Evaluation of the effect of natural and emotional stress of labor on lactation and breast-feeding

Abstract

The amount of stress experienced by both the mother and fetus during labor and delivery varies considerably and is likely to be different in primiparous and multiparous women as well as in those who receive analgesia during labor and those who do not recieve.
In this study, we explored relations between stress during birth experience and lactogenesis of 100 women, who experienced vaginal delivery in Department of Obstetrics and Gynecology of University Hospital of Alexandroupolis.
Stress hormones (cortisol and glucose) were measured in serum (cord and maternal blood) immediately after delivery. Moreover, breast-feeding frequency on day 4, the time when the subjects first felt fullness in the breasts, milk volume on day 4 postpartum and duration of labor were recorded. Also, we recorded maternal exhaustion score during labor and positive and negative affects, posttraumatic stress score and mother-infant bonding rate, with the use of questionnaires.
There were significant intercorrelations among the outcome variables. Mothers who experienced pain, exhaustion and negative feelings in a stressful and long labor had delayed onset of lactation.
These results indicate that primiparity, long labor, stress to the mother and fetus during labor and delivery, negative affects and high score of posttraumatic stress are risk factors for delayed lactogenesis.

Full text

MATERNAL-FETAL MEDICINE
Evaluation of the effect of natural and emotional stress of labor
on lactation and breast-feeding
Marina Dimitraki
1
•Panagiotis Tsikouras
1
•Bachar Manav
1
•Theodora Gioka
2
•
Nikoletta Koutlaki
1
•Stefanos Zervoudis
3
•Georgios Galazios
1
Received: 17 December 2014 / Accepted: 1 June 2015
ÓSpringer-Verlag Berlin Heidelberg 2015
Abstract
Background The amount of stress experienced by both
the mother and fetus during labor and delivery varies
considerably and is likely to be different in primiparous
and multiparous women as well as in those who receive
analgesia during labor and those who do not recieve.
Objective In this study, we explored relations between
stress during birth experience and lactogenesis of 100
women, who experienced vaginal delivery in Department
of Obstetrics and Gynecology of University Hospital of
Alexandroupolis.
Method Stress hormones (cortisol and glucose) were
measured in serum (cord and maternal blood) immediately
after delivery. Moreover, breast-feeding frequency on day
4, the time when the subjects first felt fullness in the
breasts, milk volume on day 4 postpartum and duration of
labor were recorded. Also, we recorded maternal exhaus-
tion score during labor and positive and negative affects,
posttraumatic stress score and mother–infant bonding rate,
with the use of questionnaires.
Results There were significant intercorrelations among
the outcome variables. Mothers who experienced pain,
exhaustion and negative feelings in a stressful and long
labor had delayed onset of lactation.
Conclusions These results indicate that primiparity, long
labor, stress to the mother and fetus during labor and
delivery, negative affects and high score of posttraumatic
stress are risk factors for delayed lactogenesis.
Keywords Stress Labor Breastfeeding Stress
hormones Cortisol Glucose
Introduction
Stress is inevitable, something we all go through. It can be
psychological, organic or (usually) both [1]. Prolactin
(PRL) is synthesized in the front lobe of pituitary by the
lactotroph cells. Prolactin is a polypeptide of 198 amino
acids with a molecular weight of 22.000 bases. The pitu-
itary lactotroph cells increase in number during pregnancy
due to the mitogenic effect of estrogens. Prolactin secretion
is controlled by a complicated hormone system which
includes inhibiting and stimulating factors. Dopamine and
c-amino butyric acid (GABA) are inhibiting factors, while
some of the stimulating factors are TRH, estrogens, oxy-
tocin, VIP, angiotensin II, serotonin, endogenous opioids,
histamine and neurotensin [2]. It is worth mentioning, that
even though prolactin levels during pregnancy are very
high, they begin to decrease after labor together with the
estrogen levels. Generally, the prolactin level alterations
follow the estrogen level alterations as long as estrogens
are stimulating factors of the prolactin secretion. Even if
during pregnancy these two hormones increase, estrogens
impede the lactative effect of prolactin on breasts,
&Panagiotis Tsikouras
ptsikour@med.duth.gr
1
Department of Ob/Gyn, University Hospital of
Alexandroupolis, Democritus University of Thrace,
68100 Alexandroupolis, Greece
2
Department of Laboratory, University Hospital of
Alexandroupolis, Democritus University of Thrace,
Alexandroupolis, Greece
3
Department of Ob/Gyn, University Davilla of Romania and
Rhea Hospital Athens, Bucharest, Greece
123
Arch Gynecol Obstet
DOI 10.1007/s00404-015-3783-1

preventing milk secretion during pregnancy. But after
delivery and the following decrease in estrogen levels,
prolactin is able to stimulate the beginning of milk secre-
tion. During lactation the basal serum prolactin levels are
not significantly increased. Lactation is maintained by
periodic prolactin release which is due to breast-feeding.
The maintenance of lactation depends on the breast-feeding
frequency, but not on the breast-feeding duration [1,3].
