Preparing for a caesarean birth
Cordelia Uys, March 2021
The impact of a caesarean birth on breastfeeding
Here’s some information I’ve put together for parents who know they’re going to be having a caesarean birth. Women due to give birth via caesarean are often told that not experiencing the hormones of labour will affect their milk production, and that their mature milk will come in later. But in the almost 20 years I've worked with expectant and new parents, first as a birth doula and then as an NCT breastfeeding counsellor, this hasn’t been what I’ve observed. My belief is that having a caesarean birth can make it harder to do lots of skin-to-skin, both straight after the birth, and in the following days, and it is reduced skin-to-skin contact that can delay the onset of mature milk production.
Skin-to-skin in the operating room
Despite innumerable studies showing how crucial those first two hours of uninterrupted skin-to-skin are for mother and baby bonding, and for milk production, - here’s a very recent study on the importance of skin to skin after a caesarean: https://www.sciencedirect.com/science/article/abs/pii/S1871519222000117 - it’s still not routine for hospitals to facilitate immediate skin-to-skin after a caesarean. The reason given is often that the operating room is too cold, despite research showing that when a baby is placed in skin-to-skin contact on their mother’s chest, her body will warm her baby up very effectively.
Thermal synchrony
In fact, via a phenomenon known as thermal synchrony, if a mother of newborn twins places one baby on each breast, her breasts will warm up to different temperatures, depending on each baby’s needs.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1890034/
Even in a cold operating theatre, all that’s needed is for the baby to be dried by patting them down as soon as they emerge. They can then be placed straight on to their mother’s chest, with a blanket or towel covering their body.
It can be helpful to put your surgical gown on backwards beforehand, so that it’s easier to open when your baby is placed on your chest. Because it can be harder to administer the anaesthetic with the gown on backwards, some hospitals might prefer that you put the gown on as normal, but just tie it loosely. Make sure to ask that they are careful where they place the monitoring equipment, so that your chest is free.
There’s rush to weigh your baby
As long as both mother and baby are well, they can then stay in skin-to-skin contact while the incision is being sutured. There’s no rush to weigh the baby – that can wait.
If immediate skin-to-skin is not possible – please don’t despair
If you are not able to have immediate skin-to-skin with your baby, please tell your health care professionals that you would like to have it as soon as possible. If you and your baby have to be separated, skin-to-skin will provide a magical and powerful way of reconnecting, and calming you both.
Skin-to-skin with fathers or partners
If you are not well enough to hold your baby straight after their birth, skin-to-skin with your partner will provide them with a lot of valuable comfort and closeness.
Ask to meet your doctors in advance
If you are having a planned caesarean birth, if possible, I would recommend that you ask for a meeting in advance with both the surgeon and the anaesthetist, so you can tell them how important skin-to-skin is to you. You could print out a few of the studies below. A client of mine did this and was able to get her doctors to agree to immediate skin-to-skin, even though it’s not the hospital's usual policy.
Research on skin-to-skin
This film and these articles on skin-to-skin following a caesarean might help to know what to ask for:
https://www.youtube.com/watch?time_continue=2&v=0jCjk73Xpn8
The Natural Caesarean – Newbury Doula
The continued importance of skin to skin on the postnatal ward and at home
Once you’re on the postnatal ward, and in the first week or two at home, try to ensure that you continue spending the majority of your time in skin-to-skin with your baby. If possible, it’s really helpful to have a friend or relative with you who can pass the baby to you, as bending down and picking your baby up out of a cot is difficult in the first few days after a caesarean.
Frequent skin-to-skin contact in those early days will speed up the onset of your mature milk production. It will also allow you more easily to notice your baby’s early feeding cues and therefore breastfeed them more often, which is also really good for stimulating your milk supply.
Weighing your baby at 24 hours
There is research showing that when babies are born by caesarean, it’s best practice to use their weight at 24 hours old as the reference for weight loss (when they’re weighed by the midwife on Day 5), rather than their birth weight. This is because babies take on board some of the intravenous fluid given to their mother during the procedure, and this artificially inflates their birth weight. They then pee out that extra fluid in the first 24 hours.
https://www.ncbi.nlm.nih.gov/m/pubmed/29356561/
If you can’t weigh your baby at 24 hours, please be aware that they might have a greater weight loss on Day 5, than one would expect for a baby born vaginally, for whom a 5-7% weight loss is normal.
