Elective Cesarean Delivery - Wiley Online Library

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BIRTH 37:4 December 2010

Elective Cesarean Delivery: Does It Have a Negative Effect on Breastfeeding? Vincenzo Zanardo, MD, Giorgia Svegliado, MD, Francesco Cavallin, MS, Arturo Giustardi, MD, Erich Cosmi, MD, Pietro Litta, MD, and Daniele Trevisanuto, MD ABSTRACT: Background: Cesarean delivery has negative effects on breastfeeding. The

objective of this study was to evaluate breastfeeding rates, defined in accordance with World Health Organization guidelines, from delivery to 6 months postpartum in infants born by elective and emergency cesarean section and in infants born vaginally. Methods: Delivery modalities were assessed in relation to breastfeeding patterns in 2,137 term infants delivered at a tertiary center, the Padua University School of Medicine in northeastern Italy, from January to December 2007. The study population included 677 (31.1%) newborns delivered by cesarean section, 398 (18.3%) by elective cesarean, 279 (12.8%) by emergency cesarean section, and 1,496 (68.8%) delivered vaginally. Results: Breastfeeding prevalence in the delivery room was significantly higher after vaginal delivery compared with that after cesarean delivery (71.5% vs 3.5%, p < 0.001), and a longer interval occurred between birth and first breastfeeding in the newborns delivered by cesarean section (mean ± SD, hours, 3.1 ± 5 vs 10.4 ± 9, p < 0.05). No difference was found in breastfeeding rates between the elective and emergency cesarean groups. Compared with elective cesarean delivery, vaginal delivery was associated with a higher breastfeeding rate at discharge and at the subsequent follow-up steps (7 days, 3 mo, and 6 mo of life). Conclusions: Emergency and elective cesarean deliveries are similarly associated with a decreased rate of exclusive breastfeeding compared with vaginal delivery. The inability of women who have undergone a cesarean section to breastfeed comfortably in the delivery room and in the immediate postpartum period seems to be the most likely explanation for this association. (BIRTH 37:4 December 2010) Key words: breastfeeding, cesarean section, elective cesarean delivery

Anecdotal evidence suggests that lactogenesis and breastfeeding outcomes are dependent on the mode of the infant’s delivery (1). Several studies have reported that emergency cesarean deliveries have a negative effect on breastfeeding, particularly during the early postpartum period (2,3). Nevertheless, these studies were biased in that they did not distinguish infants born after an emergency from those born after elective cesarean section, and lactation performance patterns in infants born after an elective cesarean section are not

entirely clear (4–6). This issue is relevant, considering the increase in rates of cesarean deliveries over the past 30 years in the Western hemisphere (7). In particular, the incidence of elective cesarean deliveries has increased, largely because of the use of repeat procedures (8–11). Lactogenesis is a function of a finely tuned feedback mechanism, which is potentially susceptible to pharmacological, physical, and psychological manipulations on the part of the mother, her infant, or both (2,12–18).

Vincenzo Zanardo is a Neonatologist and Aggregated Professor of Pediatrics; Giorgia Svegliado is a Fellow in Pediatrics; Francesco Cavallin is a Statistician; Arturo Giustardi is a Pediatrician; Erich Cosmi is an Obstetrician and Aggregated Professor of Obstetrics and Gynecology; Pietro Litta is an Obstetrician and Associate Professor of Obstetrics and Gynecology; and Daniele Trevisanuto is a Neonatologist in the Department of Pediatrics at Padua University, Padua, Italy.

Address correspondence to Vincenzo Zanardo, MD, Department of Pediatrics, Padua University School of Medicine, Via Giustiniani, 3 35128 Padua, Italy. Accepted April 23, 2010 2010, Copyright the Authors Journal compilation 2010, Wiley Periodicals, Inc.

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Many important factors can influence a mother’s decision to begin and continue breastfeeding, and problems encountered at the beginning may have a long-term effect on supplemental feedings or the decision to give up breastfeeding altogether (12,13). The objective of this study was to evaluate breastfeeding rates, defined in accordance with World Health Organization (WHO) guidelines, from delivery to 6 months postpartum in infants born by elective or emergency cesarean delivery and in infants born vaginally, in an industrialized area of northern Italy where high cesarean delivery rates are prevalent.

