Having a Baby? Quick Guide for Success in the First Few Days -- For C-section Moms, Too.

 Some Guidelines for Successful Breastfeeding in the First Days

     Have your baby delivered immediately and directly onto your abdomen, skin to skin.  Keep the baby there until s/he latches and breastfeeds.  Normal newborn procedures can be delayed.  This step is more important than weighing, measuring, applying eye medication, and so on. 

  
Spend the first hour or two after birth relaxing  in a semi-reclined position and with your baby skin to skin.  Baby’s front should rest against your body. All baby’s body parts should be in contact with you

Drawing courtesy of Le Leche League International.

   or perhaps with baby’s legs resting against a pillow (no body part should dangle in the air).   Babies are more likely to breastfeed when they are in direct contact with mother and are relaxed after the birth.  This  position works well with twins, also.  Healthy babies, if not affected by medications mom received in labor, will usually complete 8 steps to finally latch on the the breast.  The steps include some rest phases.  Most babies have self-attached by about one hour, and then will breastfeed for several minutes.  Most usually go to sleep at around the second hour of life, whether or not they have nursed. 

   This semi-reclined position is comfortable for later nursings, too.  If mom has had a C-section, baby can be positioned to avoid placing pressure on mom's incision.

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       NOTE:   If being delivered by C-section, some babies can be put skin to skin on mom's chest soon after birth and before the surgery is complete.  A light blanket can be laid over baby and mom.  Many times, C-section newborns will latch and breastfeed in the operating room.  Advantages include proper management of colonization of baby's gut, exposure to mom's flora right away, and stabilization of infant's blood sugar.  New research has lead to some care providers swiping the mother's perineum with a sterile gauze and then wiping the newborns nose and mouth, face and hands with it once the baby has been placed on mom's chest.  This gives the baby the organisms it would have picked up from the birth canal during a vaginal delivery.  This is thought to be very important because these organisms, plus the ones on the mother's skin, provide the proper set up of the baby's G.I. and respiratory tract "micorbiome", or microbial environment.  This is a major part of the baby's immune system.  It also helps protect the G.I. tract from inflammation and other problems due to the imbalance of commensual, symbiotic, and pathological microbes.  However, be aware that there is not much information on possible negative effects, including infection, of doing this, so talk with your care provider for professional advice on this option.

  

The Semi-Reclined position and different positions for baby while mom is semi-reclined.  Drawings courtesy of La Leche League International.

   This time is special for mother, baby, and baby’s  father, and it is  recommended that other family members visit with the baby later.  Let your baby take the lead.  You can help your baby as you choose.  Routine newborn procedures can usually be delayed so nothing will interfere with the normal pace of this unique time together after birth.  If you want this option, tell your nurse your plan to do this at delivery.  Don't ask permission, just tell the health care providers this is how you are going to care for your baby immediately after birth (obviously, as baby's condition and your condition allows).  Tell them, if there is some push-back,  that your baby's health takes precedent over routine procedures, and that you are firm in your plan.  However, I have been finding from mothers I have taught that there is little to no problem with supporting this "magic hour" routine at the hospital where I work.

   2.  Watch for feeding cues.  Breastfeed  early and  by the time the baby is “rooting” (when his/her hand is at her mouth and the baby is trying to suck his or her  hand).  Crying is a late cue and crying newborns may not nurse very long  because they used a lot of energy when crying. They also become "disorganized" and go back to sleep in order for their bodies to "reorganize".

  Using a pacifier in the early weeks can interfere with this form of baby’s communication.    It is normal for newborns  to nurse often in the first few days because their stomachs are very small at first.  Also, the baby's sucking is causes changes inside your breast to release special components to help the baby's G.I. tract develop properly.  However, many newborns sleep a lot  during the first DAY of birth, especially with a medicated labor.  Remember lots of skin to skin time if this happens.  When your baby latches, let him or her feed as long as s/he wants.  As your baby grows, s/he will not eat as often and will finish more quickly.  The time you invest early on pays big dividends of time and money saved later.

