Breast feeding and labour Flashcards
Advantages of breast feeding- health
Breastfeeding reduced the risk of: Gastroenteritis, chest infection, ear infections, urinary infections, diabetes, allergies, childhood cancers and SIDS, heart disease
Breast feeding reduces the risk of (mother): breast cancer, ovarian cancer, hip fractures
Formula milk
- Water
- Protein- cow milk protein and soy, 3 times as much protein as breastmilk, can cause weight gain in later years
- Carbohydrate- Lactose
- Fats- usually vegetable based, fat content in breast milk varies during feeds but in formula its static
- Additives are added, unsure how long term this will affect health
- A nutritionally adequate breast milk substitute
What do we need to discuss with mothers who choose to formular feed
- Making up feeds correctly
- Sterilisation of feeding equipment
- First stage milks for first year
- Amounts to give – link stomach size
- Responsive bottle feeding
How to support a mother with breastfeeding
- Keep mother and baby together – Room in.
- Help mothers to recognise feeding cues
- Allow unrestricted, frequent feeds
- Support mothers to breastfeed at night, refer to ‘Caring for your baby at night Guide for parents’ Leaflet (Unicef.)
- Avoid supplements
- Avoid dummies
- Support should start antenatally and continue through the postnatal period
- One-to-one support from trained personnel at a time when the mother needs or is expecting it
Maternal standards
- Ensuring pregnant women are prepared
- Supporting closeness and feeding straight after birth
- Ensuring breastfeeding off to a good start
Informed decisions re other food for babies - Encouraging close and loving relationships
How are maternity standards provided
There is a breastfeeding assessment at 5 days. Within the first 7 days a minimum of 2 assessments are carried out. Specialist services can be provided to some mothers. Mothers should be signposted to social support in their local area
Formular- when giving feeds its encouraged to hold the baby close and give the majority of feeds themselvex
Benefits of breast feeding for the baby
- Ideal food for newborns
- Reduced risk of diarrhoea and vomiting
- Reduced risk ear infections and chest infection
- Less likelihood of becoming obese and T2 diabetes later in life
- Breastmilk changes in composition and quality according to the baby’s needs – it is unique for that baby
Benefits of breast feeding for the mother
- Reduces risk of breast cancer and ovarian cancer
- Helps with weight loss (weight gained in pregnancy) as uses approx 500 extra calories per day for milk production
- Less costly than formula feeding
Cons of breast feeding
- It may be painful – sore and/or cracked nipples
- Not enough milk leading to baby either losing weight or not gaining weight
- Breast engorgement
- Baby not effectively latching onto breast
- Blocked milk duct
- Mastitis
- Breast abscess
Pros of formula feeding
- It is difficult to identify any established scientific benefits of formula feeding. Most of the pros highlight the potential benefit of:
- Family members sharing the feeding
- Mothers don’t have to alter their diet with regards to alcohol and caffeine
- More confident when feeding in public
Cons of formular feeding
- Formula milk can be costly
- It is not a ‘living’ product and cannot replicate all the qualities of human milk eg antibodies, enzymes, hormones, living cells etc
- Risk of dehydration if not made correctly
- Risk of weight loss if not made correctly (diluted)
- Where access to clean water and/or boiled water formula feeding can cause major health problems.
How breastfeeding works
- When the baby suckles this stimulates nerve impulses which stimulate the pituitary gland
- Hormones are released causing milk let down
Prolcatin- hormone
- Triggered by suckling
- Acts on acini cells to make milk
- Peaks 90 minutes after a feed
- Suppresses ovulation
- Needs to be stimulated early and frequently to be effective long term
Setting up milk production
- Delivery of placenta opens prolactin receptor sites on acini cells
- Prolactin surges ‘prime’ sites to begin milk production
- Receptor sites start to close if not primed
- Skin contact and lots of feeds in early days increase potential for long-term milk production
Oxytocin
- Triggered by suckling and positive thoughts
- Acts in the myoepithelial cells to eject milk
- Largest peak occurs early in the feed
- Effect may be felt as tingling
- Basal levels are higher when the baby is near
- Can be temporarily inhibited by stress
Prolactin and oxytocin
Work together to trigger feeling of love and mothering behaviour, induce calmness and a feeling of well being. Enhance the mother baby bond.
