Download Post Partum & Breastfeeding

OBgyn Week 11
Post Partum Concerns,
Breastfeeding, Breast Health
Post Partum Complications
• Postpartum hemorrhage
– Defined as blood loss over 500ml (about 2 cups)
– 5% of births end up in a hemorrhage
– Maternal hemorrhage accounts for 25% of
maternal deaths perinatally
– Bleeding to death can occur in 7 minutes
– Most likely occurs immediately post-partum but
it can happen later
• Early pp hemorrhage occurs in first 24 hours
• Late pp hemorrhage occurs within 1-6 days; usually dt
retained fragments; more likely to be complicated by
DIC
Hemorrhage
• Can be due to retained tissue
Signs/ symptoms of retained secundines:
(products of conception that are not the baby)
– Abdominal tenderness
– Slight non-involution (return to prePG state) of the
uterus
• Post-partum involution refers to the gradual return of the
reproductive organs back to their non-pregnant state
– Fever or temperature over 99.4 degrees F
Hemorrhage
• Risk factors for hemorrhage
Twins (uterine distention)
Long labor
Precipitous labor
Abnormal placental placement
Psychological factors
Decreased Hgb (hemoglobin)
Fibroids
Grand multip (>5 births)
Partial separation
Lacerations
Anesthesia
Forceps
Hemorrhage
• Characteristics of hemorrhage:
– Can gush or be slow trickle bleed
– Non-visible: clots inside uterus
– Bright red blood or pulsating: artery ruptured
Surgery required.
• Some women can tolerate blood loss better
than others; depends on:
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Quantity of blood loss
Hgb levels – higher levels = less shock
Self awareness– psychological factors
Blood volume
Body weight
Hemorrhage
• Hemorrhage may be stopped by achieving
uterine contractions/ clamping down. These
will help expel all contents:
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Nipple stimulation
Uterine massage/ bimanual compression
Methergine: causes large uterine contraction
Pitocin: usually used to stimulate labor, causes
contractions
• O2 administration and Trendelenburg position (on back
with feet above heart level) help prevent shock / shutdown of rest of body
Shock
• Shock
– CV system fails to provide sufficient circulation,
tissues eventually suffer from a lack of oxygen
• Compensatory mechanism designed to keep brain
well oxygenated during CV insufficiency
– Brain remains oxygenated by:
• Peripheral vasoconstricion of circulation so blood is
pulled to internal vital organs
• Increased HR to increase blood to brain
• Increased respirations to maximize oxygen in blood
Types of Shock
– Hypovolemic: decreased blood volume due to internal or
external hemorrhage; main type in deliveries
• May also be dt dehydration (sweating, diarrhea, vomiting)
– Cardiogenic: heart failure
– Neurogenic/vasogenic: decreased vascular tone leads to
anaphylactic shock (over release of histamine) which
leads to vasorelaxation of parasympathetic NS
• Sepsis, blood poisoning, bee sting, etc.
– Psychogenic: fainting dt vasorelaxation then
vasoconstriction
Shock S/SX
• Shock signs/ symptoms
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Restlessness
Anxiety
“Spaciness”
Foreboding feeling
Rapid, shallow respiratory rate
Increased HR but weak and thready
Skin cool, clammy pale
Nausea/ vomiting, pupils dilated
Change in BP of 10mm Hg from normal, or systolic < 80
Shock Tx
• To treat shock, stop hemorrhage
– May require ER
– Many western and Chinese herbs can help
with shock and hemorrhage
– Trendelenburg position to increase brain O2
– Acupuncture (from Dr. Fritz)
• Sp 10, Lr 1, Sp1, Sp 6, CV4, Sp 9, moxa
• Dizziness after delivery: CV 7, GV 20, Sp 6
• Shock: CV 24, K 1, Pc 5, Pc 6, Pc 7, Lu 9, ST 36
PP Complications Hematoma
• Hematoma
– Rupture of blood vessel causing extravasation of
blood into tissue – pools between tissue layers.
Enough of this can cause shock. Can be painful
as well as tissues are stretched.
– Predisposing factors:
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Prolonged second stage – in birth canal for longer
Excessive use of perineal stretching
Instrumentation – forceps i.e.
