenced the relationships among factors related to childbirth and these breastfeeding outcomes.

DESIGN

A prospective, longitudinal, cohort study.

SETTING

The postpartum units of two general hospitals in eastern Canada.

PARTICIPANTS

Ninety-seven mother-infant dyads.

METHODS

We recorded demographic, childbirth, obstetric history, and breastfeeding data through chart review. A breastfeeding observation was completed at approximately 36 hours after birth by unit nurses. Participants maintained breastfeeding logs in hospital and for 6 months after birth and completed three self-report questionnaires before discharge. We analyzed outcomes using backward stepwise linear and logistic regression.

RESULTS

One childbirth factor, labor induced with oxytocin, was negatively associated with effective initiation of breastfeeding, and none was related to breastfeeding duration and exclusivity at any time point. Maternal weight; professional support; and newborn's gestational age at birth, 5-minute Apgar score, weight loss, LATCH score, and active feeds (newborn actively suckled at the breast) were significantly associated with breastfeeding outcomes.

CONCLUSION

Induction of labor with oxytocin should be used judiciously; when used, nurses must be hypervigilant to assess the mother-infant dyad for breastfeeding issues and to intervene to prevent or remediate them.

Determinants of excessive weight loss in breastfed full-term newborns at a baby-friendly hospital: a retrospective cohort study

Background

Excessive weight loss in newborns is associated with neonatal complications such as jaundice and dehydration, which cause renal failure, thrombosis, hypovolemic shock, and seizures. The identification of the risk factors for excessive weight loss will help to discover preventive measures. The aim of this study was to determine the factors associated with excessive weight loss, defined as weight loss of ≥10%, in breastfed full-term newborns in Japan.

Methods

The present retrospective study, which was performed in a tertiary perinatal center accredited as a Baby-Friendly Hospital, included neonates who were born alive with a gestational age of ≥37 weeks. Cases of multiple births, admission to the neonatal intensive care unit (NICU), referral to another facility, or exclusive formula feeding were excluded. Multivariate logistic regression analyses were performed to assess the association between maternal or neonatal characteristics and excessive weight loss.

Results

We studied 399 newborns, of whom 164 (41%) had excessive weight loss. According to the adjusted multiple regression analysis, the factors associated with excessive weight loss were an older maternal age, primiparity, and antepartum Caesarean section, with adjusted odds ratios (95% Confidence Intervals [CIs]) of 1.07 (1.02, 1.11), 2.72 (1.69, 4.38), and 2.00 (1.09, 3.65), respectively.

Conclusions

Close monitoring of infants born to older mothers, primiparous mothers, or infants delivered by antepartum Cesarean section is recommended, and earlier supplementation with artificial milk may be considered.

Antidepressant prescriptions, discontinuation, depression and perinatal outcomes, including breastfeeding: A population cohort analysis

Objectives

To explore associations between exposure to antidepressants, their discontinuation, depression [medicated or unmediated] and preterm birth [<37 and <32 weeks], small for gestational age (SGA) [<10th and <3rd centiles], breastfeeding [any] at 6–8 weeks.

Methods

Design: A population-based cohort study.

Setting: The Secure Anonymised Information Linkage [SAIL] databank in Wales, linking maternal primary care data with infant outcomes.

Participants: 107,573, 105,331, and 38,725 infants born 2000–2010 with information on prematurity, SGA and breastfeeding respectively, after exclusions.

Exposures: Maternal antidepressant prescriptions in trimesters 2 or 3, discontinuation after trimester 1, recorded diagnosis of depression [medicated or unmediated] in pregnancy.

Methods: Odds ratios for adverse pregnancy outcomes were calculated, adjusted for smoking, parity, socio-economic status, and depression.

Results

Exclusive formula feeding at 6–8 weeks was associated with prescriptions in trimesters 2 or 3 for any antidepressants (adjusted odds ratio [aOR] 0.81, 95% confidence intervals 0.67–0.98), SSRIs [aOR 0.77, 0.62–0.95], particularly higher doses [aOR 0.45, 0.23–0.86], discontinuation of antidepressants or SSRIs after trimester 1 (aOR 0.70, 0.57–0.83 and 0.66, 0.51–0.87), diagnosis of depression aOR 0.76 [0.70–0.82), particularly if medicated (aOR 0.70, 0.58–0.85), rather than unmedicated (aOR 0.87, 0.82–0.92). Preterm birth at <37 and <32 weeks’ gestation was associated with diagnosis of depression (aOR 1.27, 1.17–1.38, and 1.33, 1.09–1.62), particularly if medicated (aOR 1.56, 1.23–1.96, and 1.63, 0.94–2.84); birth at <37 weeks was associated with antidepressants, (aOR 1.24, 1.04–1.49]. SGA <3rd centile was associated with antidepressants (aOR 1.43, 1.07–1.90), and SSRIs (aOR 1.46, 1.06–2.00], particularly higher doses [aOR 2.10, 1.32–3.34]. All adverse outcomes were associated with socio-economic status and smoking.

Implications

Exposure to antidepressants or depression increased risks of exclusive formula feeding at 6–8 weeks, and prescription of antidepressants was associated with SGA <3^rd centile. Prescription of antidepressants offers a useful marker to target additional support and additional care before and during pregnancy and lactation.

The Effect of Labor Epidural Analgesia on Breastfeeding Outcomes: A Prospective Observational Cohort Study in a Mixed-Parity Cohort

BACKGROUND

The effect of labor epidural analgesia (LEA) on successful breastfeeding has been evaluated in several studies with divergent results. We hypothesized that LEA would not influence breastfeeding status 6 weeks postpartum in women who intended to breastfeed in an environment that encourages breastfeeding.

