Does skin-to-skin contact and breast feeding at birth affect the rate of primary postpartum haemorrhage

It is well known immediate skin to skin contact and breastfeeding at birth effectively promotes breastfeeding which, in turn, is associated with multiple health benefits for babies and women (WHO/Unicef 2009).   A recent study was the first to investigate the possible effect of skin to skin contact and breastfeeding at birth on postpartum haemorrhage (PPH) rates. Postpartum haemorrhage is a major contributor to maternal illness and death and, by association, illness and death for newborns (UNICEF and WHO 2009).   In Western countries, the rate of postpartum haemorrhage has been steadily rising over the past 20 years or more.  The vast majority of cases of postpartum haemorrhage are caused by uterine atony at birth, i.e. inadequate uterine contraction around the time of the delivery of the placenta.  Uterine activity is mediated by a naturally occurring hormone, Oxytocin, which is released during times of love, bonding, sexual activity and birthing.  During the birthing process oxytocin acts by attaching to binding sites on the myometrial muscle cells causing contraction and retraction of the uterus causing the contractions needed for birth. After the placenta is born the contraction and retraction of uterine muscle compresses the blood vessels to the placental site thus preventing excess bleeding.  Skin-to-skin contact between the mother and her newborn, together with breastfeeding are known to be two powerful ways that stimulate the release of endogenous oxytocin. This was the theoretical basis for Saxton’s PhD topic.

WHO/Unicef (2009) recommends that midwives place babies in skin-to-skin contact with their mothers immediately following birth for at least an hour.  In busy maternity units, however, this uninterrupted hour rarely happens because of perceived efficiency pressures which drive midwives to weigh, measure, immunise and dress the baby quickly and clean and tidy the woman and the room. Consistent with WHO/Unicef recommendations, midwifery theory suggest that at least the first 30 minutes after birth should be focussed on facilitating thirty, uninterrupted minutes of mother-baby contact and spontaneous breastfeeding to promote optimal oxytocin release.

Circulating oxytocin, however, is not sufficient to ensure that it binds to the receptor sites on myometrial cells; the women’s autonomic nervous system must be parasympathetically dominant otherwise adrenaline is released by the sympathetic nervous system and adrenaline blocks the binding sites where oxytocin normally fits at the myometrium. Midwifery theory, concerning how to support women during and after the birth of the placenta recommends that, in addition to skin to skin contact and breastfeeding at birth, the birthing room should be warm, private and quiet. This type of environment allows the woman to feel safe and calm which promotes parasympathetic dominance thus optimising binding of the oxytocin molecules to the myometrial cell receptors (Arrowsmith & Wray, 2014; Moberg, 2011; Odent, 2001). When a woman bleeds at birth, due to uterine atony, the most likely explanation is that her autonomic nervous system is sympathetically stimulated: i.e. the fear-fight-fright-flight response.  A techno-medical birthing environment that is cold, bright, noisy and/or occupied by strangers is theoretically implicated in women feeling alert and fearful; thus increasing medicalisation of birth is linked to the rising rates of postpartum haemorrhage.  The Saxton et al (2015) study showed that only 41.8% of women experienced both skin to skin and breastfeeding within the first 30 minutes of birth. Her study only looked at these two variables and did not investigate the type of birthing environment nor did she investigates women’s experiences during the third and fourth stages of labour which would have allowed an assessment of women’s sense of privacy and safety. Thus further improvements in quality and duration of skin to skin contact and modifications to the birthing environment have the potential to further reduce postpartum haemorrhage rates.