The effect of pain, stress, and cortisol during labor on breastfeeding success

Investigating the association between labor pain and cessation of breastfeeding

Mothers encounter several challenges to sustain breastfeeding until the recommended 6 months of age. There is limited evidence on the impact of women's labor pain experiences upon cessation of breastfeeding. We aimed to investigate the association between women's labor pain experiences, intrapartum interventions, and pre-birth psychological vulnerabilities and cessation of breastfeeding. This was a secondary analysis of a clinical trial conducted in a tertiary hospital in Singapore between June 2017 and July 2021. Data were obtained from participants, electronic records and surveys administered before delivery, and postpartum 6-10 weeks. A total of 624 (76.8%) women were still breastfeeding at postpartum 6-10 weeks as compared to 189 (23.2%) that had discontinued breastfeeding. Multivariable regression analysis identified lower education level (aOR 3.88, 95% CI 2.57-5.85, p < 0.0001), having diabetes (aOR, 95% CI 1.21-5.44, p = 0.0141), presence of obstetric complications (aOR 1.57, 95% CI 1.00-2.46, p = 0.0494), artificial rupture of membrane (ARM) and oxytocin induction (aOR 2.07, 95% CI 1.22-3.50, p = 0.0068), lower age (aOR 0.92, 95% CI 0.88-0.97, p = 0.0010) and higher A-LPQ birth pain score (aOR 1.02, 95% CI 1.01-1.04, p = 0.0064) as independent associations with cessation of breastfeeding at postpartum 6-10 weeks, with AUC of the model being 0.72 (95% CI 0.68-0.77). Higher pain experienced during labor is associated with cessation of breastfeeding among several other intrapartum interventions and psychological vulnerabilities. Using risk stratification strategy, breastfeeding support services could be provided to women to optimize successful breastfeeding in the postpartum period.Trial registration: This study was registered on Clinicaltrials.gov NCT03167905 on 30/05/2017.

Synchronization of a Virtual Reality Scenario to Uterine Contractions for Labor Pain Management: Development Study and Randomized Controlled Trial

Background: Labor is described as one of the most painful events women can experience through their lives, and labor pain shows unique features and rhythmic fluctuations. Purpose: The present study aims to evaluate virtual reality (VR) analgesic interventions for active labor with biofeedback-based VR technologies synchronized to uterine activity. Materials and Methods: We developed a VR system modeled on uterine contractions by connecting it to cardiotocographic equipment. We conducted a randomized controlled trial on a sample of 74 cases and 80 controls during active labor. Results: Results of the study showed a significant reduction of pain scores compared with both preintervention scores and to control group scores; a significant reduction of anxiety levels both compared with preintervention assessment and to control group and significant reduction in fear of labor experience compared with controls. Conclusion: VR may be considered as an effective nonpharmacological analgesic technique for the treatment of pain and anxiety and fear of childbirth experience during labor. The developed system could improve personalization of care, modulating the multisensory stimulation tailored to labor progression. Further studies are needed to compare the synchronized VR system to uterine activity and unsynchronized VR interventions.

Effect of audio-visual therapy on pain and anxiety in labor: A randomized controlled trial

Background

Birth pain affects women at a physical and psychological level. Pain is subjective, and perception will vary among individuals depending on their health status, pain tolerance, and psychological state. Labor pain can drastically affect the birth process and delivery outcomes if not managed well, ranging from poor maternal satisfaction and impaired maternal-newborn bonding to prolonged labor and fetal distress. Since pharmacological pain relief methods harm the fetus, non-pharmacological pain relief methods are gaining popularity among laboring women and healthcare professionals.

Objectives

The study aimed to evaluate the effect of audio-visual therapy on labor pain and maternal anxiety.

Methods

A randomized, controlled, open-label, single-center trial was conducted among 76 primigravida women with no obstetrical complications during the active phase of labor (4-8 cm cervical dilatation). The participants were randomly assigned to an experimental group receiving 50 min of virtual reality intervention or a control group receiving standard care using a computer-generated random sequence. The data related to pain and anxiety were collected using the personal information form, anxiety assessment scale for pregnant women in labor, present behavioral intensity scale, numerical pain rating scale, and post-delivery birth satisfaction checklist.

