When positioning a newborn to breastfeed, all of the following are correct EXCEPT

Session Objectives

On completion of this session, participants will be able to:

Materials

Slides 5/1 – 5/3: Skin to skin contact.

Birth Practices Checklist (optional).

Further Reading for Facilitators

WHO, Pregnancy, childbirth, postpartum and newborn care - a guide for essential practice. (2003)

Department of Reproductive Health and Research (RHR), WHO.

Coalition for Improving Maternity Services (CIMS)

National Office, PO Box 2346, Ponte Vedra Beach, FL 32004 USA

www.motherfriendly.org gro.yldneirfrehtom@ofni

Optional book - Kroeger M, Smith L. Impact of Birthing practices on breastfeeding – protecting the mother and baby continuum. Jones & Bartlett Publishers, 2004.

1. Labour and birth practices to support early breastfeeding

30 minutes

In an earlier session, the mother in our story, Miriam, was at the antenatal clinic. A few weeks have gone by and now her baby is ready to be born. She comes to the maternity facility.

Ask: What practices during labour and immediately after birth could help Miriam and her baby to start breastfeeding well?

Wait for a few responses.

• The care that a mother experiences during labour and birth can affect breastfeeding and how she cares for her baby.

• Step 4 of the Ten Steps to Successful Breastfeeding states:

  Help mothers to initiate breastfeeding within a half-hour of birth.

  To focus on the importance of skin-to-skin contact and watching for infant readiness, this step 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 recognise when their babies are ready to breastfeed, offering help if needed.

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

  Wait for a few replies

• 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.

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  Attention to the effects of pain medication on the baby.

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  Offering light foods and fluids during early labour.

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  Freedom of movement during labour.

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  Avoidance of unnecessary caesarean sections.

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  Early mother-baby contact.

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  Facilitating the first feed.

  Ask: What practices may hinder early mother and baby contact?

  Wait for a few replies.

• Practices that may hinder mother and baby early contact and the establishment of breastfeeding include:

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  Requiring the mother to lie in bed during labour and birth.

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  Lack of support.

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  Withholding food and fluids during early labour.

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  Pain medications that sedate mother or baby, episiotomy21, intravenous lines, continuous electronic fetal monitoring and other interventions used as routine without medical reasons.

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  Wrapping the baby tightly after birth.

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  Separating the mother and baby after birth.

• Take care that these practices that may hinder early contact are only used if medically necessary.

Miriam’s sister comes with her to the maternity facility. Miriam wants her sister to stay with her during labour and the birth.

Ask: How might it make a difference to Miriam if her sister stays with her during labour and the birth?

Wait for a few responses.

Support during labour

• A companion during labour and birth can:

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  Reduce the perception of severe pain

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  Encourage mobility

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  Reduce stress

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  Speed labour and birth

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  Reduce the need for medical interventions

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  Increase the mother’s confidence in her body and her abilities.

• The support can result in:

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  Increased alertness of baby as less pain relief drugs reach the baby

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  Reduced risk of infant hypothermia and hypoglycaemia because baby is less stressed and thus using less energy

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  Early and frequent breastfeeding

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  Easier bonding with the baby.

• The labour and birth companion can be a mother, sister, friend, family member or the baby’s father or a member of the health facility staff. The support person needs to remain continuously with the woman through labour and the birth.

• The companion provides non-medical support that can include:

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  Encouragement to walk and move in labour

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  Offering light nourishment and fluids

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  Building the mother’s confidence by focusing on how well she is progressing

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  Suggesting ways to keep pain and anxiety manageable

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  Providing massage, hand holding, cool cloths,

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  Using positive words.

Pain relief

Miriam asks about pain relief and its effect on the baby and breastfeeding.

Ask: What can you tell her about pain relief?

Wait for a few responses.

• Offer non-medication methods of pain relief before offering pain medications. These non-medication methods include:

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  Labour support

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  Walking and moving around

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  Massage

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  Warm water

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  Verbal and physical reassurances

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  Quiet environment with no bright lights and as few people as possible

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  Labouring and giving birth positioning a position of the mother’s choice.

• Pain medications can increase the risk of:

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  Longer labour

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  Operative interventions

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  Delayed start to mother baby contact and breastfeeding

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  Separation of mother and baby after birth

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  Sleepy, hard to rouse baby

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  Diminished sucking reflex

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  Reduced milk intake increasing the risk of jaundice, hypoglycaemia, and low weight gain.