3. Wait until baby is about 4 weeks old before using a pacifier or other artificial nipple.  One exception will be use during circumcision.  Pacifiers provide comfort during the procedure and decrease the amount of stress hormones in baby's blood.  Once he has been returned, put the pacifier away and continue with "mama only" for the next month.  Pacifiers interfere with baby "telling" you by rooting that they want to nurse.  Instead of bringing their hand to mouth, they just keep being "pacified" until they are so hungry they cry.  They become disorganized and quickly fall back to sleep without feeding well.  This can cause their blood sugar to drop, and in turn they become sleepier and don't nurse as often as they should.  Pacifiers will cut the normal number of feedings a newborn should have.  Artificial nipples can change how the baby sucks at the breast, causing soreness and less milk to be extracted.  If your baby must be supplemented, check with the LC or nurse about other ways to feed without using artificial nipples.

  4. Spend lots of time in the first few days skin to skin with your baby.  This helps baby learn to breastfeed well and promotes a good milk supply.   Be aware that, without meaning to, visitors can disrupt breastfeeding, causing delays in feeding because the mother is uncomfortable cuddling skin to skin or feeding in front of others.  Visitors will go home and sleep.  If your baby does not get a good start with breastfeeding, you will get even less rest in the next few days!  Taking naps when your baby naps is a good way to get through the first weeks.  To prevent falls, put your baby back in the crib, or let someone hold your baby,  when you plan to sleep.  Baby should be dressed and even wrapped in a blanket when not in contact with mom’s body.

 

    5.  Make certain that the baby has achieved a deep and comfortable latch. Baby's mouth should be open W I D E, with lips flanged outward.  The chin should be touching the breast, and the nose should be very close, if not touching your breast.  (Baby's have flat noses, with a little crevice along side to provide an airway for breastfeeding.)  You should see a little wiggle from baby's jaw to its ear when s/he is suckling. 

 This video depicts older babies, but does a good job of describing a good latch.  Click the link to view:  http://www.bing.com/videos/search?q=video+of+a+good+newborn+latch&FORM=VIRE5#view=detail&mid=38C62E19AA49E8F0F97D38C62E19AA49E8F0F97D

    If the you feel pain or pinching, the latch is not correct .   Remove your baby in order to let it re-latch.  Place your finger (nail trimmed!) between its gums and hold it there (baby will clamp down on your finger and not your nipple) while removing your baby from your breast.    Allow baby to latch again until the latch is more comfortable  (it might cause a pulling sensation, but should not pinch).    If you choose, you may try the more uprights holds, or the side lying position in the first few days.  The important thing is that  you are comfortable and baby is getting milk.

6.  Keep track of the baby’s wet and soiled diapers to make sure that your baby is taking in your milk properly.   While in the hospital, at least one wet diaper on day one (if your baby peed at birth, this counts!), two on day two, and so on until baby is wetting at least 6 diapers a day around day 5 to 6 .  Baby should start passing the thick, black meconium on the first day.  The stool should begin to change color from black to  greenish black, to greenish brown, to brownish yellow and to golden yellow over the first 4—5 days.  The brownish/yellow and then yellow stools can be soft and even runny.    If  supplementation is medically required, expressed breast milk/colostrum is almost always the best choice.  It can be given, in most cases, without using a  bottle.  Bottle feeding  a breast feeding baby in the first days has been  associated with early weaning due to poor milk supply or baby refusing the breast.  Lactation consultants can show you how to feed your baby without using a bottle, as well as some trained staff nurses.