Placenta delivery results in an abrupt decrease in proges-
terone (progesterone secretion decreases just before labor),
estrogen and human placental lactogen (HPL) levels. The
decrease of progesterone levels is prior to the decrease in
estrogen levels. As a result, the circulating estrogens
stimulate the pituitary for PRL production [4]. Therefore,
the high prolactin levels signal the second stage of lacto-
genesis (the beginning of increased milk secretion) which
takes place 30–40 h after delivery [3,5].
During labor, a decrease in estrogen levels followed by a
decrease in progesterone and HPL levels is noticed. The
decrease in progesterone levels gives the signal for the
beginning of lactogenesis. Delay in lactogenesis has been
reported in women because of remaining placenta, which
continues to produce progesterone [6,7]. Additionally, the
exogenous progesterone administration in pregnant mam-
mals seems to contribute to the maintenance of lactose and
lipid production after oophorectomy. Therefore, this
decrease of progesterone levels defines the beginning of
lactogenesis [8–11].
Beyond the progesterone effect, the role of two other
hormones is basic for the beginning and maintenance of
milk production. These are prolactin and cortisol. The de-
crease in progesterone levels acts as a trigger for lactoge-
nesis. However, it seems that this decrease alone would not
be effective without the effects of prolactin and glycocor-
ticosteroids. The increase of these two factors is to an
extent a necessary basis of progesterone levels’ decrease
and of the beginning of lactation that follows [1].
The aim of this study was to investigate the effect of
physical and psychological stress that mothers and new-
borns undergo during labor, in lactogenesis and lactation.
Specifically, in the current study, the following research
hypotheses are considered:
Women with higher stress levels during labor and more
negative feelings will have lower lactation markers.
Positive feelings and the bonding with the newborn
increases after the day of delivery.
Women with painful labor (duration, hormones) will
have more negative feelings, stress and decreased bonding
with the newborn.
Women with negative feelings, stress and decreased
bonding with the newborn will have lower lactation
markers.
Materials and methods
Hundred pregnant women who were screened during their
pregnancy and delivered in The University Hospital of
Alexandroupolis from November 2009 to April 2010 were
included in this study.
Before participation in the study, their medical and
obstetric history was recorded. They were all informed in
detail about the study and signed a consent form. All the
participants had single pregnancies, were non-smokers, had
normal glucose tolerance test during pregnancy, had no
other pathologies and were from the general area of
Alexandroupolis, Evros. They all had their delivery after
the 38th gestational age. Additionally, their willingness to
feed their newborns exclusively with maternal milk was of
one the basic criteria for participating in this study. All
women had attended a 2 day training course in breast-
feeding twice during 20–25th and 35–37th week of preg-
nancy. To minimize the effects of previous experience in
breast-feeding and education on the results of the study, all
women had attended the same training course in breast-
feeding during pregnancy.
This study had the permission from the local scientific
council and was consistent with the Helsinki principles.
Some of the parturienst had epidural anesthesia during
labor. All women were supported right after delivery and
during their hospitalization concerning lactation and were
given the necessary advice and instructions about the
breast-feeding procedure by specialized midwifes of the
obstetrics and gynecology department.
All women underwent a blood sampling during the 36th
week of pregnancy, under fasting and in calm atmosphere
between 07.00–08.30 a.m., and a full hormone test was
conducted.
In the maternity department nor intravenous oxytocin or
any other medical substances or other means of active
treatment of labor were administered.
After delivery blood sample from the umbilical cord
(both venous and arterial) was taken, and within the first
10 min after delivery blood sample from the mother was
taken as well.
Furthermore, after the labor procedure was complete,
mothers were asked to:
1. evaluate the stress levels they went through according
to a 0–10 scale (0 =none, 10 =unbearable);
2. complete the PANAS questionnaire for the positive
and negative feelings imprint and evaluation;
3. evaluate their posttraumatic stress by completing the
PTSD scale;
4. complete the Mother to Infant Bonding Scale ques-
tionnaire, to evaluate the mother–newborn bonding.
Arch Gynecol Obstet
123

The total delivery duration was recorded. The beginning
time was considered to be the hour in which women were
in the active labor phase (cervix dilation [4 cm).
The hour of first breast-feeding and the hour of the first
breast-filling sense of the mothers were recorded.
On the 4th day after delivery, mothers were again asked
to complete the Mother to Infant Bonding Scale
questionnaire.
They were also asked to collect their milk, so that the
first 24 h milk volume could be assessed.
Newborns’ meal frequency was recorded on the 4th day
after delivery.
On the 4th day after delivery, the milk was collected
using an electrical breast pump and the milk volume was
measured in volumetric vessels.
The blood samples were centrifuged and refrigerated in
-20 °C, until the time they were analyzed in a laboratory.
Cortisol levels were measured by a quantitative electro-
chemiluminescence method called ECLIA, which was
destined for use in using Elecsys 1010/2010 immunoana-
lyzers and MODULAR ANALUTICS E170 (Elecsys sub-
union) immunoanalyzers of Roche and is expressed in mg/
dL.
Umbilical cord glucose was evaluated using a bio-
chemical analyzer (Olympus) and expressed in mg/dL.
