Postpartum Breastfeeding

The hormones related to pregnancy prepare a woman’s breasts for making milk. The high level of the hormone prolactin at the end of pregnancy is responsible for initiating milk production. In the last trimester of pregnancy, progesterone, estrogen and human chorionic somatomammotropin stimulate the hypothalamus gland to release prolactin-releasing hormone which stimulates the pituitary gland to release prolactin, which stimulates milk production.

The baby suckling at the breast causes the mother’s pituitary gland to continue releasing prolactin, as well as the hormone oxytocin. Oxytocin is responsible for the ‘let down’ reflex that releases the milk from the breast, as well as the mother’s desire to ‘bond’ with the baby.

Immediately postpartum a woman’s breasts secrete colostrum, a thin yellowish fluid that is highly nutritious and easily digested. Colostrum contains substances that are important to help the newborn’s digestive and immune system mature. About two to three days postpartum the mother’s milk is secreted.

The baby’s continued suckling at the breast maintains the hormonal feedback loop that continues to stimulate milk production. Every time the baby suckles, prolactin and oxytocin are released and milk is produced. If suckling stops milk production stops in a few days.

The elevated level of prolactin associated with breastfeeding suppresses the release of follicle stimulating hormone (FSH) and luteinizing hormone (LH) by the pituitary gland. Low FSH interferes with the preparation of primary oocytes for ovulation. Low LH levels prevent the release of any oocytes that might have matured, as well as interferes with the development of the secretory endometrium that is supportive of implantation. (See again Chapter 2: Reproductive Anatomy and Physiology)

The mother’s level of prolactin rises and falls in response to the baby’s suckling. Theorists on the Lactational Amenorrhea Method (LAM) of birth control state that about three to four hours without suckling will cause the inhibitory effect of prolactin on FSH and LH release to be reduced. If the baby suckles frequently, including short spells of comfort suckling, the prolactin level remains high enough to maintain its inhibitory effect on FSH and LH release. Therefore, the longer the baby goes without suckling the more able is a woman’s body to try to recover its cycles of fertility. Every woman will respond slightly differently to the presence of prolactin and its inhibiting effect on her return to fertility. Her unique response to prolactin while breastfeeding will be reflected in what the patterns of fertile and non fertile days she observes when doing her observational routine.

The first observation a woman makes after childbirth is of lochia, which is the postpartum uterine discharge, composed of blood, mucus from endometrial tissue. Lochia discharge lasts for about four to six weeks postpartum, progressing from a heavy red flow, to a moderate/ light brownish pink flow, and ending with a light/very light white or yellowish-white flow. Its odor and texture is similar to menstrual flow. Charting begins when the postpartum lochial flow is no longer red or pink in colour.  The first follow-up with the HRHP should be two to three weeks after beginning charting. As long as total breastfeeding is maintained, the first 56 days postpartum are considered infertile.

Ovulation may or may not occur before the first ‘period’ (not lochia) postpartum. Research reports state that from 33% to 50% of women ovulate before their first episode of bleeding. LAM considers that breastfeeding is 98% effective in suppressing ovulation provided the following three criteria are met:

1. The mother is using a total breastfeeding method
2. The baby is less than six months old.
3. There has been no return of menstruation.

Total Breastfeeding is defined thus: the baby's only gratification is received from the mother's breast, with the occasional sip of water, the baby suckles on demand, the baby suckles every two to four hours day and night, baby does not suckle a pacifier/soother, and the baby sleeps with mother.

Once a woman ceases total breastfeeding and begins the weaning process she can expect her body to exert itself to return to fertility. She can also expect that breastfeeding alone as a method of birth control is considerably less reliable.

Partial Breastfeeding (Weaning) is defined thus: the baby receives supplemental feeding other than the mother’s milk, the baby suckles a pacifier/soother, and the baby develops a pattern of going goes greater than four hours without suckling. Fertility returns sooner when a woman is partial breastfeeding. If partial breastfeeding is used immediately postpartum the first 27 days are considered infertile. Charting should begin immediately.

Every woman responds individually to breastfeeding’s suppressive effect on fertility. Using the Justisse Method to monitor and chart the postpartum return to fertility is essential in accounting for individual response to breastfeeding. Charting observations daily allows a woman the benefit of directly observing the return of her fertility rather than relying solely on statistics and theories that may or may not accurately reflect her individual experience.

To use the Justisse Method reliably for a method of birth control while breastfeeding, a woman, with the help of a HRHP, will need to learn how to identify her basic infertile pattern (BIP). A change from the basic infertile pattern heralds the return of fertility. The interval of time to expect a return of fertility postpartum is; 4 to 6 weeks non-breastfeeding and 14 months total breastfeeding, with a typical return to fertility in 2 to 4 weeks after beginning the weaning process (partial breastfeeding).

It is useful to make notations of the baby’s breastfeeding patterns and watch for correlations between those patterns and evidence of a return to fertility, or an attempt to return to fertility. The frequency and duration of suckling and skin to skin contact with the baby plays an important role in the delaying of ovulation. Fertility begins to show signs of return as suckling and physical connection between mother and child lessens. This happens when:

• the baby goes without suckling for intervals greater than six hours
• the baby takes nourishment from sources other than the breast
• the baby is held less by the mother as it becomes more independent of her
• the mother is away from the child on a regular basis (e.g. returns to work)

The return of fertility is marked by observations of cervical mucus. Cervical mucus patterns may come and go in a variable pattern, in response the baby’s suckling habits, eventually culminating in an ovulatory event followed by a true menstrual bleed.

Postpartum Not Breastfeeding

If a woman is not breastfeeding the high levels of prolactin which were present prior to delivery fall abruptly. The woman in this situation may consider herself infertile for the first 27 days after birth. Charting should begin immediately postpartum.