We have broken this article into 2 - the top one being a brief version, and then a second article with all the info you could ever need!

1.

There are elective caesarean births, after which babies are usually quite alert, and there are emergency caesareans that may be more stressful for both mother and baby. There are also different types of anaesthetics used depending on the circumstances. Most mothers have an epidural anaesthetic or spinal block, so they are awake and alert throughout. Sometimes a general anaesthetic is needed but the mother usually wakes up quickly from this.

Fathers

Fortunately, in the last few years, partners have been encouraged to be present in the operating theatre, to share the birth of their babies. Your partner can be an important source of moral and physical support and be involved with your baby from birth.

After the birth

Remind your doctor, the paediatrician and the midwives, that you wish to breastfeed your baby as soon as possible.

Try to have the handling of your baby by others kept to a minimum. In some hospitals the baby is placed in skin-to-skin contact with the mother while she is still on the operating table. As soon as the paediatrician is happy with the baby's condition, he is placed under the sterile drapes on his mother's chest while the doctor is stitching her up. If this is not possible, your baby may be able to be skin-to-skin with you in the recovery room. Breastfeeding can be a part of this loving and bonding time. Whatever anaesthesia you experience, it does not need to interfere with breastfeeding your baby.

Breastfeeding your baby

There is a perception that a mother's milk is slower to 'come in' after a caesarean. The 'switch on' of lactation after a baby is born is caused by the removal of the placenta, which in turn results in a change in the balance of hormones circulating in the blood. Studies have shown that some babies born by caesarean section take a little longer to regain their birth weight than other babies, but this is not significant after a few days, and is unlikely to have any long-term effects.

Positioning of your baby on the breast is very important to help establish breastfeeding and prevent nipple soreness. Whatever hold you use, make sure your baby's body is close to you, chest to chest, chin to breast and nose away from the breast. Positions you may find useful after a caesarean birth are sitting with a pillow on your lap to support your baby and protect your wound; lying down on your side; or with your baby in the underarm (or 'twin') position, with his feet towards your back.  

At the end of your hospital stay, your milk supply will still be adjusting to your baby's needs. Rest is important for any new mother, but even more so for the mother who has had a caesarean birth. Breastfeeding gives you a wonderful excuse to sit or lie down!

Some mothers find that they have a slower return to their normal energy level than if they had had a vaginal birth. As a caesarean birth is considered to be major abdominal surgery, take care not to lift or move anything that is heavier than your baby for at least 6 weeks, or until your postnatal check up, whilst your body has time to recover.

First feed

If possible, the time immediately after your baby is born is a great time to start breastfeeding. You will still be under the effects of the spinal/epidural and probably not yet feeling any discomfort. You will likely have to nurse lying on your back, because of the epidural. Since one arm may be restrained, it may get a little tricky. Try positioning baby lying face down across your breasts (similar to cradle hold, but baby is higher up and away from your incision, and mom is lying flat). When nursing in this position with a newborn, have someone nearby to make sure baby's nose doesn't get blocked, since you both may be groggy from the meds. Have your partner or a nurse help position the baby, and use lots of pillows around you to help with support.

Feed early and often

Ideally, you'll want to put your baby to breast within the first hour, but definitely no later than the first 4-6 hours. Studies show that when time to breast is longer than this, babies have more difficulty breastfeeding and engorgement is more severe. If something prevents the baby from being put to breast within the 4-6 hours, you should begin pumping with a hospital-grade breastpump.

Breastfeeding at least every 2 hours during the day with a nighttime span no longer than 4 hours is highly recommended--you're aiming for 10-12 feedings per 24 hours during the early weeks. As long as baby is nursing well, there should be no need for any supplements of any kind.

Positions

Once you can turn over, try turning to one side and nursing in a side-lying position (see below). Have your partner or a nurse help you with positioning pillows.

Another position that may be more comfortable is the football hold. Sit somewhat upright in the bed and place the baby on a pillow, between your arm and your side, with your hand cupping the underside of his head.

You may find at first that it’s difficult to find a “comfortable” position. Try experimenting as much as possible to get the most comfortable position, and don't hesitate to ask for help getting positioned from your partner, nurses, or the hospital lactation consultant. Whichever position works best, make sure the baby's tummy is towards you. You might want to bring a few extra pillows from home (or a nursing pillow), as hospital pillows are pretty small and flat.

Many mums find the side-lying position the most comfortable during the first day or so. It’s an easy way to nurse and rest at the same time. Using a small blanket, or pillow - even a rolled up towel - can help protect your incision while you nurse lying down.

Below are step-by-step instructions on getting into the side-lying position (in a hospital bed) after a c-section:

• Begin with the bed in a flat position and side rails up.
• Use extra pillows behind the mother's back for extra support.
• Carefully roll to one side while grasping the side rail and relaxing the abdominal muscles. Move slowly to avoid strain.
• To protect the incision from the baby's kicking, cover the abdomen with a small pillow or towel.
• Place a pillow between the legs to minimize the strain on the stomach muscles.
• Lean back into the pillows behind the back.

When using side-lying position, baby should be placed on his side, facing your body, chest to chest, so he doesn’t have to turn his head to nurse. Baby’s feet should be drawn in close to your body with his head either lying on the bed, or on your arm, whichever feels most comfortable to you. You can either roll your body forward to latch, or pull the baby toward you.

Avoid supplements

Be sure to let the hospital staff know they shouldn't give any supplemental bottles or pacifiers, as these artificial nipples can cause problems (see nipple confusion article). If you are told that supplements are medically necessary, request that they be given via cup or feeding syringe rather than a bottle to avoid the risk of nipple confusion.

You can request that your doctor provide written orders that the baby is to be breastfed, and have no artificial nipples of any kind (no soothers or bottles) and that IF supplements are medically required, they should be given by an alternative method rather than by bottle.

When will my milk come in?

The abrupt hormonal shift that occurs at the separation of the placenta from the uterus is what signals your milk to come in. Thus mom's body will get the same signal whether she has a cesarean or vaginal birth. Moms who have stressful births (cesarean or vaginal) tend to have their milk come in a little bit later.

Your milk may come in anywhere from day 2 to day 6 (usually around days 2-3). If your milk is slow coming in, try not to worry, but put baby to breast as often as possible and stay in contact with your lactation consultant so she can monitor how baby is doing. To encourage an abundant milk supply:

Nurse as soon after birth as possible. If something prevents the baby from being put to breast within the 4-6 hours, you should begin pumping with a hospital-grade breastpump. Get the okay from your doctor/midwife ahead of time to nurse your baby in the recovery room - this shouldn't be a problem unless you or baby are having medical problems.

Nurse frequently. Breastfeed your baby at least every 2 hours (from beginning of nursing to beginning of the next nursing) during the day, with no more than 4 hours between nursings at night. You're aiming for at least 10-12 nursings per 24 hours. More frequent nursing results in greater milk production at one week and thereafter.

Avoid unnecessary supplements. Do not supplement baby with anything (formula, water, etc) unless it is medically indicated. Supplementing will do two things - missing feedings will reduce breast stimulation and milk removal (both needed to increase milk supply), and babies who are supplemented tend to need to eat again later than if they had nursed - so again you're losing much-needed nursing time.

Ensure that baby is nursing well. If baby is not latching well and drinking well, then it can affect milk supply and the speed that your milk comes in.

Not so brief version, lots of info if you have the time! 

Caesarean sections are now about 1 in 4 births, and will probably continue to have a very significant increase in the next few years.  Therefore, many women are having to cope with having a caesarean (and all the problems associated with it) just as they are also trying to care for their newborn children.  

One area which caesareans cause concern in is breastfeeding.  Research shows fewer women breastfeed their babies after having had a caesarean.  This need not be so, and if you have had or are planning a Caesarean delivery, you absolutely can breastfeed successfully.

Breastfeeding advocates have long promoted the idea that women who have had a caesarean need EXTRA support and help to establish breastfeeding (thats if there is any at all available to start with!) However, few hospitals routinely offer extra breastfeeding support to women who have had a difficult birth or who have had a caesarean.  In fact, many hospitals have protocols that actively interfere with breastfeeding under these conditions.  

This article examines the benefits of breastfeeding after a caesarean, how a caesarean can interfere with breastfeeding, strategies for increasing breastfeeding success and bonding issues after a difficult birth.

