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      <h1 id="top">4.2 Labor interventions</h1>
      <div>
    <p> The care a mother experiences during labor and birthing can affect breastfeeding and how she cares for her baby. Birth practices that help the mother to feel competent, in control, supported and ready to interact with her baby include: </p>
    <ul>
      <li>Emotional support during labor</li>
      <li>Freedom of movement during labor</li>
      <li>Offering light foods and fluids during labor</li>
      <li>Avoidance of unnecessary caesarean section</li>
      <li>Early mother-infant contact</li>
      <li>Facilitating the first feed</li>
    </ul>
    <p> When labor interventions are considered factor in the following information. </p>
  </div>
      <div class="section" id="Analgesia_during_labor"><h2>Analgesia during labor</h2>
    <div>
      <p> The most commonly used intrapartum analgesics are potent narcotics, all of which are known to cause sedation and respiratory depression in the mother and the baby, and also to affect behavior. </p>
      <ul>
        <li>Morphine has a short half-life (1.5 - 2 hrs) and does not have an active metabolite</li>
        <li>Butorphanol (Stadol) has a half-life of 3 - 4 hours.</li>
        <li>Nalbuphine (Nubain) has a half-life of 5 hours.<sup><a href="#note1">1</a></sup></li>
        <li>Meperidine (Pethidine/Demerol) is metabolized to the active metabolite normeperidine (norpethidine) which has a long half-life (63 hours in the neonate). Meperidine/Pethidine reaches its highest levels in the fetus 2 to 3 hours after administration, however normeperidine/norpethidine levels continue to rise the longer it is until birth. Normeperidine/norpethidine still has half the pharmacological activity of meperidine/pethidine.</li>
      </ul>
    </div>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/thinker.gif" class="icon" alt="" /><h3>How long will the effects of meperidine/pethidine be experienced by the newborn baby?</h3>
      <div>
        <p>
			It takes approximately 5 half-lives for a substance to reach insignificant serum (blood) concentration. How long will it take the newborn baby to clear normeperidine and its effects from his system?
		</p>
        <p>Multiply 63 hours by 5 times; then divide by 24 to have your answer in days.</p>
      </div>
    </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
    <blockquote>
      <div>
        <ol>
          <li>Shorter-acting opiates such as fentanyl are preferred. Remifentanil is potent and has rapid onset and offset but can be associated with a high incidence of maternal apnea, requiring increased monitoring. Its transfer in utero to the fetus is minimal.</li>
          <li>Meperidine/pethidine generally should not be used except in small doses less than 1 hour before anticipated delivery because of greater incidence and duration of neonatal depression, cyanosis, and bradycardia.</li>
          <li>Nalbuphine, butorphanol, and pentazocine may be used for patients with certain opioid allergies or at increased risk of difficult airway management or respiratory depression. However, these medications may interfere with fetal heart rate monitoring interpretation. Observe the mother and infant for psychotomimetic reactions (3%).</li>
          <li>Multiple doses of intravenous analgesic, and their timing of administration may lead to greater neonatal effects. For example, fentanyl administration within 1 hour of delivery or meperidine/pethidine administration between 1 and 4 hours before delivery is associated with more profound neonatal effects.<sup><a href="#note2">2</a></sup></li>
        </ol>
      </div>
    <p class="cite">From Academy of Breastfeeding Medicine, Protocol #15. Montgomery A, Hale T, et al. 2006</p></blockquote>
    <div>
      <p>
		Other forms of analgesia such as inhaled nitrous oxide, paracervical block, pudendal block and local perineal anaesthesia expose the infant to minimal quantities of medication and may be an alternative to intravenous narcotics or epidural analgesia.
