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2.3 Management After Birth

Key Points - Case Study B

Joanne asks you what she can do before the baby is born to help her successfully breastfeed.

The Ten Steps to Successful Breastfeeding, designed by the ExternalWHO and ExternalUNICEF summarise the maternity practices needed to support and encourage breastfeeding.

Topic 2.1: Preparation Before Birth
Inform all pregnant women about the benefits and management of breastfeeding

Joanne's baby Rosie is born by spontaneous vaginal delivery at 37 weeks following a 15-hour labour. She had been given pethidine (meperidine) and an epidural for pain relief during labour. Are there any features of her birthing experience that may affect breastfeeding?

Topic 2.2: Birthing Factors that Affect Breastfeeding
Labour analgesia and near-term birth
Topic 2.3: Management After Birth
Place Rosie in skin-to-skin contact; Encourage breastfeeding on demand; Practice rooming-in, allow Joanne and Rosie to remain together 24 hours a day; Give Rosie no food or drink other than breastmilk, unless medically indicated; Give Rosie no artificial teats or dummies; Show Joanne how to breastfeed and how to maintain lactation even if she should be separated from Rosie.

Steps 4-9 of the Ten Steps to Successful Breastfeeding outline the optimal management of mothers and their infants from birth to encourage and support breastfeeding.

Step 4 - Place Rosie in skin-to-skin contact

Although Step 4 states

Help mothers initiate breastfeeding within a half-hour of birth, it is now interpreted as Place babies in skin-to-skin contact with their mothers immediately following birth for at least an hour and encourage mothers to recognize when their babies are ready to breastfeed, offering help if needed.
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Ideally Rosie will be placed prone, skin-to-skin on her mother’s abdomen or chest immediately following birth and left for at least the first hour or until she has attempted to breastfeed. Rosie can be quickly dried, and a blanket or other covering placed over mother and infant to maintain body temperature. Routine administration of medications (e.g. Vitamin K) and assessment and weighing of the infant can either be postponed until after this time, or performed with the infant undisturbed2.

Many infants are awake and alert in the first two hours after birth and when left skin-to-skin with their mothers go through an ordered series of innate prefeeding movements with most finding the breast and begin to feed within the first hour or so.3,4 Early suckling has been associated with increased breastfeeding duration and the ability to breastfeed.5

A recent Cochrane review6 has also shown that early skin-to-skin contact of healthy term infants:

Additionally, mothers are less anxious on day 3, are more confident handling their infant by hospital discharge and are more likely to exhibit maternal attachment behaviours.6

The benefits of skin-to-skin contact and early breastfeeding are of even greater importance for infants who are at risk for breastfeeding difficulties such as those born late preterm or whose mothers were given analgesia (particularly opiates) during labour. Women who give birth by caesarean section under epidural or spinal anaesthetic can also hold their infants skin-to-skin either in the operating theatre or in the recovery room. Extra assistance may be required from maternity staff.

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Step 5 - Show Joanne how to breastfeed and how to maintain lactation even if she should be separated from Rosie

Breastfeeding is a natural process; however, it is not instinctive behaviour for mothers. Therefore, even when they have attended antenatal classes, mothers benefit from skilled support and assistance when learning how to breastfeed. Consistent and appropriate help in the postpartum period increases breastfeeding initiation and duration and should be a normal part of maternity care.7,8 In particular helping women to ensure good positioning and attachment of the infant to the breast, teaching them about early feeding cues and expected course of breastfeeding in the first few days and weeks is important.

When an infant is unable to breastfeed (e.g. due to illness of the infant or mother or prematurity) or the infant and his or her mother are separated, the mother requires assistance to initiate and maintain lactation. The infant can then receive breast milk in the short term, and a normal breastfeeding relationship can be established when conditions permit. Mothers benefit from being shown how to express milk (both by hand and pump) as well as being given information regarding expression routines and the safe collection and storage of breast milk.

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Step 6 - Give Rosie no food or drink other than breastmilk, unless medically indicated

Practices that interfere with the natural rhythm of the infant’s appetite and feeding cues will have a negative effect on the establishment of lactation and on breastfeeding duration. Normal, healthy, term infants allowed unlimited access to the breast do not need water, glucose water or infant formula routinely9.

Their use affects the infant’s desire to feed at the breast – reducing prolactin release and breast emptying, adversely affecting milk supply10, and breastfeeding rates at four and 16 weeks11. Additionally, giving infant formula changes the gut environment and increases the risk of infective and atopic disease5. In some situations (eg. a delay in lactogenesis ll and subsequent excessive weight loss) supplemental feeding is medically indicated but steps to protect and increase the mother’s milk supply should also be undertaken.

