ICEA Study Guide 10 – Postpartum and Newborn Care

 

OBJECTIVES At the completion of Part 10 the learner will:

■ list newborn communication skills and sleep/wake patterns.

■ demonstrate the newborn care basic of bathing a newborn.

■ list newborn warning signs that would prompt contacting a care provider.

■ summarize physical maternal postpartum changes.

■ list maternal warning signs that would prompt contacting a care provider.

■ list various transitions the new family will experience after birth.

■ explain breast anatomy basics and breast milk production.

■ compare and contrast ‘baby blues’ and other perinatal mood and anxiety disorders.

 

OUTLINE

Fourth Stage of Labor

  1. Newborn Transition
  2. Appearance and newborn reflexes

Meeting Your Baby: if both doing well after birth, best place is on your chest with just a blanket covering you both. Skin to skin contact allows you to bond and a chance to discover what makes your baby unique. Also provides wonderful first memories. *If had a long and tiring labor, recovery may delay enjoyment of meeting newborn. If baby has trouble adjusting to life outside your womb, he may need to be separated so medical staff can care for him.

Newborn’s Appearance: may surprise you – large size and unexpected shape of head, tiny hands and feet, enlarged reddened genitals, initial dusky blue coloring and little body streaked with blood and vernix caseosa (creamy white substance that protected her skin).

Body: average full term baby weighs 7-7.5 lbs and 20 inches in length. Shoulders and hips are narrow, belly is round and arms and legs are short, thin and flexed.

Head: large in proportion to body. May be molded from pressures within pelvis during birth (cone shaped or longer than expected), but will return to normal round shape within a few days. Scalp or face may appear bruised and swollen, but will disappear with time.

2 soft spots called fontanels (bones haven’t completely fused). Large, diamond shaped on top front portion of skull and smaller, triangle shaped one at back. Larger closes by 18 months after birth and smaller by 2-6 months. A thick, tough membrane covers the fontanels, so gently brushing or washing baby’s hair and scalp fine.

Hair: full head or bald. Lanugo (fine, downy body hair) on baby’s back, shoulders, forehead, wars and face – especially if premature; usually disappears within a few weeks.

Eyes: fair skinned have gray-blue eyes at birth. Dark skinned have brown or dark gray eyes. If going to change, usually does os by 6 months old. Tear glands won’t produce many tears until about a month.

Sucking Callus (blister): intense sucking causes painless white callus on center of baby’s upper lip. Sometimes it peels. Doesn’t need treatment and disappears as lip toughens.

Skin: at birth, it’s dusky blue, wet and streaked with blood and varying amounts of vernix caseosa. Within a minute or 2 after breathing well, skin color changes to normal tones, beginning with face and trunk and soon reaching fingers and toes. Vernix often remains in skin creases even after bathing. Gently rub it into your baby’s skin – no need to remove. Fair skinned baby often looks blotchy – after a few weeks, his skin has a more even color, although may appear blotchy when cold. Stork bites and angel kisses (red areas formed by a collection of tiny blood vessels near skins surface) also common in fair skinned; often appear on baby’s eyelids, nose, forehead or back of neck. Most aren’t caused by injury and usually fade within 6-9 month. Some on neck may be permanent.

Mongolian spots (areas of dark pigmentation (commonly appear on lower back and butt of Native American, Asian, African or S. European descent (sometimes on thighs or arms). Spots are black and blue but not bruises. Gradually fade and usually gone by 4 years old. Make sure people who care for baby knows they aren’t bruises.

Most have peeling skin, particularly at wrists, hands, ankles and feet. Babies born after due dates peel more. Normal and doesn’t require treatment. If cracks on wrists or ankles bleed, apply skin ointment such as A&D ointment.

Breasts: during pregnancy, hormones may cause baby’s breasts to swell. Some leak milk (both males and females). Doesn’t require treatment. Don’t try to express milk; may cause infection. Usually disappears within a week or 2.

Genitals: hormones during pregnancy can cause baby’s genitals to swell. Can have unusually large red scrotum or milky/bloody discharge for a girl – “pseudo menstrual period”. Discharge indicates she has had a healthy response to your hormones and is now shedding its first lining. Doesn’t require treatment for either sex.

Umbilical Cord: after cut, it’s bluish-white and 1-2 inches long. To stop bleeding, caregiver applies plastic cord clamp or ties umbilical tape around cord. Cord clamp is removed when cord is dry, usually before discharge from hospital or 24-48 hrs after birth. Tape doesn’t have to be removed. Within 1-2 week after birth, cord will fall off.

Newborn’s Reflexes: loud noises, bright lights or quick movements may startle her or make her fling her arms and legs out and straighten her body, especially on her back (moro reflex) – indicates good neurological health. Also firmly grasps finger when you place it on her palm. Stepping/automatic walking reflex occurs when baby alternately moves each food when she’s held upright and her feet bear weight. Baby’s sucking and swallowing reflexes let her eagerly suckled milk from your breast or bottle nipple. May suckle at breast or suck on fingers to soothe herself. Newborn responds to a touch on her cheek or lips by turning toward it and opening her mouth wide – rooting reflex pronounced when hungry. Caregiver checks this in newborn exam. As baby matures, these will disappear.

Baby may yawn, quiver, hiccup, stretch or cry without apparent reason. Most reflexive and beyond baby’s control. Hiccups common soon after feeding and don’t require treatment.

Some reflexes protective. Baby coughs to move mucus or fluid from airway. Sneezes when needs to clear nose or when its irritate or when bright light shines in her eyes. Blinks if something touches her eyelashes and pulls away from painful stimulus such as blood draw from heel. If lying on stomach, she lifts head and turns it to side to avoid being smothered. If something placed over her nose and mouth, she twists away from it, mouths it vigorously or attempts to knock it away with her arms.

Newborn Breathing Pattern: 30-60 breaths per minute, more rapid than you. Periods of irregular breathing – worrisome but normal. When baby sleeps, may snort, squeak, pant, groan, and even occasional pause his breathing. Usually disappear within a month or two. If you observe signs of respiratory distress (blue lips, struggle to breathe, flared nostrils, or deep indentation of the chest with each breath), call caregiver immediately.

Newborn’s Bowel Movements: meconium will be sticky, green black substance that was in her intestines before birth. After 2-3 days, will produce brown, brown-green, or brown yellow stools the consistency of cake batter. After milk has come in (3-4 days after birth), baby will produce yellow, green, or brown stools that are mostly watery but may be curd-like. Fruequency and consistency depends on baby and food she eats. Breastfed typically poop after each feeding or produce at least 2 large runny tool each day after mothers milk has come in. formula fed babies poop frequently in the first several days after birth. When a week old, may produce 1-2 putty like stools each day.

 

  1. Medical procedures and tests

What Happens After the Birth – baby will stay in room at hospital and you’ll be in charge of diaper changes. If give birth at birth center, will leave 3-6 hours after birth. At home, caregiver will leave 3-6 hours after birth. Consult with caregiver about newborn care, or doula, lactation consultant or childbirth educator.

 

Newborn Tests and Procedures – ask your caregiver which tests are routinely performed at your birthplace and which are used only if medically indicated.

  • Apgar Score: evaluates baby’s well being immediately after birth
  • Vital Signs: temperature, heart rate, respiration to determine anything wrong with heart or lungs or if she needs to be warmed.
    • HR for infants is 90-160 beats per minute
    • Respiration is 30-60 breaths per minute
    • Baby should appear pink and breathe easily (without grunting, flared nostrils or deep indentation of chest)
    • Underarm temp is bw 94.7F and 99.5F; if has fever, will be admitted to nursery and may have septic workup and antibiotics. If too cool, will be placed on warm chest and warmed with blankets or under special warming light in room or nursery
  • Vitamin K – injected into baby’s thigh soon after birth to enhance blood clotting and possibly prevent bleeding disorder. Breastfed babies are slower to produce adequate amounts of vitamin K than formula fed babies since formula contains small amounts
  • Eye care/prophylaxis – erythromycin or tetracycline ointment (or rarely silver nitrate drops) is placed in baby’s eyes within an hour to prevent infection and possible blindness if she was exposed to gonorrhea or chlamydia in birth canal – all treatments can cause temporary blurring of vision. In first hour after birth, baby is very alert and wants to gaze at you – wait until after that hour to give treatment. Eye prophylaxis can’t prevent all possible eye infections caused by viruses or bacteria other than chlamydia and gonorrhea
  • Septic workup (only when medically indicated) – baby’s blood is drawn and cerebrospinal fluid may be obtained by spinal taps; samples sent to lab to test for bacteria. Results available in 48 hours. If infection suspected, baby will be admitted to nursery for IV antibiotics. If results normal, antibiotics will be discontinued. If show bacteria, will get full course of antibiotics
  • Jaundice (only when concerns) – baby’s blood is drawn from heel and sent to lab, where bilirubin level is determined. Sometimes, jaundice meter is used to estimate bilirubin levels by flashing a light onto baby’s forehead. If baby’s skin and whites of eyes are yellowing, elevated bilirubin levels suspected. Most jaundice mild and disappears with little or no treatment
  • Hepatitis B Vaccine – immunize against Hep B, a blood borne viral infection that can lead to liver infection, cirrhosis or liver cancer. Side effects rare. Some parents choose to delay, especially if mother is not carrying since baby is highly unlikely to get from usual modes of transmission (drug use/sexual encounters)
  • Hypoglycemia (low blood sugar) – blood drawn from heel. Most common in babies that weigh more than 8 lds 13 ounces or less than 5 pounds at birth, preterm or postterm. Can occur in babies who are cold or whose mothers are diabetic or received large amounts of IV fluids with dextrose during labor. Can lead to respiratory distress, lethargy, slow HR, seizures and (rarely) death. Treatment includes frequent breastfeeding or formula feeding or baby may be given IV dextrose in serious cases
  • Security – policies to prevent kidnapping, properly identified – wrist and ankle bands that match mothers. Staff should have easy to read badges. Hospital have written plan if baby missing (very rare). Having baby in room and never leaving unattended are best ways to keep baby safe.
  • Hearing screening – uses device for 10 min while sleeping – usually for premature, those with family history of hearing deficits or deafness, or exposed to pathogens or medications that put them at risk. Universal screening sometimes because 50% with hearing deficits have no known risk factors
  • Newborn screening – blood drawn from heel for various rare condition screening – affected babies greatly benefit from early diagnosis. Sickle cell anemia, beta thalassemia, phenylketonuria (PKU), hypothyroidism, and galactosemia. 29 conditions- can see state for specifics

Circumcision – surgical removal of foreskin covering glans (tip) of penis. May be oldest known surgery, dating 6000 years, done for social, cultural, religious and medical reasons. Jewish and Islamic communities use circumcision as religious ritual. Common procedure in north America, Africa, middle east. Uncommon in latin America, south America, Europe, Australia and far east. Parents should gather facts and make decision before birth

Facts about Circumcision– few medical reasons. Social/religious factors may guide choice. Takes less than 30 min; healing 7-10 days. Newborn will feel pain. Injection of local anesthesia ro reduce pain – complications rare. Local anesthesia cream less effective than injection. Sucking on special pacifier that delivers amount of sugar water during procedure also may reduce pain. Of 1,000, 2-6 will develop minor to sever complications including irritation of glans from rubbing against wet diapers, painful urination, bleeding, infection and scarring of urinary outlet; health insurance might not cover caregiver’s fee or clinic’s fee; connection between uncircumcised penis and urinary tract infection in first year, but low (1%) – exclusive breastfeeding can reduce UTIs by 300%; no evidence suggests prevention of cancer of prostate gland or STIs. International studies do link circumcision with reduced risk of HIV, however recommends other proven measures such as correct condom use. Opinions differ about whether it affects adult sexual performance. 56% boys circumcised in U.S. in 2003 and dropped to 32.5% by 2009.

Circumcision Procedure– talk about caregiver about risks and benefits, including use of anesthesia. Need to sign consent form before procedure. Baby is placed on back in special plastic bed with Velcro straps holding his body and limbs firmly in place. Receives anesthesia. Penis is washed with antiseptic. Sterile sheet with hole in center placed over trunk. Foreskin is separated from glans and removed by 1 of 3 instruments: gomco clamp, plastibell device or mogen clamp. Takes about 5 minutes and you may be allowed to stay with son.

Care of Circumcised Penis– if mogen clamp or gomco clamp was used, he’ll usually have Vaseline covered gauze applied to site for 24 hours, after which gauze falls off. Watch for bleeding, inability to urinate, or swelling. If observe any signs, call caregiver. If gauze doesn’t fall off, wrap are in warm, moist washcloth or give baby a bath. Once gauze is soaked, apply an ointment, such as A&D ointment or diaper cream on baby’s diaper when it touches his penis to prevent irritation. If plastibel device was used, a small plastic ring will remain on penis, with a suture thread tying foreskin tightly to device. Device and foreskin will fall off 7-10 days after. Do not pull ring off; let it fall off on its own. May see small yellow or white patches of normal, healing tissue. Report any swelling, bleeding, inability to urinate or pus like discharge to baby’s caregiver.

 

Care of Intact (Uncircumcised) Penis– newborn’s intact foreskin doesn’t usually retract (pull back) but instead adheres to the glans. Don’t force back baby’s foreskin to clean the glans. Regular bathing will keep the area sufficiently clean. Foreskin will gradually loosen as he matures. Most boy’s foreskins are fully retractable when between 4 and 8 years old. Once son’s foreskin can be easily retracted, glans can be cleaned with just soap and water.

How Breastfeeding Works– body began preparing for breastfeeding long before you became pregnant. In early teens, increasing amounts of estrogen stimulated growth of ductal system within breasts. Ductal system provides pathways for milk to flow out of nipple. During pregnancy, breasts prepare for lactation through complex interplay of hormones that causes rapid growth of ductal system and lobular system, which is responsible for milk production. Blood supply to breasts supports this growth and delivers the nutrients in breast milk. During 2nd trimester and as early as 16th week of pregnancy, hormone prolactin stimulates production of colostrum (first milk); hormone human placental lactogen (HPL) stimulates breasts to secrete colostrum. After you give birth, progesterone levels fall and prolactin levels increase, triggering breast milk production.

Anatomy of Your Breasts– each breast contains 7-10 milk producing units called lobes. Each lobe contains branches of alveoli (cells that make milk) and milk ducts. Milk flows from alveoli through ducts and leaves breast through 5-10 nipple openings. As baby compresses the areola (darker skin around nipple) with her lips and gums and massages it with her tongue, she draws milk in her mouth. Montgomery glands are the small bumps on areola that secrete a lubricating substance, which keeps nipple supple and helps prevent infection (use only water to clean breasts, soap removes this special lubrication).

Breasts look difference during pregnancy – larger, more visible veins and stretch marks. Areolae may appear larger and darker to help newborn see nipples. Montgomery glands appear larger. Colostrum may leak from breasts or dry into a crust on nipples.

2-6% of women have accessory mammary tissue, extra breast tissue under arm or below breast that may have a nipple. May swell during pregnancy and as milk comes in. if left alone, tissue diminishes but placing cold packs on area may decrease discomfort.

Breast size doesn’t determine quality/quantity of milk. Bigger breasts simply have more fatty tissue surrounding milk producing structures. All sizes and shapes are perfect for breastfeeding.

How Body Makes Breast Milk– prolactin and oxytocin two hormones play significant role. When baby suckles at breast, it stimulates anterior pituitary gland in brain to release prolactin into bloodstream. Prolactin causes cells in alveoli to draw water and nutrients from blood to make milk. Suckling or hear of a cry prompts posterior pituitary gland to release oxytocin. Oxytocin makes muscles around milk-producing cells contract and expel milk. Also makes ducks widen and shorten, helping with milk flow. AKA let down reflex.

2 or more let downs from each breast during each feeding. In first few weeks, may take several minutes after baby has begun suckling. After good relationship established, happens in seconds. Might not feel let down in first few days. Sensations differ – might not feel it, may feel tingling, itching or flowing.   If don’t feel it, you’ll know it occurred if hear baby swallow, see milk in his mouth or feel uterine cramping.

Frequency and duration of feedings strongly affect milk supply. The more your baby suckles and drains from your breast, the more milk you produce. You make less if you delay or limit feedings, use a pacifier, offer supplements (formula, water or other liquids), or schedule your baby’s feedings to every 3-4 hours due to a protein in breast milk called feedback inhibitor of lactation (FIL). When breast is full of milk, FIL slows milk production. When baby frequently drains, there is less FIL and milk production increases.

To help develop a good milk supply, feed baby frequently (in response to his feeding cues) and let him feed for how long he wants.

Composition of Breast Milk– first milk is called colostrum – yellowish or clear syrupy fluid that’s ideally suited to newborn’s needs. It helps speed passage of meconium and establish proper balance of healthy bacteria in baby’s digestive tract. Rich in antibodies, protects baby from infection. Higher in protein than mature milk. You make just over 1 ounce in first 24 hours, which is exactly what baby needs. Volume of colostrum produced increases over the next few days.

Transitional milk has yellowish tint and is higher in fat, calories and volume than colostrum but lower in protein

By end of first week, produce mature milk. Bluish whit liquid looks like skim milk and contains more calories than colostrum or transitional. Volume of milk production has increased substantially. By 5th day postpartum, makes about 15.5 ounces of milk a day. By 3-5 months, make s25 ounces. By 6 months, 27 ounces.

Composition of mature milk varies from beginning of feeding to end. Small amount in early feeding is foremilk. Larger milk with let down is hindmilk, which provides most of the calories and contains more fat and protein.   As baby grows, composition of milk changes to meet baby’s nutritional needs.

Components of Breast Milk– vitamins, minerals, enzymes, hormones and other components make up breast milk.

  • Nonnutritive qualities – protect against disease and promote healthy development. Include anti-infective properties, anti-inflammatory factors, enzymes, hormones and growth factors
  • Water – ~87% of milk. Helps newborns maintain body temp. in very warm climates, still has all the water a baby needs
  • Fats – cholesterol, essential fatty acids, docasahexaenoic acid (DHA) and other fats account for half calories in milk and are necessary for normal development of baby’s nervous system and brain. Fats also aid visual development and enhance the growth of a special coating on nerves as they grow (myelinization)
  • Carbohydrates – lactose (milk sugar), the primary carb, helps a baby absorb calcium. Its metabolized into simple sugars (galactose and glucose) necessary for rapid brain growth
  • Proteins – whey, the primary protein in breast milk, becomes a soft curd when a baby digests it, letter her bloodstream readily absorb the nutrients. (Casein, the primary protein in cow milk and cow milk formula, forms a rubbery curd that babies digest less easily than whey, sometimes contributing to constipation)
  • Vitamins and minerals – breast milk provides almost all the vitamins and minerals your baby needs. All breastfed babies and some formula fed babies need to receive vitamin d supplements. A few babies may need iron supplements and babies at risk of tooth decay may need fluoride.
    • Iron – full term healthy, breastfed baby rarely needs before 6 months because iron in breast milk is in a highly absorbable form, despite its small amount and because during late pregnancy, baby stores up iron
    • Vitamin D – essential for body to absorb calcium and adequate calcium is necessary for bone growth, maintenance of bone density and normal functioning of nervous system. Sever deficiency of calcium can lead to rickets, a disease that causes bone deformities. You make vitamin d when expose skin to sunlight or obtain it by eating foods supplemented with the vitamin. Because safe levels of sun exposure are difficult to determine and hard to obtain in northern climates, caregiver may recommend vitamin D supplementation. Blood test can determine if your levels are adequate. If not enough, can take a supplement with 1000-4000 IU. Or if don’t know your levels, can give baby liquid vitamin d beginning right after birth. AAP recommends breastfed baby consume 400 IU of vitamin D daily. Choose a supplement with only vitamin D. Carlson Baby D drops and Biotics Bio-D Mulsion contain 400 IU in just one drop
    • Fluoride – mineral that protects against tooth decay. Only small amount in breast milk. Natural water in some regions contain it. AAPD recommends that dentist assess teeth before giving them supplemental fluoride.

 

Prenatal Preparation for Breastfeeding– learn as much about breastfeeding as you can before birth. Attend a class, seek support of groups such as La Leche League, Nursing Mothers Counsel, new mothers’ groups, or WIC. Spend time around women who breastfeed to see how they nurse and how they make it part of their busy lives.

Choose caregivers who support. Ask them to assess changes to your breasts, evaluate your nipples, and look for the presence of scar tissue from biopsies or breast surgeries. Most caregivers haven’t had training to assess breasts for breastfeeding so may have to see a lactation consultant.

Lactation consultant is recommended if you’ve had breast surgeries, are expecting more than 1 baby, have had a previous unpleasant breastfeeding experience, or have specific concerns.

Arrange for help during first weeks after birth. Know with time, breastfeeding becomes much easier, more convenient and enjoyable.

Nipple Types and Treatment for Flat or Inverted Nipples– 3 main types. To determine type, place thumb and index finger above and below areola at its edge and gently squeeze them together under your areola.

  • Typical nipples elongate or protrude (Stick out) when squeezed. Most common type
  • Flat nipples flatten or move inward (retract) when squeezed
  • Inverted nipples are tucked into the areola. When squeezed, some protrude while others remain inverted, probably because tiny bands (adhesions) bind the tissue.

If you have flat or inverted, some correction often occurs naturally during pregnancy, as hormonal changes enlarge the nipples and improve their ability to protrude.

If nipples remain flat or inverted:

  • Contact a lactation consultant to help with early breastfeeding
  • Consider using a nipple shield, an ultrathin silicone device that you place over your nipple. When baby sucks on it, he pulls your nipple and milk into his mouth. Don’t use without help of LC
  • Baby’s sucking also helps evert (draw out) your nipple. If baby has difficulty latching on, consider using a breast pump before each feeding to draw out nipples. Also commercial “nipple enhancers” available to draw out nipples (Evert-it or Avent Niplette are 2 brands)

 

Laboratory and Diagnostic Tests

Because newborns experience many transitional events in the first 28 days of life, laboratory samples are often collected to determine adequate physiologic adaptation and to identify disorders that can adversely affect child’s life beyond neonatal period. Blood samples for most lab tests can be obtained from neonate with hell puncture, also known as a heelstick. Tests commonly performed other than blood glucose and bilirubin levels include newborn screening tests and serum drug levels.

Standard Lab Values in a Term Neonate

  • Hemoglobin (g/dl) – 14-24
  • Hematocrit (%) – 44-64
  • RBCs / uL – 4.8 x 10^6 to 7.1 x 10 ^6
  • Reticulocytes (%) – 1.8-4.6
  • Fetal hemoglobin (% of total) – 50-70
  • Platelet count /mm^3 – 150k-300k
  • White blood cells (WBCs) /uL – 9k-30k
  • Bilirubin, total (mg, Dl)* –
    • 24 hr – 2-6
    • 48 hr – 6-7
    • 3-5 days – 4-6
  • Serum glucose (mg/dl)
    • <1 day – 40-60
    • >1 day 50-90
  • Arterial blood gases:
    • pH: 7.35-7.45
    • Pco2: 35-45 mm Hg
    • Po2: 60-80 mm Hg
    • HCO3: 18-26 mEq/L
    • Base excess: -5 to +5
    • O2 saturation: 92-94%

Universal Newborn Screening – mandated by U.S. law, newborn genetic screen is an important public health program aimed at early detection of genetic diseases that result in severe health problems if not treated early. Universal screening program is state-based and involves a variety of components including education, screening, follow-up, treatment and a system for monitoring and evaluation. USDHHS recommends screening for 31 core disorders and 26 secondary disorders. Core disorders include hemoglobinopatheies (sickle cell disease), inborn errors of metabolism (phenylketonuria or PKU, galactosemia), severe combined immunodeficiency and critical congenital heart disease. The majority of disorders included in the screening are not symptomatic at birth. Individual states select additional disorders to include in the screening. The most current list is available through the National Newborn Screening and Genetics Resource Center (NNSGRC) at http://genes-r-us.uthscsa.edu/sites/genes-r-us/files/nbsdisorders.pdf (Conditions Screened by US Programs in Resources under General Info – Papers and Reports, Side Bar. LINK DOES NOT WORK Visit site for your state

Capillary blood samples are obtained from newborn infants using a heelstick; blood is collected on a special filter paper and sent to a designated state lab for analysis. Samples are usually collected in hospital after 24 hrs of age and before discharge; testing may be delayed for sick or preterm infants or those born outside hospital. Screening test should be repeated in 1-2 weeks if initial specimen was obtained when infant was under 24 hrs.

American College of Medical Genetics recommends that states retain residual dried blood filter spots. These are useful for future testing and research purposes. Ethical concerns are related to need for parental consent to retain blood samples and use them for biomedical research.

Families should be educated during prenatal period. However, this is not common practice. In majority of states, informed consent is not required for newborn screening.

Newborn Hearing Screening – hearing loss is the most commonly diagnoses genetic disorder of all the core conditions in the universal screening program. Screening recommended for all newborns before hospital discharge or no later than 1 month of age. Through early detection and intervention programs, the outcome for infants who are deaf or hard of hearing can be maximized.

Using noninvasive technology, it provides info about the pathways from the external ear to the cerebral cortex. 2 tests commonly used; initial screening done with evoked otoacoustic emissions (EOAE) test. Auditory brainstem response (ABR) test used as follow-up if initial screening is abnormal. Neither is definitive in diagnosing hearing loss; they are used to determine whether further, more accurate testing is needed. For EOAE test, a soft rubber earpiece that makes a soft clicking noise is placed in baby’s outer ear. Healthy ear will echo the click sound back to a microphone inside the earpiece. The ABR test is performed by attaching sensors to the baby’s forehead and behind each ear. An earphone is placed in baby’s outer ear and sends a series of quiet sounds into sleeping baby’s ear. Sensors measure responses of baby’s acoustic nerve. Responses are recorded and stored in a computer.

Newborns who don’t pass the initial screening should have hearing screening test repeated as part of follow-up care. If infant still doesn’t pass, a comprehensive audiologic evaluation should be done by 3 months of age. Regardless of outcome of testing, all infants should have regular and ongoing surveillance of developmental, hearing and speech-language skills through regular well-child visits beginning at 2 months so that any hearing loss can be promptly identified and treated.

Screening for Critical Congenital Heart Disease (CCHD) – added to uniform screening panel in U.S. in 2011 and endorsed by AAP. Noninvasive screening test is performed using pulse oximetry to measure oxygen saturation for purpose of detecting hypoxemia. Pulse oximetry testing can detect some critical congenital heart defects that present w hypoxemia in absence of other physical symptoms. Hypoxemia can be first sign that a congenital heart defect is present and other symptoms can develop once newborn has been discharged. Screening performed at 24-48 hrs of age. Oxygen saturation is measured in right hand and 1 foot. Passing result is greater than 95% in either extremity, with a less than 3% absolute difference between upper and lower extremity readings. Immediate evaluation needed if oxygen saturation less than 90%. Baby evaluated for hemodynamic stability and hypoxemia; an echocardiogram is usually performed.

Collection of Specimens – ongoing evaluation and screening of a newborn often requires obtaining blood by heel stick or venipuncture or the collection of a urine specimen. Lab tests may be ordered routinely or for a specific purpose.

Heelstick – most blood specimens are drawn by lab techs. Nurses may be required to perform heelsticks to obtain blood for glucose monitoring, newborn screening or other tests.

Blood samples should be collected in a manner that minimizes pain and trauma to infant and maximizes accuracy of test results. If lab tech collecting, nurse assists.

Helpful to warm heel before; application of heat for 5-10 min helps dilate vessels in the area. Cloth soaked with warm water and wrapped loosely around food provides effective warming. Disposable heel warmers available but should be used w care to prevent burns. Wear gloves. Nurse cleanses area with appropriate skin antiseptic, restrains infant’s foot w a free hand, and then punctures the site. Spring-loaded automatic puncture device causes less pain and requires fewer punctures than a manual lance blade.

Most serious complication is necrotizing osteochrondritis resulting from lancet penetration of the bone. To prevent this problem, puncture is made at outer aspect of heel and penetrates no deeper than 2.4mm. To identify appropriate puncture site, nurse draws and imaginary line form between 4th and 5th toes and parallel to lateral aspect of foot to the heel, where the puncture is made; a 2nd line can be drawn from great toe to medial aspect of the heal. Repeated trauma to walking surface o f heel can cause fibrosis and scarring that can lead to problems with walking later in life.

After specimen collected, gentle pressure applied with dry gauze pad. No further skin cleanser should be applied because it will cause site to continue to bleed. Covered w bandage.

Heelstick is traumatic for infant and causes pain. After several heelsticks, infants have been observed to withdraw their feet when touched. Nurse can reduce procedural pain using a variety of nonpharmacologic techniques including allow mom to hold skin to skin, using non-nutritive sucking with our without sucrose, or swaddling the neonate. Neonate should be cuddles and comforted when procedure is complete and appropriate pain management techniques taken.

Venipuncture – occasionally lab tests ordered that require larger samples of blood than can be collected with a heelstick. Venous blood samples can be drawn from antecubital, saphenous, superficial wrist, and rarely, scalp veins. When venipuncture is required, positioning of needle is extremely important. 23 or 25 gauge butterfly needle or hypodermic needle w syringe is used. Patience required because blood return in small veins is slow and consequently the small needle must remain in place longer than a larger needle. A tourniquet is optional but can help increase blood flow; infant is carefully restrained during procedure to prevent injury. If venipuncture or arterial puncture is performed for blood gas studies, crying, fear and agitation will affect values; every effort must be made to keep infant quiet. Pressure must be maintained over an arterial or femoral vein puncture w a dry gauze square for 3-5 min to prevent bleeding from site.

For an hour after, nurse observes infant frequently for evidence of bleeding or hematoma formation at puncture site. Infant is cuddle and comforted.

Urine Specimen– the way in which specimen is collected can influence results. Sample should be fresh and analyzed within 1 hr of collection.

Interventions

Protective Environment – current trends focus on non separation of moms and babies (rooming-in) have prompted some hospitals to abandon having a separate nursery.

Infection Control Factors – positioning of bassinets at least 3 ft apart in all directions, hand hygiene facilities and areas for cleaning and storing equipment and supplies. Only specified personnel directly involved in care of moms and infants allowed in these areas, thereby reducing opportunities for transmission of pathogenic organisms.

Hand hygiene should be performed before and after touching infant, before an invasive procedure or medication administration, after contact w potentially contaminated objects (computer keyboards, telephone, countertop surfaces) and after removing sterile or non sterile gloves.

Health care workers must wear gloves when handling infants until blood and amniotic fluid have ben removed from skin, when drawing blood (heelstick), when caring for fresh wound (circumcision) and during diaper changes.

Individuals with infectious conditions excluded from contact w newborns or must take special precautions. Includes people with upper respiratory tract infections, gastrointestinal tract infections and infectious skin conditions.

Preventing Infant Abduction – special limited entry systems. Nurses teach moms and families to check identify of any person who comes to remove baby from room. Personnel usually wear picture id badges. Some unites wear matching scrubs or special badges.

Preventing Newborn Falls – likely underreported. Approx. 600-1600 falls occur each year in U.S. hospitals. Most when mom falls asleep while holding newborn in bed or in reclining chair, although some falls occur at birth or when infant is transported. Infants who fall, even from low level surfaces such as beds or chairs, are at risk of sustaining head injury that can include skull fracture. Parents may hesitate to report due to feelings of guilt and fear of reproach from staff members.

Nurses can identify risk factors such as maternal medications (opioids) that cause drowsiness. Place newborn in supine position in bassinet for sleep. Bed sharing controversial because promotes bonding. Infants should not be placed on couches or armchairs, whether or not a parent is present. Newborns always transported in bassinets and never carried outside mothers room.

Therapeutic and Surgical Procedures

Intramuscular Injection – newborns routine receive IM injections before discharge. Single dose of vitamin K is administered shortly after birth and Hep B administered before discharge. Other IM injections may be ordered, such as dose of HepB immune globulin for infants born to mothers who are positive for HepB.

24 gauge, 5/8 inch needle used. Must be given in muscles large enough to accommodate medication, and major nerves and blood vessels must be avoided. Muscles of newborns may not tolerate more than .5 ml per IM injection. Preferred injection site is vastus lateralis. Dorsogluteal muscle is very small, poorly developed and dangerously close to sciatic nerve, which occupies a proportionately larger area in infants than in older children. Newborn’s deltoid muscle has an inadequate amount of muscle for IM administration. Key factor in preventing and minimizing local reaction to IM injections is adequate deposition of medication deep within muscle; therefore, muscle size, needle length and amount of medication injected should be carefully considered.

Nurse wears nonsterile gloves. Neonate’s leg should be stabilized. Cleanses injection site with antiseptic then stabilizes muscle between thumb and forefinger. Needle inserted into vastus lateralis at 90 degree angle. Medication injected slowly.

Needles never recapped but properly discareded in appropriate safety container. Name of medication, date and time, amount, route and site of injection documented in newborns record.

Hep B Vaccine (Recombivax HB, Engerix-B) – protective anti hep B antibodies in 95%-99% of healthy infants who receive recommended 3 doses. Duration of protection unknown. Immunized against infection caused by all known subtypes of virus. Usual dosage is Recombivax HB 5 mcg/.5 ml or Engerix-B 10 mcg/.5 ml intramuscularly at birth, at 1-2 months and at 6-18 months.

Common adverse reactions are rash, fever, erythema, swelling, and pain at injection site.

Nursing Considerations:

  • Parental consent must be obtained. If infant needs Hep B immune globulin (HBIg), use separate sites for 2 injections
  • For moms w neg HepB status, administer vaccine before discharge
  • For those with Hep B antigen (HBsAG) positive moms, administer within 12 hrs of birth
  • For those w moms unknown status:
    • <2000 g: administer HepB vaccine and HBIG w/in 12 hrs after birth
    • >2000 g: HepB vaccine w in 12 hrs; if results positive, give HBIG by 1 week of age

Immunizations – infants at highest risk for contracting HepB are those born to women who have it or whose status is unknown

Hep B Immune Globulin – provides high titer of antibody to Hep B surface antigen. Provides prophylaxis against infection of those born to Hep B positive moms. .4 ml dose intramuscularly w in 12 hrs of birth.

Circumcision – removal of all/part of foreskin ((prepuce) of penis usually performed during first few days of life but sometimes done at later time for preterm or ill neonates or for religious or cultural reasons.

Rates peaked at 64.5% in 1981, dropping to low of 55.4 in 2007. Increased slightly to 58.3% in 2010.

AAP policy 1999 and 2005 says potential benefits not sufficient to recommend to recommend routine circumcision. 2012- “Evaluation of current evidence indicates that health benefits of newborn male circumcision outweigh risks and that procedures benefits justify access to procedure for families who choose it.” Health benefits include prevention of UTI in male infants younger than 1, reduced risk for penile cancer, and reduced risk for sexually transmitted infections, particularly HIB. Still does not recommend routine circumcision.