• Extra time and assistance may be needed to establish breastfeeding and bonding if pain medications are used.

• Discuss ways to cope with pain and discomfort and their risks and benefits during antenatal care. The need for pain relief is affected by stress, lack of support and other factors in the labour ward.

Light foods and fluids during labour

Miriam is progressing well in early labour and there are no medical problems. She asks you if she can continue to drink water.

Ask: What effect might giving fluid or withholding fluid have on Miriam’s labour?

Wait for a few responses.

• Labour and birth are hard work. The woman needs energy to do this work. There is no evidence that withholding of light food and drink from low risk women in labour is beneficial as a routine practice. The desire to eat and drink varies and a woman should be allowed to decide if she wants to eat or drink. Restricting food and fluid can be distressing to the labouring woman.

• 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, and high weight loss as the baby sheds the excess fluid. An IV drip may limit the woman’s movement.

• Following a normal birth, a woman may be hungry and she should have access to food. If she gives birth during the night, some food should be available for her so that she does not need to wait many hours until the next meal is available.

Birth practices

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

Wait for a few responses.

• When giving birth, all women need:

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  A skilled attendant present.

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  Minimal use of invasive procedures such as episiotomy22.

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  Universal precautions to be followed to prevent transmission of HIV and blood-borne infections23.

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  Caesarean sections or any other intervention only used when medically required.

• Instrumental birth (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.

• Normal vaginal birth is assisted by the woman being mobile during early labour with access to fluids and food, and by being in an upright or squatting position for birth.

• Episiotomy will result in pain and difficulty in sitting during the early days after birth, which can affect early skin-to-skin contact, breastfeeding, and mother-baby contact. If the woman is sore, encourage her to lie down to feed and cuddle her baby.

• The cord should not be clamped until pulsing reduces and baby has received sufficient additional blood to boost iron stores.

• When considering birth practices remember that the practices have an effect on the baby as well as the mother.

2. Importance of early contact

15 minutes

Miriam has her baby. It is a healthy girl.

Ask: What are important practices immediately after birth that can help the mother and baby?

Wait for a few responses

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.

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  Show pictures of skin-to-skin contact and point out that the baby is not wrapped and both mother and baby are covered.

• Skin-to-skin contact:

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  Calms the mother and the baby and helps to stabilise the baby’s heartbeat and breathing.

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  Keeps the baby warm with heat from the mother’s body.

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  Assists with metabolic adaptation and blood glucose stabilization in the baby.

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  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.

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  Reduces infant crying, thus reducing stress and energy use.

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  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.

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  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.

• 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 (slide 5/3.)

  Ask: What could be barriers to ensuring early skin-to-skin contact is the routine practice after birth and how could these barriers be overcome?

Wait for a few responses.

Overcoming barriers to early skin-to-skin contact

• Many of the barriers to skin-to-skin contact are related to common practices rather than to a medical concern. Some changes to practices can facilitate skin-to-skin contact.

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  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.

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  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.

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  Mother needs to be stitched. The infant can remain on the mother’s chest if an episiotomy or caesarean section needs to be stitched.

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  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.

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  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.

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  No staff available to stay with mother and baby. A family member can stay with the mother and baby.

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  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.

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  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.

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  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.

• With twins the interval between the births varies. Generally, 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.

• It may be helpful to add an item to the mother’s labour/birth chart to record the time that skin-to-skin contact started and the time that it finished. This is an indication that skin contact is as important as other practices of which a record is required.

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  Optional: Discuss Birth Practices Checklist (at end of this session).

3. Helping to initiate breastfeeding

5 minutes

Miriam heard about skin-to-skin contact during her pregnancy and she is happy to have this contact. When Miriam had her previous baby in a different hospital, the baby was wrapped and taken to the nursery immediately, which she did not like. Miriam also heard that it was good to start breastfeeding soon after birth.

Ask: How can you help Miriam and her daughter to initiate breastfeeding?

Wait for a few responses.

How to assist to initiate breastfeeding

• When the baby is on the mother’s chest with skin-to-skin contact the breast odour will encourage the baby to move towards the nipple.

