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    <meta name="author" content="Denise Fisher" />
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      <h1 id="top">2.3 Management After Birth</h1>
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            <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study B</h3>
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			Joanne asks you what she can do before the baby is born to help her successfully breastfeed.
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		<p>
			The <cite>Ten Steps to Successful Breastfeeding</cite>, designed by the <img alt="External" src="design/external.gif" /><a href="http://www.who.int/en/" title="External link" target="_blank">WHO</a> and <img alt="External" src="design/external.gif" /><a href="http://www.unicef.org/" title="External link" target="_blank">UNICEF</a> summarise the maternity practices needed to support and encourage breastfeeding.
		</p>
		<dl><dt><a href="topic_2-1.html"><cite>Topic 2.1: Preparation Before Birth</cite></a></dt><dd class="topic-paragraph">Inform all pregnant women about the benefits and management of breastfeeding</dd></dl>
	</stage>
		<p>
			Joanne's baby Rosie is born by spontaneous vaginal delivery at 37 weeks following a 15-hour labour. She had been given pethidine (meperidine) and an epidural for pain relief during labour. Are there any features of her birthing experience that may affect breastfeeding?
		</p>
		<dl><dt><a href="topic_2-2.html"><cite>Topic 2.2: Birthing Factors that Affect Breastfeeding</cite></a></dt><dd class="topic-paragraph">Labour analgesia and near-term birth</dd></dl>
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		<dl><dt><a href="topic_2-3.html"><cite>Topic 2.3: Management After Birth</cite></a></dt><dd class="topic-paragraph">
				Place Rosie in skin-to-skin contact;
				Encourage breastfeeding on demand;
				Practice rooming-in, allow Joanne and Rosie to remain together 24 hours a day;
				Give Rosie no food or drink other than breastmilk, unless medically indicated;
				Give Rosie no artificial teats or dummies;
				Show Joanne how to breastfeed and how to maintain lactation even if she should be separated from Rosie.
			</dd></dl>
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      <a name="steps" id="steps"></a>
      <p class="listTitle">
			Steps 4-9 of the Ten Steps to Successful Breastfeeding outline the optimal management of mothers and their infants from birth to encourage and support breastfeeding.
		</p>
      <ul>
        <li>
          <a href="#step4">Step 4 - Place Rosie in skin-to-skin contact</a>
        </li>
        <li>
          <a href="#step5">Step 5 - Show Joanne how to breastfeed and how to maintain lactation even if she should be separated from Rosie</a>
        </li>
        <li>
          <a href="#step6">Step 6 - Give Rosie no food or drink other than breastmilk, unless medically indicated</a>
        </li>
        <li>
          <a href="#step7">Step 7 - Practice rooming-in, allow Joanne and Rosie to remain together 24 hours a day</a>
        </li>
        <li>
          <a href="#step8">Step 8 - Encourage breastfeeding on demand</a>
        </li>
        <li>
          <a href="#step9">Step 9 - Give Rosie no artificial teats or dummies</a>
        </li>
      </ul>
      <a name="step4" id="step4"></a>
      <div class="section" id="Step_4_-_Place_Rosie_in_skin-to-skin_contact"><h2>Step 4 - Place Rosie in skin-to-skin contact</h2>
		<p>Although Step 4 states</p>
		<blockquote>
			Help mothers initiate breastfeeding within a half-hour of birth, it 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. 
		</blockquote><sup><a href="#note1">1</a></sup>
		<p>
			Ideally Rosie will be placed prone, skin-to-skin on her mothers abdomen or chest immediately following birth and left for at least the first hour or until she has attempted to breastfeed. Rosie can be quickly dried, and a blanket or other covering placed over mother and infant to maintain body temperature. Routine administration of medications (e.g. Vitamin K) and assessment and weighing of the infant can either be postponed until after this time, or performed with the infant undisturbed<sup><a href="#note2">2</a></sup>.