The questionnaires (the PANAS, the PTSD scale and
the Mother to Infant Bonding Scale) were completed on
the 4th day after delivery by the mothers themselves,
after they had read them, without the researcher’s
interruption, in a calm environment and in a calm psy-
chological state.
Statistical analysis
For the statistical analysis of data, the statistics program
SPSS 15.0 for Windows (Statistical Package for Social
Sciences) was used. For the variables studied, mean ±s-
tandard deviation (SD) was estimated. For the control of
normal distribution, Shapiro–Wilks test was used. For the
control of equal variances between the groups, the
Levene’s test for equality of variances was conducted. For
the statistical analysis of the equality of means of two
independent samples that do not have normal distribution,
the non-parametric Mann–Whitney Utest was used. For
the statistical investigation of related samples, the Stu-
dent’s ttest, and for observations in pairs, the non-para-
metric Wilcoxon signed rank test was used. To observe the
correlation of quantitative variables, the r Pearson corre-
lation coefficient that ranges from -1 (negative correla-
tion) to 1(positive correlation) was used.
The level of statistical significance was defined at
p\0.05. Lastly, the model of multiple regressions was
used to evaluate and find the most important factors.
Maternal positive and negative feelings immediately
after delivery and PTS may be evaluated with the use and
evaluation of the Positive and Negative Affectivity Scale
(PANAS) and Posttraumatic Stress Disorders Scale (PTSD
scale). Higher score in the evaluation of the above ques-
tionnaires is linked to higher positive/negative feelings and
PTS.
Results
Five of the 100 women who were chosen to participate in
the study were excluded because of their decision to use
market milk instead of breast-feeding their newborns. From
the rest 95 women, 61 (64.2 %) were multiparous ([1
labor) and 34 (37.8 %) were nulliparous. 22 (23.15 %)
women received epidural analgesia immediately after their
induction in the active phase of labor [10 (29.4 %) nulli-
parous and 12 (19.67 %) multiparous]. All of the multi-
parous women had breast-fed their previous children.
Nulliparous differed from multiparous in BMI, in that
multiparous had obviously higher BMI [27.54 (±1.83)
versus 28.35 (±1.10)] (Table 1). All the newborns
weighted [2.500 gr. The mean age of the nulliparous was
27.25 (±3.25) years, whereas the mean age of the multi-
parous was 31.09 (±3.21). The nulliparous declared that
they underwent greater exhaustion levels than the multi-
parous women. Serum cortisol levels were about 52.42 mg/
dL (±18.82) in nulliparous and about 47.02 mg/dL
(±13.49) in multiparous women.
There were no mentioned differences between the two
groups in the newborns’ birth weight and in the Apgar
score. However, there were differences in the labor dura-
tion. As mentioned above, the first stage of labor is the time
that intervals from the begging of real-active labor (cervical
dilation [3 cm) until the complete cervical dilation,
whereas the 2nd stage of labor is the meantime between the
complete cervical dilation and the neonatal delivery. Nul-
liparous with regards to multiparous had longer duration of
the 2nd stage of labor and there was a significant difference
between the two groups in the total labor duration
(11.43 ±2.2 versus 6.24 ±1.93 h) (p=0). Between the
two groups, there was a significant difference (p=0) in the
number of newborns’ meals on the 4th day after delivery
and it seems that the multiparous women have a tendency of
breast-feeding more frequently (p=0.022). The nulli-
parous women sensed the breast filling later than the mul-
tiparous women (83.58 ±10.85 versus 45.03 ±11.59 h),
and the milk volume on the 4th day was significantly lower
(557.35 ±63.06 versus 719.01 ±60.79 ml) (p=0).
There was a difference in maternal serum cortisol levels
between nulliparous and multiparous women (52.42 ±
18.82 versus 47.02 ±13.49 lg/dL) (normal rates:
Arch Gynecol Obstet
123

6.2–11.9 lg/dL), but it was not statistically significant
(p=0.146). The neonatal blood glucose levels were also
higher in the nulliparous newborns (82.58 versus 82.08)
without statistical significance (p=0.901). However, the
difference in serum cortisol levels between the women who
received epidural analgesia during labor and those who did
not was significant (27.09 ±5.79 versus 55.54 ±11.1 lg/
dL) (p=0) (Table 2).
There was a significant difference (p\0.05) in labor
stress and exhaustion levels between the women who
received epidural analgesia and those who did not
(3.37 ±0.65 versus 7.89 ±1.1). Those who received
analgesia, breast-fed their newborn for the first time soon
after delivery (44.13 ±18.3 versus 54.04 ±22.57 min),
but the difference was not statistically significant p=0.0
(63). Statistically significant difference was not mentioned
between the two groups as far as the milk volume on the
4th day after delivery (p=0.084) (693.18 ±109.51 ver-
sus 651.5 ±94.45 ml) and time of breast filling sense
(p=0.074) (51.54 ±19.22 versus 61.02 ±22.17 h)
(Table 3) are concerned.
