Comparison of Cradle Hold Versus Football Hold Breastfeeding Positions after Cesarean Section in Primiparous Mothers

Abstract

Objective:

To compare cradle hold and football hold breastfeeding positions in terms of their effects on incision pain, breastfeeding success, and patient satisfaction among primiparous breastfeeding women after cesarean section.

Materials and Methods:

Sixty-seven breastfeeding primiparous women who underwent cesarean section were included in this crossover study. The women were instructed to use two different breastfeeding positions sequentially and change in pain intensity before and after each session were questioned. At the end of each session breastfeeding success (using LATCH breastfeeding charting system) and maternal satisfaction were assessed. In addition, mother's most preferred position was asked at the time of discharge.

Results:

A statistically significant increase was found in incisional pain score after breastfeeding with cradle hold position (p < 0.001), whereas no such change was observed in association with football hold position (p = 1.000). In contrast, total LATCH score was significantly better with cradle hold position when compared with football hold position (8.7 ± 1.1 versus 8.0 ± 1.1, respectively; p < 0.001). The two positions were similar in terms of maternal satisfaction scores (p = 0.082). Majority of the mothers (74.6%) preferred cradle hold position at the time of discharge.

Conclusions:

Although cradle hold position was associated with increased incision pain, it provided better breastfeeding experience and was more commonly preferred, which may be attributed to lesser familiarity with the latter position. Prenatal training should be provided to mothers on all breastfeeding positions. Further studies with larger sample size are warranted to better understand the relationships between incision pain after cesarean section, breastfeeding positions, and breastfeeding success.

Introduction

Breastfeeding is the most natural and an almost unequaled feeding method for healthy growth and development of infants.^1,2 Although breastfeeding is generally perceived as a pleasant experience, it may also lead to significant discomfort when improper breastfeeding positions and techniques are utilized.³

According to 2018 Turkish Demographic and Health Survey, caesarean sections comprise more than half (52%) of all births in our country.⁴ Incision pain is a major problem observed in women undergoing a caesarean section, leading to restriction of movements as well as inappropriate positioning of the infant when breastfeeding.⁵ Therefore, it is important for a mother with a surgical incision to be stress free and comfortable to ensure a pleasant breastfeeding experience both for the mother and infant alike.⁶

Achieving a proper breastfeeding position associated with minimal pain and maximum comfort during the early postpartum period should be considered a priority. Although the cradle hold represents the most common breastfeeding position used by mothers, the football hold breastfeeding is the preferred method after a cesarean section owing to reduced pressure on the abdomen.^3,7 However, as suggested in a study by Bency et al. involving Indian women, both nursing positions, that is, cradle hold and football hold, may be equally effective in terms of comfort.³

This study was undertaken to compare cradle hold and football hold positions in terms of their effects on incision pain, breastfeeding success, and patient satisfaction among primiparous breastfeeding women after cesarean section.

Patients and Methods

Patients

Among 250 mothers giving birth with cesarean section between December 2017 and March 2018 in our gynecology and obstetrics unit, 67 women meeting the inclusion criteria and consenting for participation were included in this study that compared two different nursing positions, that is, cradle hold and football hold, in terms of their effects on incision pain, breastfeeding success, and mother satisfaction. Inclusion criteria were age >18 years, being primiparous, delivery between 37 and 42 weeks of gestation, having a baby with normal birth weight (2000–4000 g), and having undergone caesarian section under spinal anesthesia. Exclusion criteria included the presence of complicated pregnancy (multiple pregnancies, pre-eclampsia, gestational diabetes, and placental abruption), fetal conditions precluding the normal course of breastfeeding (e.g., fetal anomaly, cleft palate, cleft lip, low birth weight, and intrauterine growth retardation), cesarean section under general anesthesia, areolar disorders (flattened, inverted, or cracked nipples), and other breastfeeding problems. Presence or absence of breastfeeding problems was ascertained by observing the sucking behavior of the newborns in both breasts within the first 30 minutes after delivery. The study protocol was approved by the local ethics committee (Date, November 23, 2017; no. 09/10-330-2017). All mothers provided written informed consent before study entry.

Assessments

Data collection was carried out by an investigator who performed face-to-face interviews as well as bedside observation. Twenty-four hours after the delivery, mothers were transferred from the intensive care unit to obstetric ward, where breastfeeding training was provided. At that stage, eight questions were directed to the mothers to inquire about sociodemographic characteristics (age, education, employment, and family type), information on breastfeeding (previous training and willingness for training), and newborn parameters (gender and bodyweight).

