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Formula Feeding After Emergency Cesarean Section and#195;and#162;and#194;and#8364;and#194;and#8220; A Descriptive Retrospective Cohort Study | OMICS International
ISSN: 2376-127X
Journal of Pregnancy and Child Health
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Formula Feeding After Emergency Cesarean Section – A Descriptive Retrospective Cohort Study

Sofia Zwedberg1,2*, Maja von Hofsten2 and Oskar Jurell2
1Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
2Department of Obstetrics, Karolinska University Hospital, Solna, Stockholm, Sweden
Corresponding Author : Sofia Zwedberg
Department of Women’s and Children’s Health
Division of Reproductive Health, Karolinska Institutet
Retzius väg 13 A, 171 77 Stockholm, Sweden
Tel: +46705453260
Received March 16, 2015; Accepted May 04, 2015; Published May 06, 2015
Citation: Zwedberg S, Hofsten M, Jurell O (2015) Formula Feeding After Emergency Cesarean Section – A Descriptive Retrospective Cohort Study. J Preg Child Health 2:159. doi: 10.4172/2376-127X.1000159
Copyright: © 2015 Zwedberg S, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Background: Breastfeeding rates in Sweden have decreased since the mid-nineties while the numbers of caesarean sections have increased. Infants delivered by caesarean section are breastfed to a lesser extent than infants born vaginally. The aim was to investigate the prevalence of formula supplement given to healthy newborns to first-time mothers who have undergone an emergency or immediate caesarean section (CS). Furthermore, we examined to what extent the infants received skin-to-skin contact (SSC) after delivery. Method: A descriptive retrospective study using data from a cohort of first-time mothers who received an emergency or immediate CS in 2009 at one of the largest hospitals in Stockholm, Sweden. Result: Seventy-eight percent of infants delivered by emergency or immediate CS received formula during their first three days of life. These infants had an Apgar score of >7 at 5 min and had no risk factors for receiving formula. Twenty-six percent had a medical indication for the supplementation given. The main documented reason unless medical indication was upon the request of the parents, twenty-four percent during the first three days. Conclusion: Even when we examine healthy full-term infants after an emergency caesarean section at primipara mothers and tried to exclude all risk factors for giving supplements we found that a quarter were in need of supplementation due to medical reasons. Another quarter got infant formula at the request of the parents. In half of the medical records documentation regarding if the infant had remained SSC with one of their parents after delivery was missing. SSC is a method and nursing intervention that may be significant regarding breastfeeding outcomes and supplementation feeding. To examine and evaluate nursing interventions, SSC and formula supplementation, documentation in medical records is essential.

Breast feeding; Infant formula; Caesarean section; Skinto- skin contact
Breastfeeding rates in Sweden have decreased since the mid-nineties [1], while the numbers of cesarean sections have increased. In the year 2009, more than 20% of all births were delivered by cesarean section (CS) in Stockholm County [2]. The positive health effects of breastfeeding for both mother and child has been proven, hence encouraging breastfeeding is justified [3,4]. Infants delivered by cesarean section are breastfed to a lesser extent than infants born vaginally [5]. Women delivered by emergency CS often have a delayed milk production [6,7]. This delay might be explained by physiological and psychological stress responses following emergency surgery [7]. Postoperative pain and pharmacological treatment after CS may also affect the mother’s ability to hold the child, thereby delaying breastfeeding [8]. The time lapse between birth and the first breastfeeding is longer after a cesarean section than after a vaginal birth [5,9,10]. The increased time lapse is partly explained by delayed skin-to-skin contact, SSC, [11]. Some theorize that the lower rate of breastfeeding after cesarean section is related to the delay of the first breastfeeding [12-14].
Cesarean section and delayed SSC has a negative effect on the maternal hormonal response regarding lactation [15]. Two days after birth, women delivered by CS have very few pulses of oxytocin and a flat pattern of prolactin during breastfeeding. This indicates a lower milk supply compared to women delivered vaginally who have had SSC with their infants [15]. A decrease of supplementation feeding has been observed in infants who experience SSC immediately after cesarean birth, when compared to children who are separated from their mother in the operating theatre [11].