The evaluation of the Mother to Infant Bonding ques-
tionnaire, that were completed immediately after delivery,
and that completed on the 4th day after labor shows a
distinct improvement in bonding on the 4th day, in all the
groups, regardless of whether or not they received anal-
gesia during labor [nulliparous 4.45 (±2.65) versus 0.87
(±0.99)—multiparous 2.83 (±1.98) versus 0.42 (±0.76)]
or received analgesia [nulliparous 0.9 (±1.1) versus 0—
multiparous 0.83 (±0.83) versus 0]. This difference is not
statistically significant (p=0.00, \0.05).
Women with longer labor duration had higher serum
cortisol levels and higher umbilical cord blood glucose
levels. The longer labor duration had positive correlation
with the presence of negative feelings (r=0.533), higher
levels of PTS (r=0.508) and lower maternal-neonatal
bonding levels (r=0.530), correlations statistically sig-
nificant at significance limit (p=0.103). The labor dura-
tion had a negative correlation with the presence of positive
feelings (r=-0.169, but this correlation was not statisti-
cally significant (p=0.103).
Table 1 Basic characteristics of the patients participating to the
study
Nulliparous (n=34)
Regional anesthesia: 10
(29.41 %)
Multiparous (n=61)
Regional anesthesia: 12
(19.67 %)
Maternal age
(years)
27.25 (±3.25)
a
31.09 (±3.21)
BLI (kg/m
2
) 27.54 (±1.83) 28.35 (±1.10)
Gestational age
(weeks)
39.58 (±0.62) 39.6 (±0.62)
Parturitions 1 2.2 (±0.8)
a
Mean ±standard deviation (SD)
Table 2 Correlation of maternal serum cortisol levels and umbilical cord glucose levels with the number of previous labors and receiving or not
regional anesthesia
Nulliparous (n=34) Multiparous (n=61)
?Reg. anesth. (n=10) -Reg. anesth. (n=24) ?Reg. anesth. (n=12) -Reg. anesth. (n=49)
Maternal serum cortisol (lg/dL) 27.19 (±6.09) 62.93 (±10.09) 27.01 (±5.81) 51.92 (±9.76)
Umbilical cord glucose (mg/dL) 65.3 (±10.65) 89.79 (±19.26) 66.75 (±7.47) 85.83 (±15.22)
Table 3 Results based on the correlation of the number of previous labors with receiving or not regional anesthesia
Nulliparous (n=34) Multiparous (n=61)
?Reg. anesth. (n=10) Reg. anesth. (n=24) ?Reg. anesth. (n=12) -Reg. anesth. (n=49)
Labor duration (1st–2nd st.) (h) 10.64 (±1.99) 11.77 (±2.24) 5.6 (±1.81) 6.39 (±1.95)
Exhaustion levels 3.58 (±0.75) 8.63 (±0.8) 3.2 (±0.56) 7.53 (±1.05)
1st meal after labor (min) 62.1 (±8.15) 84.04 (±8.9) 29.16 (±6.89) 39.34 (±7.45)
Number of meals (day 4) 9.3 (±0.48) 8.37 (±0.71) 9.6 (±0.49) 8.89 (±0.82)
Breast filling (h) 71.1 (±6.57) 88.79 (±7.49) 35.25 (±5.77) 47.42 (±11.67)
Milk volume (day 4) 589 (±74.6) 544 (±53.96) 780 (±15.95) 704.08 (±58.34)
Positive feelings 36.8 (±3.9) 32 (±2.5) 38.08 (±0.99) 42.4 (±4.3)
Negative feelings 13.2 (1.81) 19.75 (4.27) 14.16 (2.51) 15.55 (±3.36)
Levels of posttraumatic stress 7.1 (±2.33) 21.75 (±8.75) 7.08 (±2.81) 11.75 (±7.39)
Maternal-newborn bonding (day 0) 0.9 (±1.1) 4.45 (±2.65) 0.83 (±0.83) 2.83 (±1.98)
Maternal-newborn bonding (day 4) – 0.87 (±0.99) – 0.42 (±0.76)
Arch Gynecol Obstet
123

The maternal cortisol levels presented positive correla-
tion with the presence of negative feelings and PTS
(r=0.513), and statistically significant and negative cor-
relation with the presence of positive attitude in mothers
(r=-0.131) (statistically non-significant, p=0.205).
Maternal cortisol levels also has a significant negative
correlation with the maternal-neonatal bonding
(r=0.523).
Moreover, both the maternal exhaustion level during
labor and the umbilical cord glucose levels that reflects the
neonatal stress and exhaustion during labor, are correlated
with the maternal feelings for the labor and for the newborn
(p\0.01) (Fig. 1; Tables 4,5,6).
The longer labor duration, that was also correlated with
higher exhaustion levels, with the presence of negative
feelings, with PTS and weaker maternal-neonatal bonding,
is also, linked to lower meal frequency on the 4th day after
labor (Fig. 2).
The levels of negative feelings and the levels of PTS
mothers experienced because of the labor were strongly
correlated with variables that are considered in this study as
lactogenesis markers (milk volume on the 4th day, meal
frequency, breast filling sense, first feeding after delivery).
The levels of maternal positive feelings after labor were
strongly correlated with the milk volume on the 4th day
after labor, the time after delivery and the meal frequency
of the newborn (p\0.01), whereas the correlation was not
statistically significant regarding the time after delivery
when the first breast-feeding took place (p=0.1), as well
as the time after delivery when mothers sensed breast-
filling (p=0.7).