Too often, women who have had a long difficult labour and/or a caesarean encounter breastfeeding difficulties.  Many of these difficulties could have been avoided or fixed much sooner had the women had better or more timely help.  Unfortunately, not all women receive timely help or emotional support after birth, and so breastfeeding does not last long for some.  For a few women, hormonal, genetic, or infant conditions may prevent them from  breastfeeding their babies fully. 

Second, this article offers help to women planning to breastfeed in future pregnancies, whether those births are by Vaginal Birth After Caesarean , unplanned caesarean, or planned repeat caesarean.  If they know ahead of time the problems to watch for, they can develop a plan of action to prevent these problems from occurring, or a plan of action to get help if problems do occur.  Many women have found that they are able to breastfeed much more easily the second (or even third) time around with good resources and planning.

And third, this offers reassurance to women who have had trouble breastfeeding after past births.  It is important that women come to terms with past breastfeeding difficulties so that they can grieve the experience and find a measure of peace about it.  They need to read other women's stories so that they know they are not alone in this experience, and that many other women have walked this path before them. They need to understand the breastfeeding problems they may have encountered and why they may have occurred, to understand that they made the best decisions they could at the time with the information they had, and that past difficulties with breastfeeding does not have to mean future difficulties with it.  They also need to know that although breastfeeding is very important, breastfeeding alone does not define themselves or their relationship with their babies, whatever happens. The first and most important thing is mother love.

Benefits of Breastfeeding After a Caesarean

Briefly, mothers who breastfeed lower their risk for reproductive cancers like breast cancer, ovarian cancer, etc., and may have less osteoporosis.  Infants receive superior nutrition and immunological protection that strongly lowers their rate of ear infections, gastrointestinal problems, allergies, and many other illnesses.  The longer the breastfeeding, the stronger the benefits to both mother and baby. See 100 reasons on the left menu for more info!

In addition, breastfeeding offers many benefits to the caesarean mother in particular.  These include faster uterine involution and quicker weight loss after birth.  Caesarean babies who are breastfed also receive significant benefits such as immunological protections, and prevention/minimisation of hypoglycaemia and jaundice problems.  Finally, the caesarean mother/baby duo often finds that breastfeeding is extremely healing emotionally after a difficult birth and can do much to help the pair bond under trying circumstances.  Many caesarean mums report that being able to breastfeed their child afterwards was one of the most healing things they were able to do for themselves.  

Faster Uterine Involution

After the baby is born, the uterus needs to start shrinking down in order to return to its normal size and state.  Breastfeeding stimulates uterine contractions and helps the uterus start shrinking more quickly and efficiently. Although the drugs most hospitals give will start this process, breastfeeding helps continue the process more naturally and efficiently.  

Negishi (1999) found that caesarean mothers tended to have larger uteri at one month postpartum than mothers who had had a vaginal birth, so uterine involution may be of special concern to women who have had caesareans.  They further found that by 3 months postpartum, mothers who were breastfeeding 80% or more per day had smaller uteri than those who were breastfeeding 2% or less per day.  So breastfeeding helps uterine involution strongly.  Since caesarean mothers may have more trouble with uterine involution, breastfeeding may be especially helpful in this group. 

Weight Loss

Many mothers find it difficult to return to the pre-pregnancy weight after birth, and anecdotally, this may be particularly true after a caesarean.  Restrictions on mobility, pain from the incision, anemia from blood loss, adhesions from the surgery, etc. may all combine to make a caesarean mother less active than one who has given birth vaginally, sometimes for significant lengths of time, which may affect postpartum weight loss.  

Research shows that breastfeeding helps women return to their pre-pregnancy weight levels faster than those who do not breastfeed.  Therefore, breastfeeding may be particularly helpful for losing pregnancy weight if a woman is having difficulty resuming her activity level after a caesarean. 

Immunological Protections for the Baby

Caesarean babies may be more at risk for infection for several reasons.  Babies born after the mother's waters had been broken for a long time are more at risk for infection.  Caesarean mothers also have higher rates of infection than mums who have had vaginal births, thus potentially exposing their babies to this infection as well.  Invasive procedures and equipment for the breathing problems common to caesarean babies may also further the risk for infection. And since caesarean babies stay in the hospital longer as their mothers recover, they are exposed to more germs and risk for infection, since recent research has shown that neonatal and maternity units are often home to some of the most virulent germs in the hospital.

Colostrum (the 'first milk') is extremely high in protective antibodies that help coat the baby's gastrointestinal system and protect it from harmful bacteria, and  it also contains substances that help 'kickstart' the baby's own immune system.  This helps protect the baby faster and more effectively than if the baby has to start its own immune systems without the mother's help.  Research has shown that colostrum is extremely important in reducing a child's risk for infections.  

As one doctor put it, "Breastfeeding is nature's first vaccine." Considering the possible infection risk many caesareans babies face, breastfeeding's immunological protections become especially important. 

Hypoglycemia

Because of the possibility of low blood sugar after a difficult birth, many hospitals routinely give a bottle of glucose water to caesarean babies, 'just in case.'  Unfortunately, this tends to cause a quick spike in blood sugar followed by a crash, and this unstable blood sugar can be a problem for the baby, causing a vicious cycle of treatment and re-treatment. 

Unless the hypoglycaemia is really severe, a better treatment is breastfeeding frequently.  The first milk a mother produces ('colostrum') has plenty of lactose to help raise the baby's blood sugar, but unlike glucose water, it also has a high amount of protein to help stabilize the blood sugar.  The long-term treatment for adults with low blood sugar is frequent doses of protein to help slow and stabilize the rise in blood sugar. Breastfeeding  is the most like the usual treatment for adult hypoglycaemia, plus it has the added benefits of all those immunological protections.  

Barring illness or extreme prematurity, babies who are nursed early and frequently generally have a more stable blood sugar than those given glucose water.  The Womanly Art of Breastfeeding states, "Breastfeeding at least ten to twelve times per day is the best way to stabilize a baby's glucose levels."

Jaundice

Another common complication for newborns is physiological jaundice.  This is a normal process that occurs when the body breaks down extra red blood cells that are not needed for life outside of the womb. One of the byproducts of this is bilirubin, which can make the baby appear yellowish-orange if his liver does not process it efficiently.  In low levels, bilirubin is not harmful, but high levels may potentially be harmful.  

Jaundice is most common in premature babies, sick babies, babies of diabetic mothers, and when labour was induced or augmented artificially with pitocin.   Many of these babies end up with caesareans.  Thus jaundice is not an unusual finding in caesarean babies, not because of the caesarean itself but because of the conditions and drugs that tend to cause a higher caesarean rate.

Frequent breastfeeding causes the baby to stool more frequently, and much of the bilirubin in the first days is eliminated through the baby's meconium (stool).  If the baby does not stool enough, the bilirubin is reabsorbed through the intestines.  Because the colostrum acts as a laxative, it helps the body process and excrete the extra bilirubin instead of re-absorbing it.  Thus breastfeeding frequently is one of the best ways to minimize jaundice. Research clearly shows that breastfeeding 7 or more times a day significantly decreases the occurrence of jaundice (Yamauchi and Yamanouchi, 1990). 

Although in the past jaundice was often treated by giving bottles of glucose water to help "flush" out the jaundice, research has shown that this does not help and may actually increase jaundice. Breastfeeding early and frequently and exposing the baby to indirect sunlight are the best treatments for normal physiological jaundice.  If extra help is needed, treatment with 'phototherapy' lights can also help lower bilirubin levels.  

Many babies that end up with caesareans may be at more risk for physiological jaundice.  Breastfeeding is one of the best treatments for mild jaundice, and in conjunction with other therapies, can help even in more serious cases.  But the benefits are strongest when the baby is able to nurse as soon as possible after birth, and as frequently as possible in the first few days. 

Bonding

Bonding is often an issue after a caesarean.  Many mothers report feeling distant and detached from their caesarean babies.  In part, this may be because the mother is not able to actually "see" the baby emerging from her body, and is usually one of the last people to get to hold and snuggle baby for any real time.  Many women wonder if the baby handed to them is actually theirs.  Others are so preoccupied with physical pain, grogginess from drugs, and exhaustion that they find it hard to care about their children the way they thought they would. Some women experience anger at the baby for being 'too big' or 'turned the wrong way' or for going into distress.  After birth, some women report feeling like they were simply 'babysitting' their children for someone else, and this can cause real feelings of guilt. 

