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      <h1 id="top">3.0 Pregnancy Care</h1>
      <div class="section" id="Baby_Friendly_Step_3_and_Point_3"><h2>Baby Friendly Step 3 and Point 3</h2>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><h3></h3>
      <div><span style="font-weight: bold;">Step 3</span> of the Ten Steps to Successful Breastfeeding, and <span style="font-weight: bold;">Point 3</span> of the Seven-point Plan for Sustaining Breastfeeding in the Community both state:<cite></cite> <br /></div>
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        <div>Inform all pregnant women about the benefits and management of breastfeeding.</div>
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        <p>
          <span class="aside">Australia: Point 3 - Inform women and their families about breastfeeding being the biologically normal way to feed a baby and about the risks associated with not breastfeeding</span>
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    <div><p class="listTitle">The prenatal discussion should cover</p><ul><li>the importance of exclusive breastfeeding for the first 6 months,</li><li>the health associations of breastfeeding</li><li>the risks of artificial feeding, and<br /></li><li>basic breastfeeding management.</li></ul><p class="listTitle">Pregnant women of 32 weeks or more gestation should confirm that the health associations of breastfeeding and implications of not-breastfeeding have been discussed with them, including at least two of the following:</p><ul><li>infant nutrition,<br /></li><li>disease protection,</li><li>maternal-infant bonding,</li><li>health benefits to the mother, and</li><li>that they have received no group education on the use of infant formula.</li></ul><p class="listTitle">They should be able to describe at least two of the following breastfeeding management topics:</p><ul><li>importance of rooming-in,</li><li>importance of feeding on demand,</li><li>how to assure enough milk, and</li><li>positioning and attachment.</li></ul>(Source: The Global Criteria for the WHO/UNICEF Baby Friendly Hospital Initiative)<sup><a href="#note1">1</a></sup><br /></div>
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      <p>Some of these topics we've already covered, the remainder will be covered in following modules. Review the <span style="font-style: italic;">Topic 1.3 Relative Risks</span> to ensure that you are confident to talk to mothers about risks of artificial feeding as well as the 'benefits' of breastfeeding.</p>
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      <div class="section" id="Broaching_the_topic"><h2>Broaching the topic</h2>
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      <p>Consider how you would continue the discussion following the mother's reply to the following questions.</p>
      <table class="dialogue"><tbody><tr class="speaker0"><th>Health worker:</th><td>How are you going to feed your baby?</td></tr><tr class="speaker1"><th>Mother:</th><td>I'm going to bottle feed.</td></tr></tbody></table>
      <p>OR</p>
      <table class="dialogue"><tbody><tr class="speaker0"><th>Health worker:</th><td>Are you going to breastfeed?</td></tr><tr class="speaker1"><th>Mother:</th><td>Yes.</td></tr></tbody></table>
      <p> These are closed questions and don't allow you to broaden the discussion without it being challenging to the mother, regardless of her response. </p>
      <table class="dialogue"><tbody><tr class="speaker0"><th>Health worker:</th><td>What do you know about breastfeeding?</td></tr></tbody></table>
      <p> This open question will give you the opportunity to discuss any barriers that the woman may see to breastfeeding, or to discuss problems she may have had with previous breastfeeding and to begin discussion of the topics listed above. </p>
      <p> It is also implicit in the question and following conversation that you consider breastfeeding to be relevant. The importance of the health care provider's attitude is significant when we find that a woman's attitude to breastfeeding has been shown to correspond closely to that of her health care provider.<sup><a href="#note2">2</a></sup></p>
      <p> Discussing breastfeeding with pregnant women needn't take more than a few minutes at each visit. For example, at the first visit... </p>