If the answers to the questionnaires that the mothers
completed on the 4th day after delivery are taken under
consideration, the aspect which was analyzed in the first
part of the current study, according to which, some lack of
emotion and a feeling of estrangement immediately after
delivery is very common, but soon and rapidly is overtaken
by the emotional bonding that is gradually developed
between the mother and the newborn, is confirmed. The
maternal-neonatal bonding level, immediately after deliv-
ery was significantly correlated with the lactogenesis
markers of this study, the milk volume on the 4th day after
delivery (r=0.373),the breast filling (r=0.412),the meal
frequency and the time of the first meal after delivery
(r=-0.513, r=0.377) (Table 7; Fig. 2).
In the analysis of multiple regressions, independent
variables (labor duration, number of labors, epidural anal-
gesia and age) were estimated with reference to the PTS
levels. The results of this analysis showed that analgesia
(b=0.375, p\0.001) and labor duration (b=0.446,
p=0.001) are strongly linked to PTS (the total model
predicts R
2
=0.39) (Tables 8,9).
PositiveFeelings
337,0042,0041,0040,0039,0038,0037,0036,0034,0033,0032,0031,0030,0029,00
Cortisol(µg/dL)
80,00
60,00
40,00
20,00
10
8
9
Fig. 1 The correlation of serum
cortisol levels with the degree of
maternal positive feelings
Arch Gynecol Obstet
123

Discussion
In the current study, to evaluate the sentimental state of
participating women, the Panas Scale questionnaire was
used. Many scales of sentimental evaluation have been
created and proposed during the past years, without relia-
bility in result. In 1988, Watson Clark and Tellegen col-
lected the data they had until then, and proposed the Panas
Scale. It is about a psychometric scale, of answer autoex-
posion in questions, which concerns moods and feelings at
a specific time. At the beginning, it included 60 items but
later it was restricted to 20 items. The scale consists of 2
subscales of 10 items each, one for the positive (joy,
interest, determination, optimism, power, concentration)
and one for the negative feelings or subjective dysphoria
(fear, anger, shame, guilt, anxiety, exhaustion). Responders
are asked to rate the extent to which they have experienced
each particular emotion within a specific time period
(24 h), with reference to a 5-point scale. The scale points
are: 1 ‘‘very slightly or not at all’’, 2 ‘‘a little’’, 3 ‘‘mod-
erately’’, 4 ‘‘quite a bit’’ and 5 ‘‘very much’’. The scale is
extensively used in psychology and other sectors for the
measurement of affects both in present and past. It is brief
and easy, and has shown high reliability and validity. Many
assert that this specific scale offers reliable (reliability of
the PA scale ranged from 0.86 to 0.90, the NA scale from
0.84 to 0.87), precise and an absolutely independent mea-
surement of PA and NA, regardless the subject, the time
frame and the way of answer [12,13]. According to uni-
versal research documents from reputable universities of
Europe and the United States, it has been proved that
specific catastrophic past events had a great impact on
psychological and body health of human beings. The term
posttraumatic stress disorder is universally used to describe
the psychological statement of a person after a catastrophic
life event and in most cases, persists for a long time after
the event takes place. According to the American Psychi-
atric Association, this syndrome is classified to stress dis-
orders. The association itself has defined a great amount of
symptoms among which, the most common include sleep
disorders (ex. nightmares), constant revival of the
Table 4 Correlation of labor
factors with positive and
negative feelings, posttraumatic
stress and maternal-newborn
bonding (r, Pearson correlation
coefficient)
Cortisol Glucose Exhaustion levels Labor duration
Positive feelings -0.131
2
-0.143
2
-0.108
2
-0.169
2
Negative feelings 0.513
1
0.458
1
0.518
1
0.533
1
PTS 0.513
1
0.446
1
0.508
1
0.505
1
Maternal-newborn bonding 0.533
1
0.496
1
0.530
1
0.371
1
1
S(p\0.01)
2
NS (p[0.01)
Table 5 Psychological characteristics among women who received
or not epidural analgesia
Epid. analgesia NMean
Bonding I Yes 22 0.8636
No 73 3.3699
Bonding II Yes 22 0.0000
No 73 0.5753
PTSD Yes 22 7.0909
No 73 15.0411
Positive feelings Yes 22 37.5000
Negative feelings Yes 22 13.7273
No 73 16.9315
Table 6 Comparison between
women who received regional
analgesia with those who did
not-significance test, test for
equality of variances between
groups
Levene’s test for equality of variances t-test for equality of means
FSig. tdfp
Bonding I 15.733 0.000 -4.875 93 0.000
-7.366 85.729 0.000
Bonding II 62.672 0.000 -3.109 93 0.002
-5.685 72.000 0.000
PTSD 34.636 0.000 -4.025 93 0.000
-6.637 92.767 0.000
Positive feelings 0.779 0.380 -0.195 93 0.846
-0.354 74.764 0.725
Negative feelings 16.021 0.000 -3.457 93 0.001
-4.709 66.779 0.000
Arch Gynecol Obstet
123

traumatic event, decreased ability of mnemonic redial,
severe concentration difficulties(especially in mental
work), obsessions, disturbing thoughts, severe internal
tense, depression syndromes, paranoia, estrangement and a
number of problems/conflictions in interpersonal relation-
ships. Another important symptom of PTSD is ‘‘the
survivor’s guilt’’. It represents the sense of injustice sur-
vivors feel towards familiar or lovely people who have not
been as lucky as them [14].
