**4.3 Dealing with practical difficulties after a cesarean birth**

In a recent qualitative study exploring the breastfeeding behavior of mothers following a cesarean birth, some of the main reported challenges for breastfeeding after a CS included the physical discomfort and the lack of knowledge and coping skills in managing their depressive mood after a CS [54]. It is important to realize that health professionals need to provide extra care and consultation to women after a CS. Women that feel greater levels of pain and discomfort are usually more easily to quit breastfeeding, as they feel that they are not able to do it properly. Health professionals need to provide encouragement, emotional support and empowerment to these women to adopt their nourishing role. They also need to provide adequate analgesia for mothers so as not to feel sore while breastfeeding [50]. It needs to be explicit that there are numerous analgesic and antibiotic drugs that are compatible with breastfeeding and women and their families need to be aware of that. At this point, it is important to comment that mothers who require anesthesia or sedation sometimes may receive inconsistent information from health care professionals regarding the passage of drugs into their breast milk. This can potentially lead to the interruption of feeding, discarding of their breast milk or early cessation of breastfeeding. A recent consensus document launched by the Association of Anesthetists and endorsed by the Royal College of Midwives and the Royal College of Obstetricians and Gynecologists clearly states that '*breastfeeding is acceptable to continue after anesthesia and should be supported as soon as the woman is alert and able to breastfeed, and that breast milk should not be discarded'* [73].

Health professionals need to provide consultation and guidance on a more practical level such as advising on different breastfeeding positions that women may find useful and comfortable after the surgery [50]. Midwives need to assist newborns to latch on effectively, especially if they are drowsy from medication or if the mothers' breasts are engorged after having intravenous fluids. They also need to ensure that the newborn is feeding frequently. In case the newborn cannot

#### *Cesarean Section and Breastfeeding Outcomes DOI: http://dx.doi.org/10.5772/intechopen.96658*

breastfeed directly, they should assist the mother to express her milk and provide it to her newborn, so that the milk supply will be maintained and promoted.

Another very important element for health professionals is to provide the accurate birth weight to CS newborns. Researchers propose that using newborns' weight at 24 hours rather than the immediate weight after birth, could be a more accurate reference for weight loss and in turn could support breastfeeding by reducing supplementation rates in the absence of a clinical need. We know that fluids administered intravenously during labor due to the transplacental passage could lead to the newborn's weight inflation immediately after a cesarean birth [74]. In a recent study, it was noted that when the 24-hour weight was used as a reference among healthy full-term newborns delivered by CS, the overall supplementation rate decreased from 43.6% pre-intervention to 27.4% post-intervention, and in first-time mothers from 51.9% to 31.0% [75]. Thus, health professionals need to take under consideration these findings and not easily attribute any newborn's loss of weight to the lack of adequate milk supply which in turn can easily enhance maternal stress and lead to formula supplementation and no or less breastfeeding.

Women following a cesarean birth tend to face more practical difficulties with breastfeeding than women following a vaginal birth. Therefore, midwives and health professionals will need to offer ongoing support providing necessary advice and consultation on practical issues such as breastfeeding positions. Some comfortable breastfeeding positions for mothers after a cesarean birth include the following:


There are many different breastfeeding positions that a mother after a cesarean birth can try while breastfeeding. The most important element is to find a comfortable position for her that she can maintain for as long as her baby wants to feed. She also needs to feel free to ask for assistance from the health personnel while in hospital and from her family members while at home. It has been mentioned in the literature that women following a cesarean birth were not feeling comfortable asking for help from the health professionals as they considered it being a sign of failure, so they tried to endure as long as they could. This eventually led to exhaustion, frustration and the decision to quit breastfeeding quite early [54].

### **4.4 The significance of peer support and the partner's role**

There is a growing trend on the use of social media and mothers' support groups among new mothers to find support and guidance while breastfeeding. The WHO has recently commented in a positive manner on their effectiveness to encourage women while breastfeeding. A recent Cochrane database systematic review on interventions for promoting the initiation of breastfeeding included 107,362 women from seven countries and found low-quality evidence that healthcare

professional-led breastfeeding education and non-healthcare professional-led counseling and peer support interventions can result in some improvements in the number of women beginning to breastfeed [76]. Another systematic review that tried to identify effective interventions for women having a cesarean birth to increase uptake and duration of breastfeeding, identified a limited number of effective interventions such as immediate or early skin-to-skin contact, parent education, the provision of side-bed bassinets when rooming-in, and the use of breast pumps. However, there was one study that tested a bundle intervention consisting of parent education and targeted breastfeeding support and found an increased initiation and continuation of breastfeeding [77]. Both of the above mentioned systematic reviews conclude that more research is needed to explore the effectiveness of several interventions that are initiated prior to conception or during pregnancy and postpartum.

The role of the father or partner during breastfeeding has also been supported in the literature. A quasi-experimental study in China has shown that families where fathers in the antenatal period were specifically informed about ways to support their wives with breastfeeding, maintained exclusive breastfeeding at four and six months postpartum in a larger proportion than families who received standard antenatal care [78]. A recent systematic review highlighted the value of including fathers or partners in interventions to support breastfeeding. The review showed that the inclusion of fathers or partners in breastfeeding interventions improves breastfeeding initiation, duration, and exclusivity rates. Interventions that include face-to-face information delivery, that are designed in a culturally appropriate manner, and provide information on how partners can support breastfeeding are more likely to have a beneficial effect [79]. In a recent qualitative study from Canada, it was shown that fathers themselves perceived their role as much more complex than the limited role of a breastfeeding facilitator that is usually attributed to them. They see themselves as stakeholders in decision-making on how their child is to be fed and they react to the imbalance created by breastfeeding. They want to be considered as partners during the decision-making and they acknowledge the importance of providing emotional and practical support to their breastfeeding spouses. The researchers of this study comment that health professionals need to include fathers in the parental preparation programs and should find ways to support them effectively in managing their various roles [80].
