Within a Woman

http://www.cirp.org/library/procedure/plastibell/

Newborn Exam
Within a couple of hours of birth, usually after the first feeding, a head-to-toe exam is done of your baby. He or she is measured and weighed. The heart and lungs are listened to, and the baby is checked for any abnormalities from the ears and mouth, to the number of toes. Normal newborn reflexes are checked for - their absence could mean a problem with the central nervous system. Anything unusual is referred to a pediatrician. Feel free to ask questions during the exam, and to touch your baby and talk to him/her. We prefer to start when the baby is calm and are as gentle as possible, but some babies object to the necessary handling and will cry. If a pediatrician has been called to the delivery because we have a concern about the baby’s welfare, the newborn exam will be done by him/her very soon after the birth.

Eye Prophylaxis
Erythromycin, an antibiotic ointment, is routinely applied to babies’ eyes within an hour of birth. Gonorrhea and chlamydia can infect the eyes and cause blindness if untreated. They can be present with no symptoms in the mother, and lab tests occasionally have false negatives.

You may choose to have swabs done during pregnancy to look for gonorrhea and chlamydia, and be treated if either is present. Some parents choose not to expose their newborns to antibiotics.

Vitamin K
Vitamin K is important in blood clotting. It is manufactured in the intestines by bacteria. Babies need to be colonized by the bacteria from their parents and start making their own Vitamin K as soon as possible. A baby with insufficient Vitamin K may develop neonatal hemorrhagic disease - which can range from bruising with normal handling to fatal bleeding. Brain damage can result. Research shows an incidence from 1/500 to 1/1,500. Statistically, breastfed babies have a higher rate of hemorrhagic disease.

You may choose to have your baby receive Vitamin K by a single injection (IM) at the time of the newborn exam, or your baby may receive three doses of Vitamin K by mouth (PO). The first is done within a few hours of birth, the second at 4 -10 days and the third at 4 - 6 weeks. Research supports injectable Vitamin K. Oral Vitamin K appears to work, but doesn’t have extensive research to support it.

Neonatal Metabolic Screen
This is a blood test that checks for metabolic problems which could permanently damage your baby: phenylketonuria (PKU), hypothyroidism, galactosemia and MCAD. If these problems are caught early and treated your baby can avoid harm.

Phenylketonuria is an inability to metabolize a protein. Abnormal amounts build up in the body and can damage the brain. The incidence in B.C. is 1/18,000 live births. Treatment is a special diet low in phenylalinine. Your baby may be able to receive some breast milk, depending on the severity of the disease.

Hypothyroidism is an abnormally low production of thyroid hormones. These are important for normal brain development. The incidence in B.C. is 1/3,000 births. Treatment is a daily dose of thyroid medication.

Galactosemia is an inability to break down the milk sugar galactose. Galactose builds up in the body causing failure to thrive, jaundice, vomiting, diarrhea, liver damage, hypoglycemia, cataracts and mild to moderate brain damage. The incidence in B.C. is 1/25,000 newborns. It is treated by a special diet with no lactose.

Medium Chain Acyl-CoA Dehydrogenase Deficiency (MCAD) causes problems with fat metabolism. It can cause hypoglycemia and sudden unexpected death. It is found in 1/20,000 infants. Treatment is a special diet and supplements.

The test is done by warming the infant’s foot (to bring blood close to the surface) and then pricking the heel. Sometimes the baby must be pricked more than once to get enough. Blood is collected in four circles on blotter paper. The paper is dried and sent to a lab in Vancouver for testing. There is not an alternative test and once symptoms of these diseases are noticeable irreversible damage may have been done.

The best time to do these tests is 24 - 48 hours after the birth. A test done before 24 hours will need to be repeated. If you have an early discharge from the hospital and wish to have your midwife do the test in your home the next day you will have to sign a form saying you are deferring the test. Of course, if you have a home birth, the test will be done in your home. You can hold and comfort, or nurse, the baby while the test is being done. Most babies cry briefly but aren’t upset for long.

Circumcision
Medical societies like the Canadian Pediatric Society and the American Academy of Pediatrics have advised since the 1970s that routine circumcision of infants be discontinued. Newborn circumcision is no longer done in the hospital. It is not covered by medical insurance and will cost over $100. It is considered cosmetic surgery as there is NO medical reason for circumcising a newborn.

Circumcision carries risks – as any surgical procedure does – including infection, excessive bleeding and scarring. Baby boys are strapped down on a board. Local anesthetic is usually used, but there will be pain (the penis is well supplied with nerves) when the anesthetic wears off.

If you choose to circumcise an infant son for religious or personal reasons, please organize the surgery during your pregnancy.

Group Beta Streptococcus (GBS)
Print this PageWhat is GBS?
GBS is a common type of bacteria present in about 30% of adults. This bacteria is found in the rectum, bladder, and also in women’s vaginas. During pregnancy we become more concerned about the colonization of GBS because it can be passed on to the newborn. It is estimated that between 40-70% of GBS positive women will pass this bacteria onto their babies during birth. While the majority of babies are not affected by the bacteria, a very small number (1-2%) of these babies will go on to develop an infection. GBS infected babies may have mild to severe problems which can affect their blood, brains, lungs, or spinal cord. Therefore parents should be informed of this disease, consider GBS screening, and be aware of the recommended course of treatment and knowledgeable in identifying GBS infection in a newborn.

The current standard of care involves determining a woman’s GBS status:

Between 35-37 weeks gestation a screening test can be used to identifying women who are colonized with GBS. (It is possible to have a negative test result and still be GBS positive.)
To culture for GBS a swab (similar to a Q-tip) is inserted into the lower vagina and rectum and then is placed in a special medium and sent to the lab.
A women with GBS in her urine this pregnancy, or who has delivered an infant with GBS disease is recommended to be considered GBS positive.
Women who are determined to be GBS positive will be recommended to have antibiotics.

During active labour intravenous antibiotics are given to GBS positive women usually every 4 hours.
Although an anaphylactic reaction to antibiotics is rare, women planning a home birth must go to the hospital for their first dose of antibiotics.
If a women’s GBS status is not determined, treatment with IV antibiotics is strongly recommended if there is:

Preterm labour (less than 37 weeks),
Ruptured membranes for longer than 18 hours,
Maternal fever during labour (temperature greater than 38 C orally or 100.4 F),
Previous delivery of a newborn with GBS or evidence of GBS urinary infection.
Facts Associated with GBS
Women
GBS can trigger premature labour and has also been linked with maternal infection. Including infection of the urinary tract, amnionitis (infection of the bag of waters) endometritis (infection of the uterus).
Women who carry GBS but do not develop a fever during labour > 38 C or 100.4 F, have ruptured membranes over 18 hours or have labour or ruptured membranes before 37 weeks, have a relatively low risk of delivering an infant with GBS disease.
With antibiotic therapy a mild allergic reaction to penicillin (such as rash) occurs in 1 out 10 women.
There is a 1 in 10,000 chance of developing a severe allergic reaction (anaphylaxis). This is a life-threatening condition which requires emergency treatment.
Newborn
The likelihood of GBS disease of the newborn is about 2/1000 live births.
The likelihood of a GBS positive mother delivering a baby with GBS disease is approximately 1 out of every 100-200 births if no antibiotics are given. This is reduced to 1:4000 if antibiotics are given.
Preterm infants and infants weighing less than 2500g have a much higher infection rate.
Babies that survive a serious infection with GBS, particularly those who have meningitis, may have long-term problems, such as hearing or vision loss or learning disabilities. Approximately 15-20% of GBS infected babies will not survive.
Alternatives and their Risks/Benefits
Herbal immune enhancing/antimicrobial formulas (e.g.: Congaplex by Standard Brands or EHB by NF Formulas, vaginal suppositories with tea tree oil or colloidal silver) are available. Some have anecdotal evidence of clearing GBS colonization, but no scientific studies are available. Beware of formulas containing Goldenseal as it can induce preterm labour