WHO recognizes importance in reducing risk for HIV in men.

Opponents feel it is unnatural and unnecessary and it violates basic human rights. Complications such as hemorrhage, infection and penile injury (removal of excessive skin, damage to meatus or glans) and long-term implications such as adverse effects on sexual function and please. Websites such as www.intactamerica.org discourage parents from circumcising newborn sons.

Parental Decision – parents usually decide for 1 or more of following reasons: hygiene, religious conviction, tradition, culture or social norms. Cost and insurance coverage also considerations.

Expectant parents need to learn during prenatal period, but often not discussed with parents. In many instances it is only when mother is being admitted to hospital or birthing unit when confronted with decision. Because stress of intrapartum period makes this a difficult time for decision making, its not an ideal time. Requires informed consent

Procedure– not performed immediately after birth because of danger of cold stress and decrease clotting factors but usually done before discharge. Jewish males on 8th day in ceremony called bris; timing is logical from physiologic standpoint because clotting factors decrease somewhat immediately after birth and do not return to prebirth levels until end of 1st week.

Feedings may be withheld up to 2-3 hrs before circumcision to prevent vomiting and aspiration, although in some hospitals, infants allowed to breastfeed until ready. Positioned on plastic restraint form ; penis cleansed w soap and water or antiseptic such as povidone-iodine. Draped to provide warmth and sterile field and sterile equipment readied.

Usually performed using Gombo (Yellen) or Mogen clamp or PlastiBell. Takes only a few minutes. Clamp technique minimizes blood loss. Small petrolatum gauze dressing applied for first 24 hours; then parents instructed to apply it to keep penis from adhering to diaper. With PlastiBell, plastic rim remains in place for a bout a week and falls off after healing has taken place, usually within 5-7 days. Petroleum dressings not applied with PlastiBell.

Procedural Pain Management – Circumcision is painful. Pain characterized by physiologic and behavioral changes in infant. 4 types of anesthesia and analgesia used: ring block, dorsal penile nerve block (DPNB), topical anesthetic such as eutectic mixture of local anesthetic (EMLA) (prilocaine-lidocaine) or LMX4 (4% lidocaine) and concentrated oral sucrose. Nonpharmacologic methods such as nonnutritive sucking and swaddling can be used.

Cochrane group found DPNB most effective intervention for decreasing pain. Includes subcutaneous injections of buffered lidocaine at 2 o clock and 10 o clock positions at base of penis. Ring block is subcutaneous injection of buffered lidocaine on each side of penile shaft. Should not be performed for at least 5 min after injections.

EMLA cream can be applied at least 1 hr before circumcision. Just before procedure, cream Is removed.

Infant can be fussy for several hrs and have disturbed sleep-wake states and disorganized feeding behaviors. Some infants will go into a deep sleep after circumcision until awakened for feeding. Liquid acetaminophen 10-15 mg/kg may be administered orally after procedure and repeated every 406 hrs for max of 30-45 mg/kg/24 hrs.

Care of Newly Circumcised Infant – protocols vary. Site assessed for bleeding every 15-30 min for 1st hr and hourly next 4-6 hrs. Nurse monitors urinary output, noting time and amount of first voiding after procedure.

If bleeding occurs, nurse applies gentle pressure w folded sterile gauze pad. Hemostatic agent such as Gelfoam powder or sponge can be applied to help control bleeding. If bleeding not easily controlled, blood vessel may need to be ligated.

Newborns typically cry when diaper changed and when petrolatum gauze removed and reapplied.

Care of Circumcised Newborn at Home

  • Wash hands
  • Check for bleeding w each diaper change
  • If bleeding occurs, apply gentle pressure w sterile gauze. If doesn’t stop, notify dr
  • Check to see infant urinates; should have wet diaper 2-6x per day the first 1-2 days and then 6-8x per day after 3-4 days
  • Change diaper and inspect every 4 hrs
  • Wash w warm water to remove urine and feces. Apply petrolatum to glans with each diaper change. Do not use baby wipes because contain alcohol
  • Do not was w soap until healed (5-6 days)
  • Apply diaper loosely to prevent pressure on circumcised area
  • Glans penis is dark red and becomes covered w yellow exudate in 24 hrs, which is normal and will persist for 2-3 days. Do not attempt to removed it.
  • Redness, swelling, discharge or odor indicates infection. Notify dr
  • Handle area gently
  • Provide comfort measures – skin to skin, cuddling, swaddling, rocking
  1. Adaptation to environment: skin to skin is best

Your Baby’s Birth– 2nd stage of labor ends with baby’s birth. If baby’s position is head down (occiput anterior or posterior), first the crown of his head emerges, followed by his brow, and face. Head appears bluish-gray and is soaking wet. After head is out, it rotates to the side to allow his shoulders to slip more easily through pelvis. One shoulder emerges, followed by rest of body, perhaps rather quickly. You or partner may want to catch baby.

Baby’s body may appear bluish at first and streaked with blood, mucus and vernix caseosa (white, creamy substance that protects baby’s skin in womb). Skin color becomes normal with baby’s first breath. All babies, regardless of color, experience this color change as respiration and circulation become stable.

Birthplace policy may require that baby have nose and mouth suctioned immediately after birth. However, studies find that healthy vigorous newborns don’t benefit from the procedure. Discuss your preferences in birth plan.

While awaiting delivery of placenta, baby may be dried and immediately placed on mom’s abdomen or in mom’s arms. Umbilical cord is typically clamped and cut around this time; however, there are long-term advantages for you baby if cord clamping is delayed. Some hospitals assess a newborn’s well being while in baby warmer in birthing room. However, research shows newborns are warmer and begin breastfeeding earlier when kept skin-to-skin with mothers; and most women report greater satisfaction when they have their babies immediately after birth. In birth plan, express preference to hold baby immediately after birth (if he’s doing well). Caregiver can assess baby while he’s in your arms or at a later time after he’s had at least an hour of skin to skin with you.

Your Reactions After the Birth– may feel grateful contractions and delivery is over and baby is out of body, and this may overtake your interest in baby, especially if you’ve had a long, tiring labor.

Or you may temporarily forget about you labor and birth the moment you see or hear your newborn. You may be surprised or awed by your baby’s appearance. May hold your breath in suspense until you hear baby breathe, smiling with relief and joy when you hear her first cry.

If caregiver needs to inspect perineum to check for separation of placenta, you may find procedures painful and distracting.

Note to Partners- birth of baby requires great physical effort, even if she’s had an epidural. Ways to assist during this stage: help her change positions and physically support her as needed, encourage her to relax her pelvic floor as she pushes, cheer her on as she pushes, but don’t override caregiver’s directions.

When baby is born, you may experience happiness, exhaustion, relief, wonder, joy and love for your partner and baby – all at the same time. Baby becomes focus of your attention.

If baby can’t remain in partner’s arms immediately after birth, stay with him so you can report what you see being done to him to your partner. Talk to your baby; he knows your voice and hearing it calms him.

Third Stage of Labor: Delivery of Placenta– lasting between 10 and 30 minutes, 3rd stage is shorter and less painful than earlier stages. Begins with birth of baby and ends when placenta is delivered.

What to Expect– after baby is born, contractions stop briefly, then resume with the purpose of separating the placenta from your uterine wall. Typically less intense than before birth, but may still need relaxation techniques and rhythmic breathing. May be so engrossed with baby that you don’t notice contractions. Caregiver may direct you to give a few small pushes to deliver placenta. May appreciate seeing placenta after delivery as it’s an amazing organ that allowed your baby to thrive in your womb.

Newborn Assessment with Apgar Score– within 1 minute after birth and again at 5 min, caregiver evaluates baby’s well being. As soon as baby is breathing and dried off, caregiver considers 5 factors and gives a score of 0 to 2 points for each. Score of 7-10 indicates baby is in good condition. Score of 6 or less means baby needs additional medical attention and observation.

Can be done while you hold baby. Babies rarely receive a 1- on first score (most babies hands and feet are bluish for a while after birth). If score 6 or less, may have to go to baby warmer or oxygen. 2nd score is usually higher than 1st score, indicating improvement with time or medical assistance.

Helps determine if baby needs immediate medical attention, but can’t predict baby’s overall health or long term well being. More thorough exam will be done within 24 hours of birth to more accurately assess baby’s condition.

Apgar Score

  • HR – Absent (0); <100 BPM (1); >100 BPM (2)
  • Respiratory effort– Absent (0); Slow, irregular (1); Good, crying (2)
  • Muscle tone– Limp (0); Arms and legs flexed (1); Active movement (2)
  • Reflex irritability (reaction to something placed in nose) – No response (0); Grimace (2); Sneezing, coughing, pulling away (2)
  • Skin Color– Bluish-gray, pale all over (0); Normal skin color, except for bluish hands and feet (1); Normal color all over (2)

Clamping and Cutting Umbilical Cord– soon after birth, baby’s umbilical cord is clamped and cut with scissors; partner may cut cord

Timing of cord clamping an cutting affects baby’s blood volume. Before birth, baby’s blood circulates via the cord to and from the placenta, allowing the exchange of oxygen, nutrients and other substances. At birth, 1/3 or more of baby’s blood is in placenta, but over the first few minutes, it transfers to your baby. The blood vessels in the cord are gradually compressed by a substance called Wharton’s jelly, which expands when cord is exposed to air. If cord is clamped immediately (which is still common practice), baby doesn’t receive a large portion of the blood from the placenta. Delaying clamping until cord stops pulsating allows baby to receive as much blood as possible. Some blood remains in placenta after pulsation stops.

For years, OBs taught that placenta blood is “extra” and if it got to baby, it could cause jaundice. This belief has been disproved. Delayed clamping benefits baby by helping increase blood levels of iron and reduce anemia from 2-6 months. May also hasten separation and delivery of placenta by decreasing its size.

To achieve optimal blood volume, baby is placed on mother’s abdomen (level with the placenta) until cord stops pulsating. Then it is clamped and cut. Holding baby high above or low below the mother may alter the speed of transfer of blood that passes between placenta and baby, but placement on mother’s abdomen is the most physiologic and seems appropriate under most circumstances.

In challenging situations, baby may benefit even more from delayed cord clamping. Some hospitals wait a few minutes to clamp and cut cord after a cesarean. For a baby who needs medical attention or resuscitation, these procedures can often be carried out with the cord intact so the baby, while remaining next to his mother, continues to benefit from oxygenated blood transferring to him. Discuss preference with caregiver and put in birth plan.

Collection and Storage of Umbilical Cord Blood– blood in umbilical cord is rich source of stem cells, which generate and continually renew supplies of red cells, platelets and white cells. Stem cells make it possible for a person to use oxygen, clot blood, and fight infection. Those found in umbilical cord are easier to match to another person’s tissue than mature stem cells found in bone marrow. They can be used to successfully treat people with disease such as immune deficiencies, severe inherited anemia and childhood leukemia and other cancers. They are also used in the search for cures of these diseases.

Some parents consider having babies’ cord blood collected and stored. It’s done after baby’s cord is cut and is accomplished most successfully within 10 minutes of birth, which means that baby still benefits from delayed cord cutting. After collection, stem cells are separated from blood in a lab and stored either in a blood bank for use by the public or in a private storage facility for later use, if needed, by the child or her family.

AAP encourages parents to donate cord blood to public and cautions against using private cord banks because more conditions that they may treat (such as precancerous changes and genetic abnormalities) already exist in baby’s cord blood, which means that her stored cord blood stem cells won’t treat the condition if she develops it later. Its also expensive. Public donated blood is tested for disease and genetic abnormalities before being approved for use. Do research before due date.

Fourth Stage of Labor: Recovery– begins just after placenta is delivered and lasts until your condition is stable, typically an hour or 2 after birth. This stage may last longer if you had anesthesia, if you labor was difficult or prolonged, or if you had a cesarean birth.

After delivering placenta, caregiver checks perineum and birth canal for bleeding. If had vaginal tear or episiotomy, tissues are stitched to speed healing (lasts <30 min). Unless given anesthesia in labor, will receive a local anesthetic by injection before perineum is stitched. Should be painless, but injection may sting and may need to use rhythmic breathing. If perineum is intact or have shallow tear, don’t need stitches, but area may become swollen or bruised. Whether have stitches or not, will appreciate an ice pack placed on perineum to reduce any swelling and relieve discomfort.

After birth, uterus begins process of involution (returning to nonpregnant size); it continues to contract, which close blood vessels where placenta was implanted in order to prevent excessive blood loss and to prompt the shedding of the uterine lining that build up during pregnancy. You pass lochia, the heavy red discharge made of the extra blood and fluid that supported your pregnancy and the uterine lining that sustained your baby. Maternity pad is necessary.

Once placenta is delivered, caregiver checks uterus frequently to make sure it remains firm. If uterus is relaxed, she massages it firmly, causing it to contract and preventing excessive blood loss. Uterine (or fundal) massage can be painful, and you may want to do it yourself to control the amount of pressure and perhaps reduce pain to a tolerable level.

How to Massage Uterus – empty bladder. Lie on back and check uterus by pressing on area below navel. If uterus feels as firm as a grapefruit, you don’t need to massage it. If cant feel uterus, it has relaxed and softened. With one hand slightly cupped, massage lower abdomen firmly with small circular movements until you feel you uterus contract and become firm. This action may be painful. If can’t make uterus contract, tell caregiver. Because uterus can bleed excessively if it’s not firm, don’t skip this on the first couple days after birth. Afterward, you may periodically check to see if it needs massage.

Contractions during involution may be painful, especially if have given birth before. Although these afterpains are common and aren’t nearly as intense as labor contractions, you may need to use slow breathing to help manage.

After baby’s birth, legs may tremble, which is normal. Warm blanket may reduce trembling. May have missed meals during labor, so eat and drink to satisfy hunger and thirst.

This stage gives you a chance to get to know your baby without disturbances and to let him nuzzle at your breast. Most babies are ready to suckle within 20-60 minutes after birth.

Baby’s Hormones in 4th Stage– baby’s stress hormones (catecholamines) after birth stimulate her adaptation to life outside womb. They absorb fluid in her lungs so she can breathe easily, jump start her ability to regulate her temperature and make her alert and heighten her reflexes for the first few hours, during which time she begins feeding, exploring her world and seeing you for the first time.

During labor, baby produces beta-endorphins; after birth, she produces prolactin. She also begins producing oxytocin in synchrony with you. These 3 hormones help strengthen the bond between you, increase her interest in breastfeeding, and stimulate you to care for her. Other people can produce oxytocin too – to a lesser degree-by holding baby skin to skin, keeping eye contact and caring for her. By snuggling with baby after birth, skin-to-skin allows for mutual regulation of hormones as you adjust to new life together.

Entering Parenthood– this new role, along with other postpartum changes, may overwhelm you or bewilder you.

Enjoy baby’s first hours of awake time. He’s likely alert, calm and bright-eyed as he begins observing and sensing new sounds, smells, sights, touches and tastes. If light isn’t too bright, he’ll stare, particularly at your face (dim lights if too bright). These moments are time for falling in love with each other. Include partner.

Family-centered and baby-friendly hospitals encourage parents and babies to stay together as much as possible, unless problems develop. Caregiver performs routine observations or procedures while in mom’s arms. Check hospital – if caregivers routinely send healthy newborns to nursery, ask to issue an order to delay or bypass your baby’s admission.

A few hours after birth, baby will fall into a deep sleep. Someone who’s alert should periodically observe baby’s vital signs and yours, including skin color, pulse, respiration, blood pressure and temperature. In the hospital, nurse does this job. At home birth, midwife or birth assistant takes on job before passing on to rested friend or relative.

Processing Birth Experience– it isn’t over until you’ve had a chance to think about and understand it. Will become one of most vivid and poignant memories. Compare and contrast your feelings, thoughts and impressions with those who attended birth, getting answer to any question and look at photos. Write story or draw or paint a picture of it – each is a great way to preserve the special memory for you and your child.

Processing it may takes weeks, months or even years. If it was particularly difficult or disappointing, processing it may take longer. Dealing with a difficult birth may also bring up strong, disturbing feelings. If this is the case for you, talk with your caregiver, doula, childbirth educator or a counselor knowledgeable about childbirth.

 

Position in 1st Stage of Labor – indirect consequences to breastfeeding of maternal nonvertical position included longer labor w delayed onset of lactogenesis, compromised fetal oxygenation, excess molding of baby’s head, fetal distress, and more mechanical forces on fetal cranium. 1st stage may be ~1 hr shorter for women who are upright or walk around.

Many mothers instinctively assume a position that favors effect and comfortable labor. If fetal head is OP, assuming hands and knees can help fetal head rotate to OA for easier delivery. Labor with persistent OP can be more painful due to increased pressure on sacrum, leading to increased need for pain medication. Malpresentation and laboring without gravity is likely to result in prolonged labor, possible use of oxytocin augmentation, additional pain medication, and often an assisted delivery or cesarean surgery. All of these can impair early, effective breastfeeding.

 

Restoration and Recovery – for breastfeeding to succeed, the newborn must have access to mom many hours a day; be able to cue for feeds; and suck, swallow and breathe in a coordinated pattern. Mom’s body must heal and recover; her breasts must make milk and she must be supported in her close, frequent-contact relationships with her baby. BFHI’s (Baby Friendly Hospital Initiative) supports evidence based care of exclusive breastfeeding for 6 months followed by breastfeeding with appropriate complementary foods for 2 years or beyond.

The 3 most important and urgent post-birth strategies to support breastfeeding are 1) skin-to-skin 2) skin-to-skin and 3) more skin-to-skin. Separating the mother-baby dyad for any reason except resuscitation is unjustified and harmful to both.

AAP says baby should be placed immediately after delivery on mom’s chest until first feeding is accomplished. The alert, healthy newborn is capable of latching on to a breast without specific assistance within the first hour of birth…dry the infant, assign APGAR scores and perform initial physical assessment while infant is in skin-to-skin contact with mother. Mother is optimal heat source for baby. delay weighing, measurement, bathing, needle sticks and eye prophylaxis until after first feeding is complete.

Original Step 4 of 10 Steps to Successful Breastfeeding is “help mothers initiate breastfeeding within a half hour of birth”. Says to put baby for at least an hour and encourage moms to help baby if needed. Immediately is interpreted as within 1 min after birth, without placing the infant anywhere else first.

Newborns born with behavioral capability to breastfeed, regulated by limbic system of the brain. However, this capability is fragile, and requires uninterrupted presence of mother, with specific stimuli at early critical periods working to reinforce the inborn ability.

The simple action forms the foundation of neurodevelopment of the infant and mother. The mother’s body forms the baby’s habitat – the place where inborn behaviors can unfold normally. The mother’s body provides rich sensory input: auditory, gustatory, olfactory, proprioceptive, tactile and visual. Senses of smell and touch are esp powerful triggers of infant and maternal behavior, because the nerve fibers lead directly to the amygdala, the seat of emotional memory and fear conditioning. The newborn’s sense of smell is esp acute in the first hours, triggering breast-seeking behavior and movements. Washing or bathing mother or baby removes olfactory cues that support breastfeeding and attachment, and thus should be avoided. Bathing newborns shortly after birth increases risk of hypothermia, despite use of warm water and STS care for thermal protection of newborn.    Hypoglycemia increases risk of baby beging given unnecessary prelacteal feeds, which compromises initiation of breastfeeding.

Time immediately after birth – infant’s catecholamine levels are high, pupils are dilated, reflexes are keen, and newborn is in wide-awake, alert state. Newborns in skin-to-skin (STS) contact exhibit specific coordinated patterns of newborn hand and sucking movements and massage of mother’s breasts, crawl or scoot toward breast, and begin feeding effectively.

Skin-to-skin, ventral-to-ventral contact between mom and baby triggers a flood of hormonal changes, esp releasing oxytocin, which builds trust, fosters caregiving behaviors and memory, and releases milk to the newborn. Tactile contact increases gastrin secretion in mom and baby, promoting gastrointestinal motility and digestion.   Mom’s body and breasts will increase or decrease in temp to keep newborn appropriately warm. Thermal instability is a common reason for separating mom and baby and may cause or exacerbate hypoglycemia and result in inappropriate supplementation.

Mother’s position immediately after birth also matters. She should be assisted into a position of her choice to hold and examine baby. Primitive neonatal reflexes that stimulate breast-seeking and breastfeeding behaviors are highest when mother is in semi reclining (not supine) posture. 24 hr rooming in w safe bed sharing strongly supports breastfeeding. Newly delivered mothers can and should eat and drink a wide range of nutritious foods. Postpartum mothers can and should be offered pain-relieving medications for any surgeries or injuries sustained during birth, because most of theses compounds transfer poorly to human milk.

Risks of Separation, Pain and Newborn Procedures that Affect Feeding – infant’s oral cavity is very sensitive and if infant crawl to breast and latches unassisted, an effective and comfortable suck-swallow-breathe pattern is established. Although routine suctioning has been standard for years, no research supports for a vigorous infant. Even when meconium is present in amniotic fluid, suctioning is no longer recommended and does not prevent meconium aspiration syndrome. Study of meconium-stained infants found 3.8% of intubated group had “mild and transient” complications including bradycardia, hoarseness or stridor, larynogospasm, apnea, bleeding at vocal cords and cyanosis. Theses often result in separation from mother. AAP recommends avoiding procedures that may interfere w breastfeeding or that may traumatize infant, including unnecessary, excessive and overvigorous suctioning of oral cavity, esophagus, and airways to avoid oropharyngeal mucosal injury that may lead to aversive feeding behavior. Even the timing of clamping of the umbilical cord affects breastfeeding, because early clamping increases infant’s risk of anemia, a rationalization for formula for supplementation in the first 6 months.

AAP policy recommends delaying weighing, measuring, bathing, needle-sticks and eye prophylaxis until after first feeding is completed. Infants affected by maternal medications may require assistance for effective latch-on.

One study reported circumcision had a negative effect on early maternal-infant interactions and many anecdotal reports of infant refusal to breastfeed after being circumcised exist. Others show no evidence of association.

Separated babies cry longer and harder than babies in skin-to-skin contact. Prolonged crying raises bp, increases intracranial pressures and reduces oxygen in circulating blood. Crying resembles the Valsalva maneuver, obstructs venous return and can reestablish fetal circulation, shunting blood through a reopened foramen ovale in the newborn’s heart during the first 4-5 days of life. Separated babies in cots or warmers are colder, have more irregular cardiac and respiratory rhythms and have more interrupted sleep that those in skin to skin contact. Crying triggers stress and insecurity in mothers regarding breastfeeding sufficiency.

Separated and swaddled babies in cot cried more, and had lower body temp and lower blood sugar 90 min postpartum. The distress calls of separated babies led to crying in other babies. Cry of separated babies was a discomfort cry according to sound spectrography.

Poor feeding may indicate intracranial bleeds. Documented bleeding related to vacuum extractor use by conducting CT scans on infants w negative US scans were exhibiting apnea, disturbances in suck and swallow, poor tone, tremors and jerks.

Separation destabilizes newborns, esp vulnerable preterms. Yet, majority of babies still not in moms arms after birth. In 2002 Listening to Mothers Survey, 60% were not in moms arms in 1st hour; in 2006, 66% weren’t in mom’s arms. Separated babies do not initiate breastfeeding effectively.

Denial of opportunity to exercise inborn behaviors may have more adverse consequences for development. Because mother so clearly frames the infant’s social world, her emotional state will be of importance to the infant’s optimal development even at this early stage of life. Practices that optimize her well-being are likely to have consequences for both.

Cesarean surgery and operative births have a negative impact on skin-to-skin, even in Baby-Friendly facilities. There has been an effort to ensure cheek-to-cheek contact and gazing time at BFHI hospitals. In U.S, its usually father who is first to hold and snuggle a cesarean section born infant. Although skin-to-skin w a family member is a better alternative than nursery, may foster rationalizing that early mom-baby contact can wait.

See video Delivery Self-Attachment (5:51):

Breast Crawl (importance of uninterrupted contact bw mom and newborn) – scenes based on study published in Lancet 1990. 72 mom-infant pairs put into groups, babies from medicated & unmedicated moms in each group. Babies in 1st group left naked on mom’s abdomen for 1 hr – they began crawling after ~20 min & were suckling by 50 min. Babies born in 2nd group after medicated labor didn’t all crawl to breast; some that did, suckled poorly.

Baby removed for cleaning & measurements after 20 min; medicated labor – infant senses no direction to the breast even when mother tries to help. Baby never self-attaches.

Babies in 2nd group who were separated from mom but unmedicated displayed poor suckle in half of the cases. If babies were both separated and medicated, none of them managed to suckle well.

Stepping/crawling reflex enables newborn to crawl to breast. A baby can crawl to the breast for several weeks after birth or as long as the reflex is intact.

To facilitate suckling, drugs given to mother in labor should be restricted & newborn babies should be left undisturbed w mother until read for first breastfeeding

———————————————————————————

Separating during postpartum showed an association with less affectionate maternal behavior and more frequent feelings of incompetence and lack of confidence. Delays of mothers first opportunity to hold her infant has short and long term consequences with the mother’s normal beneficial gut and skin bacteria prevents colonization by pathogenic bacteria prevalent in most hospitals and hospital personnel. Delay in first holding is associated w elevated mood disturbance in the postpartum period, and persists at least 8 months. If separation undermines breastfeeding, the baby is at increased risk of abuse or neglect.

 

Helping Parents Recognize, Interpret and Respond to Newborn Behaviors

Nurses can teach the following:

  1. Identify 3 newborn zones
    1. Resting Zone – sleep states
      1. Still/deep sleep – baby is completely still. Breathing is regular. No spontaneous activity. No movement of eyes and eyelids stay shut. No vocalizing. Muscles totally relaxed
      2. Active/light sleep: baby may wiggle or vocalize. Eyes may flash open. Baby may make sucking movements- but still be asleep
    2. Ready zone – alert state- baby’s eyes are bright. Baby can focus on an object or person. Baby reacts to stimulation. Motor activity is minimal.
    3. Rebooting zone – fussy/crying state – baby’s motor activity increases and is jerky. Baby is less responsive and moves from fussing to crying
  2. Identify signs of stress – SOSs (Signs of Over-Stimulation)
    1. Body SOSs – changes in color (becoming more red or pale); changes in breathing (more irregular/choppy); changes in movement (jerky/more tremors)
    2. Behavioral SOSs – spacing out, switching off, shutting down
    3. When baby shows an SOS, parents should decrease stimulation (quiet ones voice, glance away from baby, encourage baby to suck finger/mom’s breast, swaddle baby, skin to skin)
  3. Help baby sleep well (distinguish between active/light sleep and still/deep sleep)
    1. Prepare baby to sleep – swaddling may help, feed in quite, dark room at night and active, light environment during day
    2. Get baby to sleep – put baby down for sleep while he/she still awake
    3. Help baby stay asleep – don’t pick up during active/light sleep
  4. Help baby eat well
    1. Recognize early sings of hunger – wiggling, making sucking movements, bring hand to mouth
    2. If baby spaces out or shuts down when trying to eat, bring baby skin to skin and decrease stimulation
    3. Don’t wake baby from deep sleep to eat (light sleep okay)
  5. Help crying baby; consider “TO DO”
    1. T: Talk quietly in sing-song voice
    2. O: Observe to see if baby takes self-calming actions, brings hands to his/her mouth, makes sucking movements or moves into fencing reflex
    3. DO: Bring baby’s hands to his chest; encourage sucking; make gentle shooshing sounds, swaddle baby and bring skin to skin
  6. Play with baby so he/she can learn and grow
    1. If SOS occurs, decrease stimulation

Discharge Planning and Parent Education – infant care activities can cause anxiety for new parents. Avoid trying to cover all content at one time because parents can be overwhelmed and become more anxious. Reliable websites – www.healthychildren.org. Nurse follows parent’s cues. Knowledge deficits or gaps should be identified.

Cultural Considerations – some Asians, Hispanics, E. Europeans and N. Americans delay breastfeeding until mothers milk is in (day 3 or 4)because they believe colostrum is bad. Some Hispanics and African Americans place a belly band over infant’s umbilicus. Some Hispanics have infants wear a special bracelet to protect them from evil eye (mal de ojo).   Birth of male child generally preferred by Asians and E. Indians, and some Asians and Haitians delay naming infants. Families of Hindu heritage name baby on 11th day during cradle ceremony. Some women from India keep cord of male as good omen that will ward off evil and bring more male infants in future. Skin to skin may conflict with cultural beliefs about thermoregulation; some women from Africa prefer that newborn is wrapped prior to being placed on mothers chest. Women from Mexico are wrapped in warm blankets after birth and wrap newborn insider their blankets. Cultural beliefs influence when newborn is taken out of house, such as after cord falls off or after mother’s confinement period is over (approx. 30 days after birth). Weighing infant can raise concerns for some women such as those from rural India, who may believe frequent weighing will slow infant’s growth.

Temperature:

  • Causes of changes in body temp (overwrapping, cold stress with resultant vasoconstriction, or minimal response to infection) and body’s response to extremes in environmental temp
  • Ways to promote normal body temp, such as dressing appropriately and protecting from sunlight
  • Use of warm wraps or extra blankets in cold weather
  • Taking axillary temp, and normal values
  • Signs to be reported – high/low temps with accompanying fussiness, lethargy, irritability, poor feeding and excessive crying

Respiration: normal characteristics; signs of infection

  • Normal variations in rate/rhythm
  • Reflexes such as sneezing to clear airway
  • Bulb syringe
  • Steps to take if choking
  • Protecting infant from:
    • Exposure to people w upper respiratory tract infections and respiratory syncytial virus
    • Secondhand smoke
    • Suffocation from loose bedding, water beds and bean bag chairs, drowning in bath water, entrapment under excessive bedding or soft bedding, anything tied around infants neck, poorly constructed playpens, bassinets or cribs
  • Sleep position – back
  • Avoid use of baby powder bc of lung irritation
  • Notify care provider if difficulty breathing/swallowing, nasal congestion, excess drainage of mucus, coughing, sneezing, decreased interest in feeding, fever
  • If infant has respiratory illness such as common cold:
    • Feed smaller amounts more often to prevent overtiring
    • Hold baby in upright position to feed
    • Raise infants head and chest by raising mattress 30 degrees to sleep (no pillow)
    • Avoid drafts; don’t overdress baby
    • Don’t use OTC meds
    • Use nasal saline drops in each nostril and suction well w bulb syringe to decrease/relieve secretions

Infant Safety:

  • Baby on back to sleep
  • Room sharing but not bed sharing
  • Never put baby on cushion, pillow, and waterbed. Baby may suffocate
  • No bumper pads, blankets, stuffed toys or other soft objects – risk of suffocation
  • Don’t cover with blankets or quilts; dress in light sleep clothing
  • Slats no more than 2.24 inches apart; space between mattress and sides less than 2 finger widths
  • Mattress firm and fit snugly against crib rails
  • No crib w drop rails
  • Don’t leave baby alone on bed, couch, table
  • Don’t put infant carrier in high place – table, sofa, store counter
  • Approved care seat – rear facing until 2
  • Don’t leave baby in bath alone – babies can drown in 1-2 inches water
  • Check hot water heater set at 120F or less
  • Don’t tie anything around baby’s neck (pacifiers)
  • Keep crib away from window blind and drapery cords
  • Keep crib away from radiators, heat vents, portable heaters. Linens can catch fire
  • Smoke detectors every floor. Check 1x month. Change batteries 2x yr
  • Avoid cig smoke or cigar smoke. Passive exposure greatly increases likelihood that infant will have respiratory symptoms and illnesses
  • No not pick baby up or swing baby by arms or throw him up in air. Never shake baby

Elimination:

  • Color of normal urine and # of voidings each day: at least 2-6 first 1-3 days; min of 6-8 thereafter. Urine pale yellow (lemonade)
  • Changes in color/consistency of stool (meconium to transitional to soft yellow or golden yellow) and # of bowel movements
    • Formula fed infants may have as few as 1 stool every other day after first few weeks of life; stools pasty to semi-formed
    • Breastfed infants should have at least 3 stools every 24 hours for first few weeks. Stools are looser and resemble mustard mixed with cottage cheese; odor less offensive than formula fed

Safe Sleeping, Positioning and Holding: supine position during 1st year to prevent SIDS. Firm surface, specifically firm crib mattress covered by fitted sheet. Soft materials – bumper pads, comforters, quilts, pillows, sheepskins, stuffed toys not in crib. Room sharing but not bed sharing recommending; bed sharing can increase risk of suffocation and falls.

Mnemonic ABC “I sleep safest Alone, on my Back, in my Crib”.

Infant’s shape – barrel chest and flat, curve less spine facilitates infant to roll from side to prone position; side lying position not recommended for sleep. When infant awake, tummy time under parental supervision so infant can begin to develop appropriate muscle tone for eventual crawling; place when awake aids in preventing misshapen head (positional plagiocephaly).

Prevent infant from rolling off flat, unguarded surfaces. Should always keep 1 hand placed securely on infant when on such a surface.

Infant always held securely w head supported because newborns unable to maintain erect head posture for more than a few moments.

Diaper Rash – majority of infants develop at some time. Dermatitis or skin inflammation appears as redness, scaling, blisters or papules. Various factors contribute: infrequent diaper changes, diarrhea, use of plastic pants to cover diaper, change in infant’s diet such as when solid foods added, or when breastfeeding moms eat certain foods.

Diapers should be checked often and changed as soon as infant voids/stools. Plain water w mild soap, if needed, is used to cleanse diaper area; if baby wipes are used, they should be unscented and contain no alcohol. Skin should be dry before applying another diaper. Exposing buttocks to air can help dry up diaper rash. Bacteria thrive in moist, dark areas; exposing skin to dry air decreases bacterial proliferation. Zinc oxide ointments can be used to protect infants skin from moisture and further excoriation.

Most cases resolve within a few days.

Optimal environment for Candida albicans growth – warm, moist atmosphere in diaper area. Dermatitis appears in perianal area, inguinal folds and lower abdomen. Affected area is intensely erythematous with a sharply demarcated, scalloped edge, often with numerous satellite lesions that extend beyond larger legion. Application of anticandidal ointment such as clotimazole or miconazole with each diaper change. Sometimes infant is given oral antifungal preparation such as nystatin or fluconazole to eliminate any gastrointestinal source of infection.

Other Rashes – rash on cheeks can result from infant’s scratching w long unclipped fingernails or from rubbing face against crib sheets, particularly if regurgitated stomach contents not washed off.

Newborns skin begins natural process of peeling and sloughing after birth. Dry skin may be treated with an emollient applied 1-2x daily. Newborn rash, erythema toxicum is a common finding and needs no treatment.

Clothing – simple suggestion is to dress child for environment, adding no more than 1 layer. Overheating should be avoided. A cap or bonnet needed to protect scalp and minimize heat loss in winter or to protect against sunburn. Flame-retardant clothing encouraged. Eyes should be shaded if sunny/hot; infant sunglasses available.

