A combination of strong emotions such as these after a challenging birth can put a woman in a compromised position to develop a breastfeeding relationship with her baby. If a woman did not feel central to the birth experience and her expert role was not acknowledged and supported then she may not have gained a feeling of her own importance in her baby's life. This may translate to feeling incapable, and a lack of confidence in caring for her baby ("I couldn't even birth him…how can I care for him?").

"Breastfeeding requires a woman to try new things, attempt a new skill and use unfamiliar methods of caring for another person. It can be challenging for anyone to develop a new skill in the throes of a life-changing event.

Breastfeeding requires a woman to try new things, attempt a new skill and use unfamiliar methods of caring for another person. It can be challenging for anyone to develop a new skill in the throes of a life-changing event. When developing this new skill has the added pressure of providing nutrition for another human, it can be very stressful indeed.

If a woman has just experienced a birth where she felt disempowered, degraded, out of control or unable to ask questions, she may not suddenly feel overly confident in asking for help and advice when breastfeeding. She may be feeling overwhelmed, shocked or that her 'voice' was taken from her during the birth. She may struggle to find that voice when attempting the task of breastfeeding, and feel unable to seek the help she needs.

"[After being separated for three hours after the birth, then being sent out of the Special Care Unit without my baby after a first unsuccessful breastfeeding attempt] I felt helpless and my anxiety was really starting to build. Plus I was completely drained from the long labour, two nights with minimal sleep and the difficult birth. Emm

Two hours later [after my traumatic birth] my son was forced onto my breast despite me saying I wanted him to be coaxed gently. The problems started there. He wouldn't latch very well and, as I was in a private room, I had to ring for help at every feeding. I was in a state of shock and feeling really detached from everything, including him. Barbara

No wonder emotions are running high as women attempt to feed their babies, with so much riding on it and so much fall out behind them. Unfortunately, the high levels of anxiety and strong emotions can compromise the situation further, by impacting on the very hormones required for breastfeeding. This leads us to the next factor: adequate hormonal support.

Lack of optimal hormonal support

There is a certain combination of hormones necessary for a normal, vaginal birth and for solid bonding to occur. A similar hormonal mix also provides the optimal situation for breastfeeding to establish.

Dr Sarah Buckley notes there is an "elaborate interplay between these hormones of labour, birth and breastfeeding"(1). Dr Buckley explains that labour and birth involve the hormones oxytocin and prolactin at peak levels. Oxytocin is known as the hormone of love, while prolactin is the major hormone of breast-milk synthesis, and is known as the 'mothering hormone'. Another hormone of labour and birth, beta-endorphin, helps the body release prolactin, and plays a role in bonding.(2)

However, this delicate interplay of hormones can be interfered with in a number of ways that can impact on breastfeeding.

Having pharmacological intervention during birth

"This is absolutely NOT a judgement about any decision to have pain relief.

This is absolutely NOT a judgement about any decision to have pain relief; it is just an explanation of how it can impact on breastfeeding, to help you understand reasons why breastfeeding may have been difficult – reasons that nobody may have mentioned to you before now.

If a woman has pharmacological intervention in the form of synthetic hormones (for example, morphine, pethidine, Syntocinon), it can interfere with her body's natural hormone production, which can then impact on breastfeeding. One recent study found that "mothers who received labor pain medications were more likely to report a delay in the onset of lactation, regardless of delivery method"(3). If a woman experiences this delay, and is not made aware that it may be connected to the pain relief she was given in labour, then she can easily see herself, incorrectly, as having failed.

Natural hormones, such as oxytocin, are produced in the brain and have follow-on neurological effects, such as feelings of love. The synthetic counterparts, such as Syntocinon or Pitocin, administered into the blood stream, cannot replicate the same effects as they can't cross back from the blood into the brain. As Dr Sarah Buckley notes, "This means that Pitocin, introduced into the mother's body by injection (IV), does not act within her limbic system as the hormone of love, and may interfere with the labouring woman's own oxytocin system"(4). The end result is not optimal, hormonally, for breastfeeding.

