First and foremost: You’ll find important resources toward the end of this article. The first part is designed to incentivize you to read them.
A challenge experienced by any professional whose responsibilities include helping with breastfeeding initiation is supporting parents as they wade through the unfamiliar misinformation and hospital protocols that frequently undermine the process. To illustrate this point, let’s walk through the experience of a statistically typical mother birthing in a hospital in the US and planning to breastfeed. Due to both cultural expectations and protocols such as those limiting movement, labor feels unmanageable and an epidural is ordered. In order for an epidural to be administered, the mother must first receive a liter of IV fluids (although likely she’s been on the IV since her arrival). The IV fluids will be continued throughout the labor once the epidural is placed, because they help to mitigate risk from the procedure, such as a drop in blood pressure.
Any parent who has received multiple bags of fluids will remember the bloating that follows–looking back at photos and saying, “Woah–look at my face!” The swollen hands and feet that were enhanced by the added fluids. The frequent trips to the bathroom in the days that follow, as the body strives to reach a normal level of hydration.
Keep this in mind as we move forward.
As a doula, I encourage my clients to keep their baby in the room with them, and more and more hospitals are moving toward this practice, to keep the nursing dyad as close as possible to learn and enjoy one another in these early hours. The more frequently the baby nurses effectively, the more times the mother’s pituitary sends the message, “Let’s make milk!” to the body. These are some of the primary tenants of nursing: nurse effectively, and nurse frequently.
So I’m the doula. The baby has been born, vaginally even–hooray.! The family is all tucked in together in their postpartum room and the plan is that this is where the baby will stay. I’ve done my all, until I check in with them in a bit, and as their doula, you’d think I’d be feeling pretty confident about where things are going. Thing is, I’m not. Not at all. Because I’ve seen this play out so many times. Unless I’m headed home from one of a minority of hospitals that are truly up to date on their breastfeeding support, I know that things are likely about to go down hill. Here’s what I’m expecting:
Remember all those IV fluids? I marked this earlier, for this reason: You know who else received IV fluids? The baby. That’s right, that baby is plumped up like mama’s hands and feet. And the baby’s body knows what to do about it. So the baby pees. And pees. And pees again.
In the breastfeeding world, one of the criteria parents and others are told will help to evaluate “success” is wet diapers. As new parents, we count wet diapers and in the hospital are even required to log them. “Things are going great!” reports my client. “He’s had 5 wet diapers already. They say he’s really nursing well.” Deep in my heart, I groan. In a baby whose mother hadn’t received IV fluids, this would mean something. In this baby? A baby whose mama received multiple bags of fluid in the hours leading up to the birth? It means nothing. It means that she received IV fluids, which we already know. It doesn’t tell us if the baby’s latch is ideal. It doesn’t tell us how frequently the baby is feeding. It doesn’t tell us if the baby is actually drinking. It doesn’t tell us if the baby is awake and engaged during the feed. But nurses are overworked and protocols lean heavily on those charts the parents are filling out. So parents are made to feel confident based on misinformation.
As their doula, I know this is only the first shoe, and soon enough the other one drops.
“He’s lost 8% of his body weight! They say I have to give him formula.” She’s in tears. This conversation often takes place within hours of the first. Certainly within a day. How can this be? The afore-described peeing is the culprit. All those wet diapers from the IV fluids, the ones that were so reassuring? Each of those pees carried weight. And after enough of them, the baby’s weight drops. Basic, logical, and seeming to come as a complete surprise to the staff each and every time. The same artifact of birth interventions which was at first celebrated has now reached its final destination: crisis and intervention. Because once the baby begins receiving formula, the mechanics of breastfeeding and the parents’ confidence are both disrupted. This is why my doula heart groaned earlier.
For perspective, Listening to Mothers Survey https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3894594/, tell us that 67% of mothers experience epidurals. The overall IV fluid rate would be much higher than this. So this is happening all the time.
Why is this constant cycle maddening? Because we know better.
Even if the mother didn’t receive IV fluids, we have this important study https://web.uri.edu/nursing/2020/02/27/nursing-professors-study-on-infant-birth-weight-breastfeeding-wins-national-award-from-leading-womens-health-organization/?fbclid=IwAR0cKYXt7iLJWTKGFLkHs-xRvrBiB5VrlpBM14IMOZvN_5KvKt1OGeg6nhs indicating that “…the average breastfed baby loses 8% of birth weight…most babies who did lose more than 7% in the first two weeks still gained weight at an adequate pace over the next two weeks.” Often this great crisis is not, in fact, a crisis. It is an artifact of the cascade of intervention that began when the IV was administered.
Breastfeeding expert Nancy Mohrbacher explains the science behind the inflated birth weight phenomenon with a great overview: http://www.nancymohrbacher.com/articles/2011/10/31/newborn-weight-loss-and-iv-fluids-in-labor.html
My favorite of the studies Mohrbacher cites is this one: https://pediatrics.aappublications.org/content/127/1/e171?sso=1&sso_redirect_count=1&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token
Unlike most studies, these authors actually used their conclusion as the title: “Excess Weight Loss in First-Born Breastfed Newborns Relates to Maternal Intrapartum Fluid Balance” Reading this, I found myself relating to the authors, their frustration and exhaustion in championing their cause, and the hope that their message might lodge in the minds of doctors skimming titles but not reading studies. The obvious choice: Make it as simple as possible. Which breastfeeding often is, when we support and facilitate it… and at the very least, keep out of the way.
Written by Jackie Kelleher
Jackie is assistant editor at Pathways magazine, as well as the Pathways group coordinator. Her life has been a tapestry of family support–doula, lactation professional, group facilitator, and doula trainer. Her book, Nurturing the Family: A Doula’s Guide to Supporting New Families, is now available.