Car Seat Safety – federally approved rear-facing safety seat. Shoulder harnesses placed in slots or at below level of infant’s shoulders. Harness is snug and retainer clip is placed at level of infant’s armpits as opposed to on abdomen or neck area.

  1. Nutrition
  2. Breastfeeding

ICEA Position Paper on Infant Feeding

All expectant moms should be given evidence-based info about breastfeeding in order to make an informed decision. Breastfeeding affected by events in entire reproductive process and is most successful when mom is given emotional and social support w out anxiety, fear and danger.

Whereas human milk has been overwhelmingly documented as superior food for human infants, AAP has stated it is normative standard for infant feeding and nutrition. AAP states that it should be considered a public health issue and not just a lifestyle choice. Infants should be fed human milk exclusively for first 6 months. At 6 months, other foods should complement breastfeeding for up to 1 year and then as long thereafter as mother and baby desire. WHO recommends same and also specifies 2 yrs of more as recommended duration. Less than 40% of infants globally receive 6 months of exclusive breastfeeding.

In 1990, U.S. Deptmt of Health and Human Services began Healthy People, a program of setting 10 yr science based goals for prevention of disease and promotion of good health for nation. Healthy People 2020 goals w respect to breastfeeding:

  • Increase the proportion of infants who are ever breastfed from the 2007-09 level of 74.0% to 81.9%.
  • Increase the proportion of infants who are breastfed at 6 months from the 2007-09 level of 43.5% to 60.6%.
  • Increase the proportion of infants who are breastfed at 1 year from the 2007-09 level of 22.7% to 34.1%.
  • Increase the proportion of infants who are breastfed exclusively through 3 months from the 2006 level of 33.6% to 46.2%.
  • Increase the proportion of infants who are breastfed exclusively through 6 months from the 2006 level of 14.1% to 25.5%.
  • Increase the proportion of employers who have worksite lactation support programs. In 2009, 25% of employers reported providing an onsite lactation/mother’s room. The goal for 2020 is 38%.
  • Reduce the proportion of breastfed newborns who receive formula supplementation within the first 2 days of life from the 2006 level of 24.2% to 14.2%.
  • Increase the proportion of live births that occur in facilities that provide recommended care for lactating mothers and their babies from the 2007 level of 2.9% to 8.1%4.

Benefits of Breastfeeding – those listed in AAP’s position statement, Breastfeeding and Use of Human Milk are those w strongest research support. Benefit is usually associated w certain duration and degree of exclusivity of breastfeeding.

Infant Outcomes:

  • The risk of hospitalization for lower respiratory tract infections in the first year is reduced 72% if infants are breastfed exclusively for more than 4 months.
  • Infants who exclusively breastfed for more than 6 months had one quarter of the risk of pneumonia compared with infants who were only breastfed exclusively for 4 months.
  • The severity (duration of hospitalization and oxygen requirements) of respiratory syncytial virus (RSV) bronchiolitis is reduced by 74% in infants who breastfed exclusively for 4 months compared with infants who never or only partially breastfed.
  • Any breastfeeding is associated with a 64% reduction in the incidence of nonspecific gastrointestinal tract infections, and this effect lasts for 2 months after cessation of breastfeeding.
  • Feeding human milk to preterm infants is associated with a 58% reduction in the incidence of necrotizing enterocolitis (NEC). For more on NEC, see http://www. ncbi.nlm.nih.gov/pubmedhealth/PMH0002133/ . One case of NEC could be prevented if 10 infants received an exclusive human milk diet, and 1 case of NEC requiring surgery could be prevented if 8 infants received an exclusive human milk diet. This is one reason that safe sources of donor human milk need to be available.
  • Breastfeeding is associated with a 38% reduced risk of sudden infant death syndrome (SIDS). The positive effect of breastfeeding on SIDS has been shown to be independent of sleep position.
  • 3-4 months of breastfeeding confers a protective effect against clinical asthma, atopic dermatitis and eczema, reducing their incidence by 27% in a low risk population and 42% in infants with a positive family history.
  • There is a 52% reduction in the risk of developing celiac disease in infants who were breastfed at the time of gluten exposure. Overall, increased duration of breastfeeding is associated with reduced risk of celiac disease. Gluten- containing foods should be introduced while the infant is receiving only breast milk and not infant formula or other cow’s milk products.
  • Breastfed infants have a 31% reduction in risk of childhood inflammatory bowel disease.
  • Although many factors confound studies of obesity, there is a 15-30% reduction in adolescent and adult obesity if any breastfeeding occurred in infancy, compared with no breastfeeding. The duration of breastfeeding is also inversely related to the risk of overweight, with each month of breastfeeding being associated with a 4% reduction in risk.
  • Up to a 30% reduction in the risk of type 1 and 40% for type 2 diabetes mellitus is reported for infants who are breastfed at least 3 months.
  • 20% reduction in risk of acute lymphocytic leukemia and 15% reduction in risk of acute myeloid leukemia in infants breastfed for 6 months or more.
  • There are many confounding factors regarding intelligence, but a large, randomized Promotion of Breastfeeding Intervention Trial provided evidence that adjust outcomes of intelligence scores and teacher’s ratings are significantly greater in breastfed infants. Higher intelligence scores were noted in infants who breastfed for at least 3 months. Very significant positive neurodevelopmental effects from human milk feeding are seen in preterm infants, who are at greatest risk for adverse outcomes.

Maternal Outcomes:

  • Cumulative duration of breastfeeding of longer than 12 months is associated with a 28% decrease in breast cancer (premenopausal) and ovarian cancer. Each year of breastfeeding has been calculated to result in a 4.3% reduction in breast cancer.
  • Decreased postpartum blood loss and more rapid involution of the uterus.
  • Increased child spacing due to lactational amenhorrea.
  • Mothers who do not breastfeed or who wean early have been shown in prospective cohort studies to have an increase in postpartum depression.
  • A large prospective study on child abuse and neglect by mothers found, after correcting for confounders, the rate of abuse/neglect was significantly increased for mothers who did not breastfeed as opposed to those who did.
  • A popular maternal benefit is that it supposedly speeds the return to pre-pregnancy weight, but findings are inconclusive on this. However, mothers can be encouraged knowing that the 600 calories a day used to make milk for a singleton will contribute to weight loss when combined with a healthy diet and exercise.
  • In mothers with no history of gestational diabetes, breastfeeding duration was associated with a decreased risk of type 2 diabetes mellitus; for each year of breastfeeding, there was a decreased risk of 4% to 12%. No beneficial effect of breastfeeding was noted in mothers with gestational diabetes.
  • There is an inverse relationship between the cumulative lifetime duration of breastfeeding and the development of rheumatoid arthritis.
  • A study of more than 139,000 postmenopausal women showed a relationship between cumulative lactation experience and the incidence of adult cardiovascular disease. A total of 12-23 months of lifetime breastfeeding was associated with a significant reduction in hypertension, cardiovascular disease and diabetes.

Contraindications to Breastfeeding:

  • An infant with classic galactosemia, a metabolic disorder
  • Mothers who are positive for human T-cell lymphotrophic virus (HTLV) type I or II
  • Mothers with untreated brucellosis
  • Mothers with active, untreated tuberculosis, until treated for 2 weeks and no longer infectious
  • In the industrialized world, it is not recommended that mothers with HIV breastfeed, but in the developing world the risk of mortality from not breastfeeding may outweigh the risk of acquiring HIV from human milk. In areas where HIV is endemic, babies who breastfed exclusively for 3 months are at lower risk of acquiring HIV than those who receive formula or mixed feeds.
  • Mothers who test positive for illicit drugs (however, narcotic-dependent mothers who are enrolled in a supervised methadone maintenance program can be encouraged to breastfeed)

Common Reasons for Early Breastfeeding Cessation – mothers often struggle due to nipple and or breast pain or perception of low milk supply for babies. In first 4 weeks, women state they stop due to sore nipples, insufficient milk production and their babies’ breastfeeding difficulty. First days are critical of establishment of mothers’ milk supply and her confidence. Perception that infant was not satisfied by milk alone was consistently cited as 1 of top 3 reasons to stop. Large scale survey in 2008 associated w cessation of breastfeeding during 1st yr include being younger, unmarried, primiparous, less educated, poorer, a WIC participant, and a resident of Midwest or South. Studies have shown that >50% of breastfeeding women perceived their milk supply to be low during early months of breastfeeding, although their babies seemed satisfied that moms may be concerned as a result of a lack of knowledge regarding the normal process or lactation or technical difficulties in feeding.

Birth Practices that Affect Breastfeeding

Some birth practices, especially separation of the mother-baby dyad, contribute to problems. A survey was conducted by the Centers for Disease Control in 2007 regarding United States hospital birth practices related to breastfeeding. It was called the Maternity Practices in Infant Nutrition and Care (mPINC) and included responses from 2687 facilities, which was 82% of those contacted. The summary concluded that “1) a substantial proportion of facilities used maternity practices that are not evidence-based and are known to interfere with breastfeeding, and 2) states in the southern U.S. generally had lower mPINC scores, including certain states previously determined to have the lowest 6-month breastfeeding rates.” Studies have shown that mothers will be more successful at breastfeeding if they receive information about breastfeeding, have support from a person of their choosing during labor, initiate skin-to-skin contact immediately after birth, have early and unlimited breastfeedings, room-in with their babies, avoid pacifiers and supplemental feedings of formula or water.

Human Milk Donation

Throughout human history, mothers have sought milk from other mothers when they could not provide their own. WHO and the Human Milk Banking Association of North America
(HMBANA) state that when a mother’s own milk is lacking (especially when the newborn is premature or high risk) the next best choice today is pasteurized donor milk. Historically, milk banks distributed unprocessed milk to ill and premature infants. In the 1980’s with the advent of the AIDS crisis, the majority of milk banks around the world closed, recognizing the need for more complex screening and treatment of donor milk. By the 1990’s, with increased evidence on the benefits of human milk and the awareness of ways to make shared milk safe, milk banks are coming back, around the world. HMBANA milk banks all use the same procedures for screening, testing, processing and distributing donor milk. Donors are screened by interview and blood testing for HIV, HTLV, Hepatitis B & C and syphilis. Even after a mother passes the screening, her donated milk may be discarded due to the presence of excess bacteria which would not cause a problem for that mother’s own full-term, healthy baby, but which could be harmful to a fragile pre-term infant. Accepted milk is processed in a hot water bath for just enough time to kill nearly all harmful bacteria and viruses, but still retain the majority of its immunological and nutritional properties. Since pasteurized donor milk is in short supply, (the use of it) requires a prescription from a doctor and is very expensive (and not always covered by insurance), informal milk sharing is practiced among friends as well as through Internet sites, albeit a risky practice. ICEA encourages donation to HMBANA milk banks so that the supply can meet the demand. Another way that mothers with an abundant supply may share it is by giving it to a for-profit milk bank, which will process it into human milk fortifier. Mothers should be aware that the milk they are giving away is being used for the profit of that company.

The International Code for the Marketing of Breast Milk Substitutes – One thing that deters some parents from exclusively breastfeeding is the way infant formula is marketed. Advertising and free formula giveaways have led some mothers to think it is the hospital-sanctioned, scientific and modern way to nourish their babies. Once they begin using it, their own milk supply is impaired. If they cannot continue to afford to purchase it they might dilute it too much to make it go farther, which has led to infant mortality. This is a matter of such concern globally that WHO and UNICEF developed this code in 1981 to prevent the marketing and distribution of breast milk substitutes from interfering with the promotion and protection of breastfeeding. It states in detail how any product intended to substitute in whole or in part for breast milk, as well as bottles and teats, must be marketed without idealizing them or implying they are as good as breast milk. ICEA supports the Code and will only conduct business with or accept advertising from Code-compliant businesses.

The Baby Friendly Hospital Initiative (BFHI)

This was issued in 1991 by WHO and UNICEF to direct maternity hospitals toward adopting evidence-based practices that strengthen breastfeeding in the perinatal period. It is based on ten principles, known as the “Ten Steps to Successful Breastfeeding”. A facility can achieve “Baby-Friendly” recognition if it does not accept free or low cost formula and it adheres to the Ten Steps. Since the BFHI began, more than 15,000 facilities in 134 countries

have been awarded Baby-Friendly status. In many areas where hospitals have been designated Baby-Friendly, more mothers are breastfeeding their infants, and child health has improved

Implications for Practice

Childbirth educators and doulas can help reduce breastfeeding problems with information, anticipatory guidance and support during labor and postpartum. Our mission of giving parents freedom to make decisions through knowledge of alternatives requires that students/clients are aware of the risk of not breastfeeding and ways they might manage their birth experiences to enhance their odds of success at it. The educator or doula should be familiar with which, if any, facilities in her community are Baby-Friendly or working towards this designation. She should be able to refer childbearing families to International Board Certified Lactation Consultants (IBCLC) for help with problems that may arise.

 

Feeding Your Baby – although both formula or breast milk help triple baby’s birth weight and help him grow 10-12 inches during first year, only breast milk provides nutrients that encourage rapid, healthy growth of brain, nervous and digestive systems and development of immune system. How you feed also important to growth – the way baby gets nourishment influences his physical, social and emotional well-being. Feeding when he’s hungry helps foster emotional development.

Breast Milk or Formula? Personal choice. Before making decision, become informed about breastfeeding, feeding expressed breast milk by bottle and formula feeding.

Why Health Care Providers Recommend Breast Milk and Breastfeeding – breast milk’s nutritional composition is ideal for babies. Unlike cow milk and formula, it adapts to meet baby’s changing nutritional needs. More easily digestible. Enhances development of baby’s brain and may contribute to higher IQ and better cognitive test scores.

Those who exclusively breastfeed for >3 months have fewer and less sever allergies. Breastfed babies less likely to be hospitalized for infections, have fewer ear infections, respiratory infections, UTIs and infections from bacterial meningitis.   Also fewer occurrences of diarrhea and vomiting. Can lower baby’s risk of SIDS.

Can reduce incidence of some diseases that occur later in life such as insulin-dependent diabetes mellitus, asthma, obesity, leukemia, lymphoma and multiple sclerosis.

Reduces postpartum bleeding for mom and helps uterus shrink to normal size faster. Reduces risk of diseases, including premenopausal breast cancer, ovarian cancer and osteoporosis. Fewer hip fractures after menopause.

Economical and convenient (cost free and always available). Promotes close nurturing relationship.

If Have Concerns About Breastfeeding – maybe had trouble before or question its convenience.. may be concerned about returning to work. May worry about medical condition, or may be pregnant w more than 1 baby. talk to caregiver, lactation consultant, baby’s caregiver or childbirth educator before making a decision.

Breastfeeding more difficult for premature baby or one w a congenital condition such as Down syndrome or cleft palate – lactation consultant can show you special techniques. Breastfeeding/providing pumped milk can be excellent way to help baby grow and stay healthy.

Breast reduction might or might not affect ability to breastfeed. Talk to LC.

If pregnant w twins, triplets or more, may be challenging, but can still provide breast milk by expressing.

If worried about other partner’s ability to parent, there are other ways they can actively parent – cuddle/soothe baby, bathe her and change diapers.

How to Find a Qualified Lactation Consultant – breastfeeding experts who dedicate work to its promotion, support and protection. IBCLC successfully passed exam. Ask childbirth educator or local LLL group. If birth in hospital, ask caregiver or nurse. Ilca.org for referrals. If cant find IBCLC, find nurse trained in support, doula, midwife, LLL, childbirth educator, experienced mom

When Health Care Experts Recommend Formula Feeding – if baby has galactosemia (rare condition in which baby can’t digest sugar in breast milk), formula becomes necessary. Mother’s health is usually reason for recommendation. Formula feeding is best if mom is HIV positive (and lives in developed country), has untreated tuberculosis, takes certain meds that can harm baby (lithium/radioactive meds), uses street drugs (heroin, coke, meth), is receiving high doses of methadone or had extensive breast surgery.

Some concerns are psychological. Some anxious about nursing in public, some chronically worry they don’t produce enough milk or damages breasts’ appearance. Survivors of sex abuse may have concerns. Talking about them may help.

Concerns About Formula – in 1980s, U.S. Congress enacted and amended Infant Formula Act, mandating min levels of 29 nutrients and max levels of 9 nutrients. Still doesn’t contain most of more than 200 nutrients and components in breast milk. Why formula can’t enhance development of baby’s immune system.

Some less healthful than others. Low iron formula more likely to have anemia (lower cognitive test scores). Occasionally, manufacturing errors put formula at risk for contamination and recalled.

 

Making Sure Baby is Getting Enough Breast Milk – by 3rd/4th day after birth, most babies lose 5-8% of birth weight. Once moms milk is in, babies steadily gain weight. Full term babies usually gain weight they lost are return to birth weight by 10-14 days. After milk comes in (3-5 days), watch for following 6 signs to know baby is getting enough milk:

  1. Suckles frequently – 8-12x in 24hrs
  2. Swallowing – hear baby swallow often. Sometimes after every suck. Sometimes sucks a few times before swallowing. Fully extends jaw when swallowing
  3. Satisfaction – seems satisfied after most feedings; breasts feel softer
  4. Soaking – # of wet diapers = days of baby’s life for 1st After milk comes in, 5-8 wet diapers in 24 hrs. Disposable diapers wick away moisture from baby’s skin and its difficult to tell when urinating; can place tissue/small piece of paper towel inside
  5. Stools – baby produces 3 diapers in 24 hrs when milk comes in. yellow/seedy. First month – many babies poop after almost every feeding or up to 12x/day. Later on, poop less.
  6. Scales – gain ½ – 1/5 oz a day. If baby’s weight doesn’t return to birth weight in 10-14 days, 2 possible explanations:
    1. Baby has trouble getting milk
    2. Might not be producing enough milk and need to take measures to increase milk

Signs That Baby Isn’t Getting Enough – risk of dehydration of problems w weight if baby doesn’t get enough. Call caregiver and have baby assessed/weighed if:

  • Baby feeds fewer than 8x in 24 hrs
  • She doesn’t produce at least 1 poopy diaper in 24 hrs
  • She has few wet diapers or produces urine that has reddish brick dust in it
  • Baby seems constantly hungry and is seldom content after feedings
  • Baby’s feedings worry/concern you

Call caregiver immediately if:

  • Baby is lethargic and has no interest in nursing
  • Inside of mouth doesn’t glisten w moisture (baby’s lips can appear dry normally)
  • When gently pinch skin on arm, leg, ab, skin stays tented
  • Eyes, face chest and abdomen yellow

When Baby Doesn’t Get Enough Milk– several possible reasons a baby can’t get enough milk. Some cases, baby are cause. In others parents/caregivers introduce problem. In other cases, medical condition prevents it.

  • Ineffective latch – if you cant help baby latch well, get help from lactation consultant. Most times can be corrected. Sooner you get help. Sooner problem will be resolved
  • Scheduled feedings – newborns, esp ones who gain weight slowly need to feed more frequently than 1x every 3 hrs. all newborns need to fee da night; it shouldn’t be postponed til morning.
  • Feeding from only 1 breast – risk inadequate milk production and may limit amt of milk she gets. Always offer 2nd For 1st week, ay nurse very little from 2nd breast but may want both breasts over next month or so. At 1-2 months, may nurse from only 1 breast at most feedings if you have good supply
  • Pacifiers – can lead to faulty sucking patterns and may shorten overall duration of breastfeeding. Avoid in early weeks
  • Sleepy baby – long periods bw feedings may prevent baby from getting enough milk. Try waking her every 2-3 hrs during day and every 3-4 hrs at night. If sleeping soundly, try again in 30 min. Might not get much milk if drowsy, pauses for long intervals of falls asleep. If remains lethargic, call caregiver.
    • After baby has returned to birth weight (10-14 days) and is feeding well, no need to wake her.
  • Jaundice – high levels of bilirubin in blood cause jaundice which causes yellowish tint in face, chest, abdomen and white of eyes. Call caregiver. Getting inadequate amt of milk increases incidence, which sometimes appears in first 2 weeks. Babies often sleep and uninterested in feeding; disinterest can diminish milk intake. Frequent breastfeeding helps relieve jaundice. Avoid giving baby bottles of water; bilirubin isn’t excreted in urine and water supplements may reduce amt of milk baby consumes. Once treated, baby may become more interested in feeding

How to Wake a Sleepy Baby– once newborns 24 hrs old, need to feed 8x in 24 hrs. if baby doesn’t awaken from light sleep, try:

  • If swaddled, unwrap. Remove clothes leaving just diaper
  • Dim lights so he can open eyes. Talk to him
  • Hold in supported standing or sitting position
  • Massage his arms, legs and chest
  • Rub expressed colostrum or milk onto his lips. Be patient. If he nuzzles at first, good start
  • Press on breast to enhance milk flow and entice him to suckle more
  • Burp him or change diaper
  • Change to another feeding position or switch breasts.

If tried for 10-15 min, let him sleep in arms and let him try again when awake. If trouble feeding, get help of a nurse. If not feeding well by 24 hrs after birth, use breast milk to express milk. Pumping stimulates breasts to make more milk and ensures baby gets colostrum.

Inadequate Milk Supply – sometimes mom not producing enough to meet baby’s needs

  • Feed frequently, at least 8-12x in 24 hrs
  • Never limit feedings; let them feed as long as they like (10-30 min each breast)
  • Make sure baby latches well and you can hear him swallow. If you don’t, detach and try again
  • To reduce stress/increase breast stimulation, have a babymoon. Spend 24 hrs in bed w baby. have postpartum doula, family or friends help w meals, chores and other children so you don’t have to leave bed except for bathroom. Nurse as much as possible, snuggle skin to skin, eat/drink well, sleep, nurture yourself, let others nurture you. Can help improve baby’s weight gain
  • Get help from lactation consultant who may suggest:
    • Double breast pump; pump after each feeding for 10-15 min; if baby can’t nurse, can build milk supply by pumping when he takes bottle
    • If need to supplement baby’s feedings, use syringe or feeding device to feed expressed breast milk (or prescribed formula) through tube attached to breast. Baby receives milk from breast and stimulates it to make more.
  • Take herbal medication such as fenugreek, by itself or w blessed thistle. (Don’t take if diabetic)
  • Take prescribed medication such as Reglan or Domperidone (not available in U.S.); fewer side effects.

When Milk Supply Dwindles– you’ve had adequate supply and baby has been gaining, but milk supply decreased. Consider following:

  • Begun taking birth control w estrogen
  • Begun using prescribed estrogen cream to treat vaginal dryness
  • Returned to work or another time-consuming activity, which has made you nurse less frequently
  • Offering baby more supplemental bottles and not breastfeeding as often
  • You’re pregnant

When Have Problem w Let-Down– extreme stress, inadequate nipple stimulation, and excessive amts of alcohol, caffeine, and tobacco may delay/inhibit let-down reflex.

 

Expressing and Storing Breast Milk – when baby isn’t available/able to nurse, need to express milk to relieve fullness and maintain supply. Expressing by hand or w pump becomes easier w practice.

  • Hand Expression– effective, inexpensive, always available. May only get drops at first.
  • When Pumping Is Helpful/Necessary– using pump more efficient and desirable if:
    • Must leave baby bc of travel/work
    • Baby is in NICU and can’t yet feed frequently
    • Trying to build/rebuild milk supply
    • Baby can’t get enough milk by breastfeeding alone
    • Having medical procedure that requires meds unsafe for baby. Don’t save pumped milk
  • Finding/Using Breast Pump– Kellymom.com has discussion on pump selection. If baby only needs occasional bottle, hand expression or manual pump sufficient.   If need to pump several bottles a day or building/maintaining supply, need electric pump. Double breast most efficient; available to rent.
    • Center nipple in pump. If not centered, friction on areola causes soreness. Use only enough suction to make milk flow. Too much stretches areola and pulls too deeply into pump, possible injuring tissues and causing nipple soreness. Many come w different sized cups. Some have soft silicone insert to increase comfort. If too large/too small, check w manufacturer to find right size
    • Can buy device to hold in place so can use hands for other tasks. To make own, buy sports bra and cut slits in center of each bra cup wide enough to hold them snugly against breast
    • May help increase flow:
      • Private, warm environment free of interruptions and distractions
      • Cup breast and gently but firmly stroke them from chest toward areola. Jiggle or gently shake breast or stroke light w fingertips to stimulate sensations of let-down
      • Develop ritual such as cup of tea or relaxing music
      • Imagine nursing baby or look at pics of baby and visualize milk flowing
    • Storing Breast Milk– clean bottles or jars, plastic bottles of feeding bags designed for it. Experts debate whether plastic or glass safest
    • Using Stored Breast Milk– use in following order:
      • Freshly expressed milk
      • Newly refrigerated milk, then all other refrigerated milk
      • Frozen milk (use oldest first to keep supply as fresh as possible)
      • To warm refrigerated breast milk or thaw frozen milk, never use microwave or stove. Can destroy many important anti-infective properties and may heat milk unevenly, increasing hot spots that can burn baby
      • Place milk container in bowl of warm water. As water cools, replace w more warm water. Baby can drink milk at room temp or slightly warmer
      • Swirl it gently to mix fat (rises to top during storage). Store thawed milk in fridge for up to 24 hrs but don’t refreeze
      • Breast milk does lose some (but not all) of anti-infective and nutritional properties over time and w freezing/heating. Still far more nutritious than formula

How To Store Breast Milk – (ill/premature babies may need to follow other guidelines). When storing for >1 day, label w date

  • For 10 hrs in room whose temp ranges from 66G-72F
  • For 8 days in fridge 32-39F
  • 3-6 months in standard freezer set to coldest setting (put milk at back). Leave room at top for expansion. Don’t refreeze thawed milk
  • 6 months in deep freezer 0F or colder

Feeding Baby Expressed Breast Milk or Supplemental Formula

  • Tubes – use paper tape to attach tubes next to nipple. Pink milk container (syringe, bottle or bag) to shirt or hand from cord around neck. Baby draws milk from container through tubes. May be temporary, but if can’t produce enough milk, can use device for as long as necessary
  • Droppers, spoons, small cups– to feed small amts of supplemental milk. Temporary solution for supplementation and prevent early intro to bottle nipples, which may cause confusion
  • Bottles– if gone for extended time. Wait to introduce until certain baby is nursing well and gaining weight steadily (4 weeks). Begin introducing bottle 2 weeks before baby will feed while away. First feeding may be challenging. Some learn quickly, others not.

When Breastfed Baby Refuses Bottle

  • Let baby learn to suck from bottle when calm
  • Choose bottle/nipple brand that seems durable and easy to clean, stick w it until baby becomes familiar w it
  • Introduce before expecting baby to use on his own. Offer ½ -1oz after breastfeeding
  • Warm bottle and nipple w running warm water
  • Hold him as do when breastfeeding. Or distract by talking, singing, something don’t do while breastfeeding
  • Don’t force. Use dropper, cup or spoon to feed to take edge off hunger. Try later w bottle.
  • If want to continue breastfeeding, make sure breastfeed more than bottle

Situations That May Make Breastfeeding Challenging

  • Cesarean birth or difficult labor/birth – may be exhausted and require more medical and nursing care, repairing incision, episiotomy, or lacerations or resolving any emergency (hemorrhaging) may delay 1st feeding, which may delay when milk comes in. Smaller and less frequent releases of oxytocin and minimal rise in prolactin may delay milk.
    • Studies show those w cesareans or difficult labors feed just as long as long as have commitment
    • Ask to see, hold and nurse baby ASAP. Breastfeeding b4 epidural or spinal anesthetic wears off helps reduce any pain you may feel. Nurse frequently while lying on side and take advantage of help offered
    • When home, concentrate on rest, comfort and feeing baby
    • May be most comfortable breastfeeding while lying down or sitting upright w back support and pillow on lap
    • Continue taking pain meds, which appear only in trace amts. Unrelieved pain can make it more difficult
  • Premature, ill or hospitalized babies– breastfeeding lets you care in important way by giving her closeness and helps her immune system/protect against infection. Moms of premature babies produce milk higher in protein, nitrogen, sodium, calcium, fat and calories. Since at higher risk for infection (if hospitalized), breast milks protective components esp important. Breastfed premature babies have lower rates of infection and serious bowel problems. Higher IQs at age 8. If baby cant nurse or suckle well, express w pump. Feed by tube or dropper until she can nurse. Spend time in nursery w baby to expose yourself to organisms that can cause infection in her. Your mature immune system can make antibodies. Ability to make antibodies increases w skin to skin. Other parents of premature/hospitalized babies can help w advice.
  • Nursing while pregnant– need to decide whether to continue breastfeeding or to wean child. Doesn’t harm pregnancy; at birth, babies of similar size. Early pregnancy symptoms (sore nipples/fatigue) may interfere. Hormones decrease volume of milk and cause flavor to change; child may become less interested.
  • Tandem nursing– mom who feeds newborn and older child at same time. Sometimes older child’s desire temporary as adjust to new baby. Provides opportunity to bond together. Feed newborn first to satisfy her needs for colostrum and breast milk. Once mature milk is in, can feed both without problems. Challenging when older child feed frequently and can’t wait.
  • Breastfeeding multiples – more complex, esp if babies premature. Its possible, even exclusively. Use breastfeeding pillows. Lactation consultant can help arrange support in early days and weeks postpartum doulas esp helpful. Support groups for parents of multiples. In beginning, may be easier to feed 1 at a time. As become comfortable, nursing at same time will save you time. Eat well and enough and consume more calories than those feeding one.
  • Breastfeeding when Ill/hospitalized – speak w hospitals lactation consultant. If baby can stay w you, you can breastfeed/pump and have chance to cuddle her. Many hospitals let partner stay in room and care for baby. if separated, may be able to pump so baby can have at home
  • Taking medications/drugs during lactation – w few exceptions, any med/drug you take is in milk. Some do affect baby, most don’t. Pain relief meds used after birth generally safe and important to take them for your comfort. Stool softeners and hemorrhoid meds don’t significantly affect breast milk.
    • Consult w caregiver about safety of drug while breastfeeding.
    • Always avoid street drugs (cocaine, heroin, methamphetamines etc) bc effects of these drugs pose serious health risks for you and baby.
    • Most vaccinations safe except smallpox – causes sore at vaccination site; if baby is exposed, may cause sores to develop on his skin. Flu and MMR safe.
    • Avoid oral contraceptives w estrogen; can decrease milk supply. Progestin only, including mini pill and Depo-Provera, don’t interfere w milk production
    • Smoking affects babies in 2 ways: ingesting breast milk containing nicotine and other chemicals and by breathing it in. can increase fussiness, but mother who smokes should still breastfeed. Breast milk produced by smoker better protects baby’s health than formula. Formula fed babies of smoking moms 7x more likely to develop respiratory illnesses. Try to quit or cut down. Avoid smoking around baby. secondhand smoke increases risk of SIDS and respiratory/ear infections.

Questions About Meds & Breastfeeding (including herbs) to ask caregiver:

  • Do I absolutely need this medication now? Can ideally taking it until baby is more mature and can better handle its effects?
  • Is there a safer alternative to medication?
  • Can I take it topically? (Rubbed on skin instead of orally usually pass into bloodstream/milk in lower levels)
  • Can we schedule timing so smallest amt in breast milk? Time release meds and some drugs take a long time to leave body
  • When I take meds unsafe for breastfeeding, should I temporarily stop nursing? (if yes, pump and discard milk until treatment complete and med out of system)
  • What symptoms and possible side effects should I watch for in baby?
  • Do you have access to most accurate info about medication use during breastfeeding (Medications and Mothers Milk by Thomas Hale regularly revised and well respected)

 

Relactation – if breastfeeding has been interrupted long enough to stop your milk production, its possible to restart it – but it requires persistence, commitment and a baby interested in nursing.

Frequent, around the clock nursing is most effective method. May use a tube-feeding device to encourage baby to suckle at empty or near empty breast while receiving supplemental formula. Stimulates milk production while device provides baby w nutrition. Electric breast pump after a feeding may also increase supply as may taking herbal meds and prescribed meds. Contact lactation consultant for support.

Mothers of adopted babies can use same methods to try to produce milk, even if never been pregnant or nursed a baby. They don’t usually produce a full supply, but may produce some. Feeding a baby even a small amount reduces likelihood of having problems common w formula fed babies (constipation). If mother can’t produce milk to feed adopted baby, can still experience breastfeeding to a degree by using tube-feeding device to feed her formula.

Breastfeeding and Fertility – for as long as you exclusively breastfeed, you greatly reduce chance of becoming pregnant. Have less than 2% chance if:

  • Baby <6 months
  • Don’t menstruate until after 56 days postpartum
  • Nursing frequently (every 4 hrs during day and 6 hrs at night)
  • Rarely supplement and give him tastes of foods/fluids occasionally

After baby eats table foods, can extend contraceptive benefits by nursing before table foods and continue to feed day and night.

May ovulate before first period. Barrier methods (Condoms/diaphragms), IUDs and progestin only pills and injections don’t interfere w breastfeeding. Pills containing estrogen affect supply.

Identifying body’s fertility signs trickier bc of fluctuating hormone levels required for breastfeeding. Taking Charge of Your Fertility book by Toni Weschler can help.

Weaning – it benefits baby for as long as you decide. AAP recommends 1 yr. don’t make decision on others opinions or suggestions. Sometimes its child’s decision.