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Step 7 - Practice rooming-in, allow Joanne and Rosie to remain together 24 hours a day

Rooming-in 24-hours a day enhances the mother’s ability to watch and learn about her infant so that she is aware of these early feeding cues and responds to her infant accordingly. This close contact also conditions the milk-ejection reflex resulting in the release of oxytocin and hence availability of milk, three to ten minutes before a feed- just as the infant begins to stir.12

Rooming-in has been associated with more frequent feeding, greater weight gain,13 and longer duration of breastfeeding.14 Additionally, mothers who room-in tend to look at, touch and talk to their infants in more intimate ways.15 Rooming-in does not affect the amount or quality of a mother’s sleep.13

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Step 8 - Encourage breastfeeding on demand

During the first breastfeed after birth most infants will take between 0 and 5 mls of colostrum. This volume gradually increases as the milk changes from colostrum to mature milk over the first week or so.16 The increase in volume is instigated by a drop in progesterone levels following the delivery of the placenta. Subsequently the amount of milk produced is regulated by prolactin release and breast emptying, both dependent on the number and length of breastfeeds – a reflection of the infant’s appetite.

On average, infants will breastfeed between 3-8 times in the first 24 hours, and then between 5 -10 times a day until day 7,16 however, there is considerable variation in the number and length of breastfeeds between infants and between days with the same infant. Unrestricted access to the breast in the early days of breastfeeding allows for this variation, assists with the regulation of milk supply, provides milk for the infant according to his or her needs, results in lower weight loss or better weight gains and improved breastfeeding rates.5,13 Breastfed infants require no additional supplements or water, even in hot weather, until they are six months old.

Feeding the infant 'on demand', that is when he or she displays early feeding cues such as hand to mouth movements, rooting, mouthing or body movement in light sleep provides unrestricted access to the breast. There is no evidence that breastfeeding 'on demand' increases the extent or duration of nipple tenderness.

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Step 9 - Give Rosie no artificial teats or dummies

Dummy or pacifier use, especially before breastfeeding is well established has also been linked with a shorter breastfeeding duration5,10. This problem is more pronounced when the dummy or pacifier is used as an alternative to quieten an infant rather than breastfeeding him or her. Infants also use a different sucking action with bottle teats (artificial nipples) or dummies than when breastfeeding. There is concern that some infants are unable to adjust their sucking actions between the different modalities and using teats or dummies may exacerbate sucking difficulties at the breast17. Therefore dummies and artificial teats should not routinely be used for infants who are breastfed.

Recent studies suggest that the risk of SIDS is reduced in infants who use a dummy while going to sleep, especially if the infant has an unsafe sleep environment (e.g. sleeping prone or with a mother who smokes)18. This finding needs to be balanced against evidence that SIDS risk is reduced in breastfed infants19, and dummy use has an impact on breastfeeding success. The American Academy of Pediatrics20 and UNICEF UK Baby Friendly Initiative21 recommend that parents who wish to use a dummy to settle their infant to sleep not do so until breastfeeding is well established – at around four weeks. Other points to note are: it is preferable that dummies not be used at other times; not all infants will accept a dummy and many will not retain the dummy for the whole of the sleep period21. There is no evidence that forcing an infant to take a dummy, or replacing it if it has fallen out of the sleeping infant’s mouth is beneficial18,20.

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Case Study Activity

Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.

Notes

  1. # World Health Organization (2006) Baby-Friendly Hospital Initiative: Revised, Updated and Expanded for Intergrated Care
  2. # Academy Of Breastfeeding Medicine Protocol Committee (2003) ABM clinical protocol #5: Peripartum breastfeeding management for the healthy other and infant at term.
  3. # Righard L et al. (1990) Effect of delivery room routines on success of first breast-feed
  4. # Matthiesen AS et al. (2001) Postpartum maternal oxytocin release by newborns: Effect of infant hand massage and sucking
  5. # Philipp BL et al. (2004) The Baby-Friendly way: the best breastfeeding start.
  6. # Moore ER et al. (2007) Early skin-to-skin contact for mothers and their healthy newborn infants
  7. # World Health Organization Evidence for the 10 Steps to Successful Breastfeeding
  8. # Forster D et al. (2007) Breastfeeding initiation and birth setting practices: A review of the literature
  9. # AAP Policy Statement, Section on Breastfeeding (2005) Breastfeeding and the Use of Human Milk
  10. # Howard CR et al. (2003) Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding
  11. # Szajewska H et al. (2006) Effects of brief exposure to water, breast-milk substitutes or other liquids on the success and duration of breastfeeding: A systematic review
  12. # McNeilly A et al. (1983) Release of oxytocin and prolactin in response to suckling
  13. # Child and Adolescent Health and Development (CAH) (1998) Evidence for the ten steps to successful breastfeeding
  14. # Scott JA et al. (2001) Factors associated with breastfeeding at discharge and duration of breastfeeding
  15. # Prodromidis M et al. (1995) Mothers touching newborns: a comparison of rooming-in versus minimal contact
  16. # Kent JC (2007) How breastfeeding works
  17. # Wilson-Clay B (1996) Clinical use of silicone nipple shields
  18. # Hauck FR et al. (2005) Do pacifiers reduce the risk of sudden infant death syndrome? A meta-analysis
  19. # Ip S et al. (2007) Breastfeeding and maternal and infant health outcomes in developed countries
  20. # American Academy of Pediatrics (2005) The changing concept of Sudden Infant Death Syndrome: Diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reducing risk
  21. # UNICEF UK Baby Friendly Initiative (Accessed April 28, 2008) UNICEF UK Baby Friendly Initiative statement on dummy use