	</p>
    </div>
  </div>
      <div class="section" id="Neuraxial_pain_relief_epidural_spinal_"><h2>Neuraxial pain relief (epidural/spinal)</h2>
    <div>
      <p> Anesthetics such as lignocaine and bupivacaine are commonly administered via the epidural route to mothers in labor to provide pain-free birthing. This local anesthetic is almost always combined with narcotics such as morphine, fentanyl or sufentanil, providing a rapid onset of pain relief while reducing the intensity of immobility for the mother. </p>
      <p class="listTitle">While epidurals in labor provide greater pain relief than non-epidural methods, they are also associated with:<sup><a href="#note3">3</a></sup></p>
      <ul>
        <li>longer first and second stages of labor,</li>
        <li>maternal fever<ul><li>followed by septic work-up of infant, and maternal/infant separation, and possibly antibiotic therapy</li></ul></li>
        <li>a drop in blood pressure<br /><ul><li>fluid 'loading' used routinely; commonly associated with postnatal breast engorgement and additional weight loss in the infant during the first two days<br /></li></ul></li>
        <li>problems passing urine</li>
        <li>an increased use of oxytocin augmentation</li>
        <li>an increased incidence of fetal malposition,</li>
        <li>an increased need for instrumental vaginal delivery</li>
        <li>the mother being unable to move for a period of time after the birth, and</li>
        <li>the possibility of a postdural puncture headache<sup><a href="#note4">4</a></sup> palliatively treated by horizontal bed rest, and usually further medical intervention.</li>
      </ul>
    </div>
    <blockquote>
      <div>Medications administered via epidural or spinal routes rapidly enter the maternal circulation, are measurable in the fetal circulation within 10 minutes<sup><a href="#note5">5</a></sup> and may persist for up to 3 days in the newborn.<sup><a href="#note6">6</a></sup> <br /></div>
    </blockquote>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/thinker.gif" class="icon" alt="" /><h3>Did you know?</h3>
      <div>Another side effect of epidural administration is the fall in maternal serum beta endorphins.<sup><a href="#note7">7</a></sup> <span style="font-weight: bold;">Beta-endorphins</span> are a naturally occurring opiate that, like other opiates, act as an analgesic, inducing feelings of pleasure, euphoria, and dependency or, with a partner, mutual dependency. <br /><p></p> <ul><li>levels increase throughout pregnancy; high levels at the end of pregnancy are associated with a decreased need for intrapartum analgesia.<sup><a href="#note8">8</a></sup> Such high levels help the laboring woman to transmute pain and enter the altered state of consciousness that characterizes an undisturbed birth.<sup><a href="#note9">9</a></sup></li><li>Beta-endorphins are found in colostrum; it is thought they contribute to postnatal fetal adaptation, to overcoming birth stress, to the postnatal development of several related biologic functions of breastfed infants and may persist for up to 3 days.<sup><a href="#note10">10</a>,</sup><sup><a href="#note6">6</a>,</sup><sup><a href="#note11">11</a>,</sup><sup><a href="#note12">12</a></sup></li></ul><p></p></div>
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  </div>
      <div class="section" id="Cesarean_caesarean_section_or_vaginal_instrumental_birth"><h2>Cesarean (caesarean) section or vaginal instrumental birth</h2>
    <div>
      <p>
		Cesarean birth is most often associated with delayed skin-to-skin contact between mother and baby and longer time to first breastfeed. Hospitals practicing Step 4 of the 10 Steps to Successful Breastfeeding are, however, diligent at ensuring a minimum disruption to this important bonding and breastfeeding step.
	</p>
      <ul>
        <li>Rowe-Murray et al (2002)<sup><a href="#note13">13</a></sup> reported a significant delay in initiating breastfeeding compared with women giving birth vaginally, with or without instrumental assistance.</li>
        <li>Shawky &amp; Abalkhail (2003)<sup><a href="#note14">14</a></sup> found caesarean section delivery to be significantly related to earlier cessation of breastfeeding.</li>
        <li>Leung et al (2002)<sup><a href="#note15">15</a></sup> identified caesarean delivery was a risk factor for not initiating breastfeeding, for breastfeeding less than 1 month, and it remained a significant hazard against breastfeeding duration.</li>
      </ul>
    </div>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/thinker.gif" class="icon" alt="" /><h3>Interesting research</h3>
      <div>An interesting study<sup><a href="#note16">16</a></sup> looked at whether the hormonal patterns of oxytocin, prolactin and cortisol differed between women delivered by emergency cesarean section or vaginally, and if those patterns showed any relation to the duration of breastfeeding. They found that the mothers birthing vaginally had significantly more oxytocin pulses on Day 2 than the cesarean section mothers. Furthermore, the cesarean section women lacked a significant rise in prolactin levels at 20-30 min after the onset of breastfeeding. They were able to link the oxytocin pulsatility on Day 2 to the duration of exclusive breastfeeding.</div>
    </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
    <div>
      <p>
		Don't forget the effects of the operation itself: an abdominal incision, pain, restricted movement, intravenous therapy, a urinary catheter, analgesics for several days, restricted oral intake and any complications arising from these interventions. Rooming-in is more difficult, at least initially.
