Comparison of Breast Crawl Between Infants Delivered by Vaginal Delivery and Cesarean Section

Abstract

Background:

Exclusive breastfeeding is the single most cost-effective intervention to reduce infant mortality. Breast crawl (BC) is deemed a natural way for the baby to behave immediately after delivery. BC is the method that may help initiation of breastfeeding in the most natural way. The aim of this study is to compare successful BC between neonates born through vaginal delivery and those born through cesarean section (CS) and factors associated with a positive outcome.

Methods:

Participants were mothers who delivered their babies during the period of October 2012 to December 2013 in Alzahra Hospital in Tabriz, through cesarean or vaginal delivery. Infants were placed prone on their mothers' abdomen after delivery.

Results:

Data show that babies delivered through vaginal delivery had significantly more success in BC than babies born through the cesarean delivery (88.01% versus 11.21%). Moreover, babies in the CS group used significantly less time to achieve BC (45 versus 28 minutes).

Conclusion:

There is a remarkable difference in completion and length of time used to achieve BC between infants with regard to the delivery mode. Encouraging BC in all dyads, especially in cesarean births, may unduly delay the infant's first breastfeed.

Introduction

The World Health Organization (WHO) recommends exclusive breastfeeding without any food or liquid for the first 6 months of life and continued breastfeeding up to 2 years of age.^1,2 Exclusive breastfeeding is the single most cost-effective intervention to reduce infant mortality in developing countries.³ Edmond et al. in Ghana showed that 16% of neonatal deaths can be prevented by breastfeeding infants from day 1, rising to 22% if breastfeeding begins within 1 hour of birth.⁴ Fewtrell in a review article suggested that breastfeeding had several beneficial effects on later cardiovascular risk factors, including blood pressure and plasma lipid profile, reduces the risk of childhood obesity, improves cognitive development, and reduces the incidence of familial atopy.⁵

Some professionals believe breast crawl (BC) is the most natural way for the baby to behave immediately after delivery. In 1987, Swedish authors were the first to describe a sequence of prefeeding behaviors that was disrupted in children who had undergone gastric suction. Later, in 2011, the same group of authors further elaborated on this observation and outlined nine predictable phases. In this observational study based on 28 healthy term vaginal births, 15 (54%) began suckling spontaneously after 120 minutes. They hypothesized that going through the “nine behavioral phases” results in “optimal self-regulation.”⁶

BC has been described as an instinctive postpartum behavior for full-term babies after a vaginal birth. In majority of Iranian hospitals, babies are separated from their mothers immediately after birth in order for the nurse to complete routine care such as measurement of weight, height, head circumference, wrapping procedures, and injection of vitamin K. One of the most important steps of “Ten Steps to Successful Breastfeeding” published by UNICEF includes encouraging skin-to-skin contact of mother and neonate during first half hour after birth and breastfeeding during first 1 hour after birth.⁷

The aim of this study is to compare successful BC between neonates who are delivered by vaginal delivery or cesarean section (CS) and factors associated with a positive outcome.

Methods

This study was approved by ministry of health and medical education ethics committee. The sampling method in this study was purposeful sampling.

Participants were mothers who had either an elective cesarean delivery or an unmedicated noninstrumented vaginal delivery during the period October 2012 to December 2013 in Alzahra Hospital. This hospital is a university-affiliated hospital in Tabriz, State of Eastern Azerbaijan. Mothers were considered eligible if they had no preexisting physical or psychiatric condition. None of the mothers with vaginal delivery received labor analgesia. Infants in both groups were excluded if they were born before 37 or after 41 weeks gestation and if there were multiple births and delivered by operative vaginal delivery, including vacuum. Furthermore, the babies who had a 5-minute Apgar score less than 7 and either had medical complications at birth or were meconium stained were considered ineligible.

Deliveries were classified as vaginal and elective CS. Vaginal delivery was defined as spontaneous onset, unaugmented, without obstetrical intervention, and without regional anesthesia, although episiotomy with analgesia using Lidocaine 2%, 5 cc was indicated as the vaginal delivery. All of the participants in the CS group were planned CS (without labor), for each mother in the CS group used epidural analgesia. Indication for elective CS was repeat CS. The participants in both groups did not receive any type of pain relief during BC period.

Breast Crawl

The neonate was placed on the abdomen and mother's chest so that the baby's toes touched on symphysis pubis of mother after vaginal delivery, but before expulsion of placenta, even while the mother's episiotomy was being sutured. The infant was given 60 minutes to independently reach the nipple and take at least one suck. He/she was covered by a semi-warm towel and dried on the mother's chest.

For mothers who had cesarean delivery, the neonate was placed on the mother's abdomen immediately after the return from recovery room (15–20 minutes after expulsion of neonates), without washing. During this 15–20 minutes, the neonate was dried by semi-warm towel, cleared mucus from the mouth and nose gently with a suction bulb (manual polar), and the cord was cut. After that, neonate was placed on a warming bed and an identification tag was attached to the wrist of infant.

