1
Q
What are the 4 phases of the postnatal period
A
1- first few hours
2- Early days
3- Early weeks
4- Completing the transition to parenthood
(Phase 1 & 2: are focused on physical recovery and psychological wellbeing)
2
Q
What model of healthcare does Midwifery fall into?
A
Midwifery is primary healthcare in action and its practice is supported by the Social model of Health
3
Q
Which 2 Millennium Development Goals (2000) refer to the postnatal period
A
MDG 3: Promotion of gender equality and empowerment of women
MDG 5: Improve maternal health
4
Q
List some of WHO’s postnatal care recommendations
A
First 24 hours after birth- provide postnatal care for every birth
Hospital birth- delay discharge for 24hrs
Home births- visit women and babies within first 24hrs
Postnatal visits- provide a minimum of 4 visits for mother and baby (first 24hrs- day 3- between days 7-14- 6 weeks)
5
Q
List WHO’s recommendation 8- assessment of the mother
A
- first 24hrs: all women have regular assessment of uterine involution, vaginal bleeding, urine void, obs. Repeat obs/urine within 6 hours
- Beyond 24hrs: contact and assessment of general wellbeing, urination/bowle habits, perineal recovery, breast and uterine tenderness, lochia
- At each visit: breastfeeding ability, emotional wellbeing, lochia, social support
- ## 10-14 days after birth: address resolution of maternal blues
6
Q
Explain: Postpartum blues
A
- occurs in approx 75% of women
- occurs in first few days peaking around day 4/5
- usually resolved by day 10
- Symptoms: low mood, irritability, feeling overwhelmed, anxiety, insomnia, loss of appetite and tearfulness
7
Q
Explain: Postnatal depression
A
- occurs in approx 10-16% of women
- a low mood that lasts longer than the first 10days
- symptoms: irritability, anger, guilt, lack of interest in activities, low energy and tearfulness
8
Q
In low income countries most infants are breastfed to what age
A
1 year
9
Q
What percentage of infants in high income countries are BF up to 1yr of age
A
20%
10
Q
What was the purpose of the Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding (1990)
A
WHO/UNICEF sponsored policy makers meeting.
- This declaration encouraged National authorities to incorporate breastfeeding affirming initiatives into their health and related policy platforms.
- Ensured that facilities providing maternity services adopted the “Ten Steps to Successful Breastfeeding” set out in the joint WHO/UNICEF statement
11
Q
When was the Baby-friendly Hospital Initiative launched
A
1992
12
Q
What factors influence whether a woman will breastfeed
A
- intention to breastfeed prior to conception
- age
- socio-economic group,
- level of education.
- self-efficacy and confidence
13
Q
What are the rates of BF
A
- Breastfeeding was initiated for 96% of children aged 0–2 years.
- Around 69% of infants were still receiving some breastmilk at 4 months of age, although only 39% were exclusively breastfed to 3 months, and around 60% were still receiving some breastmilk at 6 months, but only 15% were exclusively breastfed to 5 months.
- A total of 47% of infants were predominantly (fully) breastfed to 3 months, dropping to 21% predominantly breastfed to 5 months.
14
Q
When did the Australian Breastfeeding Association begin?
A
1992 (was known as Nursing Mothers Association)
15
Q
What was the purpose of the ABA
A
is an organisation which supports, informs and enables women to make informed choices around infant feeding for their babies.
16
Q
What are some social determinants that apply to the postnatal period
A
Housing
Education
Social support
Culture
17
Q
Explain: 4 phases of the postnatal period
A
Phase 1 & 2- physical recovery is a main focus of concern for most women, along with caring for and being able to breastfeed the baby.
Phase 3- as a woman’s physical recovery and parenting role progresses, she will gain confidence in her ability to care for herself and her baby.
- At some point the emotional aspects of the changes to her social world will start to have an impact.
