the midwife`s journal < contents

26. breastfeeding is meant to work
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A newborn baby knows how to seek the breast. Nothing could be more natural or more reasonable. Breastfeeding is as much part of birth as are the stages of labour.

Birth is the great climax, the unveiling of a masterpiece of creation. The masterpiece is human flesh, not canvas or marble or granite. Creation in the present tense.

The transition from nourishment in the womb to nourishment at the breast is both complex and wonderful.

Most babies, given the right conditions, will get it right whether we understand what is happening or not. Today I am reflecting on those who don’t get it right.

I think that the realisation that breastfeeding is not working, whether that realisation comes at three days or three weeks, is a terrible blow to the new mother. Her baby represents unspoiled newness, purity, a fresh start, high ideals and expectations – a state of mind that cannot be easily reconciled to pain and mental anguish, so close to her heart, every time her baby needs to be fed. Nipples cracked and bleeding, breasts swollen and hot – nothing like the image of the contented Madonna with the quiet, nursing child.

The baby faces a similar emotional dilemma. Under instinctive forces she searches for the breast, all senses alert. The human race would not have survived if this were not so. She becomes frustrated and angry when her efforts to nurse are not rewarded. She cries, arching her back, her little hands flail about causing her mother to pull back, avoiding further nipple trauma. Another baby becomes passive when held to the warm safe breast. She may appear to be nursing, but shortly after falling asleep she is awake and hungry again.

If breastfeeding is instinctive and normal, as I claim it is, why do so many mothers and babies fail to establish breastfeeding? Why do so many women who fully intend to give only the very best to their babies become disillusioned within a few days or weeks of giving birth? Why is there such a discrepancy between the number of women who are theoretically able to breastfeed (almost all) and the number who succeed with breastfeeding for even one month? Has modern civilisation reversed natural selection, which demands that infants who are not adequately nourished by their mothers should die without significant intervention?

The answers are probably far more complex than my mind is able to comprehend. I realise that my quest for understanding takes me to a realm of the unseen; that as I touch and handle each woman and each baby, their lives are complex beyond my field of view. We are not dealing with a simple physical need for food – that each baby needs a certain amount of food at certain intervals, or just the physical supply and demand principle which ensures ongoing milk production. We are also talking about two people, a mother and a baby, who both have feelings, instincts, and experiences. I don’t know how a baby’s pre-birth experiences impact on his physical make-up, but I believe they must. I see profound effects on newborn babies of unsuccessful attempts to nurse. What the poor wee one is learning conflicts with his instinct to seek nourishment. I believe that when anything – physical, emotional, or mechanical – interferes with the natural process of breastfeeding, the baby’s wellbeing is immediately threatened.

I am often consulted to advise on breastfeeding difficulties when it seems that all else has failed. I meet the woman, listen to her story, and try to understand what is happening from her perspective, and her baby’s. The woman is often weary, demoralised, anxious and depressed. Her dreams are but distant hazy memories, and the thought of failure is not far from her sense of self.

To the woman I come as yet another stranger, yet another bearer of potentially conflicting advice in a care system that is fragmented and out of control. I often sense a look of distrust in the faces of these women.

I do not try to build confidence in myself. I believe that success for such a woman depends on her ability to take the leading role, to understand her particular situation, and to work through a plan that leads to effective breastfeeding. I can offer advice and suggest how to proceed. I can provide support. But I can’t do it. The sooner these women accept the fact that they are not ill, that they do not need doctors and nurses looking after them, and they reclaim the authority for their own bodies, the sooner they will overcome early breastfeeding difficulties.

I find that I say almost the same thing to every woman.

"Ensure that breastfeeding is effective."

"Be certain that your baby is rewarded with abundant milk every time she tells you she is hungry." This is, of course, referring to well babies, after the initial few days, when colostrum is the right food, and quantities may be small.

We talk about positioning at the breast.

"Is she being held in a way that allows her good access to the breast, or is her body turned away from yours? Is she securely held to your chest, or is her weight dragging away on pillows? Is her little head being forcibly jammed onto your breast? Can you swallow when someone is pushing your head into a forward tilt? Of course not."

What about the baby’s attachment?

"Is her mouth open, taking a large amount of breast well into the back of her mouth? Or does she have ‘prissy lips’, sucking strongly on her own tongue, and drawing in her cheeks?"

The mother’s nipple in this situation will be wedged firmly against the baby’s gum and hard palate, and will very soon become creased, blistered, and grazed. This baby has learnt a method of sucking which is ineffective. She will not thrive. The small amount of milk she receives when sucking this way will be no better than a tease. She will be called ‘fussy’, ‘naughty’, ‘windy’, ‘colicky’, ‘demanding’ and many other names, until someone realises that she is hungry.

Many mothers in such situations will resort to using dummies, and sometimes progress to giving a bottle of formula rather than facing another painful, tearful breastfeeding episode. And the result is that her baby falls into an exhausted sleep, and everyone is relieved. This mother and baby learn very quickly that breastfeeding is not a good idea.

In my brief consultation with the woman and her baby I must somehow offer strategies to restore that baby’s instinctive breastfeeding behaviours, and over-ride the learned, incorrect ones. Baby massage, encouraging stabilisation and strengthening of the muscles of the jaw and neck, is a simple and effective step. Co-bathing offers an opportunity for both mother and baby to relax in the familiar water environment. Baby is able to rest skin to skin in that peaceful, unhurried place, and proceeds to re-enact the instinctive breast-seeking behaviours that are seen in newborns who are allowed prolonged skin contact at birth. I believe that somehow the baby’s intuitive knowledge is triggered at this time.

Once the baby gets it right, amazing things happen. Baby has to stay focused, working hard to coordinate the suck-swallow pattern of effective breastfeeding, which he is possibly experiencing for the first time. Mother notices that it doesn’t hurt! She also notices the consistent, rhythmical action of her baby’s jaw, and she notices the softening of her breasts as milk is effectively transferred. When baby comes off she notices that her nipple is less squashed, and has been drawn much further than usual into her baby’s mouth.

Babies are very clever. They know the difference between a good feed and a pathetic one. A couple of opportunities to ‘get it right’ will usually be enough to change sucking patterns. Besides, babies love the water, and they love to be close to their mothers. This is not new. I have a photo of my first child nursing as we took a bath together 25 years ago. A friend of mine said she often had a bath with her babies, because she knew they would have a really good feed, followed by a good sleep.

A small experience of success works wonders for both mother and baby. Trust is restored. The mother-baby nurture bond can be renewed. Breastfeeding is meant to work.

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