Tips When decide to wean:

  • Wean slowly. If change mind, can rebuild supply
  • Cut out the feeding you/baby enjoy least. Then slowly cut out feeding’s one at a time leaving best loved feeding for last
  • Gradually replace breast milk w formula or whole cow or goat milk, depending on baby’s age
  • Use comfort measures to treat swollen breasts
  • May want to wait until spring until after cold/flu season
  • Can cuddle instead – read book together, bath together or nap together
  • Write baby letter about what nursing her meant to you
  • As wean, hormone levels change, bringing return of menstrual cycle. Expect emotions to fluctuate
  • After weaning, some milk remains in breasts. Gradually disappears over weeks to months

When You Need to Wean – if must wean bc of medical reason or infertility treatments, possible to wean gradually over several days. Can donate expressed milk to milk bank. Wear snug-fitting supportive bra to provide comfort as breast swell. Apply ice packs over bra or light clothing and take ibuprofen to reduce inflammation. Sore breasts may last a day or two, but may leak milk for week or longer

Formula Feeding and Bottle-feeding

  • Types of formulas and formula prep – AAP recommends iron-fortified for those under 1. Evaporated milk mixtures don’t suit baby’s needs. Whole, 2%, 1% of fat free cow/goat milk lack many important and necessary nutrients and difficult for babies under 1 to digest. Baby needs 2-2.5 oz for every pound he weighs in 24 hr period.
  • Types of formulas – most made of cow milk or soybeans and many fortified w iron to reduce baby’s risk of becoming anemic. Doesn’t increase incidence of colic, constipation, diarrhea, fussiness or vomiting. Babies who consume low iron formula have lower cognitive scores at age 5.
    • Some parents switch brands after noticing 1 brand seems to make baby gassy/fussy. Switching formulas does not decrease gas or reduce fussiness. All babies gassy and fussy at times and should stick w brand baby tolerates.
    • If babies seems allergic to cow milk, may try hypoallergenic formulas
    • If baby can’t digest lactose (galactosemia), or if family eats vegan diet, soymilk available. 25% of those allergic to milk also allergic to soy.
    • rog
  • Preparing formula – available in ready to feed bottles/cans, canned liquid concentrates and powdered forms. All have equal nutritive value. Powdered least expensive and ready to feed most expensive.
    • Follow package instructions. If use too little water, can cause diarrhea, dehydration and other problems. If use too much, dilute formula and baby doesn’t receive enough calories and nutrients to thrive. Formula fed babies don’t need extra water until begin eating table foods
    • If water supply is fluoridated, mix formula w distilled, purified water free of minerals and ions, or water filtered by reverse osmosis. Using fluoridated water to prepare formula can permanently discolor teeth when they consume in greater than optimal amounts.
  • Bottles and nipples – most either glass or plastic. Plastic lightweight and don’t crack/break easily. Debate on toxicity of plastic made of polycarbonate (contains bisphenol A or BPA) so choose bpa free. Some say affects neurology and behavior or babies and children. FDA says no concern. Glass bottles stain proof, easy to clean but can break. Avoid using plastic that have recycling symbol 7, which contain BPA; choose symbols 1, 2 or 5; they’re made of polyethylene or polypropylene. Some use feeding bags and not bottles, a plastic bag inside plastic container – check to see if bags BPA free. Feeding supplies w out BPA – softlanding.com
    • Stay w type of nipple baby likes. If flows in stream, hole is too big and may consume too fast and may spit up. If very slow or not at all, baby may tire of sucking and not consume enough or any milk. If too big, discard. If too small, remove dried breast milk that may be clogging or enlarge w clean needles.
    • If water supply safe for drinking, don’t need to sterilize bottles and nipples. Wash by hand or in dishwasher. Clean nipples w nipple brush and hot soapy water. Rinse w hot water and dry
    • Heat bottles in warm water; don’t use microwave or stove. If using plastic bottles, high heat ore likely to release chemicals into milk.
  • Tips for bottle-feeding
    • Hold baby so he’s semi-reclined. More comfortable than lying on back and prevents swallowing air
    • To promote normal development of baby’s eye muscles and symmetrical development of neck muscles, hold him sometimes in left arm and sometimes in right arm
    • Burp baby hallway through. Babies that gulp air need to burp more often.
    • As he grows, hell begin to burp on his own and wont need your help
    • Trust that baby knows how much to eat. For first few days, full term feed 8-12x in 24 hrs. As grow, will consume more at each feeding and eat less often. Won’t want same amt at each feeing. If doesn’t finish bottle, don’t make him. When baby rapidly and consistently finishes bottle at each feeding, add more (1 oz) to next feeding.
    • Offer baby warmed (but not hot). As he grows, may prefer cool or room temp
    • Never prop bottle to feed baby. Interacting w you and others helps him thrive emotionally and develop trust
    • Never mix cooked or raw honey (or dip pacifiers). Infant botulism can occur in babies under 1.

Key Points

  • Responding to feeding cues develops baby’s sense of trust, security and well-being. Cuddling while feeding, while smiling and talking to her promotes emotional development and stimulates senses
  • Breastfeeding best. >200 nutrients, easily digestible, promotes health and prevents illness
  • Breastfeed 8-12x for newborn. Let feed as long as want (10-30 min) then offer 2nd Count wet/poopy diapers and monitor weight gain
  • If using formula, use iron fortified

a. Anatomy

  1. Breastfeeding Basics

Breastfeeding Basics

First Feedings: special time to get to know baby. Most newborns alert and interested in feeding in first hour after birth. Take advantage of this time to establish milk supply and avoid early breastfeeding problems. Research shows frequent and unrestricted feedings help prevent engorgement (painful swelling of breasts) and promote an abundant milk supply.

Helpful Tips: Breastfeed ASAP after birth (can put in birth plan). Keep baby with you (preferably skin-to-skin) and let her suckle frequently. Try to nurse baby in a calm, peaceful environment so you can focus on feeding. If had cesarean, recovery may delay first feeding beyond 1 hour and you may need help establishing breastfeeding. Don’t hesitate to ask others to leave (can ask partner or nurse to ask them to leave).

Breastfeeding Positions: Bring baby to breast with his nose near your nipple and his ears, shoulder, and hips in a straight line. Nestle him close and support his body from neck to hips. When you stabilize body, he can easily move his head and help with the latch. Can use a pillow to support your arm while feeding.

  • Cradle Hold: Cradle baby’s head in crook of 1 arm and have her facing breast. Use forearm to support her body and your hand to support her buttocks.
    • Advantages: easiest, most comfortable once baby in nursing well; convenient for a bigger baby
  • Cross-cradle or Alternate Cradle Hold: Hold baby with arm opposite of the breast from which you’re feeding, with his tummy against your chest. Support his head with your fingers and thumb on the nape of his neck behind his ears
    • Advantages: supporting baby’s neck and shoulders with hand instead of forearm allows you and baby to have more control of head; easiest position to learn how to latch him onto breast; especially helpful for premature baby or baby who’s having difficulty latching
  • Football or Clutch Hold: Tuck baby beside your body. Support her body with your arm and cradle the nape of her neck with your fingers and thumb. Bring her up toward your breast as needed so she can easily latch on – she may be lying on her back or side or be sitting up against your chest
    • Advantages: easy to see baby has latched effectively; may be most comfortable if you’ve had cesarean because baby isn’t pressing on incision; helpful if you have large breasts, because baby’s chest helps support your breasts
  • Lying Down – Lie on side with lower arm tucked around your baby (Or lie on side with lower arm placed under your head). Lay baby on his side, tucked alongside your body facing your lower breast. Use pillows for comfort. To feed from top breast, lean over slightly to bring nipple toward baby’s mouth
    • Advantages: easy to rest during feedings; comfortable if you have hemorrhoids or are recovering from episiotomy or tear
    • Disadvantages: often takes practice to learn; may be difficult to see if baby latched on well so have someone check
  • Baby Sitting Upright: seat baby on lap (or pillow on lap) so she faces you and her legs straddle your leg or body. Support back w forearm and support shoulders/neck w hand
    • Advantages: easy to see if baby has good latch
    • Helpful if baby has gastroesophageal reflux or if you have very active let down and large volume of milk. Sitting upright helps baby swallow rapidly flowing milk w out difficulty

Helping Baby Latch Onto Breast:

  • Use comfortable position – ex. cross cradle
  • Hold baby close to you
    • Have body touch your chest and arms near your breast instead of tucked bw 2 of you (may need to lay other breast over his diaper)
    • Support head w fingers and thumb behind his ears – this allows him to move his head, which will help him latch (avoid pressing back of head)
    • If lean back w feet up on footstool, easy to keep him near you
  • Bring baby to breast
    • If hold breast w hand, keep fingers/thumb away from areola. Allow breast to remain where it naturally falls
  • Help baby have good, deep latch
    • Have his nose and upper lip near nipple
    • Press on his upper back so his head tilts back slightly
    • Place his chin on your chest and his lower lip on outer edge of areola – encourages him to open his mouth and grasp areola and nipple
    • Wait for him to open his mouth WIDE (yawning), then bring upper lip over nipple
  • Indicators that baby has deep latch on breast include:
    • His chin indents your breast and his nose is near or barely touching breast
    • He has more areola in mouth near his lower jaw and you see more areola above his lips
    • You hear and see him swallowing – hear ugh sound, see pause in suckling
    • After feeding, nipple should be evenly rounded or same shape as before feeding. Should not look compressed or have ridge in middle or on one side
  • Keep baby close during feeding
    • Press on his upper back w palm, tuck bottom in close to you or lean back. Use pillows to support your arm.

If have trouble getting good latch when breasts very full, use hand expression to make areola more graspable. Breast pressure or compression can increase milk flow to encourage sucking and swallowing.

Challenges with Latch during First Days: some babies know how to latch from birth while others seem sleepy, uninterested or have difficulty.

Early feedings – baby may immediately latch, tugging and sucking energetically. May grasp/pull on nipple so firmly, it surprise you w discomfort. Or she may tentatively lick and mouth your breast, struggling to get a good latch. Don’t worry if baby doesn’t get it on first try or if it takes a lot of work before she latches well. If baby’s nose was suctioned at birth, she may need time for stuffiness to clear. Long labor can tired babies and some meds can make them drowsy or uncoordinated.

You also may need rest and nourishment to combat fatigue of long, difficult labor. May have painful contractions (afterpains) when nursing, esp if not first baby. afterpains gradually subside over 1st week and slow breathing and other relaxation techniques should help.

Whether baby nurses well or not, stimulation of her nuzzling, licking and closeness to boy encourages milk production.

When Baby Latches Well: signs of good latch are usually easy to spot – she opens her mouth as wide as a yawn, w tongue down and forward. She draws nipples and much of areola into her mouth, giving her a deep latch. Her chin indents breast and her nose is close to your breast. Her lips (esp lower lip) are flanged outward and tongue is extended over lower gum

Baby begins feeding w short, rapid sucks, her jaw moving rhythmically as she suckles. After milk has let down, she settles into slower pattern, w bursts of sucking and short pauses. Can hear her swallow. In first few days, she may need to suckled 5-10x before she has enough milk to swallow. Once milk has come in, you can hear her swallow each time she suckles. May sound like a huh rather than a loud gulp.

When Baby Doesn’t Latch Well: he might not get enough milk and breastfeeding may become difficult. Signs easy to spot:

  • Baby’s lips are pursed as though sucking on a straw
  • His cheeks appear sunken, bc there’s not enough breast tissue to fill his mouth
  • You hear clicking noises during a feeding
  • You don’t hear him swallow
  • He slips off your breast and roots frantically
  • You feel nipple pain that continues after the first minute of feeding

Contact lactation consultant or other breastfeeding expert for help.

When to Feed Baby: watch for feeding cues:

  • Baby roots toward anything that touches her cheeks/lips
  • Brings hand toward mouth
  • Thrusts out tongue often or makes lots of mouth movements
  • Makes lots of body movements
  • Awakes from drowsy state

Most show signals before beginning to fuss or cry, which are last-ditch efforts to communicate needs. Trying to feed crying baby is difficult.

Burping Baby: when baby feeds or cries, he may swallow air that travels to his stomach, causing fullness and possible discomfort. Burping releases the swallowed air, and until he can burp on his own (~2 weeks), he needs help doing so. Even after he can do on his own, may still need help if gulps air.

Burp after done feeding at each breast. If bottle-feeding, burp after 2 oz.

  • Over the shoulder – his head peeking over. Support across back and buttocks
  • Over the lap– lay baby on his tummy across your lap
  • Sitting and rocking – sit baby on your lap so he faces your side. Place thumb/index finger under chin. Gently rock from his front to his back.

Gently pat or rub baby’s back. If after a min or 2 he hasn’t’ burped, stop trying – he doesn’t need to.

When Baby Spits Up: during or after feedings, many babies spit up a dribble or more of milk (up to 2-3 tbsp common). Newborn has immature sphincter muscle at top of stomach, which lets milk and swallowed air back up esophagus. Not harmful and occurs only occasionally and baby is otherwise healthy. Typically outgrow ~6 months old, when begin eating solids.

More likely to spit up if you have a strong let-down reflex and abundant milk supply causing her to eat too much too quickly or swallow air. Try leaning back when nursing or sitting baby up during feedings. May spit up if she cries hard before a feeding.

Can reduce by burping baby when done nursing from each breast or every 2 oz after formula and don’t overfeed. To keep milk in baby’s belly, position upright in arms or on side if awake or sitting in car seat/swing w head elevated.

If continuously spits up or frequently vomits w force (projectile), may have serious condition. Call caregiver:

  • Baby seems in pain when spitting up (may be gastroesophageal reflux)
  • Baby vomits after every feeding and doesn’t poop frequently
  • Baby vomits after each of 2-3 consecutive feedings and seems weak, limp or lethargic.

Baby’s Feeding Patterns: frequency and duration change to facilitate growth. Breasts adapt to these changes.

  • First Days After Birth: after feeding vigorously during first few hrs postpartum, many healthy newborns show little interest in eating until 20-24 hrs old. By that time, most babies perk up and are eager to feed again. Moms should keep trying to feed throughout first day.
    • May want to feed in clusters (5+x in 3 hrs followed by deep sleep) or constantly until milk comes in. Watch for feeding cues. Newborns need to feed at least 8x every 24 hrs (1x every 3 hrs), but some may need 15-18x in first days.
  • Increasing Breastfeeding Success during First Days: if baby nurses well after birth, off to good start. Feed when hungry or at least 1x every 3 hrs. nurse most vigorously on first breast offered. Let at first breast for as long as he likes (10-30 min on avg in early days). When detaches from breast on his own, offer other breast (might/might not take it). Begin next feeding w other breast (make sure baby stimulates both breasts to make milk; if forget which one, see which one feels more full).
    • Ask staff to bring baby to you for nursing. Ask not to give baby bottles. Routine use of supplemental bottles can increase problems w breastfeeding by diminishing baby’s hunger and interfering w his desire to nurse. Milk supply might not increase enough to meet his needs.
    • Sucking on bottle nipple entirely different from sucking at breast. May develop nipple confusion. May find feeding from bottle easier and refuse breast
    • Pacifiers can also cause problems in first days and weeks. Using to delay feedings or distract interferes w milk supply. May lead to poor weight gain. Avoid offering until breastfeeding well established.
    • If hasn’t breastfed well before leaving hospital, get help from lactation consultant to prevent baby from becoming dehydrated or losing too much weight.

The First Weeks After the Birth: if baby is nursing frequently, can expect milk to come in on 2nd-5th day. Body gradually stops making only colostrum and begins to make milk. When milk comes in, breast become heavy, full, and tender. Nipples may appear flattened bc of swelling.

As baby gets older, eats every 1-3 hrs. as weeks pass, consumes more at each feeding, which may reduce # of feedings. Also begins to feed less at night and more during day. Babies don’t always eat at regular schedule, baby may cluster feedings, eating 4-5x in 5-6 hrs and then sleep

The First Months After the Birth: when baby is 2-3 wks old and has recovered from birth, begins to fuss and fret for ~hr or longer every evening as a way to cope w new stimulation. Baby cries, feeds frequently (as often as every 30-40 min), takes brief rests, then cries and feeds again. Frequent nursing stimulates breasts to make more milk to meet baby’s needs.

May experience fussy stages at 6 wks, 3 months and 6 months when baby is acquiring new skills. At 3 weeks old, baby awakens to his world. At 6 weeks old, starts to interact w others by smiling. 3 months- very alert to surrounding, recognizes 1 parent from another and can become overstimulated. At 6 months, masters sitting unaided.

Acquisition of new skills can affect feeding and sleep patterns until baby masters them. Feeding baby in quiet, dimly lit place can help him feed more during day. w/in a few days to a week, baby returns to more predictable schedule.

  1. Alternative feeding – Pasteurized donor milk
  1. International Code of Marketing of Breastmilk Substitutes 

  1. Newborn communication skills

Your Baby’s Communication: communicates via infant cues. Hungry – rooting, sticking out tongue, being wakeful or sucking on hand. Sleep – yawn and half close eyes. If don’t respond to cues, may fuss/cry to let you know hes hungry, lonely, uncomfortable or overstimulated. May take longer to satisfy his needs bc have to calm first.

Engagement Cues: return gaze when baby wants attention. From birth, baby can imitate facial expressions – try sticking out tongue or putting mouth in O. at 6 weeks old, baby begins to smile and coo. If overstimulate her, she may stiffen, arch her back or spread her fingers wide as if trying to push something away. Consider taking parent-infant class.

Crying: won’t spoil child by responding to his cries. He has no other way to tell you he needs something. Crying is often baby’s last attempt to tell you hes hungry, overstimulated, tired or uncomfortable. May cry bc has gas and needs to be burped. May cry bc has wet/dirty diaper (esp if cold), diaper rash, or sore circumcision site. May cry if ill or bc he wants to be held.

Responding to cries develops trust in your ability to meet his needs.

Soothing baby easier if you know why he’s crying.

  • Try feeding baby first. Some babies need to nurse frequently before taking a longer rest (>1 hr) bw feedings
  • Take bath w baby – warm water may calm her and she may breastfeed
  • Give baby gentle massage
  • Take baby for walk in baby carrier or stroller
  • Try Five S’s

If find self losing temper, put baby safely in bed/car seat and take a short break. If baby still agitated, never shake or roughly handle him. Call partner, friend to help.

The 5 S’s: Dr. Harvey Karp suggests calming babies w 5 S’s. Provides womb-like environment. Some need all 5; others just a few

  • Swaddling– increases how long baby sleeps by preventing her from startling herself awake. Use large, lightweight blanket or sleep sack. Can also put baby snugly inside baby carrier or bouncy seat. See PCNGuide to learn effective double swaddle technique
  • Side/stomach position – hold baby in your arms on her side (may aid digestion) or on stomach w gentle pressure against abdomen. Being held on back may cause her to startle easily
  • Shushing – near baby’s ear or use white noise (fan, radio static) loudly enough so she can hear it over her crying
  • Swinging – repetitive motion helps soothe babies. Sway, rock, jiggle, gently bounce on exercise ball. Swing from side to side in hammock made by holding 2 corners of a blanket while someone holds other corners. Baby swing.
  • Sucking– pacifier/finger. Feeding also calms her.

Colic or Fussy Periods: Bw 3-12 weeks, most have predictable fussiness in evening and early night (fuss and feed). In past, was called colic, defined as 3+ episodes each week for 3+ weeks, each lasting 3 hrs+.

Dr. T. Berry Brazelton – expert in infant development says normal touchpoint or parenting challenge. Overload of stimuli (Bright lights, loud noises, feelings of hunger) throughout day causes it. Baby’s immature nervous system begins to cycle into shorter sleep periods, more frequent feeding and more fussiness. At end of period, babies setting into longest stretch of sleep that may last 3 hrs+.

Bc overstimulation often causes excessive crying, use calming technique for several min before trying something new. The calmer you are, the easier it is for baby to settle.

All babies have gas; if baby seems esp gassy, use comfort holds that provide pressure against abdomen (sitting in arms, holding stomach when baby sideways). Can give baby simethicone (Mylicon) drops, but research hasn’t shown any better than placebo. Some give gripe water, which contains gas-reducing ingredients such as fennel, spearmint and ginger.

Some mistake colicky for GER or reflus (gastroesophageal reflux). Some of acidic stomach contents flow up esophagus, making tissue inflamed and painful. Babies w GER often arch and stiffen during feedings, may spit up or cough, may have sour breath and are esp uncomfortable on backs. Difference is GER constant during day and night; can be treated w medication and by positioning baby upright after feedings and for sleep.

If baby constantly crying in addition to vomit, spit up, cold, fever or constipation, call caregiver.

Fussy periods can be stressful – can see parents of colicky babies or support group for advice. If spending several hrs each day soothing baby, take a break now and then. Let a trusted person relieve you so you can take a walk. Or take baby on walk w other new parent and baby. These will end w time.

  1. Care of Newborn
  2. Baby basics: hygiene, clothing, diapering, safety, cord care

Caring For Your Baby at Home: once anticipation of birth is over, parents suddenly realize they are responsible for this tiny person, and whether they are up to challenge. Becomes easier w practice.   During 1st days/weeks, you’ll master diapering, bathing, dressing and comforting baby. Take newborn class before birth. Consider postpartum doula to help with baby care.

Car Safety: law in U.S. that every baby must be in car seat that meets safety standards. Will need ot have car seat that’s right size correctly installed in vehicle. www.aap.org/family/carseatguide.htm or www.saferchild.org/carseat.htm

If baby premature/weighs 5.5 lbs or less, staff will place baby in car seat for an hour to assess her ability to breathe adequately. If can’t breathe well at any point during hour, they will provide special car bed.

Diapering Your Baby: several options

  • Cloth diapers – design similar to most disposable brands, w Velcro tabs and elastic around leg holes. Usually used w diaper wrap or plastic pants to prevent leaks. Diaper services.
  • Pocket diapers – diaper wrap on outside and fleece liner on inside, which keeps baby dry and reduces diaper rash. Fill pocked w cloth diaper, hemp or other material that can be more absorbent than cloth diaper. Launder at home.
  • Disposable – may be more expensive.
  • Ecologically friendly disposable diapers and biodegradable diapers – can be composted if wet w only urine. Portion can be flushed if poopy.
  • Elimination communication (EC) – avoid diapers entirely or part of time. Common practice worldwide, where access to diapers/ability to launder is limited/unavailable. Requires paying close attention to cues to urinate/have bowel movement but eliminates/reduces cost and is ecologically friendly. Parents dress babies w diaper area open and unrestricted. When observe babies cues, hold baby over sink or special potty. Some people begin right after birth, some wait until baby is older. Some use around the clock, others during day or while at home.

Diaper Rash: many substances can cause, including urine/stool, laundry detergent, chemicals in disposable diapers. Can appear if inadequately launder baby’s cloth diaper.

Change diapers frequently and rinse skin w water at each change. Let skin air dry or blow dry w low/no heat.

Run cloth diapers through extra rinse cycle to reduce irritation from detergents or use milder detergent. To reduce amt of ammonia (urine), add ½ c vinegar to diaper pail or to rinse cycle. Plastic pants can trap moisture and cause irritation, may need to switch covers.

Diaper rash cream after clean/dry area. Visit www.cosmeticsdatabase.com to choose safe/effective. If persists, consult caregiver

Constipation: small, hard, dry stools that can be painful to pass. More common in formula fed than breastfed bc formula harder to digest.

If breastfeeding, ~1 month after birth may notice she’s pooping 1x a day/week – doesn’t indicate constipation. Her digestive system has begun to efficiently use more of your milk. If concerned, call caregiver.

Diarrhea and Vomiting: frequent, watery bowel movements and vomiting serious for babies bc can dehydrate quickly. Formula fed babies experience more often bc formula harder to digest and may be exposed to more contaminants.

Symptoms include more frequent stools that may smell foul, look bloody or contain mucus. Baby may appear ill, weak or listless. Call caregiver if see any signs.

Baby Clothes and Equipment: see pg 160 for list of things that appeal to you

Bathing Your Baby: newborns need bathing only 1-2x/wk. can bathe w wet soft cloth, but tub bath may be more enjoyable for both of you. Babies stay warmer/calmer. Warm water may soothe fussy babies and won’t increase risk of infection in cord or newly circumcised penis.

Fill sink/baby bathtub w comfortably warm water. Hold baby securely w head resting in crook of your arm of bend of your wrist, w hand gently grasping his arm. Lower into water so covers only body – not head/neck. W free hand, use only water to clean eyes/face. Wash hair w mild soap, massaging head w fingers or soft brush. Wash body w water or w mild baby soap. Let baby enjoy warmth of water. When bath done, make sure skin and hair are completely dry before dressing.

Many enjoy bathing w babies as a way to relax together. Fill w comfortably warm water. Get into tub first and have someone hand you baby. if no one available, line baby’s care seat w towel (to keep him warm and car seat dry if you return him there), set next to tub and pick up when in water. Lay him on his back on your thighs so water covers his body but not neck/head. Wash body w water or mild baby soap.

Cord Care: many different rituals/treatments to promote separation of umbilical cord from baby’s abdomen while preventing infection. Researchers have only studied a few.

Cleaning w rubbing alcohol and each change or letting cord dry naturally – infection didn’t result from either, cord that dried naturally separated a day earlier. Best care requires minimal intervention.

  • Wash hands before touching cord
  • Use baby soap (or no soap) to bathe baby, to maintain acid pH of her skin that helps reduce bacteria growth
  • To keep cord dry/clean, fasten baby’s diaper, diaper wrap and plastic pants below cord
  • If cord is soiled, gently clean w warm water and let dry thoroughly
  • If red, emits foul odor, oozes pus or bleeds bright red blood in a spot larger than a quarter, call caregiver. (When falls off, some dark brownish-red blood or clear yellow sticky fluid normal)
  • If baby leaves hospital w cord clamp attached, have caregiver remove at later date. Do not cut it off.

 

  1. Sleep and waking cycles

Baby’s Sleeping and Waking Patterns – after period of wakefulness after birth, many babies sleep for much of 1st day. Might not be interested in feeding. Others are awake, fussy, and feed frequently.

After adjusted, they sleep 12-18 hrs a day, in short but frequent intervals. As long as baby feeds and is growing well, how long they sleep shouldn’t be a concern.

When baby is older, may awaken at night to feed and then fall back to sleep. If hungry, she’ll root, suck on anything close by and wave her arms/legs vigorously. If don’t respond, she’ll cry.

Sleep Location – experts recommend babies sleep in same room in early months to reduce SIDS. Some have babies in cosleeper, basket, bassinet or crib near bed. Allows parents to quickly respond and to comfort baby w sounds of their breathing.

Others find they get more sleep if baby is in bed w them. Newborn has long wakeful periods at night just as he did while in womb and may sleep better w parents. Many put babies in crib, bassinet, cosleeper at beginning of night and then move into bed as morning approaches.

As baby grows older and needs you less at night, can move to crib or own bed in your room or another room. Or he can continue sleeping in bed w you.

Baby needs to be on back on a firm surface to reduce risk of SIDS.

Baby’s Sleep-Activity States – 6 states: deep sleep, light sleep, drowsiness, quiet alert, active alert, crying. Baby’s temperament affects states; you can’t control them

  • Sleep states
    • Deep sleep – baby still and relaxed; breathing rhythmic. Occasionally jerks or makes sucking movements, but rarely awakens.
    • Light sleep – most common; baby’s eyes closed but may move behind eyelids. Moves, makes momentary mewing or crying sounds, sucks, grimaces or smiles. Breathes irregularly. Responds to noises and efforts to arouse or stimulate her. When baby moves and makes sounds, wait a few moments to see if she’ll fall back asleep
  • Awake states
    • Drowsy, appears sleepy, activity level varies and may yawn/startle. Heavy-lidded eyes open and close for brief periods, lose focus or appear cross-eyed. Breathes irregularly and slowly reacts to sensory stimuli. If want to fall asleep, shush or pat him to settle. If want to be awake, pick up, sing or dance.
  • Quiet alert – most pleasing and rewarding. Baby lies still and looks calmly w bright, wide eyes. Breathes w regularity and focuses attentively on what he see/hears. By providing him something to look at, listen to, or suck on, you encourage longer times in this state
  • Active alert – baby is starting to need something, although he might not know what it is yet. Cant lie still; may be fussy. Eyes open but not as bright/attentive as when quiet-alert. Breathes irregularly and makes faces. Hunger, fatigue, noises and too much stimulation affect baby and may lead to fussiness/crying. If shows feeding cues, feed. If looks away, give less stimulation. If act immediately, may calm before cries.
  • Crying – baby’s last attempt to tell you he can’t cope any longer. If hungry, overstimulated, tired, sick, gassy, frustrated, wet, cold, hot or lonely, may have tried to communicate w subtle cues. Moves body actively, opens or closes eyes, makes unhappy faces, breathes irregularly. Sometimes, crying is a way to move into another state. Most often needs comfort.

Recording Baby’s Sleeping and Activity Patterns – by charting baby’s feeding, sleeping, quiet alert and crying/fussing periods for a week, may notice how long baby sleeps, is awake/content or cries. may notice fussy period at certain time. Or may notice takes long nap at certain time of day. As baby matures, patterns will continue to change. See PCNGuide for sample chart.

Tummy Time – babies sleep on back, spend time in car seats/swigs, back of heads can become flattened. To prevent misshapen head and give opportunity to lift head and strengthen neck muscles, place baby on tummy when awake for as long as she’s happy in position. Limit time in car seat etc that puts pressure on head. Many fuss when first on tummies but overtime begin to enjoy

  • Lay baby across lap
  • Lay baby on floor w nursing pillow supporting chest
  • Lay baby on exercise ball, hold her steady, and roll ball gently forward and back
  • Hold baby tummy-side-down while practicing postpartum exercises.
  • Baby upright in arms or baby carrier (Moby wrap or Ergobaby) provides tummy time

 

  1. Signs of illness needing medical help

Infant Massage – good way to calm/soothe baby and communicate love/care. Look for classes

  • Give baby bath. Make sure room is warm. Remove towel and lay baby on back on floor and kneel in front. Or lay on lap.
  • Vegetable oil/olive oil on palm, rub hands together to warm (don’t use baby lotion or oil – baby lotion will soak into skin too quickly and baby oil and other petroleum products aren’t healthy for babies)
  • Always keep 1 hand on baby. Massage arms, legs and other areas. Use as much pressure as enjoyable. Tell baby what you’re doing, sing a song. Don’t massage belly if belly is full and stop if not enjoying
  • Stroke w open palms, stroke w thumbs/fingers, rake w fingertips, tap lightly w fingertips, massage arms/legs w gentle wringing motion

Playing w Baby – when baby grabs/shakes rattle or plays peek a boo, discovering that he can make things happen. When you talk, coo, laugh, hug and kiss baby, he’s learning his responses affect you.

  • Sing and talk to him, dance w him
  • Caress, touch, cuddle when changing/feeding
  • Massage
  • Games such as peek a boo or age appropriate toys
  • Exercise w him
  • Use baby wrap, sling, carrier to keep hands free while baby experiences your everyday activities

Baby Wearing – 10 Reasons to Wear your Baby by Laura Simeon. Babywearing by Maria Blois book. Birthandbeyond.com, howtochbaca.html and wearyourbaby.com. Search YouTube.

Medical Care for Baby:

  • Well-Baby Care – periodic routine well baby exams. 3-4 days after birth, caregiver will assess feeding, check for jaundice and discuss concerns. May have another checkup at a week or 2 to possibly repeat newborn screening tests.
  • Vaccinations – biological agents, prepared in a lab, that can protect babies and children from specific diseases and common complications – including death.
    • Schedule – cdc.gov/vaccines/recs/schedules to see current schedule.
    • Potential side effects after injection.
    • Choosing against is a decision not to be made lightly. Mercury was once used as preservative and was though by some to increase risk of autism. Hasn’t been used since 2001; only exception is flu vaccine in multidose vial, which babies shouldn’t receive (after 6 months, should receive from single dose vial that doesn’t contain thimerosal).
    • Gather as much reliable info as possible. Dr. Sears Vaccine Book. PCNGuide has info about individual vaccines. Public health departments publish local data about # of cases in past month and year where you live. May influence decision about certain vaccinations.
    • Talk w baby’s caregivers. May decide not to follow schedule. Many child-care centers, preschools and schools require proof of certain vaccinations.
    • If baby has reaction to vaccine, inform caregiver so they can add to VAERs and record it. May also want to contact National Vaccine Injury Compensation Program (VICP). Hrsa.gov/vaccinecompensation

Tips to Protect Baby’s Health

  • Before picking up baby, feeding her and after diaper changes, wash hands or use sanitizer
  • Keep anyone w cold, cough, sore throat, rash, fever etc away from baby. if you are ill, wash hands thoroughly before feeding/caring for baby
  • Make sure parent/baby groups – all know not to attend if baby is sick
  • If baby is premature or has chronic health condition, ask caregiver for addtl info

Taking Baby’s Temp – anytime she seems sick (listless, weak, unusually fussy, loss of appetite, runny nose etc). Compare warmth of chest, abdomen or back to warmth of back of your neck. Don’t feel hands or feet as they are often cold even if body is warm.

  • Take temp under arm on skin or in rectum. Don’t use ear probe thermometers, temp strips place of forehead or pacifier thermometers as they aren’t accurate.
  • If temp <97.4F or >99.5 or temporal/rectal >100.4, call caregiver.
  • Axillary – hold under armpit until it beeps.
  • Temporal artery (TemporalScanner) is accurate, noninvasive and quick. Start above nose and move towards hairline. Studies show more accurate than rectal and ear (not accurate in babies under 6 months).   More expensive.
  • Rectal – lubricate bulb w nonpetroleum jelly or A&D ointment. Put baby on back and hold ankles in 1 hand. Insert until can’t see tip (1/2 inch). Hold for 3 min. clean w cold water and soap or alcohol.