Colostrum
- Produced from 16 weeks gestation, continues for 3-4 days postpartum
- Yellow-orange thick fluid: concentrated form of breast milk
- Lower levels of carbohydrate and fat
- Newborns have immature kidneys and only able to cope with small volumes of fluid
- Having small amount of colostrum allows infant to learn co-ordination of sucking, swallowing and breathing.
- Has a laxative effect – aids passage of meconium from the gut
Contents of colostrum
- Rich in growth factors
- White cells and antibodies (especially IgA)
- Fat soluble vitamins (especially vitamin A)
- Protein minerals
What’s contained in breast milk- fat and protein
- Fat- main source of energy, half of all calories. Mainly triglycerides. Long chain fatty acids aid brain and eye development, nervous and vascular system
- Protein- about 40% casein (carry calcium and phosphate) and 60% whey (contains anti-infective proteins). Lactoferrin binds to iron. Bifidus factor inhibits growth of harmful bacteria in the gut. Taurine is required for conjugation of bile salts and absorption of fats.
Whats contained in breast milk- carbohydrates and iron
- Carbohyrates- Lactose is the main carbohydrate, its quickly broken down into glucose and is important for brain growth
- Iron- low levels are bound by lactoferrin. Artificial milk has higher levels which promote growth of bacteria in the gut and risk of infection.
What contained in breast milk- electrolytes, minerals and pre-biotics
- Electrolytes and minerals: sodium, potassium, chloride, calcium, phosphorus and magnesium
- Pre-biotics: interact with intestinal epithelial cells to stimulate the immune system. Reduces gut pH causing infection to prevent pathogenic bacteria and the number of bifidus bacteria on the mucosa
Breast milk- fat soluble vitamins
- Vitamin A & E levels adequate
- Vitamin D & K not always at desired level ( current guidelines are to supplement)
- DoH recommend Vitamin D supplementation
- Vitamin K routinely administered to infants
- As infants gut is colonised Vitamin K levels rise
Breastmilk- immunoglobulins
- Cannot be replicated in formula milk
Present in 3 ways:
* Antibodies from previous maternal infections
* Secretory IgA which lines the digestive tract
* Entero-mammary and broncho-mammary pathways
Breast milk production amount
- At birth: up to 5ml
- Within 24 hours: 7-123 ml/day
- Between 2-6 days: 395-868 ml/day
- 4 weeks: 395-868 ml/day
- 6 months 710-803 ml/day
Bracho-mammary and Entero-mammary pathway
When pathogens are inhaled (broncho) or ingested (entero). Antibodies are produced by the mother and incorporated into the breast milk.
Baby’s instinctive behaviour
Birth cry, relaxation, awakening, activity, crawling, resting, familiarisation, suckling, sleeping
Skin to skin contact
- Stimulates release of prolactin and oxytocin
- Calms and relaxes baby and mother
- Regulates baby’s heart rate and breathing
- Regulates baby’s temperature
- Stimulates breast-seeking behaviour and interest in feeding
- Stimulates endorphin release
- Protects baby from infection
Can help with: positioning and attachment, unsettled babies, breast refusal, postnatal depression
What defines a normal labour
- Spontaneous in onset
- Regular, painful contractions
- Progressive dilatation and effacement of the cervix
- Spontaneous vaginal delivery
- Vertex position
- Between 37 and 42 weeks
- Mother and infant in good condition
What are the cardinal movements and most common presentation
Cardinal movements- 7 movements which allows the fetal head to move through the pelvic floor.
Most common presentation- longitudinal cephalic line.
Cardinal movements 1-3
- Engagement- largest diameter of the fetus head fits into the largest diameter of the maternal pelvis. Thne moves towards the pelvis brim in either the left or right occipto-transverse position.
- Descent- the baby descends through the pelvic inlet towards the pelvic floor. Occurs due to uterine contraction, amniotic fluid pressure and abdominal muscle contractions.
- Flexion- fetal head meets the pelvic floor and cervical flexion occurs. Allows foetus to be sub-occipito bregmatic. In this position the fetal skull has the smallest diameter
Cardinal movements 4-5
- Internal rotation- pelvic floor has a gutter shape (forward and downward slope), causes the head to rotate from a left or right occipto-transverse position to an occipto-anterior position.
- Crowning- largest diameter of the fetal head goes through the narrowest part of the bony pelvis. The head is visible at the vulva and no longer retreats between contractions.