		</p>
		<p>
			Many infants are awake and alert in the first two hours after birth and when left skin-to-skin with their mothers go through an ordered series of innate prefeeding movements with most finding the breast and begin to feed within the first hour or so.<sup><a href="#note3">3</a>,</sup><sup><a href="#note4">4</a></sup> Early suckling has been associated with increased breastfeeding duration and the ability to breastfeed.<sup><a href="#note5">5</a></sup>
		</p>
		<p class="listTitle">A recent Cochrane review<sup><a href="#note6">6</a></sup> has also shown that early skin-to-skin contact of healthy term infants:</p><ul><li>Increases the likelihood of a successful first breastfeed;</li><li>Reduces the time to the first effective breastfeed;</li><li>Increases breastfeeding rates at hospital discharge, at four months and six months;</li><li>Encourages better thermal regulation by the infant;</li><li>Improves cardio-respiratory stability in late pre-term infants;</li><li>Increases blood glucose levels;</li><li>Reduces crying; and</li><li>Reduces maternal pain from engorgement on day 3</li></ul><p class="listFoot">
				Additionally, mothers are less anxious on day 3, are more confident handling their infant by hospital discharge and are more likely to exhibit maternal attachment behaviours.<sup><a href="#note6">6</a></sup>
			</p>
		<p>
			The benefits of skin-to-skin contact and early breastfeeding are of even greater importance for infants who are at risk for breastfeeding difficulties such as those born late preterm or whose mothers were given analgesia (particularly opiates) during labour. Women who give birth by caesarean section under epidural or spinal anaesthetic can also hold their infants skin-to-skin either in the operating theatre or in the recovery room. Extra assistance may be required from maternity staff.
		</p>
		<p>
			<a href="#steps">Δ [return to steps]</a>
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      <a name="step5" id="step5"></a>
      <div class="section" id="Step_5_-_Show_Joanne_how_to_breastfeed_and_how_to_maintain_lactation_even_if_she_should_be_separated_from_Rosie"><h2>Step 5 - Show Joanne how to breastfeed and how to maintain lactation even if she should be separated from Rosie</h2>
		<p>
			Breastfeeding is a natural process; however, it is not instinctive behaviour for mothers. Therefore, even when they have attended antenatal classes, mothers benefit from skilled support and assistance when learning how to breastfeed. Consistent and appropriate help in the postpartum period increases breastfeeding initiation and duration and should be a normal part of maternity care.<sup><a href="#note7">7</a>,</sup><sup><a href="#note8">8</a></sup> In particular helping women to ensure good positioning and attachment of the infant to the breast, teaching them about early feeding cues and expected course of breastfeeding in the first few days and weeks is important.
		</p>
		<p>
			When an infant is unable to breastfeed (e.g. due to illness of the infant or mother or prematurity) or the infant and his or her mother are separated, the mother requires assistance to initiate and maintain lactation. The infant can then receive breast milk in the short term, and a normal breastfeeding relationship can be established when conditions permit. Mothers benefit from being shown how to express milk (both by hand and pump) as well as being given information regarding expression routines and the safe collection and storage of breast milk.
		</p>
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			<a href="#steps">Δ [return to steps]</a>
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      <a name="step6" id="step6"></a>
      <div class="section" id="Step_6_-_Give_Rosie_no_food_or_drink_other_than_breastmilk_unless_medically_indicated"><h2>Step 6 - Give Rosie no food or drink other than breastmilk, unless medically indicated</h2>
		<p>
			Practices that interfere with the natural rhythm of the infants appetite and feeding cues will have a negative effect on the establishment of lactation and on breastfeeding duration. Normal, healthy, term infants allowed unlimited access to the breast do not need water, glucose water or infant formula routinely<sup><a href="#note9">9</a></sup>.
		</p>
		<p>
			Their use affects the infants desire to feed at the breast  reducing prolactin release and breast emptying, adversely affecting milk supply<sup><a href="#note10">10</a></sup>, and breastfeeding rates at four and 16 weeks<sup><a href="#note11">11</a></sup>. Additionally, giving infant formula changes the gut environment and increases the risk of infective and atopic disease<sup><a href="#note5">5</a></sup>. In some situations (eg. a delay in lactogenesis ll and subsequent excessive weight loss) supplemental feeding is medically indicated but steps to protect and increase the mothers milk supply should also be undertaken.