When to Call for Medical Help – write down temp and any symptoms that worry you

  • Physical symptoms – abnormal temp, breathing difficulties, coughing, vomiting, diarrhea, constipation, fewer wet diapers than normal, rash
  • Behavioral symptoms – listlessness, weakness, loss of appetite, unusual fussiness/irritability, change in typical behavior and activity level
  • Any newborn warning signs
  • Home treatment you’ve provided and baby’s response; meds (what/when)
  • Recent exposure to illness, someone at home/day care who is sick
  • PCNGuide has work sheet to organize thoughts

Common Health Concerns:

  • Newborn Jaundice – after birth, baby has normal excess of red blood cells that break down into substance called bilirubin, which she excretes in her bowel movements. If baby develops jaundice, she has excess of bilirubin that causes skin or whites of eyes to become yellow by 3-4th day after birth. Half of newborns have milk yellowness in faces by this time, which disappears w out treatment. Occasionally, its more pronounced and may require treatment. To confirm baby’s chest is yellow, press fingers on breastbone; if looks yellow when you remove fingers, call caregiver. Caregiver may take blood sample from baby’s heel then use blood test to measure bilirubin level. Caregiver will make sure baby is getting enough milk; inadequate feeding may cause it bc baby who feeds poorly has fewer stools and can’t rid body of bilirubin. If necessary, baby receives phototherapy – procedures that shines special type of cool light on baby’s skin causing bilirubin levels to drop. 2-4 days until blood tests show bilirubin has fallen to safe level.
    • Can receive in 3 ways: in hospital, special overhead lights (bili lights) shine on baby’s naked chest/back; soft pads protect eyes; at home or in hospital, baby is wrapped in special blanket – can hold & feed baby w out removing from light source; at home/hospital, baby lies on back in net hammock over phototherapy source. Jaundice that appears on 1-2 days after birth (early jaundice) is more serious than 3-4 days; may require intensive treatment such as phototherapy or on rare occasion when bilirubin level very high, blood exchange transfusion to lower bilirubin to safe level and prevent possible hearing loss or severe neurological damage. If develops after 2 weeks, call caregiver. Causes (besides inadequate feeding) include prematurity, bruising during labor/birth, exposure to certain drugs given to mom in labor, liver/intestinal problems, sepsis (infection), and blood incompatibilities such as Rh or ABO incompatibility (when mom blood Is O and baby’s is A,B, or AB). Sepsis and blood incompatibilities typical causes of early jaundice.
  • Rashes – in first week, some develop red blotches w waxy yellow/white pimples in middle (erythema toxicum). Appears on trunk, arms, legs; doesn’t cause itching and disappears w out treatment. For first few months, common for baby to periodically have mild facial rashes (smooth pimples, small red spots or rough red spots). Rarely require treatment. Small white spots (milia) on baby’s nose, cheeks and chin occur when tiny skin flakes trapped in small pockets on skin surface. Milia disappear w/in a month or 2 of appearance. Red bumps (baby acne) may appear on baby’s face in first several weeks, due to increased oil production that began when some of your hormones transferred to him before birth. Applying breast milk as a lotion may help reduce rash.
    • Prickly heat is common warm-weather rash that appears on overdressed babies – found most often on shoulders, trunk and neck, looks like clusters of tiny pink pimples surrounded by pink skin. As it dries, rash becomes slightly tan. May look worse than it feels for baby. don’t let baby get overheated.
    • Yellowish, scaly, patchy cradle cap may appear on baby’s scalp and behind ears. Daily washing/brushing of scalp may help treat/prevent. Gently comb or brush using baby comb, fingernail brush or soft toothbrush. Wash w mild soap. Repeat every day or every other day until scales are gone. Massage w breast milk or veg oil before washing.
  • Colds – normal for baby to have slightly stuff nose or make rattle-like noise when breathes through nose, may have a cold if she had a very runny nose and goopy eyes, is fussiness than usual, has trouble eating/sleeping and perhaps has slight fever. To reduce risk, minimize # of ppl she comes into contact w, esp when younger than 3 months. Ppl w colds/other illnesses should stay away from baby. Make sure all who want to handle her wash hands thoroughly. Consult caregiver. May suggest using cool-mist vaporizer and putting her in semi-reclined position (car seat) to sleep. Clear baby’s nostrils by dripping saline/breast milk into each one then gently milking her nose to clear mucus (breast milk soothes mucous membranes and contains antiviral and antibacterial properties). Run a hot shower/bath then take baby into bathroom to breathe steam to ease congestion. Don’t give baby cold meds such as decongestants and cough medicine – not safe for infants.
  • Medications – if baby’s caregiver prescribes meds/vitamins:
    • To dispense liquid med, use medicine dropper placed bw baby’s cheek and gum; don’t squirt on tongue. Hold baby in semi-upright position and let them suck medicine as you gently squeeze dropper
    • Pour liquid medication into empty bottle nipple, then have him drink it all. When nipple is empty, fill w water and have baby drink it all as well. Ensures baby receives full dose bc he’ll drink any remaining medicine that was coating the nipple
    • Don’t mix medication in w pumped breast milk, formula, juice or water. If baby refuses to finish full bottle, you won’t know how much medication he’s received
    • Give only medication that’s specified. Aspirin – even baby aspirin- is no longer recommended bc associated w Reye’s syndrome, a serious disease
  • SIDS – sudden death of baby <1 that remains unexplained after thorough investigation. Cause not fully understood. Following facts may help fears:
    • Rare, occurring in 1/2000 babies in U.S
    • Most common bw 2-4 months
    • No one is to blame; cant be predicted/prevented
    • Death occurs quickly and painlessly; isn’t result of suffocation, asphyxiation or regurgitation
    • Isn’t caused by vaccinations. Statistically more common in those not vaccinated
    • Isn’t contagious
    • Support groups can help. First Candle, American SIDS institute.
    • To help prevent risk during pregnancy, eat healthful diet, don’t use cocaine/heroin, don’t smoke and avoid exposure to secondhand smoke and have regular prenatal care to reduce risk of prematurity
    • After baby is born, breastfeed her – can lower risk. Avoid overdressing baby. to keep warm, swaddle her or use blanket/sleep sack. Don’t expose her to 2ndhand smoke and place in safe position in safe location to sleep.

Safe Sleeping to Reduce Risk of SIDS – everyone who cares for baby – place baby on back to sleep. Tummy or side increases risk. If baby unhappy on back/wakens easily, try swaddling.

  • Make sure sleep space is safe – firm flat surface; avoid waterbeds, couches, sofas, pillows, duvets, quilts, comforters, soft materials, loos bedding, soft toys, lambskins and bumper pads in cribs. Make sure no space bw mattress and headboard or walls or bw crib mattress and crib slats – these may entrap baby and lead to suffocation
  • AAO recommends sleeping in same room as mom, but not in same bed. Controversial bc other experts recommend bed sharing for such benefits as frequent/convenient breastfeeding, reduced crying and better sleep for parents and babies.   Read sleeping w your baby by James McKenna, an international authority on cosleeping and its impact on reduction of SIDS.
  • Bed share safety: don’t share if parent has consumed sedatives, medication, alcohol or any substances that causes extreme drowsiness or unawareness, which increases risk of rolling onto baby and smothering. Baby shouldn’t share bed w smoker. If parent markedly obese, shouldn’t sleep next o baby to avoid causing depression in mattress that baby could roll into on his stomach.
  • Some use pacifiers to help baby fall asleep. Small decrease in SIDS w use, leading AAP to recommend them after a month old. Controversial bc breastfeeding may just as effectively help babies sleep. Only baby can decide if they want pacifier, not parent.

Babies w Special Circumstances – babies born early/small for gestational age may have special needs

  • Premature Babies – if born b4 37th week and weighs less than 5.5 lbs. Advances in care have increased survival rates and have greatly reduced long-term respiratory and neurological problems experienced by babies a decade go. Babies born as early as 24 weeks can thrive
    • If baby born before term, she looks different than full term baby does. She’s small, limp and frail. Skin is reddish and appears tissue paper thin and she has little to no fat or muscle. Head appears disproportionately large. Vernix caseosa and lanugo abundant, fingernails and toenails haven’t grown out and tiny ears are soft and hug her head. Cry is feeble and she may be more difficult to soothe
    • Physically vulnerable until grows older. Sucks weakly and swallow/gag reflexes unreliable. May need to be fed by tube into stomach

Newborn Warning Signs – if any appear in first month, report to caregiver

  • Fever (axillary >99.5F); infection
  • Temp <97.4F; may indicate infection caused by Group B streptococcus (GBS) or other bacteria
  • Baby’s face, chest and whites of eyes yellow; jaundice
  • Changes in baby’s behavior, such as listlessness or unusual fussiness or irritability – illness such as cold, viral illness or diarrhea
  • Problems w umbilical cord, including bright red bleeding, redness around cord or foul odor or pus-like discharge; infection or other problems w cord
  • Problems w circumcision, including continues bright red oozing or bleeding, swelling, foul discharge or inability to urinate – infection or bleeding from circumcision site
  • Problems w feeding, including breastfed baby who feeds fewer than 7-8x in 24 hrs, or any baby who feeds poorly; difficulty w breastfeeding, jaundice, illness or prematurity
  • Fewer wet diapers than expected: in 1st week, expect # to at least equal to day of life (3 on day 3; after day 7, expect 6+ in 24 hrs); inadequate feeding or illness
  • Problems w bowel movements, including no bowel movement in any 24 hr period in 1st After breastfed baby a month old, normal not to have for a day or longer; inadequate feeding
  • Problems w breathing, including blue lips, struggle to breathe, flared nostrils or deep indentations of chest when breathing; prematurity, illness or heart/lung problem

 

Hemolytic Disorders and Congenital Anomalies

Nurse should be alert to any deviations from normal, ranging from obvious congenital anomaly such as myelomeningocele, to a less obvious deviation such as congenital heart defect that can be asymptomatic at birth.

Complications that affect newborns can stem from 3 basic problems 1) problems relating to gestational age or intrauterine growth that do not follow normal patterns, such as preterm birth 2) acquired problems resulting from maternal or newborn physiologic factors, such as ABO incompatibility or infection and 3) congenital defects.

Hyperbilirubinemia – total serum bilirubin level in blood is increased. Normal values determined by gestational age, days of life, and baby’s general physical condition. Yellow discoloration of skin, mucous membranes, sclear and various organs. Discoloration referred to as jaundice or icterus. Jaundice primarily caused by accumulation in skin of unconjugated bilirubin, a breakdown product of hemoglobin formed after its release from hemolyzed RBCs. First appears in infant’s face and head and progresses toward toes. Dissipates in reverse order. Physiologic jaundice is most common finding in newborns and is usually benign. Challenge is to distinguish physiologic jaundice from serious clinical pathologic condition.

Physiologic Jaundice – occurs in >60% healthy term newborns and almost all preterm infants. Beginning after 24 hrs of age, unconjugated bilirubin levels in Caucasian and African American neonates gradually increase from 2 mg/dl to peak levels of 5-6 mg/dl at 72-96 hrs of age. In Asian-American infants, this takes 7-10 days.

More common in preterm infants, with serum bilirubin level typically reaching a mean peak of 10-12 mg/dl by 5th or 6th day of life. Takes longer for maximal concentration to be reached in preterm than full-term infants because of preterm infant’s immature liver function and slower metabolic processes.

Pathologic Jaundice – result of increased level of total serum bilirubin that if left untreated can result in acute bilirubin encephalopathy or kernicterus. Terms used interchangeably – acute bilirubin encephalopathy describes acute central nervous system manifestations seen in first weeks after birth, whereas kernicterus is used to describe the chronic and permanent results of bilirubin toxicity. Kernicterus, though rare, still occurs. Guidelines by AAP should result in kernicterus becoming largely preventable.

Diagnosis of pathologic jaundice that warrant further investigation:

  • Serum bilirubin concentrations of greater than 5 mg/dl in cord blood
  • Clinical jaundice evident within 24 hrs of birth
  • Total serum bilirubin levels increasing by more than 5mg/dl in 24 hrs or increasing at a rate of .5mg/dl/hr
  • Serum bilirubin level in term newborn that exceeds 12.9 mg/dl at any time
  • Serum bilirubin level in preterm newborn that exceeds 15 mg/dl at any time
  • Any case of visible jaundice that persists for more than 14 days of life in term infant

AAP guidelines note need for universal screening to identify elevated bilirubin levels in newborns to facilitate prevention of acute bilirubin encephalopathy and kernicterus. Use of hr-specific serum bilirubin levels to predict newborns at risk for rapidly rising levels is an official recommendation for monitoring of healthy neonates at 35 weeks of gestation or more before discharge from hospital. Use of nomogram helps determine which newborns might need further evaluation after discharge. In many institutions the nomogram is used to determine infant’s risk for development of hyperbilirubinemia requiring medical treatment or closer screening. Risk factors recognized to place infants in high risk category for developing severe hyperbilirubinemia included gestational age less than 37 weeks, exclusive breastfeeding, previous sibling who required phototherapy, predischarge transcutaneous bilirubin TcB or total serum bilirubin (TSB) level in high risk zone, cephalhematoma or other significant bruising, blood incompatibility with positive direct antiglobulin test, other known hemolytic disease such as glucose-6-phophate dehydrogenase (G6PD) and East Asian race.

Recommended that healthy infants (35 weeks+) considered low to intermediate risk of hyperbilirubinemia should receive follow up care within 2 days, w assessment of bilirubin levels based on risk assessment using tools such as hr-specific nomogram. Infants at higher risk for hyperbilirubinemia should be seen by health provider within 24 hrs or sooner, with assessment of TSB level. Other key recommendations include promoting successful breastfeeding; recognizing that visual estimation of degree of jaundice, particularly in darkly pigmented infants, can lead to errors; and providing parents with written and verbal info about newborn jaundice.

Many potential causes of pathologic hyperbilirubinemia are found in neonates. Most common are hemolytic diseases of newborn.

Potential Causes of Pathologic Hyperbilirubinemia in Neonates

Maternal Factors:

  • Rh and ABO or other blood group incompatibilities
  • Maternal infections
  • Maternal diabetes
  • Oxytocin administration during labor
  • Maternal ingestion of sulfonamides, diazepam, or salicylates near time of birth

Fetal/Newborn Factors:

  • Prematurity
  • Hepatic cell damage by infection or drugs
  • Neonatal hyperthyroidism
  • Polycythemia
  • Intestinal obstruction such as meconium ileus
  • Pyloric stenosis
  • Biliary atresia
  • Sequestered blood (from cephalhematomas, ecchymosis or hemangiomas)
  • Maternal blood swallowed by neonate
  • Glucose-6-phosphate dehydrogenase (GSPD) deficiency
  • Thalassemia

Hemolytic Disease of Newborn – occur most often when blood groups of mom and baby are different. Most common are ABO and RH factor incompatibilities.

4 major blood groups in ABO system are A, B, AB, and O. People with type A blood have A antigen; those with type B have B antigen; those with type AB have both A and B antigens and those with type O have no antigens. People with type A have plasma antibodies to type B blood; those with type B blood have antibodies to type A blood; those with type AB blood have no antibodies and those with type O blood have antibodies to types A and B blood. If person receives or is exposed to incompatible blood type, he will form antibodies against antigen in blood, with agglutination, or clumping, occurring as antibodies in plasma mix with antigens of different blood group.

Rh facto, genetically determined factor present on RBCs, can be a major source of incompatibility. Of several forms of Rh antigen, D antigen is most significant because it causes most antibody production in a person who is Rh negative.   Person who has Rh factor considered Rh positive; person without it is Rh negative. Mother who has A negative blood has A antigen, plasma antibodies to B antigen and no Rh factor on her RBCs.

Hemolytic disorders occur when maternal antibodies are present naturally or form in response to antigen from fetal blood crossing placenta and entering maternal circulation. Maternal antibodies of immunoglobulin G (IgG) class in turn cross placenta, causing hemolysis of fetal RBCs, resulting in hyperbilirubinemia and jaundice.

  1. Comfort measures

 

III. Maternal Transition

  1. Physical wellness

Physical Recovery: Later Postpartum Period – 3-8 weeks after birth, will get phsycial exam (including pelvic) to assess recovery and discuss any physical/emotional problems. Discuss family-planning.

Breast Self-Exam: examine every month. Visit komen.org/bse. Best to check right after menstrual period, when softest. If breastfeeding, check on first day of each month, after a feeding.

Only small % of changes indicate cancer, tell caregiver about thickening breast tissue, lumps that don’t disappear w/in a day or two, or non-milk discharge. Early detection can prevent growth/spread of disease.

Physiological third stage and maternal physiology – the process of returning to pre-pregnant physiology, which haemodynamically means reducing the circulating blood volume, commences immediately after birth. Active management postpones passage of blood per vagina to heavier lochia on days 2 and 3 and, if total blood loss could be compared between active and physiological methods at 3 days, the amounts would be very similar. The extra circulating blood has to be excreted – it is just the timing that differs according to 3rd stage care.

The extra bleeding of physiological care cleanses the uterine cavity, flushing out the placenta in the process. Active management, where bleeding is reduced, would result in more retained placentas. Early cord clamping results in blood being trapped in placental body causing baulking. Detachment from uterine wall is then more difficult. Only one trial of active management revealed more retained placentas.

Unclamping the maternal end to allow drainage of blood after severing the cord may reduce the incidence of retained placentas. This practice mimics physiological care where blood continues to flow, via the cord, out of the placental body after birth.

Early skin to skin showed benefits on duration of breastfeeding, mother infant attachment, less infant crying and cardio-respiratory stability. Active management does compromise immediate skin to skin a little. The cord has to be cut and placenta delivered by controlled cord traction all within minutes of birth. This may require the mother to move to a bed and a semi-recumbent position and this further disturbs skin to skin.

  1. Body restoration

Care in Days Following Birth

Your Care in the Days Following the Birth – if vaginal birth, postpartum stay is typically 1-2, unless there’s a medical reason. If cesarean, 2-4 days. At birth center, stay is 3-6 hours. Home birth, midwife leaves 3-4 hours after birth. Ask provider for newborn care tips and postpartum recovery tips. Can attend classes on these topics. You should be examined 3-4 days after birth (both you and baby) to detect jaundice, dehydration, and excessive weight loss in baby, your physical recovery, feeding issues, assess and treat pain and answer questions about baby care. If pain or a fever before this visit, or baby looks yellow, has trouble feeding or seems sleepy or listless, contact health provider. For non-medical concerns, childbirth educator, breastfeeding counselor, doula or other parents can give advice.

Physical Recovery: Early Postpartum Period: care provider will check temperature, pulse, respiratory rate, and blood pressure. Vaginal bleeding, uterus’s size, firmness and position, functioning of bladder and bowels. If you had anesthesia, they’ll monitor return of feeling and movement in your legs.

Uterus: returns to prepregnant size (called involution) ~6 weeks after birth. Immediately after birth of placenta, can feel the top of your uterus (fundus) at your navel. Uterus involutes (drops) the width of 1 finger each day and is firm and tight to prevent heavy blood loss from the site where the placenta attached to your uterus. Soon after birth, you or your nurse massages your uterus, stimulating it to contract. Nursing baby also helps. Afterpains can occur during pregnancy and are more common if you’ve given birth before. Usually disappear within 1 week. Ibuprofen helps.

Lochia is the bloody, fleshy smelling discharge that comes 6-8 weeks after the birth. Jellylike clots is normal, especially in first few days. It’s heavier when you change positions, are overactive, breastfeed or have a bowel movement. Within 10 days, it becomes pale pink or rust in color. After several weeks, it becomes white, yellowish white or tan.

If not breastfeeding, can resume menstruation 4-8 weeks after birth. If breastfeeding, can be several months or until you wean (you can become pregnant because you may ovulate before period). Can be heavier/longer than usual or lighter than normal until it returns to normal.

Cervix/Vagina: cervix approaches prepregnant size as uterus does. After birth, vagina gradually regains its tone and labia remains somewhat looser, larger and darker than before.

Breasts: 24-72 hours after birth, secrete colostrum (highly nutritious). Mature milk between 2nd and 5th day. Breasts may become engorged, which can present feeding challenges.

  • If not breastfeeding – to reduce production and increase comfort, apply ice packs to avoid stimulation. On 2nd or 3rd day after birth, wear snuggly fitting sports bra or wrap an extra wide elastic bandage across breasts to decrease swelling that occurs as milk comes in. Rewrap every few hours. Keep bound for 24-48 hours. Once milk comes in, apply ice for 20 min every 4 hours to decrease pain from inflammation and swelling. Can use frozen peas, corn etc. Tylenol for pain relief.
  • If baby has died, suppressing milk may cause a “second grieving”. Some mothers donate milk in honor of their babies.

Hormonal Changes: once you deliver placenta, estrogen and progesterone levels drop rapidly and remain low until ovaries begin producing these hormones again. If breastfeed, production of prolactin and oxytocin increases, while estrogen and progesterone remain low until you wean.

Circulatory Changes: you accumulate extra blood and fluid during pregnant. During birth, bleeding naturally occurs as uterus contracts to compress blood vessels that flowed to the placenta. Average blood loss ~1 cup. If had episiotomy or stable perineal tear, may lose more blood. Continue to lose blood in lochia for a few weeks. In early postpartum period, you urinate often and sweat heavily (especially at night) to lose the extra fluid accumulated during pregnancy. May lose as much as 5 lbs of fluid during the first week after birth.

Abdominal & Skin Changes: abdominal muscles are loose after birth and take several months to regain firmness.   Exercise speeds up the process. Stretch marks fade from red to silver but don’t completely disappear. If skin darkened during pregnancy, pigmentation will fade. Increased hair growth will disappear gradually. If pushed hard for a long time, rapid changes in blood pressure during and between pushes may have caused broken blood vessels in your eyes and on your face and neck; will disappear within a week or 2.

Hemorrhoids: swollen varicose veins in rectal area that can be as small as a pea or large as a grape. May itch, bleed, sting or ache, especially during a bowel movement. Many women develop during pregnancy, some develop after birth. Most disappear in 1st month postpartum. To prevent or help reduce discomfort/promote healing: take steps to prevent constipation, do Kegels – with emphasis on anal muscles, use witch hazel on area, take sitz baths, avoid heavy lifting (if have to pick up older child, do a super Kegel and hold it as you lift).

Bowel and Bladder Function: may have trouble urinating after birth because of a tear near urethra or swelling around it (from birth or bladder catheter). To help start flow, try to relax perineum, drink lots of liquids, or pour warm water over perineum (or try urinating in shower or bath). If still can’t urinate, call caregiver.

Birth may cause you to become constipated because of loose abdominal muscles, episiotomy, hemorrhoids or a sore perineum. Iron supplements and narcotic pain medications may also cause constipation. Prevent constipation by eating lots of fresh and dried fruits, veggies and whole-grain cereals and drinks lots of water. Add flax meal to food. Walking and exercising abdominal muscles helps restore normal bowel function, as does moving bowels when you have the urge (instead of waiting until later). If caregiver provides stool softener, follow instructions. When moving bowels, support perineum by gently pressing toiled paper against stitches to prevent tissue from bulging. If these tips don’t help, caregiver may prescribe laxative, suppositories or an enema.

Perineal Care: needs care, especially if bruised/swollen or have stitches for episiotomy or tear. Stitches dissolve in 2-4 weeks and tissue usually heals within 4-6 weeks, although can feel discomfort for some time. Discomfort during intercourse may persist for months. Contact caregiver if discomfort worsens or continues beyond several months.

Steps for Perineal Care:

  • Apply ice after birth and for next several days. Put crushed ice or a frozen wet washcloth in a zip lock bag and wrap in several layers of paper towel. Hold in place with perineal pad. Or dampen maxi pad with witch hazel and freeze.
  • Begin doing Kegels immediately after birth. Frequent pelvic floor exercises increase circulation, promote healing and reduce swelling.
  • After urinating, clean yourself by pouring warm water from front to back. Peri bottles helpful. Use toilet paper to pat dry.
  • Don’t use tampons before postpartum checkup
  • Don’t douche
  • Sitz bath – clean tub of warm water for 10-20 minutes. After bath, lie down for 15 minutes to decrease swelling caused by warm water. Can also use cold water, which doesn’t increase swelling.
  • Sit on plastic donut pillow to lift perineum off surface. Can make own by rolling bath towel lengthwise and shaping into a horseshoe.
  • Sit on firm surface if stitches causing pain
  • Lie down and rest as often as you can in first weeks after birth. Gravity can increase swelling and cause pelvic floor to ache.

 

Nutrition While Breastfeeding

Your Nutrition While Breastfeeding: During pregnancy, body prepares for lactation by storing 5 to 7 pounds of extra fat to provide calories necessary for milk production. In first month after birth, you lose a large amount of the weight gained, but may maintain some (or all) of this extra fat for the entire time you breastfeed.

In addition to stored fat, body draws on vitamin and mineral reserves to make milk. Although body can produce plenty of healthy breast milk regardless of what you eat, eating a poor diet may deplete your nutritional stores over time. Eating poorly also affects your health and your overall well being.

To maintain nutritional stores, make sure you diet consists of a variety of healthy foods and includes additional protein (which helps produce milk) and calcium. Many women’s diets don’t include enough calcium, as well as vitamin B, thiamine, folic acid, vitamin D, zinc and magnesium. A diet that’s deficient of these vitamins and minerals reduces a mother’s nutritional stores and poses health risks for both her and her baby. Caregiver may recommend that you take a vitamin and mineral supplement.

May have avoided certain foods during pregnancy – such as soft cheeses, raw fish and luncheon meats. These foods don’t harm your breast milk and baby when he consumes. Old wives tales say baby should nursing women should avoid cabbage, broccoli and spicy foods to prevent colic, but there’s no evidence to support.

Foods you eat flavor breast milk, which benefits your baby by introducing the flavors of foods he’ll eventually eat. Researchers found babies drank more breast milk when moms took garlic capsules. Breastfed babies ate peas and beans more readily than formula-fed babies, likely because they recognized the flavors of these veggies in mom’s milk.

Increasing volume of fluids does NOT increase milk production. Well-hydrated body simply keeps you from feeling thirsty and maintains your overall well-being. You are drinking enough when your urine is pale yellow.

Caffeine: Less than 1% of the caffeine you consume appears in your breast milk. A serving or 2 a day doesn’t affect baby. If you limited during pregnancy, you may find your sensitive to it postpartum.

Alcohol: concentration of alcohol in blood approximately equals the alcohol content in your breast milk. Best to avoid or drink only occasionally until baby is weaned. Researchers found babies consumed less breast milk after mothers drank.

If you drink, consume in moderation. Don’t drink more than 8 ounces of wine, 2 beers or 2 ounces of liquor per day. Breastfeed your baby before having a drink. That way, you satisfy his needs and allow time for the reduction or elimination of alcohol in your bloodstream (and breastmilk) before he nurses again.

Dieting: By 3 months postpartum, may women have burned the 5-7 lbs. of fat they acquired during pregnancy for milk production. After you’ve reached your prepregnancy or desired weight, consume enough calories to maintain your weight. You may only need ~300 more calories per day while breastfeeding. (If breastfeeding multiples or newborn and toddler, you need more).

If you haven’t shed extra weight and find extra pounds frustrating, limit weight loss to 1 pound per week. Consume at least 1,500 calories a day and avoid liquid diets and diet medications. Severely restricting calories compromises nutritional health and may make you produce less breast milk.

Food Sensitivity: Moms rarely eat foods that adversely affects baby. Baby may become excessively fussy or develop eczema, a rash or diarrhea after consuming breast milk containing protein from certain foods. Babies born into family with food allergies may react to some of the foods her mother eats. Most common allergens include cow milk, soy, wheat, eggs, fish, shellfish and nuts.

If you think a certain food bothers your baby, eliminate it for a week or so and see if baby improves. (If you eliminate milk, be sure to get enough calcium from other foods or a supplement). Discuss with caregiver or LC.

Some babies react negatively when moms eat large quantities of certain foods. Ex. Entire bowl of cherries, pitcher of juice, enormous amount of chocolate. Solution is prevention: eat all foods in moderation.

Some foods (kelp, seaweed, artificial colors) and vitamin/mineral supplements can tint the color of breast milk, but they don’t pose problems for most babies.

Early Breastfeeding Challenges and Solutions:

  • Breast Fullness and Tenderness: when breasts are full, best way to relieve normal discomfort and swelling is to nurse frequently. Full breasts can lead to swollen, flattened nipples and areolae, which your baby may have trouble latching onto. Can soften nipple and areola by hand-expressing a few drops of milk. Applying warm packs or standing n a warm shower may also start milk flow, making areola softer and easier for baby to latch onto. Once baby is feeding, press on breasts to enhance milk flow. Let baby feed for as long as she wants on first breast. If she doesn’t feed from other breast, hand-express or use a pump to reduce fullness in that breast. If baby can’t nurse after you’ve expressed milk, seek a LC.

If breasts are tender after feeding, apply a cool, moist pack or an ice pack (wrap in dish towel or apply over light clothing). Some women find applying cool cabbage leaves reduces tenderness and swelling. Can take ibuprofen to reduce discomfort and relieve inflammation.

Engorgement is fullness and tenderness you feel when milk comes in, but not symptoms of true engorgement, which is a more serious condition caused by unrelieved breast fullness. True engorgement may produce a fever higher than 101 degrees F, acute continuing breast pain, tingling and numbness in the arm and fingers, and difficult removing milk from the breast even with a pump.

Breast fullness and tenderness when milk comes in usually doesn’t last longer than a day or two and can be relieved by mother, whereas true engorgement may need help of LC.

  • Sore Nipples: nipples may become sore any time you breastfeed, but are most common during first weeks. May have it only when baby first latches on, or soreness may last throughout entire feeding and between feedings. May cause discomfort or intense pain, but treatment almost always resolves problem. Common cause is overly vigorous or incorrect pumping. Other causes:
    • Early tenderness: most women’s nipples are tender at beginning of feedings, but usually lasts only a few weeks. As baby learns to nurse, his mouth tugs, compresses and rubs your nipple and areola. As feeding progresses for 30 sec or so, pain lessens or ends. After feeding, nipples may appear slightly reddened, bruised, or swollen. To help reduce, hand-express a few drops of milk to soften areola before feeding, then help baby latch on well.
    • Poor latch: if nipples remain sore throughout feeding (and afterward) or begin to crack or bleed, poor latch is likely the cause. Baby might not latch well if mom’s breasts are too full or engorged, or if mom has flat or inverted nipples. Baby may also have trouble if she bites instead of suckles, if she tucks her lower lip inward during feedings, or if her mouth is only slightly open (not wide open) and she latches onto only the nipple. Premature or ill babies may latch poorly. A neurological or anatomical condition may prevent otherwise healthy babies from latching on and sucking well. A tight frenulum (“tongue tie”) is when the thin membrane that extends from the bottom of the tongue is too short to let the tongue protrude from the mouth.
      • Suggestions for treatment: Correct the latch; nurse frequently (if you delay, breast become fuller making it harder to latch); start on least sore breast because babies feed vigorously at beginning of feeding; hand-express some milk before feeding to often areola and make latching easier; if sore where baby’s bottom lip rests on your breast, she may be tucking that lip inward over her gum – gently pull her lip out when she feeds; before pulling baby from breast to reposition her, first slip your finger into her mouth and break the suction so your nipple comes out easily; if using nursing pads, change whenever wet; take a pain relief medication, such as ibuprofen; see a lactation consultant – she may recommend nipple shields, nipple creams or a hydrogel
    • Infection: persistently sore breast or nipples (often cracked and bleeding) are typically result of bacterial infection (most often Staphylococcus aureus), a fungal (yeast) infection, or a herpes infection (if its herpes, you must discontinue breastfeeding on that breast until the herpes sore heals). If bacterial, physician may prescribe antibiotic cream or suggest using a combination cream to treat bacterial and yeast infections and reduce inflammation; they occasionally recommend oral antibiotics. Yeast infections cause soreness less often than other infections. If you have a yeast infection, your nipples may look dark pink, shiny and irritated, or they may look normal. Small blisters may appear. Antibiotic therapy often precedes yeast infections and a vaginal yeast infection can lead to a yeast infection of the nipples. Yeast infections also occur when a baby has a yeast diaper rash or has a yeast infection of the mouth (thrush). For a yeast infection, bot you and baby need treatment. Eating yogurt is one home remedy you may try, by itself or in combination with other treatments. Be sure it contains live cultures, particularly acidophilus and bifidus, to restore the delicate balance of microorganisms in your body. Stress or antibiotic use can upset this balance and cause an overgrowth of yeast. Can also take acidophilus pills or probiotics. Caregiver may prescribe oral medication and suggest using a topical over the counter anti-fungal cream to teat nipples and baby’s diaper rash. Baby’s caregiver may prescribe a liquid medication such as nystatin suspension to apply to baby’s mouth.
    • Breast Pain Caused by Let Down: At the beginning of a feeding, some women experience a sharp, deep pain behind the areola that subsides when the milk begins to flow. This pain doesn’t indicate a problem and usually disappears over time without treatment. Oxytocin is probably the cause; the release of this hormone shortens and widens the ducts, thereby increasing pressure as milk flows through them. If you had breast surgery, let-down may stretch scar tissue and cause pain. Slow breathing may help relieve pain.
    • Leaking: During first few weeks or months, breast may leak milk. As breasts “learn” how much to make and when to let down, the leaking usually subsides. It typically occurs when breasts are very full, wen you hear your baby cry, or when you’re sexually aroused. Preventing leaking: when feel milk letting down, discreetly press your hands or forearms firmly against your breasts to slow milk flow; compress nipple between thumb and index finger to stop flow; to prevent soaking clothes, wear washable cotton or wool nursing pads or disposable pads and change when become damp. Avoid using pads with plastic liners; they retain moisture, which contributes to nipple soreness.   Some mothers like using silicone pads that exert gentle pressure over the areolae to stop leaking (Lilypadz is a popular brand)
    • Plugged Ducts: if breast gradually develops a tender, swollen lump or a sore area (but you don’t have a fever), you probably have a plugged duct. The area near the plugged duct may be reddened. Apply a warm, moist washcloth to the sore area before and during feedings; feed from the sore breast first; press from behind the sore area toward the nipple during feedings; nurse your baby in a different position so his mouth puts pressure on different places on the breast; while showering, massage breast, pressing from plugged duct toward nipple; avoid wearing poorly fitting bras – they may obstruct milk ducts. Check fit of baby carrier – some straps press on breasts and affect milk flow; pay attention when using a breast pump – pressing the flange unevenly on your breast can reduce milk flow in one area. It may take a few days to clear, but have caregiver evaluate any lump that doesn’t disappear in a week or two.
    • Mastitis: infection of the breast that appears suddenly and can occur any time while you’re nursing. Besides a tender, reddened breast, symptoms include fever, chills, fatigue, headache, and sometimes nausea and vomiting. Caregiver will prescribe antibiotics and advise to: continue to nurse from both breasts (the milk isn’t infected and doesn’t harm baby); take all prescribed antibiotics (if you stop when you feel better, it will return); rest in bed until you feel better; drink plenty of fluids; apply a warm, wet washcloth on the painful area to help increase blood circulation to the breast; take ibuprofen or acetaminophen to reduce fever, pain and inflammation; avoid wearing constricting bras and clothing so milk can flow easily. During feedings, massage or gently rub your breasts if pressure around the sore area feels good. If you don’t feel better within 24 hours after starting antibiotic treatment, call caregiver. You may need a different antibiotic.

Softening Areola by Hand Expression (to soften nipples to make them easier for baby to grasp, follow these steps before he latches on):

  • Place thumb at top edge of your areola (where it meets your skin) and your fingers on the bottom edge
  • Lift breast with fingers and thumb (to keep them from slipping to the end of your nipple, gently press breast toward your chest with your hands)
  • Gently squeeze your breast for 5-10 seconds. Then move fingers and thumb other locations at the edge of your areola. Continue squeezing and pressing your breast against your body until milk releases.
  • Stop when you see a few drops of milk or when the areola is smaller in diameter.

Enhancing Milk Flow with Breast Pressure and Compression: When breasts are very full, pressing on breast helps milk flow toward your nipple. Sometimes called breast massage, this method doesn’t call to rub breast in circles. Instead, you apply breast pressure or compression. Press milk toward nipple openings and into baby’s mouth, which prompts a burst of suckling.

Breast Pressure: helps relieve breast fullness; helps empty plugged ducts and provides more high-calorie hindmilk for baby

  • When baby takes long pauses at the breast of stops suckling, put your palm on your chest near the outer edge of your breast.
  • Slide your palm on your breast until you feel the firm milk glands
  • Press gently from the outer breast toward the nipple. Stop before you get close to the areola. Pressing near the areola can affect baby’s latch
  • When your baby begins to suckle less, move your hand to another part of your breast and repeat these steps.

Breast Compression: helps babies eat more, especially those gaining weight slowly and entices sleepy babies to continue feeding

  • Cup breast with your hand, placing your thumb and one to two fingers near the outer part of your breast
  • Squeeze your finger(s) and thumb together and slightly press into your breast, then out toward your nipple
  • When baby begins to suckle less, cup your breast in another position on the breast and compress it again.
    1. Self-care with support

Physical Recovery: Later Postpartum Period – 3-8 weeks after birth, will get general physical exam & pelvic exam to discuss physical /emotional problems and family planning. Will recommend regular pap smears.