Phase 4- the completion of the transition to parenthood. Involves a woman and her family accepting the change in family dynamics, and confidence increases
18
Q
Explain: Baby Blues
A
occurs around day 3-10 (usually resolved)
- Signs are usually tearfulness, anxiety, irritability, low mood, tendency to cry for no reason, feel overwhelmed, tired, and for everything to ache or feel sore.
19
Q
How can midwives support women with the ‘baby blues’
A
- help the women to have rest
- encourage family support
- ensure physical comfort (such as food, fluids, being pain free and able to get some sleep) at this time to promote wellbeing
- discuss pain relieving methods
20
Q
What % of women experience the ‘baby blues’
A
50-80% of all women (espesically primiP’s)
21
Q
What % of women experience postnatal depression
A
between 10-28% of all women
up to 75% of women will develop this in the antenatal period
22
Q
How many lobes are there within each breast
A
15-20 lobes extending from the nipple
23
Q
Is breast size a predictor of breastfeeding success
A
No
24
Q
What are the small swelling located on the areola
A
Montgomery’s tubercles (areolar glands)
25
Define: Lactogenesis
refers to the ability of the breast to function as a secretory gland to synthesise and secrete breast milk and occurs across the continuum of pregnancy, birth and the postpartum period in three distinct phases.
26
Explain: 3 phases of Lactogenesis
Lactogenesis I- occurs during pregnancy and refers to the maturation of the mammary gland to reach the potential to synthesise breast milk.
Lactogenesis II- reflects the secretion of breast milk by the breast and occurs approximately 60 hours after birth.
Lactogenesis III- is the production and maintenance of mature breast milk and gradually occurs from the 10th to 14th day postpartum until the 4th to 6th weeks postpartum
27
Define: Weaning (involution)
if breastfeeding ceases or reduces in frequency, peptides in the breast milk begin to inhibit cell production and cells die with a gradual reduction of breastmilk volumes produced
28
What are the 2 main hormones involved in lactation
Prolactin
| Oxytocin
29
What is the role of Prolactin in lactation
In the initial weeks following birth, breast-milk synthesis is directly stimulated by maintained plasma prolactin levels and by early frequent and effective infant suckling
- Frequent infant suckling stimulates the production of prolactin receptor sites within lactocyte cells in the alveoli, which stimulate breast-milk production once bound with prolactin
30
What is the role of Oxytocin in lactation
Although oxytocin does not stimulate breast-milk synthesis directly, this hormone supports the removal of breast milk from the breast with newborn suckling.
- The ‘let-down reflex’ or ‘milk ejection reflex’ is triggered when the baby suckles at the breast
- Oxytocin stimulates the contaction of the myoepithelial cells in the alveoli
31
Explain: 3 types of breastmilk
Colostrum- is produced from 16 weeks’ gestation and continues for the first 3–4 days postpartum. Volume ranges 2-29ml per feed
Transitional breast milk is produced between colostrum (from 3–4 days) and mature milk and lasts for approximately 10 days to 2 weeks postpartum.
Mature breast milk contains approximately 90% water with 10% proteins, carbohydrate and fats with vitamins and minerals
32
What type of breastfeeding preparation is available to women
- discussions with antenatal care provider
- discussion with friends and family
- antenatal classes
- breastfeeding preparation classes (ABA, hospital)
- readings books
- dad's BF support sessions/resources
33
What was the purpose of the Australian Infant Feeding Surevy (AIFS)
It provides
- national baseline data on the prevalence and duration of breastfeeding
- national baseline data on other foods and drinks consumed by infants and toddlers
- national baseline data on perinatal depression
- reports on the barriers to initiating and continuing breastfeeding
34
Intention to breastfeed can be influenced by...