Breastfeeding can help restore the bond between mother and baby, healing the separation that has occurred.  Women often report that breastfeeding helped them reconnect with their babies in a way that nothing else did, helped them feel competent and whole again, and brought them emotionally closer to their babies. For many women, breastfeeding was the most healing thing in their lives after going through the caesarean.  

Breastfeeding is important for caesarean mothers and babies not only for physiological reasons, but for emotional ones too.  Unfortunately, too many hospitals do not place a priority on breastfeeding, or have routine protocols that actively interfere with breastfeeding.  

How a Caesarean Can Interfere with Breastfeeding

Breastfeeding is more difficult after a caesarean for many reasons.  These include maternal pain and fatigue, delayed access to baby, increased supplementary feedings, separation of mother and baby, blood loss causing anemia, mechanical problems in feeding, interference from medications, etc.  Fortunately, although these can place significant barriers in front of the caesarean mom, many women manage to go on and breastfeed their child anyhow, in spite of the difficulties. 

Maternal Pain, Stress, and Fatigue

Mothers who have had a caesarean tend to initiate breastfeeding less often than mothers who have had a vaginal birth.   Most women plan to at least 'try' to breastfeed, but after a caesarean, many change their minds as the physical toll of the caesarean saps their physical and emotional resources.  They may be groggy from drugs, woozy with pain, and exhausted from labour, surgery, and significant blood loss.  Suddenly breastfeeding may seem overwhelming and too much trouble, or they may be too 'out of it' to try very effectively.  In this situation, bottlefeeding often seems easier and more convenient.  

Stress clearly can affect people strongly, and women who have had a difficult labour and then an unexpected caesarean (or women who have a bad caesarean experience) may be especially susceptible to stress-related breastfeeding problems.  Dewey (2001) found that maternal stress interfered with the release of oxytocin, the hormone responsible for milk ejection reflex.  It also found that stressed newborns were more likely to be weak or too sleepy to latch and suckle effectively.  

Research clearly shows that after a caesarean, fewer women initiate breastfeeding at all, or give up within the first month.  DiMatteo (1996), Perez-Escamilla (1996), Samuels (1985), Weiderpass (1998),  Menghetti (1994), Ever-Hadani (1994), Mansbach (1991), and Dewey (2001)  all show that women who had a caesarean had lower breastfeeding rates.

Delayed Access to Baby

Breastfeeding your baby as soon as possible after birth ensures the jumpstarting of hormonal processes designed to ensure milk supply, and aids in the physical recovery afterwards.   Studies show that the most critical issue for breastfeeding success after any birth is early and frequent breastfeeding (Asselin and Lawrence 1987, Sozmen 1992, Samuels 1985).   Research shows that breastfeeding works best if the first breastfeeding takes place within the first hour after birth.  Unfortunately, even in vaginal births many hospitals are hard-pressed to meet this standard, but delays tend to be especially long after a caesarean.  

Although a few women are able to nurse their babies right on the table during surgery, most are told to wait until they are in the recovery room.  This means a delay of almost an hour, and sometimes more.   Although not ideal, this is not insurmountable.  But a few misguided hospitals still have the outdated practice that forbids breastfeeding even in the recovery room, so their babies must wait even longer to nurse for the first time.  In addition, many women are so groggy from drugs after the surgery that they are not able to nurse for many hours after that as well.  All of these delays can add up.   

Women who have a caesarean tend to receive their children much later than if they had had a vaginal birth, and in some places, the delay can be many hours.  Dasgupta (1997) found that although their hospital had adopted guidelines stipulating that caesarean babies should be nursed for the first time within at least 4-6 hours, not a single baby in their hospital was nursed within this time period.  

This delay in first breastfeeding can cause critical differences in hormone levels (Nissen, 1996) and impact milk supply.  It also helps delay the appearance of mature milk (Chapman and Perez-Escamilla 1999, Vestermark 1991), putting the baby at risk for dehydration or excessive weight loss after birth, which often leads to supplementary formula.  All of this combines to undermine a woman's confidence and desire to breastfeed.  

Because breastfeeding is very much a function of supply and demand, early and frequent breastfeeding is EXTREMELY important for establishing breastfeeding.  Studies show that the more the first breastfeedings are delayed, the higher the rate of problems (Mathur, 1993).  Similarly, frequent breastfeeding (every 2-3 hours or so) in the first day is VERY important in helping the mature milk to come in more quickly.  

The more feedings of colostrum (the early milk) that the baby receives, the more immunological protection the baby gets.  In addition, early and frequent breastfeeding can help lessen or treat a baby's tendency towards hypoglycemia and jaundice, problems common after birth scenarios that lead to caesarean.  So not only does early and frequent breastfeeding promote earlier 'mature' milk and greater milk supply, it also is protective against many of the problems babies can face after difficult pregnancies or births.  

Supplementary Feedings

Many caesarean babies are given bottles of formula routinely (Vestermark 1991), which research clearly shows also lowers the rate and duration of successful breastfeeding (Samuels 1985, Hill 1997).  Blomquist (1994) found that, "Infants given a supplementary feeding had 4x the risk of not being breastfed at 3 months."  Cronenwett (1992) found that "30% of mothers whose babies received bottles in the hospital reported severe breastfeeding problems, as compared with 14% of those whose babies did not."

Chapman and Perez-Escamilla (1999) also found that exclusive formula-feeding before onset of lactation was a strong risk factor for delayed onset of lactation (mature milk coming in late), which can lead mothers to think they 'don't have enough milk' and stop breastfeeding.  Yet many hospitals still have policies requiring routine bottles, or nurses who aggressively insist that a postpartum bottle is necessary to 'prevent hypoglycemia' or 'test the baby's ability to suck and breathe at the same time.'  

Even pediatricians rarely understand just how much supplementary feedings can interfere with breastfeeding.  Freed (1995) studied over a thousand pediatricians and pediatric residents, and found that "Only 64% of practitioners and 52% of residents knew that supplementing during the first few weeks of life may cause breast-feeding failure." Thus the culture and traditions of hospitals and their personnel regularly promote supplementary feedings without recognition of just how harmful these can be.

When the mother's access to the baby is delayed, the baby is often given a pacifier to soothe it and keep it quiet in the meantime.  Even when 'only' a pacifier and no supplementary bottles are given, research shows that breastfeeding can still be affected. Righard and Alade (1997) studied the effect of pacifier use on breastfeeding duration.  They found that, "The breastfeeding rate at 4 months was 91% in the nonpacifier group and 44% in the pacifier group." The findings of Righard (1998) and Victora (1993) also support that pacifiers can interfere with breastfeeding.  So not only should routine supplementation be abolished, but routine pacifier use should also be avoided whenever possible. 

One circumstance that can sometimes necessitate supplementary feedings is when the baby loses a great deal of weight after birth and does not regain it quickly.  In some cases, this is truly worrisome and indicative of problems, but in other cases, it can be caused by the policies of the hospitals themselves. Many women are given IV fluids during birth, sometimes excessively, and especially so before epidural or spinal anaesthesia.  Some of this may transfer into the baby and make him appear larger than normal at birth.

Henci Goer  (The Thinking Woman's Guide to a Better Birth) documents that this overload of fluids  "also result[s] in a transfer of water into the baby's tissues.  This extra fluid inflates the baby's birth weight and the subsequent weight loss after birth.  Doctors and others often gauge breastfeeding adequacy by how fast the baby regains her birth weight, so this misleading weight loss may lead a doctor or mother to mistakenly conclude that breastfeeding is inadequate" or that supplementary feedings are needed.  Because of this, many babies are given supplementary feedings that seem necessary at the time but which are actually caused by the interventions used on the mother.  

Although supplementary feedings should be avoided as much as possible, sometimes circumstances or medical conditions really do necessitate them.  If they must be done, research shows that doing them by non-bottle means preserves breastfeeding more often than if the baby is given a bottle.  Mathur (1993) found that 87% of babies who had 'prelacteal feeds' by spoon went on to total breastfeeding, while only 33% of babies who had prelacteal feeds by bottle went on to total breastfeeding.  So why aren't hospitals avoiding bottles when supplementation truly is needed? 