	</p>
      <p>
		The baby has an increased risk of respiratory problems, and is subjected to suctioning of mouth and oropharynx. Some units purposely separate the post-cesarean delivered baby from its mother for "observation" for several hours and may perform routine heel prick blood tests. Due to separation and the desire of the staff to let the mother 'rest', the baby may be given formula supplements.
	</p>
      <p>
		All of these factors have the potential to limit the frequency, effectiveness and, ultimately, duration of breastfeeding.
	</p>
    </div>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><h3></h3>
      <div class="captionBox"><object classid="clsid:d27cdb6e-ae6d-11cf-96b8-444553540000" codebase="http://fpdownload.macromedia.com/pub/shockwave/cabs/flash/swflash.cab#version=8,0,0,0" width="425" height="350"><param name="movie" value="http://www.youtube.com/v/m5RIcaK98Yg" /><param name="wmode" value="transparent" /><embed wmode="transparent" src="http://www.youtube.com/v/m5RIcaK98Yg" type="application/x-shockwave-flash" pluginspage="http://www.macromedia.com/go/getflashplayer" width="425" height="350"></embed></object><p>The Natural Caesarean. A wonderful way to support the mother and respect the baby when birth is by caesarean. This 12 minute video is from Youtube. (Some hospitals block youtube - view from a home computer) </p></div>
    </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
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            <td class="body"><img src="design/group.png" class="icon" alt="" /><h3>Pregnancy classes</h3>
    <div>
      <p>
			What is included about birthing interventions in the curriculum of the pregnancy classes where you work? Do all pregnant women know the effects of interventions on themselves and their baby? Do they have to give consent prior to any of these procedures? How well informed is this consent?
		</p>
      <p>
			Form a group to review the pregnancy class curriculum.
		</p>
    </div>
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      <div class="section" id="Assisting_a_mother_following_an_assisted_delivery"><h2>Assisting a mother following an assisted delivery</h2>
    <div>
      <ul>
        <li> Initiate skin-to-skin contact as soon as possible <ul><li>immediately following vaginal delivery if baby does not require advanced life support.</li><li>as soon as possible if caesarean section under epidural or spinal analgesia. <span class="aside">Many hospitals facilitate this while the surgeon closes the wound.</span></li><li>as soon as the mother is responsive if caesarean section under general anaesthetic. <span class="aside">Place baby in skin-to-skin contact with father or other close family until mother available.</span></li><li>If contact must be delayed initiate skin-to-skin contact at the earliest opportunity.</li></ul> </li>
        <li> Assist with breastfeeding as soon as possible. <ul><li>The mother does not need to be able to sit up, to hold her baby, or meet other mobility criteria in order to breastfeed.</li><li>It is the baby that is finding the breast and suckling.</li><li>As long as there is a support person with them, the baby can go to the breast if the mother is still sleepy from anesthesia.</li></ul> </li>
        <li>Help the mother find a comfortable position. <ul><li>Side-lying in bed. This position helps to avoid pain in the first hours and allows breastfeeding even if the mother must lie flat after spinal anesthesia.</li><li>Sitting up with a pillow over the incision or with the baby held along the side of her body with the arm closest to the breast.</li><li>Lying flat with the baby lying on top of the mother.</li></ul> </li>
        <li>Facilitate rooming-in with assistance, until mother is able to care for baby.</li>
      </ul>
    </div>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/books.png" class="icon" alt="" /><h3>Workbook Activity 4.3</h3><p>Complete Activity 4.3 in your workbook.</p></td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
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            <td class="body"><img src="design/thinker.gif" class="icon" alt="" /><h3>What can you do?</h3>
    <div>
      <ul>
        <li>Discuss ways to cope with pain and discomfort, and their risks and benefits, during antenatal care.</li>