   7.  It is a good idea to express colostrum a few minutes  4 or 5 times a day for the first 3 or 4 days.  This helps build your milk supply.   To hand express, place your thumb on one side of your breast and your fingers on the other side.  Place them about an inch to inch and a half away from the base of your  the nipple.  This may or may not be on the areola (the dark circle around the nipple) depending on the size of your areola.  Push your hand back toward your chest wall (“press”) and then push your thumb and fingers toward each other (“compress”)  then release.  Repeat the “press, compress, release” sequence.  Rotate your hand position  every few compressions.  Switch between breasts, going back and forth a few times during the session.  You can express a little colostrum to coax your baby to feed,  You can also express some colostrum after the baby has finished feeding to help stimulate milk supply.  If you are  advised to use a breast pump in the first day  or two, it will be for stimulation only.  Pumps are not designed to express colostrum so don’t expect to get much, if any, milk if pumping the first few days.   Continue to hand express, though, as It may work better for stimulating milk supply, and you will be better able to get colostrum if baby needs it for supplementation.  Click this link to see a video on how to hand express. 

 http://newborns.stanford.edu/Breastfeeding/HandExpression.html

Whenever you hand express, give the baby some of the colostrum with a spoon (ask your nurse or LC how to do this).  Those little bits of colostrum (about 1/2 cc or a little "puddle in the middle" of a disposable teaspoon) provide some energy for your baby to breastfeed well.  You can save extra colostrum in a sterile container with a label with your name on it.  Ask your nurse for some.  At first you will get drops, or a "puddle in the middle" of a plastic teaspoon.  Give this to your baby.  When you are able to get an entire teaspoon or more, put it in the sterile container, or just express directly into the container.  Label it, and ask the nurse to put it in a refrigerator.  Be sure to take this home with you.  You can freeze it and give it in little bits, mixed with regular breast milk later.

Some women experience a delay in their transitional (colostrum to mature milk) coming in.  These include (SOMETIMES -- NOT IN EVERY CASE), women who have a higher body mass index, and women who gave birth by C-section.  Additional pumping and hand expression, and most especially lots of skin to skin contact and frequent breastfeeding can minimize this.

If you had a lot of fluids in labor, or had a Cesarean section and received and IV, you baby received extra fluid, too.  This can skew your baby's birth weight.  Do not give consent for formula go be given to your baby because it lost "too much weight" (some hospitals say 5%, others 7%, 8%, or 10%) in the first few days until you have spoken with the MD, discussed your birth experience (fluid overload from IVs), and discussed how well the baby is feeding, peeing and pooping. Ask what other indications of dehydration your baby is exhibiting. Weight loss alone is not the best indicator.

Giving formula disrupts the proper colonization and systems set up of the GI tract, setting the stage for further problems throughout the baby's life.   If the doctor convinces you your baby truly needs supplementation because of obvious signs in your baby, not just an arbitrary percentage of weight loss, your baby can receive your colostrum instead of formula if you have been hand expressing in addition to breastfeeding and pumping.  Also, the LC or nurse can show you how to give it to your baby without using a bottle.

If your baby has to go to a special care nursery and they want to give the baby formula, insist they give the baby pasteurized breast milk.  This can be overnighted to the hospital in most cases.  Tell them formula will damage the baby's G.I. tract and prevent set up of the normal microbiome, which is an important part of the G.I. system.  Discuss pros and cons of giving baby nutrients and fluids via and IV until the pasteurized breast milk arrives.  If they say they CAN'T order breast milk, ask them "why not?".  If the baby's condition allows, ask about transferring the baby to another hospital which does provide human milk for it's sick babies.  Talk with administration.  This issue is important enough for the decision makers at the hospital to hear why you want human milk ONLY to enter your baby's G.I tract, at least for the first two weeks.

If your baby is not in the special care nursery, and a care provider insists your baby take some formula, discuss the negative effect on the baby's immune system.  Explain how any foreign substance disrupts the proper set up of the microbiome of the GI and respiratory tracts.  Let them know you do not want to increase the chance of your baby developing asthma or diabetes, or other health issues as a result of a weakened immune system.  Tell them you will agree ONLY to human milk supplementation while baby is in the hospital.  Again, this will get the attention of the staff at hospitals which do not keep PBM on hand. Even if it turns out there is no way go get PBM for your baby (if baby truly needs supplementation), you will have caused them to begin considering this health preserving "treatment". 

If your baby is born prematurely, hand express and pump within the first hour, just like a full term newborn would.  This helps to establish a better milk supply as you continue to pump until your baby can breastfeed well.