Signs of GBS infection in the Newborn
GBS is usually present as blood poisoning, pneumonia, or meningitis. Signs of GBS infection usually become apparent within the first two days of life, but may occur within hours of birth. Signs of an infection in a newborn can be difficult to determine. They include lethargy, poor feeding, high/low temperatures, irritability, high/low breathing rates, and breathing difficulties as seen by flaring of the nostril, laboured breathing, grunting noises, and/or a blue appearance.

Post-term pregnancy is defined as pregnancy that goes beyond 42 weeks since the woman’s last menstrual period. The reported frequency varies from 4-14% depending on the different factors of the population surveyed.

The main concern of post-date pregnancy is that the placenta may not work as efficiently as it ages beyond 41 weeks gestation. This can lead to a number of effects, including dry skin, loss of fat and meconium (fetal wastes) in the bag of waters. In rare cases, it can result in low oxygenation, meconium aspiration syndrome, convulsions or even death. However, the vast majority of babies are born healthy whether they arrive at 40 weeks or later.

Concern for the baby’s welfare has prompted considerable controversy surrounding the management of the time intervals prior to and beyond the point of postdate pregnancy. There are two main methods of care after 41 weeks:

Expectant Management
This is a wait-and-see approach, along with various tests to monitor fetal well-being. An NST (non-stress test) involves listening to the baby’s heart rate for a period of time to monitor for a normal pattern. Often at 42 weeks an ultrasound will be recommended. This test can assess the baby’s health by observing fetal movement, and assessing levels of amniotic fluid.
Labour Induction
This involves going to the hospital to have your labour artificially induced by medications. Two frequently use techniques are:

i) Prostaglandins — A doctor applies medication (usually a gel) to your cervix;
ii) Oxytocin — A synthetic hormone is given intravenously to stimulate labour contractions.
Currently the obstetric society has adopted a policy of recommending labour inductions at 41-42 weeks gestation.
More about Induction
The rate of induction beyond 41 weeks gestation has been steadily increasing so that in 1999 it was recorded to be as high as 38%. According to the American College of Obstetrician and Gynecologists (ACOG), the increased rates are related to the widespread availability of cervical ripening agents, pressure from patients and physicians, as well as legal constraints.

Prior to an induction, a woman’s cervix is evaluated for ripeness. If the cervix is firm and closed, Prostaglandins is often applied to soften the cervix. Frequently, more then one application is required before labour can begin. The baby’s heart rate will be monitored prior to an induction and afterwards for approximately 30 minutes. Once a cervix is considered ripe enough the doctor will either continue with the prostaglandins or use a synthetic hormone called Oxytocin. This hormone is similar to the body’s own natural hormone and generally is effective to begin labour. Oxytocin is always given intravenously, and will require continuous monitoring of both the mother and baby to ensure the procedure is being tolerated well.

Advantageous of Induction
Inductions are typically arranged for a scheduled time at the hospital, which may help families to organize for their baby’s arrival,
For women whose care provider shares a call schedule, it may ensure your preferred provider is present.
Inductions can also eliminate the need for the ongoing waiting of labour to begin.
Disadvantageous of Induction
An intravenous and monitoring instruments can limit a mother’s ability to move into different positions and locations during labour which may lead to longer intervals in bed.
Adverse complications caused by induction have also been well-documented and include contractions that are difficult to handle, increased need for epidurals, hyper-stimulation of the uterus, possible placental abruption and uterine rupture.
Additional risks factors for the baby may include heart rate abnormalities, hypoxia, and fetal distress.
There has been little research on women’s actual experience and satisfaction with induction, so it is difficult to say how women rate this experience.
More on Expectant Management
At 41 weeks a woman’s chances of giving birth naturally are still very much in her favor. Six women out of ten will have their babies in the next 3 days, and nine will have it in the next 7 days. Health care providers will often recommend monitoring the baby to ensure it is managing well. A Non-stress Test (NST) is often done between 41-42 weeks and involves tracking the baby’s heart rate with a monitor for a minimum of 20 minutes. The pattern of the baby’s heart rate is indicative of its general health. Ultrasound is often recommended to assess fetal health by monitoring fetal activity, and determining levels of amniotic fluid. These tests indicate how the baby is managing in real time but cannot predict the baby’s future welfare. Daily monitoring of fetal movement is also recommended.

Other Facts
Knowing which pregnancies are truly at risk would be the ideal situation in the case of post-term pregnancy. Unfortunately we have not developed or adequately researched methods to determine this. Research has determined that:

Smaller term babies run a greater risk then larger babies for complications,
Sometimes there is a familial or genetic component to post-term pregnancy. A small correlation between mothers, daughter, and sisters has been seen in this regard.
The strongest indicator for a prolonged pregnancy, and reduced rate of post-date complications occurs with women who have had a previous prolonged pregnancy.
Post-term babies have a greater tendency to be boy babies.
Daily monitoring of the time it takes your baby to move 10 times should be fairly consistent.
If you’re paying close attention, and you are not aware of fetal movement you should contact your care provider.
Fetal movement counts are a positive way to connect with your baby.
Preventing Post-term Pregnancy
Women can try to stimulate their labour through alternate methods, but for the most part these methods have not been researched for safety and/or effectiveness. Things you may consider are:

Walking — which naturally pushes your baby’s head against the cervix.
Sexual intercourse — as both nipple stimulation and the release of hormones with orgasm and ejaculation are helpful to soften the cervix in preparation for labour.
Women who use upright and forward leaning posture, particularly during the last 6 weeks of pregnancy (2-3 weeks for a multigravida) give the baby an excellent chance of positioning itself into the best position for labour. Activities of swimming and yoga encourage this, while semi-reclining, sitting crossed legs, and squatting are not advisable.
Professional guidance may be sought for other modalities including hypnosis, acupuncture and homeopathy.

Slow Labour Progress

Latent labour covers the period of time from the beginning of labour to the point when dilation begins to progress actively. This is generally from the onset of regular contractions to the point where the woman’s cervix is 3-4cm dilated. Little to no descent of the presenting part occurs during the latent phase. Contractions become more established, increasing frequency, duration, and intensity. Usually women are happy and excited that the end of the pregnancy has come.

Labour duration can vary from woman to woman. Those women experiencing their first labour tend to average a 8-9 hour of labour latent. labour is consider prolonged if it last upwards of 20 hours. Women having their second or subsequent labour tend to have latent labour lasting approximately five hours. For those more experienced mothers latent labour is considered prolonged if it lasts more than 14 hours.

