sesi 5-Birth Practices.pptkukukukukuuuuu

SESSION 5
BIRTH PRACTICES AND
BREASTFEEDING - STEP 4
1
Breastfeeding Promotion and Support
A Training Course for Health Professionals
Adapted from the Baby Friendly Hospital Initiative:
Revised, Updated and Expanded for Integrated Care (Section 3)
WHO/UNICEF 2009

Session Objectives:
At the end of this session, participants will be able to:
1. Describe how the actions during labour and birth can
support early breastfeeding.
2. Explain the importance of early contact for mother and
baby.
3. Explain ways to help initiate early breastfeeding.
4. List ways to support breastfeeding after a caesarean
section.
5. Discuss how BFHI practices apply to women who are not
breastfeeding .
2
2
Session 5 : Birth Practices and Breastfeeding
Ministry of Health Malaysia

1. Actions in Labour and Birth can
support early Breastfeeding
3

The Special Role of Maternity Services
• A woman’s experience during labour and
delivery affects her motivation towards
breastfeeding and the ease with which to
initiate it
– WHO/UNICEF 1989 Promoting, Protecting and Supporting
Breastfeeding: The Special Role of the Maternity Services
4

• Step 4 of the 10 Steps to Successful Breastfeeding :
“Help mothers to initiate breastfeeding within
half hour of birth.”
• New interpretation:
• “Place babies in skin-to-skin contact with their
mothers immediately following birth for at least
an hour and encourage mothers to recognise
when their babies are ready to breastfeed,
offering help if needed.”
5

• The current implementation in Malaysia is:
to place babies in skin-to –skin contact with
their mothers immediately following birth for
at least 10 minutes, however longer period
up to one hour is recommended and
encourage mothers to recognise when their
babies are ready to breastfeed, offering help
if needed.
6
Session 5: Birth Practices and Breastfeeding

What practices may help a woman to
initiate breastfeeding soon after birth?
7

Mother Friendly Care
Practices that may help a woman to feel competent, in
control, supported and ready to interact with her baby who is
alert
•Emotional support during labour
•Attention to the effects of pain medication on the baby
to avoid opiates analgesia, epidural analgesia if
applicable.
•Offering light foods and fluids during early labour
•Freedom of movement during labour
•Avoidance of unnecessary caesarean sections
•Birthing position of mother’s choice
•Early mother-baby contact
•Facilitating the first feed
8

What practices may hinder early mother and
baby contact?
9

Current labour practices
• Mother lie in bed during labour and birth
• Lack of support
• IV lines/CTG monitoring
• No food and drinks
• Pain medication
• Episiotomy
• Wrapping babies tightly after birth
• Baby separated from mother immediately after
birth
10

Implications
• All these practices:
– hinder mother and baby early contact
– Hinder the establishment of breastfeeding
11

How might it make a difference to a patient
if her husband stays with her during labour
and birth?
12

Support during labour : Why
• A companion can:
– Reduce perception of severe pain
– Encourage mobility
– Reduce stress
– Speed labour and birth
– Reduce need for medical intervention
– Increase mother’s confidence in her body and
ability
13

The support can result in:
• Less pain relief drugs used
– Increased alertness of baby
• Baby less stressed , use less energy
– Reduced risk of infant hypothermia
– Reduced risk of hypoglycaemia
• Early and frequent breastfeeding
• Easier bonding with the baby
14

Support during labour : Who
• husband, mother, sister, family member
• friend
• member of the health facility staff.
**needs to remain continuously with the
woman through labour and the birth.
15

Support during labour : What
• non-medical support :
- Encouragement to walk and move in labour
- Offering light nourishment and fluids
- Building the mother’s confidence by focusing on how
well she is progressing
- Suggesting ways to keep pain and anxiety manageable
- Providing massage, hand holding, cool cloths,
- Using positive words (Practice ritual individual religion
needs).
16

Positions for resting during labour
17

Physiologic Positions for birth
18

Mother friendly birthing room
19

What can you tell a patient about pain
relief?
20

Pain relief
• Offer non-medication methods of pain relief
before offering pain medications.
– Labour support
– Walking and moving around
– Massage, warm water
– Verbal and physical reassurance
– Quiet environment/no bright lights
– Labouring and birth positions of mother’s
choice
21