I have one last tip for moms who receive antibiotics during or soon after labor (this includes ALL C-section moms).  Candida albicans, a common type of yeast, is the primary organism which causes thrush.  It likes an environment which is warm, moist, and "sugary".  The nipples of breastfeeding moms and the mouths of nursing babies is utopia to candida albicans.  A very large percentage of breastfeeding moms, who received antibiotics near the time of delivery, end up with painful nipples beginning around day 7 - 14.  The usual cause is thrush.

Symptoms of thrush for mom include, burning pain especially at latch on, shooting pain in the breasts during the breastfeeding session, itchy or tender nipples, a "hot pink" hue to the nipple of Caucasion women, and a shiny appearance to darker skinned mothers.  Sometimes the nipple appears dry and flaky.  Babies will often begin, over time to exhibit "off -on" breastfeeding behavior  (latch on, suckle, pull off, repeat, sometimes with "fussing"); increased gassiness; reflux, slow weight gain over time; rash over the trunk and parts of extremities; a red diaper rash near the anus; reflux; a whitish nasal discharge; and on rare occasions -- ALTE  (a life threatening event, usually a few moments of having stopped breathing).  Some babies develop the whitish, caseous plagues on their tongues and inside cheeks.  Some only have a reddened appearance to the inside of their mouths.  The "off-on" breastfeeding behavior is due to tenderness and even pain of their oral cavity from the infection.  They seem to be able to tolerate a bottle nipple better because less pressure is required to get the milk.  However, the goal should be to continue breastfeeding as this is the best for the babies (and your) health over the long term.

Antibiotics kills both bad and good bacteria.  Good bacteria helps keep yeast on an in our bodies under control.  Yeast can overgrow when antibiotics are used.  To minimize overgrowth, and thus a thrush infection on you nipples and/or babies mouth, you can do the following:

1.  Make a solution of 50% filtered water and 50% white vinegar OR purchase a tube of antifungal cream, like Gyne-Lotrimin.

2.  About 4 times a day for the first two weeks, do the following:  breastfeed, rinse your nipples with water, pat dry.  Apply either the white vinegar solution OR massage a little bit of antifungal cream into the nipple and areola.  You can rinse or wipe off your nipples just before the next feeding.

Either one of these approaches should keep yeast from overgrowing during a critical time period.  If you have to take antibiotics at any point while you are breastfeeding, you may want to use this routine for 10 to 14 days, beginning about half way through the number of days you are taking the antibiotic medication.  You can also ask you physician for a prescription for fluconazole (150 mg. pill).  The dosage you will receive will not CLEAR a thrush infection on your breast, but may help, along with either of the two substances discussed above, PREVENT one.  You should probably take the medication around the half way point of taking the antibiotic prescription to help maximize the antifungal's effectiveness.

Grape fruit extract is another, natural way to treat thrush, so it makes sense that it can prevent it from developing while on antibiotics.  Here is a link with more information about GFE -- http://drjaygordon.com/breastfeeding/thrush.html

There are no studies to support this prophylactic intervention.  The book "Medications and Mother's Milk" by Thomas Hale, PhD (a pharmacist), indicates there is no danger to mother or baby in using the over the counter antifungal cream.  

I started telling mothers about this approach when I was working in a NICU.  At around 10 days to two weeks after they delivered, many moms would call or stop by the office to tell me there pump was making them sore.  A visual exam showed common signs of yeast infections of the nipples.  We would then tell the how to treat the problem, including calling their physicians for a prescription.  Once we started telling all mothers at their initial visit to us, usually when baby was one to three days old, how to treat their nipple prophylactically, the calls and complaints went to practically zero.

I have shared this "recipe" with many pregnant women and new moms who were going to receive antibiotics (planned C-sections, etc.) or who had received them.  The ones I was able to follow did not experience thrush. Again without pre-treatment, many breastfeeding mothers will develop it post antibiotic therapy.

As always, consult with your physician before using any medication, including over the counter medication, while pregnant or breastfeeding.