The “active” phase covers the period of time from the start of active progression of dilation to completion of dilation, generally from 3- 4 cm to 10cm dilated. Progressive descent of the presenting part occurs during the latter part of the active phase and during pushing. A prolonged active phase is defined by the total duration of hours in labour, or failure of the cervix to dilate. Normal first-time mothers can expect active labour for six hours, with an upper limit of about 12 hours. Women having their second or subsequent labours normally take three hours to fully dilate, and have an upper limit of six hours to dilate at this stage. A dilation rate of 1 cm per hour is typical.

The second stage of labour refers to a time from full dilation to the birth of the baby. First babies usually take an hour to be born with upper limits of three hours. Women with 2 or more babies average 20 minutes but have a upper normal of 1 hour. Slow second stage is encouraged with position changes, information on effective pushing techniques, and sometimes through medical interventions such as forceps.

Prolonged Labour
Prolonged or slow progress is caused by a combination of factors including the cervix, the uterus, the fetus, and the mother’s pelvis. The power of a woman’s contractions will obviously have an effect on the rate of dilation. labour contractions generally start mild and progress in intensity with time. The interval between contractions shortens and the duration and strength of the contraction increases. The midwife will be monitoring a woman’s labour and looking for signs of progression. This is done through monitoring the contractions and vaginal exams.

If labour is not progressing and the power of contractions does not seem to be increasing interventions will sometimes be required. Natural methods of intervention used to promote labour include nipple stimulation, position changes, food and fluids, herbs, homeopathy, and rupturing the membranes. A more medical approach may involve having an intravenous with a hormone called oxytocin.

The baby’s positioning is very important for the progress of labour. Some problems that can occur include:

A posterior baby has its back lined up along the woman’s back rather then with its back anterior towards her abdomen. This is known as “back labour”. Forward sitting in the last trimester can help prevent this type of labour.
The baby may not a have a well-flexed head. Flexing the head presents the smallest diameter first.
The baby’s head may be ascynclitic (not centered or crooked to one side).
A women’s pelvis or bones must be internally shaped to allow a baby’s head to fit through its diameter. The psychology or a woman’s mental state can also factor in. It’s important that a labouring women feel safe and relaxed. Fear or stress can interfere with labour progress.

Help with a Slow Prolonged Labour
Try to get lots of rest before labour begins. When your labour starts, try to stay relaxed. It’s easy to get overly excited and wear yourself out early. Instead, think about getting enough rest, eating well-balanced foods, and drinking plenty of fluids. There are so many factors that can cause a prolonged labour it’s important to recognize that some may correct themselves but others won’t no matter what you do. In situations where labour is prolonged and none of the suggestions the midwife makes seem to change the pattern, sometimes medical interventions are needed. It’s important to keep all avenues open and sometimes medications can help the woman get some much-needed rest.

Natural Pain Relief
Supportive Companion(s) — Think carefully about the people who will attend your birth. Pick people who will help you feel relaxed and supported. Women cope and progress better when they aren’t stressed out. A trained doula may be a consideration.
Paced Breathing — Focusing on your breath is an age-old method for managing labour and highly effective.
Music — Women often find rhythm and music can help them be distracted from labour discomforts.
Water — Many women find that warm water effectively reduces the discomfort of labour contractions. Either a shower or a soak in a warm tub can be effective. You might even consider a water birth if water has helped you with relaxation and pain in the past.
Massage/Therapeutic Touch — Having someone massage or apply pressure on your back often is helpful to reduces the sensations during a tightening.
Apply heat or cold — Heat often promotes relaxation while cold compresses can numb an area.
Pharmacological Pain Relief
With prolonged labour pharmacological pain relief may prevent exhaustion by promoting rest but can also bring with them the possibility of negative side-effects. Some commonly used treatments include:

Sedatives, Hypnotics and Tranquillizers administered in pill form may be helpful to reduce anxiety and promote relaxation. Side effects include: dizziness, low blood pressure, sleepiness, and occasionally nausea or restlessness.
Narcotics, such as Demerol/Phentenol, administered by injection or intravenously can reduce pain, promote sleep and relaxation. They generally last longer with injection into muscles, and act more rapidly if injected intravenously. Side effects: nausea, drowsiness, may cause respiratory depression in the newborn.

Inhalation Analgesics such as Entonox 50% oxygen/50% nitrous oxide administered by facial mask are rapid acting with minimal or no side effects.
Epidural catheter placed between lumbar vertebrae can be quite effective at relieving labour discomforts but requires an intravenous, continuous monitoring of the fetal heart rate, frequent blood pressure checks, and catheter placed into the bladder. Side effects: may cause blood pressure to drop, itchiness, may interfere with internal rotation of the baby and increase likelihood of assisted delivery. It may also cause depression in newborn. In rare cases, epidurals can cause spinal headache if improper placement occurs.

Life with children can seem chaotic, at times even out of control. Establishing some basic routines can restore a sense of order that will make life easier for both parents and children. A routine doesn’t mean a rigid schedule; young children need structure with flexibility (especially on weekends). For most families, things work better when everyday activities follow a predictable pattern.

Benefits for children
• Sense of security - When things happen in the same order every day, children learn to predict what comes next. They feel safe and secure because someone
else is taking care of things for them; they don’t have to worry.
• Trust - Children learn to trust when the people who care for them follow a dependable routine. This is the foundation on which they build their trust in the larger world.
• Self-confidence - Children’s confidence in themselves also increases when they are able to predict what will come next.
• Good habits - Routines, such as regular exercise, build good health habits that teach children to look after themselves.

Benefits for parents

• Planning - Having a routine helps parents plan to accomplish necessary chores. Especially with a small baby, finding time to take a shower and buy groceries can be a challenge!
• Discipline - Children are less likely to test the rules by misbehaving when regular tasks become part of an established routine. If tidying up toys always comes before washing hands and sitting down to eat, most children will stop protesting and get to work fairly quickly. If bath is always followed by bed, a story, a song, a goodnight kiss and a wave from the
bedroom door, sleep will come more easily.

What makes a good routine?

We are all individuals; there is no recipe for a routine that works for every family. Here are some factors to consider, along with examples of questions to ask yourself when planning a routine. Remember to take into account the needs and preferences of both parents and children.

• Physical needs - Is everyone fed and well rested before taking part in other activities? Is there time for physical activity (a walk to the park, energetic dancing in the living room) every day? Does the routine let everyone get enough sleep?
• Social needs - Are toddlers getting together with other children their age? Are parents seeing friends? (Playgroups can answer both these needs.)
• Intellectual needs - Do children get time to play in ways that stimulate their understanding of their surroundings? Are parents getting enough adult conversation?
• Emotional needs - Are babies getting the comforting they need? Do children feel secure in their parents’ attention? Are parents getting support?
• Stage of development - Does the routine take into account how needs change as children grow? More snacks during a growth spurt? More choices offered
to toddlers? (For instance, “Will you brush your teeth before the bath or after?”) More responsibilities transferred to older children. (For instance, helping to prepare snack or making a school lunch.)
• Individual differences - Does the routine allow for a child’s particular temperament? For instance, limiting the number of errands because this child has trouble making transitions from store to car to store to car….Or lots of flexibility because this child has irregular
body rhythms and isn’t hungry at the same time every day. Or always the same routine because this child doesn’t like surprises.