The midwife is obliged to protect, promote and support breastfeeding [16] and the golden standard to initiate breastfeeding is uninterrupted SSC after birth [17]. Therefore, the midwife should promote and facilitate SSC in accordance with her knowledge and the midwives’ ethical code of conduct.
The amount of breast milk increases the more the child suckles [18]. When a child receives formula it will suckle less, decreasing the mother’s milk production. As a result, some mothers may distrust their ability to produce enough milk and therefore choose to partially breastfeed quite soon after birth. According to Häggkvist et al [19], children have given formula during their first week of life breastfeed for a shorter period of time than children who are not given formula. In addition, if the formula is given soon after delivery, the total breastfeeding period is reduced [19-21]. Therefore, infant formula should be noted in the medical record of both mother and child [22].
Since infants delivered by CS are at greater risk of receiving supplement formula, we wanted to explore if this is also true for healthy infants delivered by emergency or immediate cesarean section through study the prevalence of formula given to these infants. Few studies have examined whether breastfeeding is affected differently depending on whether the patient underwent an emergency or a planned CS.
The aim of this study is to investigate the prevalence of infant formula given to healthy newborns to first-time mothers who undergo an emergency or immediate CS. We also included the additional aim of examining to what extent the infants received SSC after delivery.
Materials and Methods
This is a descriptive retrospective study using data from a cohort of first-time mothers who have received either an emergency or immediate CS in 2009 at one of the biggest hospitals in Stockholm. The hospital had a total of 880 CS of 4577 births during the year 2009, including planned, emergency and immediate CS. The records of all first-time mothers who underwent either an emergency or immediate cesarean section, performed with epidural, spinal or general anesthesia, were reviewed.
Inclusion and exclusion criteria
The aim of this study was to describe the rate of infant formula given to healthy newborns after an emergency or immediate CS. Therefore children with a medical need of supplementation, diagnosed before or at the time of delivery, were excluded. To prepare the study’s inclusion and exclusion criteria we used the hospital’s guidelines for supplement feeding. These guidelines are mandatory in the hospital for giving supplement. We also decide to only include first time mothers, due to earlier experience of motherhood can do the mothers more calm and relaxed in their own decisions of supplements or not, to the infant.
Inclusion criteria: First – time mother, underwent either an emergency or immediate CS, delivered in week 37+0-41+6, infants with an Apgar score ≥7 at five minutes
Exclusion criteria: Not first-time mother, insulin-treated diabetes, growth retardation (weight <-2 SD for gestational age), heavy for the length (weight >1 SD higher than height SDS), malformation that hinder breastfeeding, complications or conditions that require care in a neonatal ward.
Data collection
Medical records were obtained from the data base Obstetrix using diagnosis codes. First, we searched for all records containing the diagnostic code for emergency or immediate CS during the year 2009. Out of the 880 CS performed during 2009, 407 were emergency CS and 77 were immediate CS. Thereafter, the medical records of emergency and immediate CS were scanned after our inclusion and exclusion criteria using existing diagnostic codes in the system of Obstetrix. This resulted in 208 medical records to review of primipara mothers. The records were obtained from the data base and were de-identified.
The 208 medical records were manually reviewed according to our inclusion and exclusion criteria, resulting in the exclusion of 57 medical records. Ultimately, 151 medical records were included in the study.
A protocol was established for the review of the medical records. In this protocol we noted the following for each medical record: A) whether the infant had received any supplement formula during their stay at the hospital. B) The indication for supplement feeding noted in conjunction with the first feeding. The first indication was noted. The indications were distributed either according to the hospital guidelines for supplement feeding (hypoglycemia, weight loss >10% of birth weight, jaundice treatment or mothers unable to breastfeed due to pharmaceutical treatment) or indications not represented in the hospital guidelines. Supplement feeding outside of the hospital guidelines included: prescribed by pediatrician without a specified medical cause, mother separated from the infant due to receiving care at postoperative or intensive care unit, the mother needs temporary relief from breastfeeding, supplement feeding according to the wishes of the parents and other reasons. The category “other reasons” was used for all supplement feeding that did not apply to the categories stated above. C) The time of the first supplement feeding divided into three categories: The first day, the second day and the third day or later. D) The timing of the first medical record entry regarding breastfeeding and whether the child at that point had breastfed or not. E) The timing of the first documented SSC between the infant and its parents.