Methods Mothers and all term newborns admitted to the regular nursery of the Department of Pediatrics in the University of Padua School of Medicine in Italy, a Level III hospital with full resources for obstetric and complete neonatal intensive care, from January 1 through December 31, 2007, were eligible for inclusion in this study (Table 1). The study was approved by the Institutional Review Board of the hospital. Outcome variables, methods of analysis, and inclusion and exclusion criteria were determined prospectively. Data on the mode of delivery, gestational age, birthweight, Apgar scores, and breastfeeding initiation and duration rates were recorded for all the newborns and subsequently entered into a computer database by trained personnel. Of these newborns, 513 (19.0%) were initially excluded (36 because they were admitted to the neonatal intensive care unit, 467 because their mothers were unable to speak and read Italian, and 10 refusals). Breastfeeding outcomes for these newborns were verified by a telephone follow-up interview concerning breastfeeding prevalence at three time points in the postpartum period: at 7 days and at 3 and 6 months. Only information related to the breastfeeding patterns of the mothers who participated in the interviews (1,567,

72.1%) were considered for analysis. Thus, 597 untracked mothers (31 had a changed telephone number and 566 were inaccessible), 8 refusals, and 1 maternal death, were excluded. Deliveries were classified as vaginal, elective cesarean section, and emergency cesarean section. We classified term cesarean sections before the onset of spontaneous or induced labor as elective cesarean sections and after labor began as emergency cesarean sections. Labor was defined as regular uterine contractions with progression of cervical dilatation. Complications that occurred during or after delivery were not taken into consideration when women were being evaluated for eligibility for inclusion because only factors that could be identified prenatally were considered to reflect the information available to the obstetrician when planning a delivery. Resuscitation in the delivery room was carried out according to the international guidelines for neonatal resuscitation (19). Mothers and infants spent at least 72 hours postpartum after a vaginal delivery and 96 hours postpartum after a planned or an emergency cesarean delivery in the study hospital. Standard practices to optimize immediate skin-to-skin contact, breastfeeding initiation in the delivery room, and breastfeeding at request in a rooming-in regimen, although not easy after cesarean section, were routinely ensured for mothers who gave birth vaginally and for those who underwent a cesarean section. After delivery the infant was triaged to the regular nursery, while the mother, who was transferred to a postnatal ward, received information and practical instruction on how to breastfeed, the purpose of rooming-in, and the advantages of breastfeeding. For initial analysis, the obstetric study population comprised those women whose pregnancy terminated between the 37 0 ⁄ 7 and 41 6 ⁄ 7 weeks of gestation (estimated on the basis of the last menstrual period or, if uncertain, by a sonogram). Subsequently, they were classified into two groups: women with vaginal delivery and women with caesarean delivery. The cesarean

Table 1. Anthropometrical and Clinical Parameters of the Study Population by Mode of Delivery

Characteristics Maternal age (yr), mean ± SD Gestational age (wk), mean ± SD Birthweight (g), mean ± SD Apgar score £ 5, No. (%) 1 min 5 min Weight at discharge (g), mean ± SD Breastfeeding In the delivery room, No. (%) Initiation (hr), mean ± SD

Vaginal Delivery (n = 1,496)

Emergency Cesarean Delivery (n = 279)

Elective Cesarean Delivery (n = 398)

