Birth and the first breastfeed

How do I prepare for the first breastfeed?

It is important for mothers and their babies to be together for the first two hours after birth. Babies have a well-developed sense of touch and are reassured by skin-to-skin contact. If they are separated from their mothers right after birth, they are more likely to have difficulty breastfeeding. The same is true if they are disturbed or in pain. For that reason, if medically sound, painful procedures should be delayed until after the baby’s first feed or later. If possible, tests should be done with the baby in skin-to-skin contact with the mother. Healthy babies who are not premature and not too sleepy from medication or a difficult delivery may be able to crawl to the mother’s breast and will usually breastfeed within the first hour of delivery.

A) The importance of keeping mother and baby together

The sense of touch is the first to develop in a baby’s brain before birth (Fagard 2018). When the baby is born at full term, this sense is well developed. The lips in particular are very responsive to touch (Meltzoff 2018).  

In addition to the many other benefits of skin-to-skin care, keeping mothers and babies in skin-to-skin contact with the baby on the mother’s tummy, gives babies a reassuring touch and in a position from which they can reach the breast through the breast crawl.

All of the following recommendations including keeping mothers and babies together, allowing babies to breastfeed as soon as they are ready after delivery, and delaying painful procedures are found in the guidelines for Baby-Friendly Hospitals.

B) How to keep mothers and babies together

After birth, mothers and babies ideally are kept skin-to-skin with little or no separation and disturbance for two hours (Császár-Nagy 2018; Henderson 2011; Hernández-Aguilar 2018). If the mother is not available, her partner or another support person can provide skin-to-skin care. This applies to all babies regardless of how they are delivered.

If babies are separated from their mothers right after birth, disturbed, or in pain, they are more likely to have difficulty breastfeeding (Karakoyunlu 2019).

Health-care providers and hospital policies vary and some do not routinely keep babies skin-to-skin with their mothers (Boundy 2018).

To avoid disturbing the baby (Holmes 2013):

  • An Apgar assessment (a quick test to check the health of a newborn) should be done with the baby on the mother’s chest.
  • Painful procedures and examination should be delayed until after the first hour, if possible.
  • Necessary painful procedures and examination should be done when the baby is in skin-to-skin contact.
  • Vitamin K injections should be given after the first feed but within six hours of birth (CPS and CFPC 1998; Holmes 2013; Ng 2018).
  • Routine preventive eye treatment should be delayed up to six hours after birth. However, babies at increased risk of infection should be treated immediately (Holmes 2013; Moore 2015).

Bathing should be delayed until the baby is at least 24 hours old and is stable (Chamberlain 2019; Preer 2013; WHO 2013). When bathing, the baby should be immersed in warm water instead of being given sponge baths (Brogan 2017). Delaying the bath:

  • Increases breastfeeding rates (DiCioccio 2019).
  • Decreases the risk of the baby getting cold (Warren 2020).
  • Decreases the risk of low blood sugars (hypoglycemia) (Warren 2020).

C) The first feed: establishing breastfeeding

Immediately after birth, a healthy baby’s behaviour follows a predictable pattern of the breast crawl followed by breastfeeding (Widström 2011):

  1. The birth cry, during which the lungs expand.
  2. Relaxation without any movement once the baby is placed on the mother’s tummy.
  3. Awakening with small movements of the head and shoulders.
  4. Activity with more movement of the head and shoulders.
  5. Crawling toward the breast.
  6. Exploration of the nipple and breast with the hands and mouth.
  7. Sucking at the breast.
  8. Sleep.

If the baby is sleepy, has had a difficult delivery, or is ill, they may be unable to manage some or all of these steps.

Healthy babies who are not premature and not too sleepy from medication are usually successful at the breast crawl and will breastfeed within the first hour after delivery and then every two to three hours afterward. If the baby cannot breastfeed normally, mothers should express colostrum within one hour of delivery and for every feed that the baby misses to establish their milk supply and minimize the risk of their milk coming in late or having a low milk supply.

Early, regular, and effective milk removal is critical to establishing the milk supply and breastfeeding success (Chien 2007; DiGirolamo 2008).

Breastfeeding within the first hour protects the baby from illness (Raihana 2019; Smith 2017). However, the first breastfeed is often delayed.

D) Delaying the first feed

1) Practices around the world

The timing of the baby’s first feed can vary between health-care providers, between hospitals, and between countries (Mallick 2021). A delay of more than one hour results in significant increases in the rates of illness and death (Pretorious et al. 2020; UNICEF, WHO 2018).

2) Reasons for delaying the first feed

A delay in breastfeeding may be necessary because of illness in the mother or baby but may also be for non-medical reasons.

The most common reason for delaying the first breastfeed is delivery by Caesarean section (Guo 2020). Health-care workers’ knowledge and hospital routines are important factors determining the start of breastfeeding after deliveries at hospitals. When mothers deliver at home, their beliefs and those of the family members and midwives are important.

Breastfeeding can be delayed when babies are given non-medically necessary milk supplements by hospital staff or by the mother because of concern about the quality and quantity of colostrum. Such supplements have many risks.

Breastfeeding can be delayed when mothers have received opoid pain medication during labour (Fan 2020) or are depressed (Cato 2019).

3) Babies at risk of feeding problems

The ability of a newborn to crawl to the breast, latch, and breastfeed effectively can be significantly affected by conditions before, during, and after labour. These include:

  • A difficult delivery (such as a long labour, the use of forceps or vacuum, or an emergency Caesarean section) (Chien 2007)
  • The mother receiving pain medication and oxytocin (Brimdyr 2019; Martin 2018)
  • The baby being born at less than 39 weeks (early-term or pre-term)

Such babies should be monitored to ensure they are not becoming sleepy, underfed, newborns.

E) Building the mother-baby relationship while in hospital

1) Reasons for keeping mothers and babies together

During the remainder of their hospital stay, mothers and babies should not be separated without a medical reason (AAP Section on Breastfeeding 2012; ACOG 2007; Holmes 2013; Moore 2016; Pound 2012; WHO 2013).

Keeping mothers and babies together in hospital improves infant feeding as it:

  • Increases the chance of the babies being exclusively breastfed when leaving hospital (Jaafar 2016).
  • Gives mothers the time to get to know their babies’ feeding patterns, behaviour, and smells (Uebi 2019).
  • Allows mothers to respond quickly to their baby’s hunger signs, preventing underfeeding.

Babies who are kept in the same room as their mothers show lower levels of stress (De Bernardo 2018).

2) Inappropriate mother-baby separation

One survey of U.S. hospitals showed that only half the hospitals kept mothers and babies together more than 90% of the time (Barrera 2018).

Mothers and babies are inappropriately separated for:

  • Hearing tests
  • Blood tests
  • Baths
  • Examination by health-care providers
  • Photos

Hospitals can be busy places. It can be helpful for the mother’s partner and the hospital staff to protect the mother and baby from unnecessary outside pressures and visitors (Grassley 2018; Lawrie 2021).

3) How to safely keep mothers and babies together

Mothers who are caring for their babies should (Feldman-Winter 2016):

  • Be supervised as they interact with their baby if they are under the influence of medication that can make them sleepy or dizzy.
  • Not hold the baby without supervision if they are at risk of falling because of dizziness or weakness.
  • Get extra help if they have had a Caesarean section.
  • Not fall asleep with the baby in bed, as this increases the risk of suffocation and of dropping the baby.

References

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