All of the 151 medical records were reviewed separately by the authors MJ and OJ according to the established protocol. Each variable was transferred to a numerical value and entered into the protocol review template. In cases where the review differed between the authors, the medical record was reviewed once again. When the authors were not in agreement, a discussion was held until consensus regarding the interpretation of the record was reached. The data of aforementioned records was thereafter entered into the protocol. Statistical analysis was performed using IBM SPSS (SPSS v 18).
Ethical considerations
This study was performed as part of the thesis of two midwifery students at Karolinska University and did therefor not require a formal ethics committee approval, according to Codex rules [23]. The Head of the Clinical Department of Karolinska University Hospital approved the study; permit number 20101103. The study adhered to the guidelines governing nursing research in the Nordic countries [24]. Diagnosis codes were used to find relevant medical records. The records were de-identified before processing and analysis, securing the anonymity of all participants.
All but two mothers had initiated breastfeeding during the hospital stay, which means that 98.7% or 149 out of 151 children were exclusively or partially breastfed during their stay at the maternity ward. Two mothers did not initiate breastfeeding. In one case this was due to the mother’s pharmaceutical treatment and in the other the mother chose not to breastfeed.
Supplement feeding was common in the study group, 78, 1% (118 infants) were given infant formula on one or several occasions (Table 1). Only 21, 9% (33 infants) received no supplement feeding according to the records.
Supplement was given according to hospital guidelines to 26, 3% of the infants who received supplement feeding. The most common indication was hypoglycemia, followed by weight loss >10%. No infants in the study group were given supplement feeding due to phototherapy treatment of jaundice. The remaining 73, 7% of the infants receiving supplement feeding were given formula without adhering to hospital policy. The indications for supplement feeding identified were as follows: 1) The mother cannot breastfeed, for example due to separation of mother and child during the mother’s post-op care. 2) According to the parents request. 3) Relief for the mother, when the mother is too tired or does not have the strength to breastfeed. 4) Prescribed by pediatrician without a specified cause. 5) Other reasons, all remaining causes that could not be classified into the above categories. 6) Not specified.
The indications for supplement feeding are summarized in Table 2. Out of the 118 children who received formula, 44% (52/118) were introduced to supplement feeding during the first day after birth (Table 3). The results showed that the most common documented indication for supplement feeding during the first day was at the request of the parents (Table 4). Hypoglycemia was the indication for supplement feeding in 17% during the first day and was given according to hospital guidelines, while the rest of the supplement was given without the support of hospital guidelines. In 21% the indication was not documented. For the infants introduced to infant formula during the second day the most common indication was “Other reasons” (44%), followed by according to parent’s request (21%) (Table 4). The most common documented indication for supplement feeding within hospital guidelines was hypoglycemia. During the third day and later, weight loss>10% was the most common indication for introduction to infant formula (Table 4). The timing of the first documented breastfeeding observation varied between 1 and 47 hours after delivery. The median of breastfeeding observation was 4 hours after delivery for the 149 infants (2 were not breastfed). Just over a third of the infants had not yet breastfed at the time of the first breastfeeding observation. The majority of the infants (92/149) had breastfed at the first observation (Table 5). Documentation regarding if the infant had remained skin to skin with one of their parents was missing in 75 out of the 151 records. Only 37% (57/151) of the records stated that the infants had been placed skin to skin within two hours postpartum.
We found that 78% of the infants, born either with an emergency or immediate CS included in our study received supplementary formula within the first three days after delivery. This was a higher rate than we had expected considering that the mothers and infants were healthy, Apgar scores were >7 at 5 min and there were no underlying medical indications for supplementary feeding. It has been shown that women who have undergone a CS have lower levels of Oxytocin when compared to vaginally delivered women [15]. Parry et al [25] showed that CS increases the likelihood of supplementary feeding and several studies have found lower breastfeeding rates after CS due to delayed milk production [7,26].