33.0 ± 4.4 39.4 ± 1.1 3,387 ± 397

33.2 ± 4.1 39.3 ± 1.3 3,398 ± 411

35.0 ± 4.3 38.4 ± 0.9 3,286 ± 421

4 ⁄ 1,496 (0.3) 0 3,220 ± 387

1 ⁄ 398 (0.3) 0 3,239 ± 398

0 0 3,106 ± 396

1,071 (71.5) 3.1 ± 6.0

4 (1.4) 13.4 ± 13.1

14 (3.5) 10.4 ± 9.0

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section group was further subdivided into those who underwent elective cesarean section and those who underwent emergency cesarean section. Indications for elective cesarean section were repeat cesarean section (197, 49.4%), and other causes of uterine scarring (i.e., antecedent myomectomy 33, 8.2%); severe medical conditions such as myopia (39, 9.7%); and medical contraindications to vaginal delivery (8, 2.0%) such as multiple gestation (13, 3.2%), malpresentation (74, 18.5%), macrosomia (17, 4.2%), patient choice (8, 2.0%), and ‘‘old’’ primiparas (9, 2.2%). The main indications for emergency cesarean section were fetal distress (70, 25.0%), dystocia (54,19.3%), preeclampsia (15, 5.3%), long labor (57, 20.4%), clinical chorioamnionitis (14, 5.0%), and other (69, 24.7%). Feeding modalities, defined according to WHO guidelines (20), were as follows: exclusive breastfeeding (breastmilk only), predominant breastfeeding (additional water-based liquids), mixed feeding (breastmilk and formula), and formula feeding (exclusive formula only). The type of feeding ‘‘at discharge’’ was the type of feeding the infant had received during the last 24 hours of hospital stay. Exclusive and predominant breastfeeding were categorized together as exclusive breastfeeding. Differences between groups were tested using the chisquare or Fisher exact test for categorical variables and the Student t test for normally distributed variables. The relative risk with 95% confidence interval was used to analyze the effects of explanatory variables on dependent variables, exclusive breastfeeding, and mixed feeding or formula feeding at regular nursery discharge, at day 7 and months 3 and 6 postpartum. Statistical analysis was carried out with SPSS statistical software package (21). A p value of < 0.05 was considered significant.

Results From January 1 through December 31, 2007, 2,686 term newborns were admitted to the nursery of the Department of Pediatrics of the University of Padua School of Medicine. Anthropometrical and clinical data for the eligible maternal and neonatal study population (2,173, 80%) are outlined in Table 1. In particular, 677 (31.1%) newborns were delivered by cesarean section, 398 elective (18.3%) and 279 emergency (12.8%), and 1,496 were delivered vaginally (68.8%). Elective cesarean section was performed for 224 newborns (56.2%) before the 39 0 ⁄ 7 weeks of gestation. Elective cesarean delivery was performed at a significantly earlier gestational age (p < 0.001) compared with that of the vaginal and emergency cesarean deliveries, respectively. The birthweight of electively delivered infants was likewise significantly lower (p < 0.001). Furthermore, mothers who delivered electively were

older (p < 0.001) compared with those who delivered vaginally or after an emergency cesarean section. In addition, breastfeeding prevalence in the delivery room was significantly lower (p < 0.001) after elective cesarean delivery compared with that after vaginal delivery, and the interval was longer (p < 0.05) between birth and first breastfeeding in the elective cesarean section mothers. Breastfeeding rates at the time of hospital discharge and during the follow-up in relation to the mode of delivery are presented in Table 2. Mothers of 1,567 (72.1%) newborns agreed to respond to telephone interviews. The sample was comparable to an original cohort for delivery modalities (69.7% vaginal delivery, 12.1% emergency cesarean section, and 18% elective cesarean delivery). No difference was found in breastfeeding rates between elective and emergency cesarean deliveries. Compared with elective cesarean delivery, vaginal delivery was associated with a higher breastfeeding rate at discharge from the regular nursery and at the subsequent follow-up steps (at 7 days and at 3 and 6 mo of life).

Discussion This study, carried out in an industrialized area of northeastern Italy where cesarean delivery rates are high (11), demonstrated that elective and emergency cesarean delivery is negatively associated with breastfeeding. Published data indicate that particularly emergency cesarean sections can have a marked effect on breastfeeding during the early postpartum period (4,22–24). Emergency cesarean section, which often follows a long, difficult labor, does not seem to facilitate breastfeeding, particularly during the early postpartum period and characterized by confinement to bed, fasting, analgesia and ⁄ or anesthesia for pain, oxytocin augmentation, and anxiety and stress (4,22–24). These difficulties are also faced and shared by mothers who electively decide to have a cesarean section. After a surgical delivery, unassisted mothers are almost certainly unable to hold their newborns in the delivery room or for the frequent breastfeeding periods that follow (25), and bottle-feeding has become a common clinical practice in these cases (4,6). In addition, feeding milk-based formulas will reduce the newborn’s sucking capacity and consequently the mother’s lactation stimulus. If the newborn becomes accustomed to bottle (formula) feedings, he or she may have difficulty adjusting to breastfeeding, which may cause the mother to become discouraged and to consider giving up breastfeeding (16). The most striking aspect of this study is the finding, the implications of which are probably not fully comprehended, that elective cesarean delivery is a significant

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Table 2. Breastfeeding Follow-up in Term Infants by Mode of Delivery

Characteristics

Vaginal Delivery No. (%)

Emergency Cesarean Delivery No. (%)

Elective Cesarean Delivery No. (%)

1,496 (68.8) 1,312 (87.8)

