Arturo Giustardi

Elective Cesarean Delivery: Does It Have a Negative Effect on Breastfeeding?

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.

Impact of anxiety in the puerperium on breast-feeding outcomes: role of parity.

Objective: Studies in animals indicate that stress and anxiety can depress lactation, but there is much less information available concerning humans. We aimed to determine whether maternal anxiety in puerperium, potentially exacerbated by the primiparity inexperience, has a negative impact on breast-feeding outcomes. Subjects and Methods: The state-trait anxiety inventory Y form (Spielberger, 1983) was administered to a total of 204 mothers, 101 primiparae, and 103 pluriparae on the third to fourth day postpartum. Results: We found that primiparae had state anxiety (T) scores significantly higher than pluriparae (44.57 ± 5.85 vs 43.28 ± 7.10, P = 0.03). Increased state anxiety levels impaired breast-feeding success. In addition, in the logistic regression analysis model used to assess factors predictive of breast-feeding longer than 3 months, maternal state anxiety was the most significant risk factor (odds ratio 0.99; 0.88–0.98, P < 0.01). Conclusions: In the puerperium, anxiety, potentially exacerbated by primiparae inexperience, is associated with impaired lactation. Alleviating maternal anxiety could be beneficial for stimulating breast-feeding in more vulnerable women.

Mother infant relationship and bonding myths and facts

Mother-infant relationship has always interested researchers worldwide. This paper reviews the development of the concept of mother infant bonding through the years.

Impaired lactation performance following elective delivery at term: role of maternal levels of cortisol and prolactin

Objective: Lactation performance depends on stress surrounding labor and delivery, and it is likely to be different in women who underwent elective cesarean delivery (ECD) or vaginal (VD). The aim of this study was to assess the relationship between cortisol and human prolactin (hPRL), following ECD and lactation performance, from the delivery room to the 6th month of life. Methods: A total of 106 mothers were consecutively enrolled: 38 after ECD, 28 after emergency cesarean delivery (EmCD), and 40 after VD. Results: Basal stress-, lactogenic-hormones, cortisol, and hPRL were comparable on day 3 postpartum in all the women. Multivariate analysis indicated that ECD has a negative impact (OR; 95% CI) on breastfeeding prevalence on the seventh day (0.14; 0.0–0.44, p = 0.008) and at third month post partum (0.19; 0.05–0.71, p = 0.05) in comparison to VD. In addition, hPRL levels proved to have a statistically significant role in early breastfeeding (1.01; 1–1.01, p = 0.002). Conclusions: ECD is a risk factor for successful lactation performance. This information should be provided to mothers and caregivers for extra breastfeeding guidance.

Body image in breastfeeding women with depressive symptoms: a prospective study

Abstract The purpose of this prospective study was to investigate the relationship between body image perception and breastfeeding in puerperae with postpartum depression symptoms. The participants (147 healthy puerperae) completed The Edinburgh Postnatal Depression Scale (EPDS) and the Body Uneasiness Test (BUT-A and BUT-B), investigating body image perception and specific worries about particular body parts or functions. One month after discharge, new mothers participated in telephone interview concerning postpartum lactation practices. The subset of puerperae with EPDS score >9 also participated in psychological EPDS and BUT 6-month follow up. Mothers with EPDS score >9 (28/147, 19.04 %) had significantly higher scores on BUT-A Global Severity Index (0.69 ± 0.64 versus 0.37 ± 0.31, p < 0.0001) and on BUT-B Positive Symptom Distress Index (0.74 ± 0.57 versus 0.41 ± 0.42, p < 0004). In addition, the mothers with symptoms of depression were more likely (1:2) to interrupt full breastfeeding in the first month postpartum. At the 6-month follow up, the subset of new mothers with depression symptoms maintained elevated BUT-A and BUT-B scores, while EPDS >9 persisted in one-third of these. In conclusion, mothers with symptoms of depression have longlasting negative body image perception, persistent depressive symptoms, and they interrupt early full breastfeeding.

Breastfeeding success after laryngeal mask airway resuscitation.

