POSTPARTUM test #3 study guide Flashcards
- Review the evidence for breastfeeding
Infant: Higher infant morbidity and mortality in formula-fed infants as they do not receive antibodies from breast milk. Risk of contamination of the formula during manufacturing. Risk of malnutrition or GI problems due to over- or under- dilution when mother prepares the formula.
- Compare the risk and costs of using manufactured infant milk compared to human breast milk to the infant and the family.
Mother: higher risk of osteoporosis, premenopausal breast cancer, and ovarian cancer. More likely to develop type 2 diabetes than breastfeeding mothers. Less rapid weight loss.
Costs: approximately 150 cans of ready-to-feed in the first 6 months of full artificial feeding (a lot of money!!). Higher healthcare costs as child is sick more often, more days of missed work for mother/family.
- Define the Healthy People 2020 objectives for breastfeeding.
Increase the proportion of infants who are breastfed to 81.9%
Increase the proportion of infants who are breastfed at 6 months to 60.6%
Increase the proportion of infants who are breastfed at 1 year to 34.1%
Increase the proportion of infants who are breastfed exclusively through 3 months to 46.2%
Increase the proportion of infants who are breastfed exclusively through 3 months to 25.5%
- Review the Baby Friendly Hospital Initiative.
1) Written breast feeding policy routinely communicated to staff
2) Train all staff in skills necessary to implement this policy
3) Inform all pregnant woman about the benefits and management of breast feeding
4) Help mother’s initiate breastfeeding within 30 minutes of birth
5) show mothers how to breastfeed even if separated from infant
6) Give infants no food or drink other than breastmilk unless medically indicated
7) practice rooming in 24 hours a day
8) Encourage breastfeeding on demand
9) No pacifiers
10) Foster Breastfeeding support groups
Lactogenesis:
transition from pregnancy to lactation. lactogenesis I (mid-pregnancy to day 2PP): initiation of milk synthesis, differentiation of alveolar cells from secretory cells, prolactin stimulates mammary secretory cells to produce milk. Lactogenesis II (day 3 to 8 PP): triggered by rapid drop in mother’s progesterone levels, onset of copious secretion of milk, fullness and warmth in breasts, switch from endocrine to autocrine control. Significant fall in breastmilk levels of sodium, chloride, and protein, and a rise in lactose and milk lipids.
Galactopoiesis:
maintenance of the established milk production. Based on the supply-demand response. (emptying of breast)
Progesterone
Progesterone can cause delay of the effects of prolactin f placental fragments retained after birth Prolactin initiating and maintaining milk production.
breast changes
during pregnancy increased breast mass and cell differentiation (peptides: angiotensin 11 gonadotropin-releasing hormone (GnRH) and vasopressin all stimulate prolactin.
Anterior Pituitary
releases prolactin 7-20 x in 24 hours peak 200-400ng/ml at term-secreted in greater amounts during sleep following circadian rhythms
lactogenesis II
mild secretions shifts from endocrine to autocrine control controlled by the hypothalmus: infant suckles-hypothalmus inhibits release of dopamine (a prolactin-inhibiting factor), this drop in dopamine stimulates the release of prolactin (surge-doubles)=milk production.
prolactin
Need at least 8 feedings a day to prevent decrease in prolactin before the next feeding. Prolactin levels will remain elevated for as long as the mother breastfeeds even if it is years. Prolactin is present in breast milk and thought to benefit the infant. Prolactin enhances development of B & T lymphocytes
Posterior pituitary/oxytocin-milk ejection, uterine involution
Cortisol-main glucocorticoid-
synergisitc with prolactin secreeted by adrenal glands help regulate water transport across the cell membrane during lactation-a High cortisol level will delay lactogenesis
Thyroid Stimulating Hormorne-permissive-promotion of mammary growth and lactation increases on 3-5 postpartum days.
- Review the immune and anti-allergic properties in breast milk.
Breastfeeding promotes intestinal ecosystem-bifidobacteria and lactobacilli (pro and prebiotics)
- Review the key concepts at the end of chapter 5 discussing drug therapy and breastfeeding.
