A new study shows how some very common labor medications affect newborn behavior in the first hour. As the video below explains, there are 9 stages newborns go through after birth. Perhaps you've seen videos of the "breast crawl", which show babies finding their mother's nipple with minimal help. Keep in mind that these are unmedicated babies. If a mother has an epidural or gets Pitocin to speed up labor (and very often she gets both), it goes to her baby and depresses either the instinct to breast crawl or the ability to do so. The exposure to Pitocin and fentanyl was dose-dependent, meaning that the longer the mother had the epidural and/or the Pitocin the less likely it was for her baby to latch within the first hour.
It is very clear from other studies that breastfeeding sooner leads to better breastfeeding outcomes and less cases of dangerous jaundice. These relationships should be clearly explained and understood before labor, so that mothers know what they might be dealing with as a consequence of an intervention.
There are many, many factors that play a part in whether breastfeeding will be easy or fraught with difficulty. I wanted to point out a few things in your labor that aren't normally seen as related to breastfeeding that could make a difference in your experience.
Contrary to popular opinion, an epidural is anything but risk-free. Just like any intervention, there are side effects. A study finds that babies lost more weight after an epidural, probably because of the fluids required (see IV fluids below). Babies lost an average of 226 g after an epidural and without one the loss was only 142 g! I've never heard of this side effect being explained by the anesthesiologist before the epidural was given. This could be the reason a study found a relationship between epidural use and less mothers breastfeeding at 1 month. Perhaps when milk production is reduced at the beginning, the frustration of breastfeeding doesn't seem as worth it. This is especially important to consider if your baby is even slightly preterm, you've had milk production problems before, or you have any complicating factors such as previous breast surgery.
Starting labor artificially should only be done when there is a clear medical reason. It can make breastfeeding more difficult for a variety of reasons. Both mother and baby don't have the benefit of the normal hormones of labor, leaving them more tired and feeling worse than they otherwise would. It also means the baby may be premature and not have a completely mature nervous system, enough body fat, or be strong enough to nurse efficiently. If there is a health reason to induce early, be proactive in meeting with a lactation consultant. You may need to pump and/or supplement your baby for at least a little while.
I have other posts on induction here and here.
Often women are given antibiotics in labor if they are positive for the GBS bacteria or if their water has broken. Although GBS infection is relatively rare, the use of antibiotics should be weighed against your other risk factors because the consequences could be deadly for your newborn if he develops the infection. Most babies who are treated in labor would not have developed the infection anyway.
Currently, there is no evidence that there is benefit to giving antibiotics vs. treating a non-GBS infection that develops later. The way this can affect breastfeeding is that when the balance of bacteria are disturbed by the antibiotics yeast can take over and thrush can develop on mother's nipples and baby's mouth. This is an infection that is common these days and difficult to get rid of unless both mother and baby are treated at the same time. Keep in mind these treatments are not without their own side effects, like sores in baby's mouth. It should be clear by now how one intervention in the natural process-even if warranted-leads to other problems down the road.
IV Fluids in Labor
Studies clearly show that IV fluids will cause the baby to weigh more at birth, and then that leads to it looking like they're losing more weight than they really are. That extra weight is just water from the IV.
This drop in weight could lead to advice to supplement with formula, which can be a hard thing to recover from.
Another reason that IV fluids could hurt breastfeeding is that it causes swelling in mom's breasts. This makes it difficult for baby to latch onto, sort of like trying to bite a beach ball. There are some other less common problems, like cause low sodium in the baby.
It is standard practice in most hospitals to swaddle babies tightly. We know it's important to keep babies warm, so it seems like a good idea. Evidence is plentiful now, however, that babies actually do much better in several ways when they are skin-to-skin. Not only does mom's chest keep the baby warm, but mom produces milk better with the skin contact. In studies swaddled babies were the coldest and drank the least amount of milk!
Mothers who have a Cesarean delivery (and about a third do) have many challenges after the birth. It is surprising to many when their milk is delayed in "coming in". After a vaginal delivery a mother can expect her milk to start being produced in greater volume around day 3, but after a Cesarean it's often more like day 5. This can be frustrating and could lead to supplementation if the baby loses too much weight. Often, babies born by Cesarean are not able (because of medical problems or because of hospital procedure) to nurse during the first hour after birth, which is known to be important for preventing breastfeeding problems. There are also problems created by IV fluids, antibiotics, and presence of the wound site which makes it difficult in the first days and weeks especially.
The good news is that there are solutions to problems a new mom may be experiencing. A doula or lactation consultant will have ideas to make the process easier. With a lot of determination many women have pushed through a difficult labor to establish a long-term nursing relationship. These are just some things to consider when thinking about your birth plan and breastfeeding goals.