Changing the routine

Sometimes, changing the routine can solve behaviour problems.
• Change the sequence - Even if people tell you a bath before bed calms children, your child may get excited and have trouble going to sleep. The problem might disappear if you move bath time before supper.
• Recognize a need - If your child always has a tantrum before supper, maybe she’s hungry. Try
adding an afternoon snack to the routine. Or maybe she needs to be sure of your attention. Try a short playtime with you before you start cooking or let her shred the lettuce beside you.
• Smooth transitions - Children often misbehave when it is time to change activities. To avoid trouble, try adding a song to the routine to signal upcoming changes. For example, if a toddler has to stop playing to go meet an older brother’s school bus, sing “Johnny’s bus is coming soon, we will go to meet him,” sung to the tune of “Frère Jacques.” The song gives children time to adjust and make the transition.

Routines are never set in stone; they will always need to be adapted as conditions change. By observing your children, by knowing your own needs, you will be able to make a predictable routine that suits your family.

by Betsy Mann, with help from Linda Martin, Family Visitor
Program Coordinator, Better Beginnings, Better Futures, Ottawa.

Skin to Skin Contact
There are now a multitude of studies that show that mothers and babies should be together, skin to skin (baby naked, not wrapped in a blanket) immediately after birth, as well as later. The baby is happier, the baby’s temperature is more stable and more normal, the baby’s heart and breathing rates are more stable and more normal, and the baby’s blood sugar is more elevated. Not only that, skin to skin contact immediately after birth allows the baby to be colonized by the same bacteria as the mother. This, plus breastfeeding, are thought to be important in the prevention of allergic diseases. When a baby is put into an incubator, his skin and gut are often colonized by bacteria different from his mother’s.

We now know that this is true not only for the baby born at term and in good health, but also even for the premature baby. Skin to skin contact and Kangaroo Mother Care can contribute much to the care of the premature baby. Even babies on oxygen can be cared for skin to skin, and this helps reduce their need for extra oxygen, and keeps them more stable in other ways as well (See www.kangaroomothercare.com).

To appreciate the importance of keeping mother and baby skin to skin for as long as possible in these first few weeks of life (not just at feedings) it might help to understand that a human baby, like any mammal, has a natural habitat in which he is supposed to be: with and on his mother. When a baby or any mammal is taken out of this natural habitat, it behaves in a way which is unnatural. A baby wrapped in a blanket or swaddled behaves not so much like a baby, but instead becomes too sleepy or lethargic and needs to shut down; or becomes disassociated altogether. Or, such a baby may shake and cry and protest in despair. When a baby is swaddled it cannot interact with his mother, the way nature intended, and the way that is necessary for his very survival. The mother and the baby exchange sensory information that stimulates and elicits “baby” behaviour: rooting and searching to eat, calming in his mother’s arms, staying warm and maintaining his temperature.

From the point of view of breastfeeding, babies who are kept skin to skin with the mother immediately after birth for at least an hour, are more likely to latch on without any help and they are more likely to latch on well, especially if the mother did not receive medication during the labour or birth. As mentioned in the handout Breastfeeding—Starting out Right, a baby who latches on well gets milk more easily than a baby who latches on less well. When a baby latches on well, the mother is less likely to be sore. When a mother’s milk is abundant, the baby can take the breast poorly and still get lots of milk, though the feedings may then be long or frequent or both, and the mother is more prone to develop problems such as blocked ducts and mastitis. In the first few days, however, the mother does have the appropriate amount of milk that baby requires. She is not supposed to have a large amount—that would be inappropriate for baby and no baby could safely consume a large amount of milk–Mother has enough! Yes, the milk is there even if someone has proved to you with the big pump that there isn’t any. How much does or does not come out in the pump proves nothing—it is irrelevant. Also note, no one who squeezes a mother’s breast can tell whether there is enough milk in there or not. And a good latch is important to help the baby get that milk that is available. If the baby does not latch on well, the mother may be sore, and if the baby does not get milk well, the baby will want to be on the breast for long periods of time worsening the soreness.

To recap, skin to skin contact immediately after birth, which lasts for at least an hour (and should continue for as many hours as possible throughout the day and night for the first number of weeks) has the following positive effects on the baby:

Is more likely to latch on
Is more likely to latch on well
Is more stable and has normal skin temperature
Is more stable and has a normal heart rate and blood pressure
Has higher blood sugar
Is less likely to cry
Is more likely to breastfeed exclusively longer
Will self wake when hungry

There is no reason that the vast majority of babies cannot be skin to skin with the mother immediately after birth for at least an hour. Hospital routines, such as weighing the baby, should not take precedence.

The baby should be dried off and put on the mother. Nobody should be pushing the baby to do anything; nobody should be trying to help the baby latch on during this time. Baby may be placed vertically on mother’s chest and be allowed to slowly find his way to the breast, while mother supports him if necessary. During this period mother should be encouraged to allow baby to find his way while keeping her hands off his head. The mother, of course, may make some attempts to help the baby, and this should not be discouraged. This is baby’s first journey in the outside world and the mother and baby should just be left in peace to enjoy each other’s company. (The mother and baby should not be left alone, however, especially if the mother has received medication, and it is important that not only the mother’s partner, but also a nurse, midwife, doula or physician stay with them—occasionally, some babies do need medical help and someone qualified should be there “just in case”). The eyedrops and the injection of vitamin K can wait a couple of hours. By the way, immediate skin to skin contact can also be done after cæsarean section, even while the mother is getting stitched up, unless there are medical reasons which prevent it.

Studies have shown that even premature babies, as small as 1200 g (2 lb 10 oz) are more stable metabolically (including the level of their blood sugars) and breathe better if they are skin to skin immediately after birth. The need for an intravenous infusion, oxygen therapy or a nasogastric tube, for example, or all the preceding, does not preclude skin to skin contact. Skin to skin contact is quite compatible with other measures taken to keep the baby healthy. Of course, if the baby is quite sick, the baby’s health must not be compromised, but any premature baby who is not suffering from respiratory distress syndrome can be skin to skin with the mother immediately after birth. Indeed, in the premature baby, as in the full term baby, skin to skin contact may decrease rapid breathing into the normal range.

Even if the baby does not latch on during the first hour or two, skin to skin contact is important for the baby and the mother for all the other reasons mentioned.

If the baby does not take the breast right away, do not panic. There is almost never any rush, especially in the full term healthy baby. One of the most harmful approaches to feeding the newborn has been the bizarre notion that babies must feed every three hours. Babies should feed when they show signs of being ready, and keeping a baby next to his mother will make it obvious to her when the baby is ready. There is actually not a stitch of proof that babies must feed every three hours or by any schedule, but based on such a notion, many babies are being pushed into the breast because three hours have passed. The baby who is not yet interested in feeding may object strenuously, and thus is pushed even more, resulting, in many cases, in baby refusing the breast because we want to make sure they take the breast. And it gets worse. If the baby keeps objecting to being pushed into the breast and gets more and more upset, then the “obvious next step” is to give a supplement. And it is obvious where we are headed (see handout When a Baby Has Not Yet Latched).