Macrosomia – large baby
Hematoma
• Hemotoma signs/ symptoms
– Swelling, bruising
– Signs of shock: increased pulse, hypotension
• As much as 1500cc can accumulate in broad ligament
hematoma
– Displacement of uterus
– Pain
• Hematoma management:
– Apply pressure
– Stop bleeding– mb necessary to open and ligate
vessel
– Prevent infection
PP Complications thromboses
• Thrombosis: presence of a thrombus (blood
clot still attached at the site of its formation) in
a blood vessel
– 5X more likely in the pregnant and parturient patient
– In the parturient patient high risk of pulmonary
embolism (embolus is the same as a thrombus but
it’s been dislodged); still a major cause of maternal
death
(parturient = in labor)
Thromboses
• Thrombosis predisposing factors:
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Caesarian section – many clotting factors used
> 35 yo (increased age)
High parity
Obesity
Smoking (esp combined w/oral contraceptives)
Immobility
Trauma to legs
Thromboses
• Thrombosis signs/ symptoms
– Superficial thrombophlebitis: tenderness,
very hard, feel a lump, red, and warm
– Deep vein thrombosis: pain swelling, +
Homan’s sign (lay ‘em down, raise the knee, quickly
dorsiflex the foot = pain then that’s a positive Homan’s sign)
• Diagnosed with ultrasound, venography
PP Complications - Emboli
• Pulmonary embolism signs/ symptoms
– Severe chest pain – causes necrosis in the fx’d part of
lung
– Dyspnea – esp SOB. Compromises O2 xchg.
– Shock sx
– Slight hemoptysis
– Mb asymptomatic if clot large enough; death may occur
without warning. Seems counter-intuitive.
– Collapse
– Cyanosis
– Hypotension (look for dizziness)
Emboli
• Amniotic fluid embolism
– Definition: amniotic fluid entering maternal
circulation. May cause obstruction of pulmonary
vessel but seems to more often cause anaphylaxis
– Predisposing factors:
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Precipitous labor
Multiparity
Excessive use of oxytocic drugs or prostaglandins
Uterine trauma: rupture, Caesarian, catheter insertion
Emboli
• Amniotic fluid embolism signs/ symptoms
Same sx as other embolism
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Dyspnea
Rapid, shallow respirations
Pulmonary edema
Tachycardia
Hypotension
Convulsions
Hemorrhage dt DIC
– Mortality rate up to 86%
– 25% of deaths occur in first hour
PP Complications Puerperal Fever
• Septicemia usu due to strep bacteria
• Usu accompanied by fever
• Infxn route: traumatized birth canal
tissues
• Includes infections of genital tract:
perineum, vagina, cervix, uterus,
adnexae as well as breast infxn and UTI
Puerperal Fever
• Predisposing factors
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PROM
Prolonged labor
Trauma
Intrauterine manipulation
Hemorrhage
Anemia
Malnutrition/ low socioeconomic status
Retained parts
Puerperal Fever
• Signs/ symptoms
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Temperature > 100.4 F po
Chills
Pain
Foul discharge
Body aches
• Management
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Rest and hydration
Determine source of infection
Simple meals: bone broth
Antibiotics may be necessary, but should be avoided if
possible (esp if breast feeding)
PP Complications Depression
• Post partum depression
– Approximately 10% of new moms experience PPDep
– Due to sudden change in hormones (hormones are a main
cause of depression)
• Mild form: “baby blues:
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Mood swings
Anxiety
Sadness
Irritability
Crying
Decreased concentration
Difficulty sleeping
PP Depression
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Post partum depression: signs and symptoms more intense and
longer lasting than “baby blues” (>6 weeks)
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Loss of appetite
Insomnia
Intense irritability and anger
Overwhelming fatigue
Loss of interest in sex
Lack of joy in life
Feelings of shame, guilt, or inadequacy
Severe mood swings
Difficulty bonding with baby
Withdrawal from family and friends
Thoughts of harming self or baby
Psychosis
• Postpartum psychosis
– Rare, develops within first two weeks after
delivery