As if a diagnosis of gestational diabetes (which can result in numerous tests, blood draws, food record-keeping, and daily finger-sticks) wasn’t bad enough, many women are left discouraged towards the end of their pregnancies to hear there is a risk of stillbirth along with their diagnosis. The last several weeks often involve ultrasounds and other tests, and then induction is brought up early. After all this, many moms feel like the whole pregnancy and birth are out of their control and they’re “defective”. So let’s look at the actual risk of stillbirth and the implications that has on you and your baby. (If you're not sure what gestational diabetes is, you can read my overview article.)
Physicians have thought there was a relationship between gestational diabetes and stillbirth for years, but in the biggest study on gestational diabetes there was NO association with stillbirth. The risks of gestational diabetes were: C-section, pre-eclampsia, large-for-gestational-age baby, shoulder dystocia, prematurity, birth injury, stay in the NICU, and hyperbilirubinemia (jaundice). Keep in mind several of these problems are iatrogenic (caused by health care providers), and often are a result of trying to prevent other problems, like stillbirth.
As I heard an OB say, “Because of the risk of stillbirth with gestational diabetes we induce between 37 and 38 weeks.” I’m not sure who he meant by “we”, but that’s not a general recommendation. From the ACOG bulletin on gestational diabetes, “When glucose control is good and no other complications supervene, there is no good evidence to support routine delivery before 40 weeks of gestation.”
Another study published in 2012 looked at the risk between letting the pregnancy last another week and a stillbirth occurring and the risk of the newborn dying. It wasn’t until the 39th week of pregnancy that the risk of stillbirth became evident. But to understand if this applies to your situation, understand that “this study did not differentiate between those who were only diet controlled and those who required medical therapy; thus, it is likely that our study population could have more severe disease, representing a population at higher risk of stillbirth.” In other words, if your blood sugar levels are under control there is no evidence that you have a higher chance of stillbirth than someone without gestational diabetes. GD is also associated with preeclampsia, which would also might be responsible for some of these stillbirths. Research to tease out all these factors in ongoing.
According to the study who found an increase in stillbirth, it is of note that 1,518 women must be induced at 39 weeks (and take on the risks associated with that) to prevent 1 stillbirth. Also, with gestational diabetes even at 40 weeks only 4.4 stillbirths occur in every 10,000 pregnancies. Even the authors do not recommend that all women be induced at 39 weeks “Because the absolute risks of stillbirth and infant death are so low, an increase in short-term neonatal morbidities such as NICU admissions associated with a policy of early delivery may have a public health ramification that overshadows any small mortality benefit.”
Since many moms, especially those with gestational diabetes, are often advised to come in for tests such as an ultrasound and a biophysical profile, it is important to note that a Cochrane Review (that looks at all studies) has found no evidence that the test improves outcomes. ACOG also does not recommend testing when blood glucose is under control with diet. That's something parents have a very hard time understanding when faced with the pressure to undergo them. These tests increase Cesareans and inductions, but do not decrease death or low Apgar scores. This should be made clear to everyone choosing to undergo such a test. Ultrasounds are not reliable in determining the baby’s size, especially as the pregnancy progresses.
I would also like to add into the mix my perspective from a breastfeeding standpoint. There are many factors associated with Cesareans, inductions, and prematurity that negatively affect breastfeeding both for the baby and from the maternal side. These kinds of consequences are often not even considered when a family is deciding between an induction or a naturally starting labor.
To summarize (and I really tried to keep this short & sweet!), moms should ask their care provider:
*what their individual risk is with gestational diabetes based on their own blood sugar readings and personal history
*what they can do to keep their glucose levels low before resorting to medication
*what the side effects of any medication will be (insulin and related drugs often affect the baby after birth, necessitating more tests)
*why specifically an induction is being suggested. Is there any indication the baby is in trouble? How reliable is the test?
*if the baby is showing signs of distress, why an induction would be a better option than an emergency Cesarean?
*have they ever seen a shoulder dystocia? How did they handle it?
*how any intervention could affect your long-term goals, such as number of children or breastfeeding
If you’d like to read more on the subject, here is an excellent review that includes more relevant studies and information on treatment options for GD.
Oxytocin is a multipurpose hormone our bodies produce at times of pleasure. It makes us feel good. Specifically, it makes us feel connected, bonded, and it's called the "love hormone". It plays an important role in birth, lactation, and sex, as well as sharing a meal with a friend or receiving a hug. In babies, it is involved in brain development. They grow up to become social creatures partly because of oxytocin.
When it was discovered that one effect of oxytocin was to produce uterine contractions the obvious use for a synthetic version was clear. The oxytocin molecule is actually not very complicated, so laboratory versions were produced to help start and speed up labor.
