Breastfeeding and Lactation Management

Lactation  Management

Introduction

Lactation is a complex physiologic process under neuroendocrine control,whereas breast feeding is the process by which milk is transferred from the maternal breast  to the infant. Lactation is the biologic completion of the reproductive cycle . Starting at about 16 weeks gestation the breast develops and prepares for full lactation. In the first few postpartal hours and days the breast responds to hormones and the stimulation of the infants sucking to produce and release milk

Physiology of lactation

 The physiological basis of lactation is divided into 4 phases

• Preparation of breasts (Mammogenesis)
• Synthesis and secretion from the breast alveoli (lactogenesis)
• Ejection of milk (galactokinesis)
• Maintainance of lactation (galactopoiesis)

Mammogenesis

• It is the remarkable growth of both the ductal and lobulo-alveolar systems

Lactogenesis

• Secretory activity begins during pregnancy but accelerated after delivery. Milk secretion actually starts from the 3^rd or 4^th postpartum day

Galactokinesis

• Discharge of milk from the mammary glands depends not only on the suction exerted by the baby during suckling but also on the contractile mechanism which expresses the milk from the alveoli into the ducts.

Galactopoiesis

• Prolactin appears to be the single most important galactopoietic hormone
• For maintainance of effective and continuous lactation ,sucking is essential.

 Advantages of Breast feeding

•  Ideal composition for easy digestion with  low osmotic load
•  Protection against infection and deficiency states
• It contains adequate protein, carbohydrate  and fat which is easily digestible. It contains Vitamin D which protects the baby against rickets
• It contains- lactoferrin,l ysozyme, lactoperoxidase, compliments and leukocytes that hinder the growth of e-coli and thereby prevents gastroenteritis
• It contains long chain W-3 fatty acids that is important for the neurological development of the baby
• It contains Secretory antibody IgA, which prevents gastrointestinal infections
•  It is readily available sterile and is given to the baby at body temperature 
• It has laxative action and anti allergy properties

Positioning for breast feeding- cradle hold

• Cross cradle hold
• Football hold
• Side lying position
• Australian Hold
• C hold and latch on

Correct attachment (latch-on) at the breast include:

1)      newborn's nose close to or touching the breast while it breathes through the nasolabial folds;

2)      rooting by the infant to move in and grasp the areola well behind the nipple, forming a teat;

3)      tongue moving forward beyond the lower gum, cupped and forming a trough, then removing milk from the lactiferous sinuses by peristaltic waves;

4)      the jaw moving down, creating a negative pressure gradient that facilitates transfer of the milk into the oral cavity

5)      Correct attachment of baby to the breast

6)      Burping allows the swallowed air to be realeased  from the infant's stomach.

Maternal conditions associated with breast feeding Problems

Acquired prior to pregnancy and lactation

• Inverted or retractile nipples
• Breast surgery
• primary glandular insufficiency of the breasts
• Breast trauma

 Acquired because of breast feeding Problems

• Sore, cracked nipples
• Engorgement
• Blocked ducts
• Mastittis

 Interference with lactation

• Anxiety
• Medical Problems
• Nutrition and fluid intake
• Infant's Health

Signs of Good Breastfeeding

• Frequent feedings of 8 to 12 times every 24 hours (the baby does not have to take both breasts at each feeding)
• The baby is allowed to feed until finished on one side (time will vary greatly with each individual mother-baby dyad)
• Intermittent episodes of rhythmic sucking with audible swallows
• Stools should be about 1 tablespoon or larger
• After the third day, soft and yellow stools ranging from 4 (if large) to 10 (if small)

Breastfeeding Warning Signs (requires infant evaluation)

•  Fewer than 6 wet diapers per 24 hours after the third day

• Dark black, green, or brown stools after the third day
• Fewer than 3 to 4 yellow stools (from the fourth day to the fourth week)
• The baby seems to be nursing continuously, always hungry, and never satisfied
• The baby is exceptionally “good” rarely crying and consistently sleeping more than 4 to 6 hours
• Milk comes in, but swallowing or gulping is not audible
• Milk does not seem to have come in by the fifth day
• Sore and painful nipples throughout most feedings
• Significant engorgement (breasts are very hard and do not soften after feeding)
• Average daily weight gain of less than 15 to 30 g (once the milk comes in)

Baby friendly Hospital Initiative

In 1992, UNICEF and WHO launched the baby friendly initiative among all health personals ,in hospitals and maternity centres to promote ,protect and support breast feeding.

Objective: to re-establish the superiority of breast feeding in order to protect the newborn's health by becoming baby friendly.

Ten Steps

1.       There must be a written breast feeding policy

2.       All health care staff must be trained to implement this policy

3.      All pregnant women must be informed about the benefits of breast feeding

4.      Mothers should be helped to initiate breast feeding within half an hour of birth

5.      Mothers should be helped to initiate breast feeding within half an hour of birth

6.      Unless medically indicated no other food should be given

7.      To practice 'rooming in' by allowing mothers and babies to remain together

8.      To encourage demand breast feeding

9.      No artificial teats to be given to babies

10.  Breast feeding support groups are established and mothers are referred to them on discharge

Nurses Role

• The nurse must help the mother develop skills so that she is able to feed the baby on her own
• Emotional Support: Encouragement and reassurance
• Practical Support: Teaching the fundamentals of good attachment so that feeding is pain free and successful
• Informational Support: Importance of exclusive breast feeding,feeding pattern, switching breasts.