Many hospitals strongly resist non-bottle supplementation options because they are not aware of other options, are not trained or encouraged in other options, or are stuck in old, rigid protocols.  Many different types of non-bottle options are available, including syringes, cup feeding, finger feeding, eyedroppers, spoon feeding, supplementary breastfeeding systems, etc. 

Separation of Mother and Baby

Research shows that rooming in (having baby stay in the room with you instead of staying in the nursery) also increases breastfeeding rates.  This is probably because the baby nurses more often (stimulating milk supply) and gets less supplementation. Because some hospitals do not permit women who have had a caesarean to have their babies room in with them, this can negatively affect breastfeeding rates.  

For example, Mathur (1993) found that 68% of women whose babies were not separated from them practiced total breastfeeding, versus only 35% of women whose babies were separated from them.  Flores-Huerta and Cisneros-Silva (1997) found that 61% of those who had 'joint lodging' breastfed exclusively for the first month, while only 42% of those who did not room together breastfed exclusively in that time.  Samuels (1985) also found that keeping the infant in the room during the hospital stay encouraged breastfeeding rates.  Rooming in makes a difference!

Some nurses offer to take the baby to the nursery for the night in a well-meaning gesture to help the mother recover better. But Anderson (1989) found that women who roomed in with their babies used less pain medication and slept just as well as those whose babies went to the nursery.  In addition, the babies' blood pressures were lower, they cried less, and their vital signs stabilized more quickly.  

Anderson (1989) also noted that secretion of prolactin (an important hormone in milk supply) is 10x higher at night, and therefore breastfeeding frequently at night "may be more important than daytime in the establishment of lactation."  Frequent breastfeeding at night is much more likely if the baby rooms in than if it goes to the nursery, where the nurses may or may not call the mother for a feeding, and sometimes give surreptitious bottles. Although well-meaning, taking the baby to the nursery for the night for "respite" care often exacerbates problems with low milk supply.

Many women also report that sleeping with their babies in the hospital bed (once they are aware and responsible after anaesthesia) makes life after a caesarean much easier.  It is easier to get the baby ready and into position when it's time to nurse, and they tend to nurse the baby more often and respond to its hunger cues more quickly when baby is right beside them.  As long as safety precautions are followed and the mother is not too drugged, sleeping with the baby after a caesarean can work very well.

Since frequent feedings are an important part of establishing milk supply in a timely manner, rooming in is an important part of helping caesarean mothers breastfeed  more easily, and sleeping with the baby in your arms can help even more.   

Anaemia From Blood Loss

Research shows that women having a caesarean lose about twice the amount of blood as women having a vaginal birth.  If a woman experiences excessive blood loss during surgery, she may experience anemia afterwards, which can interfere with milk supply significantly (Willis and Livingstone, 1995).  Yet few doctors are aware that anemia can affect milk supply, and few check for it or treat it aggressively afterwards.  

More women may be anemic postpartum than doctors recognize.  Bodnar et al. (2001) found that 27% of women were anemic postpartum, and that the rate of anemia rose to 43% among non-Hispanic black women.  Yet much of this anemia goes unrecognized and untreated. 

Henly (1995) studied the relationship between anemia and insufficient milk syndrome in 630 first-time mothers.  They found that 22% of the mothers were anemic, and of the anemic women, about 20% reported symptoms of insufficient milk syndrome.  These mothers breastfed fully for a shorter period of time and weaned earlier as well. The authors summarized their study by saying, "This study suggests that anemia is associated with the development of insufficient milk, which in turn, is related to duration of full breastfeeding and to age at weaning."  

Women most at risk for anemia postpartum include those who were anemic prenatally; those whose babies were born by caesarean; those who experience a hemorrhage during or after birth; those with certain placental problems like placenta previa, accreta or abruption; women carrying multiples; those with a history of prior post-partum hemorrhage; those with uterine atony; and heavy women (because of extra blood vessels feeding extra tissue).  Bodnar (2001) found that minority women and women from low socioeconomic groups may also be at greatly increased risk for anemia.

Although surgeons and breastfeeding staff should be on alert for anemia in all women post-surgery, sadly this is a condition that is often missed.  Even when it is caught, problems with breastfeeding are often not connected to it.  If you experience dizziness, weakness, fainting, or extreme fatigue after your caesarean, strongly request that your iron levels be checked.  Early treatment can prevent or minimize problems with milk supply and speed your recovery significantly.  Iron supplements (herbal or traditional) and modifying food intake to include more iron and folic acid can usually take care of the problem if it is caught early enough.

Mechanical Issues

Caesarean surgery also makes positioning the baby for breastfeeding more painful.   The usual 'cradle' breastfeeding position can be painful after a caesarean, since this places baby against an abdomen that has just been traumatized.   Placing a pillow over the incision may help cushion it sufficiently, but for some women even this places too much pressure on a tender area.  

Many nurses tell women to nurse lying down instead, which some caesarean mums do find to be easier.  However, others find this position quite difficult, especially when they have to turn over in bed in order to nurse on the other side.  Well-endowed women often find breastfeeding while lying down especially challenging. 

The football hold is a great hold for post-caesarean breastfeeding, as the baby is not against the incision at all, the mother can sit up (which makes controlling the baby's head and latch easier), and the mother can see to latch the baby on easier.  For more information on the football hold or any other breastfeeding position, see the "help" videos at www.breastfeeding.com. 

However, some mothers even have difficulty using the football hold.  Simply put, a caesarean presents yet another level of physical challenge to the new and unfamiliar task of breastfeeding, and the pain factor can be a significant deterrent for many women. 

Type of Anaesthesia

The type of anaesthesia used for the caesarean can also influence breastfeeding rates.  Several studies (Lie and Juul 1988, Mathur 1993, and Albania et al, 1999) have found that breastfeeding rates are significantly higher after regional anaesthesia (epidural or spinal) than after general anaesthesia.  

This may due to a number of causes.  Albania et al. speculated that the difference was probably due to faster mother-baby bonding after regional anaesthesia.  Since mothers who have general anaesthesia tend to take longer to wake up and are often more groggy and 'out of it' afterwards, they may be less inclined to nurse, or to nurse right away. Many women who have experienced caesareans by general anaesthesia also report feeling less connected to their babies, and may thus be less devoted to the idea of breastfeeding.  Also, because of the delay in access after a general, many of these babies also receive supplementary feedings in the nursery before the mother gets them.  

There may also be physical influences on the baby and mother which may affect breastfeeding.  General anaesthesia tends to reach the baby strongly, and may depress his/her responses after birth for some time.  This may make the baby harder to rouse for breastfeeding, resulting in baby getting nursed less often (creating less demand for the milk supply).  Drugs may also result in the baby being less effective at suckling, which would make his breastfeeding less efficient too.   Regional anaesthesia results in lower doses of the various drugs crossing the placenta to the baby, so although baby may still be affected, he may not be affected as strongly as after general anaesthesia.

Whether the caesarean was scheduled or unplanned also may make a difference in 'delayed onset of lactogenesis.'  Chapman and Perez-Escamilla (1999) found that women who had scheduled caesareans experienced delayed lactogenesis (mature milk coming in later) at a much lower rate than women who had unscheduled or emergency caesareans.  This may reflect the type of anaesthesia, the amount of medications the baby received, the amount of separation of mother and baby after the operation, or many other factors.

Inhibition of Newborn Suckling Responses by Medications

Although many women are told that pain medications (and particularly epidurals) do not reach or affect the baby, research shows that they do have some effect on babies, although authorities debate how significant these are.  The weakness of much of this research is that they often do not include unmedicated control groups, and rarely do they consider feeding ability as an outcome.  Thus, it is difficult to know how strongly babies really are affected by medications.

