The First Week: A Risky Time
In the developing world,
childbirth and the first days
postpartum are a risky time for
mother and baby.
Approximately one-fourth to
one-half of deaths in the first
year of life occur in the first
week. Many of the interventions that will
improve the health and survival of
newborns are relatively low cost and feasible
to implement. One of these interventions is
immediate and exclusive breastfeeding.
This intervention can also help women by
minimizing immediate postpartum
hemorrhage, one of the most common
causes of maternal death.
Establishing good breastfeeding practices in
the first days is critical to the health of the
infant and to breastfeeding success.
Initiating breastfeeding is easiest and most
successful when a mother is physically and
psychologically prepared for birth and
breastfeeding and when she is informed,
supported, and confident of her ability to
care for her newborn.
During antenatal counseling, health care
providers can prepare women for the events
of labor, delivery, and breastfeeding. They
can help to ensure a healthy start for the
mother/ baby partnership by implementing
the Ten Steps to Successful Breastfeeding
(see page 2). This issue of Facts for Feeding
identifies actions health care providers can
take during the first week to help the
mother and baby establish and maintain
good breastfeeding practices.
Labor and Delivery
Mothers should enter into labor
and delivery informed about
the stages of labor, drug-free
ways to cope with labor pain,
potential side effects of labor
medications, and benefits for
mother and baby of immediate
and exclusive breastfeeding. Skilled attendants can encourage the
support of a labor companion, increase a
mother's comfort, and minimize her pain.
Encourage the support of a labor companion
Continuous support to the mother by a companion during
labor and childbirth can ease labor and delivery,
reduce the need for medical interventions, and
increase a woman’s confidence in her ability to breastfeed and care for her baby. A labor companion can help to keep labor progressing normally by encouraging the mother to walk
and move around in labor, offering her light
nourishment and fluids, telling her how well she is
doing, and suggesting ways to keep pain and anxiety from overpowering her.
Increase comfort and confidence; reduce pain
Most women experience various levels of anxiety,
discomfort, and pain during labor and delivery. The risks and
benefits of different ways to alleviate pain, especially through medication,
should be discussed during antenatal counseling. Some pain medications can
increase the risk of separation of mother and newborn after delivery, delaying
the introduction of breastfeeding. Pain medication may cross the placenta,
making the baby drowsy and diminishing the baby’s sucking reflexes. As a result,
the newborn may be less ready to initiate breastfeeding.
Alternative ways of managing the pain and anxiety of labor and delivery should
be encouraged or at least tried before offering labor pain medications.
Continuous labor support, massage, soothing warm water, changes in body
position, and verbal and physical reassurance can increase a woman’s comfort
level and deflect her focus on the pain.
Ten Steps to Successful Breastfeeding
Every facility providing maternity services and care for newborns infants
- Have a written breastfeeding policy that is routinely communicated to
all health care staff.
- Train all health care staff in skills necessary to implement this
- Inform all pregnant women about the benefits and management of
- Help mothers initiate breastfeeding within a half-hour of birth.
- Show mothers how to breastfeed, and how to maintain lactation even if
they should be separated from their infants.
- Give newborn infants no food or drink other than breastmilk, unless
- Practice rooming-in—allow mothers and infants to remain together—24
hours a day.
- Encourage breastfeeding on demand.
- Give no artificial teats or pacifiers (also called dummies or
soothers) to breastfeeding infants.
- Foster the establishment of breastfeeding support groups and refer
mothers to them on discharge from the hospital
From Protecting, Promoting and Supporting Breastfeeding: The Special Role of
Maternity Services - A Joint UNICEF/WHO Statement, 1989
The first few hours after delivery are a critical time for both
mother and newborn. The mother is recovering from the sudden dramatic physical and
hormonal changes triggered by labor, birth, and the
expulsion of the placenta. The drop in placental hormones “signals” her body to begin making breastmilk in sufficient quantities to
feed her baby. Those attending the mother at birth
must keep a watchful eye to detect abnormal bleeding
and to ensure that her nutrition and fluid needs are
met and her comfort is maintained.