 

Breast Self Exam – every month. Visit www.komen.org/bse. Check right after menstrual period, when they’re softest. If breastfeeding, check on the 1st day of each month, after a feeding. Although only a small % of breast changes indicate cancer, tell caregiver about thickening breast tissue, lumps that don’t disappear within a day or 2, or non milk discharge. Early detection can prevent growth and spread of the disease.

 

Caring for Yourself after Birth – eat well, get adequate rest, and ask others for help with chores, meals and other tasks while you care for baby.

  1. Nutrition

Nutrition – In the postpartum period, continue eating healthful foods, as you did during pregnancy (See Ch. 6). If you’re breastfeeding, see page 417 for nutrition suggestions.

Don’t drastically change or restrict your diet to lose weight. The maximum amount of weight you should lose per week is 1 to 2 pounds. Most new mothers lose pregnancy weight gradually over several months without special effort.

If you’re anemic, your caregiver may recommend that you continue taking prenatal vitamins and iron supplements.

To prevent constipation, ensure your diet contains plenty of fiber.

  1. Rest and Sleep

Rest and Sleep – fatigue and sleep deprivation can greatly challenge your physical and emotional recovery. Even if can’t sleep, try to rest. Babies sleep as much during day as does at night, but will begin to sleep longer at night with family. If she doesn’t, try to sleep when baby sleeps.

  • Make sleep a priority. Forget about household needs
  • Limit visitors
  • Try relaxation techniques
  • Keep baby close so don’t strain to listen to her
  • Or have baby sleep in other room while you rest and have someone else take care
  • If partner available, take turns taking care of baby. Parenting shifts.
  • Recipe for sleep in first weeks: find out how much sleep you need to function well – that’s the amount you need. You’ll need a bit more since feedings and baby care prevent full sleep. Stay in bed until you’ve slept enough. Keep mental note of how long you’ve slept. Don’t brush teeth, shower or dress until you’ve slept requirement. May take until noon or later the next day to get out of your pajamas. May be easier for baby to sleep with you.
  • Asking for Help- Accept any offers. Can also hire part time household help or postpartum doula.
    1. Activity

 

Physical Recovery: Later Postpartum Period

Postpartum Fitness – moderate activity (walking) and gentle conditioning exercises can speed recovery. Begin when you feel ready if had normal birth. After several weeks to months, can resume more vigorous exercise. Listen to body and stop if experience pain or have increased vaginal bleeding. As you increase your exercise, energy, motivation and endurance will improve.

  • Exercises to condition muscles and release tension – abdominal muscles require exercise to recover their former shape while avoiding further separation or diastasis. Pelvic floor muscles need exercise to increase circulation, reduce swelling and promote healing in the perineum and restore vaginal and rectal muscle time. Each time you change diaper, contract pelvic floor muscles or do pelvic tilts. Before or after feeding baby, do head tilts and shoulder circles. During feeding, do transverse abdominal contractions.
  • Core and Postural Exercises – do every day or 2, especially the pelvic floor contractions
    • Reducing Separation of Rectus Abdominis Muscles –before doing and ab exercise other than transverse ab crunches and pelvic tilts, check ab muscles for separation. Muscles form chest to pubic bone. Separation normal, but your help is required to close gap. Lie on back with knees bent. Press fingers of one hand into abdomen just above navel. Slowly raise head and shoulders. A gap 1 inch or less indicates normal separation and doesn’t need to be closed. Gap 2-3 inches indicates you need to close gap before doing crunches and other ab exercises. If don’t close gap, exercise will only increase separation. To help narrow a large gap, do transverse abdominal contractions and head lifts. Can do other exercises after gap has narrowed to width of 1-2 fingers.
    • Pelvic Floor Contraction (Kegel) – after birth, do 2-3 Kegels whenever you can, then progress to 5 each hour. Work to holding contraction for up to 20 seconds (super Kegel).
    • Pelvic Tilts (contract pelvic floor when doing) pg 97
    • Transverse abdominal contractions – start w 3 per day
    • Head Lifts – as lift head, pull bellybutton toward spine and use hands to pull side abs toward each other – hold for 5. To close separation, repeat 20x/day and increase as able.
    • Bridge pose – tones hamstrings and butt. Hold for several breaths.   Repeat 5-10x/day.
    • Pectoral Stretch, Hip Flexor Stretch and Posture Check – pg 99
    • Tension Relievers
      • Head tilts – tilt head toward right ear and hold 10 sec. don’t let shoulder rise. Repeat on left. Do 1x/day
      • Shoulder Circles –
      • Relaxation and Slow Breathing – 5 min of slow breathing, passive relaxation, relaxation countdown or 5 min mediation. Do when you have a moment to realize what a phenomenal job you’re doing as a parent.
    • Peek a boo Yoga – place baby on back underneath you so baby is at eye level. Do cat pose, child’s pose, opposite limb extensions, child’s pose, downward facing dog, child’s pose, downward facing dog, child’s pose, half dog pose, bridge pose, corpse pose with 5 min meditation
    • Postpartum fitness after cesarean – ch 14 – deep breathing, knee bends, abdominal pull ins and rolling from back to side while bridging. Pelvic floor exercises. Wait 6 weeks before any strenuous exercise, including previous exercises or consult caregiver.
    • Postpartum fitness after challenging pregnancy/birth – multiples, bed rest – conserve energy initially, until you can do things normally. As resume daily activities, strength will return.   May tire quickly at first. Don’t compare progress with other women. Celebrate every accomplishment.
    • Note to fathers/partners – when partner ready, encourage her to exercise, but don’t pressure her. Help her make time so you can spend time with baby or exercise with her to spend time together.

Adapting to Postpartum Life – at some point, will experience postpartum adaptation (postpartum recovery), where life returns to more predictable pattern. You can feel rested most of the time and enjoy previous interests again.

  • Parenting Groups and New Parent Classes – connecting with other parents will ease transition. Learn about local groups and classes before baby’s birth
  • Sex Life – some say wait 6 weeks. Can do so after stiches healed and lochia decreased. Hormonal changes reduce vaginal lubrication so use water soluble lubricant. Can cuddle if not feeling ready. If don’t want touch, express feelings honest but respectfully – discuss other ways you can enjoy each other. You can become pregnant before you begin to menstruate. A condom in combination with spermicidal foam, cream or jelly is safe and effective soon after birth. If breastfeeding, may leak breast milk during intercourse, especially while orgasm. Oxytocin plays role in orgasm and milk ejection (let down).
  • Parenting with a Partner – both don’t need to do things the same way. Arrive at comfortable solution together. Consult caregiver, parent educator, postpartum doula or baby care book for ideas. Let small things go and work on large issues. Try not to interfere with each other’s parenting.
  • Fathers/partners: may feel frustrated that mother can sooth baby and meet baby’s needs better. Ch 17 & 18 baby care and soothing skills
  • Changes in family relationships – grandparents may want to be overly involved. Children may want to be involved or not. Strain on relationships – pg 361. If single parent, need help of family. Pg 362

Postpartum Emotional Changes – will decrease within a few weeks. Others may require treatment

  • Baby blues – 80% of new mothers experience within first week – crying easily, feeling overwhelmed/out of control, exhausted, anxious, sad, lacking confidence. Rarely last longer than 2 weeks. Get rest; reduce pain and surround with supportive people. If feeling sad, get support immediately.
  • Postpartum mood disorders – 20%; more serious than baby blues. Ch 16

Putting Parenthood into Perspective – live first 1/3 of life before becoming a parent/focus on relationship. Spend next 1/3 having and caring for children – and spend less time on relationship. Make time with partner for conversation and shared activities. Make time for own interests so you keep growing as an individual, as well as a parent and partner. Last 1/3 of lift with an “empty nest”. Time spend as a parent of a baby is brief.

  1. Signs of illness needing medical help

Warning Signs after Birth that require Medical Attention:

  • Fever (over 100.4) – can be uterine infection, bladder/kidney infection, breast infection (mastitis), episiotomy tear/infection, cesarean incision infection, other illness
  • Burning with urination; blood in urine – bladder/kidney infection
  • Swollen, red painful area on leg (especially calf) that’s hot and tender to touch –thrombophlebitis or deep vein thrombosis (blood clots in blood vessel); do not rub or massage
  • Sore, reddened, hot painful area on breasts along with fever/flu-like symptoms – breast infection (mastitis)
  • Passage of blood clot larger than a lemon followed by heavy bleeding, or any bleeding heavy enough to soak a maxi pad in an hour or less – passage of some (but not all) or a retained placenta; uterine infection
  • Vaginal discharge that has extremely foul odor (like spoiled fish); vaginal soreness or itching – uterine infection, vaginal infection
  • Increased pain at site of episiotomy or tear; may be accompanied by foul-smelling or pus-like discharge: infection of episiotomy or tear; reopening of incision/tear
  • Opening of cesarean incision; may be accompanied by pus-like discharge or blood – infection of cesarean incision
  • Rash/hives, itching – allergic reaction to medication
  • Severe headache that begins after birth and is worse when upright – spinal headache following regional anesthesia
  • Sudden onset of pain that’s new, such as abdominal tenderness or burning near perineal stitches when urinating – uterine infection; reopening of perineal tear or incision
  • Pain/tenderness in front or back of pelvis, difficulty walking and “grating” sensation in pubic joint – separation of pubic symphysis (cartilage between pubic bones in front of pelvis)
  • Feeling extremely anxious, panicky or depressed accompanied by rapid heart rate, difficulty breathing, uncontrollable crying, feelings of anger, or inability to sleep or eat – postpartum mood disorders, including anxiety and panic attacks, obsessive thinking or worrying or depression
  • Frightening relationship with partner; being verbally or physically abused – domestic violence increases during pregnancy and after the birth. Call National Domestic Violence Hotline. 800-799-SAFE
  1. Emotional wellness

In U.S, over 3.5 million women give birth each year. Perinatal depression rate is ~20% so 70,000 will become ill. Rate of gestational diabetes is bw 1 and 3% and rate of down syndrome in 35 yr old mother is 3%. Screening routine for diabetes and down syndrome, but not perinatal depression (pregnancy through 1st year postpartum), which occurs in 1 in 5 mothers.

Perinatal Psychiatric Illness – perinatal mood and anxiety disorders (PMADs) occur during pregnancy and first year after a woman gives birth. Triggered mainly by hormonal changes, which then affect brain chemicals called neurotransmitters. Life stressors (moving, illness, poor partner support, financial problems, social isolation) affect mental state. Strong emotional, social and physical support will help her recovery. Can occur at different times of day and can feel very different from other depression.

Perinatal Mood and Anxiety Disorders: 6 main ones: depression, OCD, panic disorder, psychosis, PTSD, bipolar disorder I or II (AKA bipolar spectrum disorder).

Psychiatric Issues of Pregnancy: 15-23% experience depression. Higher in teenagers and poor women. Risk factors include life stress, history of depression, lack of social support, domestic violence and unplanned pregnancy.

26.5% had histories of depression before pregnancy, 33.4 % had first occurrence during pregnancy and 40.1 % developed postpartum as first depression.

Pregnancy vs Depression

Pregnancy: mood up and down, teary, self esteem unchanged, can fall asleep, physical problems may waken (bladder, heartburn), can fall back asleep; tires easily, rest refreshes and energizes; feels pleasure, joy and anticipation; appetite increases

Depression: mood mostly down, gloomy, hopeless; low self-esteem, guilt; may have trouble falling asleep, may have early morning wakening and difficulty falling back asleep; rest does not help reduce fatigue; lack of joy or pleasure; appetite may decrease

Depression and Anxiety in Pregnancy: when difficult to function on a day to day basis, need treatment – can be traditional (counseling/meditation) or nontraditional (yoga/acupuncture). Use whatever works best. Depression during pregnancy associated with low birth weight (less than 5.5 lbs) and preterm delivery. Severe anxiety may cause harm to a growing fetus because cortisol (hormone released during stress) can place constriction of blood vessels in placenta. Rate of relapse for major depressive disorder in women who discontinue medication is between 50 and 75%. Depression/anxiety occur in 15-23% of pregnant women; higher rates in teens and women of color; can occur anytime during pregnancy. Symptoms: sad mood, irritability, lack of joy/pleasure, not looking forward to future; guilt; excessive worry or fear; social withdrawal; appetite and sleep disturbances. Risk factors: personal/family history; lack of support; stopping psychiatric medication; history of abuse, domestic violence; history of pregnancy loss

“Baby Blues” – not a disorder – used to describe milk mood swings that occur after first few weeks of birth (begins first week postpartum; should be gone by 3 weeks postpartum). Not considered a disorder since majority of mothers experience it (80%). Symptoms: moodiness, crying, sadness, worry, lack of concentration, forgetfulness, feelings of dependency. Causes: rapid hormonal changes; physical/emotional stress of birthing; physical discomforts; emotional letdown after pregnancy and birth; awareness and fear about increased responsibility; fatigue and sleep deprivation; disappointments including the birth, partner support, nursing and the baby.

Depression & Anxiety Postpartum – 15-20% of mothers; onset usually gradual but can be rapid and begin any time in first year. Symptoms: excessive worry/fear; irritability/short temper; feeling overwhelmed and unable to cope; difficulty making decisions; sadness; hopelessness; feelings of guilt; sleep problems (often can’t sleep or sleeps too much); fatigue; physical symptoms or complaints without apparent physical cause; discomfort around baby or lack of feeling toward baby; loss of focus/concentration (miss appointments); loss of interest of pleasure; lower sex drive; changes in appetite, significant weight loss or gain. Risk Factors: 50-80% risk if previous postpartum depression/anxiety; depression or anxiety during pregnancy; personal or family history; abrupt weaning; social isolation or poor support; history of PMS or PMDD; negative mood changes while taking birth control or fertility medication; thyroid dysfunction; stopping psychiatric medication

Obsessive Compulsive Disorder (OCD): up to 9% of new others; of those – over 38% have depression. Symptoms: intrusive, repetitive, and persistent thoughts/mental pictures; thoughts often about hurting/killing baby; tremendous sense of horror and disgust about these thoughts; thoughts may be accompanied by behaviors to reduce anxiety (hiding knives); counting, checking, cleaning or other repetitive behaviors; fear of germs; fears about own health. Risk Factor: personal/family history of OCD (diagnosed or not)

Panic Disorder: 10% of postpartum women. Symptoms: episodes of extreme anxiety; shortness of breath, chest pain, sensations of choking or smothering, dizziness; hot or cold flashes, trembling, rapid heart beat, numbness or tingling sensations; restlessness, agitation or irritability; during attach the woman may fear she is going crazy, dying or losing control; panic attack may wake her up; often no identifiable trigger for panic; excessive worry or fears (including fear of more panic attacks). Risk Factors: personal/family history; thyroid dysfunction

Psychosis: serious – person loses touch with reality. 1-2 per 1000 perinatal woman. Onset usually within first 2 weeks after birth. 5% suicide and 4% infanticide rate. Symptoms: seeing, hearing, feeling thing that others do now (voice of God, devil, secret messages from TV); delusional thinking (infants death, denial of birth, or need to kill baby); mania; confusion; paranoia; symptoms that come and go (normal one minute, hearing voices the next). Risk Factors: personal/family history of psychosis, bipolar disorder or schizophrenia (diagnosed or not); previous postpartum psychotic or bipolar episode

Post-traumatic Stress Disorder (PTSD) – occurs following life-threatening or injury producing events such as sexual abuse or assault or traumatic childbirth. Occurs in up to 6% of women; rates are higher (up to 30%) for parents who have a child in NICU. Symptoms: recurrent nightmares; extreme anxiety; reliving past traumatic events. Risk factors: past traumatic events; traumatic birth; severe physical complication or injury related to pregnancy/childbirth; baby in NICU

Bipolar Disorder I or II (sometimes referred to as Bipolar Spectrum Disorder): AKA manic depression, bipolar disorders are characterized by mood swings from very high (mania) or high (hypomania) to low mood (depression). No data about how often this occurs. Women usually seek help during episode of depression and commonly misdiagnosed as depression rather than bipolar. Symptoms: mania (bipolar I)or hypomania (low level of mania in bipolar II); depression; rapid and severe mood swings. Risk Factor: personal/family history

Consequences of Untreated Parental Depression on Children: placed on top of list affecting children’s readiness for school. Impact may continue through childhood and into teen years. 50% of kids who have depressed moms will have depression by end of adolescence. At least 10% of fathers are moderately or severely depressed. Less than 50% of these dads report regularly reading to their 1 year olds. Children of depressed parents more likely to suffer from childhood psychiatric disturbance, behavioral problems, poor social functioning and impaired cognitive or language development. Suicide is the second leading cause of death in new mothers during the first year. Get treated right away to help ensure a healthy family.

Perinatal Loss: miscarriage occurs in 20% of pregnancies, but women don’t talk about it. Important to find support and know you are not alone. Women who’ve have had any neonatal loss need to be monitored carefully for distress in future pregnancies and postpartum period. Both parents suffer. Moms go through immediate psychological and emotional reaction; partners feel the need to be strong. 36% of dads suffer severe anxiety at 6 weeks after a pregnancy loss. Dads found to have more depression than moms at 13 months after the loss. Sometimes women interpret partners initial stoic response as a lack of caring. Couples need to communicate. Support plan should include nutrition, sleep, social support and possible medication.

 

No one is immune –doesn’t matter your profession. No matter the educational, socioeconomic level, culture, religion or personality, statistics remain consistent.

Finding a Therapist or Medical Practitioner: Postpartum Support International (PSI) at 800-944-4PPD or postpartum.net. Do not assume someone with expertise in depression or anxiety knows about perinatal mood disorders. Most insurance companies have coverage for mental health. If you can only see a doctor on their list, use these screening questions (or ask a support person to do this for you). Medical practitioners should be asked if they are comfortable prescribing psychiatric medication to pregnant/breastfeeding mothers: specific training in perinatal disorders; belong to any organization dedicated to education about perinatal mood and disorders (PPI, Marce Society, North American Society for Psychosocial OB/GYN); books recommended; theoretical orientation (research shows most effective types of therapy are cognitive-behavioral and interpersonal – you are experiencing a life crisis; long term intensive psychoanalysis is not appropriate). If can’t find, look for someone compassionate and willing to learn. Shop around until you feel satisfied that you are in capable hands.

Remind Yourself: I will recover (they have never met a women who didn’t’ after proper treatment)!; I am not alone! (1/5 women); This is not my fault (it’s a real illness); I’m a good mom (getting help shows you are taking care of family); It is essential for me to take care of myself (to get back to family). I am doing the best I can (you are taking steps, regardless of how small they seem). Depression may interfere with ability to believe these statements so say them frequently.

Basic Mom Care: many women uncomfortable asking for help since we are supposed to be supermom. It takes a village.

  • Finding Support People: we overlook those who can be of help. Physical support can be cooking, cleaning, caring for baby, shopping or taking you for a walk/appointment. Emotional support can include sitting, listening, hugging, giving encouraging words. Accept all help offered and ask for more. Brainstorm and write down list of supporter’s names and numbers – keep by phone for in times of need. Ex: partner, friends, family/extended family, neighbors, coworkers, religious communities, professionals (doulas, lactation consultants, nannies, housekeepers), hotlines and warmlines, online postpartum depression message boards, prenatal/postpartum depression support groups. Find nonjudgmental, caring support.
  • Eating: women with perinatal depression often crave sweets and carbohydrates. Try and eat something nutritious (especially protein) every time you feed baby to keep blood sugar levels even – will keep mood more stable. Try drinking food if having trouble eating (protein shakes). Avoid caffeine. Ask support person to buy yogurt, sliced deli meat and cheese, hardboiled eggs, precut vegetables, fruit and nuts. Ask people to bring food. Drink water – dehydration can increase anxiety. Appetite problems quite common. Tell practitioner about any major appetite or weight changes – can find a nutritionist familiar with depression. Women who eat a diet high in vegetables, fruit, meat, fish and whole grains had less depression and anxiety. Women with processed or fried foods, refined grains, sugary products and beer had higher rates of depression.
  • Sleeping: mood severely affected by lack of sleep. Moms more depressed, irritable and anxious when they have interrupted sleep. Nighttime sleep is the most valuable sleep in helping you recover. Sleep is necessary to restore brain health and ideally brain needs 8 hours of uninterrupted sleep each night. With 6 hours, ability to think clearly and respond is decreased, but this is what most new moms get with baby. You need to be “off duty” for a few hours per night. Baby can be fed breast milk in bottle or formula by partner or other support person.   Can split each night or alternate nights. When off, sleep away from baby in other room with earplugs. Use fan, air purifier etc to block baby noises. Even if can’t do it nightly, a few nights a week will help. Nap if you can, but naps don’t replace nighttime sleep. Sleep problems occur frequently with mood and anxiety disorders. If unable to sleep at night, talk to health practitioner.
  • Physical Activity: even a few minutes of brisk physical activity can help your mood. Walking, dancing, bike riding. If thought of walking around block is overwhelming, start slowly and work up. It gets easier as you feel better. Get support person or buddy to encourage your or participate with you. Pregnant and postpartum women who got some exercise (including walking with stroller) were found to cope better and have a reduction in depression. If have sleep problems or are sleep deprived, don’t do intense aerobics as can make sleep problems worse. Wait until you’ve had at least a couple weeks of good sleep before you resume or begin a heavy exercise program.
  • Taking Breaks: there’s no other job that’s 24/7. All good mothers take breaks. Get regularly scheduled time off each week for a minimum of 2 hours at a time (not including errands or chores – pleasure only). For every other job, breaks are mandated by law. You are not the only one who can care about your baby. Partners and family members should be given alone time to bond with baby. If not able to leave house, go to another room and use earplugs or headphones. Or maybe support person can leave house with baby and give you alone time.
  • Going Outside: world feels darker and smaller when depressed. Go outside, look up at sky, stand up straight, put arms at sides and breathe. Don’t have to actually go anywhere. Go outside 1x a day, even if standing outside front door in bathrobe.
  • Improving Your Mood – Take Control of Your Environment: avoid reading or listening to the news. If watch movie, watch a comedy. Avoid tragic/violent films. Open drapes and curtains and let sunlight. If anxious, listen to soothing music. If depressed, try music with a good beat that gets your body moving.
  • Taking care of baby: depending on level of depression, may need someone to do most, if not all of baby care. Support person, family member, doula, nanny or friend can help when partner can not. Gradually can increase care of baby as support person keeps you company.  May feel like a robot at first, but still good to experience some mommy tasks. Feelings of competence and confidence will increase and eventually you will be able to enjoy your day.   Smile, touch and interact with baby as much as able. Once up for it, sign up for infant massage or baby swimming class – these promote mother-infant bonding.
  • Scripts: Give support people suggestions of what to say and do since sometimes its hard to say how you feel. Ex: I am sorry you are suffering; we will get your through this; I am here for you; hug; this will pass.
  • For women with anxiety, fear or extreme worry: avoid caffeine and keep blood sugar level even. Turn off tv news and don’t read news. Don’t read books, magazine or internet information if you feel it makes you anxious. Avoid all media – including social media – if it fuels your worry or fear. If go to movies, select comedies. Find activities that soothe/distract you rather than stir up anxiety.
  • Preventing too much stimulation: adjust surroundings if sights, sounds, daily activity feels too much. Don’t go to family event if seems overwhelming. Lower light (if depressed, try increasing light and opening curtains). May be more sensitive to touch so wear soft clothing.

Myths About Nursing:

  • “I can’t be a good mom unless I nurse my baby” – whatever works for you and your family is the right way. Tremendous amount of pressure in our society to nurse exclusively, regardless of physical or emotional obstacles. Whether you feed your baby breast milk (from breast or bottle) or formula has no relationship to how much you love your child or what kind of mother you are. Be prepared for questions – and remind yourself you are making the best decision for your family. You can ignore questions or change subject or say “it’s none of your business”, “I can’t breastfeed; I have a life threatening illness” or “my doctor told me I can’t”. Women who breastfeed in public may also get comments. Can respond any way you like to get people off your back. Good moms make sure their babies are fed. Period.
  • “My baby won’t bond if I don’t nurse” – if this were true, there’d be whole generations of adults who never bonded with their mothers. Some mothers begin to bond when they stop breastfeeding. For moms experiencing pain breastfeeding, bottle feeding or combination will allow breastfeeding to be more relaxed and enjoyable. If you desire skin to skin, can bottle feed bare chested. Bottle feeding provides chance for good eye contact. Many chances to bond with baby – diaper changing, cuddling, bathing, smiling at baby etc.
  • “My baby can sense my depression or anxiety” – babies can sense temperature, hunger, wetness and physical contact. Babies can’t read thoughts. It’s your behavior that counts (smiling, talking, touching etc). Having a nondepressed caretaker in charge for part of time will also help as you recover.
  • “Bonding happens only immediately after birth” – no adopted children would bond if this were true. Don’t worry if not able to hold immediately after delivery. It’s never too late. Bonding is a process of familiarity, closeness and comfort that continues for years.

Recovery: whatever helps you get better quickly is what we recommend.

Antidepressant Questions and Answers

  • Will medication change my personality? Depression and anxiety change your personality – people who are usually easygoing and stable may become irritable, moody, withdrawn or worried. As medication begins to work, you will feel like yourself again.
  • How long will I have to take medicine? Treatment length varies. If first depression, recommendation is to take a dose that gets you back to yourself, then continue for 9 months to a year. If have history, may suggest longer treatment. Staying on medication for recommended time is critical to reduce changes of having a relapse or recurrence of illness.
  • Will I become dependent on the antidepressant? Antidepressants are not addictive, but you should never stop taking them suddenly. Some psychiatrists recommend 2-4 months to taper off antidepressant. Most women are able to go off medication at some point.
  • What if I have side effects? Many experience no side effects at all. If they do occur, they are usually mild and temporary, lasting less than a week (nausea, fatigue, or shakiness). If decrease sex drive, may persist through course of treatment. If severe side effects or don’t clear up in a week, contact practitioner. Some have to try more than 1 to find the one best for them. Helpful to start at a very low dose and slowly work up to dosage effective for you.
  • Which antidepressant is the right one for me? Most people do well on most. If was on one previously that was helpful or if have blood relative doing well on one, that would be first choice. If anxious, one with calming effect might be chosen. If have fatigue, one with energizing effect may be tried. Most important is one that makes you feel better over time.
  • When will I feel better? How will I know if medication is working? Most begin working within 2 weeks, while older medications can take 4-6 weeks to work. Signs they are working: not crying all the time; having more patience; singing in shower again, partner notices you happier, feel more motivated, cooking again, enjoying baby more not worrying as much, smiling/laughing more, having more fun, answering email and phone calls again.
  • Won’t medication be a crutch (temporary tool until no longer need it)? You would use crutch for broken foot. Medication restores brain chemistry to a normal state. Can also help you utilize psychotherapy more effectively.
  • I want to breastfeed, but don’t want to take anything that will harm baby. Can I take medication and nurse? When infant blood was examined, few if any metabolites of medication were found. Babies exposed as healthy as those not exposed. Going untreated can affect baby’s health and is not a good option. More important for mom to get proper treatment rather than whether she feeds baby breastmilk or formula. If worried, wean yourself slowly rather than going off treatment.  Best gift you can give baby is happy, healthy mom. Usually worry disappears once medication starts working because fear caused by illness itself.
  • I am pregnant and really depressed. Do I need to feel this way for the rest of my pregnancy? 15-23% experience depression in pregnancy. Untreated depression can have harmful affects on fetus. If depressed, may not be caring for self as should. Many women self-medicate with caffeine, cigarettes, alcohol, drugs or herbs, which can be harmful. No increased risk of miscarriage or malformations have been shown from taking medication, even in first trimester. Depression can put you at higher risk for postpartum depression and can put baby at risk for developmental delays.
  • I am embarrassed and ashamed about taking medication. Am I weak because I need a medication? There is a stigma in our society about those who take psychiatric medication, based on ignorance. It is presumed we can control our brain chemistry. If someone had diabetes or thyroid disorder, they’d have medication. Don’t have to share with others. Find people who will support you.

 

Partners – support for partner. The sooner you become involved in the recovery process, and the greater your involvement, the more you both will benefit – together and separately. The more you understand what she is experiencing, the better supported she will feel. That will speed her recovery.

Having a baby changes things; attention that had gone to partner now goes to pregnancy/baby. We hear little about mental health of partners.

More often told glowing side of parenthood – you will feel instantly bonder and fall madly in love. There are losses associated w becoming a parent. Normal for relationship to change. If she’s been drooled on, spit up on, sucked on all day, she may be touched out and you may feel rejected. Remind yourself its not a personal rejection. You can no longer jump into bed, take off to movies or go out to dinner on a whim.

15-23% of women suffer from mood/anxiety problems during pregnancy. Some come with past/current history and others develop. 1/5 will have postpartum mood or anxiety disorder.

Some partners may have history or be experiencing mood/anxiety disorder during pregnancy. Depression and anxiety disorders (in part. OCD) worsen during times of stress and sleep deprivation.

Can’t tell by looking. When mom is experiencing a disorder, her partner is at increased risk of suffering as well. 10% of dads showed moderate to severe depression 9 months after birth. Paternal mood/anxiety disorders in first 2 months in 25%. Highest rates seen 3-6 months postpartum. When mom is depressed, rate of depression in partner significantly higher -24-50%. If partner has history, this is a high risk factor w or w out depression in mom.

Not all depressed men/women experience extreme sadness. In men, may be seen as irritability, aggression and hostility. May distance themselves, find distractions to avoid family or check out. This contributes to relationship or marital distress. Other common symptoms – falling or staying asleep, appetite changes, racing thoughts or constant worry, lack of joy/pleasure in things that used to be enjoyed. Some feel helpless and hopeless. Having new baby and increased financial burden can contribute to feeling of being trapped. Like having dark glasses on – everything gets filtered/distorted; only negative things get through.

Depression in partners affects childhood behavioral and emotional development. Children 3.5 yrs old found to have problems, boys more than girls. 4 yrs old more likely to be treated for speech, language, and behavioral problems. Associated w psychiatric disorders in children 7 yrs later, in part oppositional defiant/conduct disorders in boys.

Get support! Get educated! Find a professional. Talk to partner, friends, family. Find nonjudgmental support.

Things to Keep in Mind:

  • You didn’t cause her illness and you can’t take it away – when her brain chemistry returns to normal, she will feel like herself again. Your job to support her as this happens
  • She doesn’t expect you to fix it – don’t suggest quick fix solutions. She just needs you to listen
  • Get the support you need so you can be there for her – frequently see partner depression during/after mom’s illness. Take care of yourself and get own support. Take breaks. Regular exercise or other stress reducing activity important. Provide stand in support person while your gone.
  • Don’t take it personally – irritability common. Don’t allow self to become verbal punching bag. If you feel you didn’t deserve to be snapped at, explain that to her calmly
  • Have realistic expectations – even nondepressed postpartum woman cannot realistically be expected to cook dinner, clean house and care for baby. Remind her that parenting and taking care of home is also your job. Your relationship and family will emerge from this crisis stronger. Good days and bad days. Gradually, frequency and severity of bad days will decrease. May be a # of months before consistently has good days.
  • Let her sleep at night – she needs at least 6 hrs of uninterrupted sleep per night for brain health. If want mom back quicker, be on duty without disturbing her. Many partners express how much closer they are to children bc of nighttime care. If you cant be up at night, hire someone to take your place. Temporary baby nurse will be worth her weight in gold.
  • Be on her team – tell her when you see improvement “you’re smiling more”, “you’re calling your friends again”. If don’t see improvement, gently offer to accompany her to next apptmt

What to Say, What Not To Say

Say:

  • We will get through this
  • I’m here for you
  • I’m on your team
  • I wont leave you – were here for each other through thick and thin
  • I know you’ll get well
  • If there is something I can do to help you, please tell me (care for baby, run warm bath, put on soothing music)
  • I’m sorry you’re suffering. That must feel awful
  • I love you very much
  • The baby loves you very much
  • This is temporary
  • You’ll get yourself back – point out specifics about how you see her old self returning, such as smiling again, having more patience or going out w friends
  • You’re doing such a good job – give specific examples
  • You’re a great mom – give specific examples “I love how you smile at the baby”
  • This isn’t your fault. If I were ill, you wouldn’t blame me and you’d take care of me.

Do Not Say:

  • Think about everything you have to feel happy about
  • Just relax – usually produces opposite effect. Anxiety produces hormones that can cause physical reactions such as increased heart rate, shakiness, visual changes, shortness of breath and muscle tension. Not something she can just will away
  • Snap out of it – if she could, she would have already. A person cannot snap out of illness
  • Just think positively – illness prevents positive thinking. Its keeping her from experiencing the light, humorous and joyful aspects of life

From a Dad Who’s Been There – for years came home to house w wife in tears, baby crying, house a mess, no dinner. Can’t ask wife about day. He focused on his daughter and kept telling himself he’d be there for her. Slowly his wife recovered and they have the happy home they’ve always wanted. It will get better.

 

Siblings, Family and Friends – the more educated you become, the more supportive you can be. Many changes in household after birth of baby. older children will not be expecting mom to be different. Children too young to understand but will notice mom’s behavior not normal. They notice if mom has been crying or yells/gets angry over little things. Stays in bed more, does not have energy to take to park, or does not seem to laugh much lately. Staring blank into space.

Communicating w Children

  • Words such as depression or anxiety unclear; use words like sad, cranky, tired, weepy, worried, grouchy
  • Reassure children they did not cause it; its not their fault nor could they prevent it
  • Let them know its not illness caused by germs. She didn’t catch it from anyone or cant pass it on
  • Let them know mom is getting help and will be better soon. Mom will have good times and bad times before she recovers
  • Ask children how they can help mom. Draw pretty pic, leave I love you notes around, offer to help w age appropriate tasks
  • Tell truth – don’t say mom is fine when she isn’t. She can say when she is feeling sad – it’s a feeling and doesn’t have to be logical or rational. Feelings are part of being human. Hiding sadness gives message its not okay to be sad.

Peoples reactions to new mom’s depression can critically affect her recovery. Sometimes mom feels too scared to tell partner about feelings, feeling disapproval and rejection.

When women become mothers, even if aren’t depressed, often crave company and approval of other moms. If woman’s mom deceased, extra important to have another woman who can fill that void. Depressed moms need extra reassurance, esp from adult females.

New moms in general sensitive to criticism. Compliment on mothering and avoid negative comments, esp related to parenting.

Things to Keep in Mind

  • You will not be able to cure her – recovery can be up and down; typically woman advances 2 steps forward and 1 step back. May become hopeless when dips occur since depression robs her of perspective that she’s getting well. She may voice she’s back to square 1 and not getting better.
    • Remind her its temporary, she’s getting better, and her moods will get back on track. Dip is part of process. Over time dips are shorter and not as deep and good times increase.
  • Encourage, do not insist – let her know you are willing to listen w out judging. Even just being there in total silence can be great support; she may not be able to communicate feelings
  • Stay in the here and now – reassure you understand she will be riding some waves in mood for a while and your support won’t be yanked before she’s ready
  • Don’t let looks fool you – women often appear normal to outside. Can look put together w makeup, jewelry and even a smile. Sometimes the more depressed she feels, the more she overcompensates.