– Symptoms as with PP Depression, but
more severe and also include:
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Confusion, disorientation
Hallucinations and delusions
Paranoia
Attempts to harm self and/or baby
PP Depression
• Etiology:
– Rapid drop in estrogen, progesterone, possibly
thyroid hormones
– Emotional factors: anxiety, sense of identity, loss
of control
– Sleep deprivation
• MOMS SHOULD GET SLEEP WITHIN 6 HOURS OF
DELIVERY TO HELP PREVENT PPD
– Lifestyle influences: demanding baby or older
siblings, financial problems, lack of support
PP Depression
• PPD Risk factors
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May happen after the birth of any child, not just the first
History of depression
PPD after a previous pregnancy
Stressful events in past year
Marital conflicts
Weak support system
Unplanned or unwanted pregnancy
Risk of PP psychosis higher for women who have
bipolar disorder
PP Depression
• Post partum depression
– Important to warn new moms about signs and
symptoms of PPD, explain not to get
embarrassed, that it is important to seek help
especially if having difficulty taking care of baby
– Seek immediate help if thoughts of wanting to
harm self/ baby
– If untreated, can last up to a year or longer or may
become a chronic depressive disorder
– Increases a woman’s risk of future episodes of
major depression
PP Depression
• Treatment may include:
– Counseling
– Antidepressants – common in biomedicine
– Hormone therapy (thyroid; careful with
HRT while breastfeeding!), check hormone
therapies
– Acupuncture, herbal therapy, qi gong
– Getting support network involved
PP Depression
• Prevention
– Sleep within 6 hours after delivery
– Healthy lifestyle choices that include
physical activity (preferably outdoors) and
good nutrition
– Set realistic expectations
– Mommy time
– Avoid isolation
Post Partum Resuming Sexual Activity
• Pelvic rest is indicated for 6 weeks PP
– Immediate risk: air embolism, infection,
perineal trauma, thrombus, embolism
– Later risks: infection, perineal trauma
– If episiotomy/ laceration, pelvic rest
recommended for up to 8 weeks
– ~1/3rd of women resume sex by 6 weeks
– Also, No Tampons!!
Resuming Sexual Activity
• Resuming sex is often difficult for
postpartum moms
– Low libido
• Decreased interest (normal for a few weeks to
months); focus is on baby
• Oxytocin in the system can satisfy her, so she
doesn’t really want sex.
• Decreased enjoyment
– Kegels, pelvic weights to increase vaginal tone
Dysparunea
• Dysparunea
Always a bad sign
– 40% women report pain/ discomfort with
intercourse at 3 months PP
– Evaluate healing of tissue
– Evaluate hormonal effect on mucosa
– Evaluate for infection
Resuming Sexual Activity
• Other factors affecting resuming sex
– Episiotomy or laceration
– Hormonal imbalance
– Fatigue
– Post partum depression
– Complications of labor or postpartum
– Breastfeeding: may lower libido initially;
high prolactin levels give a greater sense
of contentment
Breasts
• Breast Health
• Breastfeeding
Breast Exam
• Self Exam - starting age 20
• Clinical Exam - ages 20-39, every 1-3 years, usu done
same time as Pap exam.
Timing depends on results from Pap.
• Screening Mammogram - yearly starting age 40 or 50,
earlier if high-risk
Recently changed to age 50, but there’s a lot of
disagreement in the groups who decide these things.
And there general guidelines don’t apply if there’s a
family hx, etc.
Breast Self Exam
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May be taught by practitioner during first exam
Do same way, same time each month
Feeling for changes, asymmetry, lumps
Looking for skin changes, discharge, asymmetry
May be done in shower – soap makes it easier
Be sure to examine entire breast, including area towards
axilla
• Palpation with fingertips plus visual inspection as well
• Most breast cancers are detected first by patient
Breast Self Exam
Breast Self Exam - Visual
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Breast Changes
• Change in size, firmness, tenderness
nodularity normal with monthly cycle
Nipple discharge should be investigated, esp if one sided,
bloody.