METHODS

In this prospective observational cohort study, a total of 1204 women intending to breastfeed, delivering vaginally with or without LEA, were included; breastfeeding was recorded at 3 days and 6 weeks postpartum. Primary outcome was breastfeeding at 6 weeks, and the χ test was used for comparisons between women delivering with and without LEA, according to parity status and previous breastfeeding experience. Total epidural fentanyl dose and oxytocin use (yes/no) were recorded. A multivariable logistic regression was performed to assess factors affecting breastfeeding at 6 weeks.

RESULTS

The overall breastfeeding rate at 6 weeks was 76.9%; it was significantly lower among women delivering with LEA (74.0%) compared with women delivering without LEA (83.4%; P < .001). Among 398 nulliparous women, 84.9% delivered with LEA, compared with 61.8% of multiparous women (P < .001). Multiparous women (N = 806) were more likely to breastfeed at 6 weeks (80.0% vs 70.6% nullipara; P < .001). Using multivariable logistic regression that accounted for 14 covariates including parity, and an interaction term between parity and LEA use, LEA was significantly associated with reduced breastfeeding at 6 weeks (odds ratio, 0.60; 95% confidence interval, 0.40-0.90; P = .015). In a modified multivariable logistic regression where parity was replaced with previous breastfeeding experience, both as a covariate and in the interaction term, only previous breastfeeding experience was associated with increased breastfeeding at 6 weeks (odds ratio, 3.17; 95% confidence interval, 1.72-5.80; P < .001).

CONCLUSIONS

In our mixed-parity cohort, delivering with LEA was associated with reduced likelihood of breastfeeding at 6 weeks. However, integrating women's previous breastfeeding experience, the breastfeeding rate was not different between women delivering with and without LEA among the subset of multiparous women with previous breastfeeding experience. Therefore, our findings suggest that offering lactation support to the subset of women with no previous breastfeeding experience may be a simple approach to improve breastfeeding success. This concept subscribes to the notion that women at risk for an undesired outcome be offered tailored interventions with a personalized approach.

A priori choice of neuraxial labour analgesia and breastfeeding initiation success: a community-based cohort study in an Italian baby-friendly hospital

OBJECTIVE

To investigate whether the nature of the decision about receiving neuraxial labour analgesia is associated with breastfeeding initiation success (BIS), defined as exclusive breastfeeding until discharge associated with postnatal weight loss <7% at 60 hours from birth.

DESIGN

Single-centre community-based cohort study.

SETTING

An Italian baby-friendly hospital, from 1 July 2011 to 22 September 2015.

PARTICIPANTS

Inclusion criteria: women vaginally delivering singleton cephalic newborns and willing to breastfeed.

EXCLUSION CRITERIA

women who delivered in uterus-dead fetuses, were single or requested but did not receive neuraxial analgesia. Overall, 775 out of the 3628 enrolled women received neuraxial analgesia.

RESULTS

Compared with women who tried to cope with labour pain, those who decided a priori to receive neuraxial analgesia had less BIS (planned vaginal birth: 2121/3421 (62.0%), vs 102/207 (49.3%; p<0.001; risk difference (RD), 12.7%); actual vaginal birth: 1924/2994 (64.3%), vs 93/189 (49.2%; p<0.001; RD, 15.1%)). Multivariable analyses with antelabour-only confounders confirmed both associations (planned vaginal birth: relative risk (RR), 0.65; 95% CI, 0.48 to 0.87; actual vaginal birth: RR, 0.59; 95% CI, 0.43 to 0.80). Although women who requested analgesia as a last resort had less BIS than did those successfully coping with labour pain in the bivariable analyses (planned vaginal birth: 1804/2853 (63.2%), vs 317/568 (55.8%; p=0.001; RD, 7.4%); actual vaginal birth: 1665/2546 (65.4%), vs 259/448 (57.8%; p=0.002; RD, 7.6%)), multivariable analyses with either antelabour-only or peripartum confounders did not confirm these associations (planned vaginal birth: RR, 0.99; 95% CI, 0.80 to 1.23; actual vaginal birth: RR, 0.90; 95% CI, 0.69 to 1.16).

CONCLUSIONS

Compared with trying to cope with labour pain, a priori choice of neuraxial analgesia is negatively associated with BIS. Conversely, compared with having successfully coped with pain, requesting neuraxial analgesia as a last resort is not negatively associated with BIS.

Cessation of breastfeeding in association with oxytocin administration and type of birth. A prospective cohort study

BACKGROUND

Some studies have suggested an association between synthetic oxytocin administration and type of birth with the initiation and consolidation of breastfeeding.

AIM

This study aimed to test whether oxytocin administration and type of birth are associated with cessation of exclusive breastfeeding at different periods. A second objective was to investigate whether the administered oxytocin dose is associated with cessation of exclusive breastfeeding.

METHODS

We conducted a prospective cohort study (n=529) in a tertiary hospital. Only full-term singleton pregnancies were included. Four groups were established based on the type of birth (vaginal or cesarean) and the intrapartum administration of oxytocin. Follow-up was performed to evaluate the consolidation of exclusive breastfeeding at 1, 3 and 6months.

FINDINGS

During follow-up, the proportion of exclusive breastfeeding decreased in all groups. After adjusting for confounding variables, the group with cesarean birth without oxytocin (planned cesarean birth) had the highest risk of cessation of exclusive breastfeeding (odds ratio [95% confidence interval], 2.51 [1.53-4.12]). No association was found between the oxytocin dose administered during birth and puerperium period and the cessation of exclusive breastfeeding.

CONCLUSION

Planned cesarean birth without oxytocin is associated with the cessation of exclusive breastfeeding at 1, 3 and 6months of life. It would be desirable to limit elective cesarean births to essentials as well as to give maximum support to encourage breastfeeding in this group of women. The dose of oxytocin given during birth and puerperium period is not associated with cessation of exclusive breastfeeding.

