**3. CS and breastfeeding**

#### **3.1 The benefits of breastfeeding to the neonate and the mother**

Among the postnatal factors that may contribute to lifelong health and disease through epigenetic mechanisms, infant feeding seems to play a key role (**Table 1**) [23]. Maternal breast milk is universally considered to be the normative standard for infant feeding, as it confers unique nutritional and non-nutritional benefits that could in some extent be explained through epigenetics [24]. WHO promotes early breastfeeding initiation during the first hour postpartum, exclusive breastfeeding up until the 6th month and maintaining breastfeeding up to the second year of the infant's life or more in order to optimize its growth, development and good health [25]. The special content of breast milk with long chain poly-unsaturated fatty acids [26], oligosaccharides [27], lactoferrin [28] and other important nutrients makes it the ideal nutrition for newborns and infants.

A meta-analysis on the short-term effects of breastfeeding has indicated that breastfeeding reduces the severity of diarrhea and the risk of hospitalization and mortality due to respiratory infections by 72% and 77%, respectively [29]. With regards to the long-term effects of breastfeeding, another meta-analysis was performed by the World Health Organization in 2007 and was updated in 2013. The most recent meta-analysis suggests that a causal association exists between


#### **Table 1.**

*Significant factors affecting the long term health outcomes over the first 1,000 days of life.*

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

breastfeeding and the increased performance in intelligence (IQ ) tests during childhood and adolescence, and has been estimated to lead to an average increase of 3.5 points of IQ score. Though the maternal intelligence scoring (IQ ) was acknowledged as an important confounder, nevertheless it accounted for a small part of this association. The practical implications of this finding of the small increase of performance in intelligence tests are not yet clear [30].

The meta-analysis of 2013 also found a small reduction of about 10% in the prevalence of overweight or obese children exposed to longer durations of breastfeeding. However, there were confounding factors related to this finding since in the majority of study settings the duration of breastfeeding was higher in families with a higher educational and economic status. Breastfeeding was also found to have a protective effect against type-2 diabetes particularly among adolescents. Furthermore, a small protective effect of breastfeeding against systolic blood pressure was found, however as the authors state, residual confounding cannot be ruled out [30]. Finally, the American Association of Pediatrics [31] states that breastfeeding plays a protective role against the sudden infants death syndrome.

Breastfeeding confers numerous short-term and long-term benefits to the mother [25]. Women who do not breastfeed are in a greater risk of developing breast cancer and ovarian cancer [32, 33]. The protective role of breastfeeding is even greater among mothers with the BRCA1 mutation, and it has been estimated that those who breastfeed for at least one year have a 37% lower risk of breast cancer [34]. There is growing evidence indicating that breastfeeding seems to have a protective role against obesity later on in the mother's life [35]. Breastfeeding also confers a lower risk of developing diabetes mellitus [36] and hyperlipidemia [37]. Studies have shown that even a single month of breastfeeding significantly reduces the risk of developing diabetes in later life [38]. Finally, it seems that breastfeeding and especially long term with a duration of more than 7 months, reduces the maternal risk of hypertension and cardiovascular disease [39, 40].

#### **3.2 Cesarean birth and the initiation of breastfeeding**

Though the importance of breastfeeding is well established in the literature, the way by which the mode of delivery interferes with breastfeeding is still obscure. A systematic review and meta-analysis has shown that newborns born with a CS are almost half as likely to initiate breastfeeding before hospital discharge when compared to newborns born vaginally [41]. There is an abundance of literature reports since the late 1990's showing that women who deliver by CS are less likely to breastfeed and most probably will delay breastfeeding initiation. A recent study in Canada found that women planning to have a cesarean birth had no intention to breastfeed or did not initiate breastfeeding (7.4% and 4.3%, respectively) when compared to women with vaginal births (3.4% and 1.8%, respectively) [42]. This finding is further supported in the literature by a study from Ohio in the United States of America indicating that women who underwent a scheduled repeat cesarean delivery were less likely to initiate breastfeeding than those having a successful vaginal birth after a previous CS and those who ultimately delivered by cesarean birth after an unsuccessful trial of labor [43]. It seems that maternal choice for the mode of delivery may also influence her decision to breastfeed. This is a key element that needs to be thoroughly addressed by health care professionals, since to date the motivation of mothers to breastfeed is the most important determining factor for the success of breastfeeding. Another recent study in China calculated that the unadjusted odds ratio [OR] for lower breastfeeding rates associated with CS was 2.11 [95%CI: 1.58–2.81] and 1.36 [95%CI: 1.01–1.83] at the 5th day and 6th month post delivery. After adjusting for early breastfeeding behaviors, it is interesting that