Written and Revised by Jack Newman, MD, FRCPC 1995-2005
Revised May 2008

Starting Out Right
Breastfeeding is the natural and normal way of feeding infants and young children, and human milk is the milk made specifically for human infants. Starting out right helps to ensure breastfeeding is a pleasant experience for both you and your baby. Breastfeeding should be easy and trouble free for most mothers.

The vast majority of mothers are perfectly capable of breastfeeding their babies exclusively for about six months. In fact, most mothers should be able to produce more than enough milk. Unfortunately, outdated hospital policies and routines based on bottle feeding still predominate in too many health care institutions and make breastfeeding difficult, even impossible, for too many mothers and babies. Too frequently also, these mothers blame themselves. For breastfeeding to be well and properly established, getting off to the best start from the first days can make all the difference in the world. Of course, even with a terrible start, many mothers and babies manage. And yes, many mothers just put the baby to the breast and it works just fine.

The basis of breastfeeding is getting the baby to latch on well. A baby who latches on well gets milk well. A baby who latches on poorly has more difficulty getting milk, especially if the milk supply is not abundant. The milk supply is not abundant in the first days after birth; this is normal, as nature intended, but if the baby’s latch is not good, the baby has difficulty getting the milk. It is for this reason that so many mothers “don’t have enough colostrum”. The mothers almost always do have enough colostrum but the baby is not getting what is there. Babies don’t need much milk in the first few days, but they need some.

Even if the mother’s milk production is plentiful, trying to breastfeed a baby with a poor latch is similar to giving a baby a bottle with a nipple hole that is too small—the bottle is full of milk, but the baby will not get much or will get it very slowly—so the baby sucking at the breast may spend long periods on the breast or return to the breast frequently or not be happy at the breast, all of which may convince the mother she doesn’t have enough milk, which is most often not true.

When a baby is latching on poorly, he may also cause the mother nipple pain. And if, at the same time, he does not get milk well, he will usually stay on the breast for long periods, thus aggravating the pain. Too often the mothers are told the baby’s latch is perfect, but it’s easy to say that the baby is latched on well even if he isn’t. Mothers are also getting confusing and contradictory messages about breastfeeding from books, magazines, the internet, family and health professionals. Many health professionals actually have had very little training on how to prevent breastfeeding problems or how to treat them should they arise. Here are a few ways breastfeeding can be made easier:

The baby should be skin-to-skin with the mother and have access to the breast immediately after birth. The vast majority of newborns can be skin-to-skin with the mother and have access to the breast within minutes of birth. Indeed, research has shown that, given the chance, many babies only minutes old will crawl up to the breast from the mother’s abdomen, latch on, and start breastfeeding all by themselves. This process may take only a few minutes or take up to an hour or longer, but the mother and baby should be given this time (at least the first hour or two) together to start learning about each other. Babies who “self-attach” run into far fewer breastfeeding problems. This process does not take any effort on the mother’s part, and the excuse that it cannot be done because the mother is tired after labour is nonsense, pure and simple.
The baby should be kept skin to skin with mother as much as possible immediately after birth and for as much as possible in the first few weeks of life. Incidentally, studies have also shown that skin-to-skin contact between mothers and babies keeps the baby as warm as an incubator (see paragraph on skin-to-skin contact, below, and the information sheet The Importance of Skin-to-Skin Contact). It is true that many babies do not latch on and breastfeed during this time but generally, this is not a problem, and there is no harm in waiting for the baby to start breastfeeding. The skin to skin contact is good and very important for the baby and the mother even if the baby does not latch on.
Skin-to-skin contact helps the baby adapt to his new environment: the baby’s breathing and heart rate are more normal, the oxygen in his blood is higher, his temperature is more stable and his blood sugar higher. Furthermore, there is some good evidence that the more babies are kept skin-to-skin in the first few days and weeks of life (not just during the feedings) the better their brain development will be. As well, it is now thought that the baby’s brain develops in certain ways only due to this skin-to-skin contact, and this important growth happens mostly in the first 3-8 weeks of life.
A proper latch is crucial to success. This is the key to successful breastfeeding. Unfortunately, too many mothers are being “helped” by people who don’t know what a proper latch is. If you are being told your two-day old baby’s latch is good despite your having very sore nipples, be sceptical and ask for help from someone else. Before you leave the hospital, you should be shown that your baby is latched on properly and that he is actually getting milk from the breast and that you know how to know he is getting milk from the breast (open mouth wide—pause—close mouth type of suck). See also the videos on how to latch a baby on. There are also video clips of babies younger than 48 hours who are breastfeeding not just sucking. If you and the baby are leaving hospital not knowing this, get experienced help quickly (see also the information sheet When Latching).

Note: Mothers are often told that if the breastfeeding is painful, the latch is not good (usually true), so that the mother should take the baby off and latch him on again and again and again… This is not a good idea. Instead of delatching and relatching, fix the latch that you have as best you can by pushing the baby’s bottom into your body with your forearm. The baby’s head is tipped back so the nose is in ‘sniffing position’. If necessary, you might try gently pulling down the baby’s chin so he has more of the breast in his mouth. If that doesn’t help, do not take the baby off the breast and relatch him several times, because usually, the pain diminishes anyway. The latch can be fixed on the other side or at the next feeding. Taking the baby off the breast and latching him on again and again only multiplies the pain and the damage and the mother’s and baby’s frustration.

The mother and baby should room in together. There is absolutely no medical reason for healthy mothers and babies to be separated from each other, even for short periods, even after caesarean section. Health facilities that have routine separations of mothers and babies after birth are not doing right by the mothers and babies. Studies showing that rooming-in 24 hours a day results in better breastfeeding success, less frustrated babies and happier mothers date back to the 1930’s. Too often, irrelevant excuses are given why baby should be separated from the mother. One example is that the baby passed meconium before birth. A baby who passes meconium and is fine a few minutes after birth will be fine and does not need to be in an incubator for several hours’ “observation”.

Separation of mother and baby so the mother can rest. There is no evidence that mothers who are separated from their babies are better rested. On the contrary, the mothers are better rested and less stressed when they are with their babies. Mothers and babies learn how to sleep in the same rhythm. Thus, when the baby starts waking for a feed, the mother is also starting to wake up naturally. This is not as tiring for the mother as being awakened from deep sleep, as she often is if the baby is elsewhere when he wakes up. If the mother is shown how to feed the baby while both are lying down side by side, the mother is better rested.
The baby’s feeding cues. The baby shows long before he starts crying that he is ready to feed. His breathing may change, for example. Or he may start to stretch. The mother, often being in light sleep in sync with her baby, will wake up, her milk will start to flow and the calm baby will usually go to the breast contentedly. A baby who has been crying for some time before being tried on the breast may refuse to take the breast even if he is ravenous. Mothers and babies should be encouraged to sleep side by side in hospital. This is a great way for mothers to rest while the baby breastfeeds. Breastfeeding should be relaxing, not tiring.
Bathing. There is no reason the baby needs to be bathed immediately after birth and bathing can be delayed for several hours. Immediately after birth, the baby can be dried off but it is not a good idea to wash or wipe off the creamy layer on the baby’s skin (vernix) that has been shown to protect his delicate skin. It is best to wait at least until the mother and baby have had a chance to get breastfeeding well started, with baby coming to the breast and latching easily. Furthermore, diapering a baby before a feed is not advised as it often causes the baby to become upset. Mothers are sometimes told diapering will help the baby to wake up. It is not necessary to wake the baby for feedings. If the baby is skin-to-skin with the mother, the baby will wake when ready and search for the breast. A baby who is feeding well will let the mother know when he is ready for the next feed. Feeding by the clock makes no sense.