At this same time, the newborn is undergoing the
dramatic shift to life outside the womb. The immediate
care required by the baby includes attention to the initiation of breathing, skin-to-skin contact with the mother, warmth,
immediate and exclusive breastfeeding, and clean cord
Make initiation of breastfeeding the first routine in the first hour
For the healthy baby, the first routine after delivery
should be skin-to-skin contact and initiation of
breastfeeding. Other routines such as cord care, eye
care, and weighing can follow. Bathing is not
recommended until several hours after birth.
Suctioning of the baby’s mouth and nose should not be routine but only done if necessary to clear secretions that are preventing the baby from breathing well. A baby who is crying does not need
suctioning. If suctioning is necessary, it should be
done gently so it does not injure the delicate tissue
of the baby’s mouth and throat, which could interfere with
Place the baby skin-to-skin against the
The baby should be wiped from head to toe with a dry cloth
and placed skin-to-skin against the mother. Baby and mother should then be
covered with another dry cloth. Immediate mother/newborn contact takes advantage
of the newborn’s natural alertness following normal vaginal birth and fosters
bonding. This immediate contact also reduces maternal bleeding and stabilizes
the baby’s temperature, respiratory rate, and blood sugar level. Even a mother
who requires stitches in the birth canal can have the baby placed against her
Healthy newborns delivered vaginally are awake and alert, with inborn rooting
and sucking reflexes to help them find the breast and nipple, latch on, and
start the first feed. Most newborns are ready to find the nipple and latch onto
the breast within the first hour of birth.
Left alone on the mother’s stomach, a healthy newborn scoots upwards pushing
with the feet, pulling with the arms, and bobbing the head until finding and
latching on the nipple. A newborn’s sense of smell is highly developed, which
also helps in finding the nipple. As the baby moves to the nipple, the mother
produces high levels of oxytocin, which helps contract the uterine muscle and
keep the uterus firm, thereby minimizing her bleeding. Oxytocin also causes her
breasts to release colostrum when the baby finds the nipple.
Help mother position baby to the breast
The health care provider or labor companion can help position
the baby, so latch-on is effective and does not hurt the mother. Pillows or a
folded blanket under the mother’s head may help. Or the mother can roll to one
side and tuck the baby next to her.
A baby born by Cesarean Section can benefit from skin-to-skin contact by being
held close to the mother’s cheek right after delivery. In this situation, when
initiation of breastfeeding takes place—if possible within the first two hours
after surgery—a knowledgeable health care provider will need to help the mother
with positioning and attachment to ensure her comfort. For low birth weight and
healthy preterm babies, kangaroo care is an effective way of caring for them.
Kangaroo care is defined as “early prolonged, continuous skin-to-skin care in a
kangaroo position between the mother and the newborn.” Kangaroo care has been
shown to achieve effective and prolonged body temperature regulation and stable
heart and respiratory rates in the low birth weight newborn. Skin-to-skin care
encourages latch-on and suckling, mother-baby bonding, and establishment of
successful breastfeeding once a baby is mature enough to suck.
Praise the mother for giving colostrum,
the baby’s “first immunization”
Colostrum—the sticky, yellow-white early milk—should be the newborn’s first
taste. There should be no prelacteal feeds such as water, other liquids, or
ritual foods. Because of its high levels of antibodies, vitamin A, and other
protective factors, colostrum is often called the baby’s first immunization.