the negative effect of CS on long term breastfeeding was attenuated and was no longer significant. In fact, the authors of this study noted that although cesarean birth had a detrimental effect on early breastfeeding behaviors and long-term breastfeeding outcomes, it is not *per se* a negative factor. It rather seems that infants who have feeding difficulties in the immediate postpartum period may experience long-term feeding problems [44].

The main question therefore is whether being born with a CS increases the difficulties in breastfeeding. There is evidence that a CS can act as an independent risk factor for reduced breastfeeding rates due to the difficulties of early lactation for the mother and baby. In a recent study, women having a CS experienced more difficulties with breastfeeding, while those having an emergency CS were more likely to have an unsuccessful first breastfeeding attempt and were unable to breastfeed their baby within the first 24 h and upon leaving the hospital, than those having a vaginal birth [42]. These difficulties might originate from maternal reasons such as the adverse effect of the administered anesthesia drugs [45], postpartum maternal fatigue after a long eventful labor, or due to postpartum wound pain after the surgery [46]. Mothers after cesarean birth report greater pain scores when compared to those women having a vaginal birth, and more problems with latching on and positioning of the baby during breastfeeding [47]. Mothers after a cesarean birth need to deal with some practical difficulties, such as having to try to breastfeed with a drip in their arm, or not being able to move around easily and pick up their babies as easily as mothers after a vaginal birth. These minor issues can enhance maternal fatigue and postpartum depressive feelings following the birth [46].

Moreover, there has been fair discussion in the literature about the hormonal impact of cesarean birth on lactogenesis. Lactogenesis is the process of developing the ability to secrete milk and involves the maturation of alveolar cells. Stage I lactogenesis takes place during the second half of pregnancy whereas stage II lactogenesis starts with copious milk production after delivery. As the placenta detaches after the delivery of the neonate, there is a rapid drop in progesterone which enables the other hormones that are present in high levels such as prolactin, cortisol and insulin, to stimulate breast milk production. It has been noted that in primiparous women, stage II is slightly delayed and early milk volume is lower. A lower milk volume was also observed in women who had cesarean births compared with those who delivered vaginally [48]. It is postulated that the hormonal pathway that stimulates lactogenesis is disrupted by a CS delivery, either because of maternal stress or decreased oxytocin secretion, and can hinder the milk production [49]. This means that mothers following a cesarean birth may encounter more practical difficulties while trying to breastfeed than mothers after a vaginal birth [50].

Another issue is the breastfeeding difficulties of the new-born after the CS delivery. It has been noted that neonates after a cesarean birth are more likely to display poorly coordinated tongue movements and to perform unsatisfactory infant sucking activity [51] due to drug exposure or to a long tiring labour. Neonates born by CS are more likely to have mucus secretions, which can affect how interested they are in feeding [52]. Intravenous fluids administered during labour can cause mothers' breasts to become swollen, making it harder for the newborn to latch on properly [53].

Another important inhibiting factor to breastfeeding after a CS is the psychological factor, namely the loss of confidence. Mothers and especially those after an emergency CS might be less likely to believe in their ability to nurture and feed their baby as they experience increased feelings of failure. In addition, their family members are usually more likely to suggest offering formula milk to the newborns so they could rest after the surgery [52]. This suggestion may sometimes also originate from the health care personnel along with the advice to keep the newborn at the

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

nursery for long periods of time or overnight in order for the mother to sleep. Long separation periods between the mother and newborn make lactation establishment more difficult. It is a vicious circle where mothers do not trust their body to produce enough milk, those around them make them feel that they are not capable of feeding their offspring and that leads mothers quitting breastfeeding before practically ever starting it [54].