For years, lactation consultants have believed that pain medications affect the baby more than Obstetricians and anesthestetists believe they do.  In particular, they find that babies of highly medicated labours tend to have trouble getting started with breastfeeding.  Walker (1997) states:

Riordan et al. (2000) used a scoring system to evaluate the effect of medications on neonatal suckling in 129 vaginally-delivered babies.  Babies of medicated mothers scored lower in suckling effectiveness than babies of unmedicated mothers, and the scores were lowest in the group that received both epidurals and IV drugs.  The overall breastfeeding duration to 6 weeks postpartum was not significantly affected, but even so the authors concluded that:

Labour medications impair suckling in the early postpartum period.  Therefore, lactation consultants should be concerned that breastfeeding mothers who have received labuor medications may become discouraged, especially if they are discharged before effective breastfeeding is established.  If mothers lack adequate support at home or did not receive follow-up care, babies with poor breastfeeding behaviors are at greater risk for dehydration, jaundice, and poor weight gain.

If these effects occur in babies that were born vaginally, what about the effects on babies who went through a long and highly medicated labour and then were exposed to even more drugs for a caesarean?  Only further research will tell for sure, but it is likely these babies are affected even more strongly.   

Righard and Alade (1990) found that sucking problems were more common in babies whose mothers had received Demerol.  Walker (1997) reviewed a series of studies to determine the effect of labour medications on critical neonatal breastfeeding behaviors and time to first 'successful' breastfeed.  She found that IV narcotic medications such as Demerol, Stadol, and Nubain did affect breastfeeding by depressing or delaying behaviors such as rooting and sucking. The longer the infants had been exposed to the medications, the more the feeding behaviors were affected, and generally speaking, the longer until the first 'successful' breastfeed.  She noted that every single study reviewed "demonstrated that maternal medication had some effect on the breastfeeding behavior of the baby."  

The effects of epidurals are harder to measure.  We do know that epidurals affect newborn behavior, especially in alertness and in disorganised  movements (Sepkoski 1992).  However, Walker's review found NO studies on epidurals that specifically mentioned breastfeeding as an outcome.  Of the studies that do measure behavioral effects of epidurals, designs of the studies do not permit adequate analysis of effect on components that might affect breastfeeding. The truth is no one has really studied the issue adequately, so no can say for sure that epidurals do or do not affect breastfeeding behaviors!  

Instead, epidural studies examine the behavior of the newborn on behavioral assessment scales, but even these studies have major weaknesses, according to Walker.  Most studies use dissimilar drugs and dosages and measure differing behaviors, so comparisons are difficult.  Very few include a non-medicated control group, and even fewer include assessments of infant behavior after 24 hours postpartum, let alone assessment of breastfeeding behaviors.   Walker urgently advocates for more well-controlled studies with these parameters. 

Walker further notes that the most common drugs used in epidurals are known to cross the placenta.  Bupivacaine "enters the maternal blood stream rapidly from the epidural space.  It then crosses the placenta so that a measurable concentration is present in the fetal circulation within 10 minutes of administration."   Narcotics (such as Fentanyl) that are commonly added also "show significant placental transfer."  In a few studies reviewed for her article, some infants were affected by labour medications for as long as a month after birth (Sepkoski 1992).  

A very recent article (published after the Walker article) compared the effect of 'caine family of drugs on newborn breastfeeding behaviors.  'Caine family drugs are the anesthetics typically used in epidurals; bupivacaine is the drug most frequently used.  In this small study, 10/10 (100%) of the babies of non-medicated mothers initiated instinctive breastfeeding behaviors and successfully self-attached and suckled.  The results were far different for the babies of the medicated mothers.

Only 2/6 (33%) of the babies who received a pudendal block (using mepivacaine) successfully self-attached and suckled, and only 3/12 (25%) of the group exposed to epidural bupivacaine, narcotic, or combo of these successfully self-attached and suckled.  Although the study is extremely small, it certainly seems to indicate that medication can affect instinctive breastfeeding behaviors.   

In summary, research clearly shows that IV narcotic pain meds can affect breastfeeding behaviors.  While the effect of epidurals on breastfeeding cannot be conclusively analysed, it is likely that there is reason for concern.  This too, may be another reason why breastfeeding can be harder after a caesarean.  

Lactation Supply Inhibition Due to Medication

Some medications may inhibit milk production. For example, if a woman has had her labour induced or augmented with Pitocin, its anti-diuretic properties may inhibit milk production. This tendency towards fluid retention may make the mother's milk tend to come in late, may make the mother excessively engorged or have difficulty resolving the engorgement, and the baby may have a harder time latching on because of this engorgement.  

Certain specific labour or postpartum medications may also suppress breastfeeding. Hirose (1997) found that postoperative extradural buprenorphine decreased the amount of breastfeeding and infant weight gain for 11 days after a caesarean.  Although this study needs to be replicated, the authors suggested that extradural buprenorphine suppressed breastfeeding after caesareans.

Many women are given Fentanyl in their epidurals during the caesarean to help with post-operative pain.  Fentanyl and similar drugs are associated with a high incidence of itching (pruritis), and women are often given antihistamines to lessen the itching.  Unfortunately, antihistamines tend to "dry you out" and may interfere with milk supply if given in high amounts, or may make the baby drowsy and less responsive to breastfeeding.  

Many mothers report anecdotally that Magnesium Sulfate can interfere with establishment of breastfeeding.  Mag Sulfate is a medication used to help women with pre-eclampsia prevent seizures and other problems.  Most women report that its effects are most unpleasant, and the stress from being on this drug alone can probably interfere with breastfeeding.  

Many women are given diuretics after birth to help deal with significant swelling/edema.  Women who have had pre-eclampsia, women who have been induced with oxytocin, and women who have had lots of extra IV fluids tend to have the worst problems with edema after the birth.  To help women get rid of these extra fluids, some doctors prescribe diuretics.  However, this can also interfere with breastfeeding supply.  

Birth control pills can also decrease milk supply.  Traditional estrogen-only pills are known to decrease milk supply significantly, yet many doctors remain unaware of this problem and prescribe them anyhow.  Combined estrogen/progestin 'mini-pills' can be safely used during breastfeeding by most women, but few know that if these are prescribed too early postpartum, they can also inhibit milk supply.  Generally, it is safest to wait at least 6-8 weeks before starting the mini-pill, and even then a few women have noticed that it inhibits their milk supply (Breastfeeding Answer Book, 1997).  

Breastfeeding Holds Useful After a Caesarean

As noted, positioning can be more difficult after a caesarean. There is no one hold that is best for everyone after a caesarean; each mother has to experiment to see what works best for her unique needs.  

Many women can still use the 'cradle' position after a caesarean by putting a pillow over their incision and putting baby on top of that pillow.  This position is the one most women use permanently for breastfeeding, and although a bit awkward after a caesarean, can be done.   If this position feels fine to you and will be the position you use for breastfeeding later, don't feel that you have to use a different breastfeeding hold just because you've had a caesarean!  However, some women do find this position too difficult or painful after a caesarean and so choose other options. 

Some women nurse in a side-lying or lying-down position after a caesarean, due to either discomfort or to prevent a 'spinal headache.' This is the position some breastfeeding books recommend first after a caesarean.  A nurse or professional lactation consultant can help you use pillows to support your back and help position baby properly.  

Women who are well-endowed or who find it difficult to nurse lying down usually find the football hold the best position for breastfeeding after a caesarean.  In this position, the baby's body is held to one side of the woman, under her arm and supported by pillows. Be sure your hospital bed is cranked up to a comfortable angle---higher is better than lower. Use LOTS of pillows wedged between you and the bed railing to bring baby up to your breast level; never lean in to baby. In Kmom's personal opinion, this is the most comfortable of the breastfeeding positions for after a caesarean, and should be promoted more in breastfeeding resources. 

The advantage of the 'football' hold is that it is easier to control the baby's head and latch, and easier to support a larger breast in this position.  It also takes the weight of the baby off of your incision and allows you to sit up comfortably while breastfeeding (many women find it difficult to lie down fully after a caesarean).  It is also an excellent position for premature babies or when the mother is quite engorged.

If you find these other positions impossible, some women have luck with the Aussie hold.  In this unusual hold, the mother lies flat on her back or slightly tilted. this hold isalso great for a baby with a small jaw/ pierre robin sequence or micrognathia. She puts the baby on top of her body or with its legs slightly off to one side, with the baby's mouth at the mother's breast.  Be sure baby is able to breathe around your breast tissue. If necessary, gently depress the breast around his nose slightly to ensure that baby has ventilation. Babies' noses are flared and made just for this situation so he won't need much help, but with very large breasts this is occasionally needed.  Although it does not seem that this position would work very well from the description, some women find that this works better for them than the traditional 'lying down' position.