• Help a mother to recognise these 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. This may be a few minutes or an hour or more. The behaviours of the baby include:

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  a short rest in an alert state to settle to the new surroundings;

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  bringing his or her hands to his or her mouth, and making sucking motions; sounds, and touching the nipple with the hand;

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  focusing on the dark area of the breast, which acts like a target;

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  moving towards the breast and rooting;

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  finding the nipple area and attaching with a wide open mouth.

• There should be no pressure on the mother or baby regarding how soon the first feed takes place, how long a first feed lasts, how well attached the baby is or how much colostrum the baby takes. 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.

• The role of the health worker at this time is to:

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  provide time and a calm atmosphere;

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  help the mother to find a comfortable position;

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  point out positive behaviours of the baby such as alertness and rooting;

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  build the mother’s confidence;

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  avoid rushing the baby to the breast or pushing the breast into the baby’s mouth.

4. Ways to support breastfeeding after a Caesarean section

15 minutes

Miriam and her baby are now happy with their early contact and breastfeeding. They are both resting on the postnatal ward. However, Fatima has now come to the maternity facility. Her baby is not due for a few weeks but there are some difficulties. The doctor decides that Fatima’s baby needs to be born and that a caesarean section will be needed.

Ask: What effect could the caesarean section have on Fatima and her baby as regards breastfeeding?

Wait for a few responses.

• A Caesarean section is major abdominal surgery. The mother is likely to:

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  be frightened and stressed;

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  have an IV drip and urinary catheter inserted;

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  be confined to bed and restricted in movement;

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  have restricted fluid and food intake both before and after the birth, thus be deprived of energy to care for her baby;

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  receive anaesthetics and analgesia for pain, which can affect the responses of both the mother and baby;

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  have altered levels of oxytocin and prolactin, the hormones of lactation;

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  be at higher risk of infection, and bleeding;

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  be separated from her baby;

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  feel a sense of failure that her body was not able to work normally to give birth.

• The baby is also affected by a caesarean birth. The baby:

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  is a high risk of not breastfeeding or of breastfeeding for only short duration;

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  may have more breathing problems;

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  may need suction of mucus, which can hurt the baby’s mouth and throat;

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  may be sedated from maternal medications;

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  is less likely to have early contact;

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  is more likely to receive supplements;

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  is more likely to have nursery care increasing the risk of cross-infection as well as restricting breastfeeding.

  Fatima’s baby is born. It is a boy. He is four weeks early and small but his breathing is stable. He is given to Fatima for skin-to-skin contact. This will help his breathing and temperature.

  Ask: How can you help Fatima and her baby to initiate breastfeeding after a Caesarian section?

  Wait for a few responses.

• The presence of a supportive health worker is important for helping a mother initiate breastfeeding after a Caesarean.

• Encourage the mother to have skin-to-skin contact as soon as possible.

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  In general, mothers who have spinal or epidural anaesthesia are alert and able to respond to their baby immediately, similar to mothers who give birth vaginally.

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  Following a general anaesthesia, contact can occur in the recovery room if the mother is responsive, though she may still be sleepy or under the influence of anaesthesia.

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  The father or other family member can give skin-to-skin contact which helps keep the baby warm and comforted while waiting for the mother to return from the operating theatre.

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  If contact is delayed, the baby should be wrapped in a way that facilitates unwrapping for skin-to-skin contact later when the mother is responsive.

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  Babies who are premature or born with a disability also benefit from skin-to-skin contact. If a baby is not stable and needs immediate attention, skin-to-sin contact can be given when the baby is stable.

• 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 that is finding the breast and 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 anaesthesia.

• Help Caesarean mothers find a comfortable position for breastfeeding. The I.V. drip may need adjustment to allow for positioning the baby at the breast.

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  Side-lying in bed. This position helps to avoid pain in the first hours and allows breastfeeding even if the mother must lie flat after spinal anaesthesia.

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  Sitting up with a pillow over the incision or with the baby held along the side of her body with the arm closest to the breast.

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  Lying flat with the baby lying on top of the mother.

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  Support (e.g. pillow) under her knees when sitting up, or under the top knee and behind her back when side lying.

• Provide rooming-in with assistance as needed until the mother can care for her baby.

• When staff are supportive and knowledgeable, the longer stay in hospital following a Caesarean section may assist in establishing breastfeeding.

5. BFHI practices and women who are not breastfeeding

10 minutes

• All mothers should have support during labour and birth. Harmful practices should be avoided. Early skin-to-skin contact benefits all mothers and babies.