BACKGROUND Positive pressure resuscitation by laryngeal mask airway (LMA) may expose the neonate to gas leak and gastric air insufflation, influencing postnatal gastrointestinal adaptation and breastfeeding success. METHODS Term neonates admitted to regular nursery of the Department of Pediatrics of Padua University (Italy), from January 2005 to December 2005, after positive pressure resuscitation by LMA (Group A, 50) were compared with neonates who required positive pressure resuscitation by endotracheal tube (ETT) (Group B, 13) and to non resuscitated control neonates, matched for gestational age, (Group C, 100). RESULTS Gestational age and birth weight were comparable among Group A, B, and C neonates. In addition, their ages at the first feeding and those of the first meconium emission were comparable. Diversely, LMA-, and ETT-resuscitated neonates presented a reduced exclusive breastfeeding rate at discharge and an increased hypoglycemia occurrence during postnatal adaptation. Moreover, ETT-resuscitated neonates presented a lower Apgars score at 1 min, a significant increased regurgitation rate, and a delayed urine emission in comparison to LMA-resuscitated neonates. CONCLUSION LMA- and ETT-positive pressure resuscitation impair postnatal gastrointestinal adaptation and breastfeeding success at discharge with equal frequency and to similar degree in term neonates. Regurgitation reflex is instead, enhanced after ETT-resuscitation.

Influence of elective and emergency cesarean delivery on mother emotions and bonding

BACKGROUND Previous studies have indicated that mode of delivery could have a negative effect on bonding. AIMS To assess feelings towards newborn infants in mothers who delivered by cesarean delivery, elective (ElCD) or emergency (EmCD). STUDY DESIGN This observational prospective study took place at the Division of Perinatal Medicine, Policlinico Abano Terme, Abano Terme, Italy, from September 2014 to April 2015. SUBJECTS The sample included 573 puerperae divided into three groups: women undergone ElCD (n=73; 12.73%), women undergone EmCD (n=81; 14.13%) and women who underwent vaginal delivery (VD) (n=419; 73.12%). OUTCOME MEASURES The instrument used was the Mother-to-Infant Bonding Scale (MIBS; Taylor et al., 2005), a self-report test to measure mothers feelings towards her baby. High scores indicate worse mother-to-infant bonding and a score≥2, established as cut-off, indicates an altered bonding. RESULTS The mean MIBS global score was 0.50±1.05 in the VD mothers, 0.67 (±1.14) for ElCD mothers and 0.92 (±1.05) for EmCD mothers, resulting significantly higher in EmCD mothers (p<0.001). The percentage of altered bonding (Score≥2) in the three groups was of 11.21% (n=47) in VD, 17.80% (n=13) in ElCD and 23.45% (n=19) in EmCD, significantly higher in EmCD women (p<0.006). In addition, EmCD mothers scored significantly higher Joyful (0.074±0.26 vs 0.185±0.39; p<0.005) and Disappointed (0.063±0.25 vs 0.123±0.36; p<0.008) subscales. CONCLUSIONS It was found that EmCD negatively affects mother bonding and opening emotions, and originates in mother feelings like sadness and disappointment for the unplanned delivery evolution.

Pain in newborn

Recent scientific studies have added more and more consistent evidence that the newborn, even if preterm, is very sensitive to the nociceptive stimulus. The baby responds with a well known physiological, metabolic and hormonal reaction, that, if repeated, may lead to short and medium term negative effects on the newborn. This vulnerability to painful stimulus, especially in preterm infants, can be explained by neurophysiological mechanisms. In spite of a well developed sensory apparatus for nociception, the descending inhibitory systems and their neurotransmitters responsible for nociceptive afferents, are deficient and immature until after the term birth. Behavioral changes and reductions in the volume of some sensitive brain areas were observed in ex preterm infants admitted to the neonatal intensive care unit; the modifications were very similar to those seen in experimental model of rat with same gestational age, exposed to early and repeated painful stimulus [1]. We consider as environmental interventions all steps that can reduce stress in the baby during a painful procedure. A variety of non pharmacologic pain-prevention and relief techniques have been shown to effectively reduce pain from minor procedures in neonates. These include use of oral sucrose/glucose, breastfeeding, non-nutritive sucking, kangaroo care, facilitated touch (holding the arms and legs in a flexed position), swaddling, and developmental care [2]. The involvement of the mother is recommended through skin-to-skin or breast-feeding during a single sampling. Several studies have shown how breastfeeding during a painful procedure reduces the stress in newborn [3]. The prevention of pain in neonates should be the goal of all caregivers, because repeated painful exposures can have deleterious consequences. Neonates at greatest risk of neurodevelopmental impairment as a result of preterm birth are also those most likely to be exposed to the greatest number of painful stimulus in the NICU. We have to improve strategies for routinely assessing pain, minimizing the number of painful procedures performed, using pharmacologic and non pharmacologic therapies for the prevention of pain associated with routine minor procedures, and eliminating pain associated with major procedures.