		</p>
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			<a href="#steps">Δ [return to steps]</a>
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      <a name="step7" id="step7"></a>
      <div class="section" id="Step_7_-_Practice_rooming-in_allow_Joanne_and_Rosie_to_remain_together_24_hours_a_day"><h2>Step 7 - Practice rooming-in, allow Joanne and Rosie to remain together 24 hours a day</h2>
		<p>
			Rooming-in 24-hours a day enhances the mothers ability to watch and learn about her infant so that she is aware of these early feeding cues and responds to her infant accordingly. This close contact also conditions the milk-ejection reflex resulting in the release of oxytocin and hence availability of milk, three to ten minutes before a feed- just as the infant begins to stir.<sup><a href="#note12">12</a></sup>
		</p>
		<p>
			Rooming-in has been associated with more frequent feeding, greater weight gain,<sup><a href="#note13">13</a></sup> and longer duration of breastfeeding.<sup><a href="#note14">14</a></sup> Additionally, mothers who room-in tend to look at, touch and talk to their infants in more intimate ways.<sup><a href="#note15">15</a></sup> Rooming-in does not affect the amount or quality of a mothers sleep.<sup><a href="#note13">13</a></sup>
		</p>
		<p>
			<a href="#steps">Δ [return to steps]</a>
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      <a name="step8" id="step8"></a>
      <div class="section" id="Step_8_-_Encourage_breastfeeding_on_demand"><h2>Step 8 - Encourage breastfeeding on demand</h2>
		<p>
			During the first breastfeed after birth most infants will take between 0 and 5 mls of colostrum. This volume gradually increases as the milk changes from colostrum to mature milk over the first week or so.<sup><a href="#note16">16</a></sup> The increase in volume is instigated by a drop in progesterone levels following the delivery of the placenta. Subsequently the amount of milk produced is regulated by prolactin release and breast emptying, both dependent on the number and length of breastfeeds  a reflection of the infants appetite.
		</p>
		<p>
			On average, infants will breastfeed between 3-8 times in the first 24 hours, and then between 5 -10 times a day until day 7,<sup><a href="#note16">16</a></sup> however, there is considerable variation in the number and length of  breastfeeds between infants and between days with the same infant. Unrestricted access to the breast in the early days of breastfeeding allows for this variation, assists with the regulation of milk supply, provides milk for the infant according to his or her needs, results in lower weight loss or better weight gains and improved breastfeeding rates.<sup><a href="#note5">5</a>,</sup><sup><a href="#note13">13</a></sup> Breastfed infants require no additional supplements or water, even in hot weather, until they are six months old.
		</p>
		<p>
			Feeding the infant 'on demand', that is when he or she displays early feeding cues such as hand to mouth movements, rooting, mouthing or body movement in light sleep provides unrestricted access to the breast. There is no evidence that breastfeeding 'on demand' increases the extent or duration of nipple tenderness.
		</p>
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			<a href="#steps">Δ [return to steps]</a>
		</p>
	</div>
      <a name="step9" id="step9"></a>
      <div class="section" id="Step_9_-_Give_Rosie_no_artificial_teats_or_dummies"><h2>Step 9 - Give Rosie no artificial teats or dummies</h2>
		<p>
			Dummy or pacifier use, especially before breastfeeding is well established has also been linked with a shorter breastfeeding duration<sup><a href="#note5">5</a>,</sup><sup><a href="#note10">10</a></sup>. This problem is more pronounced when the dummy or pacifier is used as an alternative to quieten an infant rather than breastfeeding him or her. Infants also use a different sucking action with bottle teats (artificial nipples) or dummies than when breastfeeding. There is concern that some infants are unable to adjust their sucking actions between the different modalities and using teats or dummies may exacerbate sucking difficulties at the breast<sup><a href="#note17">17</a></sup>. Therefore dummies and artificial teats should not routinely be used for infants who are breastfed.
		</p>
		<p>
			Recent studies suggest that the risk of SIDS is reduced in infants who use a dummy while going to sleep, especially if the infant has an unsafe sleep environment (e.g. sleeping prone or with a mother who smokes)<sup><a href="#note18">18</a></sup>. This finding needs to be balanced against evidence that SIDS risk is reduced in breastfed infants<sup><a href="#note19">19</a></sup>, and dummy use has an impact on breastfeeding success. The American Academy of Pediatrics<sup><a href="#note20">20</a></sup> and UNICEF UK Baby Friendly Initiative<sup><a href="#note21">21</a></sup> recommend that parents who wish to use a dummy to settle their infant to sleep not do so until breastfeeding is well established  at around four weeks. Other points to note are: it is preferable that dummies not be used at other times; not all infants will accept a dummy and many will not retain the dummy for the whole of the sleep period<sup><a href="#note21">21</a></sup>. There is no evidence that forcing an infant to take a dummy, or replacing it if it has fallen out of the sleeping infants mouth is beneficial<sup><a href="#note18">18</a>,</sup><sup><a href="#note20">20</a></sup>.