Clinical Breast Exam
• Inspection
– Symmetry, contour, skin appearance (peau d’orange)
• Palpation
– Performed with patient sitting, supine (w/hands under head),
or both
– Palpate in strips or concentric circles
– Don’t forget tail of Spence
– Palpate axillary and clavicular nodes
– Assess for
• Temperature, texture, density, nodularity, tenderness,
asymmetry, mass, nipple discharge
Breast Imaging Techniques
• Mammography
– Current standard for screening and diagnosis
• Ultrasonography
– Used in conjunction with mammography, can
distinguish solid from cystic masses
• Magnetic resonance imaging
– May be useful in certain situations, no radiation
– New evidence emerging about benefits of MRI for Dx
of DCIS (ductal in situ cancer)
Imaging Techniques
• Positron emission tomography
– Assesses metabolic activity of tumors
• Technetium-99m sestamibi
– New technology, still being evaluated
• Thermography
– Not shown to be useful for screening or diagnosis
– May be useful in specialized situations
Breast Imaging
• Mammography and ultrasonography are the most
reliable and common imaging techniques for the
early detection of breast lesions
• Slowly growing breast cancers can be identified by
mammography at least 2 years before the mass
reaches a size detectable by palpation
• ~35-50% of early breast cancers can be discovered
only by mammography, and 20% can be detected
only by palpation
Breast Biopsy
• The diagnosis of breast cancer is made by
examination of tissue removed by biopsy
• Biopsy should be performed on all patients with a
dominant or suspicious mass found by PE, and on
all suspicious lesions shown by mammography,
even with a negative PE
• Mammography is not a substitute for biopsy
• Typically, biopsy is performed by needle or excision
techniques
Benign Breast Conditions
• Fibrocystic change
– Most common lesion of the breast
– Covers a spectrum of clinical signs, symptoms,
and histologic change
– Common in 35-55 year old women
– Estrogen is thought to promote clinical symptoms
– Cysts arise from breast lobules
– Rare after menopause, common during
perimenopause
Fibrocystic Change
• Clinical findings
– Pain and tenderness, often premenstrual
– Occasionally painless
– Fluctuation in size, rapid appearance and
disappearance common
– Cyclic breast pain most common symptom
– Usually multiple and bilateral
• DDX
– If a dominant mass is palpated, carcinoma must be ruled
out with mammography, ultrasonography, and biopsy if
appropriate
Tx of Fibrocystic Change
• Conventional treatment
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Supportive bra night and day
Bromocriptine – 2.5 mg BID X 3-6 months
Danazol – 100-200 mg BID
Tamoxifen
Analgesic agents - NSAIDS
Diuretics
Progestogen
Tx of Fibrocystic Change
• Naturopathic treatment
– Strategies
• Decrease inflammatory activity in breast
• Reduce relative estrogen excess and sensitivity to
estrogen – consume soy and other phytoestrogens
as they binds with the estrogen receptors and
reduces production internally…unless px has
estrogen sensitive/induced tumors.**
• Provide diuretic activity
Tx of Fibrocystic Change
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Eliminate methylxanthines, arachidonic acid
Vitamin B-6 200-800 mg/day
Evening primrose oil – 1,500 mg omega-6 EFA BID
Vitamin E 150-800 iu/day
Aqueous iodine – 3-6 mg/day*
Botanical diuretics – taraxicum, celery, juniper
Support liver function, treat constipation
Soy protein – 34 g/d*
Red clover – 40-80 mg isoflavones/d*
Intravaginal progesterone – 4 grams/d 2.5% prog cream
days 19-25*
Fibrocystic Change and
Breast Cancer
• Fibrocystic change is not associated with an