279 (12.8) 204 (73.4)

398 (18.3) 296 (74.4)

170 (11.3)

70 (25.3)

94 (23.6)

14 (0.9) 1,093 (69.7)

5 (1.7) 191 (12.1)

8 (3.2) 283 (18.0)

939 (85.9)

150 (78.5)

211 (74.5)

55 (5.0) 99 (9.0)

14 (7.3) 27 (14.2)

28 (9.8) 44 (15.7)

765 ⁄ 1,093 (69.9)

106 ⁄ 191 (55.4)

156 ⁄ 283 (55.1)

Mixed feeding Formula

108 (9.8) 220 (20.1)

25 (13.0) 55 (28.7)

40 (14.1) 86 (30.3)

6 mo Exclusive

645 (59.0)

82 (42.9)

132 (46.6)

Mixed feeding Formula

86 (7.8) 362 (33.1)

21 (10.9) 88 (46.0)

25 (8.8) 126 (44.5)

At discharge Exclusive Mixed feeding Formula Follow-up Day 7 Exclusive Mixed feeding Formula 3 mo Exclusive

risk factor for not initiating breastfeeding in the delivery room or during hospital stay and for not continuing to breastfeed in the 6-month postpartum period. Women in our study had a high rate (about 30%) of cesarean delivery, significantly higher than the 15 percent rate considered the highest acceptable by WHO (26). This finding suggests that many women underwent cesarean delivery for nonmedical reasons and that their health status was probably less likely to interfere with breastfeeding initiation during their hospital stay. In addition, the low overall rate of initiation of breastfeeding in the delivery room and the longer interval between birth and first breastfeeding indicate that planned measures to optimize postoperative breastfeeding care for women who have undergone a cesarean section, but who nevertheless need to breastfeed their infants to stimulate their natural oral searching reflex (3), have been unsuccessful. Some evidence has been reported on an association between cesarean delivery and long-term breastfeeding, and many of our findings seem relevant to this debate. Identifying elective cesarean section as a significant risk factor for breastfeeding failure extends the conclusions of previous biased studies that did not distinguish between newborns delivered by unscheduled and scheduled cesarean sections. Studies by Samuels et al and

RR (95% CI) A vs B: 1.19 (1.14–1.29) A vs C: 1.17 (1.10–1.25) A vs C: 0.45 (0.35–0.67) A vs B: 0.48 (0.38–0.60) —

A vs B: 1.09 (1.01–1.18) A vs C: 1.19 (1.06–1.30) — A vs B: 0.64 (0.43–0.95) A vs C: 0.58 (0.41–0.81) A vs B: 1.26 (1.10–1.44) A vs C: 1.26 (1.13–1.42) — A vs B: 0.69 (0.54–0.89) A vs C: 0.66 (0.53–0.81) A vs B: 1.37 (1.15–1.63) A vs C: 1.26 (1.10–1.44) — A vs B: 0.74 (0.63–0.86) A vs C: 0,71 (0.60–0.85)

Procianoy et al reported that cesarean section mothers were more likely to stop breastfeeding within the first 2 weeks and at 2 months postpartum (27,28). Vestermark et al reported that breastfeeding mothers in the cesarean section group had a later onset of full lactation during the first 4 days postpartum, but unlike the findings in our study, no statistical difference was found at 3 and 6 months in those mothers in this group who were breastfeeding at discharge (29). A prospective study by Janke likewise found no difference in breastfeeding outcomes by delivery method (30). This finding is important, because support and encouragement have been recognized as key indicators of breastfeeding success even after surgical births. Some limitations in our study should be noted. We did not determine the role of fatigue, stress, pain, and health complications in scheduled cesarean deliveries. Lacking assistance, the mother may be unable to breastfeed initially, which can affect lactation and cause breastfeeding to fail. Another limitation relates to the external validity of our findings because our participants did not include mothers with limited socioeconomic means and foreign mothers. Similar and more advanced studies carried out in different regions and with different samples of mother groups are warranted.


Conclusions Our data indicate that elective and emergency cesarean delivery is associated with a decreased rate of exclusive breastfeeding at various time points after birth when compared with vaginal delivery. The difficulty that women who have undergone a surgical delivery have when they attempt to breastfeed in the delivery room and immediately thereafter, and the lack of preparation on the part of hospital staff to sustain these new mothers would appear to be the most likely explanation for this association.

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