        <li>Provide a supportive environment for birthing - lessens need for analgesia and assisted delivery.</li>
        <li>Be prepared to allow extra time and assistance to establish breastfeeding and bonding following intrapartum medications and assisted delivery.</li>
      </ul>
    </div>
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      <div class="section" id="What_should_I_remember_"><h2>What should I remember?</h2>
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      <div>
        <ul>
          <li>all interventions in labor carry a risk for both mother and infant which must be weighed against the need for the intervention</li>
          <li>that all drugs given in labor transfer to the infant and most will have a deleterious effect on the infant's ability to breastfeed, or the mother's lactation</li>
          <li>when interventions are unavoidable mother and baby both need extra help and support to establish their relationship and breastfeeding<br /></li>
        </ul>
      </div>
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  </div>
      <div class="section" id="Self-test_quiz"><h2>Self-test quiz</h2>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><h3></h3>
      <div></div><div class="activity" id="activity_h">
<script type="text/javascript">
/* <![CDATA[ */
var hqs = {settings : {type : 'mcq'}, questions : [
	new MCQ('Which of the following forms of analgesia available to a laboring mother will have the least transfer to, and therefore the least effect on her baby?', [{text:'intramuscular injection of pethidine/meperidine',feedback:'No, this drug has the potential to have far-reaching effects on the baby.',score:0},{text:'intravenous injection of fentanyl',feedback:'If given to the mother within an hour of birth the baby will be affected',score:0},{text:'morphine administered via the epidural or spinal route',feedback:'Absorption and transfer of drugs administered via this route is quite rapid, and therefore the baby will be affected',score:0},{text:'inhaled nitrous oxide',feedback:'That\'s right. This drug is poorly transferred to the fetus and has a very short half-life; its effects will wear off the baby very rapidly.',score:1}]),
	new MCQ('This potent pain suppressant, that aids the infant to overcome birth stress and contributes to postnatal fetal adaptation, is found in high levels in the colostrum of women who have not had epidural pain relief in labor.', [{text:'prolactin',feedback:'This hormone is found in breastmilk, but does not have this function.',score:0},{text:'meperidine (pethidine/demerol)',feedback:'This drug is found in breastmilk, but does not have any positive effects on the infant.',score:0},{text:'beta endorphins',feedback:'Correct. This naturally occurring opiate has many positive effects on mother and baby, but is reduced when neuraxial pain relief is used.',score:1},{text:'lignacaine or bupivacaine',feedback:'These drugs do not have this effect.',score:0}]),
	new MCQ('Epidural analgesia has been noted to have all of the following effects on breastfeeding, EXCEPT:', [{text:'increases the mothers risk of engorgement',feedback:'That\'s true. The increased fluids administered with an epidural may cause edema/oedema of the breasts; and also a baby feeding poorly often results in engorgement too. (I know this wasn\'t in your notes - even the quiz is for learning.)',score:0},{text:'babies experience more stress',feedback:'Longer labor, more risk of instrumental delivery, reduced endorphins to help them adapt ... sounds pretty stressful.',score:0},{text:'babies are less likely to breastfeed effectively in the first 24 hours',feedback:'This happens too, but not because they didn\'t want to breastfeed - they have just as many attempts as other babies, but are less able to suckle effectively.',score:0},{text:'babies are less likely to be breastfeeding at 2 months and 6 months of age.',feedback:'This has been found by some researchers.',score:0},{text:'detectable levels of the drug used is still found in breastmilk up to 24 hours after the epidual was removed',feedback:'Fortunately this is not true. The mother\'s liver and kidneys is much more efficient than the neonates and she will clear the drugs from her system, including her breastmilk, quite quickly - once the epidural is discontinued.',score:1}]),