increased risk of breast cancer unless there is
histologic evidence of epithelial proliferative
changes
– In women with FC who underwent breast biopsy,
70% had non-proliferative changes, and 30% had
proliferative changes
– Those with proliferative changes have a 5 fold
higher risk of breast cancer than the nonproliferative group
Benign Breast Tumors
• Fibroadenoma
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Most common benign tumor of the breast
Account for up to 50% of breast biopsies
Usually occur in 20-35 year old women
Occur rarely after menopause, but calcified ones can
be found
– Thought to be responsive to estrogen stimulation
– Transformation into cancer is rare
Fibroadenoma
• Clinical findings
– Young patient usually notices a mass while showering or dressing
– Physical exam findings
• 2-3 cm firm, smooth, rubbery mass*
• Non-tender, discrete borders, unilateral, mobile*
• No inflammation, no skin retraction
– DDX – R/O malignancy
• Mammography and ultrasonography
• Needle or excision biopsy – partial or complete
– Treatment
• None necessary, ND’s may want to reduce estrogen exposure
*all = opposite of cancerous
Other Benign Breast
Conditions
• Nipple discharge – in non-lactating
women
– Is usually benign (>96%)
– Most common causes
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Intraductal papilloma
Papillomatosis
Fibrocystic change
Carcinoma
Nipple Discharge
• Evaluation of nipple discharge
– Serous, bloody, or milky
– Associated mass
– Uni or bilateral
– Single or multiple ducts
– Spontaneous or provoked
– Relation to menses
– Pre or postmenopausal
– Hormonal medications
Nipple Discharge
• Unilateral, spontaneous, bloody or
serosanguinous discharge from a single duct is
usually caused by an intraductal papilloma or
intraductal cancer
• Diagnostic testing – for persistent, spontaneous
d/c
– Cytology – negative does not rule our cancer
– Mammography, ultrasonography, ductography
– Excisional biopsy
• Prolactin level with bilateral milky discharge to R/O
pituitary adenoma
Fat Necrosis
• Rare
• Caused by trauma, but patient may not report an injury
• Unilateral breast mass that may be accompanied by skin or nipple
retraction, may see ecchymosis near mass
• May be tender or painless
• DDX – must R/O CA
– Imaging plus needle or excision bx
• Untreated, will gradually disappear
Erosive Adenomatosis of the
Breast
• Rare, mimics Paget’s dz of the breast
• Sx’s – pruritis, burning, painful nipple, can be
enlarged during menses
• PE – nipple can be ulcerated, crusting, scaling,
indurated, and erythematous
• DDX – squamous cell CA, psoriasis, contact
dermatitis, seborrheic keratosis, adenocarcinoma
mets to the skin, Paget’s dz, other primary nipple
tumors
• DX – biopsy
• TX – local excision
Breastfeeding
• Anatomy
– Breast has 15-20 lobes of glands arranged
circularly which secrete milk
– Lobe is made up of alveoli and alveolar ducts that
are surrounded by myoepithelial cells
– Alveoli drain into a lactiferous duct
– Lactiferous ducts underneath the nipple form milk
sinuses and open onto the surface of the nipple
Breastfeeding
Breastfeeding
• Breast changes of pregnancy:
– Increase in ductal sprouting and branching
and lobular formation from luteal and
placental hormones
• Estrogen stimulates ductal growth
• Progesterone stimulates the branching and
• Prolactin stimulates alveolar growth
Breastfeeding
Breastfeeding
• Breast tissue also contains:
– Fat
– Connective tissue
– Montgomery glands: large sebaceous
glands surrounding the areola that secrete
an antibacterial lubricant
– Nipple and areola have smooth
musculature that is responsive to tactile,
sensory or autonomic stimulation
Who Can Breastfeed?
