Supportive Interventions to Initiate Breastfeeding for Pre-Eclamptic Parents.

Initiating breastfeeding is one of the biggest challenges in caring for a new mother and baby. Many factors affect success in the inpatient setting during a normal post partum course. Introducing magnesium therapy into this mix, adds a unique element that needs to be considered carefully when caring for the mother/baby couplet. With the support of educated and compassionate providers and nurses, breastfeeding while on magnesium therapy is safe and can help a mother bond with their baby and bring a sense of normalcy to an otherwise stressful delivery. The following will outline normal breastfeeding challenges, how magnesium affects mom and baby both intrapartum and post partum, and provide tips for providers in supporting this population.

Eliminating Barriers to Breastfeeding

Many elements play into the success of breastfeeding with the mother baby couplet in the inpatient setting. These include exhaustion from labor and delivery, interruptions in care, anatomy, thermoregulation of the infant, willingness to learn of mother, support of care partners, socioeconomic factors, and availability of lactation consultants. Providers and nurses caring for these couplets have the responsibility of creating an environment of support. Many hospitals have begun “quiet hours,” where patients have time to rest and bond with their baby. Clustering care and having direct access to nurses and lactation consultants via hospital phones can help staff to be present when the parents request. Pumping supplies should be readily available with instruction and proper fitting to help with couplets that are separated during their stay. Education prior to delivery is key in minimizing surprises in their course of care and early screening of patients can help identify potential issues that may arise in the postpartum phase.

Understanding Magnesium Sulfate Treatment

Magnesium Sulfate treatment is used to lower the seizure threshold in patients that are diagnosed with preeclampsia. This is diagnosed in the second or third trimester through elevated blood pressures, elevated liver enzymes, protein in urine and/or symptoms reported by the patient. These symptoms include rapid swelling, vision changes, headaches, and epigastric pain. Once a diagnosis is confirmed by the presence of 2 or more of these criteria, a plan will be made for delivery. If delivery is part of that plan magnesium therapy will be initiated. ACOG recommendations are a 4gm infusion bolus of magnesium sulfate followed by a 1- 2gm maintenance infusion until 12- 24 hours post delivery.

Magnesium therapy has a multitude of symptoms for mothers. Flushing, nausea, fatigue, depressed respirations, decreased reflexes, and decreased urine output are monitored hourly by the nursing team during treatment. Magnesium sulfate is a smooth muscle relaxer and therefore slows down the uterus, so Pitocin is used to induce/augment labor. This combined with the frequent interruptions in rest for checks can lead to a long labor for the mother. Unfortunately, this combined with continuation of magnesium therapy post delivery adds a huge barrier to initiating breastfeeding. Magnesium only minimally crosses the placental barrier in trace amounts. Although a NICU team will be present for delivery due to increased risk for respiratory depression, the majority of full term babies do fine and experience a normal course during their first days of life.

During lactation, magnesium does cross into the colostrum. According to the NIH, trace amounts of magnesium in colostrum were detected within 48 hours of discontinuing magnesium and normal at the 72 hour mark. More importantly, this study (updated in 2024) showed that lactogenesis II was delayed in patients receiving 1gm of continuous infusion by 36.5 hours when given for 24 hours post partum and 25.7 hours in those receiving treatment for only 12 hours. Fluid intake during treatment is also closely monitored due to the effects on the kidneys. All of these factors create a challenging environment for those supporting the breastfeeding mother.

Strategies for Breastfeeding Success

In addition to the recommendation above there are many things that supporting staff can do to ensure a successful breastfeeding journey. First is preserving the now standard practices set forth by the American Academy of Pediatrics for delivery. Delayed cord clamping for one minute aids in preventing fetal anemia and physiologic jaundice. Skin to skin contact with mom in the first hours of life is imperative to helping baby to maintain thermoregulation. Thermoregulation is very important in the first 24 hours of life, as it also helps to stabilize insulin and glucose balance. These are simple ways to not add any additional conditions that would further impair breastfeeding. Skin to skin contact also helps to calm the mother and support the initial breastfeeding. Babies are able to smell colostrum on the mom’s breast and will naturally be drawn to the breast for the first feed. Nursing staff should remain at the bedside to help mom adjust during her recovery and assure baby’s safety.

Support of mom should include education of the family of challenges ahead, while maintaining normalcy by providing assurance that their first 24 hours will include proper time to bond, feed and rest. Patient advocacy is important as well. Cluster care and advocate for q2 hours magnesium checks and ending treatment at the 12 hour mark when appropriate. Timing checks on mothers with the interdisciplinary teams can decrease interruptions. Recommendations for feeding are still the same with the healthy newborn, 8-12 feeds in the first day of life and working with parents to read baby’s feeding cues will empower them to care for the baby. Increasing fluid intake as soon as safely possible will help mom’s body to regulate and properly hydrate to support milk production. Remind the patient that their only job is to heal, rest and feed the baby. Support partners to care for the baby in between feeds to allow mom to rest.

Another challenge can arise when a pre-term delivery is indicated. In rare cases pre-eclampsia can be severe enough to deliver early. In these cases staff should try to still complete delayed cord clamping and skin to skin should be initiated as soon as possible after the baby is stabilized. Breastfeeding attempts should still be made as appropriate in the NICU or special care nursery. Early and scheduled pumping will be key in establishing supply and demand and all colostrum should be provided to the infant. It will be imperative that extra attention is given to the mom to assure that flange fit is proper and that pumped milk is safely stored and fortified as needed.

Once the mother is off their treatment and stable connection time with baby and feeding attempts should be prioritized. Initiating breastfeeding with mothers on magnesium treatment poses additional challenges, however most mothers with proper education and support can go on to have a normal and successful breastfeeding journey.

References:

Drugs and Lactation Database (LactMed®) [Internet]. Bethesda (MD): National Institute of Child Health and Human Development; 2006-. Magnesium Sulfate. [Updated 2024 Jan 15]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK501339/

Bailey et al. (2015). Skin-to-Skin Care for Term and Preterm Infants in the Neonatal ICU. American Academy of Pediatrics. https://publications.aap.org/pediatrics/article/136/3/596/61276/Skin-to-Skin-Care-for-Term-and-Preterm-Infants-in?autologincheck=redirected