Owing to the crossover design of the study, the first breastfeeding position was decided by drawing of lots, followed by using the alternative breastfeeding position in the next breastfeeding session.

Before each breastfeeding, mothers were placed in the semi-Fowler position, and were supported by pillows to ensure a comfortable posture for breastfeeding. The pain intensity due to the incision was questioned and recorded using the Verbal Categorical Scale, where the pain intensity is scored in a four-point scale (1, mild; 2, moderate; 3, severe; and 4, very severe) based on responses from the mother.⁸ The first breastfeeding position as determined by the drawing lots was evaluated using LATCH breastfeeding charting system (L, latch on breast; A, audible swallowing; T, type of nipple; C, comfort of breast/nipple; and H, hold), in which each criterion is scored between 0 and 2 points to yield a maximum total score of 10. No cutoff points have been defined for LATCH, and higher scores indicate higher breastfeeding success.^9,10 After the breastfeeding, incision pain was reassessed using the Verbal Categorical Scale. Approximately 1–3 hours after this first breastfeeding session, the aforementioned steps were repeated for the second breastfeeding position.

After completion of the second breastfeeding episode, mothers were asked to assess the two breastfeeding positions (i.e., cradle hold and football hold) separately in terms of their satisfaction levels, which were scored between 1 and 5 (1, no satisfaction at all; 2, partly satisfied; 3, moderately satisfied; 4, rather satisfied; and 5, very satisfied). Mothers were revisited at postpartum 48 hours before discharge to inquire into the most preferred breastfeeding position and the reasons for the preference.

Statistical analysis

Statistical Package for Social Science (SPSS) 24.0 was used for statistical analysis. Descriptive data were presented as number (percent) or mean ± standard deviation, where appropriate. Normality of continuous variables was tested using Shapiro–Wilk test and non-normally distributed variables were compared using Wilcoxon signed-rank test. A p-value <0.05 was considered the indication of statistical significance.

Results

Maternal and fetal characteristics

Table 1 shows maternal and fetal characteristics. 31.3% of mothers were in the 25–29 years age group. Majority of the mothers were not working. Although only about one-third had received training on breastfeeding during pregnancy, majority (73.1%) were willing to receive consultancy on breastfeeding.

Table 1.

Maternal and Fetal Characteristics

Characteristic
Age, years (mean ± SD)	25.7 ± 5.8
Education, n (%)
No education	4 (6.0)
Only literate	4 (6.0)
Primary school	7 (10.4)
Secondary school	24 (35.8)
High school	14 (20.9)
University	14 (20.9)
Occupational status, n (%)
Not working	53 (79.1)
Working	14 (20.9)
Nuclear family type, n (%)	53 (79.1)
Received breastfeeding training, n (%)	23 (34.3)
Willing to receive breastfeeding consultancy, n (%)	49 (73.1)
Fetal birth weight, g (mean ± SD)	3425.7 ± 565.8
Male fetal gender, n (%)	34 (50.7)

SD, standard deviation.

Changes in incisional pain

After the breastfeeding sessions with cradle hold position, 25 (37.3%), 1 (1.5%), and 41 (61.2%) mothers reported increase, decrease, and no change in incisional pain, respectively. In contrast, none of the mothers reported change in incisional pain after the breastfeeding sessions with football hold position. A statistically significant increase was found in incisional pain score after breastfeeding with cradle hold position (p < 0.001), whereas no such change was observed in association with football hold position (p = 1.000).

LATCH and maternal satisfaction scores

Total LATCH score was significantly higher with cradle hold position when compared with football hold position (8.7 ± 1.1 versus 8.0 ± 1.1, p < 0.001), indicating better breastfeeding experience. In contrast, the two breastfeeding positions were similar in terms of maternal satisfaction scores (3.9 ± 1.0 versus 3.6 ± 1.1 for cradle hold and football hold, respectively, p = 0.082).

Maternal preferences

Majority of the mothers (74.6%) preferred cradle hold position at the time of discharge, mainly due to maternal/fetal comfort and habits. Table 2 shows the details of maternal preferences for breastfeeding position along with reported reasons.

Table 2.