- Focus on providing the ‘best’
- Positive exposure to breastfeeding through family and friends
- A social culture which supports breastfeeding
- Supportive partner and mother
35
What do we know about the initation and duration of breastfeeding in Australia
initiation rates are high
| duration rates are below WHO recommendations
36
What were the initiation of breastfeeding rates for smokers, lower education level women and high income women
Smokers- 88%
37
Does support play a role in the duration of breastfeeding
Yes
| - professional and peer support
38
Mclelland et al study found 4 key themes impacting on the provision of breastfeeding support
- Guiding women over hurdles: discussing the realities of BF
- Timing and time to care: times constraints and a lack of support beyond the first couple of days
- Continuity of care: lack of continuity contributed to conflict BF advice and limited relationship rapport
- Imparting BF knowledge: more education needed for staff and consistency
39
List the 10 steps of successful breastfeeding
Step 1: Have a written breastfeeding policy that is routinely communicated to all health care staff.
Step 2: Train all health care staff in skills necessary to implement this policy.
Step 3: Inform all pregnant women about the benefits and management of breastfeeding.
Step 4: Place babies in skin-to-skin contact with their mothers immediately following birth for at least an hour and encourage mothers to recognise when their babies are ready to breastfeed, offering help if needed.
Step 5: Show mothers how to breastfeed, and how to maintain lactation, even if they should be separated from their infants.
Step 6: Give newborn infants of breastfeeding mothers no food or drink other than breastmilk, unless medically indicated.
Step 7: Practice rooming-in - allow mothers and infants to remain together - 24 hours a day.
Step 8: Encourage breastfeeding on demand.
Step 9: Give no artificial teats or dummies to breastfeeding infants.
Step 10: Foster the establishment of breastfeeding support and refer mothers on discharge from the hospital
40
Explain: Baby led attachment
Is when a baby is placed skin to skin with the mother and during the first hours following birth the newborn infant exhibits instinctive behavioural pattern
- Sucking and rooting reflexes, hand movements, and within 1 h postpartum can find the mother’s breast and begin suckling
- 9 behavioural stages that infants exhibit when skin to skin with mother immediately after birth
41
What are the 9 behavioural stages a newborn goes through during baby led attachment
1. birth cry,
2. relaxation,
3. awakening,
4. activity,
5. crawling,
6. resting,
7. familiarization,
8. suckling and
9. sleeping self-regulation.
42
What factors facilitate baby led attachment
- a semi reclined position
- skin to skin contact
- placing baby between mothers breasts upright
- allow baby to move across chest and to the nipple
- supporting baby's neck and body (avoid holding the head as baby will move this throughout process and for breathing)
- allow baby to self-attach
43
Explain: Mother-led attachment
is more frequently seen and used
- mother hold baby in a comfortable position
- uses breast to open baby's mouth with nipple aimed towards top of mouth
- inserting nipple well into the baby's mouth once widely opened
44
List signs of good attachment
- baby's chin pressed into breast with nose clear
- lips are widely spread over areola (not sucked in)
- baby has much of the areola in its mouth
- no pain for mother
- no sounds form baby's mouth
45
List indicators of sucsessful feeding in babies
- audible and visible swallowing
- sustained rhythmic suck
- relaxed arms and hands
- moist mouth
- regular soaked/heavy nappies.
46
List indicators successful breastfeeding in women
- breast softening
- no compression of the nipple at the end of the feed
- no pain
- woman feels relaxed and sleepy.
47
Explain: characteristics of baby's sucks when breastfeeding
Initial sucks- quick, short, shallow to stimulate milk ejection
Nutritive sucks- regular, slow, long and deep with pauses
48
Describe: BF in the early days
- feeding is frequent
- can be 1-2hrly at different times of the day (corresponds with gastric emptying/sleep cycle)
- frequent feeding stimulates development of prolactin increasing breastmilk production
- Unrestricted breastfeeding, that is responsive to infant need, increases breastfeeding duration
49
Define: Cluster feeding
is when there is an increase in feeding frequency at various times of the day
- can be associated with periods of growth
50
How can you confirm milk supply with urine output
- Urine output is an indicator of breastmilk volumes.