• Size of breasts does NOT determine ability to
breastfeed
• Inverted nipples may make feeding more difficult
at first, but does not usually prohibit feeding
(surgery possible if severe)
• Some surgeries affect breastfeeding ability
– Mastectomy
– Breast reduction - may damage ductal system
– Augmentation - nerves may be severed, implant may
impede milk flow
Breastfeeding Support
• Women who are encouraged and supported
in breastfeeding:
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Are more likely to breastfeed
Are more successful with breastfeeding
Breastfeed longer on average
Have more satisfaction with process
• Lactation Consultants / Specialists
Databases to locate LCs:
http://www.breastfeeding.com/directory/states/texas.html
http://www.ilca.org/i4a/pages/index.cfm?pageid=3337
Breastfeeding Support
• Primary caregiver is extremely important
to success of breastfeeding
– Provide education
– Referrals as appropriate
– Provide breast-feeding area in waiting room
– Help troubleshoot problems that may arise
Breastfeeding
• Breastfeeding physiology
– Prolactin
• Starts to rise about 8 weeks gestation; increase in
estrogen suppresses dopamine, which stimulates
pituitary prolactin secretion
• Stimulates breast growth and colostrum production
– Progesterone inhibits lactation during pregnancy
– Oxytocin
• Contracts myoepithelial cells (uterine and breast)
• Empties alveoli and allows alveoli refilling
– Release is stimulated by suckling (let-down
reflex), infants hand mvmts, and psychologic
stimuli
Newborns use hands and mouth
to stimulate oxytocin after birth
Breastfeeding
• Post partum
– Takes about 3-4 days for E and P levels to fall to
let prolactin circulate
– Suckling stimulates nerve endings in the nipple to
release prolactin, oxytocin, and TSH (plays a role
in prolactin secretion)
– Milk supply usually equal to demand
– Breast will store milk for about 48 hours, after
which the supply diminishes
– Important to set maternal breastfeeding baseline
within first week after birth, else milk supply can
be insufficient or dry up
Establishing Baseline
Breastfeeding
• Advantages of breastfeeding:
– Bonding
• Prolactin stimulates relaxation
• Prolactin and oxytocin promote attachment
• Mother feels she is truly nourishing the baby
– Nutrition (more later)
– Milk composition changes to accommodate
infant’s nutritional needs
– Immune support for infant
– Decreased allergies, illnesses, and
hospitalizations for infant
Breastfeeding
• Incidence (on average):
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65% breastfeed at birth
45% at 2 months
35% at 3 months
20% at 6 months
<10% at 1 year
Milk Volume
Breastfeeding - Nutrition
• Colostrum:
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Can be expressed from 12 weeks gestation
10-40mL day
Thick, yellowish pre-milk
Lower calorie, fat, and volume than milk but higher in
minerals, protein, and fat-soluble vitamins; high in Ig
and antibodies
Important to establish bifidus acidophilus in gut;
babies without colostrum don’t establish good gut flora
Laxative: aids baby in passing meconium
Helps clear bilirubin from body
Has high levels of endorphins (2x mom’s blood level)
– Helps with postnatal adaptation and development
Nutrition
• Nutrition in breast milk
– Increased lactose, water, and fat content during
baby’s first week (lower protein and minerals)
– Contains lactoferrin (milk source of iron); nursing
babies do not require iron supplementation
• Bioavailability of iron in milk is 50% vs. 7% formulas and
4% in infant cereals
– Bioavailability of
• Calcium: 75% vs. 50% in formula
• Zinc: 60% v. 35% cow milk formula, 14% soy formula
– 90% water; baby does not need plain water
– Contains cholesterol (removed from infant formula)
Breastfeeding Benefits
– Decreases allergy to cow and soy milk
– Provides immunologic protection
• No IgA protection for first year in newborn
• Full antibody response not mature until age 2
– Inhibits and kills harmful bacteria (IgA component)
– Breastfed babies given formula for more than half
their feedings don’t have the immunological
advantage of the exclusively breastfed baby
– Decreases colic, otitis media, pneumonia,
bacteremia, meningitis, respiratory infections,
asthma, UTIs, atopic eczema, Crohn’s disease,
insulin-dependent diabetes, lymphoma
Breastfeeding
• Nutrition
– Immunologic component
• sIgA: highest immunoglobulin present in milk
• IgG: rises rapidly after birth then declines around 2
weeks
• IgM: same as IgG