Stress during pregnancy, gestational weight gain, and body mass index

We read with interest the article by Kominiarek et al. [1] designed to evaluate the association between prenatal stress by Life Experiences Survey (LES) [2] and gestational weight gain (GWG), defined according to IOM [3]. Stress appears to be associated with GWG and stress reduction interventions during pregnancy may be a novel way to promote appropriate GWG, with the potential to influence the obesity epidemic across generations. These findings are clinically relevant because it highlights a consistent group of pregnant women that may benefit from stress reduction interventions, with the potential to promote appropriate GWG and, meeting their GWG goals, to reduce gestational obesity development. However, we feel it is also necessary to bring to attention some considerations emerging from the method used for this original analysis. Firstly, GWG is variable from woman to woman and frequently yields a discrepancy between prepregnancy and gestational BM. However, the data from Kominiarek et al. [1] study reported only pre-pregnancy obesity rates among inadequate, adequate, and excessive GWG and the observed results may not apply to a wider number of women moving from a body mass index (BMI) range category to another or with gestational obesity. Secondly, stressful life changes may have a different impact among underweight, normal weight, overweight, and obese women, and yet among obese class I to III women. Most importantly, if psychological factors do affect GWG disorders, then targeting these modifiable factors with directed interventions may prove to have a greater impact on both abnormal GWG and gestational obesity than the current interventions that primarily focus on health behaviors such as diet and exercise. Nevertheless, understanding these associations is complex, because prepregnancy BMI and its shift across gestation are closely linked to lifestyle factors and genetic traits that are also correlated with maternal physiological and social characteristics. Finally, although these characteristics are important, psychosocial factors such as stress and eating disorders have been shown to be associated with a variety of adverse behaviors, including those related to body weight disorders, and should therefore be further studied in the context of GWG and obesity across gestation [3, 4]. In conclusion, the problem of pre-pregnancy and gestational obesity is now recognized as a major public health concern. The study by Kominiarek et al. [1] has the relevant merit to elicit the scientific interest on a novel way, based on stress reduction interventions, to promote appropriate GWG and better perinatal outcomes. Interventions shown to reduce rates of excessive GWG have the potential to influence the obesity epidemic across generations [5]. Nevertheless, we still need to evaluate the contextual relevance of GWG determinants in different BMI prepregnancy women categories to understand the direction and magnitude of the stress effect on gestational obesity, in low income and developed countries.

Prepregnancy Body Mass Index shift across gestation: primary evidence of an association with eating disorders

Abstract Objective: Previous studies indicated that gestational weight gain-related disorders share many similarities with feeding and eating disorders (EDs). Design: To examine the association of prepregnancy Body Mass Index (BMI), defined according to 2009 Institute of Medicine (IOM), and its shift across gestation with symptoms of feeding and EDs, defined by EDE-Q. Setting: This prospective cohort study took place at the Division of Perinatal Medicine of Policlinico Abano Terme, Italy, from Jannuary 2015 to October 2015. Population and sample: The sample included 655 healthy at term puerperae. Main outcomes measures: We correlated gestational BMI in different women categories to EDE-Q Global score and Restrain, Eating concern, Shape concern, and Weight concern subscales, by Spearman’s correlation test. Results: Among 655 women, 59 (9.0%) were categorized as underweight, 463 (70.7%) normal weight, 98 (15.0%) overweight, and 35 (5.3%) as obese in prepregnancy period. At the end of gestation, underweight women category disappeared, normal weight women lightened to one third, overweight women tripled, and obese women doubled. At the same time, EDE-Q global scores increased from normal weight (0.25 ± 0.41), to overweight (0.47 ± 0.58), and to obese (0.72 ± 0.70) puerperae. In addition, EDE-Q global scores were significantly correlated with gestational BMI increase in Global score (rho = 0.326; p < .001) and in the four subscales: Restrain (rho = 0.161; p < .001), Eating concern (rho = 0.193; p < .001), Shape concern (rho = 0.335; p < .001), and Weight concern (rho = 0.365; p < .001), respectively. Conclusions: It was found that the shift of woman BMI across an uncomplicated pregnancy is a warning indicator of unhealthy eating and feeding symptoms.