The lower breastfeeding rates after CS may be a result of the increased length of time before the first breastfeeding [12-14]. The golden standard to facilitate breastfeeding is allowing the infant immediate skin to skin contact for at least one hour after birth [27]. The newborn is most likely to follow his/hers instincts and attach to the breast during this period. If the baby isn’t disturbed most of them follow nine distinct natural steps [28]. Crenshaw et al [29] found that if the newborn goes through all of the initial nine steps to the breast it increases the probability of exclusive breastfeeding upon discharge from the hospital. This strategy also increases the total duration of breastfeeding after a normal vaginal birth [30]. A recently published review article concluded that SSC had the potential to improve breastfeeding outcomes and maternal satisfaction even after a SC [31]. Hospitals generally do not enable SSC between mother and newborn after CS [31,32]. Impediments that limit SSC in the operating theatre can be overcome [11]. A potential explanation for the lack of SSC after a CS is a lack of knowledge regarding its benefits. Midwives are often well-informed of the advantages of SSC, but everyone is not aware of the importance of uninterrupted SSC until the first breastfeeding [17]. Many professionals are involved in a CS and there is a challenge in educating all of them about the advantages of SSC. The midwives sometimes find it easier to separate mother and newborn due to the lack of knowledge among other professionals in the operate theatre [32]. Hung and Berg [11] found that the professionals of the operating theatre were reluctant and resistant to promote SSC. However, they were more positive to this practice after undergoing education regarding SSC.
In this study all but two mothers initiated breastfeeding. The first breastfeeding observation noted in the medical charts occurred 1 to 47 hours after delivery, (mean 4 hours). At the first observation, one third of the infants had not attempted suckling yet. In half of the medical records we could not find any documentation regarding SSC. We found this remarkable considering the evidence of positive benefits of SSC. It helps the newborn maintain thermoregulation [33,34], blood glucose levels [30,34] and also helps the baby reduce the stress of being born [35]. Twenty-six percent of the newborns in our study received supplementation due to a medical need, the most common reason being hypoglycemia. This raises questions: Could this be prevented if the children had been given the opportunity to have SSC to a greater extent after CS? A decrease of supplementation feeding has been shown in infants who experience SSC immediately after cesarean birth when compared children who are separated from the mother in the operating theatre [11].
In this study, 44 percent of the supplemented newborns were introduced to supplement formula during the first day. According to Swedish guidelines, the indication for giving supplementation should be documented in the medical records [22]. However, in one fifth of the medical records no indication was given. In almost a third of the medical records the indication for introducing supplementation was the wish of the parents. Why parents have this wish is unclear and demands further investigation. Our hypothesis is that if SSC was implemented to a higher degree, the parents would feel more calm and satisfied with the infant’s behaviour. Both general care and breastfeeding are interactional in nature and can be regarded as the outcomes of a “negotiations process” triggered by interactive initiatives of the infant and the caregiver’s interpretations and responses thereto. A parallel negotiation process is evident between a mother and her midwife [36]. Both caring and non-caring behaviour may influence women’s experiences of their infants, as well as their experiences of motherhood [37]. Immediate or early SSC after CS, can help mothers establish a connection to their infants [11,38], and requires support from the midwife.
Reviewing medical records retrospectively imposes certain limitations. The result is dependent on how well the studied phenomenon is described in the records. In our review supplementation according to medical guidelines was well documented and therefore easy to distinguish and present. Reasons for giving supplementation were incompletely described if there were no medical reason. This reflects a culture where the medical perspective is superior to the nursing perspective [39]. A large share of supplement formula was given according to “other reasons”. This indication was often documented vaguely and was difficult to classify.
Since the study population received care at a particular hospital there are limitations regarding generalize ability of our results. The authors are aware that the result may reflect this hospital’s culture regarding supplementation, and variations between hospitals may be considerable.
Infants delivered by emergency or immediate CS to first-time mothers, who had an Apgar score of >7 at 5 min and no other risk factors for supplement feeding still receive supplement formula. During their first three days, 78 % received infant formula at the hospital. Twenty-six percent of these infants had a medical indication for the supplementation given, the most common one being hypoglycemia. The main reason and indication for giving formula was upon the request of the parents. The medical records presented very little documentation regarding skin to skin care, a nursing intervention that may be significant regarding breastfeeding outcomes.
Health professionals should facilitate SSC between parent and newborns to the extent possible and further studies are needed to evaluate if SSC can reduce the rate of supplementation after emergency or immediate CS. If the mother due to medical reasons is unable to have SSC, the partner should be encouraged to SSC. The nursing interventions should also be clearly documented in the medical records.



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