Results

Groups were homogenous in terms of demographic and obstetric variables. The virtual reality intervention reduced the experimental group's reported pain intensity and anxiety score. However, no statistically significant difference was noted in maternal vital signs and labor and neonatal outcomes between the groups.

Conclusion

The virtual reality intervention reduced labor pain intensity and anxiety among laboring women compared to standard care.

Tools for assessing labour pain: a comprehensive review of research literature

ABSTRACT

The experience of pain associated with labour is complex and challenging to assess. A range of pain measurement tools are reported in the literature. This review aimed to identify current tools used in research to assess labour pain across the past decade and to evaluate their implementation and adequacy when used in the context of labour pain. A literature search was conducted in databases MEDLINE and Cumulative Index of Nursing and Allied Health Literature, using search terms relating to labour, pain, and measurement. A total of 363 articles were selected for inclusion. Most studies (89.9%) assessed pain as a unidimensional experience, with the most common tool being the Visual Analogue Scale, followed by the Numerical Rating Scale. Where studies assessed pain as a multidimensional experience, the most common measurement tool was the McGill Pain Questionnaire. Only 4 studies that used multidimensional tools selected a tool that was capable of capturing positive affective states. Numerous variations in the implementation of scales were noted. This included 35 variations found in the wording of the upper and lower anchors of the Visual Analogue Scale, some assessment tools not allowing an option for "no pain," and instances where only sections of validated tools were used. It is clear that development of a standardised pain assessment strategy, which evaluates the multidimensions of labour pain efficiently and effectively and allows for both positive and negative experiences of pain to be reported, is needed.

The contributions of parental lactation on offspring development: It's not udder nonsense!

The Developmental Origins of Health and Disease (DOHaD) hypothesis describes how maternal stress exposures experienced during critical periods of perinatal life are linked to altered developmental trajectories in offspring. Perinatal stress also induces changes in lactogenesis, milk volume, maternal care, and the nutritive and non-nutritive components of milk, affecting short and long-term developmental outcomes in offspring. For instance, selective early life stressors shape the contents of milk, including macro/micronutrients, immune components, microbiota, enzymes, hormones, milk-derived extracellular vesicles, and milk microRNAs. In this review, we highlight the contributions of parental lactation to offspring development by examining changes in the composition of breast milk in response to three well-characterized maternal stressors: nutritive stress, immune stress, and psychological stress. We discuss recent findings in human, animal, and in vitro models, their clinical relevance, study limitations, and potential therapeutic significance to improving human health and infant survival. We also discuss the benefits of enrichment methods and support tools that can be used to improve milk quality and volume as well as related developmental outcomes in offspring. Lastly, we use evidence-based primary literature to convey that even though select maternal stressors may modulate lactation biology (by influencing milk composition) depending on the severity and length of exposure, exclusive and/or prolonged milk feeding may attenuate the negative in utero effects of early life stressors and promote healthy developmental trajectories. Overall, scientific evidence supports lactation to be protective against nutritive and immune stressors, but the benefits of lactation in response to psychological stressors need further investigation.

The Relationship of Preterm, Term, and Post-Term Births to Maternal Stress and Human Milk Cortisol Levels