Give the mother a vitamin A supplement
where postpartum dosing is a national policy
The risk of vitamin A deficiency is higher for infants whose
mothers are vitamin A deficient. A single high-dose (200,000 IU) vitamin A
capsule will help build up the mother’s vitamin A stores, increase the vitamin A
content of breastmilk, and reduce the risk of infection in the mother and her
Continue to monitor and assist mother
Mother and baby should be kept together. During the first few
hours after delivery, the mother’s temperature, pulse, blood pressure—often
called vital signs—and bleeding can be checked while the baby remains on her
abdomen. The baby’s temperature, breathing, and heart rate can also be checked
Following birth, newborns need:
During the first
days mothers want to know how often to feed the baby, whether breastfeeding is
going well, and if the baby is getting enough milk. Women who have had a history
of feeding problems can be encouraged to try new behaviors to prevent the same
problems. Reassurance from health care providers and support from family is
particularly important at this time.
Observe breastfeeds; offer assistance
The newborn should be observed for correct positioning and
attachment. The baby should be held close to the mother, facing the breast with
the baby’s ear, shoulder, and hip in a straight line. Signs of correct latch-on
include wide-opened mouth with the nipple and much of the areola (the dark area
around the nipple) in the mouth, lips rolled outward, and tongue over the lower
gum. Visible jaw movement drawing milk out and rhythmical suckling with an
audible swallow should be evident.
Provide additional support when
initiation is delayed
Under special circumstances, initiation may be delayed
because mother and infant are separated for medical reasons. Also, premature
babies may initially have difficulty suckling at the breast. Health care
providers should provide additional assistance and support so that nearly every
mother will, in time, be able to breastfeed her baby.
Teach the mother to express her
colostrum and breastmilk
Teaching the mother to effectively express colostrum and to
feed it to her baby will enable her to give the baby the nutrient-rich and
protective first milk, establish the milk supply, and help avoid engorgement
when the milk “comes in.” For a mother recovering from a difficult or surgical
delivery, it is very important that she not have to contend with the added
difficulties of overly full breasts.
Teach the mother to feed expressed
breastmilk from a cup
If a baby cannot suckle at the breast, an excellent way to
give expressed breastmilk is with a small cup. Cup feeding may be needed for low
birth weight and premature infants and for those separated from their mother for
other reasons. Cups are easier than feeding bottles to keep clean. The feeding
behavior the baby learns with ‘lapping’ the milk from the edge of the cup does
not interfere with latch-on when the baby is ready to feed at the breast.
Artificial nipples do not conform to a baby’s mouth the same way as a mother’s
nipple. A baby can rapidly become accustomed to a way of sucking from an
artificial nipple which, when applied to the mother, can cause her pain and be
less effective in removing the breastmilk.
Counsel on frequent, exclusive
A mother and her family need to be reassured that colostrum
meets all of the baby’s nutrient and fluid requirements. The more the baby
suckles, the sooner mature breastmilk is produced.
As a guideline, newborns should breastfeed at least 8–12 times in 24 hours. The
length of the feed will vary from feed to feed and from baby to baby.
Unrestricted (on-demand breastfeeding day and night) stimulates milk production
and helps prevent engorgement. Infant formula, animal milk, herbal teas, water,
or any other type of liquid or food may introduce dangerous contaminants,
interfere with mother’s milk production, and begin a cycle where less frequent
breastfeeding leads to less breastmilk production. Mothers should be encouraged
to feed on the first breast without time restriction before offering the second
breast to ensure that the baby gets the rich fat content in the hind milk.
Reassure the mother
During the first days after childbirth, women are recovering
from profound physical and hormonal changes. They may at times be discouraged
and experience discomfort, anxiety, and exhaustion. Mothers and their families
should know that these feelings are common among mothers during the first week
or two after birth. They should not worry if a mother has a low-grade fever (not
above 37.6 C or 100 F) on the day her milk comes in. This fever should last no
more than 24 hours. They should also know that the sharp contractions of the
uterus that a mother may experience during or after breastfeeding for the first
several days— particularly if she has given birth before—are normal and will
Involve family in care and support
Birth is a life-giving and life-changing experience. Mothers
need emotional support, good nutrition, and rest during this profound period in
their lives. Their self-confidence increases knowing that they are providing
their baby with the very best nourishment, comfort, and care.