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			<a href="#steps">Δ [return to steps]</a>
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            <td class="body"><img src="design/group.png" class="icon" alt="" /><h3>Case Study Activity</h3>
		<div></div><div class="activity" id="activity_u">
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	{ c : '\n			<p>\n				<strong>A mother in the antenatal clinic expresses concern that your hospital no longer has a nursery in the maternity ward and that dummies were no longer routinely supplied. What points would you make to explain the rational of these decisions to her?</strong>\n			</p>\n		', r : '\n			<p>\n				This hospital provides an environment that supports and assists women to breastfeed. Rooming-in helps a mother get to know her baby before going home from hospital and helps establish breastfeeding early without reducing the amount of sleep she gets. Dummies may interfere with breastfeeding, especially in the early days. Therefore, they are not recommended, at least until the milk supply is well established and the baby is feeding well.\n			</p>\n		' }
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<p class="blurb">Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.</p></div><script type="text/javascript">renderActivity('u');</script>
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      <div id="footnotes">
        <h3>Notes</h3>
        <ol>
          <li id="note1"><a href="references.html#worl06" title="See full details">#</a> World Health Organization (2006) Baby-Friendly Hospital Initiative: Revised, Updated and Expanded for Intergrated Care</li>
          <li id="note2"><a href="references.html#acad03" title="See full details">#</a> Academy Of Breastfeeding Medicine Protocol Committee (2003) ABM clinical protocol #5: Peripartum breastfeeding management for the healthy other and infant at term.</li>
          <li id="note3"><a href="references.html#righ90" title="See full details">#</a> Righard L et al. (1990) Effect of delivery room routines on success of first breast-feed</li>
          <li id="note4"><a href="references.html#matt01a" title="See full details">#</a> Matthiesen AS et al. (2001) Postpartum maternal oxytocin release by newborns: Effect of infant hand massage and sucking</li>
          <li id="note5"><a href="references.html#phil04" title="See full details">#</a> Philipp BL et al. (2004) The Baby-Friendly way: the best breastfeeding start.</li>
          <li id="note6"><a href="references.html#moor07" title="See full details">#</a> Moore ER et al. (2007) Early skin-to-skin contact for mothers and their healthy newborn infants</li>
          <li id="note7"><a href="references.html#worl98" title="See full details">#</a> World Health Organization Evidence for the 10 Steps to Successful Breastfeeding</li>
          <li id="note8"><a href="references.html#fors07" title="See full details">#</a> Forster D et al. (2007) Breastfeeding initiation and birth setting practices: A review of the literature</li>
          <li id="note9"><a href="references.html#aapp05" title="See full details">#</a> AAP Policy Statement, Section on Breastfeeding (2005) Breastfeeding and the Use of Human Milk</li>
          <li id="note10"><a href="references.html#howa03" title="See full details">#</a> Howard CR et al. (2003) Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding</li>
          <li id="note11"><a href="references.html#szaj06" title="See full details">#</a> Szajewska H et al. (2006) Effects of brief exposure to water, breast-milk substitutes or other liquids on the success and duration of breastfeeding: A systematic review</li>
          <li id="note12"><a href="references.html#mcne83" title="See full details">#</a> McNeilly A et al. (1983) Release of oxytocin and prolactin in response to suckling</li>
          <li id="note13"><a href="references.html#chil98" title="See full details">#</a> Child and Adolescent Health and Development (CAH) (1998) Evidence for the ten steps to successful breastfeeding</li>
          <li id="note14"><a href="references.html#scot01" title="See full details">#</a> Scott JA et al. (2001) Factors associated with breastfeeding at discharge and duration of breastfeeding</li>