Artificial nipples should not be given to the baby. There seems to be some controversy about whether “nipple confusion” exists. Thus, in the first few days, when the mother is normally producing only a little milk (as nature intended), and the baby gets a bottle (as nature intended?) from which he gets rapid flow, the baby will tend to prefer the rapid flow method. Babies like fast flow. You don’t have to be a rocket scientist to figure that one out and the baby will very quickly. By the way, it is not the baby who is confused. Nipple confusion includes a range of problems, including the baby not taking the breast as well as he could and thus not getting milk well and/or the mother getting sore nipples. Just because a baby will “take both” does not mean that the bottle is not having a negative effect. Since there are now alternatives available if the baby needs to be supplemented (see the information sheets Lactation Aid, and Finger and Cup Feeding) why use an artificial nipple? Using a lactation aid, finger feeding or cup feeding to supplement when the baby does not need a supplement is only marginally better than using a bottle to supplement.
No restriction on length or frequency of breastfeedings. A baby who drinks well will not be on the breast for hours at a time (see the video clips of very young babies getting milk very well). Thus, if the baby is on the breast for very long periods of time, it is usually because he is not latching on well and not getting the milk that is available. Get help to fix the baby’s latch, and use compression to get the baby more milk (See the information sheet Breast Compression). Compression works very well in the first few days to get the colostrum flowing well. This, not a pacifier, not a bottle, not taking the baby to the nursery or nurses’ station, will help. Babies often feed frequently in the first few days of life—this is normal and temporary. In fact, babies tend to feed frequently during the first few days especially in the evening or night-time. This is normal and helps to establish the milk supply and facilitate mother’s uterus returning to normal. Latching a baby well, using compressions, and maintaining skin to skin contact between mother and baby helps this transitional period to go smoothly.
Supplements of water, sugar water, or formula are rarely needed. Most supplements could be avoided by getting the baby to take the breast properly and thus get the milk that is available. If you are being told you need to supplement without someone having observed you breastfeeding, ask for someone to help who knows what they are doing. There are rare indications for supplementation, but often supplements are suggested for “convenience” or due to outdated hospital policies. If supplements are required, they should be given by lactation aid at the breast (see the information sheet Lactation Aid), not cup, finger feeding, syringe or bottle. The best supplement is your own colostrum. It can be mixed with 5% sugar water to give more volume if you are not able to express much at first. It is difficult to express much at first because even though there is usually enough for the baby, expressing is not always easy when there is not a lot of milk, as is expected in the first few days. Formula is hardly ever necessary in the first few days. (See our GamePlan for Protecting and Supporting Breastfeeding in the First 24 hours of Life and Beyond, which can be ordered at nbcionline.org
Free formula samples and formula company literature are not gifts. There is only one purpose for these “gifts” and that is to get you to use formula. It is very effective and it is unethical marketing. If you get any from any health professional, you should be wondering about his/her knowledge of breastfeeding and his/her commitment to breastfeeding. “But I need formula because the baby is not getting enough!” Maybe, but, more likely, you weren’t given good help and the baby is simply not getting the milk that is available. Even if you need formula, nobody should be suggesting a particular brand and giving you free samples. Get good help. Formula samples are not help.

Under some circumstances, it may be impossible to start breastfeeding early. However, most “medical reasons” (maternal medication, for example) are not true reasons for stopping or delaying breastfeeding, and you are getting misinformation. See the information sheets Medication and Breastfeeding and also Illness and Breastfeeding. Get good help. Premature babies (see the information sheet Premature Baby and Breastfeeding) can start breastfeeding much, much earlier than 34 weeks of age that seems to be the rule in many health facilities. Studies are now quite definite that it is less stressful for a premature baby to breastfeed than to bottle feed. Unfortunately, too many health professionals dealing with premature babies do not seem to be aware of this (See the information sheet Premature Baby and Breastfeeding).

Not latching/Not breastfeeding? If for some reason baby is not taking the breast, then start expressing your colostrum by hand (often much more effective than using even a hospital grade pump) should be started within 6 hours or so after birth, or as soon as it becomes apparent baby will not be feeding at the breast. See the information sheet When the Baby Does Not Yet Latch On.

Written and revised (under other names) by Jack Newman, MD, FRCPC, 1995-2005
Revised Jack Newman MD, FRCPC, IBCLC and Edith Kernerman, IBCLC, 2008, 2009

Why Would A Baby Not Latch?

There are many reasons a baby might refuse to latch on. Often there is a combination of reasons. For example, a baby might latch on even with a tight frenulum if no other factors come into play, but if, for example, he is also given bottles early on, this may very well change the situation from “good enough”, to “not working at all”.

Some babies are unwilling to nurse, or suck poorly as a result of medication they received during the labour. Narcotics are responsible for many such situations, and meperidine (Demerol) is particularly bad as it stays in the baby’s blood for a long time and affects the way he sucks for several days. Even morphine given in an epidural may cause the baby to be unwilling to nurse or latch on, since medication from an epidural definitely does get into the mother’s blood, and thus into the baby before he is born. Other interventions during labour and birth (e.g. intravenous fluids in large amounts, vigorous suctioning of the baby at birth which is simply not necessary for a health full term baby) can also cause difficulties with the baby latching on. For more information see the book The Latch and other keys to successful breastfeeding, chapter 4, Causes of Latch Problems.
Abnormalities of the baby’s mouth may result in the baby’s not latching on. Cleft palate, but not usually cleft lip, causes severe difficulties in latching on. Sometimes the cleft palate is not obvious, affecting only the part inside the baby’s mouth.
A baby learns to breastfeed by breastfeeding. Artificial nipples interfere with how the baby takes the breast. Babies are not stupid. If they get slow flow from the breast (as is expected in the first few days of life) and rapid flow from the bottle, they will not be confused—many will figure it out quite quickly.
If the mother’s nipples are particularly large, or inverted, or flat, these nipple variations may make latching on more difficult, not usually impossible.
A tight frenulum (the whitish tissue under the tongue) may result in a baby having difficulty latching on. This is not, strictly speaking, considered an abnormality, and thus, many practitioners do not believe that it can interfere with breastfeeding; many studies indicate that it does interfere.

However, one of the most common causes of babies’ refusing to latch on arises from the misguided belief that babies in the first few days must breastfeed every 3 hours, or on some other insane sort of schedule. This results in anxiety on the part of the staff when a baby has not fed, for example, for three hours after birth, which results, frequently, in babies being forced to the breast when they are not ready yet to feed. When the baby is forced into the breast, and kept there by force, when the baby is not interested or ready, we should not be surprised that some babies develop an aversion to the breast. If this misguided approach then results in panic, and “the baby must be fed”, alternative feeding methods (the worst of which is the bottle) are then used, resulting in worsening of the situation and the beginning of a vicious circle.