	new MCQ('How soon after either a cesarean section or an assisted vaginal delivery should the infant be placed on the mother\'s chest in skin-to-skin contact?', [{text:'immediately',feedback:'Yes that\'s correct. Mother and baby are going to need all the help they can get to establish their relationship and begin breastfeeding following a birth that included interventions.',score:1},{text:'as soon as possible after the mother has been made comfortable',feedback:'No, this is too much delay. Both mother and baby need your support immediately.',score:0},{text:'after the initial steps or resuscitation and baby has been dried and well wrapped for warmth',feedback:'No. Resuscitation can occur in skin-to-skin contact, as can drying the infant. The mother will stabilise the baby\'s temperature.',score:0},{text:'Upon return to her room when she is able to sit up and hold her infant.',feedback:'This care is very draconian. Mother and baby need each other and should not be separated.',score:0}])
]};

/* ]]> */</script>
</div><script type="text/javascript">renderActivity('h');</script>
    </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
  </div>
      <div id="footnotes">
        <h3>Notes</h3>
        <ol>
          <li id="note1"><a href="references.html#hale02" title="See full details">#</a> Hale TW (2002) Medications and Mothers' Milk</li>
          <li id="note2"><a href="references.html#mont06" title="See full details">#</a> Montgomery A et al. (2006) ABM clinical protocol #15: analgesia and anesthesia for the breastfeeding mother.</li>
          <li id="note3"><a href="references.html#anim05" title="See full details">#</a> Anim-Somuah M et al. (2005) Epidural versus non-epidural or no analgesia in labour.</li>
          <li id="note4"><a href="references.html#vinc98" title="See full details">#</a> Vincent RD et al. (1998) Epidural Analgesia During Labor</li>
          <li id="note5"><a href="references.html#rose81" title="See full details">#</a> Rosenblatt DB et al. (1981) The influence of maternal analgesia on neonatal behaviour: II. Epidural bupivacaine</li>
          <li id="note6"><a href="references.html#sepk92" title="See full details">#</a> Sepkoski CM et al. (1992) The effects of maternal epidural anesthesia on neonatal behavior during the first month</li>
          <li id="note7"><a href="references.html#rais84" title="See full details">#</a> Raisanen I et al. (1984) Pain and plasma beta-endorphin level during labor</li>
          <li id="note8"><a href="references.html#dabo10" title="See full details">#</a> Dabo F et al. (2010) Plasma levels of beta-endorphin during pregnancy and use of labor analgesia.</li>
          <li id="note9"><a href="references.html#buck02" title="See full details">#</a> Buckley S (2002) Ecstatic Birth: The Hormonal Blueprint of Labor</li>
          <li id="note10"><a href="references.html#ombr08" title="See full details">#</a> Ombra MN et al. (2008) beta-Endorphin concentration in colostrums of Burkinabe and Sicilian women.</li>
          <li id="note11"><a href="references.html#zana01a" title="See full details">#</a> Zanardo V et al. (2001) Labor Pain Effects on Colostral Milk Beta-Endorphin Concentrations of Lactating Mothers</li>
          <li id="note12"><a href="references.html#zana01" title="See full details">#</a> Zanardo V et al. (2001) Beta Endorphin Concentrations in Human Milk</li>
          <li id="note13"><a href="references.html#rowe02" title="See full details">#</a> Rowe-Murray HJ et al. (2002) Baby Friendly Hospital Practices: Cesarean Section is a Persistent Barrier to Early Initiation of Breastfeeding</li>
          <li id="note14"><a href="references.html#shaw03" title="See full details">#</a> Shawky S et al. (2003) Maternal factors associated with the duration of breast feeding in Jeddah, Saudi Arabia</li>
          <li id="note15"><a href="references.html#leun02" title="See full details">#</a> Leung GM et al. (2002) Breast-feeding and its relation to smoking and mode of delivery</li>
          <li id="note16"><a href="references.html#niss96" title="See full details">#</a> Nissen E et al. (1996) Different patterns of oxytocin, prolactin but not cortisol release during breastfeeding in women delivered by caesarean section or by the vaginal route</li>
        </ol>
      </div>
