OSCE P + A Flashcards
- Using the model breast identify the structures and their functions 4
Hello, my name is Ayesha, and I am a student midwife. Today we’ll be talking about positioning and attachment during breastfeeding. Before we begin, it is important to understand the anatomy and physiology of the breast and I’ll be explaining this using this model breast here. So, the breast is made up of adipose and connective tissue which gives the breast its shape. Here is the nipple which is made of erectile tissue and the highly pigmented area around the nipple is called the areola. On the areola there are raised dots called the Montgomery’s tubercles which release sebum to keep the area supple.
Moving internally into the breast, there are alveoli all over which contain milk producing cells called lactocytes. Myoepithelial cells surrounding the alveoli contract to expel the milk. Milk travels to the lactiferous ducts which propels the milk to the milk ducts in the nipple.
- Name the hormone that stimulates milk production and identify its source and target cell.
Explain the physiological process which stimulates the initiation of milk production.
Give three examples of how effective milk production can be achieved/stimulated. 3
- There are two main hormones involved in breastfeeding. The first one is prolactin which is released from the anterior pituitary gland, and this stimulates milk production.
- prolactin levels rise immediately following the birth of the placenta and this is in coordination with a drop in estrogen and progesterone.
– Early feeding; as soon as possible after baby is born. - Good positioning and attachment.
- Effective emptying of the breast.
These will all help to raise prolactin levels.
- Identify the hormone responsible for the ‘let down reflex.’
Where is it released from?
Name the cells this hormone acts on and the effect it has on them
Explain the factors which will help or hinder the release of this hormone. 7
- The other main hormone is called oxytocin, and this is produced from the posterior pituitary gland. This is responsible for the let down reflex. There’s contraction of the myoepithelial cells and there’s propulsion of milk along the lactiferous ducts. Oxytocin’s role is to cause the release of milk out of the breast through the milk ducts.
- post pit gland
- There’s contraction of the myoepithelial cells and there’s propulsion of milk along the lactiferous ducts. Oxytocin’s role is to cause the release of milk out of the breast through the milk ducts.
Factors that will help the release of oxytocin are being close to your baby, hearing, seeing and smelling them and having anything of theirs close to you. - Anything that makes you feel good.
However, oxytocin can also be inhibited by factors such as feeling unsafe or a traumatic birth experience, or being separated from your baby, anxiety or a lack of sleep.
- Name the whey protein involved in the autocrine production and maintenance of breastmilk. Explain how this works. 2
There’s also a protein involved in the maintenance of breast milk, and this is called the feedback inhibitor of lactation, and this protein increases as breast milk accumulates in the breast when the breast is full. This increase in feedback inhibitor of lactation exerts a negative feedback mechanism and stops further supply.
This means that if milk is not removed effectively, production of breastmilk will cease so that’s why it’s important to have good positioning and attachment as to empty the breasts effectively and increase the supply demand.
- How should Robyn prepare herself for the feed? 4
Ensure that she is comfortable and that she has privacy, whatever this means and looks like for her. Try to be in a relaxed and calm environment. I would also advise her to go to the toilet beforehand so that you’re not interrupted during the feed. It would also be important that she has whatever she may need nearby such as snacks or water. The midwife may also be available to talk her through the feed and should always use a hands-off approach. The midwife would want to be able to equip her with the correct knowledge and to empower her confidence to feed independently when she is at home.
- Using a doll demonstrate the suitable positions that Robyn can adopt prior to attaching baby Zac to her breast. Give reasons for the adopted position. 2.5
There are various positions that you can adopt whilst feeding your baby and you will find one or more which is most comfortable for you.
- ‘across’. Baby across chest with head and neck in line and you’re supporting your baby with your arm and supporting baby’s head and neck with your hand as well. You mostly want baby’s head to be free so that they can find the nipple themselves by bobbing their head around, so not fully holding baby’s head to allow movement.
- ‘Rugby ball hold’. Bringing baby towards your back and supporting the baby’s body with the crook of your arm. Again, your baby’s head is free.
- ‘lying down’. Placing baby naturally where the nipple would fall.
- Whilst lying down, you could also take a biological nurturing position which is especially promoted during that first golden hour. This is allowing baby to lie stomach down on your tummy and allowing it to crawl up and find the breast.
- With the aid of the doll and using the CHINS acronym– demonstrate good positioning of baby Zac at the breast prior to attachment giving reasons for your action. 5
We use the CHINS acronym to help us remember the steps to take in order to ensure a good positioning and attachment.
C – close, you want your baby to be close to you
H – head free, as we mentioned earlier
I – in alignment, it is important your baby’s spine head and neck are in line so that they aren’t straining to find the nipple.
N – nose to nipple, when you’re bringing baby on to the nipple you want to make sure to bring their nose to the nipple.
S – sustainable. Making sure that you are in a sustainable position, so feeling comfortable enough that you won’t harm your back or feel the need to readjust constantly. This is why it’s important to prepare before beginning to feed.
It is advised to use baby lead or responsive feeding. This means looking out for cues that baby is hungry, such as moving their head, open mouth, sucking hands etc. Responsive feeding would be when you want to feed for reasons such as wanting to bond with your baby.
- Detail the steps taken by Robyn to attach baby to the breast 6
The steps to attach the baby. You want to bring baby to breast rather than breast to baby. You want to wait until baby is calm and not crying and has a wide open mouth. Then you will bring the chin in first and aim the nipple to the roof your baby’s mouth. You also want your nipple to be quite far back into baby’s mouth so that it’s reaching the soft palate and not the hard palate. This will also ensure they aren’t sucking at the tip of your nipple which will be painful and may cause damage to your skin. During feeding, the baby’s bottom lip should be downturned, and their nose shouldn’t be squashed against the breast. This may be difficult for you to notice whilst you are feeding, so the midwife will be able to observe this out for you.
These are all things that you can keep in mind when trying to get that good positioning and attachment.
- Explain to Robyn the signs of good attachment 8
Signs to look out for are your baby’s chin indenting the breast and as talked about earlier their bottom lip should be downturned. There should be more of the areola visible above the baby’s top lip than areola visible below the baby’s bottom lip. You also want to look for a wide open mouth and if your baby has a good attachment you will be able to see a full, round mouth rather than dimples in their cheeks. The feed should also be pain free. You would also want to listen for the sucking sound; this shouldn’t be a clicking sound. Your baby’s sucking pattern will also vary at different times of the feed; so in the beginning it may be more rapid, and once the let down reflex is initiated, baby’s sucking pattern will slow down. This is all very normal. At the end of the feed, your baby will do what’s called flutter sucking and this is baby receiving a high fat milk at the end of the feed. Your baby should remove themself from the breast spontaneously and you will also want to check if your nipple is the same shape after baby is off the breast.
- Robyn asks you how she will know that her baby has had enough milk from her breast. What advice would you give her? 3
Babies should be feeding 8 to 12 beats in 24 hours and the feed should last between 5 and 40 minutes per breast. Baby should also be producing regular wet and dirty nappies, and you will want to observe baby’s stool changing colour which will depend on how old your baby is. Your midwife will also be checking your baby’s weight during visits as required and this will also be an indication if your baby is feeding enough. Your baby should also be settled between feeds and as mentioned before, they should come off the breast spontaneously.