Furthermore, recent studies showed that those who
suffered PTSD obtained irreversible changes in their brain.
They had increased epinephrine, norepinephrine,
Laborduration(hours)
14,2012,6011,509,808,908,407,907,206,505,805,104,303,702,90
Firstfeeding(min)
100,00
80,00
60,00
40,00
20,00
0,00
Fig. 2 The correlation of labor
duration with first breast-
feeding
Table 7 Correlation of
lactogenesis-breast-feeding
markers with labor factors (r,
Pearson correlation coefficient)
(p\0.01)
Breast
filling (h)
Milk volume
on the 4th day (ml)
1st meal
(min)
Meal frequency
on the 4th day
Cortisol 0.514 -0.488 0.492 -0.737
Glucose 0.362 -0.314 0.285 -0.608
Parturition -0.852 0.786 -0.883 0.235
a
Labor duration 0.881 -0.850 0.857 -0.604
Analgesia -0.679 0.623 -0.703 0.053
b
Exhaustion 0.454 -0.436 0.464 -0.649
Positive feelings -0.87
c
0.205
a
-0.17
d
0.211
a
Negative feelings 0.577 -0.453 0.498 -0.570
PTS 0.561 -0.507 0.531 -0.508
Maternal-newborn bonding (after labor) 0.412 0.373 0.377 -0.513
a
Statistical significance at p\0.05
b
p=0.613
c
p=0.7
d
p=0.1
Arch Gynecol Obstet
123

testosterone, cortisol levels and increased thyroxin func-
tion [14]. In 1980, the American Psychiatric Association
added the PTSD scale in the third version of the diag-
nostic and statistic classification manual of mental dis-
orders (DSM-III). Even if it was controversial at first, the
PTSD scale has filled up an important gap in psychiatric
theory and practice. From historical point of view, the
important alteration is that this scale introduces the idea
according to which the causal factor is out of the person (a
traumatic event), not the person’s internal weakness. The
key to understanding the scientific basis and the clinical
symptoms of PTSD is the word, trauma. Neurobiological
researches show that posttraumatic stress can be associ-
ated with stable changes in the center as well as the
peripheral nervous system. Psycho physiological changes
that are linked to posttraumatic stress include hyper
stimulation of the sympathetic nervous system, increased
sensibility, increased reflexes, sleep disorders, etc. [14].
There are converging indications that 2 % of women
fulfill the PTSD criteria after delivery. Researches asso-
ciate stressful labor with posttraumatic mental disorders
after delivery [15–17]. Initially, it should be underlined
that the term connection refers to the bonding that
describes the mother’s feelings towards the newborn, not
including the baby’s attachment.
An important role in the maternal–newborn relationship
plays the delivery its self. However, this relationship starts
earlier, during pregnancy. The effect of perinatal events in
this relationship and in the development of the child
attracts great interest [18–20]. Taylor et al. [21] ended up to
a negative correlation of postpartum sentimental instabil-
ity-depression with the maternal–newborn bonding level.
However, the maternal–newborn relationship development
is the most important psychological procedure during the
puerperium period. Studies have shown that although many
mothers are indifferent to the newborns at first touch, an
Table 8 Multiple regression of
the factors that predict
posttraumatic disorder
Model summary
R
2
Adjusted R
2
Std. error of the estimate
0.392 0.0365 6.97206
Coefficients
b
Model Unstandardized coefficients Standardized coefficients tSig.
BStd. error b
1 (Constant)
a
-10.397 8.260 -1.259 0.211
Labor duration (hours)
a
1.212 0.362 0.446 3.345 0.001
Epidanalgesia
a
7.730 1.741 0.375 4.440 0.000
Age (years)
a
0.080 0.224 0.034 0.355 0.724
Nolab
a
-1.372 2.605 -0.076 -0.527 0.600
a
Predictors: (constant), no lab, epid analgesia, age (years), labor duration (hours)
b
Dependent variable: PTSD
Table 9 Multiple regression of
factors that predict the bonding
with the newborn
Model summary
Model RR
2
Adjusted R
2
Std. error of the estimate
1 0.577
a
0.333 0.304 1.96575
Coefficients
b
Model Unstandardized coefficients Standardized coefficients tSig.