• Unless there is a known medical reason for not breastfeeding, (for example that the woman has been tested and found to be HIV-positive and following counselling during pregnancy has decided not to breastfeed) all mothers should be encouraged to let their baby suckle at the breast. If a mother has a strong personal desire not to breastfeed, she can say so at this time.

• The breastfeeding baby receives colostrum in the first feeds in small amounts suitable for a newborn’s stomach. If the baby is not breastfeeding, replacement feeds should start with small amounts25. Arrangements will need to be made to ensure there are replacement feeds available for any infants who are not breastfeeding.

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  Discuss how replacement feeds could be made and given in the first few hours after the woman has given birth.

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  Ask if there are any questions. Then summarise the session.

Session 5. Summary

• Step 4 of the Ten Steps to Successful Breastfeeding states: Help mothers to initiate breastfeeding within a half-hour of birth. This step 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.

• 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. Encourage a family centred maternity care approach at birth with involvement of the father or close family member during labour and birth.

• Supportive practices include: support during labour, limiting invasive interventions, paying attention to the effects of pain relief, offering light food and fluids, avoiding unnecessary caesarean sections, and facilitating early mother and baby contact.

• Early contact and assistance with breastfeeding can be routine practice after a caesarean section also.

• Provide uninterrupted, unhurried skin-to-skin contact between every mother and her healthy baby. Start immediately or as soon as possible in the first few minutes after birth. The baby should be unwrapped, and the mother and baby both covered together. Provide this contact for at least one hour after birth.

• Encourage the mother to respond to the baby’s signs of readiness to go to the breast.

• These supportive practices do not need to change for women who are HIV-positive.

Session 5 Knowledge Check

List four labour or birth practices that can help the mother and baby get a good start with breastfeeding.

List three ways to assist a mother following a caesarean section with breastfeeding.

Name three possible barriers to early skin-to-skin contact and how each might be overcome.

Additional information – Session 5

Initiation of breastfeeding

• Encourage the mother to breastfeed when the baby shows that she or he is ready (usually within an hour). It is unnecessary to hurry and force babies to the breast. A mother and her baby should be quietly kept in skin-to-skin contact until they are both ready to breastfeed. This may be a few minutes or an hour or more.

• Early touch of the nipple and areola results in a release of the hormone oxytocin. Oxytocin helps:

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  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.

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  The mother to feel more loving and attached to her baby.

• Colostrum, the first milk in the breast, is vitally important to the baby26. 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.

• Prelacteal feeds are any fluid or feed given before breastfeeding starts. They might include water, formula, traditional feeds such as honey, dates or banana, herbal drinks or other substances. Even a few spoonfuls of these fluids or feeds can increase the risk of infection and allergy to the infant. If prelacteal feeds are used in the area, during pregnancy discuss with the mother the importance of exclusive breastfeeding and how she might achieve this.

• Newborn infants do not need water or other artificial feeds to ‘test’ their ability to suck or swallow. In the rare situation where a baby has an abnormality of swallowing, colostrum (a natural physiological substance) is less risk to a baby’s lungs than a foreign substance such as water or artificial formula.

• A mother who breastfeeds in the delivery room is more likely to breastfeed for more months than when the first breastfeed is delayed.

• If a baby has not started to breastfeed in the delivery room, ensure that the postnatal ward staff know this. Ask them to ensure that skin-to-skin contact continues, and to watch for signs of readiness to feed.

Optional activity

Observe a mother and baby in skin-to-skin contact soon after birth. What behaviours of the baby do you see that are leading to the baby going to the breast?

21

The perineum is cut to give more room for the baby’s head. The perineum is then stitched after the birth.

Invasive procedures include vaginal examinations, amniocentesis, cardiocentesis or taking a sample from the placenta, artificial rupture of membranes, episiotomy, and blood transfusions as well as suctioning of the newborn.

Universal Precautions protect the birth attendant so they do not need to fear the woman with HIV and also protect the woman from any infections that the birth attendant may have.

If there is a risk of harm to the baby a support person needs to be present both to encourage the mother to hold her baby and for the baby’s protection.

There is no research evidence to advise on when a full-term healthy baby who is not breastfed needs to get a first feed. Most healthy babies who are not breastfeeding do not need to be fed in the first hour or two after birth.

See section on colostrum in the Additional Information section of Session 3.

What is the correct position for breastfeeding?

What are the 4 kinds of breastfeeding positions?