Breastfeeding Outcomes After Oxytocin Use During Childbirth: An Integrative Review

INTRODUCTION

Despite widespread use of exogenous synthetic oxytocin during the birth process, few studies have examined the effect of this drug on breastfeeding. Based on neuroscience research, endogenous oxytocin may be altered or manipulated by exogenous administration or by blocking normal function of the hormone or receptor. Women commonly cite insufficient milk production as their reason for early supplementation, jeopardizing breastfeeding goals. Researchers need to consider the role of birth-related medications and interventions on the production of milk. This article examines the literature on the role of exogenous oxytocin on breastfeeding in humans.

METHODS

Using the method described by Whittemore and Knafl, this integrative review of literature included broad search criteria within the PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane, and Scopus databases. Studies published in English associating a breastfeeding outcome in relation to oxytocin use during the birth process were included. Twenty-six studies from 1978 to 2015 met the criteria.

RESULTS

Studies were analyzed according to the purpose of the research, measures and methods used, results, and confounding variables. The 26 studies reported 34 measures of breastfeeding. Outcomes included initiation and duration of breastfeeding, infant behavior, and physiologic markers of lactation. Timing of administration of oxytocin varied. Some studies reported on low-risk birth, while others included higher-risk experiences. Fifty percent of the results (17 of 34 measures) demonstrated an association between exogenous oxytocin and less optimal breastfeeding outcomes, while 8 of 34 measures (23%) reported no association. The remaining 9 measures (26%) had mixed findings. Breastfeeding intentions, parity, birth setting, obstetric risk, and indications for oxytocin use were inconsistently controlled among the studies.

DISCUSSION

Research on breastfeeding and lactation following exogenous oxytocin exposure is limited by few studies and heterogeneous methods. Despite the limitations, researchers and clinicians may benefit from awareness of this body of literature. Continued investigation is recommended given the prevalence of oxytocin use in clinical practice.

'It's your body, but…' Mixed messages in childbirth education: Findings from a hospital ethnography

OBJECTIVE

to investigate the personal, social, cultural and institutional influences on women making decisions about using epidural analgesia in labour. In this article we discuss the findings that describe practices around the gaining of consent for an epidural in labour, which we juxtapose with similar processes relating to use of water for labour and/or birth.

DESIGN

ethnography.

SETTING

tertiary hospital in Australian city.

PARTICIPANTS

sequential interviews were conducted with 16 women; hospital staff (primarily midwives and doctors) participated during six months of participatory observation fieldwork.

FINDINGS

women were not given full disclosure of either practice and midwives tailored the information they gave according to the institutional policies rather than evidence.

KEY CONCLUSIONS

informed consent is an oft-cited human right in health care, yet in maternity care the micro-politics of how informed consent is gained is difficult to ascertain, leading to a situation whereby the concept of informed consent is more robust than the reality of practice; an illusion of informed consent exists, yet information is often biased towards medicalised birth practices.

IMPLICATIONS FOR PRACTICE

as primary maternity care-givers, midwives have a role in providing unbiased information to women; however it appears that hospital culture and policy affect the way that this information is presented. It is arguable whether women in such instances are giving true informed consent, and for this reason, the ethics of these hidden practices are questioned.

Predictors of supplementation for breastfed babies in a Baby-Friendly hospital

PROBLEM

Supplementation of breastfed babies is common during the hospital stay.

BACKGROUND

The Baby Friendly Hospital Initiative (BFHI) optimises practices to support exclusive breastfeeding, yet supplementation is still prevalent.

OBJECTIVE

To determine predictors for supplementation in a cohort of breastfed babies in a Baby-Friendly hospital.

METHODS

Electronic hospital records of 1530 healthy term or near term singleton infants and their mothers were examined retrospectively and analysed to identify factors associated with in-hospital supplementation using Poisson regression (unadjusted and adjusted).

FINDINGS

Fifteen percent of breastfed infants were supplemented during their hospital stay. Analysis by multivariable Poisson regression found that supplementation was independently associated with overweight (reference normal weight) (aRR [adjusted relative risk]=1.46; 95% CI: 1.11-1.93); primiparity (aRR=1.40; 95% CI: 1.09-1.80); early term gestation (37-37⁶ weeks, aRR=2.79; 95% CI: 1.88-4.15; 38-38⁶ weeks, aRR=2.03, 95%CI: 1.46-2.82); birthweight less than 2500 grams (reference 3000-3499 grams) (aRR=3.60; 95% CI: 2.32-5.60) and use of postpartum uterotonic (aRR=2.47; 95% CI: 1.09-5.55). Greater than 65 minutes of skin-to-skin contact at birth reduced the risk of supplementation (aRR=0.66; 95% CI; 0.48-0.92).

CONCLUSION

These identified predictors for supplementation, can inform the development of interventions for mother-infant pairs antenatally or in the early postpartum period around increased breastfeeding education and support to reduce supplementation. It may also be possible to reduce supplementation through judicious use of postpartum uterotonics and facilitation of mother-infant skin-to-skin contact at birth for greater than one hour duration.

Nitrous oxide labor analgesia and pain relief memory in breastfeeding women

OBJECTIVE

The use of labor pain relief medications is a controversial issue that has engendered heated discussions among health care professionals about safety, interference with birthing, and breastfeeding.

METHODS

This is a case-control study with 62 puerperae treated with nitrous oxide and 124 control women (ratio 1:2), matched for age, gestational age, parity, delivery route, labor augmentation, and spinal regional analgesia. We tested anhedonia, anxiety, and depression symptoms at hospital discharge by The Edinburgh Postnatal Depression Scale (EPDS), and the intensity of nitrous oxide labor pain relief and satisfaction memory by a retrospective Visual Analog Scale (VAS, 0-10 Numeric Rating Scale) at a set cut off time of 3 months of a child's age.

RESULTS

Nitrous oxide use did not influence EPDS subscales upon discharge. Its use was instead associated with a lasting positive labor pain relief experience (VAS, 7.3 ± 2.2) in 83.5% of women, and labor satisfaction memory (VAS, 8.9 ± 1.8) in 90% of women, respectively, and with a significantly higher breastfeeding rates from the seventh day after discharge (p < .031), to the 1st (p < .043), and the third month of life (p < .016).