Strategies for Increasing Breastfeeding Success

What if you must have a caesarean because it is medically necessary? Or if you are going for a vaginal birth but want to be prepared for a better breastfeeding experience in case a caesarean becomes necessary?  Does breastfeeding after a caesarean HAVE to be difficult?  What things can you do to help ensure breastfeeding goes well?

Even if you had a bad experience breastfeeding before, it doesn't have to happen that way again.  Research shows that most women who have had problems breastfeeding a prior child have a better breastfeeding experience with a subsequent child (Ingram 2001).  There are never any guarantees, of course, but chances are very good that things will be better this time.  Remember, this is a DIFFERENT CHILD, a DIFFERENT BIRTH, and a DIFFERENT EXPERIENCE.  Consciously choose to make as many things different this time as possible, and let those differences help you make a totally new experience this time.   

Here are some ideas that may help facilitate a smoother transition to breastfeeding. The main thing is to be as informed as possible about breastfeeding, nurse early and frequently, have lots of expert resources, get help quickly if needed, and make the best decisions you can at the time.   Then you can go forward, knowing that you did the very best you could do for your child and for yourself, whatever happens.

These ideas are drawn from the research cited above.  Some of them may work for you; others may not be appropriate in your situation.  As always, take what you need and leave the rest behind.  

Summary of the Research: Hints for Breastfeeding Success

• Go for a vaginal birth if possible; the hormones of labour will help breastfeeding get started sooner and more easily
• If you must have a caesarean, utilise regional anaesthesia (epidural, spinal, or combined spinal epidural) instead of general anaesthesia
• Breastfeed  as early as possible after the baby is delivered, especially before regional anaesthesia wears off
• Take pain medication as needed in order to be comfortable
• Pursue regular, frequent feedings
• Don't limit time on the breast
• Use relaxation tapes and guided imagery to help decrease stress and increase milk output
• Utilise the support of a professional lactation consultant to help with positioning and latch-on concerns 
• Avoid artificial nipples and unnecessary supplements
• The ' football' or 'clutch' hold is often more comfortable after a c-section
• Room in with the baby to increase the breastfeeding success rate
• Have a family member (father or other relative) help with bringing baby to you when home.
• Sleep with the baby, which can greatly ease regular feedings (yes its safe if youre sensible )
• Be sure your nutrition is excellent and that you are getting plenty of extra fluids
• Watch carefully for thrush (a yeast infection)  after a c-section
• If experiencing problems, get expert help from a professional lactation consultant as soon as possible
• . 
• Utilize regional anaesthesia instead of general anaesthesia for the caesarean
• As noted above, breastfeeding seems to go easier after regional anaesthesia (epidural, spinal, or combined spinal epidural) rather than general anaesthesia.  This is probably because the mother is able to nurse sooner, with better pain control, and is less 'out of it' from the drugs.  Also the baby is exposed to a lower dosage of drugs in regional anaesthesia and thus may suckle more effectively than after general anaesthesia.  Unless there is a true emergency where every second counts, women should have regional anaesthesia for their caesareans. If you had trouble with an epidural last time, a spinal or combined spinal epidural is often a good alternative and offers much better coverage.  Discuss with your anesthesiologist your desire to sit up to breastfeed as soon as possible in recovery, and ask for ways to avoid a spinal headache or drug combinations that may cause problems.  Working with your providers to express your concerns and desires ahead of time often helps women have a better experience and avoid the problems that occurred previously.
• Nurse as early as possible after the baby is delivered, especially before regional anaesthesia wears off
• Nurse as early after birth as possible.  Some women are able to breastfeed the baby right on the delivery table as the surgeons finish up their repairs, but most women nurse for the first time in the recovery room.  Breastfeeding within the first hour after birth and frequently thereafter helps bring the mature milk in sooner and increases supply.  If possible, nurse the baby before the effects of the regional anaesthesia wear off. You will be relatively alert and free of pain, which will help the first breastfeeding go better than if you are worn out, in pain, or in need of sleep.  
• Take pain medication as needed in order to be comfortable

After the regional anaesthesia has worn off, don't hesitate to take enough pain medication to be comfortable.  You cannot nurse well or enjoy your baby if you are in pain from the surgery.  Take what pain relief that you need so that feeding and enjoying your baby will be your top priority.  The pain medication that you are given will be safe for your baby and will only be passed on in small amounts that won't affect baby very much.  Occasionally some women find that their babies are more affected by pain medication; these women must find a balance between getting enough  pain relief to function yet easing off the amount in order to make baby less lethargic. But most women find that it is best to take pain medication as needed, and that adequate pain relief helps them be more able to breastfeed frequently.  

• Pursue regular, frequent feedings

Research shows that breastfeeding goes best if mother and baby breastfeeds early and frequently in the first few days.  Experts note that babies do best when nursed at least 8-12 times in the first days.  Breastfeeding is very much a supply and demand process, and the best and simplest thing you can do is to nurse AT LEAST every 2-3 hours for the first several days to a week.  After that, use your baby's cues to help you know how often to nurse; about every 3 hours works well for most babies.  

• Don't limit time on the breast

Many hospitals, even today, tell women that they do not need to breastfeed their babies more than about 5-10 minutes on each side.  This is poor advice.  Some babies nurse more efficiently than others, while some are sleepy at first and may take a long time to finish a feed.  Limiting time on the breast does NOT eliminate sore nipples, and can lead to low weight gain in babies.  Babies need to receive plenty of the fat-rich hindmilk (which  comes in the last part of a breastfeeding session) in order to regain their birth weight more easily; limiting time on the breast also limits baby's weight gain.  Instead, be sure baby gets plenty of time breastfeeding at each breast so that they get plenty of foremilk AND hindmilk.  Babies don't need to nurse constantly, but neither should they be artificially limited to small amounts of time.  Let your baby set its own feeding cues as long as it seems like they seem like they are getting enough.  If there is any doubt about baby's weight gain or whether there is sufficient intake, nurse frequently and don't limit time on the breast.  

• Use relaxation tapes and guided imagery to help decrease stress and increase milk output

Dewey (2001) discusses a study where the use of of relaxation and guided imagery audiotapes before breastfeeding helped nearly double the milk output of a group of pumping mothers of premature babies.   Holding preemies skin to skin also helps increase the mother's milk supply.  If you are having trouble with milk supply, take time to do relaxation exercises, and hold your baby skin to skin as much as possible.  You can also ask a lactation consultant about herbs and/or medications to help increase milk supply. Read our article on increasing your supply.

• Utilise the support of a professional lactation consultant to help with positioning and latch-on concerns 

If you are having trouble getting the baby latched on properly, finding a comfortable breastfeeding position, or are experiencing lots of soreness, don't hesitate to call in a PROFESSIONAL lactation consultant.  They are experts at assessing the latch of a baby, the suck of a baby, and helping mothers find the best way possible to help their babies breastfeed.  Nurses on the hospital staff may say that they are trained in breastfeeding issues (and some genuinely are), but so much misinformation about breastfeeding is passed on in the medical and breastfeeding professions that you never know if they really have been well-trained. Many give out well-intentioned but incorrect information. A professional lactation consultant with the initials "IBCLC" after their name has taken a standardized and carefully prepared course of learning, and has passed a rigorous exam in order to become board-certified. If in doubt, call the true experts, the IBCLCs.  

• Avoid artificial nipples and unnecessary supplements as much as possible

Above all, avoid bottles if at all possible. Bottles are a quick way to breastfeeding problems, especially if used in the first few weeks of life. If you need to use them for working, they can be introduced later, but they can greatly complicate breastfeeding during the initial weeks. If supplementation becomes medically necessary, there are other methods that pose less interference with a baby's sucking mechanism, such as syringe, finger-feeding, flexible cups, etc. Although some babies can successfully switch from bottles to breast and back, many have difficulties with it.  Unfortunately, you cannot predict ahead of time which babies will have problems with nipple confusion and which will not. Therefore, it's best to try to avoid bottles if at all possible, and to use alternative methods should supplementation become necessary. 