Key concepts:
Avoid medications that are not absolutely necessary
Choose drugs with less toxicity and those commonly used in infants
Maternal plasma levels of the drug at time of breastfeeding: Choose drugs with published studies
Molecular weight of the medication
Oral bioavailability of the medication in mother and infant: choose ones with poor oral bioavailability to reduce oral absorption in infants
Evaluate the infant’s medications, to see if there are drug interactions-evaluate the infant: age, stability, condition-can they handle exposure to this medication (pre-term infants have impaired clearance mechanism so they are at risk)
If a drug enters CNS-crosses blood/brain barrier-it will likely enter breastmilk
medications & breastfeeding
protein-binding of the medication
passive diffusion of drugs into milk
First 2-3 das of life breast tissue is porous-meds cross easily by passive diffusion, but after intercellular junction closes this decreases.
Must take into consideration-the absolute amount of colostrum ingested by infant is low 50-60 ml/day thus clinical dose of medication is low
<10 meds that are selectively transported into human milk are best.
Avoid Breastfeeding during peaks of medication, effective for drugs with short half-lives. Choose drugs with shorter half-lives over those with longer half-lives
Drugs that may inhibit milk production-progestins, estrogens, ethanol, bromocriptin, ergotamine, cabergoline, pseudoephedrine(even nasal). Especially prior to establishment of milk supply. Advise mother to watch for changes in breast milk production
No ASA in Breastfeeding women d/t Reye’s syndrome
Risk vs benefit assessment before prescribing
only a few medications are unsafe under any circumstances
A relative dose of less than 10 percent is generally considered compatible with breastfeeding
HIV & Breastfeeding
Use of anti-retroviral drugs and avoiding breastfeeding reduced risk of trasmission of HIV to less than 2%. CDC recommends against breastfeeding by HIV-infected women living in developed countries. New studies show that exclusive breastfeeding by women in 3rd world countries has improved survival rates, reduces transmission of HIV by keeping gut flora intact-decreased diarrhea and should be encouraged over formula-introduces bacteria and other contaminants which causes inflammatory responses and damages the mucosa-HIV penetrates GI mucosa-once the decision to not exclusively breastfed, woman must stop as it is no longer protective.
HBV & Breastfeeding
virus is present in breastmilk, but also antibodies so Safe to breastfeed. Transmission of HBV would occur during delivery, 5-15% before birth, not BF-unless acute infection with no antibodies, potential risk with bleeding nipples. Infant should receive Hep B Immunoglobulin within 12 hours of birth and be tested after completion of the series. Lack of BF places infant at greater risk of contracting the disease.
HCV & Breastfeeding
virus is present in breast milk, but infant May breastfeed-unless acute infection with no antibodies. potential risk with cracked, bleeding nipples. Perinatal transmission 6%
HSV & Breastfeeding
: Mother’s milk may be free of virus, ocasionally HSV-1 can be cultured from breastmilk (rare). If mother has herpetic lesions on breasts, do not breastfeed. Active lesions should be covered to prevent contact with infant. Advise about hand-washing before breastfeeding. (see table in p.203) If primary infection during pregnancy-50% transmission only 1-3% if recurrent. Congential infection most serious infections in neonates.
CMV & Breastfeeding
CMV virus can be found in breastmilk, but no serious illness or clinical symptoms in neonates secondary to breastfeeding. Breastfeeding will confer passive immunity. Danger of CMV infection is in potential transmission to the fetus or newborn of woman who has a primary infection during pregnancy. Pasteurization of milk appears to inactivate CMV
• Varicella
Can breastfeed. If mother contracts varicella while breastfeeding, continue BF - will give baby passive immunity-antibodies develop in 48 hours and will decrease the severity of illness in infant. However, If mother contracts varicella in 1st trimester=neurological problems, if within days of delivery can be life threatening-manage with airborne and contact infection control precautions-it says isolate the infant from the mother if the infant doesn’t have lesions and protect the infant from the mother’s lesions. Mother is to pump-not clear about feeding or dumping until antibodies present at 48 hours. However if the infant has lesions it says isolate couplet together and continue breastfeeding.