Epidural pain relief has a major effect on the hormones of labour: the release of beta-endorphin (a hormone important in breastfeeding) is dramatically inhibited, oxytocin levels decline and the oxytocin peak that occurs at birth is also inhibited when an epidural is in place. (5)

Dr Buckley says that epidural drugs may affect a mother's breastfeeding physiology, citing research that found "women who had received an epidural plus Pitocin during labour had a marked reduction in their oxytocin release during breastfeeding… [and] the more Pitocin the mother had received during labour, the lower her breastfeeding oxytocin release, two days after birth".(6)

Mental alertness affected

The woman's and baby's mental alertness can also be affected by the pharmacological intervention, which means they are not primed to start their breastfeeding relationship. One Australian research study (7) found that women emerge more quickly from a general anaesthetic than men, but take twenty-five per cent longer to recover, despite the women opening their eyes and obeying commands more quickly (8). Women were also found to be "more likely to suffer from side effects such as nausea, vomiting, headaches, backaches and sore throats"(9). According to Associate Professor Paul Myles, who led the research, "Women recover more slowly, suggesting they are more sensitive to the side-effects of the drugs, or recover more slowly from the effects of surgery itself. We have known for some time that women have higher rates of nausea and vomiting after surgery; but [this] study has found they also have more headaches, and backache. Importantly, their overall quality of recovery is worse"(10).

I was taken off for a tear repair under general anaesthetic, and my daughter went to my husband's chest for skin on skin. I saw my daughter again about two hours later in the postnatal ward. I was very groggy and felt cold. I don't remember this, but as soon as I saw them my husband offered for me to hold her, and apparently I said, "Not yet". While I had been away, she had been very alert, eyes open and had found my husband's nipple and tried to latch onto it. By the time I saw her, she was sleepier and unsettled. Rosemary

Effects on baby

The baby can also be affected by the mother's labour pain medications, with many studies showing an association between the mother receiving these medications and "suboptimal infant breastfeeding behavior, including diminished early sucking"(11). This can potentially affect the onset of lactation, as these suboptimal behaviours can affect the ability of the baby to effectively latch on, extract milk, and stimulate the breasts(12).

Mode of delivery?

It is worth noting that some studies have focused on the mode of delivery and its impact on breastfeeding. One study found that women who had caesareans had lower levels of prolactin and a less pulsatile oxytocin release pattern when breastfeeding a couple of days postbirth, compared with women who had vaginal births(13). Knowing that both prolactin and oxytocin are critical for successful lactation(14), it is understandable that a woman recovering from a caesarean might need special support to overcome these hormonal discrepancies for a more optimal breastfeeding situation.

But it is not just caesarean mums who struggle with breastfeeding after a traumatic birth. Beck and Watson report on other studies reflecting this, for example, a vacuum extraction in a vaginal birth was a significant predictor of stopping breastfeeding early(15). In another study on Guatemalan women, stress during labour and delivery was identified as a likely significant risk factor for delayed onset of lactation(16), and stress during labour has also been shown to reduce women' plasma concentration of the hormone prolactin(17).

We suggest that, really, any birth where there are significant levels of stress has the potential to send the delicate balance of hormones into disarray, and upset the perfect environment for mother and baby to initiate a healthy breastfeeding relationship.

You are not to blame

We want to make it really clear that in NO way is any of this an indication that you made the wrong decision if you had pain relief medication or other interventions.

Firstly, we would take a guess that no one mentioned the extent to which these interventions could impede your breastfeeding or that there were ways to support your breastfeeding through these interventions. So you were likely not making that decision with the information you needed to receive (and this is not your fault). It's not likely you were told, "It would be reasonable to consider an epidural, but did you know that this may impact on breastfeeding so you may need some extra support, guidance and information to establish your baby's breastfeeding?"

It is also important to know that this does not mean that you cannot choose pain relief in future births. Being fully informed and aware of the possible hormonal challenges means you can create more options. You can take steps as part of your postnatal plan to stimulate those hormones in other ways, to promote a more optimal breastfeeding environment should you require pain relief medication.

The situation is the issue

As we say at the start of this article, there are many reasons why it can be so hard to breastfeed after a traumatic birth, and none of them are the mother's fault. Many of the challenges are strongly related to the situation, rather than to the woman's actual ability. It is the situation that has compromised the hormones a woman's body requires to promote breastfeeding, and we will keep reiterating, because it can be so important to hear : that is not the woman's fault.