Pedia Notes
Pedia Notes
Pedia Notes
Practices that may help a woman to feel competent, in control, supported and ready to interact with
her baby who is alert, help to put this Step into action.
These practices include:
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Emotional support during labour.
Attention to the effects of pain medication on the baby.
Offering light foods and fluids during early labour.
Freedom of movement during labour.
Avoidance of unnecessary caesarean sections.
Early mother-baby contact.
Facilitating the first feed.
Practices that may hinder mother and baby early contact and the establishment of breastfeeding
include:
Effect of Support during labour. A companion during labour and birth can:
Increased alertness of baby as less pain relief drugs reach the baby
Reduced risk of infant hypothermia and hypoglycaemia because baby is less stressed and thus
using less energy
Early and frequent breastfeeding
Easier bonding with the baby.
The companion provides non-medical support that can include: What support can the doula give
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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.
Offer non-medication methods of pain relief before offering pain medications. These non-medication
methods include:
Labour support
Walking and moving around
Massage
Warm water
Verbal and physical reassurances
Quiet environment with no bright lights and as few people as possible
Labouring and giving birth positioning a position of the mother’s choice.
Longer labour
Operative interventions
Delayed start to mother baby contact and breastfeeding
Separation of mother and baby after birth
Sleepy, hard to rouse baby
Diminished sucking reflex
Reduced milk intake increasing the risk of jaundice, hypoglycaemia, and low weight gain.
Ask: What effect might giving fluid or withholding fluid have on Miriam’s labour?
Labour and birth are hard work. The woman needs energy to do this work.
Gets hungry after normal delivery
Intravenous (IV) fluids for woman in labour need to be used only for a clear medical indication.
Ask: What birth practices might help and what practices are better avoided unless there is a medical
reason?
Ask: What are important practices immediately after birth that can help the mother and baby?
Skin-to-skin contact:
Ensure uninterrupted, unhurried skin-to-skin contact between every mother and unwrapped
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. A longer period
of skin-to-skin contact is recommended if the baby has not suckled by one hour after birth.
Show pictures of skin-to-skin contact and point out that the baby is not wrapped and both mother and
baby are covered.
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.
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.
Reduces infant crying, thus reducing stress and energy use.
Facilitates bonding between the mother and her baby, as 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, which is more likely to result in effective
suckling than when the baby is separated from his or her mother in the first few hours.
Concern that the baby will get cold. Dry the baby and place baby naked on the mother’s chest.
Put a dry cloth or blanket over both the baby and the mother. If the room is cold, cover the
baby’s head also to reduce heat loss. Babies in skin-to-skin contact have better temperature
regulation than those under a heater.
Baby needs to be examined. Most examinations can be done with the baby on the mother’s
chest where baby is likely to be lying quietly. Weighing can be done later.
Mother needs to be stitched. The infant can remain on the mother’s chest if an episiotomy or
caesarean section needs to be stitched.
Baby needs to be bathed. Delaying the first bath allows for the vernix to soak into the baby’s
skin, lubricating and protecting it. Delaying the bath also prevents temperature loss. Baby can be
wiped dry after birth.
Delivery room is busy. If the delivery room is busy, the mother and baby can be transferred to
the ward in skin-to-skin contact, and contact can continue on the ward.
No staff available to stay with mother and baby. A family member can stay with the mother and
baby.
Baby is not alert. If a baby is sleepy due to maternal medications it is even more important that
the baby has contact as he/she needs extra support to bond and feed.
Mother is tired. A mother is rarely so tired that she does not want to hold her baby. Contact
with her baby can help the mother to relax. Review labour practices such as withholding fluid
and foods, and practices that may increase the length of labour, which can tire the mother.
Mother does not want to hold her baby. If a mother is unwilling to hold her baby it may be an
indication that she is depressed and at greater risk of abandonment, neglect or abuse of the
baby. Encouraging contact is important as it may reduce the risk of harm to the baby24.
Ask: What effect could the caesarean section have on Fatima and her baby as regards breastfeeding?
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Early touch of the nipple and areola results in a release of the hormone oxytocin. Oxytocin helps:
The uterus to contract more quickly which may control bleeding. Routine use of synthetic oxytocin and
ergometrine are not necessary when a mother is breastfeeding after birth.
Colostrum, the first milk in the breast, is vitally important to the baby. It provides many immune factors
that protect the baby, and it helps to clear meconium from the baby’s gut, which can keep levels of
jaundice low. Colostrum provides a protective lining to the baby’s gut, and helps the gut to develop.