      <table class="dialogue"><tbody><tr class="speaker0"><th>Health worker:</th><td>What changes have you noticed in your body so far?</td></tr><tr class="speaker1"><th>Mother:</th><td>I have noticed that my breasts seem to have grown. What's causing that?</td></tr><tr class="speaker0"><th>Health worker:</th><td>Your breasts are preparing themselves for breastfeeding your baby, growing extra milk-making ducts. Look, here's a diagram of what is happening inside your breasts.</td></tr></tbody></table>
      <p> At this point you could give her some more information on how her breasts will make and release her breastmilk according to how often her baby feeds. In just a few minutes you've covered how to assure enough milk and importance of feeding on demand, without it becoming a 'lecture' for the mother. </p>
      <p> A little bit of information given like this at each visit normalises breastfeeding as a part of childbearing and motherhood. At a later visit, closer to 32 weeks when you feel you've gradually covered all the information necessary and answered any questions raised, you could spend more time confirming the mother's understanding of breastfeeding. </p>
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            <td class="body"><a href="images/UKanchecklist.pdf" target="_blank"><img src="design/article.png" class="icon" alt="" /></a><h3><a href="images/UKanchecklist.pdf" target="_blank">Audit tool</a></h3>
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      <p> Does your clinic have a method that records that all the topics listed above have been discussed with all pregnant women? If not, a sample checklist is available from Baby Friendly UK. Clicking on the icon to the left will take you to their checklist. Another sample checklist, developed by WHO/UNICEF is available by clicking <img alt="PDF" src="design/page_white_acrobat.png" /><a href="images/antenatal_checklist.pdf" target="_blank" title="PDF file (21.1KiB)">here</a>. </p>
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            <td class="body"><img src="design/thinker.gif" class="icon" alt="" /><h3>Don't force a premature, uninformed decision</h3>
    <div><p>Many health units ask the pregnant mother what her feeding intention is early in pregnancy prior to providing education. <br />It is not reasonable to expect anyone to make an informed decision without knowledge; but once she has given an answer, particularly if she chose artificial feeding, education about breastfeeding is frequently withheld. <br /> </p>Think about the impact of such a simple question, asked at the wrong time, could have.<br />If this is a practice at your Unit discuss the implications with your colleagues with view to providing the education first.<br /></div>
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      <div class="section" id="When_the_mother_does_not_breastfeed"><h2>When the mother does not breastfeed</h2>
    <div>There are circumstances when breastfeeding is contraindicated. Be aware that this could be a difficult emotional situation for the mother, requiring thoughtful counseling. Some of these circumstances include: <br /> <ul><li> Infant conditions: <ul><li> classic galactosemia </li><li> maple syrup urine disease </li></ul> </li><li> Mother: <ul><li> radio-active iodine-131 precludes breastfeeding for about 2 months. This should be avoided given that safer alternatives are available. </li><li> during cytotoxic chemotherapy </li><li> HIV, only if replacement feeding is acceptable, feasible, affordable, sustainable and safe. </li></ul> Other conditions may require the mother to temporarily withhold her breastmilk, or the infant to receive only limited amounts of breastmilk in conjunction with a specialized formulation. <ul><li> very low birth-weight or very preterm infants </li><li> infants with phenylketonuria; with careful monitoring </li><li> infants with hypoglycemia that does not respond to breastfeeding or breastmilk feeding; though due to the seriousness of this condition intravenous therapy is preferred management. </li></ul> </li></ul> <p> A mother may also choose not to breastfeed for reasons of her own. It is important that the mother receives the education already mentioned and is aware of the short- and long-term effects of breastmilk substitutes on her child before she makes this decision. A mother who is forewarned about the effects will be in the best position to prevent or seek early treatment of those risks. </p></div>