- Expectation during the first 2 days is one to two wet nappies
- Once Lactogenesis II has occurred the amount of urine output should increase gradually until by day 5 expect to have 6-8 nappies in a 24 hour period
51
How can you confirm milk supply with bowel output
- Colour, consistency and frequency of bowel movements
- Transitional stool colour can confirm lactogenesis II has occurred as the stool changes from black and sticky meconium (day1) to mustard yellow stool with the appearance of seeds or curds (day 4).
- Within the first 6 weeks it is expected the infant will have at least one bowel movement in a 24 hour period.
52
Explain: Physiological weight loss
occurs in the first 2 weeks of life and is expected due to the passage of meconium and loss of stored fluid
53
When is weight loss considered abnormal
when weight loss is >10% at day 4-6
- Infants should return to birth weight by the 10th day and thereafter gain approximately 150-210gms per week.
54
What's the prevalence if PND
1-2 in 10 women
55
How many mls of colostrum are approximately available to an infant
2-29mls
56
What is higher in colostrum than in mature milk
Immunoglobulins and white blood cells
57
When does transitional milk occur
starts day 3-4
| Ends around day 10-14
58
What ingredients in BM increase from transitional milk
Carbohydrates
| Fat
59
Mature milk consists of..
90% water
| 10% fat
60
Explain: difference between Whey and Casein
Whey is liquid consistency
| Casein is soft curd and harder to digest
61
What is the ratio of whey to casein in breastmilk and formula
Breastmilk- 60% whey, 40% casein
Formula- 20% whey, 80% casein
62
What is the amino acid in breastmilk
Taurine- used for brain maturation
63
Is the fat content in BM static
no
64
Is the nutritional content of BM dependent on the mothers diet
No, however if the mother has deficiency's in micro-nutrients when the baby is likely to be missing out on these in their diet
65
What is the breast tissue ratio in non-lactating women
1:1
66
Why is it recommended parents introduce complementary food into their baby's diet from 6 months
because vitamin and mineral content in breastmilk declines from 6 months postpartum
67
List some of the benefits of breastfeeding
- provides all essential nutrients for growth and development
- boost immune system (less childhood infections)
- minimises allergies
- increase in intelligence
- reduce risk of diabetes and obesity
- reduces risk of breast cancer
- facilitates bonding
- helps uterus contract to pre-pregnancy state
- uses excess weight gained in pregnancy for milk production
68
What is the recommended age infants be exclusively breastfed til
6 months of age
69
What can initiate breastfeeding challenges
- Normal physiology is interrupted
- Breastfeeding is not yet established
- Insufficient and inaccurate advice is given
- There are physical impediments to breastfeeding
70
Common Challenges- Breastfeeding
Explain: Nipple pain and trauma
- sensitivity is common in the first few days-1week. Usually resolved within a minute of feeding
- Ongoing pain is associated with incorrect position and attachment (nipple placement inside infants mouth)
71
Common Challenges- Breastfeeding
Explain: Nipple trauma Recommendations
- gently break seal of baby's mouth on breast
- express a few drops of milk and rub onto nipple
- leave nipples to air dry
- Ensure nipple is as far into infants mouth as possible when sucking
- if necessary use nipple shields
72
Common Challenges- Breastfeeding
Explain: Breast engorgment
caused by rapid increase in milk production, or an obstruction of milk ducts from insufficient draining
73
Common Challenges- Breastfeeding
Explain: Breast engorgement Recommendations
- unrestricted breastfeeding
- emptying one breast before starting on the other
- hand expression (can be used to encourage baby)
- reverse pressure softening (massage)
74
Common Challenges- Breastfeeding
Explain: Blocked milk duct
can be caused by poor attachment, over supply, engorgement, supplementation with formula, disruption in BF pattern, pressure on the breast and insufficient draining of the breast
75
Common Challenges- Breastfeeding
Explain: Blocked milk duct Recommendations
- Unrestricted feeding,
- ensure correct attachment,
- feed from affected side first,
- massage the lump during feed,
- change feeding positions,
- and the use of a heat pack on breast before feed may be helpful.