Introduction: Maternal stress can lead to changes in the composition of human breast milk. The present study evaluates cortisol levels in the breast milk of mothers after giving birth preterm, term, or post-term, and ascertains whether the levels are associated with maternal stress. Materials and Methods: Included in the study were mothers who gave birth vaginally after 32 weeks of gestation between January and April 2022. The breast milk was expressed with an electronic pump under the supervision of a nurse on day 7 following birth, and 2 mL samples of the milk were transferred into microtubes and stored at -80°C. Stress in the mothers was measured using the perceived stress scale developed by Cohen et al. The human breast milk cortisol levels were determined using an enzyme-linked immunoassay in a single session. Results: A total of 90 mothers, including 30 with preterm births, 38 with term births, and 22 with post-term births, were included in the study. The median stress scale score was 28 (17-50) and the median breast milk cortisol level was 0.49 ng/mL (0.1-1.96 ng/mL). A significant positive correlation was noted between the stress scale scores and breast milk cortisol levels (r = 0.56, p < 0.01). The breast milk cortisol levels and maternal stress scale scores were significantly higher in the preterm birth group than in the term birth group (p = 0.011 and p = 0.013, respectively). Conclusion: Although there is an association between maternal stress and preterm labor and milk cortisol levels, we believe that more studies are needed to establish a causal link.

Delivery in a vertical birth chair supported by freedom of movement during labor: A randomized control trial

To evaluate the effect of delivery in a vertical birth chair (VBC) and traditional delivery table (DT) supported by women's movement during labor on the labor process, fetal outcome, maternal hormone levels, birth comfort, and satisfaction. This randomized controlled trial was conducted with 1:1:1 allocation. Group 1: in the VBC in upright position, Group 2: on the DT in supine position, these groups supported by freedom of movement, control group: on the DT in supine position, labor in bed. The duration of second stage of labor was not different between the groups (p = 0.246). The occurrence of instrumental birth, episiotomy, and perineal laceration was also not different among the groups (p = 0.772, p = 0.953, and p = 0.124). The use of uterotonic was observed in control group (p = 0.001). 1 and 5 APGAR scores of newborns were not different in all groups (p = 0.121, p = 0.268). The lowest pain score was observed in Group 1 (p = 0.001). Birth comfort and satisfaction were higher in Group 1 (p = 0.001 and p = 0.001). Decreased postpartum prolactin levels and increased postpartum oxytocin levels were observed in the control and Group 1 (p = 0.004, p = 0.006). Freedom of movement during labor and delivery using VBC in upright position can play birth-promoting and supporting role. There were no negative effects on the fetal outcome.

Cortisol, Maternal Stress, and Breastfeeding Rate at Hospital Discharge: A Systematic Review

Introduction: Breastfeeding is considered the best way to provide essential and necessary nutrients to the newborn, intervening in its growth and development. However, early abandonment of this method is quite common, due to various factors such as stress. Objectives: To determine whether the level of postpartum cortisol can serve as an indicator of maternal stress and whether there is a relationship between the level of cortisol and the rate of exclusive breastfeeding (EBF) at hospital discharge. Methodology: Systematic review of the literature under the PRISMA guidelines. PubMed, Web of Science, CINAHL, and Scopus databases were used. Original articles published from 2017 to 2022 in English, French, Portuguese, and Spanish were included. All study designs were eligible. Of the 3,712 records initially identified, 15 studies were included in this review. Results: Elevated cortisol levels, due to immediate postpartum stressors, have direct effects on the performance of the essential hormones in breast milk production. The EBF rates are negatively influenced by perceived maternal stress. Conclusion: Cortisol levels may be a good indicator of the level of stress to which the mother is subjected during the immediate postpartum period.

Maternal Stress and Neonatal Nutrition during the COVID-19 Era

Objective

COVID-19 pandemic has put a tremendous amount of stress on people, which can negatively affect nursing. Previous studies showed that perceived stress and cortisol levels in the postpartum period correlate with the LATCH scores, which is a simple tool to assess the pattern of nursing. Likewise, greater prenatal anxiety was associated with a shorter breastfeeding duration. We aimed to evaluate whether pregnant women were under extra stress due to the COVID-19 pandemic and if this stress affected their breastfeeding patterns and anthropometric measures of the neonates.

Methods

Pregnant women giving birth to healthy neonates were included. Coronavirus Anxiety Scale (CAS) and Beck Anxiety Inventory (BAI) were used to assess the anxiety levels of the mothers, and LATCH breastfeeding assessment tool was used to assess the nursing. The results of these scales and anthropometric measures of the neonates were recorded.