There is no evidence that a healthy full term newborn must feed every three hours during the first few days. There is no evidence that they will develop low blood sugars if they don’t feed every three hours (the whole issue of low blood sugars has become a mass hysteria in many postpartum areas which, like all hysterias, results from a grain of truth, perhaps, but actually causes more problems than it prevents, including the problem of many babies getting formula when they don’t need it, being separated from their mothers when they don’t need to be, and not latching on). Babies should be together, skin to skin with their mothers, most of the day (Seeinformation sheet Skin to Skin Contact). When they are ready, most will start looking for the breast. Having the baby with the mother skin to skin immediately after birth and allowing the baby and the mother the time to “find” each other will prevent most situations of the baby not latching on. Mother and baby skin to skin will also keep the baby as warm as being under a heating lamp. Having the baby and mother together for 5 minutes though, is not the answer. The mother and baby should be together until the baby latches on, without pressure, without time limits (“we’ve got to weigh the baby”, “we’ve got to give the baby vitamin K,” etc—these procedures can wait!). This might take 1-2 hours or more.

But the baby is not latching on!

Okay, so how long can we wait? There is no obvious answer to that. Certainly, if the baby has shown no interest in nursing or feeding by 12 to 24 hours after birth, it may be worthwhile to do something, mostly because hospital policies usually require the mother to be discharged by 24 to 48 hours. What can be done?

The mother should start expressing her milk, and that milk (colostrum), either alone, or mixed with sugar water, should be fed to the baby, preferably by finger feeding *(read on). The mother should start expressing her milk as soon as baby has refused the breast—preferably within the first 6 hours. If it is difficult to get colostrum (often hand expression works better than a pump in the first few days), then sugar water alone is fine for the first few days. With finger feeding, most babies will start sucking, and many will wake up enough to attempt going to the breast. *As soon as the baby is sucking well, finger feeding should be stopped and the baby tried at the breast (Often a minute or two of finger feeding will do the trick). Finger feeding is essentially a procedure to prepare the baby to take the breast, not primarily a method to avoid the bottle, though it will do that too. Therefore it is done before attempting the baby at the breast, to prepare him to take the breast. See Finger and Cup Feeding.
Before discharge, early, competent help needs to be arranged so that the mother and baby are getting help by day four or five at the latest. Many babies not able to latch on in the first few days will latch on beautifully once the mother’s milk supply has increased substantially as it usually does around day 3 or 4. Getting help at this time avoids the negative associations with the breast that many babies develop as time goes on.
A nipple shield started before the mother’s milk becomes abundant (day 4 to 5) is bad practice. Starting a nipple shield before the mother’s milk “comes in” is not giving time a chance to work. Furthermore, used improperly (as I see it often being used), a nipple shield may result in severe depletion of the milk supply. See below on the importance of maintaining a good milk supply.

We’re Home From Hospital, the Baby Won’t Latch On, What Do I Do?

The single most important factor influencing whether or not the baby latches on is the mother’s developing a good milk supply. If the mother’s supply is abundant, the baby will latch on by 4 to 8 weeks of life no matter what. What we try to do at the clinic is get the baby latching on earlier, so that you won’t have to wait that long. So, it is more important you keep up your supply, than avoid a bottle. The bottle interferes, and it is better you use other methods (such as a cup) if you can, but if you feel you have no choice, you should do what you need to do.

Learn how to get the best position and latch from an experienced lactation specialist (Also see When Latching and videos). As the baby comes onto the breast, compress the breast so that the baby gets a gush of milk. Try the baby on the breast he seems to prefer, or the breast that has more milk, or the side you feel most comfortable with if neither of the previous apply, not the breast he resists more.
If the baby latches on, he will start sucking and start drinking (get information on how to know a baby is actually getting milk at the breast—see Is My Baby Getting Enough Milk? and videos).
If the baby doesn’t latch on, don’t try to force him to stay on the breast; it won’t work. He will either get hysterical or “go limp”. Move him away from the breast and start again. It is better to go on-off, on-off several times than to push him into the breast when he hasn’t latched on.
If the baby goes to the breast and sucks once or twice, he hasn’t latched on a little; he hasn’t latched on at all.
If the baby refuses the breast, don’t keep at it until he’s angry. Try finger feeding a few seconds to a minute or two, and try again, perhaps on the other side. Finger feeding is primarily used to prepare the baby to take the breast, not primarily to avoid a bottle.
If the baby doesn’t latch on, finish the feeding with whatever method you find easiest. Cup feeding works and is better than a bottle.
Using a lactation aid at the breast may be helpful, but often requires an extra hand.
At about two weeks after birth, a change in what you have been doing often seems to send a message to the baby that “there’s more than one way to do this”. If you have been finger feeding only, a change to a cup or bottle will sometimes work. If you have been bottle feeding only, switching to finger feeding may work (only before attempting the baby at the breast is good enough if finger feeding is too slow, and finishing the feeding with cup or bottle).

How to Maintain and Increase Milk Supply

Express your milk as often as is practical, at least 8 times a day, using a reliable pump that expresses both breasts at the same time. Using compression while pumping increases the efficiency of pumping and increases the milk supply (another hand is helpful, but mothers have rigged up the pump so that they don’t have to hold onto the tubing or flanges while pumping and thus can compress without help).
If the baby hasn’t latched on by day 4 or 5, start fenugreek and blessed thistle to increase milk flow. See Herbal Remedies for Increasing Milk Supply. Domperidone may also be useful. See information sheets Domperidone, Getting Started and Domepridone, Stopping.
If you must use a nipple shield, do not use one at least until the milk supply is well established (at least 2 weeks after the baby is born). Get good hands on help first—a nipple shield is really a last resort.

Do not get discouraged. Even if your milk supply is not up to the needs of your baby, your baby is still likely to latch on. Get good hands-on help. Do not try to do this on your own.

Written and Revised by Jack Newman, MD, FRCPC 1995-2005
Revised May 2008

Introduction

The best treatment of sore nipples is prevention. The best prevention is getting the baby to latch on properly from the first day.

Sore nipples are usually due to one or both of two causes. Either the baby is not positioned and latched properly, or the baby is not suckling properly, or both. However, babies learn to suck properly by getting milk from the breast when they are latched on well. (They learn by doing). Thus, “suck” problems are often caused by poor latching on. Fungal infection (due to Candida albicans) may also cause sore nipples. Vasospasm (due to poor latching and or a fungal infection) may also cause sore nipples (see below). The soreness caused by poor latching and ineffective suckling hurts most as you latch the baby on and usually improves as the baby breastfeeds. The pain from the fungal infection goes on throughout the feed and may continue even after the feed is over. Women describe knifelike pain from the first two causes. The pain of the fungal infection is often described as burning, but may not have this character. A new onset of nipple pain when feedings had previously been painless is a tip off that the pain may be due to a yeast infection, but the pain may be superimposed on pain due to other causes. Cracks may be due to a yeast infection. Dermatologic conditions may also cause late onset nipple pain. There are several other causes of sore nipples.

Proper Positioning and Latching (See information sheet When Latching)

It is not uncommon for women to experience difficulty positioning and latching the baby on. Proper positioning facilitates a good latch and good latching reduces the baby’s chances of becoming “gassy”, and also allows the baby to control the flow of milk. Thus, poor latching may also result in the baby not gaining adequately, or feeding frequently, or being colicky (handout #2 “Colic in the Breastfed Baby). See also videos that show how to latch a baby on, how to know a baby is getting milk and how to use compression.