      <div id="footer"><a href="topic_4-1.html" rel="prev" class="prev">&laquo; Previous</a><a href="topic_4-3.html" rel="next" class="next">Next &raquo;</a><br style="clear: both" /><a href="#top" id="topLink">Back to top</a><a href="javascript: window.print()" id="printLink">Print this page</a><span class="noPrint"> | </span>&copy; 2012 Health e-Learning<p class="printOnly">COPYRIGHT: You are permitted to print ONE (1) copy for your personal use only. No graphics, tables, quizzes, videos, etc, may be used in any form without express written consent. Author: Denise Fisher</p></div>
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      <h1>Breastfeeding Essentials</h1>
      <ol>
        <li>1.0 <a href="topic_1-0.html">Why Breastfeeding is Important</a><ol><li>1.1 <a href="topic_1-1.html">Biochemistry</a></li><li>1.2 <a href="topic_1-2.html">Immunology</a></li><li>1.3 <a href="topic_1-3.html">Relative risks</a></li></ol></li>
        <li>2.0 <a href="topic_2-0.html">Communication Skills</a><ol><li>2.1 <a href="topic_2-1.html">Non-verbal</a></li><li>2.2 <a href="topic_2-2.html">Listening skills</a></li><li>2.3 <a href="topic_2-3.html">Building confidence</a></li><li>2.4 <a href="topic_2-4.html">An example</a></li></ol></li>
        <li>3.0 <a href="topic_3-0.html">Pregnancy Care</a><ol><li>3.1 <a href="topic_3-1.html">The feeding decision</a></li><li>3.2 <a href="topic_3-2.html">The barriers</a></li><li>3.3 <a href="topic_3-3.html">Physical preparation</a></li></ol></li>
        <li>4.0 <a href="topic_4-0.html">The Birth Experience</a><ol><li>4.1 <a href="topic_4-1.html">The first hours</a></li><li class="current">4.2 <img src="design/bullet_arrow_right.png" alt="*" title="You are here" /><a href="topic_4-2.html">Labor interventions</a></li><li>4.3 <a href="topic_4-3.html">Postnatal interventions</a></li></ol></li>
        <li>5.0 <a href="topic_5-0.html">Breastfeeding the Baby</a><ol><li>5.1 <a href="topic_5-1.html">Positioning Principles</a></li><li>5.2 <a href="topic_5-2.html">Breastmilk transfer</a></li><li>5.3 <a href="topic_5-3.html">Assessing breastfeeding</a></li></ol></li>
        <li>6.0 <a href="topic_6-0.html">A time to learn</a><ol><li>6.1 <a href="topic_6-1.html">Practical skills</a></li><li>6.2 <a href="topic_6-2.html">Breastfeeding messages</a></li><li>6.3 <a href="topic_6-3.html">Normal growth</a></li><li>6.4 <a href="topic_6-4.html">Sleep</a></li><li>6.5 <a href="topic_6-5.html">Psychological support</a></li><li>6.6 <a href="topic_6-6.html">Discharge planning</a></li></ol></li>
        <li>7.0 <a href="topic_7-0.html">Infant Challenges</a><ol><li>7.1 <a href="topic_7-1.html">Late preterm infant; Non-latching</a></li><li>7.2 <a href="topic_7-2.html">Hypoglycemia; Jaundice</a></li><li>7.3 <a href="topic_7-3.html">Supplementation</a></li><li>7.4 <a href="topic_7-4.html">Crying baby</a></li><li>7.5 <a href="topic_7-5.html">Inadequate weight gain</a><ol><li>7.5.1 <a href="topic_7-5-1.html">Feeding-line device at the breast</a></li><li>7.5.2 <a href="topic_7-5-2.html">Cup feeding</a></li><li>7.5.3 <a href="topic_7-5-3.html">Finger Feeding</a></li><li>7.5.4 <a href="topic_7-5-4.html">Bottle feeding</a></li></ol></li></ol></li>
        <li>8.0 <a href="topic_8-0.html">Maternal Challenges</a><ol><li>8.1 <a href="topic_8-1.html">Engorgement</a></li><li>8.2 <a href="topic_8-2.html">Nipple Pain</a></li><li>8.3 <a href="topic_8-3.html">Breast Problems</a></li><li>8.4 <a href="topic_8-4.html">Insufficient breastmilk</a></li><li>8.5 <a href="topic_8-5.html">Medical, Surgical Issues</a></li></ol></li>
        <li>9.0 <a href="topic_9-0.html">Promotion, Protection and Support</a><ol><li>9.1 <a href="topic_9-1.html">The International Code of Marketing of Breastmilk Substitutes</a></li><li>9.2 <a href="topic_9-2.html">The Baby Friendly Initiative</a></li><li>9.3 <a href="topic_9-3.html">Young Child Feeding</a></li><li>9.4 <a href="topic_9-4.html">Local initiatives</a></li><li>9.5 <a href="topic_9-5.html">Infant feeding in emergencies</a></li></ol></li>
        <li>10.0 <a href="topic_10-0.html">Closing session</a><hr /></li>
        <li class="appendix"> <a href="references.html">List of references</a></li>
        <li class="appendix"> <a href="contents.html">Course contents</a></li>
        <li class="appendix"> <a href="full.html">Print version</a></li>
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