Normal Puerperium

Normal Puerperium

Puerperium is the period immediately following labour during which, the reproductive organs return to their pre pregnant stage. Lactation is initiated, and the mother recovers from the physical and emotional experiences of parturition. Puerperium begins as soon as the placenta is expelled and lasts for 6 weeks (42 days). The process whereby the genital organs revert back to their original state is called Involution.

Involution of the uterus:

• Immediately following delivery, the uterus becomes firm and weighs about 1000gm.
• At the end of 6 weeks, its measurement is almost similar to that of the non-pregnant state and weighs about 60gm.
• By the end of second week after delivery, the uterus becomes a pelvic organ.

Lochia:

Lochia are the discharges from the uterus, cervix and vagina for the first fortnight during puerperium. They are alkaline in reaction and contain bloods, debris of deciduas, and liquor amnii, lanugo, vernix caseosa and meconium.

Colour of lochia:

1. Lochia rubra (red) lasts for 1-4 days.
2. Lochia serosa – lasts for 5-9 days. Colour is yellowish or pink or pale browne.
3. Lochia alba- (pale white) lasts for 10-15 days.
4. The character of the lochia gives useful information about the abnormal puerperal state.

Puerperal complications:

1. Postpartum hemorrhage
2. Thrombo embolic manifestations
3. Puerperal infections
4. Postpartum psychosis
5. Lactation failure

Lactation:

• Initiation of breast feeding is more important during the immediate postnatal period. For the first two days, colostrum will be secreted from the breasts, which is a yellow serous fluid rich in protein and immunoglobulins. It provides resistance against infection to the newborn.
• The first feeding is an important experience to the mother and baby. The success of breast-feeding depends on mother’ s learning of a good breast-feeding technique in a happy and positive way.
• Breast-feeding should be given on demands of the baby and normally a healthy baby takes breast feeds 6 to eight times in 24 hours, for not less than 10 minutes each.

Advantages of breast-feeding:

1.      Ideal composition. Helps in easy digestion for the baby.

2.      Breast milk contains a number of protective factors. Breast fed babies are less likely to develop infections like diarrhea and respiratory infections.

3.      Breast milk is readily available, usually sterile.

4.      It is convenient, requiring no preparation and costs nothing.

5.      It protects against allergies like asthma.

6.      It has a laxative action for the baby.

7.      It enhances emotional bonding between the mother and the baby.

8.   Breast-feeding acts as a natural contraceptive. Chance of conception is less during lactation period.

9.      Helps in involution of uterus.

10.  Breast fed babies have a higher IQ and have less chance of developing hypertension, diabetes mellitus, coronary heart disease, liver disease and cancer in later life.

11.  For mother, breast-feeding reduces the risk of breast and ovarian cancer.

12.  Breast-feeding saves money and time and conserves energy. The family and society spend less on milk, health care and illness.

Management of puerperium:

The basic principles of post-natal care include.

• Promotion of physical well-being by good nutrition, adequate fluid intake, comfort, cleanliness, and sufficient exercises to ensure good muscle tone.
• Early ampulation is insisted to prevent deep vein thrombosis.
• Establishment of emotional well-being.
• Promotion of breast-feeding.
• Prevention of complications.

Important Considerations of Postnatal Care

1. Adequate rest and sleep:
2. Watch for the signs and symptoms of infection and excess bleeding.
3. Diet: A balanced diet containing sufficient protein (90 gm) minerals and vitamins should be given. Additional fluid intake is encouraged. Fresh fruits and vegetables should be included in the main meals.
4. Antibiotics and analgesics are given to combat infection and to relieve pain and discomfort.
5. Perinial care with aseptic precautions to prevent puerperal infections
6. Micturition: Difficulty with urination is quite common during the first few days due to trauma. It must be ensured that the bladder emptied completely.
7. Constipation: It is common during puerperium as there is a tendency of the bowels to be sluggish. A diet rich in fibre will overcome the problem.
8. Postnatal exercise: The importances of post-natal exercises are stressed to the mother and are also taught to her to regain the muscle tone, which are stretched during pregnancy and labour.
9. Continuance of supplementary iron therapy.
10. Advise for a gradual return to day-day activities.
11. Advise on breast-feeding and care of newborn including immunisation.
12. Family planning advice and guidance.
13. To have a postnatal check up after 6 weeks.

Partograph

The Partograph is a tool that can be used by midwifery personnel to assess the progress of labor and to identify when intervention is necessary. Studies have shown that using the partograph can be highly effective in reducing complications from prolonged labor for the mother (postpartum hemorrhage, sepsis, uterine rupture and its sequelae) and for the newborn (death, anoxia, infections, etc.).

A partograph must be started only when a women is in labor. In the latent phase (cervix dilatation not more than 2 cm), she should have two or more contractions in 10 minutes, each lasting 20 seconds or more. In the active phase (cervix dilatation more than 3 cm), she should have one or more contractions in 10 minutes, each lasting 20 seconds or more. 

Uses of Partograph

• To monitor all stages of labor of all women arriving at the maternity or health facility. 
  
• To monitor the progress of labor: cervical dilatation, descent of fetal head, and uterine contractions. 
• To monitor fetal conditions with the following parameters: fetal heart rate, membranes and liquor and moulding of fetal skull
• To monitor maternal conditions like: pulse, blood pressure, temperature, urine, drugs, IV fluids, and oxytocin. 
• To assist in making the correct decision about transfer, Caesarean section, or other life-saving interventions.