Today, synthetic oxytocin, called Pitocin, is used extravagantly to induce and augment labor. Pitocin and oxytocin are spoken of interchangeably, but they are not the same thing. It seems like such a wonderful thing to be able to create useful contractions with the drip of an IV. There are questions, however, that have either not been adequately answered or not even asked about its effects.
The Blood/Brain Barrier
Oxytocin made by the body is produced mostly in the brain. There is something called the blood/brain barrier which keeps some molecules in the blood stream out of the brain. When Pitocin is given it is through an IV, so although it acts on the uterus it doesn't affect the brain. This can make it harder for a new mother to adjust to motherhood. The oxytocin that would normally be released increases mothering behaviors. Could this lack of oxytocin in the brain contribute to postpartum depression and lack of bonding between mother and baby? It's certainly something to be considered.
Effects on Baby
We know that Pitocin does not have the same effect as oxytocin. For instance, oxytocin is released in small pulses, which is why contractions only happen every 3-20 minutes for only about a minute. Pitocin is released in a more steady drip, causing contractions to be stronger, longer, and closer together. This is what the goal of an induction or augmentation is, after all. These increased contractions can be too much for the baby to handle. Sometimes the uterus can even become so stimulated that it can't relax. Without the breaks between contractions that allow blood flow to be restored the baby is in danger of being stressed and being rushed for an emergency C section.
Contractions and Only Contractions
When mice who didn't have oxytocin were studied they showed much less maternal behaviors than normal mice. This includes not being able to feed their pups. The strange thing is, they were able to deliver their pups normally. This lets us know that oxytocin has a role in labor, but it's not the hormone that kicks it off. Our modern understanding is that proteins from the baby's lungs begin the complex labor process once they're ready. Ironically, modern obstetrics is using it for the one thing it does NOT do, which is begin labor! This explains why so many inductions actually fail. Your chances of a successful induction improve with a favorable cervix, which Pitocin does not do.
There are definitely consequences to both mom and baby in labor with Pitocin, but what about effects in the long run? In Oxytocin Pathways and Evolution of Human Behavior by Carter, there are startling if not altogether unexpected consequenses of oxytocin given in large doses, especially at a young age.
"There also is increasing evidence that the effects of exposure to exogenous oxytocin are not
necessarily associated with increases in positive sociality. In prairie voles a single low-dose oxytocin
injection given on the first day of life facilitated pair-bond formation in adulthood. However, high
doses of oxytocin had the opposite consequences, producing animals that preferred an unfamiliar
partner (Bales et al. 2007b). Repeated exposure to oxytocin early in life in pigs also disrupted
subsequent social behavior, under some conditions producing piglets that were less capable than
normal animals of appropriate and reciprocal social interactions (Rault et al. 2013). Oxytocin
given intranasally to prairie voles during adolescence also did not reliably facilitate social behavior
and, once again, at some doses disrupted the tendency of this species to show a partner preference
(Bales et al. 2013). "
This brings to mind the seemingly anti-social behavior many of us have noticed in the younger generation. Could the huge doses of Pitocin around the time of birth interfere with brain development? Perhaps the reliance on technology is a byproduct of a reduced ability to connect with other people. It's at least plausible enough to consider.
Pitocin use in labor has been associated with autism, and those with autism show changes in their oxytocin receptors. Since we know oxytocin acts on behavior, it wouldn't be surprising. Labor where Pitocin was used increases a baby's chance of autism. It's especially pronounced in boys, where the risk is 35% greater. Hopefully these implications will be studied further. It is important to remember that our bodies are very complicated, and adding a large dose of a hormone at a very sensitive time should definitely only been done if it has been thoroughly studied and the benefits outweigh the risks.
I'm not saying that an induction or augmentation is never warranted, or even that Pitocin isn't the best choise for it. I mainly wanted to point out that PITOCIN IS NOT OXYTOCIN. It's a drug, and should be used with the same level of informed consent as any other.
What is gestational diabetes?
During pregnancy glucose (sugar) is released at higher levels into the blood stream. This makes sense, because the developing baby uses this sugar as an energy source for development. One of the more common diagnoses during pregnancy is gestational diabetes. About 7% of all pregnant women will be told they have it. It's when you have more glucose circulating in your blood than we think you should. (The exact “right amount” is currently unknown). This is different from diabetes that existed before you were pregnant and has different outcomes.
How is it diagnosed?
Some women are at such low risk they won’t be tested at all. For most women, though, around 26 weeks you’ll be asked to drink a glucose-containing drink and your blood tested before and after. If your level is high another, longer test is done and if two values are high the diagnosis is made.
How will it affect my pregnancy?
Often, a pregnant mother with gestational diabetes is counseled about her diet in order to bring her blood sugar numbers under control. You likely will be asked to keep a food diary and learn to take your own blood sugar numbers at home with a finger stick. If you can be strict about limiting carbohydrates you often won’t need any further medication. If diet doesn’t work, insulin or other medications can be used. These have side effects on the baby once born, but the benefits may outweigh the risks depending on how high your glucose is and your other risk factors.
