Midwifery Knowledge 3 Flashcards
Identify the 9 stages of infant led attachment
- Birth Cry
- Relaxation
- Awakening
- Activity
- Rest
- Crawling
- Familiarisation
- Suckling
- Sleeping
Explain infant led attachment (Birth crawl)
The process of allowing the infant to find it’s own way to the breast/nipple to feed using a series of physiological processes.
- Birth crawl; occurs shortly after birth facilitating the transition to extrauterine life, they baby fills their lungs with oxygen.
- Relaxation; is a definite period following the birth cry where the neonate has a period of rest due to the catecholamine surge. The neonate will settle onto the warmth and comfort of the mothers skin.
- Awakening; the baby is alert to surrounding stimuli and begins to make small exploratory movements such as rooting, movement of the head, face and shoulders.
- Activity; the babies movements become more pronounced as the baby becomes more determined with their movements. Greater range of motion may be noticeable as the baby begins lifting its head, using the rooting reflex reaching its arms and legs or lifting its head.
- Rest; the baby may pause for a period recuperating and gaining energy to continue the birth crawl, processing the stimuli. This may occur within or between each of the other phases
- Crawling; the baby makes its way close to the nipple by using the stepping reflex to move its body into an optimal position. These movements may be small and gradual or the baby may thrust towards the nipple.
- Familiarisation; the baby has reached the nipple and is now exploring using its hands and mouth. The grasp reflex and root reflex may be evident, and may be licking the nipple.
- Suckling; the baby latches onto the nipple and areola, and draws out the milk.
- Sleeping; the baby has finished feeding and is now resting and comfortable until it is ready for it’s next feed.
What is Jaundice
As the newborn transitions to extrauterine life and the neonate is exposed to oxygen the high levels of fetal haemoglobin in utero are no longer required. Thus red blood cells are haemolyzed by the liver creating a byproduct called bilirubin. If the neonate is unable to conjugate and excrete bilirubin a buildup will occur causing jaundice. Bilirubin is water soluble and easily secreted in urine and faeces. However, if it is unconjugated it is fat soluble and hard to excrete. Often jaundice presents as physiological jaundice (incidence of 60%) can occur which commences around day 3 peaking on day 4 and begins to resolve on its own. In physiological jaundice serum bilirubin levels do not exceed 200-215 mmol/L. If asymptomatic ie good bowel and urine, waking for feeds etc. no action is required, if symptomatic take a serum bilirubin blood test and refer if needed.
What is the breast friendly hospital initative
The breast friendly hospital initiative was launched in 1991 by WHO/UNICEF to improve globally declining breastfeeding rates. It focused on the premise that health institutions had a responsibility in creating breast feeding promotion spaces for women. It was then introduced in Australia in 1993 and spread to 152 countries globally and almost 20 000 health facilities.
In 1998 the ten steps to successful breastfeeding were released and it was encouraged that every facility supporting newborns should implement this action plan.
What are the 10 steps to successful breastfeeding
- Policy; every hospital should have a written policy regularly communicated to all staff.
- Educate; staff with the skills necessary to support and promote breastfeeding
- Inform; women of the benefits and maintenance of breastfeeding
- Show; mothers how to maintain lactation and breastfeeding when separated from their newborn
- Skin to skin; for at least the first hour after birth and encourage the mother to recognise feeding cues.
- Exclusivity; offer no other food or drink other than breastmilk unless medically indicated
- Practice rooming in 24/7
- Encourage demand feeding
- No alternatives; do not offer alternative teats or dummies whilst establishing breastfeeding
- Community; provide the woman with community groups and contacts to refer to upon discharge.
List some common methods of contraception
Fertility awareness methods
Lactation amenorrheic method
Calendar method
Natural family planning
Apps and technology
Basal body temp
Monitoring discharge
Barrier methods
Male condom
Female condom
Diaphragm
Combined hormonal methods
Oestrogen/Progesterone pill ‘the pill’
Progesterone only pill ‘mini pill’
NuvaRing
Implant
Depo shot
Hormonal IUD
Permeant methods
Vasectomy
Hysterectomy
Tubal ligation
Emergency contraception
Progesterone pill
Hormonal IUD
Discuss some common contraception methods (Fertility awareness method)
- Lactation amenorrhea; uses breastfeeding as contraception, as the high levels of prolactin inhibit the release of hcg reducing the production of FSH and LH. 98% protection provided the woman remains amenorrheic. Return of menses in BF women is 28.4 wks ranging from 15-48 wks.
- Natural family planning relies; relies on recognising the changes in a womans cycle to predict ovulation. Perfect failure of 2-9% by typical failure 25% in the first year.
- Calendar based method uses the premise that ovulation occurs 11-16 days before the next period. Thus caution should be taken during this window.
- Basal body temp; relies on the detection of a 0.2 - 0.5 degree rise in temp following ovulation due to the secretion of progesterone. The temp remains elevated until the onset of the period. Only notifies once ovulation has already occurred.
- Monitoring discharge; relies on the daily observation of discharge as it changes throughout the cycle.