What to Say, What Not to Say

Say:

  • I’m here for you
  • I’m sorry you are suffering. That must feel awful
  • You’re doing a great job
  • Be specific whenever you can (you’re a great mom. I love how you smile at baby)
  • You’re a great (sister, daughter, aunt)
  • You will get well
  • Would you like me to (insert task)
  • I went through this too (only if you truly did)

Do Not Say:

  • Just buck up and tough it out – not getting adequate treatment puts women at risk of chronic illness and relapse
  • I don’t get what the big deal is – depression makes everything feel like a big deal. Shes overwhelmed and unable to cope. Even small chores may seem too difficult
  • You have so much to be happy about – depression makes it hard to see positive
  • You just need more sleep
  • You just need a break from baby
  • I went through this too – don’t minimize
  • Women have been having babies fro centuries –

What You Can Do To Help

  • Make dinner
  • Watch baby (or other children) so she can take a break
  • Do laundry
  • Do dishes
  • Make lunch for her
  • Sit and listen
  • Clean house
  • Take a walk together
  • Go shopping or do errands for her
  • Write thank you notes for her
  • If partner not home, be on duty at night so she can sleep

 

Health Practitioners – important not to underreact or overreact to these women’s symptoms. Treat them as matter-of-factly as any other common perinatal experience such as gestational diabetes.

Warning sings of distress not always obvious for a variety of reasons – shame, guilt or fear of judgment may cause woman to hide her feelings. She may present more socially acceptable complaints such as fatigue, headache, marital problems or a fussy baby. Just bc she is smiling or well groomed, don’t assume she feels good. Although risk factors to help predict PMADs, no particular type of person who becomes ill. Standardized screening improves detection.

She might feel accused of being a bad mom w questions and become defensive. Once she understands no shame should be attached to issues of mental health, she’ll accept info.

Culture and Language – reactions to disorders vary among cultures. Where shame is a great personal threat, women may be more reluctant to discuss symptoms and need reassurance.

Sociocultural factors and literacy levels should be considered. Coping styles differ across cultures. Will affect woman’s response to recommendations regarding treatment methods.

Do not assume an educated woman will automatically understand her condition better than a woman w less education.

What to Say, What Not to Say:

Say:

  • These feelings are quiet common
  • This is treatable
  • You will get well
  • Here is some info that will help

Do Not Say:

  • This is normal – while common, not normal
  • Join a new moms group – may be a damaging suggestion, depending largely on leader of group. Depressed mom already feeling different and inadequate compared to other new moms. Attending “normal” group may intensify her alienation. If you know leader is sensitive to mood problems, she’ll be fine in group. Ideally, she should join group designed for moms w postpartum depression and anxiety. Some belong to both groups.
  • Take a vacation – she takes brain chemistry w her. Anxiety/depression may increase due to financial investment, leaving baby, and guilt that trip didn’t cure her
  • Just get some exercise – most moms feel overwhelmed. Some have barely enough energy to wash a bottle or take a shower, let alone go to gym. Exercise alone will not cure depression. When she’s able to leave her house and take a short walk, encourage her to do so
  • Do something nice for yourself – nice but wont be enough to regulate depressed mom’s neurotransmitters
  • Sleep when baby sleeps – even nondepressed moms have difficulty sleeping when baby naps during day. Esp for those w high levels of anxiety, this will be impossible. What’s most important is that she sleeps at night when baby sleeps.

Screening – use standardized screening surveys specifically designed for perinatal use such as PPDS and EPDS (Postpartum Depression Screening Scale; Edinburgh Postnatal Depression Scale). PHQ-9 (Patient Health Questionnaire) more widely used and many familiar w it.

Prenatal Screening – if time too limited to use screening questionnaires, questions in risk assessment should be asked. At minimum, questions relating to personal/family history of mental illness, previous postpartum mood disorder and severe premenstrual mood changes should be asked (those w asterisk below).

Prepregnancy and Pregnancy Risk Assessment

Warning Signs

  • Missed apptmts
  • Excessive worrying (about own health or health of baby)
  • Looking unusually tired
  • Crying
  • Significant weight gain/loss
  • Physical complaints w no apparent cause
  • Flashbacks, fear, or nightmares regarding previous trauma
  • Her concern she won’t be a good mother

If she answers yes to any questions, she’s an increased risk of perinatal mood/anxiety disorder

  • Have you ever had episodes of being down or sad, extreme worry, panic attacks, repetitive thoughts or behaviors that are troublesome, bipolar or extreme mood swings, loss of touch w reality or an eating disorder?* Women w history should be educated about high risk for perinatal episode
  • Are you taking any medications (prescription or nonprescription) or herbs on a regular basis? Women self-medicating for insomnia, anxiety, sadness or other symptoms may indicate mood disorder?* Some use caffeine, cigarettes, marijuana, herbs, alcohol and drugs to ease emotional pain
  • Have you had a previous pregnancy or postpartum mood or anxiety disorder?* women who answer yes at extremely high risk
  • Have you ever taken and medication for depression or anxiety or mood?*
  • Have you ever had severe premenstrual mood changes PMS or PMDD?* women whose moods are affected by hormone changes are at high risk
  • Do you have any family history of mental illness (undiagnosed or diagnosed) psychiatric hospitalization or suicide?*
  • Do you have any personal or family history of substance abuse?
  • If pregnant, how have you been feeling physically and emotionally?
  • Do you feel you have adequate emotional and physical support?
  • Have you had a pregnancy or birth-related trauma (or other emotional, sexual, or physical abuse)?
  • Are you experiencing any major life stressors (moving, job change, deaths, financial problems)?
  • Have there been any health problems for you or fetus? Having twins, triplets, or multiple births puts mother at increased risk
  • Do you have a personal or family history of thyroid disorder?

Postpartum Screening – EPDS developed in 1987 by Dr. John Cox. 10 question self-report screening tool translated into many languages and used all over world. Effective w teens and dads. Can be found on many internet sites. Also shortened 3 question version.

PDSS developed in 2002 – accurately screens both postpartum depression and anxiety. Can use short or long format. Elevated score in particular symptom indicates greater amt of distress than avg. Symptom scales are Sleeping/Eating Disturbances, Anxiety/Insecurity, Emotional Lability (mood swings), Mental Confusion, Loss of Self, Guilt/Shame, Suicidal Thoughts.

PDSS more likely to identify women w symptoms of sleep disturbance, mental confusion and axiety. Refer her to perinatal specialist.

PHQ9 originally designed for family practice not more widely used in perinatal settings.

Postpartum Risk Assessment – those not screened prenatally, ask first 6 questions from PrePregnancy and Pregnancy Risk Assessment as well

Warning Signs in Mom:

  • Missed appointments
  • Excessive worrying (often about moms own health or health of baby)
  • Looking unusually tired
  • Requiring a support person to accompany her to appointments
  • Significant weight gain or loss
  • Physical complaints w no apparent cause
  • Poor milk production or breastfeeding problems (could indicate thyroid dysfunction)
  • Evading questions about her own well-being
  • Crying
  • Not willing to hold the baby or unusual discomfort handling or responding to baby
  • Not willing to allow others to care for baby
  • Excessive concern about baby despite reassurance (ex: eating sufficiently, development, weight gain)
  • Rigidity or obsessiveness (ex: regarding baby’s feeding/sleeping schedules)
  • Excessive concern about appearance of herself or baby
  • Expressing that baby doesn’t like her or that she’s not a good mom
  • Expressing lack of partner support

Warning Signs in Baby

  • Excessive weight gain or loss
  • Delayed cognitive or language development
  • Decreased responsiveness to mom

Questions to Ask:

  • How are you doing? Have good eye contact w her while you ask
  • How are you feeling about being a mom? Women who feel like they’re doing a bad job or who generally don’t like the job may be depressed
  • Do you have any particular concerns?
  • How are you sleeping (quality and quantity)? 6 hrs of uninterrupted sleep per night required for clear thinking/functioning
  • Can you fall asleep and stay asleep at night when everyone else is asleep? (Sleep problems common in every mood and anxiety disorder)
  • How is baby sleeping? Poor infant sleep is associated with maternal depression and anxiety
  • Who gets up at night w baby?
  • Have you had any unusual or scary thoughts? If yes, refer to perinatal psychotherapist or psychiatrist for immediate evaluation. Some thoughts may be normal; however, others may indicate obsessive-compulsive disorder (less urgent) or psychosis (emergency)
  • Are you receiving adequate physical and emotional help? A good support system of family and friends can make a significant difference
  • Do you generally feel like yourself? Women w perinatal mood disorders often report not feeling like their usual selves, or having a different personality
  • How is your appetite? A significant change in appetite is a warning sign. Check for rapid weight loss or gain
  • What and how often are you eating and drinking?
  • If breastfeeding or pumping, how is it going? Poor milk production may indicate a thyroid dysfunction or be a result of anxiety
  • If using formula, when and how quickly did you wean the baby? Abrupt weaning can precipitate a mood disorder or anxiety disorder
  • When was your last period? Fist menses after delivery can be a precipitating factor
  • Are you taking any medications or herbs on a regular basis? Women who are self-treating for insomnia, anxiety, sadness, fatigue or other symptoms that may indicate a mood or anxiety disorder should be evaluated by a perinatal psychotherapist
  • Are you feeling moodier than normal (tearful, irritable or worried)? This is common in mood disorders.
  • Have there been any healthy problems for your or the baby? These factors increase the risk for mood and anxiety disorders
  • How are you feeling toward your baby? Ambivalence and anger are 2 examples of feelings that may indicate postpartum depression. Discomfort around the baby may indicate anxiety or OCD.

Psychotherapists, Psychologists or Social Workers – critical element and being a part of her preconception planning and perinatal safety net. Be familiar w risk factors and most current info on how to reduce risk factors. Be familiar w research regarding relapse and current medication recommendations. Help monitor symptoms. Have info in resources section available.

Primary Care Providers – evaluate pre-pregnancy risk. Have info from resources available as well as referrals to local professionals trained in perinatal mood and anxiety disorders. Woman taking psychotropic medications who are pregnant/planning a pregnancy should be encouraged to consult psychiatrist specializing in perinatal disorders in order to determine whether to continue meds. Women on medication for bipolar disorder or psychosis should be referred to perinatal psychiatrist to develop medication plan. Need careful monitoring throughout pregnancy and postpartum.

Pediatricians and Neonatologists – well documented that mental health of parents has tremendous impact on development of children in home. If mom has been on meds during pregnancy, reassure parents that baby is fine and not experiencing any withdrawal or neonatal complications. Support mom if she wishes to feed her baby breast milk while taking antidepressant. Mothers w depression or anxiety nurse or pump for shorter durations; they give up. Moms on medications feed their babies breast milk for longer duration then those untreated.

  • Parents w babies in intensive care at high risk for depression/anxiety; they need extra support and screening. Have referrals to local professionals available.
  • Use standardized postpartum screening tool; women should be assessed throughout 1st
  • Women already on meds or those who you assess who need medical evaluation should be referred to psychiatrist specializing in mood and anxiety disorders.

OB/GYNs, Midwives and Other Women’s Healthcare Providers – many women will not be forthcoming w negative feelings or concerns unless specifically asked. Women w history of neonatal loss need monitoring and extra support.

  • Woman taking psychotropic medication who is pregnant or planning pregnancy should be encouraged to consult perinatal psychiatrist to determine whether to continue/change meds. Women on mediation for bipolar or psychosis should develop medication plan; they need careful monitoring throughout pregnancy and postpartum.
  • Use standardized postpartum screening tool.
  • Women already on meds should be referred to psychiatrist specializing in perinatal mood.

Psychiatrists – research findings and recommendations about medications in pregnancy and lactation constantly changing. Make sure give patients name of psychotherapist trained in PMADs. Essential to have list of local resources and referrals.

Birth Doulas – studies show use of doula contributes to reduction of postpartum depression. Can screen prenatally/watch for early warning signs of emotional problems. If when doing prepregnancy and pregnancy risk assessment, you discover woman has suffered previous traumatic delivery or childhood sexual abuse, she may experience flashbacks during birth.

  • Women taking psychotropic meds who is pregnant or planning pregnancy should consult w psychiatrist specializing in PMADs to determine whether to continue. Women on meds for bipolar or psychosis should be referred to psychiatrist to develop medication plan. Need careful monitoring throughout pregnancy and postpartum.
  • If interviewed before employment, can ask about particular concerns about birthing or postpartum. Let woman know that one of your strengths is sensitivity to various emotions that can occur during birth or postpartum.
  • If continue to see women postpartum, use Postpartum Risk Assessment. Info can be gathered informally, simply through chatting.

Postpartum Doulas and Visiting Nurses – can observe home and social environments of mom, which can given crucial info about her well-being and that of family unit. If notice lack of partner support or signs of marital conflict, she’s at greater risk for PMAD. If house unusually neat/clean, want to find out who is doing housework; if she’s obsessively cleaning or awake in middle of night vacuuming, this is not normal.

  • Help to create healing/supportive environment, such as opening curtains to give more light, checking to see if she has healthful food and eliminating unnecessary noise to make her home calmer and more soothing.
  • Use standardized postpartum screening tool such as EPDS or PDSS.

Lactation Consultants – may be first professional to see the mom/baby during initial postpartum weeks. Can observe/listen for potential emotional problems. Postpartum moms listen carefully to what you advise and are quite trusting of you.

  • If physical/emotional health declining, it’s not good for baby. Support person will need to feed baby during half of night if not getting enough sleep (6 hrs a night at least a few nights a week).
  • Breastfeeding difficulties may be associated w sexual abuse, childbirth trauma, OCD, depression and anxiety. Women suffering w depression and anxiety give up breastfeeding more quickly. When mental health improves, often lengthens duration of breastfeeding. Sudden weaning can precipitate mood or anxiety disorder, esp when woman is predisposed. If she’s suffering, abrupt weaning can greatly exacerbate symptoms. Esp if woman is depressed and not feeling good about herself, there can be great amount of guild if at any point she cannot or should not continue breastfeeding.   What you say or do not say at the time can make a big difference regarding how she feels about herself as a mom.
  • Many professionals unaware of current research regarding psychotropic meds in breast milk – important to be informed so you can advocate for women who want to continue taking meds. Have referral to psychiatrist w experience prescribing medication during lactation. Use standardized postpartum screening tool.

Childbirth Educators – so often heard “why didn’t we learn about this during pregnancy?” have a responsibility and opportunity to educate couples about perinatal mental illness.

  • Can invite expert in field to speak to class.
  • Rate of depression in pregnancy 15-23%. Some of women already suffering in class and at risk for postpartum disorders. No danger in giving info and great danger in omitting it. Partner might soak up info if mother to be doesn’t. often spouse who recognizes symptoms and encourages wife to seek help.
  • Hand out info from resources section and name and number of professional trained in perinatal mood disorders. If follow up w participants, ask about feelings regarding challenges as well as joys of parenthood. Be sure to call participants who didn’t attend reunion. May not be doing well and could be trying to avoid an uncomfortable situation. PSI DVD (Resources) will be helpful.

New Parent Group Leaders – statistically 1-2/10 will have PMAD. Rarely will woman disclose since she most likely will be experiencing guilt and shame. Will be aching for someone to open door and give her permission to express how she’s really feeling. If partners present, ask them how they themselves are doing. Dads/partners may have preexisting mood or anxiety disorders.   Stress of pregnancy can also worsen symptoms. Dads and partners need and deserve support too.

  • Encourage discussion about normal feelings accompanying adjustment to parenting and relationship to oneself, partner, baby, friends and family.
  • Can invite professional.

Adjunct Professionals – many others who touch lives of pregnant and postpartum women. Physical therapists, instructors in prenatal and postpartum exercise should mention possibility.

 

Treatment

Why is Treatment Necessary?

Research about perinatal mood and anxiety disorders has taught us new things. In past, ppl thought didn’t exist, or if they did, women didn’t need treatment and should suffer through them, and that they would eventually recover on their own. Now know that’s incorrect. Untreated illness in pregnancy will most likely lead to postpartum illness. At 7 months postpartum, depression continues in 25-50% of women who aren’t treated. They may go away after a time, but increase likelihood of another episodes or episodes later in life. The brain is at least as important as any other part of the body.

Untreated mood/anxiety illness in pregnancy associated w:

  • Self medication w potentially unsafe OTC remedies – tobacco, alcohol, drugs
  • Poor nutrition and lack of self care
  • Appetite changes and abnormal weight gain/loss
  • Poor fetal growth and low birth weight
  • Premature birth
  • Babies who cry more and are more difficult to sooth and calm
  • Behavioral problems in preschoolers
  • Developmental delays in toddlers
  • Antisocial, aggressive, and violent behavior in teens

Moms who have untreated postpartum illness may:

  • Have babies whose brain waves show depression
  • Have difficulty w bonding and attachment
  • Have babies who cry more
  • Have children w poor language and cognitive (thinking) development and poor school readiness
  • Be less likely to use car seats and are more likely to use harsh discipline
  • Have children who are 50% more likely to suffer anxiety or depression when teens

Treating parents not always enough to repair mother-child relationship; activities that involve physical touch (infant massage) shown to be helpful.

Untreated illness affects whole family. You need and deserve to be well!

Research – doesn’t always tell whole story

  • Where is it reported? Google not a reliable source. Forums/blogs not scientific. Large well-respected news sources blur scientific conclusion to create attention-getting headline
  • How many people studies? Smaller, less meaningful. Most valuable have 1000s of participants or at least other research that repeats smaller study
  • What was measured/studied? How was it measured? Many studies on effects of meds on fetus – some base on prescriptions written. Just having prescription, even if not filled, does not mean woman took medication. May not have taken dose prescribed necessary to treat. May not take into account other critical factors – cigarettes, drugs, alcohol, poor nutrition or effects of depression/anxiety if woman on inadequate dose. Genetic risk important when looking at autism etc.

Prevention – ultimate goal.  Study – Women at high risk offered extended postpartum hospital stay (5 days) in private room. Babies slept in nursery at night so moms could sleep w out interruption. Less likely to suffer from PPD and for those who did, it was milder.

Psychotherapy can be used effectively for prevention.

Women at high risk who started sertraline (Zoloft) w in 15 hrs of delivery reduced incidence.

All new moms need wellness plan bc all moms need nurturing. Need uninterrupted sleep, food/eating arrangements, breaks away from baby during week.

Treatment Guidelines – pregnant and postpartum women need to be as symptom-free as possible. Pre-conception it may be reasonable to find/change medication that’s low risk in pregnancy and of low concentration in breast milk. If woman discovers she is pregnant and is doing well on meds, fetus ahs been exposed. Risk of illness due to changing meds is high. Risk of med must always be weighed against risks of illness – on mom, fetus, infant and family. Always rule out bipolar disorder before giving antidepressants. Goal of treatment is that woman feels like herself again as quickly as possible.

Psychotherapy – talk therapy. Need perinatal mental healthcare provider – training in general population not enough. Should be familiar w local resources as well as those on web and in print. Can be done w individual, couple, family members or group setting.

Treatment involves crisis mgmt. Treatments most effective are short-term or brief psychotherapies focused on symptom reduction and improvement in functioning. Not time for long-term psychodynamic or psychoanalytic therapy. 2 models studies and effective for prevention/treatment – Interpersonal Psychotherapy (IPT) and Cognitive-Behavioral Therapy (CBT). Therapist plays active role facilitating and directing discussion and teaching problem-solving skills. Psychotherapy has been shown to have long-lasting positive impact.

IPT works to help clients address role changes, transitions and conflicts and loss and grief and build interpersonal skills as well as support resources.

CBT works by helping monitor and change thinking and behavior through education and skill building; helps clients develop new ways to think/evaluate life experiences and teaches practical skills to use immediately.

When woman unable to process/apply psychotherapeutic strategies, medication often indicated.

Social Support – provides nonjudgmental empathetic emotional support, feedback, active listening and info. Creates environment where women see they are not alone or to blame. Often uses specially trained women who have recovered. Includes support groups, telephone support, home visitors, email and online groups, faith communities and family/friends.

A variety effective in helping women recover. Contact Postpartum Support International.

Complementary and Alternative Therapies – studies being conducted on treatment that doesn’t involve meds. Therapeutic effect of massage beginning to emerge. Morning bright light therapy (natural sunlight or special light boxes) already being used either as alternative or in addition to meds. Effectiveness of omega-3 essential fatty acids DHA and EPA in prevention & treatment apparent. APA recommends 1 gm EPA plus DHA daily. From fish oil, not plant sources, which are different. Recommended to enhance, but not replace, standard treatment. Talk w care provider before taking supplements of any kind. If take omega-3s while nursing, baby’s neurological development may also be enhanced (these lipophilic acids have been added to many baby formulas).

~5% of pregnant women report using marijuana; detectable in placenta, amniotic fluid and fetus. Found to be associated w poor fetal growth in mid/late pregnancy, w effects on low birth weight being most noticeable. Even w legal medical marijuana, no safe dose has been established. Increasing concerns about long-term neurodevelopment, behavioral and possibly even metabolic consequences.

Marijuana also found in breast milk and may be higher than that found in mom’s blood. May affect brain development in children under 1. If using on regular basis, talk to care provider; there are other well-research ways to treat nausea, depression and anxiety.

A new nonmedication treatment is repetitive transcranial magnetic stimulation (TMS). Uses noninvasive brain stimulation and is showing great promise in treatment of major depression. Approved by FDA for treatment of major depressive disorder in adults and a few small studies have been done on depressed pregnant women. Depression was reduced significantly w/in 3 weeks and no ill effects were seen on mom/baby. not yet widely available. May be effective therapy for women who choose not to go on meds.

Acupuncture might be helpful treatment for treating depression in pregnancy. Some insurance companies will pay for alternative treatment.

Use whatever is known to be safe and works.

21% of pregnant women smoke, 19% use alcohol and 6% use illegal drugs as a way to alter moods.

Herbs can be wonderful, but also dangerous. Poisonous mushrooms are natural and digitalis, the heart medicine, is from a plant. Little research has been done on effectiveness of herbs during pregnant/nursing.

Very few studies on St. John’s wort during pregnancy or in breast milk. No research that shows its an effective treatment for anxiety or OCD. St. John’s wort interacts w a # of meds, including meds for heart disease, depression, seizures, certain cancers and birth control (makes less effective). You can’t tell quality/quantity of active ingredient in each dose.

No gov. regulation on herbal remedies and measured amts of active ingredients varied considerably from those claimed on labels – 0-109% for capsules and 31-80% for tablets. Like an antidepressant, SAMe, St. John’s wort and bright light therapy can all trigger hypomania or mania in women w bipolar illness.

Placenta – articles claim prevents postpartum blues and possible protects against PPD and anxiety. Part of cultural rituals around the world. No one has measured emotional health of women or animals that eat placenta. As of mid 2015, still no studies on effectiveness or benefits of placenta ingestion and mood in humans. 30% of people will feel better when given placebo.

For many years, FDA used confusing and misleading rating scale for safety labeling of meds during pregnancy – A, B, C, D, or X. meds w less research often labeled as safer, while meds that had more research sometimes labeled less safe. As of 6/2015, that system will be discarded and replaced by more informative safety labeling of meds used during pregnancy and breastfeeding.

Immediate goal is to alleviate suffering as quickly as possible. Start meds at low dosage and increased as rapidly as possible to whatever right dosage is for that woman. Undertreating can lead to chronic problems/suffering and increases risk of relapse.

All treatment must be individualized. See psychiatrist w expertise in perinatal illness. If one provider or medication/treatment doesn’t work or feel like a good fit, try another. Goal is to feel like you again. Feeling OK or better is not good enough.

Pregnancy and Medication – use of meds in pregnancy has evolved in past few years. Shift has focused on harmful effects on fetus when maternal mental illness untreated. All normal pregnancies have 3-5% of birth defect. Pregnancy causes changes in metabolism and blood volume; higher doses may be required to achieve adequate reduction in symptoms. In order to remain symptom free, 2/3 of women needed increase in dosage at 6.5 months pregnant.

American Journal of Ob/Gyn stated when psychiatric condition requires meds, benefits of med far outweigh potential minimal risks of medication. American Journal of Psychiatry published article stating that not prescribing antidepressants to woman who is depressed or likely to become ill again during pregnant may cause more risks to mom/fetus than risks of exposure to meds.

Commonly used prescription meds for perinatal/anxiety disorders:

  • Antianxiety Medications – while SSRIs are often used to treat anxiety, panic and OCD, it can sometimes take weeks before reduction in symptoms is noticed. Benzodiazepines are used for immediate relief of anxiety, but can become addictive. Women so worried about becoming addicted they don’t take enough to control symptoms. Can be used for occasional episodes of anxiety. Sometimes used w SSRIs to keep anxiety under control, on short term basis. Alprzolam (Xanax) and lorazepam (Ativan) are shorter acting (out of system more quickly) while diazepam (Valium) and clonazepam (Klonoin) are longer acting. Literature regarding antianxiety meds (benzodiazepines) during pregnancy limited. Concern before that caused birth defects such as cleft lip and palate, but now evidence that maternal anxiety itself may contributes. Risk of birth defects in 1st trimester very low and can be used w out concerns about defects in 2nd/3rd Babies born to women taking high doses at end of pregnancy may experience temporary problems. Lowest effective dose for shortest period of time recommended
  • Antidepressants – brand names vary by country
    • Do they cause miscarriage? Analysis of over 735 studies in 2013 review shows risk same in women w depression as those who took antidepressants. Neither selective serotonin reuptake inhibitors (SSRIs) nor tricyclics (TCAs) pose any increased risk
    • Can they cause prematurity? Study 2013 showed no difference in women on antidepressants vs depressed women not on meds
    • Do they cause birth defects? In all births, there is 1-3% chance. Large studies in 2013 looked at buproprion (Wellbutrin), citalopram (Celexa), fluoxetine (Prozac), paroxetine (Paxil), escitalopram (Lexapro), mirtazapine (Remeron), sertraline (Zoloft), venlafaxine (Effexor), fluvoxamine (Luvox), and nefazadone (Serzone) found that use even in 1st trimester not associated w increased risk. Growing body of research on safety of duloxetine (Cymbalta) and venlafaxine (Effexor). No consistent evidence showing risk of stillbirth. No babies had pulmonary hypertension, while babies not exposed to meds did. Motherrisk Program (studies medications that cause birth defects) found no increased risks for major malformations.
    • What about Persistent Pulmonary Hypertension of Newborn? Occurs in .1% of newborns. Rare, but serious. Didn’t show increased risk. Many of known risk factors of PPHN (obesity, smoking, shorter pregnancies, cesarean birth) more commonly seen in depressed women
    • Do they cause poor neonatal adaptation or withdrawal? Refers to symptoms (breathing problems) sometimes seen in newborns whose moms are on meds during last trimester. Unclear if caused by too much serotonin in baby or withdrawal from meds. Reported rates vary from 10-30% and seem more common in women who take paroxetine (Paxil). Symptoms begin in first few days of life and usually gone w in 3-5 days. Discontinuing meds to avoid symptoms in newborn may lead to relapse in mom. This is a mild syndrome that most often does not require treatment. Goes away by itself. Stopping meds in last trimester puts mother at greater risk of depression at end of pregnancy and during postpartum course.
    • Do they cause autism?
    • Has anyone found problems in older children exposed during pregnancy?
  • Antipsychotics – also called major tranquilizers. Older high-potency antipsychotics such as haloperidol (Haldol) have been recommended in past over low-potency or atypical agents. Children aged 4 exposed had normal IQs. No increased risk of birth defects or complciations seen of newer atypical antipsychotic meds olanzapine (Zyprexa), risperidone (Risperdal) or quetiapine (Seroquel). Newer drugs seem to have fewer side effects, although may increase weight gain. Sign up for National Pregnancy Registry for Atypical Antipsychotics: womesnmentalhealth.org/clinical-and-research-programs/pregnancyregistry/.
  • Electroconvulsive Therapy (ECT) – considered acceptable treatment for severe depression or psychosis in pregnancy. Not used for prental anxiety, panic or OCD
  • Mood Stabilizers – women w bipolar disorders should consider continuing meds throughout pregnancy bc danger of relapse so high. 24% of women w history of chronic bipolar disorder became ill during pregnancy even while on meds, so stopping quite risky. Those who stopped – half relapsed within 3 months and ~70% had relapses. Restarting lithium after stopping in 1st trimester doesn’t protect well against relapse. Medications used for seizure disorders often used as mood stabilizers. Valproate (Depakote) can cause serious birth defects and its use is not widely recommended for women of childbearing age. Lamotrigine (Lamictal), an antiseizure medication, now considered the antiepilectic drug of choice. Lithium an antimania med used to treat bipolar disorders. Risk of Ebstein’s anomaly (heart defect in fetuses) w lithium use in 1st trimester is 1-2/1000. Fetal cardiac ultrasound bw 18-20 wks recommended for those w 1st trimester exposure. No significant neurobehavioral or developmental problems reported in children. Other mood stabilizers, such as carbamazepine (Tegretol) and valproic acid (Depakote), increase rate of neural tube defects and other birth defects. Children at 3 found to have decreased IQ when exposed to Tegretol. Increased dose of folic acid used in addition to Tegretol or Depakote if these medications must be continued. Consult w psychiatrist familiar w latest research.
  • Sleep Aids – depression/anxiety can cause problems falling or staying asleep. Sleep an essential part of treatment plan. Several OTC meds considered fine while pregnant – doxylamine (Unisom) and diphendramamine (Benadryl). Trazadone (Deseryl) and amitriptyline (Elavil) are antidepressants that have a sedative effect. Zolpidem (Ambien) has faster rate of onset and considered acceptable. When anxiety contributing to sleep difficulty and other methods not effective, antianxiety meds such as Ativan or Xanax can be quite helpful.

Postpartum – birth of baby may bring about need to change med treatment plan. While growing fetus exposed to higher doses of maternal meds, a few medications can be problematic for infants receiving breast milk. Some women choose to restart or begin meds after birth. Most found in low levels in breast milk and most considered very low risk to infant.

  • Thyroid – >10% of postpartum women will develop postpartum thyroiditis. In early stages, women may experience anxiety/depression. Sometimes temporary and will go away w out treatment in ~6 months. For others, can lead to chronic thyroiditis and hypothyroidism (Hasimoto’s thyroiditis). Ask provider to check blood – suggested timing is 2-3 months postpartum: free T4, TSH, anti-TPO and antithyroglobulin test. Important to check for antithyroid antibodies (anti-TPO and antithyroglobulin) since many cases when T4 and TSH levels w/in normal ranges. If abnormal, see endocrinologist.
  • Hormone Therapy – still being evaluated for effectiveness. Research w estrogen holds promise for treatment of PPD and PPP. Has certain risks and needs to be evaluated on case-by-case basis. Its not a low level of hormones that cause mood problems for most; rather it’s a shifting of levels that women are sensitive to. Those sensitive to shifts who choose oral contraceptives (birth control) need to be monitored closely. Women may experience fewer problems on a monophasic bcp (same ratio estrogen: progesterone) as compared to a triphasic bcp (ratio of estrogen and progesterone changes weekly). Women w history of increased moodiness on bcp should consider alternative methods. Synthetic progesterone (progestin) including minipill has been associate dw worsening of symptoms. Medroxyprogesterone acetate (Depo-Provera), a long-acting progesterone injection, not a good option since cannot be discontinued should it aggravate mood problems. Reports of mood problems after insertion of progesterone releasing IUD. These resolve once its removed. Hormone therapy not recommended, at this time, as sole treatment for disorders. Research has started looking at use of estrogen patch as form of treatment.
  • Medications – if you or blood relative had positive experience w meds, that’s first choice. 1 study found venlafaxine (Effexor) and another found sertraline (Zoloft) to be effective for PPD. Buproprion (Wellbutrin) for women w depression but w out anxiety seems to be energizing and also reduces sex side effects. Not one med that is better than other. Best is one that works for her. All SSSRIs work well. Each women has individual chemistry. Woman should start SSRI at low dose w regular follow up, increasing dosage until adequate response achieved. Treatment of anxiety, including OCD usually requires higher dose. She should report feeling 100% back to herself. Undertreating can lead to chronic illness and increased risk of relapse

Meds & Breast Milk – for some women, breast milk may feel like only positive thing they have to offer. Most meds found in very low amts in breast milk and babies. A few are not recommended/must be used w caution.  

  • Antianxiety meds – low doses of short-acting meds such as alprazolam (Xanax) or Lorazepam (Ativan) can be used on occasional basis for anxiety, panic and poor sleep. Acceptable to take benzodiazepines (antianxiety meds); no adverse effects seen in infants 2 weeks+
  • Antidepressants– of most commonly used antidepressants, sertraline (Zoloft) and paroxetine (Paxil) detected in smallest amts in infant. Fluoxetine (Prozac), citalopram (Celexa) and Escitalopram (Lexapro) found in small amts in infatns blood and no significant probs in infant. Found to have normal development and IQ at 1 yr. generally safe to breast feed while taking antidepressants. First choice should be med that’s worked in past or successful w blood relative. Benefits of breast milk far outweigh risks of meds.
  • Antipsychotics– aka major tranquilizers, used to treat psychosis and also used to treat women suffering from severe anxiety. Also enhance effectiveness of SSRIs. High-potency antipsychotics such as haloperidol (Haldol) used for moms who breastfeed. Babies should be watched for sleepiness but no reports of infant problems. 2nd generation or atypical antipsychotics Olanzapine (Zyprexa), Risperidone (Risperdal) or Quetiapine (Seroquel) seen in very small amts in breast mill and considered compatible.
  • ECT– acceptable treatment for severe depression or psychosis postpartum and doesn’t affect breast milk. May be used in treating bipolar disorder postpartum. Not used for postpartum anxiety, panic or OCD
  • Mood stabilizers – safety of taking carbamazepine (Tegretol) or valproate (Depakote) while breastfeeding is undecided. In past, women told not to breastfeed if taking lithium. Small studies have shown little risk to infant. Babies need to have blood tests to monitor lithium levels. Lamotrigine (Lamictal) considered acceptable.
  • Sleep aids– Zolpidem (Ambien), Temazepam (Restoril), Trazadone (Deseryl), Nortirptyline (Pamelor) and amitriptyline (Elavil) frequently prescribed.