BStd. Error b
1 (Constant) -5.175 2.329 -2.222 0.029
Labor duration (hours) 0.303 0.102 0.414 2.968 0.004
Epidanalgesia 2.367 0.491 0.426 4.822 0.000
Age (years) 0.030 0.063 0.048 0.481 0.632
Nolab 0.256 0.734 0.052 0.349 0.728
a
Predictors: (constant), no lab, epid analgesia, age (years), labor duration (hours)
b
Dependent variable: bonding I
Arch Gynecol Obstet
123

affective relationship is developed during the period of first
week [22]. A disappointing lack of feelings, that sometimes
is accompanied by an estrangement feeling is very com-
mon, but does not cause great concern as it almost always
in brief. However, a small minority of these mothers may
develop a persistence apostrophe towards the newborn (in
general community these disorders affect 1 in 100 women)
[23,24]. The maternal–newborn relationship develops and
grows through common pleasure, as in all other relation-
ships. The baby has the power of awaking mother’s emo-
tions, so the target is to create conditions under which the
mother and the baby may enjoy each other [24,25]. The
investigation of this early emotional relationship and
mother’s early attitude towards the newborn is very
important. Nowadays, there are many questionnaires that
may be used to detect the ‘‘bonding’’ disorders early. One
of them is the Mother to Infant Bonding Scale question-
naire, which can be completed and gives immediate
information. In the current study, women were asked to
complete this specific questionnaire twice. First, just after
the delivery and then on the 4th day after delivery, based
on the conviction that the maternal–newborn bonding is
gradually evolved, before the baby is born until the early
postpartum period and during the infancy. Higher score in
the evaluation of this questionnaire is linked to lower
maternal–newborn bonding.
Delivery is a stressful fact which causes alterations in
women’s hormone profile affecting mainly the hormones
that are related to stress. It is also known that successful
lactation depends on physiological–hormonal factors, as
well as on psychological and social factors that may affect
the beginning of lactation.
The current study aimed to investigate the factors that
are linked to delayed lactogenesis, focusing mainly on
events that are associated with the labor itself (duration,
pain), in stress hormones and in psychological parameters
arising from the labor itself, as a procedure, as well as in
lactogenesis-lactation markers after labor (the time
between labor and first feeding, meal frequency and milk
volume on the 4th day after labor, the time after labor
mothers felt their breasts filled).
As mentioned above, stress during this period, which
frames the labor time, in some level, is normal and has
positive correlation with lactogenesis. Beck et al. examined
the impact of birth trauma on mothers’ breast-feeding
experiences and concluded that birth trauma either pro-
moted or impeded breast-feeding [26]. However, it seems
that experiencing great stress during labor (both mothers
and newborns) has dramatic effects on breast-feeding [27–
29].
Stress may be distinguished in physical or physiological
(pain, exhaustion, etc.) and in emotional state (anxiety). It
is not known whether the way the body responds to the two
types of stress has different effects on lactation. Moreover,
researches in animals have shown suppression of lactation
in cases of exposure to stressors [30].
It seems that a stressful labor may be linked to the delay
in beginning of lactation and to the problems in newborn’s
suction reflexes. The two mechanisms correlating stress
with lactation have been mentioned above [25,31,32].
The long labor time, as well as null parity contributes to
increase in both maternal and newborn’s stress levels
during labor and according to studies, consists delayed
lactation’s risk factors [33–36].
Dewey et al. [31] mentioned maternal and neonatal risk
factors of delayed lactogenesis. In neonatal risk factors,
forceps delivery, irritability and anxiety or newborn’s
indolence, the consumption of market milk or dummy,
wrong breast-feeding position, short tongue frenulum,
hyperbilirubemia and hypoglycemia, were included. As
long as the maternal risk factors are concerned, the same
authors evinced the long labor duration, the caesarian
delivery, the nullparity, the nipple retraction, previous
breast surgery, previous child’s breast-feeding failure,
Diabetes Mellitus type I, obesity and multiple childbirth.
Our study’s results are in accordance with the aforemen-
tioned researchers’ reports, at least concerning the variables
or factors we study, like the labor duration or nulliparity.
The results of our study are also relevant to other studies
that have linked maternal or neonatal stress during labor
with delayed lactogenesis [31,32,37–40]. Some of these
studies included women who placed the newborns to their
breast immediately after delivery, excluding incomplete
breast evacuation from delayed lactogenesis factors [1].
Nulliparity affects probably the time lactogenesis occurs
but it is difficult to determine its precise role because it is
linked to other components as well. In the current study that
included 95 women, the nulliparous had longer labor
duration and had the tense to feed newborns less than the
multiparous. The nulliparous women also had lower milk
volume on the 4th day after delivery and experienced breast
filling later than the multiparous women. Subsequently, in
our study, nulliparity was thought to be a risk factor of
delayed lactogenesis. This result is compatible to results of
other researchers, who rank nulliparity and the lack of
previous experience in breast-feeding to lactogenesis
problems [37,38,41]. However, the lower milk volume on
the 4th day after delivery in nulliparous women may be due
to other factors, like the newborn’s meal frequency.
The long labor duration was also correlated with delayed
lactogenesis, lower milk volume on day 4 and the sense of
breast filling. Some researchers have shown that the long
labor duration is a maternal and neonatal stress factor,
resulting in cortisol levels increase in both. It seems that
increased cortisol levels act inhibiting lactation [37].