- Apps and technology are designed to assist determining fertile windows. Devices that incorporate testing for the presence of LH which is detectable in urine approx 6 days before ovulation are more reliable.
Discuss common contraception methods (barrier methods)
- Male condom; is a latex, plastic or synthetic non allergenic rubber used to prevent the passage of sperm. Perfect failure 2%, typical failure 15%.
- Female condoms; approx 10x more expensive than condoms. Similar to condoms but the female inserts into her vagina. Perfect failure 5%, typical failure 21%.
- Diaphragm; is similar to a female condom but is reusable hypoallergenic medical grade silicone inserted into the vagina and remains in place 6 hours post sex. Perfect failure 12%, typical failure 18%.
Discuss common contraception (Long acting reversible contraceptives)
- IUD; Plastic backbone which is wrapped with copper or hormone releasing plastic sleeve. Fertility returns on removal. Copper is toxic to sperm blocking fertilisation and progesterone thickens the cervix and thins the endometrium to prevent conception. Perfect failure of less than 1%. Safe for BF, copper can be inserted immediatley but expulsion rate of 70% in first 4 weeks and hormonal should be deferred to 4 wks if BF.
- Implanon; is a small progesterone releasing Rodd inserted under the skin of the upper arm. Thickens cervical mucus and thins endometrium. Failure rate of less than 1 in 1000.
Discuss common contraception (Hormonal methods)
- Combined contraceptive pill ‘the pill’; a pill containing oestrogen and progesterone that blocks ovulation by suppressing FSH and LH production, thickens cervical mucus, thins endometrium. Perfect failure 0.3% typical failure 8%. BF safe after 6 wks. Wait 3 wks pp in non-lactating women.
- Nuvaring; progesterone releasing ring inserted into the vagina at day 5 and remains for 3 wks, removed for 1 wk. Same mode of action and implications for BF as pill.
- Progesterone only pill ‘mini pill’; pill containing only progesterone with no placebo tablets. Thickens cervical mucus, thins endometrium. BF safe any time postpartum.
- Injectable contraception; depo inject lasts 12 wks. Perfect failure less than 1%, typical failure 6%. Same mode of action as previous. Fertility may take a year to return after cessation. BF safe, safe immediately postpartum.
Discuss common contraception (permanent methods)
- Vasectomy; is when the vas deferens are cut and the ends blocked to prevent the passage of sperm from the testes. Takes 16 ejaculations or 6 wks to be effective. Failure rate of 1-2 in 1000.
- Tubal ligation; where the females tubes are occluded. Immediately effective, failure rate of 1 in 500 in first year and 1 in 54 by 10 years. 1/3 of failures occur as ectopic pregnancies.
- Hysterectomy; only performed where medically indicated.
Emergency contraception
- The pill containing 1500 mcg of progesterone which delays or inhibits ovulation. Can be obtained without prescription. Will not disrupt already implanted pregnancy or cause harm during early pregnancy. 95% effective within 24 hours, 85% effective within 72 hours. Safe to use beyond 3 wks postpartum.
- IUD can be used if implanted within 5 days post sex with a failure rate of 0.14%.
Identify the role of midwives in discussing contraception
- 50% of pregnancies are unintended or mistimed and poor birth spacing can have harmful effects of the mothers health.
- After birth woman may want a different birth control or want information on the safety when breastfeeding so it is vital we can provide this.
Identify the benefits of breastfeeding
Breastfeeding is the gold standard of infant feeding and it is recommended by WHO that infants exclusively breastfeed for 6 months, at which point solids are introduced whilst continuing BF for 2 years and beyond. Benefits;
- Save 823 000 children and 20 000 mothers each year
- Save 300 billion US dollars annually.
- For newborn; increased cognitive function, boosts immunity, reduces risk of SUDI/SIDS, lower rates of obesity and diabetes etc.
- For mother; reduces risk of ovarian and breast cancer, weight loss, amenorrhea, improves birth spacing, reduces risk of diabetes, facilitates bonding and attachment etc.
Discuss the composition of breastmilk through each of the stages
Varies within and between women.
Colostrum; Breastmilk begins as colostrum produced from 16 weeks gestation. Low in volume, high in immunoglobulins, antibodies and immune cells, low in fats and carbs.
Transitional milk; occurs from 3-5 days postpartum. It has the immunological properties of colostrum but the fats and carbs of mature milk.
Mature milk; is composed of 90% water and 10% vitamins, minerals, protein, immunological properties. 0.9% protein. Protein is made up of whey and casein in the ration 60/40. Whey is a liquid easily digestible consistency, whereas casein has a curd like consistency that is harder to digest.
What is lactogenesis - Identify the 3 phases
Lactogenesis refers to the ability of the secretory glands in the breast to secrete and maintain the synthesis of breastmilk.
Lactogenesis 1 refers to the development of the glandular tissue in the breast during pregnancy to allow for breastmilk synthesis. From mid pregnancy progesterone, hpL and prolactin stimulate breast growth. Small drops of colostrum may collect.