CONCLUSIONS

Nitrous oxide labor analgesia is associated with favorable effects on both women's psychoemotional experience of labor and breastfeeding success.

Practice Bulletin No. 177: Obstetric Analgesia and Anesthesia

Labor causes severe pain for many women. There is no other circumstance in which it is considered acceptable for an individual to experience untreated severe pain that is amenable to safe intervention while the individual is under a physician's care. Many women desire pain management during labor and delivery, and there are many medical indications for analgesia and anesthesia during labor and delivery. In the absence of a medical contraindication, maternal request is a sufficient medical indication for pain relief during labor. A woman who requests epidural analgesia during labor should not be deprived of this service based on the status of her health insurance. Third-party payers that provide reimbursement for obstetric services should not deny reimbursement for labor analgesia because of an absence of "other medical indications." Anesthesia services should be available to provide labor analgesia and surgical anesthesia in all hospitals that offer maternal care (levels I-IV) (). Although the availability of different methods of labor analgesia will vary from hospital to hospital, the methods available within an institution should not be based on a patient's ability to pay.The American College of Obstetricians and Gynecologists believes that in order to allow the maximum number of patients to benefit from neuraxial analgesia, labor nurses should not be restricted from participating in the management of pain relief during labor. Under appropriate physician supervision, labor and delivery nursing personnel who have been educated properly and have demonstrated current competence should be able to participate in the management of epidural infusions.The purpose of this document is to review medical options for analgesia during labor and anesthesia for surgical procedures that are common at the time of delivery. Nonpharmacologic options such as massage, immersion in water during the first stage of labor, acupuncture, relaxation, and hypnotherapy are not covered in this document, though they may be useful as adjuncts or alternatives in many cases.

The Relationship of the Administration of Intrapartum Synthetic Oxytocin and Breastfeeding Initiation and Duration Rates

AIM

The consequences that intrapartum administration of hormones can have on breastfeeding are unclear. The aim of the study is to determine if synthetic intrapartum oxytocin, used routinely for induction/stimulation, has a relationship to initiation/duration of breastfeeding.

PATIENTS AND METHODS

We conducted a cohort study that was carried out in a tertiary university hospital distinguished by WHO-UNICEF as a BFHI (Baby-Friendly Hospital Initiative). A group of 53 mother and newborn dyads who had been exposed to intrapartum synthetic oxytocin were compared with 45 nonexposed dyads. A breastfeeding questionnaire was administered by a midwife blind to patient group through phone calls 3 and 6 months after delivery.

RESULTS

No statistically significant differences were observed between the two groups in the rates of mothers exclusively breastfeeding (EBF) or nonexclusively breastfeeding. The percentage of those who were EBF when discharged was 97.3% in the oxytocin-nonexposed group and 87.1% in the oxytocin-exposed group (p = 0.14). At 3 months, the group rates of exclusive breastfeeding were 72.5% in the nonoxytocin-exposed group versus 65.9% in the oxytocin-exposed group (p = 0.71). At 6 months, rates of breastfeeding were 31.4% versus 27.9% (p = 0.53) in the oxytocin-nonexposed and oxytocin-exposed groups, respectively.

CONCLUSIONS

In this study, no statistically significant effect of intrapartum synthetic oxytocin administration was observed pertaining to the initiation or duration of breastfeeding.

Paradox of the institution: findings from a hospital labour ward ethnography

BACKGROUND

Interest in the influence of culture on birth practices is on the rise, and with it comes a sense of urgency to implement practices that aid the normalisation and humanisation of birth. This groundswell is occurring despite a broader cultural milieu of escalating technology-use and medicalisation of birth across the globe. Against this background, rates of epidural analgesia use by women in labour are increasing, despite the risk of side effects. Socio-cultural norms and beliefs are likely to influence pain relief choices but there is currently scant research on this topic.

METHODS

This study was undertaken to gain insight into the personal, social, cultural and institutional influences on women in deciding whether or not to use epidural analgesia in labour. The study had an ethnographic approach within a theoretical framework of Critical Medical Anthropology (CMA), Foucauldian and feminist theory. Given the nature of ethnographic research, it was assumed that using the subject of epidural analgesia to gain insight into Western birth practices could illuminate broader cultural ideals and that the epidural itself may not remain the focus of the research.

RESULTS

Findings from the study showed how institutional surveillance, symbolised by the Journey Board led to an institutional momentum that in its attempt to keep women safe actually introduced new areas of risk, a situation which we named the Paradox of the institution.

CONCLUSIONS

These findings, showing a risk/safety paradox at the centre of institutionalised birth, add a qualitative dimension to the growing number of quantitative studies asserting that acute medical settings can be detrimental to normal birth practices and outcomes.

The adaptive psychological changes of elective induction of labor in breastfeeding women

BACKGROUND

Labor induction has been associated with breastfeeding suppression, but reasons for why this association exists have not been well determined.

METHODS

We examined the influence of elective labor induction by vaginal prostaglandin at gestational week 41⁺³days on affective, cognitive, and behavioural adaptations early in puerperium and on breastfeeding pattern at 1 and 3months.

RESULTS

One hundred and eighty consecutive puerperae were assigned to two groups: mothers having received vaginal prostaglandin E2 gel (Prepidil®, dinoprostone) before labor (PGE group, n=90) and mothers having received no treatment (unmedicated group, n=90). The day of discharge mothers completed the Edinburg Postnatal Depression Scale, (EPDS), State and Trait Anxiety Inventory (STAI-Y), and Mother to-Infant Bonding Scale (MIBS). Later they participated in telephone interviews concerning their breastfeeding practices at 1 and 3months, which were classified according to WHO definitions. When compared with unmedicated, PGE group puerperae scored [median, (IQR)] significantly higher EPDS [9 (7-13) vs 5 (3-8), p 0.003], STAI-state [46 (39-51) vs 39 (34-48), p 0.002], STAI-trait [39 (36-48) vs 34 (32-45), p 0.04], and MIBS [10 (5.25-10) vs 5 (3-4), p 0.002] scores. In addition, while the breastfeeding practices were similar at hospital discharge, at follow-up the labor induced mothers were less likely to maintain full breastfeeding with respect to untreated mothers: 1month (p 0.001); and 3months (p 0.003).

