Waterbirths - a hidden cause of breastfeeding problems?

The popularity of water births has increased dramatically in recent years; not only do many hospitals now offer a pool, but the price to hire or buy one has fallen too, making them more accessible to mums birthing at home.  Water births are also often suggested as a natural way to try and avoid pharmacological pain relief, which may impact upon labour outcome, baby or breastfeeding.

But is the assumption water births do not affect breastfeeding correct?  I've always been a big advocate, but I'm now not convinced things are that cut and dry.  I know this will probably raise eyebrows for a lot of people, but I now think there is a very real possibility that water births can contribute to problems.

As many lactation supporters will know, when a healthy baby is born naturally without exposure to medication, when placed on mums chest they will crawl to the breast, root, self attach and begin breastfeeding.  All their instincts are primed for this immediately after birth, which is why UNICEF and  the World Health Organisation strongly recommend skin to skin and initiating breastfeeding within half an hour.



As long as there are no underlying issues such as tongue tie or palate abnormalities - this group by far has the highest rate of early lactation success, and it's far less common to find mums in this position suffering from problems such as sore nipples, latching issues, breast refusal and so on.

But I'm not sure this is the case for water births; as the "breast crawl" becomes more well known, mothers are starting to mention it - and I'm finding more are stating their baby simply didn't do it.  In fact now when I'm supporting a mum who describes a normal unmedicated delivery followed by problems initiating feeding, my next question is "was it in water?".

How could water cause a problem?
As mentioned above, the primary instinct for a newborn is to locate the breast and feed - but how does it do that?  We know that during pregnancy the nipples and areola darken and enlarge,  because we know newborns with immature vision, see the contrast between dark and light most easily; but infants do not rely solely on sight, in fact it may actually play quite a small role in terms of initially locating the breast.

The infant's senses are stimulated by the sounds and feel of the mother's body and more importantly in this case, scent - as you can see in the clip above, baby is constantly smelling and tasting.

Why?
Mum's sweat and the amniotic fluid on baby, both play a very significant part in the breast crawl and newborn breastfeeding (and many sources also link this with bonding, but one for another blog post I think!).  Mum's sweat smells the same as amniotic fluid, which is still present on baby's hands - so he uses this taste to guide him to the breast, which is also conveniently located close to the armpit.  As the breast is actually an enlarged and modified sweat gland, this means the odour is strongest in the area baby needs to reach.

A 1994 study examining whether the infant found the nipple by smell states:

One breast of each participating mother was washed immediately after delivery. The newborn infant was placed prone between the breasts. Of 30 infants, 22 spontaneously selected the unwashed breast.  We concluded that the infants responded to olfactory differences between the washed and unwashed breasts.

Lancet. 1994 Oct 8;344(8928):989-90 

I don't have access to the full study to find out what the other 8 did, but they may not have crawled anywhere or become disorientated due to analgesics, perhaps separated from mum too - which as seen in the clip above can also influence co-ordination.  I think this also clearly highlights why babies should not be removed, wiped and wrapped in a towel before being given to mum!

Evidence?
A 1997 study entitled "Unique salience of maternal breast odors for newborn infants" found:

Human infants are particularly responsive to olfactory cues emanating from their mother's nipple/areola region. Beginning within minutes after birth, maternal breast odors elicit preferential head orientation by neonates and help guide them to the nipple. Such odors also influence babies' general motor activity and arousal, which may contribute further to successful nipple localization and sucking. To some extent, the chemical profile of breast secretions overlaps with that of amniotic fluid. Therefore, early postnatal attraction to odors associated with the nipple/areola reflect prenatal exposure and familiarization

There's more...
I also found a small study from 2001 that specifically explored crawling behaviour based solely on scent:

Breast odour as the only maternal stimulus elicits crawling towards the odour source -This study investigated the influence of breast odours per se on orientated physical movement of neonates. In total, 22 babies were observed during two trials on a warming bed. In one trial, a pad carrying the mother's breast odour was placed 17 cm in front of the baby's nose; in the other trial a clean pad was used. More babies moved towards and reached the breast pad than the clean pad. Conclusion: Natural breast odours unsupported by other maternal stimuli therefore appear to be sufficient to attract and guide neonates to the odour source.

