Breastfeeding is the physiological norm for human babies, and has nurtured their growth and development for 200 000 years. The effects of feeding babies with modified cows’ milk are still coming to light (Box 43.1), but breastfeeding provides optimal nutrition, primes the immune system, stimulates neurological development, facilitates a loving mother–baby relationship and enhances maternal health.
Despite social pressures to bottlefeed, many women choose breastfeeding but some struggle due to lack of skilled support and stop sooner than they wanted. Midwives are key to helping women achieve their breastfeeding goals.
During labour, ask the women how she would like to welcome her baby and explain the benefits of skin-to-skin contact (Box 43.2). With her consent, place the newborn on her chest, where it can be assessed and dried. Let the baby rest; covered with a dry towel and hat. Observe them frequently to maintain safety. If undisturbed and un-medicated (no opiates in labour), babies will crawl and attach at the breast using a series of instinctive behaviours. This is best facilitated with the mother in a laidback position as gravity holds the baby against the mother’s body, enabling them to move and suckle. Encourage the mother to follow her instincts to help her baby.
Laidback feeding is most restful but some women prefer an upright position. This can be more difficult for the baby as gravity pulls them away from the nipple. Figure 43.1 shows different ways she can hold her baby. Help the woman get comfortable with her back and shoulders supported. She should hold the baby very close to her body ensuing the baby’s arms are not between them. The baby’s head should be free to tilt back. The baby’s ear, shoulder and hip should be in line, not twisting to reach the nipple. Finally the baby’s nose should be level with the nipple so when the baby tilts its head back to open its mouth wide, the nipple is in the right place. The mother can express a little milk and brush the nipple against the baby’s lips to stimulate the rooting reflex. If she is holding her breast, her fingers should be well behind the nipple. When the baby opens its mouth wide, she should swiftly bring them closer (with the nipple directed towards the roof of the mouth) so the baby can draw in a good amount of the pigmented areola as well as the nipple.
Give verbal guidance and demonstrate using a doll. Avoid holding the woman’s breast – this can be disempowering compared with achieving a successful latch for herself. If a woman wants more practical help, offer to put your hands over hers to guide her as she helps her baby. Once the baby is well latched, encourage the woman to relax. The baby should remain in skin-to-skin contact until after this first feed. Encourage the mother to ask for help with the next feed.
Feeding should be part of a sensitive reciprocal relationship. Keep mother and baby together, encourage the woman to notice early feeding cues (e.g. stirring, lip-licking, rooting) and to hold, watch and feed her baby frequently. These behaviours raise maternal oxytocin levels, triggering the milk ejection reflex (driving milk down the ducts to the nipple) and facilitating bonding by enhancing mothering behaviours. Infant oxytocin levels are also raised and stimulate brain development. The more she watches her baby the sooner the mother will understand their needs. She should offer the breast in response to any early cues for feeding or comfort, well before the baby get distressed as they cannot feed when crying. Each feed triggers the pituitary gland to release prolactin. This hormone stimulates the lactocytes in the breast to secrete more milk – so frequent feeding will establish a good milk supply.
Ask the mother how she feels feeding is going and listen carefully to any concerns she has. Consider her wellbeing as pain, anaemia or infection can affect her ability to cope with feeding. Ask about the baby’s feeding pattern and nappy contents. Infrequent wet and dirty nappies or a slow change from meconium suggest insufficient milk transfer. Examine the baby to confirm wellbeing or detect signs of poor feeding such jaundice. Most newborns lose weight initially as they pass meconium and excrete (as urine) the excess fluid they were born with. Whilst a loss of up to 10% of birthweight is considered acceptable, a baby who has lost 7–10% should be carefully assessed and the mother supported to increase milk transfer. Greater weight loss requires an infant feeding specialist or medical practitioner referral.
Observe a breastfeed to give the mother positive feedback about her skills or if you have concerns about her feeding experience or the baby’s wellbeing. Box 43.3 indicates signs of effective feeding. If the woman is experiencing nipple pain, suggest alternative ways of holding and latching the baby, based on the CHINS acronym (Box 43.4). If you or the mother are concerned about milk intake, encourage her to enjoy periods of skin-to-skin contact, feed more frequently, including at night (more prolactin is released at night), offer both breasts every feed, and stimulate the baby to keep suckling. Also offer additional visits from a breastfeeding support worker.
Praise and encouragement help women keep going through early difficulties. Breastfeeding can take a few weeks to get established but becomes a lovely relaxed experience as the mother’s confidence grows.