CONCLUSION

We present evidence that elective induction of labor by prostaglandins at gestational week 41⁺³days is associated with reduced exclusive breastfeeding rates at 1 and 3months after discharge and higher EPDS, STAI, and MIBS scores.

Labor Epidural Analgesia and Breastfeeding: A Systematic Review

Despite widespread use of epidural analgesia during labor, no consensus has been reached among obstetric and anesthesia providers regarding its effects on breastfeeding. The purpose of this review was to examine the relationship between labor epidural analgesia and breastfeeding in the immediate postpartum period. PubMed, Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature were searched for articles published in 1990 or thereafter, using the search term breastfeeding combined with epidural, labor epidural analgesia, labor analgesia, or epidural analgesia Of 117 articles, 23 described empirical studies specific to labor epidural analgesia and measured a breastfeeding outcome. Results were conflicting: 12 studies showed negative associations between epidural analgesia and breastfeeding success, 10 studies showed no effect, and 1 study showed a positive association. Most studies were observational. Of 3 randomized controlled studies, randomization methods were inadequate in 2 and not evaluable in 1. Other limitations were related to small sample size or inadequate study power; variation and lack of information regarding type and dosage of analgesia or use of other intrapartum interventions; differences in timing, definition, and method of assessing breastfeeding success; or failure to consider factors such as mothers' intention to breastfeed, social support, siblings, or the mother's need to return to work or school. It is also unclear to what extent results are mediated through effects on infant neurobehavior, maternal fever, oxytocin release, duration of labor, and need for instrumental delivery. Clinician awareness of factors affecting breastfeeding can help identify women at risk for breastfeeding difficulties in order to target support and resources effectively.

The interaction of personality profile and lactation differs between mothers of late preterm and term neonates

Late preterm birth, a rapidly growing segment of premature deliveries, has the potential to cause deleterious effects on women's psycho-emotional experience of labor and the establishment of successful lactation. We compared personality traits by the Lüscher Color Test, the mother-to-infant bonding attitudes by the Mother-to-Infant Bonding Scale (MIBS) and lactation outcome, between mothers of late preterm and at term infants. Our results indicated that mothers idealize their condition and wish to enjoy this magic and extraordinary time in spite of feeling stressed. However, late preterm mothers feel too sad and distressed to relax in their own space after the premature birth event. In addition, their total MIBS score (mean ± SD) was significantly higher (1.364 versus 0.581; p 0.026), as related subscales: Dislike (p 0.005) and Disappointed (p 0.012). Finally, they significantly reduced breastfeeding rates from discharge (p < 0.0001), to the first (p < 0.001), the third (p = 0.002) and sixth postnatal month (p = 0.0002). We concluded that there is a relation between unconscious deep stress along with bonding limits of late preterm new mothers and impaired breastfeeding initiation and duration.

Toward Early Identification of Sensory Over-Responsivity (SOR): A Construct for Predicting Difficulties With Sleep and Feeding in Infants

Sensory over-responsivity (SOR) is a type of sensory modulation disorder in which heightened sensitivity to non-noxious sensations interrupts daily life. In this preliminary study within a larger investigation, we used infants with sleep/feeding difficulties as a proxy for later development of SOR. We tested evidence for construct validity and internal reliability of preand perinatal factors that, together, could predict infant sleep/feeding difficulties. We obtained retrospective data on 360 mother-infant dyads on 38 pre- and perinatal variables and linked the data with infant referral for sleep/feeding difficulties. We analyzed the data with Rasch analysis to examine evidence for a unidimensional construct. Our results show good evidence for a construct comprising 18 of the 38 pre- and perinatal variables examined. This construct may represent a step toward early identification of SOR and provide therapists with evidence to support the use of pre- and perinatal information as predictors of infant sleep/feeding difficulties.

Effect of early-onset sepsis evaluations on in-hospital breastfeeding practices among asymptomatic term neonates

OBJECTIVE

To examine the effect of separation for early-onset sepsis (EOS) evaluations due to perinatal risk factors on breastfeeding practices among asymptomatic term newborns.

METHODS

This observational study included 692 nulliparous women with term, singleton uncomplicated pregnancies who intended to breastfeed and whose infants were well appearing at birth. We examined the rate of early breastfeeding initiation (within 2 hours of birth) and formula supplementation (in the first 24 hours) among this mother-infant cohort.

RESULTS

Asymptomatic infants separated for EOS evaluation within 2 hours of birth were more likely to have delayed initiation of breastfeeding (46.5% vs 12.5%; P<.001). This association remained significant when adjusted for potential confounders (adjusted odds ratio [aOR]: 5.5 [95% confidence interval (CI): 3.4-8.9]; P<.001). Among infants separated for EOS evaluation, mother-infant time together of ≤0.5 hour in the first 2 hours of life significantly delayed initiation (aOR: 8.9 [95% CI: 1.5-53.7]; P=.02) compared with infants spending >1.5 hours with their mothers. In bivariate analysis, both separation and initiation were associated with formula supplementation. After adjusting for confounders, only delayed initiation remained significantly associated with supplementation (aOR: 1.9 [95% CI: 1.1-3.5]; P=.03).

CONCLUSIONS

Early separation of asymptomatic infants from their mothers for EOS evaluation was significantly associated with delayed initiation of breastfeeding, which in turn was associated with increased formula supplementation in the first day of life. This unintended consequence of EOS evaluations among asymptomatic infants may be minimized by delaying early separation for performance of the evaluation, attempting breastfeeding initiation before separation, and/or applying more efficient criteria for identifying infants requiring evaluation.