Birthing in water strips the process of these vital odours and tastes for baby - given the above it seem to me it at least explains why some babies born in water don't crawl.  I cannot locate any research examining breastfeeding success rates following a water birth, but I would be fascinated to see any if it exists.

My first thoughts were that if using water in later, it would from a breastfeeding point of view make most sense to use just in early labour, to give time for mums body scent to return to normal levels; but many advocates suggest hitting the water too early can slow labour.  I wonder how feasible it is to keep waist up out of the water if the room is nice and warm and perhaps if you have large breasts that would still end up submerged, wearing a comfortable bra (amazingly as per the picture I managed to find!)  it may also be worth leaving the pool for delivery and ensuring you were dried thoroughly to prevent any dilution of amniotic fluid.  If this does not appeal, until I've seen hard evidence examining water birth impact on the breast crawl - I'd say it's worth considering staying where we normally reside, on dry land.

Alternative natural pain relief ideas:

Exercise during pregnancy: may make your labour shorter and less painful. A study published in the American Journal of Obstetrics and Gynecology, reported that women who continued running or aerobic dancing during pregnancy enjoyed labours about 30 percent shorter than women who stopped exercising. Women who maintained a regular exercise program also required less labour stimulation and fewer epidurals, episiotomies, and caesarean deliveries. An Italian study in the same journal examined women having their second or third babies, who rode an exercise bike three times a week for thirty minutes. They began around the fifth month of pregnancy, and during labour maintained higher endorphine levels and reported less pain than a matching group of sedentary women.  The link contains more information about exercising safely whilst pregnant.

Heat: In the same way heat can help period pains, it can also help in labour.  Wheatgerm bags (or alternative filled bags) may be safer than hot water bottles if you are moving about lots and perhaps applying pressure with them.  The link also contains details of how to make your own.

Active birth: although the media most often portrays labour women flat on their back, this is the not a productive position - think about gravity.  Trying positions like kneeling over a bed or birth ball; squatting and rocking hips can often not only offer more relief but help to keep labour progressing.

Massage: Some mums like to be massaged during labour, whilst others prefer not to be touched.  Avoiding oils on the chest which could mask mum's own odour would appear to be a sensible idea.

Hypnobirthing: Many mums swear by hypnobirthing as a fantastic way to reduce pain.  If you do not fancy going the whole hog, visualisation techniques such as imagining the baby moving down the birth canal or balloons inflating with each contraction, then floating away as they dissipate can be great coping strategies.

Nesting: Some mums find making themselves a big nest of beanbags and duvets to snuggle in can provide security to feel comfortable and relaxed during labour.  As muscles are contracting, the more relaxed you can be, the less pain you will feel!

Explore the pain and breathe: A natural reaction to pain is to recoil and if it's your first labour, perhaps be afraid.  Some women find focusing on the pain and exploring it mentally, helps to reduce how much it hurts.  This is based on the concept that pain is how the brain interprets labour contractions because of our inbuilt cultural belief labour hurts - read about the opposite end of the spectrum and orgasmic birth here

Tens Machine: Another popular choice although scientific evidence shows mixed results.  Women seem to find this method of pain relief most effective, when worn over a longer period, ie it's less effective if put on when the pain gets severe in labour - you need to put it on as soon as you get the first twinge for maximum benefit when things get going.

Finally...

Good pain relief in labor is not the same as a perception of personal control or satisfaction in childbirth. In other words, you may have significant pain during your labor, but feel in control during the process and have great satisfaction afterward. On the other hand, you might have total pain relief during your labor, but feel totally out of control and unhappy about your experience when it is over. 

In most languages, the word for the process of giving birth describes a process of work (labor), not of pain. Remember that labor pain is more than a physiological process; coping with labor pain is emotional and complex and results in feelings of fulfillment and achievement for women. Therefore, satisfaction with labor is not necessarily related to the efficacy of pain relief. Your midwife should work with you during the prenatal period to identify personal coping strategies and encourage you to make efficient and effective use of these resources (2).

from an excellent article here