• IgE: absent in human milk
• Several other and proteins and components that provide
immune function: mucins, lysozyme, bifidus factor
– Enzymes: anti-infective, digestive
– Hormones (thyroid, prostaglandins, insulin-like
growth factor)
Breastfeeding
• Maternal advantages
– More rapid uterine contraction back to normal
– Protection against ovarian cancer
– Decreased risk of premenopausal breast cancer esp. if
first lactation is before age 20 and is for 6 months
– Less risk of osteoporosis as bone loss during nursing is
replaced and mb to levels above baseline
– Cost-effective
– Convenient
– May suppress ovulation – space children apart
Effects of Analgesia
• Epidural or other pain meds (IV or IM)
Effects on newborn:
– Decrease alertness
– Lower neurobehavioral scores
– Inhibit suckling
– Delay effective feeding
Time to Successful Breast Feeding
by Analgesia Use and Time of First Feed
Journal of Nurse Midwifery
To breast
To breast after
within 1 hour
1 hour
No analgesia or
given less than 1
hour before birth
6.4 hours
49.7 hours
(n = 8)
(n = 19)
Analgesia given
more than 1 hour
before birth
50.3 hours
62.5 hours
(n = 9)
(n = 7)
Advantages of Early BF
Establishment
• Earlier establishment of effective
sucking and feeding
• Temperature stability
• Higher blood sugar
• Increased stooling, decreased jaundice
• Longer duration of breastfeeding
Breastfeeding
• Timing
– Best to have first nursing within 1 hour of birth,
baby is alert and eager and ensure adequate
blood sugar
– Good for bonding
– Environment important: relaxed and private, sit up
straight, have water readily available for mom
– Use of pillows to support baby and mom’s arms
– Lactation coach can assist with position and latch
(this is not a good latch)
Breastfeeding
• Intervals
– Mom should nurse on demand as long as
baby is nursing 8-12 times per day
– Maximum interval 4-6 hours in one 24 hour
stretch
• During the day every 2 hours and every 3-4 h
at night if baby allows during first 2 weeks
• If baby does not wake within 6 hours to nurse
there is likely a problem with his blood sugar–
needs to be woken up
Advantages of
On-Demand Feeding
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Less engorgement
No increase in nipple soreness
Less jaundice
Stable blood sugar
Faster onset of mature milk
Less weight loss, faster weight gain
Breastfeeding
• Duration: 15-25 min average per feeding
• Cues that baby is hungry:
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Increased alertness
Arm and leg movement
Rooting
Hand to mouth movements
Tonguing
Lip smacking
Crying (late sign)
Breastfeeding
• Signs of an adequate milk supply
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Baby is satisfied at end of feeding
Comfortable baby for 2-4 hours
Appropriate weight gain
6-8 wet diapers/ day
Bowel movements
Moist mucous membranes and good skin turgor
Milk changes from colostrum to milk
Mother experiences contractions and thrist when
baby feeds
Breastfeeding
• Maternal nutrition
– Mom should stay on prenatal vitamin while nursing
– Most vitamins increase in milk as maternal intake
increases (except vitamins C, B1 and K)
– Increased need for protein, vitamin D, B6, calcium,
zinc, vitamins A, C and folate
– More calories needed than when pregnant; 300500 calories over pregnancy level (generally 25003000 calories/ day)
– Drink to thirst, but at least 10-12 glasses/day
Breastfeeding
• Dieting
– Most breastfeeding moms lose about 1-2#/month
– If breastfeeding for over 1 year, they lose more
weight in second set of 6 months
– Not recommended to lose more than 4#/month
– Food choices affect weight gain and loss!
– Aerobic exercise does not affect quantity or
composition of milk as long as caloric intake is
adequate
Breastfeeding and
Cigarettes
• Maternal substance use
– Cigarettes
• More nicotine is absorbed by infant through the
respiratory tract than via breastmilk
• Breastmilk is protective against SIDS which has
higher incidence in smokers; smoking mothers
should therefore still breastfeed
Breastfeeding and Alcohol
• Alcohol should be discouraged
– Affects taste of milk
– Diminishes ejection let-down reflex
– Infants whose mothers drank heavily were
behind in gross motor skills at 1 year of age
• Unclear whether dt drinking during PG or lactation
– One beer high in hops (IPA) may help with milk
production– ok once in a while
– Only small % of alcohol gets into milk, but
remember infant has low body weight
Breastfeeding - Colic
• If infant colicky or fussy, look into mom’s diet.