Maternal Breastfeeding Position Preferences on Discharge with Reported Reasons

	n (%)
Preferred breastfeeding position
Cradle hold	50 (74.6)
Football hold	9 (13.4)
Both cradle and football hold	7 (10.5)
Lying position	1 (1.5)
Reasons for preferring cradle hold (n = 50)
I feel more comfortable	33 (66.0)
My baby sucks better	20 (40.0)
I get used to feed with this position	14 (28.0)
Reasons for not preferring cradle hold (n = 9)
I feel pressure on abdomen	5 (55.6)
I have pain during feeding	2 (22.2)
Reasons for preferring football hold (n = 9)
I feel more comfortable	8 (88.9)
I have less pain/less abdominal pressure	8 (88.9)
Reasons for not preferring football hold (n = 23)
My baby does not hold	4 (17.3)
The other is more well known	3 (13.0)
The other is more comfortable	3 (13.0)
Very difficult position	3 (13.0)

Discussion

In this study, we found that cradle hold position was associated with increased pain perception at incision site, whereas the football hold position was devoid of such an effect in mothers who gave birth with a cesarean section. Despite this finding, cradle hold position provided better breastfeeding success and the two methods were comparable in terms of mother satisfaction. Furthermore, most of the mothers reported a preference for the cradle hold position. Although the effect of breastfeeding position on breastfeeding efficacy is well known, only few studies have examined the effects of different positions. Accordingly, our literature search did not yield any studies investigating the comparative effects of cradle hold, that is, the most common breastfeeding position, and the football hold, that is, the position recommended after a cesarean section, on incision pain and breastfeeding success in mothers after a cesarean section.

In a Nigerian study, football hold position was reported to pose a reduced risk of maternal musculoskeletal disorders due to breastfeeding when compared with cradle hold and cross-cradle hold positions.¹¹ Aoki et al. examined six different breastfeeding positions (cradle hold, cross-cradle hold, football hold, lying-back, side-lying, and Australian hold) and concluded that the side-lying position was associated with the highest incidence of pain.¹² Puapornpong et al. compared incision pain with seated position versus side-lying position among 152 Thai mothers who underwent a cesarean section¹³ and found no statistically significant differences in pain scores on postpartum days 1 and 2. Of these two positions, although the side-lying position is able to prevent the pressure exerted by the weight of the newborn on mother's abdomen, seated position is associated with pressure on the incision site. However, the pain scores did not differ significantly.¹³ Since cesarean section is a major surgical procedure, pain is not an unexpected outcome. However, prolonged postpartum pain may adversely affect the breastfeeding process.¹⁴ In case of severe postoperative pain, appropriate body position for breastfeeding may be difficult to achieve, leading to delayed breastfeeding. This, in turn, may have an impact on the initiation of breastfeeding, ability of the newborn to grasp the nipple, and consequently the breastfeeding rate.¹³

In this study, comparison of breastfeeding success showed that the cradle hold position was associated with more successful breastfeeding experience, despite causing more pain. This finding is not surprising, given the fact that most females, before having their own child, have an opportunity to observe this position in other mothers as a successful breastfeeding technique. In contrast, it may be assumed that prenatal training on breastfeeding positions may allow the use of football hold position, especially in mothers with more intense pain. In the study by Bency et al., it was reported that mothers could try both cradle hold and football hold positions, regardless of the type of delivery.³ It has also been reported that the number of breastfeeding positions learned and practiced by the mothers at postpartum day 2 may affect the breastfeeding rate over the first 6-month period after birth. For example, Puapornpong et al. compared mothers who were trained for only one breastfeeding position with those who were trained for ≥2 breastfeeding positions, and found higher continuation rates of breastfeeding at 6 months in the latter group of participants.¹⁵ Also, in our study mothers perceived shorter duration of breastfeeding with football hold position, suggesting that more practice may be needed.

In our literature search, we could not identify any publications comparing LATCH breastfeeding success scores in cradle hold and football hold positions. However, in the study from Thailand by Puapornpong et al., the mean LATCH success score was 7.2 ± 0.7 in mothers nursing in seated position versus 7.1 ± 0.6 for those who nursed in side-lying position.¹³ At postpartum day 2, LATCH scores did not differ significantly between the two groups.¹³ This may be explained on the basis of the cultural differences as well as the comparison of two different positions than in our study.

The fact that LATCH breastfeeding success scores were ≥8 in both breastfeeding positions could be related with the use of spinal anesthesia and with the introduction of breastfeeding within one hour in all participating mothers in our study. Early introduction of breastfeeding within one hour of delivery has been reported to play an important role in the continuation and success of breastfeeding.¹⁶ Seventy-one percent of the children <2 years of age in Turkey are breastfed within the first hour after delivery.⁴ Use of general or regional anesthesia for cesarean sections is one of the factors that affect breastfeeding rates. In particular, the effect of general anesthesia is more prolonged, with mothers being too drowsy to hold and nurse their babies. Epidural or spinal anesthesia is generally preferred on the basis of reduced postoperative pain and absence of drowsiness, which increase the likelihood of early initiation of breastfeeding.¹⁷ All participating women in this study underwent cesarean section under spinal anesthesia and were able to nurse their babies within the first 30 minutes after delivery. This was a strength of our study.

