Fundamentals of Midwifery: A Textbook for Students (94 page)

Within the first 24 hours after birth, baby should be passing urine and stools.

At least 1–2 voids of urine in the first 24 hours.

At least 2–3 voids of urine in the first 48 hours.

Increasing to 6 voids of urine per day by day 4–5.

1 or 2 stools of meconium in the first 24 hours.

Increasing to at least two stools per day by day 4 changing through black/green/brown and

then to yellow by day 5.

(UNICEF 2010, Breastfeeding Assessment Tool)

222

Further reading activity

Access and read the following articles by Suzanne Colson, where you can see images of laid-back

breastfeeding.

Colson, S. (2008) optimal positions for the release of primitive neonatal reflexes stimulating breastfeeding

84, pp. 441–445.

Colson S (2010) what happens to breastfeeding when mothers lie back

1, pp. 9–12.

Visit biological nurturing [available online] www.biologicalnurturing.com

A mother needs to be able to recognise sufficient milk transfer to feel confident in being able

to provide adequate nutrition for her baby. Health professionals need to be aware of the key factors indicative of sufficient milk transfer, outlined in Box 10.3. Early skin-to-skin contact, initia- tion of breastfeeding and frequency of breastfeeds with effective attachment is the foundation for sustained effective feeding.

Further reading activity

Access and read the breastfeeding Assessment Tools on the Baby Friendly Initiative website to

assist you in being able to recognise insufficient milk transfer in the baby [available online] http://www.unicef.org.uk/BabyFriendly/Resources/Guidance-for-Health-Professionals/Forms-and

-checklists/Breastfeeding-assessment-form/

There are physiological factors in the mother that can affect the mother’s ability to lactate suf- ficiently to meet the requirements of the baby. Possible factors affecting this include: anaemia, postpartum haemorrhage, polycystic ovarian syndrome, caesarean section, retained products, acute maternal illness, certain medications, diabetes, breast surgery, or anxiety in the mother (Powers 2010). However, the majority of mothers do have the physiological ability to lactate adequately. Ineffective removal of milk from the breast affecting the normal physiology of

Box 10.4 Reasons for poor milk supply

Interruption of skin to skin contact

Delay in the first breastfeed

Ineffective attachment and positioning of the baby

Inappropriate use of supplement feeds

Separation of the mother and baby

Infrequent feeding

Absence of baby-led feeding

Use of pacifiers, plastic teats, and nipple shields
Box 10.5 Recognising insufficient milk transfer in the baby

Poor urine output

Abnormal stool pattern

Weight loss is not within normal parameters

Poor weight gain

Jaundice

Lethargy, not waking to feed regularly

Baby quickly falls asleep at the breast

Baby consistently feeds for less than 5 minutes or longer than 40 minutes

Unsettled baby after feeds

Baby on and off the breast frequently during the feed

Difficulty in attaching the baby to the breast

No change in sucking pattern observed

Noisy feeding (clicking sounds heard)

Mother’s nipples sore or damaged

Mother’s breasts engorged or mastitis
223lactation, separation of mother and baby and supplementary feeds are some of main reasons for delayed or impaired lactogenesis. Box 10.4 outlines some of the reasons for poor milk supply and Box 10.5 highlights key factors for recognising insufficient milk transfer in the baby.The aim is to maintain the health of the baby, ensuring adequate nutrition and preventing dehydration. Supporting the mother to stimulate milk production, ensuring the breasts are drained adequately, maintains optimal neurohormonal balance to support successful feeding. Box 10.6 outlines some key ways to stimulate milk production.
Ankyloglossia (tongue tie)
Approximately 1 in 10 babies is born with a short, thick or tight lingual frenulum (ankyloglossia) which may restrict the forward protrusion, upward lift and or lateral mobility of the tongue (Riordan 2010). Babies initiating breastfeeding can experience difficulty gaining a deep enough attachment to the nipple/areola complex of the breast to transfer milk effectively (Dollberg224
Box 10.6 Stimulating milk production and managing insufficient milk transfer

Obtain breastfeeding history (Pollard 2012).

Obtain medical and obstetric history.

Ascertain the baby’s feeding behaviours.

Ascertain the frequency of urine and colour of stools of the baby.

Observe a complete breastfeed.

Assess the baby’s general clinical condition – refer to paediatrician if concerned.

Ascertain the use of supplementary feeds, dummies, teats, nipple shields.

Consider maternal physiology factors that may delay lactogenesis.

Encourage skin-to-skin contact.

Ensure effective positioning and attachment of the baby.

Encourage more frequent, effective feeds, throughout day and night, to increase prolactinrelease.

Offer both breasts at each feeding.

Express by hand or pump after feeds to increase milk removal and increase prolactin release.

If supplementary feed required, give baby expressed breastmilk (EBM) ideally, via a cup orsyringe. Or formula milk if mother unable to express milk.

Support the mother by instilling confidence in her abilities.et al. 2008). This can be attributed to the reduced mobility of the tongue preventing the baby from being able to protrude the tongue over the lower lip and gum ridge (Algar 2009).Breastfeeding mothers with a tongue-tied baby frequently experience breast pain and nipple damage due to difficulty latching the baby effectively onto the breast, which, subsequently, can result in reduced milk supply in the mother and poor weight gain in the baby (Messner et al. 2000; Ballard et al. 2002; Griffiths 2004; Mettias et al. 2013). The suboptimal drainage of the breast also increases the risk of mastitis in the mother. Bottle feeding babies with a significant tongue tie can also find it difficult to create a good seal around the bottle teat, resulting in excessive dribbling, prolonged feeds, spillage of milk and reflux (Hogan et al. 2005; Finigan 2014).It is important to note that the observation of a lingual frenulum underneath the tongue does not necessarily mean that the baby is ‘tongue tied’. It is the assessment of the tongue function which determines whether the baby is tongue tied. If a tongue tie is suspected and all other strategies for achieving comfortable and effective breastfeeding or efficient milk transfer from a bottle have been unsuccessful, then urgent referral to a health professional who is a qualified Frenotomy Practitioner should be sought. Frenotomy (division of tongue tie) offers a safe, simple procedure to release the tongue tie to enable the baby to feed effectively with the normal range of tongue movement restored (Hogan et al. 2005; NICE 2005; Sethi et al. 2013).
Reasons for expressing breastmilk
Every breastfeeding mother should be taught how to express by hand, as part of her initiationof breastfeeding, in the first few days after giving birth.