How will it affect my labor?
Likely, it won’t. The most common intervention faced by women with gestational diabetes is pressure to induce labor early. Since babies born to mothers that have gestational diabetes are on average heavier, the idea is to limit complications by delivering a lighter baby. However, induced labors more often end in a cesarean and the risks of a premature or baby that is “not quite ready” should be weighed against the supposed benefit of avoiding a “big baby”. Stillbirth may be increased in certain mothers with gestational diabetes (although this association is uncertain), and you can read more about that in another article.
As someone who has personally attended births of mothers with gestational diabetes who had a normal or even low-weight baby at term, I would make sure mothers understand the diagnosis does not guarantee a big baby and a big baby doesn’t even necessarily pose a problem. The thing your doctor or midwife will be on the lookout for is shoulder dystocia, or where the shoulders get stuck once the head is born. This is unpredictable, and most often is remedied by quick action of a trained attendant.
What about after pregnancy?
Women who were diagnosed with gestational diabetes are more likely to develop type-II diabetes later in life. After pregnancy you’ll be checked to see if your glucose levels have returned to normal or are still high. The bad news is that there’s about a 50% chance you’ll later have diabetes, but the good news is that there’s a lot you can do to prevent or delay it. Diet and exercise are the first step in reducing your chances of developing diabetes, and in this way, your pregnancy may have given you a “heads-up” on ways to improve your future health!
I've been there. Scouring the internet at 37 or 38 weeks pregnant trying to convince myself that pushing myself into labor early wouldn't be that bad for my baby. I didn't want to do anything harmful, but I felt soooo ready already! It would be so perfect if I could just go into labor on a Friday. From personal experience and lots of research, let me tell you straight out that unless there is a medical reason to get the baby out early it is better for both of you to go into labor naturally.
Please read this great article about what a medical induction can put you at risk for. If anyone tells you medical inductions are risk-free they are lying, and I don't know how else to say it. There are clear advantages for babies who "cook" longer, as this study showed. A baby who is born early has not finished their development yet. Currently, we think it is the baby's own finished development that triggers labor to begin. So your body is not broken if you pass your due date. Your baby is just not ready for the outside world yet. After all, that due date is just a guess of an average. Actual pregnancy length can vary by FIVE WEEKS, as this study on pregnancy length explains.
So, although it's much easier for me to say because I'm not 9 months pregnant I would encourage you to enjoy these last few days of pregnancy knowing that you're doing a good thing for yourself and your baby.
There's a major problem in our society that I see everywhere I look. It causes lawsuits all over the place and ruins lives. It's the inability for people to take personal responsibility for their decisions.
The battle between natural birth advocates and "inductions or C-sections for everyone" crowd goes on constantly, especially online.
For me, very little is black or white. Each family is different, each child is different. It all comes down to being informed and making the best decision for your situation. Everyone would agree with that, except for this little part: you then have to take personal responsibility for that decision. Ultimately, you care for yourself and your baby more than any doctor, midwife, or nurse does. Whatever happens, you made the choice.
But, but....it's the doctor's fault, it's that magazine's fault, it's my mother-in-law's fault! They told me to do something and it ended badly! It's not MY fault! I hear it all the time, but repetition does not equal validity. We are all free to make many choices, including our care provider, which procedures we agree to, and what we do to remain low-risk. This does not mean there is only one correct choice for everyone, because we're not assembly-line made robots. We're individuals, and that's really scary for some people. They want one thing to be done for everyone and for it to be forced on them if they dare disagree.
The truth is, there are no guarantees in life. Sometimes everything goes right even when bad decisions were made. Other times, disaster befalls even those doing everything right. All we can do is to get informed and then find peace with our decision. When it comes to birth, personal responsibility would greatly benefit all women. If doctor and midwives weren't so scared of being sued they would allow their patients more options. Only in cases of gross negligence should the care provider be held liable. The fact that a certain person's name was on a woman's chart when something terrible happened that was going to happen anyway shouldn't be a reason to sue for millions.
It's true there is great power in birth. (I know, shameless plug for my business.) But as the wise Spiderman's uncle said, "Where there is great power there is great responsibility." So there's a responsibility we need to accept for our own births. Our care providers can't see the future any more than we can. Thank you, Uncle What's-your-face for that nugget of birthing wisdom that, if followed, could revolutionize our health system in general and women's health specifically.
I'm a natural childbirth educator, lactation consultant (IBCLC), and doula in Athens, AL. Here is where I put healthy recipes, current research, and helpful articles for pregnancy, postpartum, and life in general. Check back often!