Documenting risk: A comparison of policy and information pamphlets for using epidural or water in labour

BACKGROUND

Approximately 30% of Australian women use epidural analgesia for pain relief in labour, and its use is increasing. While epidural analgesia is considered a safe option from an anaesthetic point of view, its use transfers a labouring woman out of the category of 'normal' labour and increases her risk of intervention. Judicious use of epidural may be beneficial in particular situations, but its current common use needs to be assessed more closely. This has not yet been explored in the Australian context.

AIM

To examine personal, social, institutional and cultural influences on women in their decision to use epidural analgesia in labour. Examining this one event in depth illuminates other birth practices, which can also be analysed according to how they fit within prevailing cultural beliefs about birth.

METHODS

Ethnography, underpinned by a critical medical anthropology methodology.

RESULTS

These findings describe the influence of risk culture on labour ward practice; specifically, the policies and practices surrounding the use of epidural analgesia are contrasted with those on the use of water. Engaging with current risk theory, we identify the role of power in conceptualisations of risk, which are commonly perpetuated by authority rather than evidence.

CONCLUSIONS

As we move towards a risk-driven society, it is vital to identify both the conception and the consequences of promulgations of risk. The construction of waterbirth as a 'risky' practice had the effect of limiting midwifery practice and women's choices, despite evidence that points to the epidural as the more 'dangerous' option.

Active management of the third stage of labor may reduce breastfeeding duration due to pain and physical complications

BACKGROUND

Evidence is growing that active management of the third stage of labor using prophylactic uterotonics may be associated with lower breastfeeding rates. The reasons underlying this relationship are incompletely understood. The aim of this article is to examine the experiences of mothers who stopped breastfeeding in relation to administration of parenteral uterotonics for postpartum hemorrhage prophylaxis.

SUBJECTS AND METHODS

Two hundred eighty-eight mothers with an infant 0-6 months of age who had a vaginal birth completed a self-report questionnaire examining injections of uterotonics during the third stage of labor, breastfeeding at birth, breastfeeding duration, and, where applicable, reasons for breastfeeding cessation, whether physical, social, or psychological.

RESULTS

No significant association was found between infant feeding mode at birth (breast/formula) and injection of uterotonics. However, mothers who had received uterotonics were significantly less likely to be breastfeeding at all at 2 and 6 weeks. Among mothers who had stopped breastfeeding, those who had received parenteral prophylactic uterotonics were significantly more likely to report stopping breastfeeding for physical reasons such as pain or difficulty.

CONCLUSIONS

These findings suggest that injection of prophylactic uteronics may reduce breastfeeding duration, but not initiation. This may be attributable to the effects of oxytocin or ergometrine on the physiology of lactation, leading to difficulties with infant latch and milk supply. If breastfeeding rates are to be optimized, this hypothesis needs to be explored in randomized controlled trials of third-stage management. Meanwhile, mothers who receive parenteral uterotonics may need additional support to establish breastfeeding.

Pharmacological Labor-Stimulating Agents and Neonatal Outcomes

This study examined the physiological and feeding outcomes of term neonates in relation to if they were delivered with pharmacological labor-stimulating agents or not. A retrospective chart review was conducted at a regional hospital. Infant and mother charts were selected from a 6-week timeframe. Descriptive and inferential statistics were used to analyze the 296 charts that were included. There were no statistically significant differences in physiological and feeding parameters of term neonates in relation to pharmacological labor-stimulating agents. The only significant difference found was that deliveries, which received no labor-stimulating agents, had higher rates of meconium staining.

Rates of obstetric intervention and associated perinatal mortality and morbidity among low-risk women giving birth in private and public hospitals in NSW (2000-2008): a linked data population-based cohort study

OBJECTIVES

To examine the rates of obstetric intervention and associated perinatal mortality and morbidity in the first 28 days among low-risk women giving birth in private and public hospitals in NSW (2000-2008).

DESIGN

Linked data population-based retrospective cohort study involving five data sets.

SETTING

New South Wales, Australia.

PARTICIPANTS

691 738 women giving birth to a singleton baby during the period 2000-2008.

MAIN OUTCOME MEASURES

Rates of neonatal resuscitation, perinatal mortality, neonatal admission following birth and readmission to hospital in the first 28 days of life in public and private obstetric units.

RESULTS

Rates of obstetric intervention among low-risk women were higher in private hospitals, with primiparous women 20% less likely to have a normal vaginal birth compared to the public sector. Neonates born in private hospitals were more likely to be less than 40 weeks; more likely to have some form of resuscitation; less likely to have an Apgar <7 at 5 min. Neonates born in private hospitals to low-risk mothers were more likely to have a morbidity attached to the birth admission and to be readmitted to hospital in the first 28 days for birth trauma (5% vs 3.6%); hypoxia (1.7% vs 1.2%); jaundice (4.8% vs 3%); feeding difficulties (4% vs 2.4%) ; sleep/behavioural issues (0.2% vs 0.1%); respiratory conditions (1.2% vs 0.8%) and circumcision (5.6 vs 0.3%) but they were less likely to be admitted for prophylactic antibiotics (0.2% vs 0.6%) and for socioeconomic circumstances (0.1% vs 0.7%). Rates of perinatal mortality were not statistically different between the two groups.

CONCLUSIONS

For low-risk women, care in a private hospital, which includes higher rates of intervention, appears to be associated with higher rates of morbidity seen in the neonate and no evidence of a reduction in perinatal mortality.

Oxytocin administered during labor and breast-feeding: a retrospective cohort study

OBJECTIVE

The relationship between labor physiology and the onset of lactation leads to assess the potential correlation between oxytocin administration during labor and duration of breast-feeding.

METHODS

This study was designed as a retrospective cohort study where patients given synthetic oxytocin during labor induction were considered as the exposed cohort, and patients not given oxytocin formed the non-exposed cohort. Four hundred of the 7465 children born at our maternity during 2006 were randomly selected. Information about breast-feeding was available for 316 of these children. Eventual confounding or adjustment factors were analyzed using stratified and multivariate analysis.