Lactogenesis 2 refers to the onset of milk production occurring from approx. 60 hours postpartum (24 - 102). Stimulated by the drop in progesterone.
Lactogenesis 3 refers to the ability to maintain breastmilk production. Synthesis of breastmilk is controlled by autocrine function (supply and demand).
Weaning (involution); if breastfeeding stops/reduces the peptides in milk inhibits cell production and cells die leading to a gradual reduction in milk. The breast tissue gradually returns to a pre-pregnant state.
Common postpartum complications; affective mood disorders
Postpartum blues - characterised by a low mood generally peaking days 3-5 postnatally and resolving within 10-14 days. Occurs in 75% of women.
Postpartum depression - characterised by low mood lasting longer than 10-14 days. Occurs in 10-16%, 1 in 7 women. Occurs in 1 in 10 men.
Postpartum psychosis is where women experience a detachment from reality. May include delusions, hallucinations. Occurs in 0.5% of women. Requires immediate treatment.
Define cultural competence and cultural safety
Cultural safety refers to the ability of the healthcare practioner to recognise their own culture and the influence this has on the care they provide. Remain constantly self-reflecting.
Cultural competence refers to the ability of the health practitioner to understand the cultural needs of their clients and adapt their care appropriately.
These can only be determined by the recipient of care.
Define immunisation vs vaccination
Vaccination refers to the process of being injected with a small dose of a live but weakened virus, a killed bacteria or virus or a modified toxin in order to produce an immune response with the body without causing illness to develop antibodies to protect against future infection. (Vaccination came from Latin word vaccinia cowpox, developed by Edward Jenner).
Immunisation refers to the process of acquiring protection against a virus as a result of being given a vaccine. In order to stop the spread of disease 90% of the population need to be immune for most diseases and 95% for highly infectious diseases (measles, Covid).
Identify the benefits of vaccination/immunisation
Vaccination;
- Protects individuals from disease - Reduce death from tetanus, diphtheria and pertussis
Immunisation;
- Creates herd immunity and protects the community - Polio has been almost completely eradicated globally - MMR, whooping cough have considerably lower mortality
Identify some common medications in the postnatal period and specify their effect.
- Movicol - Osmotic laxative
- Oxycodone Hydrochloride (Endone/Targin) - Narcotic analgesic for moderate-severe pain relief
- Ibuprofen (Neurofen) - Temporary relief of pain, inflammation, cold/flu symptoms.
- Metoclopramide (Maxalon) - antiemetic, antinausea, migraines, reflux
- Clexane - prevention of VTE, treatment of established CVT.
- Cephazolon - antibiotic
- Ural - Urinary alkalinity
- Tramadol - short term management of severe pain
- Clinamycin - antibiotic
- Labetalol - Hypertension
List some common cultural practices in the postnatal period
Common practices include various resting periods and special diets. Hot cold balance.
India = 40 day resting period, female relatives look after the household. Mother remains in home to protect from evil spirits and illness due to vulnerable state.
China = 30 day resting period. Mother remains in home and female relatives help.
Mayan Indian culture in Mexico = 20 day resting period concluded with a postpartum massage. 1 week minimal visitors.
Describe the physiological changes of the mother in the postnatal period
Emotional changes
Breast changes
Involution
Physical changes
When do breastfeeding challenges occur
Normal physiology is interrupted
Breastfeeding is not yet established
Inaccurate or incomplete advice
Physical impediments (augmentation, hyperplasia).
Common breastfeeding challenges/recommendations (Nipple pain and trauma)
Challenge; Some degree of nipple sensitivity/discomfort is normal due to the stretching of collagen fibre when sucking. Usually resolves within a minute and ceases by the end of the first week. Ongoing pain is associated with poor positioning and attachment - nipple not reaching soft palette.
Recommendations; Express colostrum onto nipple after feed and allow to airdry, ensure correct attachment, restrict comfort sucking whilst nipples are tender, break suction before removing from breast, use nipple shields if necessary.
Common breastfeeding challenges/recommendations (Breast engorgement)
Challenge; Breast engorgement is due to the rapid increase in milk production or obstruction of adequate milk removal. Can cause a flattened nipple causing nipple pain and trauma.
Recommendations; unrestricted feeding, empty one breast before starting the other, hand expression prior, reverse pressure softening.
Common breastfeeding challenges/recommendations (Blocked milk duct)
Challenge; Occurs when there is a stasis of milk as milk is not removed from the breast adequately through poor attachment, oversupply, engorgement, supplementation or disruption to feeding.
Recommendations; unrestricted feeding, ensure correct attachment, massage the lump during a feed, feed from affected side first, change feeding positions, use heat pack prior to feed.
Common breastfeeding challenges/recommendations (Mastitis)
Challenge; Localised inflammation and/or infection of breast tissue. Leading to redness, tenderness and can be accompanied by a fever. Caused by milk stasis, build up of milk or a blocked duct. Most common in the first 6 weeks.
Recommendation; Frequent feeding and/or expression, hot or cold compress, antibiotics if infected.