One of the major factors that has been acknowledged for its contribution to breastfeeding success is the early onset of lactation. Unfortunately, it has been proven that cesarean birth neonates have a delay in their onset of lactation as in many cases mother to baby contact inside the operating theatre is delayed, and when offered it is usually shorter in duration than recommended or even absent [55, 56]. Skin-to-skin contact begins ideally at birth and should last continuously until the end of the first breastfeeding [57]. This practice involves placing the dried, naked newborn in a prone position on the mother's bare chest, and sometimes can be covered with a warm blanket. Women and newborns that practice skin-to-skin contact immediately after birth have been proven to show increased rates of breastfeeding at hospital discharge and up to six months postpartum [57].

#### **3.3 Skin-to-skin contact after a cesarean birth**

As mentioned above, early skin-to-skin contact is a key element for the success of breastfeeding as it leads to early initiation of breastfeeding and to the maternal hormonal response, that is the secretion of oxytocin and endorphins which are important to establish lactation [57]. Skin-to-skin contact provides however far more benefits for the mother and baby. This intimate contact evokes neurobehaviors that ensure the fulfillment of basic biological needs and affects the future programming of the infant's physiology and behavior [57]. It is beneficial for the newborns by improving their cardio-respiratory stability [57], their thermo- and glucose regulation [57, 58], and it also reduces the stress of birth while facilitating a smooth transition to extrauterine life [59]. Moreover, since newborns born by CS do not acquire maternal vaginal microbes, skin-to-skin contact immediately after birth permits the microbial colonization of the newborn with maternal skin microbiota [60]. Mothers after a cesarean birth also benefit by appropriate skin-to-skin contact with their newborns, since due to the boost in oxytocin secretion it has been found that the risk of postpartum hemorrhage is ameliorated [61]. In addition, it reduces maternal stress, anxiety, and pain during and after the CS delivery [57]. Long term, it seems that skin-to-skin contact has significant positive effects on reducing the maternal depressive symptoms and the physiological stress she experiences during the postnatal period [62].

Although the WHO guidelines [25] state that keeping the mother and baby together for at least the first hour after birth leads to an improved initiation and duration of breastfeeding, however it is not always as easy to apply for women having a CS and especially an emergency CS [63]. Nevertheless, skin-to-skin contact is recommended by the relevant health authorities such as the National Institute for Health and Care Excellence (NICE) [50] and the Pan American Health Organization [64]. It has been reported that early initiation and a long duration of skin-to-skin contact when compared to a short time duration, has a dose–response effect on breastfeeding [65]. A recent study has shown that for infants after vaginal delivery, the average time from birth to first breastfeeding was 40.91 minutes, while for CS newborns the average time was 74.54 minutes. The duration of the first breastfeeding was maintained for 18.33 minutes for babies after a vaginal delivery, and only 14.98 minutes for those after cesarean birth (p = 0.00). Newborns after a vaginal delivery maintained a longer sucking duration for the first (p = 0.000) and

second (p = 0.008) day postpartum. Correspondingly, cesarean birth newborns were more frequently (p = 0.000) supplied with formula, and they consumed more volumes (p = 0.000) of formula within the first 72 hours after birth [44]. In another quasi-experimental feasibility study in the United States of America, it was shown that women who practiced immediate skin-to-skin contact with their newborns during their CS surgery (within one minute after birth) were more satisfied with the experience and had lower levels of salivary cortisol across time (p = 0.015 and p = 0.003 respectively) than those who practiced early skin-to-skin contact (within the first hour after birth) [66]. It has been reported in the literature that in those cases where the mother is not capable of performing skin-to-skin contact during the surgery then the father can hold the baby [66, 67]. Although this can be a reliable alternative, a recent study found a statistically significant association between skin-to-skin contact with the mother and the exclusive breastfeeding rates upon discharge, which was maintained at three- and six-months postpartum, when compared to the groups that had paternal skin-to-skin contact or no skin-to-skin contact at all [67].