Many foods are harder for infants to tolerate
when very young (may be able to tolerate
better later if avoided early on)
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Dairy
Gluten
Caffeine
Chocolate
Onions
Garlic
Strong spices
Legumes
Brassicacea family
Bottle Feeding
– Best to use breast milk in bottle
– Bottle nipple is larger and has larger hole
• Baby doesn’t need to use tongue (work as hard) to feed
– Introduce at six weeks; hold bottle horizontally
• Don’t give to baby while flat on his back
• If wait longer than 3-6 months, often baby won’t take it
– If doing bottle and breast, need to pump for
missed feedings or breast will produce less
• Storage of breast milk
– Refrigerate immediately– up to 24 hours
– Up to 6 weeks in regular freezer
– Up to 3 months in deep freezer
Breastfeeding
• Weaning
– Begins at around 6 months when begin to
introduce solid foods
– Look for cues baby is ready
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Sits upright alone
Getting teeth
Trying to eat food (watching parents eat)
Can swallow without spitting out food
Often babies/toddlers wean themselves
Toddlers: usually nurse for comfort, still beneficial
WHO: recommends breastfeeding x 2 years
Breastfeeding Complications
• Sore nipples
– Check technique: latch, nursing position
– Topical: lanolin,herbal salves, cabbage leaves,
expressed breast milk, vitamin E
– Nipple shields (can alter flow)
– Nurse more often, dry nipples after each feeding
– Enhance let down by nursing less sore breast first
• Breast engorgement
– Usu due to combination of high milk production
and decreased feeding frequency
– Treatment is hand expression, pumping, or BFing
– Hydrotherapy: alternating hot and cold to breast
Breastfeeding Complications
• Milk blister: blister on end of nipple due to
plugged nipple pore covered by epidermis
– Treat by placing warm compress, then baby
immediately to breast
– Open blister treated with analgesics, ice,
antibacterial ointment or herbal salve, breast
shields
– Time off if mom in too much pain; use breast pump
and feed baby by dropper, spoon or cup (to
prevent nipple confusion) for 24 hours
Breastfeeding Complications: Mastitis
• Mastitis: an infection of the breast tissue that
causes pain, swelling and redness of breast
• Bacteria enter breast through a break or crack in nipple
or through opening of milk duct
– Most often occurs in the first 6 weeks postpartum
– May occur in non-breastfeeding women (rare)
Mastitis
• Mastitis
– Symptoms:
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Breast tenderness or warmth to the touch
General malaise or feeling ill
Swelling of the breast
Pain or a burning sensation continuously or
while breast-feeding
• Skin redness, often in a wedge-shaped pattern
• Fever of 101 F (38.3 C) or greater
Mastitis
Mastitis
• Mastitis risk factors:
– Sore or cracked nipples (can develop without
broken skin)
– Previous bout of mastitis while breastfeeding
– Using only one position to breast feed, which may
not fully drain breast
– Wearing a tight-fitting bra (underwire can
contribute to breast compression) that restricts
milk flow
Mastitis
• Mastitis treatment
– Hydrotherapy: alternating hot/cold compresses
– Herbs: western and Chinese: take care not to
include herbs that may dry milk supply
• Try compresses/ poultices before using herbs internally
– Acupuncture: points?
– Modify risk factors
– Antibiotics when absolutely necessary
• Avoid tetracycline and sulfa drugs
Breastfeeding - Improving
Milk Supply
• What if supply is inadequate?
– Improve nutrition
– Increase fluids
– Pump
– Herbs: galactogogues
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Hops
Fenugreek
Borage
Raspberry
Breastfeeding Complications
• Thrush
– Candida infection in baby’s mouth
– Teach mom to keep nipples dry
– Bathe nipples in 1 tsp vinegar in cup water
– Decrease simple sugars in mom’s diet
– Give mom probiotics, can give baby also
Review for Final
Review Questions
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Where does fertilization usu take place?
How long is normal human gestation?
At what week of gestation does fertilization occur (approx)?
What are normal early SX of pregnancy?
What are later changes of pregnancy?
What causes these S/SX?
What symptoms would need investigation?
What is Rh incompatibility? Who is at risk?
Which weeks of gestation are embryonic stage?
At approx which week is fetus viable if born?
What is the role of the placenta?
What role(s) do oxytocin play in birth? After birth? In breastfeeding?
Review Questions
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What are the categories and types of contraceptive methods?
Which are most effective? Cheapest?
What are CIs to OCP use? SEs?
What are some ways to increase fertility and chance of
conception?
What are S/SX of SAB? Ectopic PG?
What is Preeclampsia? Eclampsia?
What is PROM? What risks are associated?
How many cms is full cervical dilation?
What are some methods of labor induction?
What does VBAC stand for?
What is meconium?
THANK YOU!
Good Luck in your endeavors!