During their hospital stay, mothers appeared to prefer the cradle hold position over football hold position despite its association with more intense pain. This was probably because mothers were most familiar with the cradle hold position. Similarly, in a study from Nigeria, 80.4% and 13.3% of the mothers were reported to prefer cross-cradle hold and football hold positions, respectively.¹⁸ In a group of Pakistani women, Rani et al. found that 70.8%, 21.3%, 5.8%, and 1.0% of the women used the cross-cradle, side-lying, cradle hold, and football hold positions, respectively.¹⁹ In D'Souza et al.'s study from India, cross-cradle hold was the most commonly reported breastfeeding position by mothers.⁶ Aoki et al. also reported that mothers generally utilized cradle hold, cross-cradle hold, or football hold positions for nursing in Japan.¹² As stated by Bency et al., Indian women also generally preferred to nurse in the cradle hold position.³ Therefore, it appears that cradle hold position is preferred over football hold position by the nursing mothers throughout the world. Possible reasons for this preference include the prominent status of the cradle hold position throughout history and recent times; social attitudes surrounding this status; and provision of limited information on other nursing positions by health care personnel, leading to increased familiarity of mothers with the cradle hold position.

In our literature search, we could not identify any studies reporting on the comparative satisfaction with cradle hold position versus football hold position among nursing mothers. However, in an Indian study by Bency et al., comfort/convenience of cradle hold and football hold position were compared in two respective groups of nursing mothers consisting of 30 participants in each, and these two positions were found to be equally effective.³ In Puapornpong et al.'s study from Thailand, satisfaction scores were higher for side-lying position as compared with nursing at seated position,¹³ which was explained on the basis of easier positioning of the baby in the side-lying position that could be maintained for longer durations of time. Also, mothers reported that they could get more rest when they used this position.¹³

According to Bency et al., mothers can see their breast and the baby more effortlessly in the football hold position, which is associated with a certain degree of comfort.³ Since this position allows better control of infant head, it was particularly recommended for mothers with flat or inverted nipples, or in babies with breastfeeding problems.³ Football hold position represents the most comfortable nursing position after cesarean section, due to its ability to prevent pressure on the mothers’ abdomen. In this position, the mother may more effectively guide her baby, due to better visualization of the nose and mouth of the baby. It has been reported that women giving birth with cesarean section are more likely to prefer the football hold position, since it is associated with lesser degree of abdominal pressure.³ In other nursing positions, a pillow may be placed over the incision site to reduce the pain.¹⁷

Effective breastfeeding relies on the correct position of the baby and correct grasping of the nipple. Training mothers on correct breastfeeding techniques is an important determinant of the successful breastfeeding.^2,20 Although mothers may experience pain and discomfort after cesarean section, breastfeeding should be started as soon as possible after delivery, and support should be provided to mothers for appropriate positioning of the baby.¹⁷ Nurses should also be aware of the limitations of the baby and mother, and relevant nurse care should be planned and implemented to achieve successful breastfeeding. In addition, consultation on different breastfeeding positions such as the football hold position should be given to mothers before delivery.

Limitations

Our study had several limitations. First, the study was carried out with primiparous mothers so as to eliminate bias based on previous experience, but this choice limited generalization. Furthermore, subgroup analyses concerning other parameters such as the demographic and clinical characteristics could not be undertaken due to small sample size.

Conclusions

Although the cradle hold position was associated with increased perception of pain at the site of cesarean section incision, this position provided a better breastfeeding experience. Mothers preferred the cradle hold position over the football hold position. One possible explanation for this preference involves lesser familiarity with the football hold position. Regardless of the position, the mother should feel comfortable for a successful breastfeeding experience. We believe that prenatal training should be provided to mothers on all breastfeeding positions (cradle, football, lying position, etc.). Mothers can adopt any one of these positions based on their comfort and habits. Further studies with a larger sample size are warranted to better understand the relationships between incision pain after cesarean section, breastfeeding positions, and breastfeeding success.

Footnotes

Authors’ Contributions

All authors have taken part in study design and conception, study conduction, writing the article, reviewing it, and revising its intellectual and technical content. All approved the final version and assume responsibility and accountability for the results.

Acknowledgments

The authors would like to thank the mothers and babies who participated in the research. The authors thank the lecturers in the master thesis evaluation jury.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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