1.3 Prenatal and Perinatal Influences on Breastfeeding

The Window Before and Around Birth

Many exam scenarios are set in the prenatal, labour/birth, and 0-2 day chronological periods, because what happens around birth largely determines whether breastfeeding starts smoothly. The IBCLC's job in this window is to prepare, protect the first feed, and anticipate the ways birth events make early feeding harder.

Prenatal Breastfeeding Preparation and Education

Effective prenatal education does more than hand out facts. The evidence favors education that is interactive, addresses the individual parent's concerns and prior experiences, and is paired with skilled support after birth — information alone has a modest effect. Useful prenatal content includes: how milk is made (supply and demand), what colostrum is and why its small volume is normal, early feeding cues, the value of skin-to-skin and the first feed, realistic expectations for frequent feeding, and the parent's own goals and support network.

Physical "nipple preparation" (rubbing, toughening) is not recommended and can be harmful; antenatal colostrum hand-expression may be taught in selected cases (for example, gestational diabetes) under guidance. The strongest prenatal lever is realistic expectation-setting plus a plan for early, frequent feeding and prompt help.

How Birth Practices Affect Breastfeeding

Birth is not neutral for feeding. Several common factors can disrupt the first days:

The recurring lesson: when a birth factor disrupts direct feeding, start early milk removal (hand expression, then pumping), prioritize skin-to-skin as soon as the dyad is stable, and monitor intake rather than assuming feeding will simply happen.

The Baby-Friendly Hospital Initiative: the Ten Steps (Revised 2018)

The Baby-Friendly Hospital Initiative (BFHI), launched by WHO and UNICEF in 1991 and revised in 2018, defines the Ten Steps to Successful Breastfeeding. The 2018 revision groups them into critical management procedures (Steps 1-2) and key clinical practices (Steps 3-10):

1. Step 1 — Comply fully with the WHO Code and relevant resolutions; have a written infant-feeding policy; establish ongoing monitoring.
2. Step 2 — Ensure staff have sufficient knowledge, competence, and skills to support breastfeeding.
3. Step 3 — Discuss the importance and management of breastfeeding with pregnant women and families.
4. Step 4 — Facilitate immediate and uninterrupted skin-to-skin contact and support initiating breastfeeding as soon as possible after birth.
5. Step 5 — Support mothers to initiate and maintain breastfeeding and manage common difficulties.
6. Step 6 — No food or fluids other than breast milk for breastfed newborns unless medically indicated.
7. Step 7 — Enable mother and infant to remain together and room-in 24 hours a day.
8. Step 8 — Support responsive feeding by recognizing and responding to feeding cues.
9. Step 9 — Counsel on the use and risks of bottles, teats, and pacifiers.
10. Step 10 — Coordinate discharge so families have timely access to ongoing support.

Skin-to-Skin and the First Hour

Immediate, uninterrupted skin-to-skin contact in the first hour (Step 4) is one of the most evidence-backed practices on the exam. It stabilizes the newborn's temperature, heart rate, and blood glucose, calms the infant, releases maternal oxytocin (aiding let-down and uterine contraction), and lets the infant move through the instinctive breast crawl to self-attach. The first hour is sometimes called the "sacred hour"; routine procedures (weighing, bathing) can usually wait so the dyad stays together for the first feed.

Rooming-In

Rooming-in (Step 7) keeps mother and infant together 24 hours a day. It lets the parent learn cues, feed frequently and responsively, and respond at the first early signs of hunger — all of which protect milk supply and reduce unnecessary supplementation. Separating the dyad (nursery care, scheduled feeds) does the opposite: missed cues, fewer feeds, lower stimulation, and more formula top-ups.

Putting the Perinatal Pieces Together

The practices in this section reinforce one another, and the exam expects you to connect them:

• Prenatal education sets realistic expectations and a support plan.
• Skin-to-skin in the first hour stabilizes the infant and enables the first feed.
• Rooming-in sustains frequent, cue-based feeding.
• Exclusive breast milk unless medically indicated protects supply and the gut.
• Anticipating birth-factor disruptions (medications, cesarean, separation) prompts early milk removal before problems set in.

When a stem describes a disrupted birth, the credited answer almost always reunites the dyad, starts early milk removal, and monitors intake rather than defaulting to supplementation or weaning.

Example: A baby born by cesarean under spinal anesthesia, separated for 90 minutes in recovery, is sleepy and has not yet fed by hour two. The IBCLC's plan reflects this section: reunite the dyad for skin-to-skin as soon as the mother is stable, teach hand expression of colostrum to feed the baby and stimulate supply (anticipating possible delayed Lactogenesis II after cesarean), wake the infant for frequent feeds, and arrange rooming-in so cues are not missed.