    <div class="section" id="Prenatal_education_"><h3>Prenatal education </h3>
      <div>
        <p> The choice of a breastmilk substitute should be made in conjunction with a pediatrician or other health professional who will have responsibility for the infant's health and growth. Factors such as a family history of allergies, weight gain issues and feeding difficulties with other siblings will guide this choice and the choice of feeding implements. The mother should bring these with her to the hospital or clinic so that she can learn how to prepare them and feed her infant while being supervised. </p>
        <p> Infants fed a breastmilk substitute that is not prepared in a safe manner are prone to hypernatremic dehydration, malnutrition, obesity and gastrointestinal infections. <sup><a href="#note3">3</a></sup> A large American study reported more than 3/4 of mothers using breastmilk substitutes did not receive instruction on formula preparation or storage from a health professional. <sup><a href="#note4">4</a></sup> Similarly in the United Kingdom a systematic review of the literature found errors in reconstitution, with a tendency to over-concentrate feeds, though under-concentration also occurred. <sup><a href="#note5">5</a></sup> </p>
        <p> Because of the frequency and seriousness of these errors, instruction on formula preparation, storage and safe feeding practices must be given individually to the parents by a health professional at the time they need it. This teaching is not effective when given prenatally. <a href="topic_7-5-4.html">Topic 7.5.4</a> details how to teach this skill. <br /> </p>
        <p> The WHO Code on the Marketing of Breastmilk Substitutes precludes group instruction of this important skill. Likewise it stipulates that instruction is to occur after the infant is born, at the time of need. <sup><a href="#note6">6</a></sup> <br /> </p>
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      <div class="section" id="What_should_I_remember_"><h2>What should I remember?</h2>
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        <ul>
          <li> Step 3 (BFHI) and Point 3 (Plan for the Community) <br /> </li>
          <li> the 3 important breastfeeding knowledge areas which must be covered with all pregnant women </li>
          <li> using open questioning and conversation techniques which can open discussion about infant feeding </li>
          <li> when breastfeeding is contraindicated</li>
          <li>when artificially-feeding parents are to receive instruction on infant formula preparation<br /></li>
        </ul>
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      <div class="section" id="Skills_Competency_1"><h2>Skills Competency #1</h2>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><a href="images/competencies1_communication.pdf" target="_blank"><img src="design/tip.png" class="icon" alt="" /></a><h3><a href="images/competencies1_communication.pdf" target="_blank">Communicating with pregnant women about infant feeding</a></h3>
      <div>Linked here is the first of 4 Skills Competencies every staff member must successfully complete to meet the staff education requirements of the Baby Friendly Initiative. Before doing this first competency you may wish to complete the whole course, ensuring you have the evidence-based knowledge to discuss the topics you must discuss with the mother and any other issues the mother may raise. <br /><br />When you feel you have the required skills and knowledge click on the title of this box to download "Communicating with Pregnant Women about Breastfeeding" competency form for you to complete with your Supervisor.<br /></div>
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      <div id="footnotes">
        <h3>Notes</h3>
        <ol>
          <li id="note1"><a href="references.html#who" title="See full details">#</a> World Health Organisation et al. (1992) Global Criteria fort he Baby-Friendly Hospital Initiative</li>
          <li id="note2"><a href="references.html#lumc01" title="See full details">#</a> Lu MC et al. (2001) Provider encouragement of breast-feeding: evidence from a national survey</li>