Positioning—For the Purposes of Explanation, Let Us Assume That You Are Feeding On the Left Breast

(Seeinformation sheet When Latching and videos)

Good positioning facilitates a good latch. A lot of what follows under latching comes automatically if the baby is well positioned in the first place.

At first, it may be easiest to use the cross cradle hold to position your baby for latching on. Hold the baby in your right arm, pushing in the baby’s bottom with the side of your forearm so that your hand turns palm upwards. This will help you support his body more easily, and also bring the baby in from the correct direction so that he gets a good latch. Your hand will be palm up under the baby’s face (not shoulder or under his neck). The web between your thumb and index finger should be behind the nape of his neck (not behind his head). The baby will be almost horizontal across your body, with his head slight tilted backward, and should be turned so that his chest, belly and thighs are against you with a slight tilt so the baby can look at you. Hold the breast with your left hand, with the thumb on top and the other fingers underneath, fairly far back from the nipple and areola.

The baby should be approaching the breast with the head just slightly tilted backwards. The nipple then automatically points to the roof of the baby’s mouth.

Latching

Now, get the baby to open up his mouth wide. The way to do this is to run your nipple, still pointing to the roof of the baby’s mouth, along the baby’s upper lip (not lower), lightly, from one corner of the mouth to the other. Or you can run the baby along your nipple, something some mothers find easier. Wait for the baby to open up as if yawning. As you bring the baby toward the breast, only his chin should touch your breast. Do not scoop him around so that the nipple points to the middle of his mouth. Instead the nipple should still be pointing to the roof of the baby’s mouth.
When the baby opens up his mouth, use the arm that is holding him to bring him straight onto the breast. Don’t worry about the baby’s breathing. If he is properly positioned and latched on, he will breathe without any problem as his nose will be far away from the breast. If he cannot breathe, he will pull away from the breast. If he cannot breathe, he is not latched properly. Don’t be afraid to be vigorous.
If the nipple still hurts, use your index finger to pull down on the baby’s chin in order to bring more breast tissue into the mouth. You may have to do this for the duration of the feed, but this is usually not necessary. The pain will usually subside. Do not take the baby on and off the breast several times to get the perfect latch. If the baby goes on and off the breast 5 times and it hurts, you will have 5 times more pain, and worse, 5 times more damage. Fix the latch when putting him to the other breast, or at the next feeding.
The same principles apply whether you are sitting or lying down with the baby or using the football hold. Get the baby to open wide; don’t let the baby latch onto the nipple, but get as much of the areola (brown part of breast) into the mouth as possible (not necessarily the whole areola).
There is no “normal” length of feeding time. If you have questions, call the clinic.
A baby properly latched on will be covering more of the areola with his lower lip than with the upper lip.

Improving the Baby’s Suck

The baby learns to suckle properly by breastfeeding and by getting milk into his mouth. The baby’s suckle may be made ineffective or not appropriate for breastfeeding by the early use of artificial nipples or from poor latching on from the beginning. Some babies just seem to take their time developing an effective suckle. Suck training and/or finger feeding (handout Finger and Cup Feeding) may help, but note, taking the baby off the breast to finger feed instead is not a good idea and should be done as a last resort only.

Vasospasm: “My Nipple Turns White After the Baby Comes Off the Breast”

The pain associated with this blanching of the nipple is frequently described by mothers as “burning”, but generally begins only after the feeding is over. It may last several minutes or more, after which the nipple returns to its normal colour, but then a new pain develops which is usually described by mothers as “throbbing”. The throbbing part of the pain may last for seconds or minutes and then it is possible the nipple will turn white again and the process repeats itself. The cause would seem to be a spasm of the blood vessels (often called “vasospasm” or Raynaud’s Phenomenon) in the nipple (when the nipple is white), followed by relaxation of these blood vessels (when the nipple returns to its normal colour). Sometimes this pain continues even after the nipple pain during the feeding no longer is a problem, so that the mother has pain only after the feeding, but not during it. What can be done?

Pay careful attention to getting the baby to latch onto the breast properly. This type of pain is almost always associated with and probably caused by whatever is causing your pain during the feeding. The best treatment for this vasospasm is the treatment of the other causes of nipple pain. If the main cause of the nipple pain is fixed, the vasospasm also disappears.
Heat (hot washcloth, hot water bottle, hair dryer) applied to the nipple immediately after breastfeeding may prevent or decrease the reaction. Dry heat is usually better than wet heat, because wet heat may cause further damage to the nipples.
Vitamin B6 multi complex can also be used, as can magnesium with calcium. On occasion, we have had to use an oral medication (nifedipine) to prevent this type of reaction. For more on these treatments see handout Vasospasm and Raynaud’s Phenomenon)
General Measures for Nipple Soreness

Nipples can be warmed for short periods of time after each feeding, using a hair dryer on low setting.
Nipples should be exposed to air as much as possible, except when there is vasospasm.
When it is not possible to expose nipples to air, plastic dome-shaped breast shells (not nipple shields) can be worn to protect your nipples from rubbing by your clothing (use the largest hole available so your nipple is not rubbing against the plastic). Breastfeeding pads keep moisture against the nipple and may cause damage that way. They also tend to stick to damaged nipples. If you leak a lot you can wear the pad over the breast shell.
Ointments can sometimes be helpful. If using an ointment, use just a very small amount after breastfeeding and do not wash it off. We use an “all purpose nipple ointment” (APNO) that we find very useful. See handout Candida Protocol for the recipe. Note, once any ointment or cream is applied to the nipples they are no longer air drying.
Do not wash your nipples frequently. Daily bathing is more than enough.
If your baby is gaining weight well, there is no good reason the baby must be fed on both breasts at each feeding. It may save you pain, and speed healing if you feed your baby on only one breast each feed. It will help to compress the breast (handout Breast Compression), once the baby is no longer swallowing on his own in order to continue his getting milk. You may be able to manage this some feedings, but not others. In very difficult situations, a lactation aid (handout Lactation Aid) can be used to supplement (preferably expressed milk), so that the baby will finish the feeding on the first side. Taking the baby off the breast is a last resort.
If you are unable to put the baby to the breast because of pain, in spite of trying all the above measures, it may still be possible to continue breastfeeding after a temporary (3-5 days) cessation to allow the nipples to heal. During this time, it would be better that the baby not be fed with a rubber nipple. Of course it is also best for you and the baby if the baby is fed your expressed milk. Feed the baby with a cup or use the technique called “finger feeding” (handout Finger an Cup Feeding). Once again, it should be emphasized that this is a last resort and taking a baby off the breast should not be taken lightly. Furthermore, it often doesn’t work.

We do not recommend nipple shields because, although they sometimes help temporarily, they often do not. In fact, they may often increase the degree of trauma to the nipples. They may also cut down the milk supply dramatically, and the baby may become fussy and not gain weight well. Once the baby is used to them, it may be impossible to get the baby back onto the breast. Use as a last resort only but get help first.

Written and Revised by Jack Newman, MD, FRCPC 1995-2005
Revised May 2008