- Partner involvement: Fathers can be active
participants in the early postpartum period. Cultures vary as to how involved
men are in the birth events, but almost all fathers are proud and eager to
have bonding time with their newborn.
- Maternal nutrition: Families can provide
breastfeeding women additional nourishing foods and fluids to help them
support lactation and maintain their health. Breastfeeding mothers do not need
excessive amounts of fluids. They should be encouraged to drink in response to
their thirst. If they live in areas where postpartum vitamin A supplementation
is national policy and did not receive a high-dose vitamin A supplement after
delivery, they should take one as soon as possible, but no later than eight
- Rest: Mothers should be encouraged to sleep when
the baby sleeps. Members of the family can take over or help with tasks
normally done by the mother.
Inform mother and family of community
Mothers should know how to contact health care providers in
the community who support exclusive breastfeeding for the first six months and
who know how to advise mothers that experience breastfeeding difficulties such
as sore, cracked nipples or engorged breasts. Mothers should also know how to
contact breastfeeding support groups and lay counselors.
the third or fourth day, most mothers notice that
their milk becomes more plentiful.
The body is beginning to transition to the
production of mature breastmilk—a process that can take about two weeks.
Reinforce good breastfeeding
practices; monitor progress
During this period of transition, special attention is
needed to prevent normal breast fullness from turning
into painful engorgement or even infection. If the breasts are very full, the health care
provider can help the mother hand express some
of the first milk to soften the nipple and the area
around the nipple so that the baby can attach well to
the breast. Exclusive, frequent breastfeeding will
help to prevent and to treat engorgement.
Counsel mother to observe the
Mothers should be alert to signs of illness and report
anything unusual to a health care provider. They should know
how to tell if the baby is getting enough breastmilk: baby passes urine at least
six times in 24 hours, mother can hear the sound of the baby swallowing, and
mother’s breasts feel softer after a feed. During days 4–7, the baby should pass
at least four stools in 24 hours. From weeks 2–6, the baby should pass at least
one stool in 24 hours. After the sixth week, the average number of stools in
infants varies widely.
Provide ongoing support
Mother and baby are just beginning their partnership. At any
time doubts, breastfeeding problems, and external factors such as the marketing
of breastmilk substitutes can disrupt the routines being established. The health
care provider and community health worker can help create a social climate
supportive to breastfeeding women by promoting evidence-based practices within
their organizations. They can advocate for policies that reinforce these
practices, link community services with the health sector, and provide families
with accurate information and quality care.
Cattaneo A et al. Kangaroo mother care in low-income
countries. International Network in Kangaroo Mother
Care. J Trop Pediatr 1998; 44 (5):279-82.
Chalmers B et al. WHO principles of perinatal care:
The essential antenatal, perinatal, and postnatal care
course. Birth 2001; 28 (3) 202–7.
Hofmeyr GJ et al. Companionship to modify the clinical
birth environment: Effects on progress and perception
of labour, and breastfeeding. Brit J of Obstet Gynecol
Madi BC et al. Effects of female relative support in
labor: A randomized controlled trial. Birth 1999; 26
Rajan L. The impact of obstetric procedures and
analgesia/anesthesia during labour and delivery on
breastfeeding. Midwifery 1994; 10:87-103.
WHO. Evidence for the ten steps to successful
breastfeeding (WHO/CHD/98.9). Geneva: WHO, 1998.
Other references available upon request.
Facts for Feeding
Frequently Asked Questions
Facts for Feeding is a publication of LINKAGES: Breastfeeding, LAM, Related Complementary
Feeding, and Maternal Nutrition Program, and was made possible through support
provided to the Academy for Educational Development (AED) by the GH/ HIDN of the
United States Agency for International Development (USAID), under the terms of
Cooperative Agreement No. HRN-A-00-97-00007-00. Mary Kroeger provided technical
assistance for the development of this publication. The opinions expressed herein are those
of the author( s) and do not necessarily reflect the views of USAID or AED.