Results

Only one mother showed coronavirus-specific anxiety. Therefore, further analysis was done based on the Beck Anxiety (BA) levels of the mothers. CAS and BA scores were positively correlated (p<0.001, r=0.444), indicating that coronavirus-specific anxiety increased with increasing general anxiety. None of the variables changed depending on the anxiety levels of the mothers, except for the % weight gain at day five (p=0.020, r=-0.248). Even though anxiety seemed to show a small effect on weight loss during the first neonatal days, percent weight gain results did not seem to correlate with the anxiety levels in later stages (first month of life). Furthermore, LATCH scores of the infants on day one were positively correlated with BA scores of the mothers (p=0.045, r=0.175).

Conclusion

COVID-19 seemed to have no additional effect on the stress levels of the mothers. The more the mothers have anxiety, the more they may stress about the well-being of their infants, which can improve their nursing pattern.

Fathers' experiences of feeding their extremely preterm infants in family-centred neonatal intensive care: a qualitative study

BACKGROUND

Extremely preterm infants need advanced intensive care for survival and are usually not discharged before they reach the time of expected birth. In a family-centred neonatal intensive care unit both parents are involved at all levels of care including the feeding process. However, studies focusing on fathers in this situation are scarce. The purpose of this study was to explore the experiences of feeding extremely preterm infants in a neonatal intensive care unit from fathers' perspectives.

METHODS

The study adopts a qualitative inductive method, reported according to the COREQ checklist. Seven fathers of extremely preterm infants (gestational age 24-27 weeks) in neonatal intensive care in Sweden were interviewed by telephone after discharge in 2013-2014. The interviews were analysed using a qualitative content analysis and confirmed by triangulation in 2021.

RESULTS

Six sub-categories and two generic categories formed the main category: "a team striving towards the same goal". The fathers were equally involved and engaged members of the feeding team all hours of the day. The fathers shared responsibility and practical duties with the mothers, and they provided as much support to the mothers as they could. However, the fathers found it difficult to support and encourage the mothers to breastfeed and express breastmilk when the breastmilk production was low. The fathers experienced a loss when breastfeeding was not successful.

CONCLUSIONS

The findings indicate that fathers want to be involved with infant care, including night-time feeds, and long and demanding feeding processes. Fathers and staff need to collaborate to provide the best support to mothers during the feeding process. This study may inspire hospital staff to acknowledge and support fathers to become more involved in the oral feeding process when an infant is born extremely preterm.

Relationships Among Factors Related to Childbirth and Breastfeeding Outcomes in Primiparous Women

OBJECTIVES

To explore the relationships among potentially modifiable factors related to childbirth and effective breastfeeding initiation at approximately 36 hours after birth and duration and exclusivity at hospital discharge, 2 weeks, 2 months, and 6 months after birth in primiparous women and to explore whether modifiable and nonmodifiable secondary factors and covariates influenced the relationships among factors related to childbirth and these breastfeeding outcomes.

DESIGN

A prospective, longitudinal, cohort study.

SETTING

The postpartum units of two general hospitals in eastern Canada.

PARTICIPANTS

Ninety-seven mother-infant dyads.

METHODS

We recorded demographic, childbirth, obstetric history, and breastfeeding data through chart review. A breastfeeding observation was completed at approximately 36 hours after birth by unit nurses. Participants maintained breastfeeding logs in hospital and for 6 months after birth and completed three self-report questionnaires before discharge. We analyzed outcomes using backward stepwise linear and logistic regression.

RESULTS

One childbirth factor, labor induced with oxytocin, was negatively associated with effective initiation of breastfeeding, and none was related to breastfeeding duration and exclusivity at any time point. Maternal weight; professional support; and newborn's gestational age at birth, 5-minute Apgar score, weight loss, LATCH score, and active feeds (newborn actively suckled at the breast) were significantly associated with breastfeeding outcomes.

CONCLUSION

Induction of labor with oxytocin should be used judiciously; when used, nurses must be hypervigilant to assess the mother-infant dyad for breastfeeding issues and to intervene to prevent or remediate them.