Pain medications: Risks
• Longer labour
• Operative interventions
• Delayed start to mother-baby contact and
breastfeeding
• Separation of mother and baby after birth
• Sleepy, hard to arouse baby
• Diminished suckling reflex
• Reduced milk intake
– Increased risk of jaundice/hypo/ low weight gain
22

What effect might giving fluid or witholding
fluid have on patient’s labour?
23

Foods and fluids during labour
• Labour and birth needs energy
• Restriction of food and fluid can be distressing
• Increase length of labour
• Should light food and drinks be withheld from
low risk women in labour?
• IV fluids should only be used for a clear
medical indication
• Following delivery, food should be available at
any time
24

IV fluids
• Intravenous (IV) fluids for woman in labour
need to be used only for a clear medical
indication.
• Fluid overload from the IV can lead to
– electrolyte imbalance in the baby,
– high weight loss as the baby sheds the excess fluid
• An IV drip may limit the woman’s movement.
25

What birth practices might help and what
practices are better avoided unless there is a
medical reason?
26

Helpful Birth practices
• A skilled attendant present
• Minimal use of invasive procedures such as
episiotomy
• Universal Precautions to prevent transmission of HIV
and blood borne infections
• being mobile during early labour with access to fluids
and food, and by being in an upright or squatting
position for birth
• Caesarean sections or any other intervention only
used when medically required.
27

Unhelpful Birth practices
• Instrumental delivery (forceps or vacuum extraction)
– can be traumatic, disrupt the alignment of the bones in
the baby’s head and affect nerve and muscle function,
resulting in problems with feeding.
• Episiotomy
– result in pain and difficulty in sitting
– can affect early skin-to-skin contact, breastfeeding, and
mother-baby contact.
• Early cord clamping
– should not be clamped until pulsing reduces for baby to
receive sufficient additional blood to boost iron stores.
28

What are important practices immediately
after birth that can help a mother and baby?
29

Skin–to-skin Contact
• Ensure uninterrupted, unhurried skin-to-skin
contact between every mother
• unwrap healthy baby.
• Start immediately, even before cord clamping,
or as soon as possible in the first few minutes
after birth.
• Arrange that this skin-to-skin contact continue
for at least one hour after birth.
30

UNICEF/WHO Breastfeeding Promotion and Support in a Baby-Friendly Hospital – 20 hour Course 2006
First Skin to Skin Contact
5/3
Dr
Nils
Bergman,
Cape
Town,
South
Africa
31
First Skin to Skin Contact

2. Importance of Skin-to-Skin Contact
32

Skin-to-skin contact
• Calms the mother and the
baby and helps to stabilise
the baby’s heartbeat and
breathing.
• Keeps the baby warm with
heat from the mother’s
body.
• Assists with metabolic
adaptation and blood
glucose stabilization in the
baby.
33

• Reduces infant crying, thus reducing stress
and energy use
• Enables colonization of the baby’s gut with
the mother's normal body bacteria gut
• provided that she is the first person to hold the
baby and not a nurse, doctor, or others, which
may result in their bacteria colonising the baby.
34

• Facilitates bonding between the mother and her
baby
• the baby is alert in the first one to two hours.
• After two to three hours, it is common for babies to sleep
for long periods of time
• Allows the baby to find the breast and self-attach
• more likely to result in effective suckling than when the
baby is separated from his or her mother in the first few
hours.
• Allows the right baby to the right mother.
35

Benefits of skin-to-skin contact
Facilitate heat exchange Feels nice! Prompts hormone
release
Regulates baby’s calms baby calms mother promotes instinctive
temp behaviour
maintains blood glucose facilitates prompts breast
mothering sucking
& bonding
Bacterial Colonisation
FACILITATING BREASTFEEDING
and
INITIAL COLONISATION WITH COLOSTRUM
36

• All stable babies and mothers benefit from skin-to-skin
contact immediately after birth.
• All babies should be dried off as they are placed on the
mother’s skin.
– The baby does not need to be bathed immediately after birth.
• Holding the baby is not implicated in HIV transmission.
– It is important for a mother with HIV to hold, cuddle and have physical
contact with her baby so that she feels close and loving.
• Babies, who are not stable immediately after birth can receive
skin-to-skin contact later when they are stable.
37