• The ' football' or 'clutch' hold is often more comfortable after a c-section

Although most breastfeeding guides suggest that women nurse lying down after a caesarean, many women find this quite uncomfortable or difficult to manage.  It can be an especially hard position for the well-endowed woman.  Although women should use whatever position they find most comfortable, many women do find that the 'football' hold ('clutch' hold )is the most position to nurse in immediately after a caesarean.  The key to using the football hold is to raise the head of the bed somewhat, and to put plenty of pillows beside you so that the level of the baby's mouth will be at your breast.  It is very important to bring the baby to YOU, instead of you leaning over to the baby.  Don't be afraid to use LOTS of pillows.

• Room in with the baby to increase the breastfeeding success rate

As noted above, rooming in has been found to strongly increase the breastfeeding success rate.  When the baby rooms in with its mother, it gets more frequent breastfeeding (and therefore more milk), and the mother's supply is stimulated more.  It is also less likely to receive a bottle if it is rooming in with the mother.  Most hospitals today recognize that rooming in is a good thing, but a few still discourage caesarean mothers from doing this.  Families may have to be assertive about keeping the baby in the room with them.

• Sleep with the baby, which can greatly ease regular feedings

As long as the mother is not too groggy from drugs, she can keep the baby in bed with her as much as possible.   This makes feedings much easier, probably helps ensure more frequent feedings and better weight gain, and can help the mother and baby bond better.  Naturally, the mother should pay careful attention to safety concerns with the baby in bed with her, using the railings and the pillows as needed to keep a barrier to the edge, and keeping the baby in her arms as much as possible so she is always sure where the baby is.  If the mother is not feeling well enough or alert enough to have the baby in bed with her, the father (or other relative) can take the baby between breastfeedings, and the baby can sleep with the father on the pullout couch. However, most women find that they are able to sleep with the baby very safely, and that it makes things much easier after a caesarean. Best of all, many women report that it speeds their emotional healing to have baby so close. 

• Be sure your nutrition is excellent and that you are getting plenty of extra fluids

If you are breastfeeding, you will need to be sure that you are getting enough extra calories and fluids and such, so continuing to follow a pregnancy diet is generally a good idea. Do not try to diet. You will probably find that breastfeeding, on its own, will promote significant weight loss with very little effort, although this is not a sure thing for all women. However, restricting your food intake can affect your milk supply or make you run down, so you will want to be sure to continue to eat well and healthily. Emphasize iron and folic acid foods to help build back up your blood supply, and drink plenty of fluids so you are well-hydrated.  Some sources also recommend  extra vitamin C in order to help tissue healing.

• Watch carefully for thrush (a yeast infection)  after a c-section

Thrush (a yeast infection of the baby's mouth and/or the mother's nipples) is a special concern after a c-section, due to the high amounts of antibiotics often given during and after surgery. If the mother tends towards glucose intolerance/insulin resistance and she consumes a lot of carbs, she may be particularly prone to developing thrush. Any pain, redness, burning/itching of the mother's nipples, or white patches seen in baby's mouth may indicate that thrush has developed and needs to be treated. Often, significant nipple soreness in the early weeks of breastfeeding is actually due to undiagnosed thrush.  There are a number of options for treatment of the baby's mouth and the mother's nipples, but it is critical that both mother and baby be treated simultaneously, since it is very common for one to reinfect the other, making the process an ongoing and stubborn battle. The mother's bras should be laundered daily to prevent re-infection from that source as well.  For more information on treating thrush/yeast, see article in left menu under “common concerns”.  

Also watch for infections in the "fold" under the belly near the incision, as a yeast infection there can easily transfer to the breasts through cross-contamination.  Use a blow-dryer on "cool" to help decrease the likelihood of infection. Taking "acidophilus" in your diet may also help.  Consult your doctor about other possible treatment options if yeast becomes a chronic problem.  For really stubborn and recurring yeast problems, some women report that a careful consultation with a naturopath can help. 

If experiencing problems, get expert help from a professional lactation consultant as soon as possible

If you have ANY problems with breastfeeding, be sure to consult a professional lactation consultant as soon as possible. Given the high occurrence of breastfeeding problems, women who have had caesareans should be receiving automatic consultations from lactation consultants, but unfortunately they often do not get this extra help. Breastfeeding presents so many benefits that it should be strongly promoted for all mums, but the reality is that help is often neglected, and many caesarean mums fall through the cracks.  If you have problems at ALL, get to a professional IBCLC as SOON as possible. Quick support is often the difference in whether breastfeeding works out or not.

Other Strategies for Success

Leave The Free Formula at the Hospital!!

Many hospitals routinely send free formula samples home with mum, which can be a difficult temptation to resist, especially in the mother's vulnerable postpartum state.  Caesarean mothers may be even more vulnerable to these samples.  Well-meaning family members may give the baby a bottle 'to give mum a break,' or the mom may be so exhausted and groggy from the surgery that she gives in to the temptation to use the formula.  Or if the baby has experienced  jaundice or low weight gain, the hospital may tell her to take the formula to help finish 'flushing out the jaundice' (see above) or to bolster the baby's weight gain. But these extra bottles can be a road straight to breastfeeding 'failure.'

Even paediatricians and new mom support groups often have free formula samples prominently on display. These free samples are unethical and a violation of World Health Organization Code, but they are still quite common. This kind of sabotage from health professionals is an outrage, but it does exist, and is insidious in its influence on breastfeeding.  Giving free samples to mothers who intend to breastfeed shortens the breastfeeding period markedly.  This affects babies' health long-term, and so is unethical and unconscionable.

Even simply having formula advertising in infant feeding information packs can lower the rate of breastfeeding.  One randomised, controlled trial (Howard 2000) found that the group exposed to formula advertisements had greater breastfeeding cessation rates in the first 2 weeks.  In particular, women with uncertain or short-term breastfeeding goals were the most affected.  The authors state unequivocally that "Formula promotion products should be eliminated from prenatal settings."  

New mothers who intend to breastfeed have to be very careful to avoid falling into these seductive marketing traps. The best strategy is to not sign up for promotional gifts, avoid formula promotional materials, and to leave the formula at the hospital so you are not even tempted to use it at home.  If you prefer, you can take the formula to your local food closet/shelter, or donate it to a friend who is already bottle-feeding. 

Of course, if you are truly struggling with breastfeeding issues and a professional lactation consultant has recommended supplementing the baby, there is no reason to feel guilty about taking home the free samples of formula.  Although most cases of 'low milk supply' are iatrogenic (caused by medical mismanagement) and can be resolved through breastfeeding alone, this is not always true.  Sometimes supplementation really is necessary and there are women who must combine breastfeeding with supplementation.  

If you need to do this, then of course, formula can be a wonderful and life-saving product.  That is a different situation than deliberately sabotaging breastfeeding because of corporate greed.  When supplementation is truly necessary, free samples can be very helpful, judiciously used, and mothers should never be made to feel bad for taking advantage of them.  

But for the majority of women who are breastfeeding, it is best to leave the free formula samples at the hospital or give them away immediately.   They are a specific marketing tool designed to sabotage breastfeeding, and this strategy is all too successful.  If you have had breastfeeding difficulties in the past, you should be particularly careful to avoid taking these home with your next baby.  

Nutrition Issues

It is important to continue to pay attention to proper eating post-partum.  It is vital that a woman be well-fed and well-hydrated while her body goes through the difficult hormonal and physical changes postpartum, and while her body is attending to the amazing physical task of starting to breastfeed. 

Yet between the time period before and after a caesarean, most hospitals strongly restrict a woman's intake for several days.  This can further interfere with the body's ability to cope with postpartum changes and to start the lactation process efficiently. Many women complain of feeling starved, yet still being deprived of food their body desperately needs to start recovering well. 

The hospitals do have a legitimate concern for using this protocol.  Surgical anaesthesia can affect the function of nearby organs, and the intestines tend to slow down (and can even be affected permanently sometimes).  To make sure a woman's intestines have started re-functioning properly after the surgery, hospitals often refuse to let a woman eat real food again until she has started to pass gas. The problem with this protocol is that if the woman has been in labour a long time at a hospital that forbids food during labour, there is no food to help make the gas.  Or the woman may have plenty of gas but the intestines are moving slowly from the surgery and with no new food the gas becomes trapped and painful.