One mother’s experience
My client Emily Winterbotham writes: “I was lucky to have a wonderful doula who helped me prepare my birth plan around a caesarean because my son was breech. When I nervously presented my birth plan to Queen Charlotte’s hospital in advance, they said my requests for delayed cord clamping, skin-to-skin, lowering the screen to see our son born were all standard practice. Obviously, we were prepared for the fact that things can go wrong and some of our preferences might not be possible. Ultimately though, feeling supported by the hospital meant that we had a wonderful c-section birth even though I had actually gone into labour a week ahead of my planned c-section. Alexis left my chest just once after birth - to go on his dad’s chest as I was shaking a bit - but then he went straight back on from theatre to recovery. The midwife in recovery was a delight (helped by the fact that it was very late at night by then as we had been waiting a while, and so were the only ones there) and helped me get Alexis latched on in recovery at my request. Alexis was only taken away for a quick weigh and check about 1.5-2hrs after birth. My milk came in the night I came home, so three days after birth.
On the mobility and picking the baby up point: I was worried about that as people talk about it a lot re c-sections. The day after was very tough (largely due to lack of sleep due to anaesthetic for me and the fear of the cut), but you’re in hospital then anyway. But two days after I had a shower and though fragile, felt fine to bend down and was moving pretty normally from then on. I know that’s not everyone’s experience, but I really felt great within 72 hours.
All in all, we had a beautiful birth, so it can be done!”
The reason Queen Charlotte’s is so supportive of skin-to-skin after a caesarean birth is that a senior midwife called Jenny Smith, who worked at QCH, pioneered what she calls Jentle caesarean births:
https://vimeo.com/373107346?fbclid=IwAR18LDpI8TXk2VXXK5mBrW1bjw9-1NI1KuMBEXCSLpOD2k4UyRyDCQqXR04
Some more women give their recommendations for establishing breastfeeding after a caesarean birth:
Varsha
“Really push for lots of skin to skin. Discuss with your midwife beforehand, put it in your birth plan, discuss with the anaesthetist so they can place cannula, drip and ECG stickers accordingly. I did this with my emergency c/section (expressed colostrum beforehand) and it feels like baby hasn’t come away from my chest since! My milk came in after 48 hours and in fact, I had oversupply.”
Hannah
“My second baby was a planned c-section. My milk came in on day 2 (a full day earlier than my first baby) and I don’t believe the c-section caused any issues whatsoever. I was lucky that I had a straightforward surgery, immediate skin to skin and my son latched straight away. I’d also done a bit of hand expressing beforehand which I think helped. Just wanted to share a positive story to balance the scare mongering!
Kirsti
“I had a more complicated c-section (my baby was breech and turned transverse pre-surgery, so the surgeon had difficulty getting her out) so I didn’t get to have any skin to skin and honestly I was very distressed — but even that didn’t cause issues. Once baby was out of NICU 7 hours later, she latched easily and my milk came in on day 2. I also managed to express a lot of colostrum post-surgery when she was in NICU (I wasn’t allowed to during pregnancy due to her being breech).”
Joanne
“My second baby was born by planned c-section and although getting him out was uneventful, I didn’t get to have skin to skin until we were out of surgery and in the recovery room (about 1-1.5 hours post-birth) because stitching me back up was more difficult than expected for a few reasons. Baby was fine (ie he didn’t have to go to NICU or anything) so he stayed in the operating room with his dad doing skin to skin with him while I was stitched up. I was a bit worried about the length of time it took for him to be skin to skin with me, but as soon as we were in recovery and I cuddled him he latched on and didn’t stop sucking for about 2 hours! My milk came in very quickly!”
Elisa
“I had my third baby by c section last year, first section and I insisted on loads of skin to skin - the midwife commented that I was “always feeding him”. He was too sleepy to feed properly so I kept encouraging, keeping him on the boob and my milk came in within a couple of days. So nothing at all to worry about, just lots of cuddles and ignore anyone on the ward who suggests you put baby down.”
Wishing you all the best for the birth of your baby or babies.
Links:
First Droplets is a website set up by the paediatrician Dr Jane Morton: ‘The cornerstone of successful breastfeeding is a plentiful milk supply. We will help mothers go into delivery understanding that milk removal in the first few hours, either by the baby, herself or her partner, is the key for future milk production. Simply put, it’s early milk out, later milk in’: https://firstdroplets.com/team/
Exclusive breastfeeding restores infant gut microbiome after a caesarean birth: https://toni-harman.medium.com/new-study-exclusive-breastfeeding-restores-infant-gut-microbiome-after-c-section-bf8fa0db15d