76
Common Challenges- Breastfeeding
Explain: Mastitis (breast inflammation)
Mastitis is localised inflammation of breast tissue +/- infection
- Caused by breast milk stasis, build up of milk in the breast or blocked duct
- Most common during early establishment of breastfeeding - first 6 weeks
- Characterised by an area of redness on the breast, may be accompanied by high temperature and flu like symptoms
77
Common Challenges- Breastfeeding
Explain: Mastitis Recommendations
management includes
- frequent feeding or expression
- hot or cold compresses
- antibiotics if infected
- positioning babys chin towards more painful areas
78
Common Challenges- Breastfeeding
Explain: Flat or Inverted nipples
Can be:
Umbilicated- retractile- ie. can be everted
Invaginated- non retractile- ie. cannot be everted
- not an indicator of breastfeeding success. Babies can draw sufficient areolar into their mouth to bring the nipple to the soft palate
79
Common Challenges- Breastfeeding
Explain: Flat or Inverted nipples Recommendations
strategies include:
- nipple stimulation
- manual/pump expression to draw out the nipple
- use of nipple shields
80
Less Common Challenges- Breastfeeding
Explain: Insufficient milk supply
caused by:
- breast reduction surgery
- mammary hypoplasia
81
Less Common Challenges- Breastfeeding
List physical signs that may indicate Insufficient Glandular Tissue
- More than a 4 cm flat space between breasts
- Breast asymmetry (one breast is much larger than the other)
- Tubular shaped breasts (the breast has a narrow base and its volume is long rather than round)
- Overly large and bulbous areolae (as if they are a separate structure attached to the breast)
- Absence of breast changes in pregnancy/ postnatally
82
Less Common Challenges- Breastfeeding
Explain: Insufficient glandular tissue Managment
- Improving attachment
Unrestricted feeding
- Continuous skin to skin
- Breast expression (especially after a feed when prolactin levels are highest)
- Possible use of galactogogues eg. Herbal preparations of fenugreek, goats rue, milk thistle, or medications such as domperidone, and metochlopramide
83
Less Common Challenges- Breastfeeding
Explain: Ankyloglossia (tongue tie)
occurs in about 5% infants
- tie impedes the infants tongue mobility making it difficult to draw the nipple to the back of the mouth
- can cause painful/damaged nipples
- Surgical release of the tongue tie (frenotomy)
84
What Act protects women who want to breastfeed in public
Women have the statutory right to breastfeed
- Under the federal Sex Discrimination Act 1984 it is illegal in Australia to discriminate against a person either directly or indirectly on the grounds of breastfeeding
85
What are some contra-indications to breastfeeding
- Infant galactosemia
- Active TB
- Herpes (lesions on the breast)
- HIV Positive women without ARV
- Some medications
86
What are some of the inhibitory factors impacting on midwives ability to support women with BF challenges
- Time restraints
- midwives to women ratio
- hospital 'churn'/production line
- emotional roller coaster post birth
- conflicting advice
87
What is the role of the IBCLC
is a clinical expert in the management of breastfeeding and human lactation, the IBCLC is trained to counsel mothers and families on initiation, exclusivity, and duration of breastfeeding, and to assist amidst any difficulties or high-risk situations.
- IBCLCs are sensitive to and support the needs of mothers, infants, children, and various family structures in working toward breastfeeding goals
88
Define: IBCLC
International Board Certified Lactation Consultant
| arose during 1970's/80's
89
Define: IBLCE
International Board of Lactation Consultant Examiners
| March 1985
90
When do infant growth spurts usually occur
2-3 weeks
6 weeks
3/6 months
91
What factors are used to confirm adequate breastmilk intake?
Urine output
Bowel habits
weight assessment
Feeding frequency (not reliable alone)
92
What is the foundational platform for the BFHI (Baby Friendly Hospital Initiative) in creating a breastfeeding friendly culture in hospitals and communities?
The Ten Steps to Successful Breastfeeding and
| The Seven Point Plan for Sustaining Breastfeeding in the Community.
93
Do partners need to be involved with discussions about breastfeeding?