BC procedure in recovery room was the same of delivery room exactly. Moreover, a nurse anesthetist controlled mother's medical condition, including o2 saturation and consciousness; however, this nurse was not involved in BC.

In both groups, mother and unwashed baby were covered with a blanket, to keep warm, while skin-to-skin contact continued. For each delivery, a midwife observed mother and the baby and BC process. If the mother was unable to tolerate BC for more than 10 minutes and objects twice, the midwife removed the baby from the mother's chest.

The criterion of successful BC in this study was for the baby to reach the nipple and have one or two effective sucking not complete sucking. Each mother was only allowed to put her hand on her baby's back. Mothers were not allowed to handle their babies; whenever baby was slipping, the midwife would straighten the baby. We choose this strict strategy to avoid any bias.

Once the babies were separated from their mother, regardless of their success in BC, they were weighed and their heights were measured and Vitamin K was administered intramuscular (IM). The babies were then returned to their mothers and the nipple was placed in the baby's mouth under the supervision of a midwife to ensure effective lactation of the baby.

Data were collected from the records and interview, by the trained midwives. The indicated time for BC was 60 minutes. If a baby could not achieve the nipple during 60 minutes, it was indicated as “unsuccessful” in the BC.

Statistical analysis

Data were analyzed using Statistical package for the social science (SPSS) Version 16. Logistic regression models in survey analysis mode were used. p-Value of <0.05 was considered significant.

Results

There were 401 mother–infant Dyads who were eligible for implementation of BC. Demographic and clinical characteristics of the dyads with regard to delivery mode are shown in Table 1. Mean (SD) age of mothers who participate in this study was 29.3 (6.3) years. All of the neonates were born between 37–41 weeks.

Table 1.

Sociodemographic Characteristics of the Participants in the Vaginal Delivery and Cesarean Section Groups

Variable	Vaginal delivery group (n = 292), n (%)	CS group (n = 107), n (%)	p
Age^a	29.62 (6.3)	31.12 (5.9)	0.06
Gravida^a	1.8 (1.2)	1.9 (0.88)	0.660
Abortion^a	0.22 (0.51)	0.19 (0.47)	0.761
Weight,^a g	3543 (172.25)	3227 (63.34)	0.549
Height,^a cm	50.15 (2.37)	49.03 (2.87)	0.019^b
Head circumference,^a cm	34.31 (1.40)	34.79 (1.47)	0.084
Employment, housewife	275 (94.17)	99 (92.52)	0.228
Education
Illiterate	38 (13.01)	12 (11.21)	0.332
Primary and junior high school	158 (54.10)	53 (49.53)
Senior high school and college	81 (27.73)	35 (32.71)
Academic	15 (5.13)	7 (6.54)
Infant's sex			0.823
Female	137 (46.91)	48 (44.85)
Male	155 (53.08)	59 (55.14)
Current cigarette smoking	3 (1.02)	1 (0.93)	0.196
Receiving breastfeeding education during pregnancy	166 (56.84)	61 (57.00)	0.261
Having previous breastfeeding experience	122 (41.7)	62 (57.9)	0.062
Successful babies in the BC within 60 minutes	257 (88.01)	12 (11.21)	<0.001^c
Time consumed for BC^a	45 (28)	28 (12)	<0.001

Data are reported based on mean (SD).

Independent t test.

Pearson's chi square.

BC, breast crawl; CS, cesarean section; SD, standard deviation.

BC was started for all neonates. However, 291 neonates (72.6%) could achieve it completely. One hundred and 10 babies (27.4%) could not succeed in BC within 60 minutes. The average time taken by neonates to initiate BC (from the time the baby was set on the mother's abdomen until he/she reached the nipple) was 40.4 (19.7) minutes (SD). Data show that the babies delivered through vaginal delivery had significantly more success in BC than cesarean delivery (88.01% versus 11.21%, p < 0.001). Out of 95 unsuccessful dyads in the CS group, 89 (93.6%) mothers could not tolerate weight of infant due to abdominal pain. Six mothers did not accept BC process due to fear of CS scar dehiscence. In the vaginal delivery group, the main reason for lack of success in BC was unfavorable feel due to weight of infant put on mother's abdomen. Only three (8.6%) mothers could not tolerate BC process due to pain in the vaginal delivery group.

There was no significant difference in average time of BC according to infant's sex, mother's age group, gravida, and maternal education. However, babies in the CS group had significantly less time consumed for BC (28 versus 45 minutes, p < 0.001).

Factors associated with successful BC

Multivariate analysis and logistic regression models showed that mother's “prior education about breastfeeding,” “prior experience in breastfeeding,” and “vaginal delivery” increased neonate's success in the BC in both groups. Maternal age, educational level, and employment were not associated with the BC (Table 2).

Table 2.