RESULTS

Oxytocin was used for delivery of 189 (59.8%) newborns, multiplying the risk of bottle-feeding by 1.451 (95% CI 1.28-1.63). The best-fit regression model of oxytocin use effect on bottle-feeding included sex and gestational age of the newborn. The use of oxytocin also multiplies the risk of breast-feeding withdrawal at 3 months by 2.29 (95% CI 1.41-3.74). This effect is confounded by maternal age, being higher for mothers under 27 years.

CONCLUSION

Oxytocin administration during labor had some impact on both onset and duration of breast-feeding, particularly in mothers under 27 years of age and newborns delivered at term. Clinical Study registered at U.S.

NIH, ID

NCT01951040.

Labor epidural anesthesia, obstetric factors and breastfeeding cessation

Breastfeeding benefits both infant and maternal health. Use of epidural anesthesia during labor is increasingly common and may interfere with breastfeeding. Studies analyzing epidural anesthesia's association with breastfeeding outcomes show mixed results; many have methodological flaws. We analyzed potential associations between epidural anesthesia and overall breast-feeding cessation within 30 days postpartum while adjusting for standard and novel covariates and uniquely accounting for labor induction. A pooled analysis using Kaplan-Meier curves and modified Cox Proportional Hazard models included 772 breastfeeding mothers from upstate New York who had vaginal term births of healthy singleton infants. Subjects were drawn from two cohort studies (recruited postpartum between 2005 and 2008) and included maternal self-report and maternal and infant medical record data. Analyses of potential associations between epidural anesthesia and overall breastfeeding cessation within 1 month included additional covariates and uniquely accounted for labor induction. After adjusting for standard demographics and intrapartum factors, epidural anesthesia significantly predicted breastfeeding cessation (hazard ratio 1.26 [95% confidence interval 1.10, 1.44], p < 0.01) as did hospital type, maternal age, income, education, planned breastfeeding goal, and breastfeeding confidence. In post hoc analyses stratified by Baby Friendly Hospital (BFH) status, epidural anesthesia significantly predicted breastfeeding cessation (BFH: 1.19 [1.01, 1.41], p < 0.04; non-BFH: 1.65 [1.31, 2.08], p < 0.01). A relationship between epidural anesthesia and breastfeeding was found but is complex and involves institutional, clinical, maternal and infant factors. These findings have implications for clinical care and hospital policies and point to the need for prospective studies.

ABM Clinical Protocol #5: Peripartum breastfeeding management for the healthy mother and infant at term, revision 2013

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Fetal exposure to synthetic oxytocin and the relationship with prefeeding cues within one hour postbirth

BACKGROUND

Prefeeding cues are oral-motor neurobehaviors that communicate feeding readiness, and the ability to self-comfort and regulate behavioral state. Intrapartum and newborn procedures have been associated with altered frequency and emergence of prefeeding cues soon after birth. Intrapartum synthetic oxytocin is commonly used for labor induction/augmentation in the US, yet there is little research on potential effects on infant neurobehavioral cues.

AIMS

To explore whether fetal exposure to synthetic oxytocin was associated with the infant's level of prefeeding organization shortly after birth.

STUDY DESIGN

Cohort.

SUBJECTS

A convenience sample of 47 healthy full-term infants (36 exposed and 11 unexposed to intrapartum synthetic oxytocin) was studied.

EXCLUSION CRITERIA

Fetal distress, vacuum/forceps, cesarean, and low Apgar.

OUTCOME MEASURES

Videotapes of infants (45-50min postbirth) were coded for frequency of eight prefeeding cues, and analyzed by level of prefeeding organization.

RESULTS

In general, fewer prefeeding cues were observed in infants exposed versus unexposed to synOT and differences were significant for brief and sustained hand to mouth cues [incidence rate ratio (95% CI)=0.6 (0.4, 0.9) and 0.5 (0.2, 0.9), respectively]. Forty-four percent of exposed infants demonstrated a low level of prefeeding organization, compared to 0% from the unexposed group. In contrast, 25% of exposed versus 64% of unexposed infants demonstrated high prefeeding organization. After adjusting for covariates, exposed infants were at 11.5 times (95% CI=1.8-73.3) the odds of demonstrating low/medium versus high levels of prefeeding organization compared to unexposed infants.

CONCLUSIONS

Newborn neurobehavioral cues may be sensitive to intrapartum synthetic oxytocin.

Association between intrapartum interventions and breastfeeding duration

INTRODUCTION

Few women who reside in Hong Kong exclusively breastfeed, and one-half stop breastfeeding within the first few months. There is little research in this population on the association between intrapartum interventions and breastfeeding duration.

METHODS

A sample of 1280 mother-infant pairs were recruited from the obstetric units of 4 public hospitals in Hong Kong and followed prospectively for 12 months or until the infant was weaned. The outcome variables for this analysis were the duration of any and exclusive breastfeeding. Predictor variables were 4 intrapartum interventions: receipt of opioid pain medication, induction versus spontaneous labor, epidural administration, and mode of birth. We used Cox proportional hazards modeling to assess the impact of intrapartum interventions on the duration of any and exclusive breastfeeding, and we constructed Kaplan-Meier survival curves to evaluate the cumulative impact of multiple intrapartum interventions on breastfeeding outcomes.

RESULTS

Bivariate analysis showed that induction of labor (hazard ratio [HR], 1.24; 95% confidence interval [CI], 1.09-1.41), opioid pain medication (HR, 1.21; 95% CI, 1.06-1.37), and having an emergency cesarean birth (HR, 1.22; 95% CI, 1.01-1.48) were associated with a shorter duration of any breastfeeding. Induction of labor (HR, 1.23; 95% CI, 1.08-1.39) and having an emergency cesarean birth (HR, 1.25; 95% CI, 1.05-1.51) were associated with a shorter duration of exclusive breastfeeding. After controlling for known confounding variables, there was no longer any association between individual intrapartum interventions and the duration of any or exclusive breastfeeding. The median duration of breastfeeding for participants who experienced a natural birth with no intrapartum interventions was 9 weeks compared with 5 weeks for participants who experienced at least 3 intrapartum interventions.