Yes for support – literature suggest that positive support systems are/is significant determinant of breastfeeding outcome.
Eg – a woman is more likely to breastfeed for longer period of time when her partner are supportive of her feeding decision, value breastfeeding and provide her with a nurturing and encouraging environment.
94
Early initiation of breastfeeding soon after birth, and frequent feeding has 3 main benefits for mothers also. What are they?
1. Stimulate release of oxytocin to initiate uterine contractions = uterine involution
2. Reduce risk of PPH
3. Release of oxytocin also has an important role in maternal-infant attachment. Suckling in the first hour after birth is associated with greater sense of maternal-infant attachment compare with when suckling does not occur within this timeframe.
95
How many wet nappies would you expect to see during day 1-2
1-2 days after birth = 1 to 2 wet nappies per day.
- Once lactogenesis II occurs urine output should increase daily therefore after a week postpartum wet nappies would increase to 6 to 8 wet nappies per day.
96
How much weight loss is expected in the first week after birth (infant)
> 10%
97
Should midwives adopt a hands-off or hands-on approach to breastfeeding support?
Hands-off approach as this supports the woman to learn through experiential learning that facilitates in maternal empowerment and breastfeeding self-efficacy.
- Hands-off approach has also been associated with improvements in breastfeeding outcome.
98
Explain: Positioning
refers to the position of the infant relative to the position of the mother. The interaction between mother’s and infant’s body position and the infant’s mouth-to-breast position that allow for effective attachment.
99
Who developed the Baby Friendly Hospital Initiative?
WHO and UNICEF (1991)
- BFHI Initiative was introduced in Australia in 1993, and is governed by the Australian College of Midwives
100
Explain: Attachment
Attachment – bringing the infant to the breast using the rooting reflex to open the infant’s mouth widely and drawing of the nipple and breast tissue into the mouth to the back of the soft palate. Tongue is forward over the gums but under the areola with the chin placed on the underside of the breast.
101
List some signs of good attachment
- no pain
- baby's cheeks look full (good mouthful of breast)
- chin pressed into breast/nose clear
- Short rapid stimulating sucks initially, long meaningful nutritive sucks when feeding
- short breaks
102
List some signs of 'not so good' attachment
- nipple pain when feeding
- baby's cheeks are sucked in
- continuous short sucks
- baby goes to sleep on the breast
- clicking sound during feeds
- nipple is mishapen, white ring around
103
Explain: Biological nuturing
woman lies semi-recumbent/almost supine, skin to skin with baby and allows baby led attachment
104
Explain: Infant bowel changes
- A transition from meconium in the first day to green-brown,
- less-sticky motions in the second 24–48 hours will indicate that the infant is digesting colostrum
- Unformed, bowel motions that are mustard yellow and that may have the appearance of seeds or curds (the less-digestible curd in breast milk) are also a positive indicator that lactogenesis II
- Within the first 6 weeks of life, the median number of defecations per day is six
- Within the first month of life, the breastfeeding infant should be expected to pass at least one substantial bowel movement every 24-hour period
105
Postpartum Physiology
What are the 4 main areas of change during the Puerperium
1. Involution of the uterus
2. Lactation
3. Body system changes
4. Emotional changes
106
Postpartum Physiology
What factors might slow down or inhibit involution of the uterus
- Prolonged labour
- Grand multiparty
- Full bladder
- Pelvic infection
- Incomplete expulsion of the placenta and membranes
107
What are the 3 types of Lochia
Lochia Rubra
Lochia Serosa
Lochia Alba
108
Explain: Lochia rubra
is red and is made up of decidua and fresh blood, discharged for about 3 – 4 days
109
Explain: Lochia serosa
is pink/brown and contains necrotic decidua, and more white blood cells than red. It usually lasts for 2-4 weeks
110
Explain: Lochia alba
is yellow-white and is mostly serous fluid, leukocytes and cervical mucous lasts for 3-6 weeks
Midwifery Knowledge 3
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