Some hospitals are beginning to question this protocol now.  A recent study (Patolia 2001) found that women who ate earlier than traditional protocols did just as well as women who ate later.  They reported feeling better and less weak.  They also were ready to leave the hospital sooner.  Although breastfeeding was not a measured outcome in this study, it would be interesting to see if the delay in food intake plays a part in the delayed lactogenesis that many caesarean mothers experience, or if it negatively affects milk supply.  At the very least, most caesarean mums would feel better to be able to eat normally again sooner instead of later.

A woman who is breastfeeding needs as many or more calories in the first few weeks as she did when she was pregnant. In addition, some sources feel that women who have had a c-section need a slight increase in calories as well in order to help with recovery and healing. So be careful to be sure that your intake in the first weeks after birth is really adequate; sometimes women are so worn out from the surgery and new parenthood that they neglect their nutrition.  And this can definitely affect milk supply and slow down healing.

As during pregnancy, QUALITY is more important than quantity; keep your emphasis on plenty of fruits and veggies, plenty of protein, and other foods in moderation. It is also important to up your consumption of fluids (preferably WATER) during this time to help flush out any edema and keep up your fluid levels for breastfeeding.  You may also want to consider adding a vitamin C supplement to help promote tissue healing.

If you have been on a somewhat restricted-calorie regimen in the past (either before or during pregnancy), you need to be sure you are getting adequate intake for this post-partum period, even if you feel like you need to emphasise weight loss. It is vitally important not to diet or to let others pressure you into limiting your intake during this very important period.  

Although research shows that women can start cutting back their calories modestly once their milk supply is well-established, this process should not begin until at least 4 (and preferably 6) weeks postpartum.  Milk supply in the first 2 months can be a delicate balance, so it's best not to throw in too many variables too early.   Increasing your exercise level won't hurt the baby and may help with weight loss, so if you are wanting to start working off that pregnancy weight gain, start with increased exercise first.  After 6-8 weeks or so, you can also start modestly cutting back on calories if you do it carefully.  Keep your emphasis on quality foods. 

Even if you did not lose a lot of blood or experience significant anemia, you should emphasize iron foods in your diet, since you did have surgery and blood loss is involved. Foods that are great sources of iron include legumes, beef, dried fruit, eggs, liver, and particularly seeds such as pumpkin and sesame (try tahini butter).  Sea vegetables are also an excellent source, if you have access to them. Iron absorption is decreased if you eat your iron foods with milk or other sources of calcium; iron absorption is increased if you eat your iron foods with vitamin C foods such as oranges, strawberries, or broccoli. So pay attention to how you schedule your foods together as well as what you eat.

Excellent nutrition is an important part of every woman's postpartum journey; it is even more important for the caesarean mother.  Make sure you continue to emphasize great nutrition just as strongly as you did in pregnancy.  Remember that you are recovering from major surgery,  nourishing another little human being, and helping your body adjust to huge postpartum hormonal changes. Nutrition is VERY important for this transition.

Lactation Consultants and Peer Support Groups

As noted, one of the best things that mothers who are having breastfeeding difficulties can do is to get expert help.  Sometimes this help is available right in the hospital, but oftentimes women must look elsewhere for it. 

Support for breastfeeding in hospitals tends to be inconsistent, and expert training in lactation issues incomplete at best.  Even nurses that have taken extra training in lactation issues often are misinformed and can do more harm than good, especially if there are special concerns like a premature baby, an extremely well-endowed mother, flat or inverted nipples, etc.  Research also shows that even pediatricians (who ought to be experts in lactation) are woefully lacking in breastfeeding knowledge and give advice that leads to breastfeeding difficulties (Freed 1995). That's why, whenever possible, it is best to bring in the true experts, professional lactation consultants. 

But how can you know that the person you are consulting is really a breastfeeding expert?  Many hospitals have people who claim to be lactation experts and may even carry that title, but who are not fully trained in lactation issues and intervention techniques.  That's why it's important to look for a lactation consultant with the title, "Internationally Board Certified Lactation Consultant."  Lactation consultants with this extra training can be identified by the initials "IBCLC" after their names.  Some hospital LCs are board-certified (IBCLCs) and can be very helpful; sometimes women need to go outside the hospital to find an IBCLC.  Whomever you find, it is important that they be truly well-trained in lactation issues.

It is especially critical to enlist the help of an IBCLC when there are supply issues. If you think you don't have enough milk, be sure to see an IBCLC right away as there are many things to be done to help with this problem but quick intervention is critical to success. An LC will evaluate your baby's latch and suck, your positioning, and help evaluate the baby's hydration and weight gain patterns.   If supplementation is necessary, the LC will guide you so that it interferes as little as possible with breastfeeding and supply.  Interventions may include pumping to increase your milk supply, medications or herbal supplements to increase your milk supply, retraining your baby's suck, or help correcting the baby's latch and/or positioning. 

Although these are the most common reasons women need to see LCs, a consultation may be helpful in any situation where you experience difficulty with breastfeeding.  Although it is disconcerting to consider exposing your breasts and breastfeeding in front of a stranger, professional LCs can help eliminate so many of the common problems that derail many breastfeeding relationships that it is worth pursuing, even if you are particularly modest.  And really, after prenatal care and childbirth, modesty about breastfeeding in front of a professional LC seems redundant!

Many mums have reported delaying seeing an LC due to embarrassment, modesty, or reluctance to seek help, yet regretted delaying so long once they saw how much help they received. It is normal to feel strange about breastfeeding in front of a stranger, but don't let that stop you from getting needed help.  Your baby is depending on you, and you deserve to have a better breastfeeding experience. 

Also remember that sometimes you may need to see more than one lactation consultant to get the right help, a new perspective, or to find the right mesh of personality styles.  Don't be afraid to try more than one LC if needed.  Another option for help is peer support through a breastfeeding support group.  If a professional lactation consultant is not available right away, then volunteer leaders from La Leche League or Breastfeeding Mother's Counsel can fill in the gaps.  The advantage of these resources is that they are completely free and sometimes peer support from another mother is less threatening than going to yet another healthcare professional.  

However, do remember that these peer support organizations are staffed by volunteers, so the skills may vary from leader to leader, and the women are mothers themselves and may be too busy to offer the amount of support you need. Usually there is more than one chapter in an urban area so if you don't get the help and support you need from one leader, try calling another chapter.  Chances are one of them will suit you and be able to help. Also take full advantage of their library of breastfeeding and parenting books that can be checked out for free; many of these are extremely helpful.

Some people are hesitant about these organizations because they are afraid of 'breastfeeding militants,' but generally most mothers find that these groups really are invaluable. What you have to do is find a group that suits your attitudes and situation, then take the advice you need for yourself and leave the rest behind.  Don't deny yourself the benefits of these groups because you might not necessarily agree with all that they say. Because these are volunteer groups, their quality and leadership will vary greatly. If you do not find one to your liking at first, keep looking. All points in the breastfeeding spectrum are represented sooner or later in these groups, and eventually you will find one that suits your needs. 

In summary, do not rely on your doctor to help diagnose or rectify breastfeeding problems; they are often too unaggressive in their approach and they usually have little training in lactation. Hospital nurses can sometimes be very helpful, but on the other hand, sometimes perpetuate breastfeeding myths and may not be adequately trained either.  

You need a lactation specialist (preferably an IBCLC), and you need it as EARLY as possible. You need the eye of an experienced professional to identify potential problems that a less-trained person might misdiagnose, to detect the subtle and very technical problems that hospital nurses and doctors are not qualified to identify or treat, to evaluate whether your baby truly needs supplementation or not, and to help you work out a plan of treatment that meets the baby's needs for nourishment while still doing everything possible to preserve breastfeeding.  Don't let problems escalate by delaying treatment. 

Finally, peer support groups can be invaluable as well, especially for the breastfeeding mother experiencing problems.  The one-to-one support from other mothers who have 'been there, done that' can help women work through the difficult emotional issues that can accompany breastfeeding problems, and put into perspective the everyday ups and downs of a breastfeeding relationship.  Although these are volunteer groups and can vary in quality at times, most women find them an extremely valuable source of support and comfort during their breastfeeding years.