• Rubella-
OK to breastfeed. Greatest risk is during 1st trimester= congenital defects. If mother is immunized to rubella postpartum the breast feeding infant will develop antibodies to rubella.
• Human Lymphotropic Virus HTLV-1
No breastfeeding Endemic in Caribbean islands, parts of Japan and Africa-linked with adult T-cell leukemia and lymphoma. The longer they breastfeed the larger the risk.
• Implications for practice
rarely requires terminating breastfeeding-infant usually already expose, breastfeeding only antibody protection, concern should not be towards mother’s with known infection but those with unknown infectious status.
- Compare and contrast breast fullness vs. engorgement.
Fullness: non-patho
Engorgement: has become pathologic; results from mis-management
Lochia
4-8wks in length, rubra, serosa, alba. Soaking greater than 1 pad per hour is an urgent reason to call Obgyn.
Afterbirth pains:
Uterus contracts and relaxes after birth. The greater the parity the greater the after birth pains. Also breastfeeding increases after birth pains. The uterus is trying to return to pre-pregnant size.
Diuresis/diaphoresis:
Day 2-5 has greatest diuresis and diaphoresis; this is body’s way of getting rid of excess fluids.
Sexuality
No reason to recommend 6 weeks, but instead is based on when patient feels ready. Birth control important to discuss
Perineal healing/pain
Pain: Witch hazel pads for comfort (hemorrhoids and lacerations), Ice packs: best used within the first 24 hours, cover ice pack with soft covering for comfort, apply to perineum. Topical pain relief: Dermoplast (benzocaine spray) can be sprayed to entire perineum for pain relief including hemorrhoids. Sitz baths: soaking bottom up to 3X daily in bath or using disposable sitz bath. Can use warm or cool water, whichever is comforting for the woman.
Constipation/hemorrhoids:
1st bowel movement usually within 2-3 days with normal bowel function returning by 2 weeks. Important to eat and drink regularly. Stool softeners helpful especially if mother has hemorrhoids or is taking narcotics for pain relief.
. Uterus
Weights ≈ 1000g after birth. Starts contracting and rotating 100-180 degrees along the axis of the internal os, assumes upright position by day 7 PP. Weighs ≈500g by the end of first week PP, and still palpable above the symphysis pubis. Usually back to nonpregant anatomic position by week 2 PP, no longer palpated abdominally
Cervix
Reconstituted in the first few days PP. By the end of first week, endocervical canal reappears and os is only about 1cm dilated. External cervical os does not return to dimple form of prepregnancy, but takes the form of a slit.
Vagina
Edematous and bruised after birth. Vaginal rugae return at about 3-4 weeks PP, prepregnant vaginal tone may never be completely restored. Vaginal epithelium usually heals by 6-10 weeks PP.
Lochia
Lochia may persist for up to 4 to 8 weeks after delivery. Median duration - 33 days.
Lochia rubra: primarily blood (red or brownish). Lasts 3-5 days.
Lochia serosa: Has a pinkish brown color. Contains some blood, but mainly wound exudate and leukocytes. Lasts approximately 22 days.
Lochia alba: Composed of leukocytes and some decidual cells. White or yellowish white color.
. Breasts
Mammary involution depends on breastfeeding status. If not BF, prolactin will decrease in the first week PP, then milk stasis, mammary epithelium cell apoptosis and mammary involution will occur. Mammary involution will take months of lactating. Regardless of BF status, breasts will nver return to prepregnant state.
GI system
Gastric tone and motility remain decreased for 2-3 days PP. Bowel movements resume 2-3 days PP, normal GI function and bowel patterns return 1-2 weeks PP.
Renal system
Gradual return to nonpregnant values of GFR, renal plasma flow, plasma creatinine, BUN, and creatinine clearance (2-3 months PP). Mild proteinuria may develop in the first few days PP (return to normal 3-5 days PP). Sodium excretion and diuresis lead to ↓ in blood volume to nonpregnant levels (return to nonpregnant state - 3 weeks or less). Urine production in days 2-5 PP can reach 3000ml and is caused by decrease in oxytocin.
Gradual return of bladder tone, size and function of bladder, ureters, and renal pelvis - 6-8 weeks or longer.