          <li id="note3"><a href="references.html#egem02" title="See full details">#</a> Egemen A et al. (2002) A generally neglected threat in infant nutrition: incorrect preparation of infant formulae.</li>
          <li id="note4"><a href="references.html#labi08" title="See full details">#</a> Labiner-Wolfe J et al. (2008) Infant formula-handling education and safety.</li>
          <li id="note5"><a href="references.html#renf03" title="See full details">#</a> Renfrew MJ et al. (2003) Formula feed preparation: helping reduce the risks; a systematic review.</li>
          <li id="note6"><a href="references.html#who08" title="See full details">#</a> World Health Organization (2008) The International Code of Marketing of Breast-Milk Substitutes: frequently asked questions. Updated version 2008</li>
        </ol>
      </div>
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      <h1>Breastfeeding Essentials</h1>
      <ol>
        <li>1.0 <a href="topic_1-0.html">Why Breastfeeding is Important</a><ol><li>1.1 <a href="topic_1-1.html">Biochemistry</a></li><li>1.2 <a href="topic_1-2.html">Immunology</a></li><li>1.3 <a href="topic_1-3.html">Relative risks</a></li></ol></li>
        <li>2.0 <a href="topic_2-0.html">Communication Skills</a><ol><li>2.1 <a href="topic_2-1.html">Non-verbal</a></li><li>2.2 <a href="topic_2-2.html">Listening skills</a></li><li>2.3 <a href="topic_2-3.html">Building confidence</a></li><li>2.4 <a href="topic_2-4.html">An example</a></li></ol></li>
        <li class="current">3.0 <img src="design/bullet_arrow_right.png" alt="*" title="You are here" /><a href="topic_3-0.html">Pregnancy Care</a><ol><li>3.1 <a href="topic_3-1.html">The feeding decision</a></li><li>3.2 <a href="topic_3-2.html">The barriers</a></li><li>3.3 <a href="topic_3-3.html">Physical preparation</a></li></ol></li>
        <li>4.0 <a href="topic_4-0.html">The Birth Experience</a><ol><li>4.1 <a href="topic_4-1.html">The first hours</a></li><li>4.2 <a href="topic_4-2.html">Labor interventions</a></li><li>4.3 <a href="topic_4-3.html">Postnatal interventions</a></li></ol></li>
        <li>5.0 <a href="topic_5-0.html">Breastfeeding the Baby</a><ol><li>5.1 <a href="topic_5-1.html">Positioning Principles</a></li><li>5.2 <a href="topic_5-2.html">Breastmilk transfer</a></li><li>5.3 <a href="topic_5-3.html">Assessing breastfeeding</a></li></ol></li>
        <li>6.0 <a href="topic_6-0.html">A time to learn</a><ol><li>6.1 <a href="topic_6-1.html">Practical skills</a></li><li>6.2 <a href="topic_6-2.html">Breastfeeding messages</a></li><li>6.3 <a href="topic_6-3.html">Normal growth</a></li><li>6.4 <a href="topic_6-4.html">Sleep</a></li><li>6.5 <a href="topic_6-5.html">Psychological support</a></li><li>6.6 <a href="topic_6-6.html">Discharge planning</a></li></ol></li>
        <li>7.0 <a href="topic_7-0.html">Infant Challenges</a><ol><li>7.1 <a href="topic_7-1.html">Late preterm infant; Non-latching</a></li><li>7.2 <a href="topic_7-2.html">Hypoglycemia; Jaundice</a></li><li>7.3 <a href="topic_7-3.html">Supplementation</a></li><li>7.4 <a href="topic_7-4.html">Crying baby</a></li><li>7.5 <a href="topic_7-5.html">Inadequate weight gain</a><ol><li>7.5.1 <a href="topic_7-5-1.html">Feeding-line device at the breast</a></li><li>7.5.2 <a href="topic_7-5-2.html">Cup feeding</a></li><li>7.5.3 <a href="topic_7-5-3.html">Finger Feeding</a></li><li>7.5.4 <a href="topic_7-5-4.html">Bottle feeding</a></li></ol></li></ol></li>
        <li>8.0 <a href="topic_8-0.html">Maternal Challenges</a><ol><li>8.1 <a href="topic_8-1.html">Engorgement</a></li><li>8.2 <a href="topic_8-2.html">Nipple Pain</a></li><li>8.3 <a href="topic_8-3.html">Breast Problems</a></li><li>8.4 <a href="topic_8-4.html">Insufficient breastmilk</a></li><li>8.5 <a href="topic_8-5.html">Medical, Surgical Issues</a></li></ol></li>
        <li>9.0 <a href="topic_9-0.html">Promotion, Protection and Support</a><ol><li>9.1 <a href="topic_9-1.html">The International Code of Marketing of Breastmilk Substitutes</a></li><li>9.2 <a href="topic_9-2.html">The Baby Friendly Initiative</a></li><li>9.3 <a href="topic_9-3.html">Young Child Feeding</a></li><li>9.4 <a href="topic_9-4.html">Local initiatives</a></li><li>9.5 <a href="topic_9-5.html">Infant feeding in emergencies</a></li></ol></li>
        <li>10.0 <a href="topic_10-0.html">Closing session</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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