          <li id="note15"><a href="references.html#prod95" title="See full details">#</a> Prodromidis M et al. (1995) Mothers touching newborns: a comparison of rooming-in versus minimal contact</li>
          <li id="note16"><a href="references.html#kent07" title="See full details">#</a> Kent JC (2007) How breastfeeding works</li>
          <li id="note17"><a href="references.html#wils96" title="See full details">#</a> Wilson-Clay B (1996) Clinical use of silicone nipple shields</li>
          <li id="note18"><a href="references.html#hauc05" title="See full details">#</a> Hauck FR et al. (2005) Do pacifiers reduce the risk of sudden infant death syndrome? A meta-analysis</li>
          <li id="note19"><a href="references.html#ipsc07" title="See full details">#</a> Ip S et al. (2007) Breastfeeding and maternal and infant health outcomes in developed countries</li>
          <li id="note20"><a href="references.html#amer05" title="See full details">#</a> American Academy of Pediatrics (2005) The changing concept of Sudden Infant Death Syndrome: Diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reducing risk</li>
          <li id="note21"><a href="references.html#unic08a" title="See full details">#</a> UNICEF UK Baby Friendly Initiative (Accessed April 28, 2008) UNICEF UK Baby Friendly Initiative statement on dummy use</li>
        </ol>
      </div>
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      <h1>Breastfeeding Essentials</h1>
      <ol>
        <li>0.1 <a href="topic_0-1.html">Introduction</a></li>
        <li>1.0 <a href="topic_1-0.html">Case Study A (Joanne)</a><ol><li>1.1 <a href="topic_1-1.html">Discussing breastfeeding</a></li><li>1.2 <a href="topic_1-2.html">What information to give</a></li><li>1.3 <a href="topic_1-3.html">Effects of Breastfeeding alternatives</a></li><li>1.4 <a href="topic_1-4.html">Common breastfeeding concerns</a></li><li>1.5 <a href="topic_1-5.html">Breast examination</a></li><li>1.6 <a href="topic_1-6.html">Contraindications to breastfeeding</a></li><li>1.7 <a href="topic_1-7.html">Conditions related to lactation outcomes</a></li><li>1.8 <a href="topic_1-8.html">Medications</a></li></ol></li>
        <li>2.0 <a href="topic_2-0.html">Case Study B (Joanne)</a><ol><li>2.1 <a href="topic_2-1.html">Preparation Before Birth</a></li><li>2.2 <a href="topic_2-2.html">Birthing Factors that Affect Breastfeeding</a></li><li class="current">2.3 <img src="design/bullet_arrow_right.png" alt="*" title="You are here" /><a href="topic_2-3.html">Management After Birth</a></li><li>2.4 <a href="topic_2-4.html">Poor Attachment</a></li><li>2.5 <a href="topic_2-5.html">Hypoglycaemia</a></li><li>2.6 <a href="topic_2-6.html">Relationship between Jaundice and Breastfeeding</a></li></ol></li>
        <li>3.0 <a href="topic_3-0.html">Case Study C (Joanne)</a><ol><li>3.1 <a href="topic_3-1.html">Early problems</a></li><li>3.2 <a href="topic_3-2.html">Risk of SIDS</a></li><li>3.3 <a href="topic_3-3.html">Contraception</a></li><li>3.4 <a href="topic_3-4.html">Milk composition</a></li><li>3.5 <a href="topic_3-5.html">Slowing of growth</a></li><li>3.6 <a href="topic_3-6.html">Introducing solids</a></li><li>3.7 <a href="topic_3-7.html">Weaning</a></li></ol></li>
        <li>4.0 <a href="topic_4-0.html">Case Study D (Sally)</a><ol><li>4.1 <a href="topic_4-1.html">Initial assessment</a></li><li>4.2 <a href="topic_4-2.html">Milk production</a></li><li>4.3 <a href="topic_4-3.html">Causes of inadequate infant growth</a></li><li>4.4 <a href="topic_4-4.html">Increasing milk supply</a></li></ol></li>
        <li>5.0 <a href="topic_5-0.html">Case Study E (Anna)</a><ol><li>5.1 <a href="topic_5-1.html">Sore nipples</a></li><li>5.2 <a href="topic_5-2.html">Factors causing nipple damage</a></li><li>5.3 <a href="topic_5-3.html">General treatment for sore nipples</a></li><li>5.4 <a href="topic_5-4.html">Further causes of nipple pain</a></li><li>5.5 <a href="topic_5-5.html">Mastitis – diagnosis</a></li><li>5.6 <a href="topic_5-6.html">Mastitis – treatment and complications</a></li></ol></li>
        <li>6.0 <a href="topic_6-0.html">In conclusion</a><hr /></li>
        <li class="appendix"> <a href="references.html">List of references</a></li>
        <li class="appendix"> <a href="contents.html">Course contents</a></li>
        <li class="appendix"> <a href="full.html">Print version</a></li>
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