Challenges with positioning will be one of the first difficulties to overcome. There are three types of mother-baby dyads with spina bifida and each will have different challenges: vaginal delivery with postnatal surgery, cesarean delivery with postnatal surgery and cesarean delivery following prenatal surgery. Mothers who deliver vaginally will probably have the fewest challenges with breastfeeding as they may be able to initiate breastfeeding more easily and have fewer positioning challenges. Full term cesarean delivery will present a number of challenges as both the mother and baby will be recovering from surgery.
Mothers and babies who undergo prenatal surgery may face some of the greatest challenges as the prenatal surgery carries a high risk of preterm birth. Mothers frequently experience premature rupture of membranes and are at high risk for other complications such as placental abruption. Most of these mothers will have the difficulty of both cesarean surgery and preterm birth.
Other issues mothers of spina bifida babies will face include pumping to bring in and maintain their milk supply during the first few weeks of their baby’s life as the baby will be under sedation recovering from surgery. Once the baby has recovered from surgery enough to feed at the breast, the baby may need help with establishing a good latch if breastfeeding was not attempted during the first few hours of life.
Mothers who deliver vaginally will not have the difficulties of breastfeeding after a cesarean surgery, however they will need to adapt to the baby’s surgical site. Before the surgery to close the lesion, a cross cradle position can be used if no pressure is placed on the lesion. After surgery, a side-lying position can be used or possibly a semi-reclined position if there is good head support for the baby and care is taken to avoid neck extension (Riordan, 561). In the author’s experience, a modified Australian hold in which the baby’s neck and head are carefully supported with both of the mother’s hands can be used as well.
A mother who delivers via cesarean section with the baby undergoing postnatal surgery will need to adjust position to accommodate both her surgical scar on the abdomen and the baby’s surgical scar on his back. Side-lying will probably be the most viable position for these mothers and babies. Many Level IV NICU’s do not have the option for parents to room-in with their babies, so having a bed to breastfeed on may not be a default accommodation for the baby’s room. Parents should ask about the possibility of moving a portable cot into the baby’s room for breastfeeding. If the hospital is not accommodating for a side-lying position, the mother and any breastfeeding helpers should see what can be done to creatively help position both the mother and the baby in a way to safely allow breastfeeding.
Mothers who deliver via cesarean after undergoing prenatal surgery may be able to use the traditional “football hold” since the baby’s surgical scar will have healed in the womb. Side-lying will also be useful for these mothers and babies when the baby can be put to the breast.
Burping the baby with spina bifida is sometimes a concern as no pressure can be placed on the surgical site until the baby has recovered from surgery. Babies who have a lesion in the lower back area can often be burped by patting the middle back area as long as there is no pressure on the surgical site. For babies who have a lesion that covers the middle back area, gently rubbing between the shoulders or rocking on a firm surface can help release air bubbles (Riordan, 561).
Advanced hydrocephalus in which the baby’s head has become severely enlarged is rarely seen in developed countries because of the availability of shunt surgery. However, a baby that has advanced hydrocephalus might be able to breastfeed in a side-lying position with a pillow to support the baby’s large, heavy head. For babies who undergo shunt placement surgery, care must be taken not to place any pressure on the incision sites as the pain could cause the baby to develop an aversion to breastfeeding. The neurosurgeon may prescribe specific limits to head elevation to prevent the ventricles of the brain from decompressing too quickly. Rapid decompression could cause regurgitation while breastfeeding, so feedings should be frequent and on demand (Riordan, 561). Babies may have to have an empty stomach before going into shunt surgery, so the mother may have to pump during the preoperative period and during recovery. The neurosurgeon will give the parents specific instructions for their baby’s surgery. Shunts can last anywhere from a few weeks to a few years, so some mothers may find themselves breastfeeding through more than one surgery during the baby and toddler years.