Jackson et al. [42] also concluded the correlation of the
Arch Gynecol Obstet
123

difficulty of the labor with lower breast-feeding cases. The
longer labor duration was correlated with higher stress
level hormones—cortisol in maternal serum and glucose
levels in the umbilical cord. There also is a positive cor-
relation between the labor duration and the maternal
exhaustion level. In contrary to our results, a study exam-
ining the correlation of postpartum uterine contractions and
abdominal pain caused by breast-feeding with parity,
showed that pain, referred pain, and uterine contractions
during breast-feeding in the immediate postpartum period
increase with parity, suggesting that childbirth can induce
central neural changes that increase predisposition for pain
during the postpartum period [43].
The results of the studies concerning the effect of
analgesia in lactogenesis-lactation markers are conflicting
[44–48]. In the current study, receiving epidural analgesia
had positive correlation with positive feelings, lower
posttraumatic stress levels and earlier first feeding after
delivery. A systematic review of the literature examining
the unintended maternal, fetal, and neonatal effects of
epidural analgesia used for pain relief in labor by low-risk
women confirmed that epidural is associated with a lower
rate of spontaneous vaginal delivery, a higher rate of
instrumental vaginal delivery and longer labors, particu-
larly in nulliparous women [49].
One of the most important effects of cortisol is
increasing gluconeogenesis in liver and decreasing the
glucose uptake and metabolism by muscles, resulting in
higher serum glucose levels. The serum glucose levels may
also increase because of fetal hypoxia [50]. Chen et al. [37]
showed that high serum glucose levels may be a reliable
marker of fetal stress and may also have a negative effect
in newborn’s wish to get breast-feeded. Other studies
should be carried out to elucidate the relationship between
high glucose levels, appetite and feeding capability, as well
as the newborns’ vigilance levels.
De Carvalho et al. [51] reported that mothers who used
to feed their newborns more frequently had higher milk
volume levels during the first 2 weeks after delivery. The
more frequent breast evacuation results in the obviation of
a topical autocrine inhibitor, which decreases milk secre-
tion by a negative feedback mechanism (dependant on the
existing concentrations). The effect of this autocrine inhi-
bitor may be more obvious in multiparous women, who are
more experienced in breast-feeding. Moreover, the expe-
rience multiparous women have is also very important in
other sectors, like the right breast-feeding position and
satisfying breast evacuation.
In addition, Kulski et al. [52] while evaluating the milk
consistence and the sense of breast-filling in women who
did not breast-feed, asserted that breast evacuation was not
necessary for the programmed physiological alterations
that are responsible for lactopoiesis (second stage of
lactogenesis). In contrary, breast evacuation after delivery
increases the ability of milk production and secretion.
Another team of researchers, Grajeda et al. [39], con-
sidered the maternal serum cortisol levels as a reliable
stress level marker during labor.
The same team of researchers used psycho-social scales
and anxiety measurement scales, and ascertained that there
is a positive correlation between the stress hormone levels
during labor and the results of the scales mentioned above.
Other researchers developed a multi-factorial predictive
model of breastfeeding self-efficacy in the first week post-
partum, the Breastfeeding Self Efficacy Scale (BSES).
BSES includes scores of 8 variables at 1-week postpartum:
maternal education, support from other women with chil-
dren, type of delivery, satisfaction with labor pain relief,
satisfaction with postpartum care, perceptions of breast-
feeding progress, infant feeding method as planned, and
maternal anxiety. According to researchers, BSES may be
used to identify risk factors, enabling health professionals to
improve quality of care for new breastfeeding mothers [53].
In the current study, for the first time, it is attempted to
correlate the maternal, fetal/neonatal stress levels during
labor and the stress hormones levels with the results of
positive–negative affects/feelings measurement scales,
with the results of PTS levels measurement scales and with
maternal–neonatal bonding. The results of this study show
that there is a correlation between all these variables. The
maternal–neonatal bonding was evaluated twice during
puerperium, as mothers were asked to complete the cor-
responding questionnaire first immediately after delivery
and then on the 4th day after delivery. Even though the
results of the maternal–neonatal bonding scale immediately
after delivery are correlated to lactogenesis, the results of
the same scale on the 4th day after delivery do not seem to
have a significant correlation. These results are to some
extent expected, as the feeling of estrangement recedes
soon after delivery (in the 90 % of puerperal). According to
the results of our study, the mother’s mood, as it is eval-
uated by the presence of positive or negative feelings and
the labor’s stress levels’ effects on her (PTS), seem to be
strongly and in many ways associated with the markers we
defined as lactation markers.
The results of our study offer another consideration,
approaching and evaluating other sectors and components,
to the topic of the effect of labor stress factors on lactation
and breast-feeding.
Conclusions
Increased physical or emotional stress during delivery may
negatively affect lactogenesis, influencing the oxytocin
secretory impulse during breast-feeding.
Arch Gynecol Obstet
123

The maternal and the neonatal stress as well, during
labor may affect the lactation.
Nulliparity (especially the delivery of a macrosomic
newborn), long labor duration, and high stress and
exhaustion levels during labor constitute risk factors of the
lactogenesis delay.
Increased emotional stress during labor has a negative
effect on lactogenesis and lactation.
Women that are in the high risk group should be sup-
ported and guided by experienced staff during the first days
after delivery.
Conflict of interest None.
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