Thus it should be the only fluid the baby receives.
Engorgement
What is engorgement?
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Slide 12/2:Picture of full breast
Normal breast fullness: When the milk is “coming in,” there is more blood supply to the
breast as well as more milk. The breasts may feel warm, full, and heavy. This is normal.
To relieve fullness, feed the baby frequently and use cool compresses between feeds. In a
few days, the breasts will adjust milk production to the baby’s needs.
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Slide 12/3:Picture of engorgement
Engorgement: If the milk is not removed, the milk, blood and lymph become congested
and stop flowing well, which results in swelling and oedema. The breasts will become
hot, hard and painful, and look tight and shiny. The nipple may be stretched tight and flat,
which makes it difficult for the baby to attach and which can result in sore nipples.
If engorgement continues, the feedback inhibitor of lactation reduces milk production.
Causes of breast engorgement include:
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Delay in starting to breastfeed soon after baby’s birth.
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Poor attachment, so that milk is not removed effectively.
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Infrequent feeding, not feeding at night or short duration of feeds.
Treatment of mastitis
Explain to the mother that she MUST:
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Remove the milk frequently (if not removed, an abscess may form).
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The best way to do this is to continue breastfeeding her baby frequently.
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Check that her baby is well attached.
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Offer her baby the affected breast first (if not too painful).
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Help the milk to flow.
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Gently massage the blocked duct or tender area down towards the nipple before and
during the feed.
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Check that her clothing, especially her bra, does not have a tight fit.
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Rest with the baby so that the baby can feed often. The mother should drink plenty of
fluids. The employed mother should take sick leave if possible.
3. Sore Nipples
10 minutes
Breastfeeding should not hurt! Some mothers find their nipples are slightly tender at the
beginning of a feed for a few days. This initial tenderness disappears in a few days as the
mother and baby become better at breastfeeding. If this tenderness is so painful that the
mother dreads putting the baby to the breast, or there is visible damage to the nipples, this
soreness is not normal, and needs attention.
The most common early causes of nipple soreness are simple and avoidable. If mothers in
your facility are getting sore nipples, make sure that all maternity staff know how to help
mothers get their babies attached to the breast. If babies are attached well at the breast
and breastfeed frequently, most mothers do not get sore nipples.
Preventing engorgement
Fullness is normal in the early days. Over-fullness is not normal.
Follow the practices of the Ten Steps:
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Facilitate skin-to-skin contact immediately after birth and initiate exclusive, unlimited
breastfeeding within one hour after birth (Step 4).
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Show mothers who need help how to attach their baby at the breast (Step 5).
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Show mothers how to express their milk (Step 5).
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Breastfeeding exclusively with no water or supplements (Step 6).
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Keep mothers and babies together in a caring atmosphere (Step 7).
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Encourage babies to feed at least 8–12 times in 24 hours during the early days (Step 8).
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Give no pacifiers, artificial teats, or bottles (Step 9).
Treating engorgement
Remove the breast milk and promote continued lactation.
Correct any problems with attachment.
Gently express some milk to soften the areola and help the baby's attachment.
Breastfeed more frequently.
Apply cold compresses to the breasts after a breastfeed for comfort.
Build the mother’s confidence and help her to be comfortable.
Treatment
Improve milk flow:
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Check the baby's attachment and correct/improve if needed.
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Check for tight fitting clothing or pressure from fingers
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Support a large breast to assist milk flow
Suggest:
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Breastfeed frequently. If necessary, express milk to avoid fullness.
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Gently massage towards the nipple.
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Apply a moist, warm cloth to the area before a breastfeed to help milk flow.
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Rest the mother not the breast.
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Anti-inflammatory treatment or analgesic if in pain.
Antibiotic therapy is indicated if:
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The mother has a fever for longer than 24 hours.
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The mother’s symptoms do not begin to subside after 24 hours of frequent and effective
feeding and/or milk expression.
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The mother’s condition worsens.
If a woman is HIV-positive and develops mastitis or an abscess she should:
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Avoid breastfeeding from the affected breast while the condition persists.
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Express the milk from that breast, which can be heat-treated and given to the baby.
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Rest, keep warm, take fluids, pain relief and antibiotics.
Sore nipples
Decide the cause, including observation of a feed. Examine the nipples and breasts.
Reassure the mother.
Treat the cause - poor attachment is the most common cause of sore nipples.
Avoid limiting the frequency of feeds.
Refer skin conditions, tongue-tie and other less common conditions to a suitably trained
person.