Skin-to-skin contact: WHEN
• Vaginal delivery
– Put the baby on mother’s abdomen while
delivering placenta and stitching epi
• LSCS
– If under epidural/spinal, skin-to skin and
breastfeeding initiated immediately after baby out
– If under GA – once mother able to
respond/recovery room
38

What could be barriers to ensuring early
skin-to-skin contact is the routine practice?
How could these barriers be overcome?
39

Barriers to early skin-to-skin contact
• Related to common practices
• Not medical concern
• Some changes can facilitate skin to skin
40

Overcoming barriers
• Concern that baby will be cold
– Dry the baby
– Place naked on mother’s chest
– Put dry cloth over both baby and mother
– If the room is cold, also cover
baby’s head to reduce heat loss
– Skin to skin contact with mother provides
better temp regulation than heater
41

Overcoming barriers
• Baby needs to be
examined
–Most examinations
can be done with baby
on mother’s chest
• Baby likely to be
lying quietly
–Weighing can be done
later
42

Overcoming barriers
• Mother needs to be stitched
– baby can remain on mother’s chest for stitching of
epi/ LSCS
43

Overcoming barriers
• Baby needs to be bathed
– Delaying first bath allow vernix to soak into baby’s
skin
• Lubricating
• Protecting
– Delaying first bath prevents temp loss
– Baby can be wiped dry after birth
44

Overcoming barriers
• Labour room is busy
– Transfer mother and baby to the ward in skin-to-
skin contact
– Continue contact in ward
• No staff available to stay with mother and
baby
– Family member/companion can stay
45

Overcoming barriers
• Baby is not alert
– More important to have contact
– Sleepy baby due to pain
medication needs extra support to
bond and feed
• Mother is tired
– Mother rarely so tired, does not want to hold baby
– Contact with baby helps mother relax
– Review practices of withholding food/fluids
46

Overcoming barriers
• Mother does not want to hold baby
– If mother unwilling to hold baby
• Get to root of problem
• Indication mother is depressed
• Greater risk of abandonment/neglect/abuse
–Encouraging contact increases bonding
potential
• Reduce risk of harm to baby
47

Overcoming barriers
• Twins
– interval between the births varies.
– the first infant can have skin to skin contact until the
mother starts to labour for the second birth.
– The first twin can be held in skin to skin contact by a
family member for warmth and contact while the
second twin is born.
– Then the two infants are held by the mother in skin to
skin contact and assisted to breastfeed when ready.
48

3. Helping to Initiate Breastfeeding
49

How can you help a patient to initiate
breastfeeding?
50

Helping to Initiate breastfeeding
• Help mother to recognise pre-feeding
behaviours or cues.
– When a mother and baby are kept quietly in skin-
to-skin contact, the baby typically works through a
series of pre-feeding behaviours.
– may be a few minutes or an hour
or more.
51

Pre-feeding behaviours/cues
- a short rest in an alert state to settle to the new
surroundings,
- bringing his/her hands to his/her mouth, and making
sucking motions, sounds
- touching the nipple with the hand
- focusing on the dark area of the breast, which acts like a
target,
- moving towards the breast and rooting,
- finding the nipple area and attaching with a wide
open mouth.
52

Instinctive baby behaviour
• Rest period of 5 to 30
minutes
• Hand to mouth
coordination
53

Instinctive baby behaviour
• Touch and feel • Smell
– Important for
mother/infant bonding
• Oxytocin involved with
olfactory system
54

Further advantage
• Skin to skin and eye contact considered to
optimise oxytocin release
• Coordinate suckling, swallowing and breathing
55

Helping to initiate breastfeeding
• There should be no pressure on the mother or baby
– how soon the first feed takes place,
– how long a first feed lasts, how well
– The first time of suckling at the breast should be
considered an introduction to the breast rather than a
feed.
• More assistance with breastfeeding can be provided
at the next feed to help the mother
• learn about positioning, attachment, feeding signs
and other skills she will need.
56