Cardinal movements 6-7
- Extension- the occiput slips beneath the suprapubic arch as the head extends, the nape of the neck pivots against the arch. Extension of the head causes stretching of the perineum.
- External rotation and restitution- the head externally rotates to face the right or left medial thigh of the mother. The shoulders rotate from a transverse position to an anterior-posterior position. The re-alignment of the shoulders with the head is restitution.
Onset of labour
- Maternal factors: rise of oestrogen/prostaglandin, Formation of oxytocin receptors
- Physical factors: stretching of uterus, pressure of presenting part on the cervix
- Fetal factors: fetal pituitary/adrenals
Labour- the passage
- Head enters the pelvis transversely, it descends in this position through the mid cavity
- It internally rotates when it hits the pelvic floor to exit in the AP diameter
Labour- the passenger and the powers
The passenger
* Attitude- degree of flexion of the fetal head
* Position- 95% are occiput anterior
The powers- contractions start in the fundus and spread downwards through the myometrium. Regular, strong contractions are essential to enable progress in labour
The three stages of labour
- First stage: onset of labour to full dilation of the cervix
- Second stage: full dilation to delivery of baby
- Third stage: delivery of baby to delivery of placenta and membranes
First stage of labour
- Latent phase: painful contractions often irregular. Cervical changes (softening/effacement). Dilation up to 4cms
- Active stage: regular painful contractions and progressive cervical dilation up to 10cm
- On average- 12 hours if primigravida and 7 ½ hours multiparous
Normal progress in 1st stage: 2cm in four hours
Progress in labour
- Varies between individuals
- Effacement (thinning)
- Dilatation (opening)
- Descent (progress through the birth canal)
- Progress assessed by vaginal examination
- Cervix moves from posterior to anterior
Descent
- Defined relative to the ischial spine
- 0 station= top of head at the spines
- +2 station= 2cm below the ischial spine
Fetal monitoring in low risk labour
- Intermittent auscultation using Doppler or Pinards stethoscope
- For one minute
- Following a contraction
- Every 15 minutes in the first stage
- Every 5 minutes in the second stage
Labour- analgesia
- Non-pharmacological: supportive birth partner, TENS, Birthing pool, Acupuncture
- Pharmacological: oral analgesia, Entonox, Opiate + anti-emetic, epidural
Second stage of labour
- Passive: from full dilation, allows spontaneous descent of presenting part, may have some involuntary urge to push, may see some anal dilation
- Active second stage: mother is encouraged to actively push, fetal head descends- perineum stretches. Head is delivered and the body with the next contraction.
Mechanism of delivery
- Descent thro the pelvis
- Flexion of the head: (chin to chest)
- Internal rotation: transverse diameter to AP
- Crowning of the head
- Extension: face sweeps the perineum
- Restitution: Head rotates to align with shoulders
- Internal rotation of the shoulders
- Expulsion: Shoulders delivered in AP diameter
Baby delivered in OA position
Moulding and Caput succedaneum
Moulding: overlapping of the fetal skull bones at the suture line. Occurs during labour as the fetus descends through the pelvis
Caput succedaneum: temporary swelling of the soft parts of the head due to compression by the muscles of the cervix. Crosses suture lines
At birth
- Baby is delivered onto the mothers abdomen
- Delayed cord clamping allows blood to flow from the placenta to the baby
- Clamp cord approx. 2cm away from the babys abdomen
- Baby placed in direct contact with mother’s skin and dried with pre-warmed towels. Initial assessment of baby’s condition.
- Early mother baby contact to be encouraged.
- Assess for perineal trauma and manage as appropriate.
The third stage of labour
- Can be active or physiological
- Physiological: can take up to an hour. Watch for signs of placental separation. Uterus well contracted at the level of the umbilicus. A sudden gush of blood, lengthening of cord
- Monitor for signs of excessive bleeding- increased risk of PPH
The third stage- active management
- IM injection of oxytocin (uteronic drug) following birth
- Observe for signs of separation
- Controlled cord traction
- Guard the uterus
Perineal trauma assessment
- 1st degree- skin around the fourchette
- 2nd degree/Episiotomy- skin plus vaginal wall and perineal muscles
- 3rd degree- all of the above plus anal sphincter
- 4th degree- most severe, all of the above plus rectal tissue