DISCUSSION

Clinicians working with new breastfeeding mothers should focus on providing additional support to mothers who experience a difficult labor and birth with multiple interventions to improve their breastfeeding experiences.

Breastfeeding duration and residential isolation amid aboriginal children in Western Australia

OBJECTIVES

To examine factors that impact on breastfeeding duration among Western Australian Aboriginal children. We hypothesised that Aboriginal children living in remote locations in Western Australia were breastfed for longer than those living in metropolitan locations.

METHODS

A population-based cross-sectional survey was conducted from 2000 to 2002 in urban, rural and remote settings across Western Australia. Cross-tabulations and multivariate logistic regression analyses were performed, using survey weights to produce unbiased estimates for the population of Aboriginal children. Data on demographic, maternal and infant characteristics were collected from 3932 Aboriginal birth mothers about their children aged 0-17 years (representing 22,100 Aboriginal children in Western Australia).

RESULTS

71% of Aboriginal children were breastfed for three months or more. Accounting for other factors, there was a strong gradient for breastfeeding duration by remoteness, with Aboriginal children living in areas of moderate isolation being 3.2 times more likely to be breastfed for three months or more (p < 0.001) compared to children in metropolitan Perth. Those in areas of extreme isolation were 8.6 times more likely to be breastfed for three months or longer (p < 0.001).

CONCLUSIONS

Greater residential isolation a protective factor linked to longer breastfeeding duration for Aboriginal children in our West Australian cohort.

Impact of birth complications on breastfeeding duration: an internet survey

AIM

To explore reasons underlying cessation of breastfeeding in mothers with uncomplicated vaginal deliveries and those experiencing complications during childbirth.

BACKGROUND

Interventions during labour and childbirth can have a negative impact on breastfeeding. Explanations include adverse reactions to medication, delayed breastfeeding initiation, and disruption of the normal endocrinology of childbirth. However, reasons for breastfeeding cessation linked to birth experience have not been fully examined. Increasing breastfeeding duration and, consequently, improving infant and maternal health in the UK depend on understanding why women stop breastfeeding.

DESIGN

An exploratory cross-sectional survey.

METHOD

Between January-May 2009, 284 mothers attending community groups in Swansea, Wales, and mothers participating in online parenting forums, who initiated breastfeeding but discontinued before 6 months postpartum, reported their birth experience, including complications and reasons for breastfeeding cessation in an internet survey.

RESULTS

Mothers who experienced birth complications breastfed for a significantly shorter duration than those who did not. Specifically, caesarean deliveries, foetal distress, failure to progress, and postpartum haemorrhage were each associated with a shorter breastfeeding duration. Mothers who experienced complications were more likely to discontinue breastfeeding for reasons of pain and difficulty than mothers who did not experience complications, yet no difference was seen between groups for social reasons such as embarrassment or a lack of support.

CONCLUSION

Certain complications during labour may increase risk of specific physical difficulties with breastfeeding, possibly due to their association with medications received. Maternity health professionals should be alert to this possibility to offer enhanced attention and care to overcome these issues and prolong breastfeeding duration.

Newborn feeding behaviour depressed by intrapartum oxytocin: a pilot study

AIM

To investigate the effect intrapartum oxytocin administration can have on Primitive Neonatal Reflexes. The secondary objective was to observe the influence of intrapartum oxytocin may have on breastfeeding.

METHODS

Twenty healthy primiparae with a single gestation at term were included. To assess Primitive Neonatal Reflexes, video film was taken during an experimental situation designed to elicit Primitive Neonatal Reflexes. Three independent observers blinded to the oxytocin dose that had been administered coded the Primitive Neonatal Reflexes. Data regarding breastfeeding were collected by telephone at 3 months.

RESULTS

Medium oxytocin dose was 1931.9 ± 1754.4 mUI. A Kappa index >0.75 was obtained for four Primitive Neonatal Reflexes: swallow, jaw jerk, suck and gazing. A negative association was found between oxytocin dose and sucking (p = 0.03). At 3 months of life, women exclusively breastfeeding (63.1%) had received a significantly lower average dose of oxytocin than those not exclusively breastfeeding (36.8%) (p = 0.04).

CONCLUSION

In this pilot study, intrapartum exogenous oxytocin seems to disturb sucking and breastfeeding duration. Further studies are required to confirm these results and to ascertain whether there could be other effects of intrapartum oxytocin on newborn behaviour.

Knowledge of the Birth Process Among Undergraduates: Impact of Screening of a Documentary Featuring Natural Childbirth in Low-Risk Pregnancies

PURPOSE: Little is known about knowledge of birthing practices, among young adults in the United States; specifically, knowledge regarding the impact of these practices on mothers and newborn. Therefore, the purpose was to assess U.S. undergraduates’ knowledge regarding risks of cesarean deliveries (medically indicated or not), before and after viewing a documentary featuring unmedicated vaginal birth in low-risk pregnancy and subsequent expert panel discussion.

STUDY DESIGN: Uncontrolled before/after study.

MAJOR FINDINGS: Of the 225 attendees, 206 completed the pretest (91.5%) and 163 completed the posttest (72.4%). Of the 206 completing the pretest, 152 identified as undergraduates, and 123 (80%) of these 152 completed the posttest. Results indicate exposure to the documentary and expert discussion panel resulted in significant increases in knowledge of risks of cesarean deliveries, regardless of gender. In addition, witnessing or viewing birth in the media was significantly associated, at posttest, with greater increases in knowledge of some risks.

MAIN CONCLUSION: These findings are important in light of the increasing trend in cesarean deliveries in the United States. Educating this population and providing credible information on delivery options should be informed by further research into these domains.