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Table 2 Clinical considerations when helping obese mothers to breastfeed successfully

From: Reduced breastfeeding rates among obese mothers: a review of contributing factors, clinical considerations and future directions

Prenatal
Obese mothers may benefit from Rationale
Strategies to limit weight gain in pregnancy Reduce the risk of preeclampsia, gestational diabetes, LGA baby, and cesarean birth [5].
Discussion of strategies such as doula care and non-pharmacological pain management to reduce the need for labor interventions. Constant support by a doula or other trained care provider during labor has been shown to shorten the length of labor and reduce the incidence of surgical birth by as much as 40 % in the general population [96, 97].
Intrapartum
Obese mothers may benefit from Rationale
Careful evaluation of adequate time to labor First stage of active labor increases with increasing BMI. Research indicates a need to reevaluate normal labor progression in obese women to establish new guidelines to prevent unnecessary augmentation and surgical intervention [52].
Assistance with non-pharmacological pain management techniques Long labor and stressful or surgical birth can contribute to DOL [98100].
Judicious use of pitocin/ IV fluids Reduce risk of DOL due to postpartum edema [101].
Constant support while laboring Obese pregnant women have been shown to have higher levels of anxiety and stress, which may contribute to excessive catecholamine levels and reduced uterine contractibility [52].
Early Postpartum
Obese mothers may benefit from Rationale
Guidance on how to know baby is getting enough milk Perception of insufficient milk is the most common reason mothers do not breastfeed as long as desired. This is even more common in obese mothers [81].
Demonstration of multiple feeding positions such as: Pain is cited as second most common cause of breastfeeding discontinuation. This is even more common in obese mothers [81]. Demonstrating multiple options for positioning allow for better tailoring to mother’s needs, and reduced nipple stress.
Laid-back breastfeeding positions
Side-lying
Cradle/cross cradle hold
Clutch/football/underarm hold Breastfeeding positions that utilize semi-reclined maternal posture may work particularly well for obese mothers as they utilize mother’s torso to support baby, obviating the need for pillows and breast support. Side-lying positions also provide additional support for breast and baby [102].
Assistance to support large breasts and to better visualize latch Mothers with large breasts may need additional assistance to visualize latch and breastfeed comfortably [103]. A rolled towel or breast sling to elevate the breast and/or a mirror to visualize nipple and latch may be helpful.
Demonstration of reverse pressure softening around areola to enable deeper latch Obese mothers are more likely to experience significant postpartum edema, which can temporarily flatten nipples, making latch difficult. Reverse pressure softening, accomplished by holding gentle reverse pressure around the areola toward the chest wall, can be useful in reducing peri-areolar edema [12, 101].
Specific Guidance to supplement only when medically necessary. Early supplementation is associated with reduced breastfeeding duration and exclusivity, and risk is elevated in children of obese mothers [81].
Use Academy of Breastfeeding Medicine Protocol #3 to verify medical need for supplementation [104]
Continued support postpartum Phone support by an IBCLC may increase breastfeeding duration and exclusivity in some populations of obese mothers [90]. Regular phone support, referral to breastfeeding support groups, and skilled in-person care should be a priority in this at-risk population.