Hematological system
RBC, hematocrit, hemoglobin → return to prepregnancy levels 4-6 weeks PP
White blood cells → 4-7 days PP
Platelets → remain stable during pregnancy and postpartum
Breast feeding influences by
- culture
- ethnicity
- level of education
- family support
- economic status
- advertising come in contact with
- additional support from caregiver
who is more likely to breast feed
→ 30 y.o
higher of education
higher income
Black Spanish or White == Spanish is more likely to INITIATE breastfeeding but
White women continue breastfeeding.
United States or Foreign born
Dual parent family
AAP recommendations
Breastfeeding exclusively for approximately 6 months and support to first year & beyond if desire by mother & child
WHO recommendations
Breastfeeding exclusively for 6 months and continue for at least 2 years with adding weaning food at about 6 months
What is the culture norms for extending breastfeeding?
30% make it til 6 months
one year is the greatest extend here in the United States
What are the risk of NOT breastbreast feeding
Breastfeeding is sterile.
Bottle is not (manufacturing, preparation : kitchen not cleanse)
Prepare formular incorrectly : dilute with H2O or rice cereal
Risks: Poor nutrition, electrolyte imbalance- water intoxication (hyponatremia ) ← life threatening
Poor weight gain
Infant risk for not breastfeeding
→ RSV, coloritis, necrosis, ***otitist media, insulin dependent diabetes, inflammatory bowel disease, pneumonia, lephoma, lower tract infection.
Mom risk for not breastfeeding
increase risk of osteoporosis because time period after breastfeeding the body will lay down calcium and aborption most in time of her life…tissue …increase breast cancer, diabetes (store abdominal fat –need to be motibilize by breast feeding)
Cost of formula
20-30-40 (depend on specialize formula)
2 billion on all family
500 million fund buying formula from WIC
WHO – baby friendly initiatives
The code for breastmilk substitute is recommending for country to adopt for standard to advertisting because of medical financial and universal risk of it use
→ there should be no advertising to the public, no free sample to mother, no sample of products in health care facility, no gifts to health care workers, no word or picture idealize artificial feeding !!!
Baby friendly initiative is a program that certified hospital as baby friendly if they include these 10 steps in labor & delivery unit: 20 thousand worldwide —143 in u.s. (1 year ago, probably more now)
* lot of centralize nursery care
* restrict advertising
* promote of breast feeding
HOspital breastfriendly policy
(1) written policy that is routinely communicate with staff about breastfeeding support
(2) all staffs trained in policy & skill in support breast feeding
(3) all pregnant patient are well inform about benefit & management of breastfeeding
(4) mother assistant to breast feeding within 30 minutes
(5) demonstration breastfeeding even during separation: NICU care
(6) no food/drink other than breast milk if not medical indicated
(7) rooming in 24 hour a day
(8) breastfeeding on demand
(9) no artificial nipple /pacifier
(10) refer mom to support group if needed.
facilitate breastfeeding by :
Skin to skin contact best intervention to support breast-feeding
Earlier initiation and longer duration skin to skin are the most beneficial so the so the soon you can get mom & baby together the better !!!
Baby who have at least 30 minutes skin to skin on chest after birth improve duration of breastfeeding
Baby on mom’s chest stimulate oxytocin –
later recognize mom’s milk
root to the smell after day 3
how much breast feeding competent when that initial contact would do
lactogenesis
stage 1 → occur during pregnancy –milk present after 16 weeks
stage II → three to two days postpartum or sometimes up to 8 days it is drop of progesterone level following by the delivery of the placenta …also result from release of prolactin from anterior pituitary gland → knowing this if mom have great milk supply at 3 days old and breast feeding very well :
what do we know about the placenta ????
it completely deliver
in the other hand if mom struggle from breastfeeding & milk has come in by 3-4 days that’s mean we should concern about → retain placenta fragments.
Prolacproesis
Suckling stimulate oxytocin produce by anterior pituitary gland →Milk rejection reflex from epithelia cell result in → release milk
Prolacproesis : control by newborn : supply & demand
→ oxytocin
produce by the result of suckling …continue to rise over time if supplement is not use ← 90mg/mL !!!