Multivariate Analysis for Successful Breast Crawl

	Odds ratio (95% CI)
Variable	Vaginal delivery group	CS group
Maternal age
<25	1.0 (0.30–3.1)	1.2 (0.41–4.2)
25–30 (reference)	1.0	1.0
≥31	0.7 (0.3–1.7)	0.9 (0.51–2.3)
Maternal education
Low	1.2 (0.5–2.9)	0.9 (0.3–3.3)
Middle	1.9 (0.7–4.8)	0.7 (0.2–4.3)
High (reference)	1.0	1.0
Previous breastfeeding experience
No	1.0	1.0
Yes	5.2 (1.7–16.4)^a	5.3 (0.9–17.8)^a
Receiving breastfeeding education during pregnancy
No	1.0	1.0
Yes	7.3 (2.3–20.8)^a	6.3 (1.8–19.6)^a
Mother's employment
Housewife	1.0	1.0
Employed	1.1 (0.5–3.5)	1.5 (0.7–5.3)

p-Value >0.05.

CI, confidence interval.

Discussion

This study aimed to compare BC with regard to delivery mode and associated factors. In the present study, nearly 70% of babies could conduct BC successfully within 60 minutes. According to Verandi, breast odors—in the absence of additional maternal cues—are sufficient to guide the baby toward the source of the odor.⁸ This suggests that olfactory stimulation stimulates early nutritive behavior and the initiation of the BC.

Although more than two-thirds of our neonates completed the BC, it seems that the prevalence of success of the babies in the BC was not as high as in the Girish study. He showed that 94% of the babies⁹ completed BC within 60 minutes. However, our result was in line with other research. In the study of Bhagat, 22 term healthy infants with normal vaginal delivery, 8 with vacuum extraction, were given to mother immediately after birth. Sixty-eight percent started the BC within 15 minutes. Sixteen (73%) “completed” in 55 minutes, but only 6 (27%) of all babies fed on their own.¹⁰

Other published data on the prevalence of successful BC are different from 54% in Wistorm's study to 63% in Richard's study.^6,11–13 In the present study, the maximum time allocated for BC was 60 minutes. It is possible, that given more time (90 minutes), more babies would successfully achieve the nipple.

Prevalence of BC in the CS group was significantly lower than the vaginal group. It is well known that cesarean section has a marked negative effect on breastfeeding during the early postpartum period.^14–16 After a CS, fasting, analgesia, stress, and anxiety can effect a mother's comfort with BC.¹⁷ In the study of Znardo, elective cesarean was known as an important risk factor for breastfeeding failure in the delivery room or during hospital stay.¹⁴ In our study, the main reason of BC failure in the CS group was pain and majority of mothers who could not tolerate BC process, complained of pain. This may be due to the lack of adequate analgesia immediately after CS in the recovery room. A few percent of mothers did not allow initiating BC due to fear of CS scar dehiscence.

Although BC may be one method of initiating breastfeeding, one needs to consider potential risks if the first feed is delayed. According to Parker, starting milk expression after the first hour may negatively impact subsequent production up to 6 weeks.¹⁸

Regarding the vital role of early initiation of breastfeeding, insistence on BC and delay of breastfeeding especially in women who had undertaken CS or mothers of vulnerable infants such as preterm infants should be reviewed.

The average time of BC in our study was 45 minutes. This is in line with the Girish's study (40 minutes).⁹ According to Widstrom, the whole activity of BC takes about 35–50 minutes.⁶ There is no difference between women who undertook vaginal delivery with or without episiotomy according to completion of BC and average time.

To our surprise, the average time taken for BC in the CS group was significantly lower than the vaginal group. Like another study¹⁹ in our hospital confirmed that women who gave birth by CS experienced a longer elapsed time between giving birth and putting their babies to the breast than women who gave birth vaginally. It is possible, this elapsed time caused to being hungry or more alertness of neonate.

Aside from being slightly older by about 20 minutes, other potential factors related to this shorter time frame remain unclear. It is probable that if baby was put on the mother's chest immediately after CS, the obtained results would be different.

The results of logistic regression model indicated that maternal educational level, employment, and economical status did not show significant association with BC in both groups.

Authors in their comprehensive literature review could not find relevant references in this area, so they could not conduct any comparison.

Factors positively influencing BC were “having information about importance of breastfeeding” and “ having prior experience of breastfeeding” in both groups. It is well known that support and education are among the most important factors for a successful breastfeeding.

According to Thulier study, training about the process of breastfeeding and breast milk production, as well as proper management of breastfeeding, can help to prevent both real and perceived inadequacies in milk supplies.²⁰

Some limitations in our study should be noted. In the present study, only full-term and healthy infants were studied, so we cannot generalize the result of this study to a special condition such as preterm infants or twins. Compared to other studies, large sample size and comparative design of study could be mentioned as a strength point of this research.

Conclusion

The results showed that there is remarkable difference in completion and the length of BC between infants with regard to delivery mode. This study addressed only full-term infants. Less mature infants may need gentle cue-based assistance, as may those who exhibit delays in arousal and nutritive behavior. A possible delay in the first feed in cesarean births and compromised or preterm infants needs further consideration and study.

Footnotes

Acknowledgments

The authors thank the participating mothers and the midwives of Alzahra Hospital for their collaboration. This project had not received any financial support.

Disclosure Statement

No competing financial interests exist.

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