Role of health care worker
• Provide time and a calm atmosphere,
• Help the mother to find a comfortable position,
• Point out positive behaviours of the baby such as
alertness and rooting,
• Build the mother’s confidence,
• Avoid rushing the baby to the breast or pushing
the breast into the baby’s mouth.
57

4. Ways to support breastfeeding after
Caesarean Section
58

What effect could a Caesarean Section have
on a Mother and her Baby with regards to
breastfeeding?
59

Effect on mother
• Mother likely to be:
– Frightened and stressed
– Have IVD/CBD
– Confined to bed with restricted movement
– Restricted fluid and food intake
– Altered levels of oxytocin/prolactin
– Higher risk of infection, bleeding
– Be separated from baby
– Feel sense of failure not able to have normal birth
60

Effect on baby
• Baby likely to be:
– High risk of not breastfeeding or breastfeed for short
duration
– May have more breathing problems
– May need suction of mucus, can hurt mouth and throat
– May be sedated from maternal medications
– Less likely to have early contact
– More likely to receive supplements
– More likely to have nursery care increasing risk of cross
infection, restricted breastfeding
61

How can you help a mother and her baby to
initiate breastfeeding after a
Caesarean Section?
62

Ways to support
• Presence of supportive health worker
– Help initiate post Caesarean
• Encourage skin to skin as soon as possible
– Spinal/epidural –immediate
– GA –contact in recovery room if mother responsive
– Skin to skin by father /family member while waiting
for mother to return from OT
– Prem/unstable baby – contact when stable
63

Initiating breastfeeding after a
Caesarian section
• Assist with initiating breastfeeding when the baby
and mother show signs of readiness.
• The mother does not need to be able to sit up, to
hold her baby or meet other mobility criteria in order
to breastfeed.
– It is the baby who finds the breast and start suckling.
– As long as there is a support person with the mother and
baby, the baby can go to the breast if the mother is still
sleepy from the anesthesia.
64

Initiating breastfeeding after a
Caesarean section (cont.)
• Help Caesarean mothers find a comfortable position
for breastfeeding
– Adjust IVD to allow for positioning of baby at the breast
– Side lying in bed –avoid pain in 1st
few hours
– Sitting up with pillow over the incision
– Lying flat with baby on top sitting up
– Support (e.g pillow) `
• under the knees when sitting up
• Under top knee/behind back when side lying
65

Initiating breastfeeding after a Caesarean
section (cont..)
• Provide rooming-in
– with assistance as needed until the mother can
care for her baby
• Supportive and knowledgeable staff
– may assist in establishing breastfeeding with the
longer hospital stay
66

5. BFHI practices and women who are
not breastfeeding
67

BFHI practices and women who are not
breastfeeding
• All mothers should have support during labour and
birth.
– Harmful practices should be avoided.
– Early skin-to-skin contact benefits all mothers and
babies.
68

breastfeeding
• all mothers should be encouraged to let their baby suckle at the
breast unless:
– there is a known medical reason for not breastfeeding, (e.g that
the woman has been tested and found to be HIV-positive and
following counseling during pregnancy has decided not to
breastfeed,)
– If a mother has a strong personal desire not to breastfeed
69

breastfeeding
• If the baby is not breastfeeding, replacement feeds
should start with small amounts.
-Similar to colostrum in small amount in first few feeds
• make arrangements to ensure there are
replacement feeds available for any infants who are
not breastfeeding.
70

Summary
1. STEP 4 of the Ten Steps to Successful Breastfeeding
states : Help mothers to initiate breastfeeding within
half-hour of birth. This step is now interpreted as:
2. Practices that result in a woman feeling competent, in
control, supported and ready to interact with her baby
who is alert, help to put this Step into action
3. Supportive practices include:
1. support during labour, facilitating early mother-baby contact
2. limiting invasive interventions, attention to the effects of pain relief,
3. offering light food and fluids,
4. avoiding unnecessary caesarean sections
71

Summary
4. Early contact and assistance with breastfeeding can
be routine practice after a caesarean section also.
5. Provide uninterrupted, unhurried skin-to-skin
contact between every mother and her healthy
baby.
6. Encourage the mother to respond to the baby’s
signs of readiness to go to the breast.
72

THANK YOU
73

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