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
WHO and
UNICEF 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
- Step 5 - Show Joanne how to breastfeed and how to maintain lactation even if she should be separated from Rosie
- Step 6 - Give Rosie no food or drink other than breastmilk, unless medically indicated
- Step 7 - Practice rooming-in, allow Joanne and Rosie to remain together 24 hours a day
- Step 8 - Encourage breastfeeding on demand
- Step 9 - Give Rosie no artificial teats or dummies
Step 4 - Immediate skin-to-skin contact
Although Step 4 states “Help mother 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.1Baby Friendly Hospital Initiative
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 undisturbed. 2
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 5 Early suckling has been associated with increased breastfeeding duration and the ability to breastfeed. 6 A Cochrane Review 7 has also shown that early skin-to-skin contact of healthy term infants:
- increases the likelihood of a successful first breastfeed;
- reduces the time to the first effective breastfeed;
- increases breastfeeding rates at hospital discharge, at four months and six months;
- encourages better thermal regulation by the infant;
- improves cardio-respiratory stability in late preterm infants;
- increases blood glucose levels;
- reduces crying; and
- reduces maternal pain from engorgement on day 3
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 labor. 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.
Step 5 - Show mothers how to breastfeed and how to maintain lactation if separated
Breastfeeding is a natural process; however, it is not instinctive behavior 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.8,9 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 breastmilk in the short term (by cup, spoon, bottle or nasogastric tube), 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.
Step 6 - Give newborns 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 routinely.10
Their use affects the infant's desire to feed at the breast, consequently reducing prolactin release and breast emptying, adversely affecting milk supply,11and breastfeeding rates at four and 16 weeks.12Additionally, giving infant formula changes the gut environment and increases the risk of infective and atopic disease.6In some situations (eg. a delay in secretory activationl 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.13
Step 7 - Practice rooming-in 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. 14
Rooming-in has been associated with more frequent feeding, greater weight gain, 15 8 and longer duration of breastfeeding. 16 17 Additionally, mothers who room-in tend to look at, touch and talk to their infants in more intimate ways. 18 Rooming-in does not affect the amount or quality of a mother's sleep. 8
Step 8 - Encourage breastfeeding on demand
During the first breastfeed after birth most infants will take between 0 and 5ccs of colostrum. This volume gradually increases as the milk changes from colostrum to mature milk over the first week or so.19 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 7,19 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.8,6 Breastfed infants also do not require additional water, even in hot weather.20,21
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.22
Step 9 - Give no artificial teats
Pacifier (dummy or soother) use, especially before breastfeeding is well established, has also been linked with a shorter breastfeeding duration6,11although judicious introduction after breastfeeding is well-established may not interfere with infant feeding. Problems are more likely to occur when the dummy or pacifier is used to quieten an infant rather than breastfeeding him or her. Infants use a different sucking action with bottle teats (artificial nipples) or dummies/pacifiers than when breastfeeding. There is concern that some infants are unable to adjust their sucking actions between the different modalities and using artificial teats may exacerbate sucking difficulties at the breast.23Therefore dummies/pacifiers and artificial teats/nipples should not be used routinely for infants who are breastfed.
Recent studies suggest that the risk of SIDS is reduced in infants who use a dummy/pacifier while going to sleep, especially if the infant has an unsafe sleep environment (e.g. sleeping prone or with a mother who smokes).24 The American Academy of Pediatrics25,10, and UNICEF UK Baby Friendly Initiative26 recommend that parents who wish to use a dummy/pcaifier 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/pacifiers not be used at other times; not all infants will accept a dummy/pacifier and many will not retain the dummy/pacifier for the whole of the sleep period.26There 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 beneficial.25,24

Case Study Activity
Notes
- # World Health Organization (2006) Baby-Friendly Hospital Initiative: Revised, Updated and Expanded for Intergrated Care
- # McCoy R et al. (2008) Clinical Protocol 5. Peripartum breastfeeding management for the healthy mother and infant at term.
- # Widström AM et al. (2011) Newborn behaviour to locate the breast when skin-to-skin: a possible method for enabling early self-regulation.
- # Righard L et al. (1990) Effect of delivery room routines on success of first breast-feed
- # Matthiesen AS et al. (2001) Postpartum maternal oxytocin release by newborns: Effect of infant hand massage and sucking
- # Philipp BL et al. (2004) The Baby-Friendly way: the best breastfeeding start.
- # Moore ER et al. (2012) Early skin-to-skin contact for mothers and their healthy newborn infants.
- # World Health Organization Evidence for the 10 Steps to Successful Breastfeeding
- # Forster D et al. (2007) Breastfeeding initiation and birth setting practices: A review of the literature
- # Section on Breastfeeding (2012) Breastfeeding and the use of human milk.
- # Howard CR et al. (2003) Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding
- # 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
- # Academy of Breastfeeding Medicine Protocol Committee (2009) ABM clinical protocol #3: hospital guidelines for the use of supplementary feedings in the healthy term breastfed neonate, revised 2009.
- # McNeilly A et al. (1983) Release of oxytocin and prolactin in response to suckling
- # Child and Adolescent Health and Development (CAH) (1998) Evidence for the ten steps to successful breastfeeding
- # Zuppa AA et al. (2009) Weight loss and jaundice in healthy term newborns in partial and full rooming-in.
- # Scott JA et al. (2001) Factors associated with breastfeeding at discharge and duration of breastfeeding
- # Prodromidis M et al. (1995) Mothers touching newborns: a comparison of rooming-in versus minimal contact
- # Kent JC (2007) How breastfeeding works
- # Sachdev HP et al. (1991) Water supplementation in exclusively breastfed infants during summer in the tropics.
- # Almroth S et al. (1990) No need for water supplementation for exclusively breast-fed infants under hot and arid conditions.
- # de Carvalho M et al. (1984) Does the duration and frequency of early breastfeeding affect nipple pain?
- # Wilson-Clay B (1996) Clinical use of silicone nipple shields
- # Hauck FR et al. (2005) Do pacifiers reduce the risk of sudden infant death syndrome? A meta-analysis
- # Task Force on Sudden Infant Death Syndrome et al. (2011) SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping environment.
- # UNICEF UK Baby Friendly Initiative (Accessed April 28, 2008) UNICEF UK Baby Friendly Initiative statement on dummy use