Medical Protocols – treatments should be followed in sequence. Effective for depression, psychosis, OCD, anxiety and panic. SSRIs are first choice in treatment of OCD, anxiety and panic. Use lowdose antianxiety or antipsychotic meds on short term basis for anxiety and panic. Often high doses SSRIs need for longer periods of time.
Prepregnancy

  • 1 episode of major depression if on meds + asymptomatic for 6-12 months
    • Treatment 1 – taper off meds + psychotherapy (monitor closely for relapse) + social support
    • Treatment 2- resume meds + continue psychotherapy + social support
  • Severe recurrent prior episodes
    • T1 – continue meds + psychotherapy + social support
    • T2 – psychotherapy + meds + social support
  • Mild major depression or severe major depression (1st episode)
    • T1 – psychotherapy + social support
    • T2 – psychotherapy + social support + meds
  • Bipolar disorder –
    • T1 – continue or switch if on Valproic acid (Depakote) or Carbamazepine (Tegretol) to lithium or Lamotrigine (Lamictal) + have psychiatrist monitor closely psychotherapy + social support
    • T2 – switch to high potency antipsychotic if necessary + continue psychotherapy + social support when stable

Pregnancy (including 1st trimester)

  • 1 episode mild major depression, currently in remission
    • T1 – try slowly tapering medication + psychotherapy + social support
    • T2 – resume medication + psychotherapy + social support
  • 1 episode severe major depression, currently in remission
    • T1 – if stable consider slow tapering off or maintenance of medication + psychotherapy + social support
    • T2 – medication + psychotherapy + social support if relapse
  • Mild major depression, first or recurrent
    • T1 – + psychotherapy + social support
    • T2 – medication + psychotherapy + social support
  • Severe major depression, first episode
    • T1 – medication + psychotherapy + social support
    • T2 – ECT + psychotherapy
  • Recurrence or relapse of depression if off meds if mild major depression
    • T1 – + psychotherapy + social support
    • T2 – resume meds + psychotherapy + social support
  • Severe major depression, currently symptomatic
    • T1 – resume meds + psychotherapy + social support
    • T2 – ECT + psychotherapy + social support
  • Psychosis in any trimester (do not rely on psychosocial interventions alone; requires hospitalization)
    • T1 – antipsychotic, add mood stabilizer or antidepressant if needed once stable; psychotherapy when stable. OR ECT + psychotherapy
    • T2 – hospitalization

Postpartum

  • Mild major depression/anxiety
    • T1 – + psychotherapy + social support
    • T2 – + psychotherapy + social support + meds
  • Severe major depression/anxiety
    • T1 – + psychotherapy + social support + meds
    • T2 – consider addition of atypical antipsychotic
  • Postpartum psychosis (hospitalization required; do not rely on psychosocial interventions alone)
    • T1 –antipsychotic + psychotherapy once stable
    • T2 – consider ECT

Prevention of Postpartum Depression in Women w History of Depression, Anxiety, Other Mood Disorder or Prior Postpartum Illness

  • 1st pregnancy
    • T1 – meet w psychotherapist when risk identified (prepregnancy or pregnancy) + psychoeducation for woman and partner
    • T2 – intervention (refer to pregnancy treatment protocol) if symptomatic)
  • Prior postpartum depression/anxiety
    • T1 – psychoeducation for woman and partner as early as possible + consider starting antidepressant (SSRI) 2-4 weeks before delivery or at delivery + psychotherapy
    • T2 – intervention (refer to pregnancy treatment protocol) if symptomatic)
  • Prior postpartum psychosis
    • T1 – refer to psychiatrist, start antipsychotic upon delivery + psychotherapy
    • T2 – intervention (refer to pregnancy treatment protocol) if symptomatic)

Resources

Websites and Helplines:

  • Childbirth and Postpartum Professional Association – CAPPA.net – doula training/locating doula
  • Doulas of N. America – dona.org
  • org – meds in pregnancy and lactation
  • The Marce Society – marcesociety.com – scientific research in field; annual conference
  • Massachusetts General Hospital for Women’s Mental Health – womensmentalhealth.org
  • Motherrisk – motherisk.org – med exposure during pregnancy and postpartum. Toll free help lines
  • MotherToBaby – evidence based info; meds and other exposures during pregnancy/lactation
  • North American Society for Psychosocial OB/GYN – naspog.org – society or researchers, clinicians, educators and scientists. Outstanding conferences
  • Pec Indman’s Website – pecindman.com
  • Postpartum Progress Blog – postpartumprogress.com – award winning blog on PPD and other mental illnesses related to childbirth
  • Postpartum Support International (PSI) – postpartum.net – telephone support, interntl directory of members. Annual conference. Healthy mom, Happy Family DVD
  • Shoshana Bennett’s website – DrShosh.com – film Dark Side of Full Moon; free app PPDGone
  • Postpartum Dads/Partners – postpartumdads.org, psotpartummen.com

Apps

  • Infant Risk Mobile App for Healthcare Providers (author of Meds in Mother’s Milk)
  • MommyMeds Pregnancy Safety Guide
  • PPDGone! – free – videos, audios, articles
  • org – 3 free texts per week during pregnancy and until baby is 1

Books

  • Postpartum Mood and Anxiety Disorders: A Guide
  • Traumatic Childbirth
  • Children of the Depressed: Healing Childhood Wombs that Come from Growing Up w Depressed Parent
  • Postpartum Depression for Dummies
  • Pregnant on Prozac
  • Why Is Mommy Sad? A Child’s Guide to Parental Depression
  • Mood and Anxiety Disorders during Pregnancy and Postpartum
  • Perinatal Mental Health: the Edinburgh Postnatal Depression Scale
  • Life Will Never Be The Same: A Real Moms Postpartum Survival Guide
  • What Happened to Mommy?
  • Jane Honikman books (founder of PSI)
  • Community Support for New Families, Guide to Organizing Postpartum Parent Support Network in Your Community
  • I’m Listening: Guide to Supporting Postpartum Families
  • Transformed by Postpartum Depression: Women’s Stories of Trauma and Growth
  • The postpartum Husband
  • Therapy and postpartum woman
  • What am I thinking? Having a baby after PPD
  • Cognitive Behavioral Therapy for Perinatal Distress
  • Dropping Baby and Other Scary Thoughts: Breaking Cycle of Unwanted Thoughts in Motherhood
  • Tokens of Affection: Reclaiming Your Marriage After Postpartum Depression
  • This Isn’t What I expected: Overcoming PPD
  • Parenting Well When You’re Depressed; A Complete Resource
  • The Smiling Mask: Truths about PPD and Parenthood
  • Mother To Mother PPD support book
  • Infanticide: Psychosocial and Legal Perspective on Mothers Who Kill
  • Understanding PP Psychosis: a temporary madness
  • The Pregnancy & Postpartum Anxiety Workbook

Resources for Neonatal Loss

  • griefwatch.com
  • handonline.org
  • missfoundation.org
  • nationalshare.org
  • Something Happens – book for children and parents
  • Molly’s Rosebush
  • Pregnancy After a Loss: a Guide to Pregnancy After Miscarriage, stillbirth or Infant Death
  • Empty Cradle, Broken Heart
  • Surviving the death of Your Baby
  • Help, Comfort and Hope After Losing Your Baby in Pregnancy or First Year
  • A Guide for Fathers: When baby Dies

 

  • Prenatal postpartum screening
  1. Risk assessment
  1. Postpartum Scale (PPDS)
  1. Edinburgh Postnatal Depression Scale (EPDS)

EPDS developed in 1987 by Dr. John Cox. 10 question self-report screening tool translated into many languages and used all over world. Effective w teens and dads. Can be found on many internet sites. Also shortened 3 question version.

 

  • Baby Blues – not a disorder

“Baby Blues” – not a disorder – used to describe milk mood swings that occur after first few weeks of birth (begins first week postpartum; should be gone by 3 weeks postpartum). Not considered a disorder since majority of mothers experience it (80%). Symptoms: moodiness, crying, sadness, worry, lack of concentration, forgetfulness, feelings of dependency. Causes: rapid hormonal changes; physical/emotional stress of birthing; physical discomforts; emotional letdown after pregnancy and birth; awareness and fear about increased responsibility; fatigue and sleep deprivation; disappointments including the birth, partner support, nursing and the baby.

  • Perinatal mood and anxiety disorders (PMAD)
  1. Postpartum depression and/or anxiety

Depression & Anxiety Postpartum – 15-20% of mothers; onset usually gradual but can be rapid and begin any time in first year. Symptoms: excessive worry/fear; irritability/short temper; feeling overwhelmed and unable to cope; difficulty making decisions; sadness; hopelessness; feelings of guilt; sleep problems (often can’t sleep or sleeps too much); fatigue; physical symptoms or complaints without apparent physical cause; discomfort around baby or lack of feeling toward baby; loss of focus/concentration (miss appointments); loss of interest of pleasure; lower sex drive; changes in appetite, significant weight loss or gain. Risk Factors: 50-80% risk if previous postpartum depression/anxiety; depression or anxiety during pregnancy; personal or family history; abrupt weaning; social isolation or poor support; history of PMS or PMDD; negative mood changes while taking birth control or fertility medication; thyroid dysfunction; stopping psychiatric medication

Emotional and Mental Health Challenges – postpartum mood disorders (PPMD) develop in first year after giving birth, such as anxiety and panic disorder, OCD, postpartum depression, bipolar disorder and PTSD. ~20% develop. They are more serious than “baby blues” and can complicate postpartum period significantly. Can be emotionally paralyzing and cause feelings of hopelessness and isolation. Our culture also finds it shameful, which can lead to affected new mothers hiding their symptoms and not seeking the treatment they need and deserve. The severity of the following vary among women.

Postpartum Anxiety and Panic Disorders – ~10%. Those with a history of anxiety and panic disorders have an increased risk. Symptoms include shortness of breath, sensations of choking, lightheadedness, faintness, rapid heart rate, chest pain, nausea and diarrhea. If you develop this disorder, an overwhelming fear of being alone, dying (you or baby), or leaving your home may immobilize you.

Postpartum Depression – ~10-20% of new mothers; with history up to 30%; with past postpartum depression, up to 70%. 2 weeks to 1 year after birth, typical onset 6 weeks – 6 months. Symptoms vary in severity: feelings of hopelessness, despair and exhaustion; feelings of extreme inadequacy and low self esteem; lack of energy; loss of interest in everything; inability to sleep, even when opportunity arises; overeating or forgetting to eat; constant crying; surprising and frightening outbursts of anger at loved ones; recurring thoughts about hurting oneself (even committing suicide) or baby

  1. Obsessive compulsive disorders (OCD)

Obsessive Compulsive Disorder (OCD): up to 9% of new others; of those – over 38% have depression. Symptoms: intrusive, repetitive, and persistent thoughts/mental pictures; thoughts often about hurting/killing baby; tremendous sense of horror and disgust about these thoughts; thoughts may be accompanied by behaviors to reduce anxiety (hiding knives); counting, checking, cleaning or other repetitive behaviors; fear of germs; fears about own health. Risk Factor: personal/family history of OCD (diagnosed or not)

Postpartum OCD – ~3-5%. Uncontrollable thoughts and compulsive rituals to protect baby. Obsessive thoughts of fear of being a “bad” mother, hurting baby or germs. Rituals can include constant hand washing (100x each day), frequent housecleaning, excessively checking on baby or constantly ensuring doors are locked.

  1. Panic Disorder

Panic Disorder: 10% of postpartum women. Symptoms: episodes of extreme anxiety; shortness of breath, chest pain, sensations of choking or smothering, dizziness; hot or cold flashes, trembling, rapid heart beat, numbness or tingling sensations; restlessness, agitation or irritability; during attach the woman may fear she is going crazy, dying or losing control; panic attack may wake her up; often no identifiable trigger for panic; excessive worry or fears (including fear of more panic attacks). Risk Factors: personal/family history; thyroid dysfunction

Bipolar Disorder or Manic Depression – BD occurs in ~2%. Woman diagnosed before pregnancy will likely relapse if not treated during pregnancy and postpartum period. Begins with extreme mood elevation, energy and grandiose thoughts with a few days to weeks after birth. Long-term period of depression may follow. Suicide is a risk during mania and depression. Women needs care of psychiatrist or therapist with expertise in condition.

Postpartum Post-Traumatic Stress Disorder – PTSD may result from difficult or frightening birth or from traumatic situations such as an unexpected illness, sudden problems for baby or insensitive or hurtful care. Can also occur if birth triggers memories of traumatic event such as physical or sexual abuse, rape or frightening hospital experience. Symptoms include: preoccupation with trauma, flashbacks to even to recurrent nightmares (maybe with anxiety/panic attacks), anger/rage and extreme protectiveness of oneself or baby.

Risk Factors for PPMD: history of mental health challenges (panic disorder, OCD, depression, BD – or history in immediate family member, physical/emotional/sexual abuse; eating disorders; substance abuse or living with someone with substance abuse); challenges with menstruation, pregnancy, birth or baby (history of severe premenstrual symptoms, history of infertility or miscarriages; unplanned and unwanted pregnancy; traumatic pregnancy or birth; high needs baby or baby with chronic medical condition; feeding problems with baby); temperament (low self esteem, high expectations to be perfect and in control); recent stressful life events (death in family, moving to new home, changing jobs or losing job, getting married, separated or divorced, financial pressures, excessive sleep deprivation); lack of support (unsupportive partner or no partner, unsupportive friends of family, poor or absent relationship with mother); health issues (thyroid disease, anemia), inflammation (research shows inflammation and lack of omega 3 fatty acids are major risk factors for PPMD, and depression in general.

Consuming too many omega 6 fatty acids (vegetable oil and processed food) can cause inflammation. Later pregnancy and postpartum stressors (such as sleep deprivation, major life stress and pain) also raise inflammation. Consuming omega 3 fatty acids (fish, flax meal) can lower high levels of inflammation and prevent or treat postpartum depression and possible other PPMD. See pg 114

  1. Psychosis

Psychosis: serious – person loses touch with reality. 1-2 per 1000 perinatal woman. Onset usually within first 2 weeks after birth. 5% suicide and 4% infanticide rate. Symptoms: seeing, hearing, feeling thing that others do now (voice of God, devil, secret messages from TV); delusional thinking (infants death, denial of birth, or need to kill baby); mania; confusion; paranoia; symptoms that come and go (normal one minute, hearing voices the next). Risk Factors: personal/family history of psychosis, bipolar disorder or schizophrenia (diagnosed or not); previous postpartum psychotic or bipolar episode

Postpartum Psychosis – rare condition that’s more serious than PPMD. Occurs soon after birth in .01% of women. Symptoms include: severe agitation, mood swings, depression and elusions. They need immediate care and psychiatric treatment. Hospitalization often necessary. Once home, continue taking medications and receive ongoing psychotherapy.

  1. Post-traumatic Stress Disorder (PTSD)

Post-traumatic Stress Disorder (PTSD) – occurs following life-threatening or injury producing events such as sexual abuse or assault or traumatic childbirth. Occurs in up to 6% of women; rates are higher (up to 30%) for parents who have a child in NICU. Symptoms: recurrent nightmares; extreme anxiety; reliving past traumatic events. Risk factors: past traumatic events; traumatic birth; severe physical complication or injury related to pregnancy/childbirth; baby in NICU

  1. Bipolar Disorder I and II

Bipolar Disorder I or II (sometimes referred to as Bipolar Spectrum Disorder): AKA manic depression, bipolar disorders are characterized by mood swings from very high (mania) or high (hypomania) to low mood (depression). No data about how often this occurs. Women usually seek help during episode of depression and commonly misdiagnosed as depression rather than bipolar. Symptoms: mania (bipolar I) or hypomania (low level of mania in bipolar II); depression; rapid and severe mood swings. Risk Factor: personal/family history

  1. Plan for wellness

Treating PPMD – if have any risk factors, arrange for professional help before birth so you can report any symptoms quickly and begin treatment. Early treatment can shorten duration. Appropriate treatment depends on severity of symptoms and may include therapy, medications and lifestyle changes, such as: eat well; avoid alcohol, caffeine and over the counter sleep medications; exercise regularly; get info on PPMD and treatments; get enough sunlight or use a light box to decrease risk of SAD; take time for yourself each day – even if it’s just for 5 minutes; get adequate rest and sleep; get enough omega 3 fatty acids to reduce inflammation. Other treatment options: attend a PPMD support group, which helps women and families understand conditions, recognize the causes and learn about resources for support. Caregiver, childbirth educator, local hospital, or health department can refer you to a support group in your area. Can visit postpartum.net or call 800-944-4773; get counseling or therapy – one who specializes in PPMD; take prescribed medication for anxiety, OCD, depression and bipolar disorder; get counseling along with taking medication (can help with more rapid recovery).

Note to Fathers, Partners, Relatives: PPMD can affect the whole family. Women with PPMD often worry about their ability to be physically and emotionally available to their babies; you may worry too. Encourage mom to get treatment, provide support and care, gather info on interacting with newborn, help with housework and find ways to ensure she gets rest and sleep. Getting enough sleep may be the most important step to recover, but can be most challenging. Help with nighttime feeding and parenting so mother can get 2 or more 3-4 hour stretches of sleep each night. Consider getting support from other family members or a postpartum doula or mother/baby support groups.

  1. Transitions for the New Family
  1. Changing role of partners

Life for a New Mother – after birth, reproductive organs return to their prepregnant state (usually within 6 weeks). During first weeks, most parents experience sudden mood changes.

Factors that influence your adjustment to postpartum life: health of mother, strength of mother’s support network. The more of these factors you have, the more likely your adjustment will be smooth (the less, the more likely your adjustment will take longer than normal 8-12 weeks):

  • Before pregnancy
    • Positive experience with how you were raised
    • Good mental and physical health (you and family)
    • Minimal exposure to trauma
    • Positive experience with previous pregnancies, birth and baby care
  • During pregnancy
    • Planned pregnancy
    • No pregnancy complications
    • Pregnant with only one baby
    • No need for prolonged bed rest or treatment for a high risk pregnancy
    • Minimal financial worries
    • Physically undemanding job
    • Adequate sleep
    • Good relationship with baby’s father or your partner
    • Presence of other supportive people
  • During labor or birth
    • Normal, uncomplicated birth
    • Presence of continuous, competent care and support from staff, your partner and other support people
  • Early postpartum period
    • Immediate contact with your baby (including breastfeeding)
    • Minimal postpartum pain
    • Good health (you and baby)
  • Later postpartum period
    • Delaying the return to employment until you feel ready
    • Your baby’s easy temperament and continuing health
    • No feeding problems
    • Adequate sleep for the whole family
    • Positive emotional state
    • Continuing supportive relationships with your partner, family and friends

 

When You’re Pregnant Again

What to Expect with This Pregnancy and Birth: every pregnancy is unique; a second won’t be like your first. Subsequent pregnancies, however, do share some predictable characteristics that make them different. Physical changes may occur sooner, but you might or might not notice them. You may feel baby’s movements about a month earlier, because you recognize the sensation sooner. Or may miss it because you’re not as preoccupied with this pregnancy. Your abdominal muscles relax more easily, so your belly enlarges sooner and your pregnancy becomes noticeable earlier. Your pelvic ligaments may soften sooner, and you may feel that you’re carrying the baby lower. Braxton-Hicks contractions may be more noticeable and numerous, especially toward the end of pregnancy, which can make in difficult to know when they indicate the start of labor.

On average, subsequent pregnancies are a few days short than a first. Labor is typically faster, and pushing is much faster. Most women report that the first stage of labor is less painful than the first time (possible because less anxious), but that second stage is as painful for more so (probably because it’s faster). Its impossible to predict how labor will go; each labor may be identical or completely different.

If previous birth was a positive experience, you’ll hope that this one will be too. If previous birth was difficult or disappointing, you naturally may worry that problems will arise again.   It’s common to feel anxious about labor, regardless of how many times you’ve given birth. Talk about your concerns with your partner, caregiver or childbirth educator can raise confidence and help make this experience a positive one.

Even if you had excellent childbirth preparation classes for your first, it may be helpful to take another series. These “refresher” classes will not only review coping techniques, but also prepare you for how this labor may differ from your first. Classes provide updated information about maternity care, offer ideas for preparing older children for the birth and how to manage your growing household, provide opportunities to talk to other parents and give you time to bond with your new baby before the birth.

Your Emotional Reactions to Having Another Baby: You may find that this pregnancy isn’t as emotionally exhilarating. Pregnancy discomforts may seem more annoying or you may be too busy to notice them. You may think less about being pregnant since older child requires your attention. Instead of thinking of developing baby, may think ahead to her as a newborn, because you already have a clear picture of yourself as a mother. Your partner may be less attentive to you, possible because he or she has greater confidence in your well-being this time around.

You may worry you won’t have enough love for your new baby. Or your love for your older child will lessen with baby’s arrival. You can never run out of love.

You may worry there isn’t enough time in the day to care for another child. Caring for a baby while parenting an older child isn’t as hard as you may imagine. It took a while to learn about baby care and time management with first child. With second child, these skills come quickly.

Including Your Child in Your Pregnancy: prepare child for pregnancy, birth and new baby in a realistic and age-appropriate manner.

When’s best time to tell child you’re pregnant? Some announce after first trimester, when likelihood of miscarriage is reduced. They also delay length for child who doesn’t understand the length of time until birth. Some tell in beginning if mom is vomiting to reassure child that mom isn’t ill. Don’t wait too long where she’ll hear about it from someone else.

What’s the best way to tell my child about the pregnancy? Talk about families, babies, big brothers and sisters. Talk about families with young babies to help him realize it’s normal for families to have more than one child. Link due date to a special event or season to make it more relatable; can also make a countdown calendar. Talk about where you will give birth and possibility of him visiting. Let him feel baby move, hiccups, how baby can hear voices. Encourage baby to talk or sing to baby. Bring baby to prenatal visit to listen to heartbeat. Show child DVDs of him as a baby. Talk about care a newborn needs and how he can help. If baby’s arrival will change where he sleeps, make sleeping arrangements months before birth to prevent child from feeling suddenly displaced. Safety proof home if haven’t since accidents can happen when busy with new baby. Younger child’s (under 2) adjustment to new baby usually occurs more rapidly than an older child’s.

Books for Children about Pregnancy and Birth: Waiting for Baby by Annie Kubler (2000) (board book); How Was I Born by Lennart Nilsson (1996) (5 year old); Hello Baby by Jenni Overend (2004); Mommy Has to Stay in Bed (2006); Hello Baby! by Lizzy Rockwell (2000); Runa’s Birth: The Day My Sister Was Born; Waiting for Baby by Harriet Ziefert (1998)

Including Child at Birth: Many families feel birth is a family event. Others feel it’s too complicated and that child may react to mom’s discomfort in labor. They wonder about logistics of his care during birth. Most home birth providers and birth centers welcome inclusion of children at births, as do some hospitals. Even if caregiver is fine with it, only you and your partner can decide whether child should attend. Assess child’s physical health, emotional readiness, personality and maturity.

If Plan to Have Child Attend Birth:

  • Take childbirth prep classes so you’ll feel comfortable at birth
  • Choose a birth setting that easily allows child’s inclusion
  • Arrange for someone to look after child during birth; it should not be partner or another labor-support person
  • Let child know what to expect at birth. Prepare for sights and sounds. Suggest things she can do during labor (take pics). Explain breastfeeding.
  • Avoid making promises you may not be able to keep (instead of saying you’ll get to see baby being born, say we hope you can be with us)
  • Let child know what will happen if circumstances prevent her from attending
  • Expect child to behave as usual. Don’t expect her to be more mature. She’ll still need you to cuddle her etc

If Child Won’t be At Birth:

  • During last weeks of pregnancy, let child know you’ll be leaving when its time to have baby. Don’t give an exact time unless its scheduled. Tell them who will care for them
  • If he’s staying elsewhere, help him pack bag with his favorite clothes, toys and comfort items
  • When labor begins, tell child when you’ll be leaving and where you’ll be going. Let him know you may leave when he’s asleep
  • Prepare for possibility of separation anxiety if giving birth in a hospital. 1 or 2 day stay is typical for vaginal birth while a 3 or 4 day stay is typical for a cesarean.
  • Plan to have child visit you and new baby
  • Have realistic expectations when child visits. He may ignore, cling excessively, cry uncontrollably when its time to leave
  • Consider having a gift for child to open when he visits your or when you phone him. Tell him gift is from baby
  • If stay is longer than expected, talk to him by phone. Can show pictures of you with new baby.

Helping Child Adjust to New Baby: Some may show fondness, some may be jealous or resentful (especially if they’ve had undivided attention for years). May have tantrums, seek attention, become excessively preoccupied with baby, withdrawn, show aggression towards you or baby, want pacifier, bottle, wet self or change eating and sleeping patterns. A child under 3 tends not to fully resent a new baby until they start crawling and interfering in her play.   Give child a doll so she has a baby to care for, too. Have party to celebrate birth of baby and birth of big sister. Let child open gifts for baby. before birth, have partner handle daily care. Schedule alone time with child and let her decide what to do. Respond to child’s requests and actions; instead of saying “we can’t go to park now because baby is eating, say “lets go later when its sunnier”.

Books For Children about Babies and Siblings: I’m a Big Brother and I’m a Big Sister by Joanna Cole (1997); My New Baby by Annie Kubler (2000); The New Baby by Mercer Mayer (2001); The New Baby by Fred Rogers (1996)

 

Care Management: Psychosocial Needs – assessing reactions to birth experience, feelings about themselves and interacting w new baby and other family members. Specific interventions are planned to increase parents’ knowledge and self-confidence.

Taking time to assess maternal emotional needs and to address concerns before discharge can promote better psychologic health and adjustment to parenting. Ongoing support for postpartum women is also needed. Fatigue will likely be an ongoing concern after discharge when woman is providing care for newborn, herself and other family members. Postpartum support esp beneficial to at-risk populations such as low-income primiparas, those at risk for family dysfunction and child abuse, and those at risk for postpartum depression (PPD).

Effect of the Birth Experience – many women need to review and reflect on labor and birth and look retrospectively at own intrapartal behavior. Partners can have similar needs. If birth experience difference from birth plan, both partners may need to mourn loss of their expectations before they can adjust to reality of actual birth experience. Inviting them to review the events and describe how they feel helps nurse assess how well they understand what happened and how well they have been able to put their birth experience into perspective.

Signs of Potential Complications – Postpartum Psychosocial Concerns – following signs suggest potentially serious complications and should be reported (may be noticed by family members):

  • Unable/unwilling to discuss labor/birth experience
  • Excessively preoccupied with self (body image)
  • Markedly depressed
  • Lacks support system
  • Partner/other family members react negatively to baby
  • Refuses to interact w baby; does not name baby, does not want to hold/feed baby; is upset by vomiting and wet/soiled diapers (cultural appropriateness of actions must be considered)
  • Expresses disappointment over baby’s sex
  • Sees baby as messy/unattractive
  • Baby reminds mother of family member/friend she does not like
  • Has difficulty sleeping
  • Experiences loss of appetite

Maternal Self-Image – how new mom feels about herself and body during postpartum period can affect her behavior and adaptation to parenting.

Feelings related to sexual adjustment after birth are often a cause of concern for new parents. Women can be reluctant to resume sexual intercourse for fear of pain or may worry that coitus will damage healing perineal tissue. Many parents anxious for info but reluctant to bring up subject.

Adaptation to Parenthood and Parent-Infant Interactions – Mother’s and partner’s reactions to and interactions w new baby. Clues indicating successful adaptation begin to appear early in postbirth period.

Parents are adapting well to their new roles when they exhibit a realistic perception and acceptance of their newborn’s needs and limited abilities, immature social responses and helplessness.

Examples of positive parent-infant interactions include taking pleasure in infant and providing care, responding appropriately to infant cues and providing comfort. Nurse can ask questions to determine if woman is experience normal “baby blues” or if there is a more serious underlying condition. Screening for PPD through use of a simple tool such as Edinburgh Postnatal Depression Scale (EPDS) can be done before hospital discharge. Screening for PPD should also be done after discharge. AAP recommends that pediatric care providers routinely perform maternal screening for PPD during infant follow-up visits at 1, 2 and 4 months.

Family Structure and Functioning – woman’s adjustment to her role as mother is affected greatly by her relationships with her partner, her mother and other relatives and any other children. Nurses can help ease new mother’s return home by identifying possible conflicts among family members and by helping woman plan strategies for dealing with these problems before discharge. Such a conflict can arise when couples have very different ideas about parenting. Dealing with stresses of sibling rivalry and unsolicited grandparent advice also can affect woman’s transition to motherhood. Only by asking about other nuclear and extended family members can nurse discover potential problems in relationships and help plan workable solutions.

Effect of Cultural Diversity – final component of complete psychosocial assessment is woman’s cultural beliefs, values and practices, which strongly influence behaviors of woman and family during postpartum period.

Nurse conducts cultural assessment. Accomplished most easily through conversation with mother and partner. Components include ability to read and write English, primary language spoken, family involvement and support, dietary preferences, infant care, attachment, religious or cultural beliefs, fold medicine practices, nonverbal communication and personal space preferences.

Rest, seclusion, dietary restraints, and ceremonies honoring mother are common traditional practices. In some cultures the postpartum period is considered a time of increased vulnerability for mother. There are restrictions on activity, diet, bathing and infant caretaking.

Postpartum period seen by some cultures as time of impurity for mothers. For as many days/weeks as she has lochial flow, she is considered impure and has limited contact with others. Sexual activity prohibited during this time.

In many Asian cultures, the balance between yin and yang (cold and hot) is necessary for balance and harmony with the environment. Practices help mom achieve this balance. Pregnancy is considered a hot condition. It is believed that birth depletes the mother’s body of heat through loss of blood and inner energy; this places her in a cold state for about 40 days until her womb is healed. Woman consumes only hot foods and beverages (rice, eggs, beef, chicken soup). Seaweed soup supposed to increase milk production and help rid body of lochia. Mother may be discouraged from showering or bathing for several days/weeks; however, there is attention to perineal care and hygiene. Mother likely spends most of time in bed to prevent cold air from entering body and she has minimal contact with infant. Family members provide care for mom and newborn. In Korean culture, mother in law is charged with caring for daughter in law and newly born grandchild. Women may refuse routine application of cold packs or pads to perineum because this conflicts with beliefs about preventing loss of heat

Hispanic and Latino women who have immigrated often observe period o f 40 days after birth as la cuarentena. Woman’s body is perceived to be open and vulnerable to drafts; la cuarentena is about closing the body (Liquid diet of nutritious drinks, soups and broths, binding abdomen, avoiding cool air, maintaining sexual abstinence). Activity is restricted and mother stay s at home. Common concern is evil eye or mal de ojo. They believe if someone admires/covets infant but does not touch him, it will cause bad luck, illness or even death. Some mothers place a bracelet with a black onyx hand, la manita de azabache on or near newborn.

Nurse needs to determine whether a woman is using complementary or alternative therapies (folk medicine) because active ingredients in some herbal preparations can have adverse physiologic effects when use in combination with prescribed medicines.

Discharge Teaching – Self-Management and Signs of Complications – women need basic instruction on nutrition, exercise, family planning, resumption of sexual intercourse, prescribed medications and routine mother-baby follow-up care. Providing written material on postpartum self-management, breastfeeding, and infant care that the woman can consult after discharge is helpful.

Nurse reviews woman’s records to see that lab reports, medications, signatures and other items are in order. Woman and baby’s id bands checked carefully.

No medication that can cause drowsiness should be administered to mother before discharge is she is the one who will be holding the baby when leaving the hospital.   In most cases, mom is seated in wheelchair and given baby to hold. Newborn must be secured in car seat.

Formula samples may be given out, even though not consistent with Baby Friendly Initiative since associated with earlier cessation of breastfeeding.

Cultural Considerations

Postpartum Care

  • Chinese, Mexican, Korean and SE Asian women may wish to consume only warm foods and hot drinks to replace blood loss and restore the balance of hot/cold in their bodies. These women desire to stay warm and avoid bathing, exercises and hair washing for 7-30 days after childbirth. Care by family members is preferred. Woman has respect for elders and authority. Some women wear abdominal binders. May prefer not to give babies colostrum.
  • Chinese: follow specific restrictions on diet and activity for 1st month, referred to as “doing the month”
  • Arabic women eat special meals designed to restore their energy. They are expected to stay at home for 40 days after birth to avoid illness resulting from exposure to outside air
  • Haitian women often wear a belt or piece of linen pulled tightly around the waist to prevent gas from entering the body; they may request to take placenta home to bury or burn. For 6-11 weeks after birth, they typically follow a strict regimen of baths, vapor baths, teas and dressing warmly.
  • Muslim women follow strict religious laws on modesty and diet. She must keep her hair, body, arms to the wrist, legs to the ankles covered at all times. She cannot be a lone in the presence of a man other than her husband or male relative. Observant Muslims will not eat pork or pork products and are obligated to eat meat slaughtered according to Islamic laws (halal meat). If halal meat is not available, kosher meat, seafood or a vegetarian diet is usually accepted.
  • Ethiopian women stay secluded for a min of 40 days after birth. They consume special foods such as gruel of oats and honey to increase breast milk production.

Family Planning

  • Birth control is gov. mandated in mainland China. Most Chinese women have an IUD inserted after the birth of their first child. Women do not want hormonal methods of contraception because they fear putting these medications into their body
  • Hispanic women may choose the rhythm method or natural family planning because most are Catholic
  • East Indian men are encouraged to have voluntary sterilization by vasectomy
  • Muslim couples may practice contraception by mutual consent as long as its use is not harmful to woman. Acceptable methods include foam and condoms, diaphragm, and natural family planning
  • Hmong women highly value and desire large families, which limits birth control practices
  • Arabic women value large families, and sons are especially prized.

Sexual Activity and Contraception – traditional postpartum visit 6 weeks after birth so discuss at hospital before discharge. For most women, risk of hemorrhage or infection is minimal by ~ 2 weeks postpartum.

Many factors can influence the timing and quality of sexual activity after birth. Perineal pain and dyspareunia (painful intercourse) are common among women with perineal lacerations or episiotomy. Some women who had episiotomies reported discomfort w intercourse for months after birth.

Discomfort is more severe and lasts longer with 3rd and 4th degree lacerations. Breastfeeding mothers often experience vaginal dryness related to high levels of prolactin and low estrogen levels. Changes in family structure and altered sleep patterns can make It difficult for a couple to find time for privacy and intimacy. Postpartum depression is associated with decreased sexual desire; medication used to treat PPD can reduce sexual desire and inhibit orgasm.

Contraceptive options should also be discussed with heterosexual women so they can make informed decisions about fertility management. Waiting to discuss until 6 week appointment can be too late. Ovulation can occur as soon as 1 month after birth, particularly in mothers who formula feed. Breastfeeding moms should be informed that breastfeeding is not a reliable means of contraception and that other methods should be used; non hormonal are best because oral contraceptives can interfere with milk production. Women who are undecided about contraception at time of discharge need info about using condoms with spermicidal foam or creams until first postpartum checkup.

Medications – women routinely continue to take prenatals during postpartum. Breastfeeding moms may continue prenatal vitamins for duration of breastfeeding. Supplemental iron may be prescribed for moms with lower than normal hemoglobin levels. Women with extensive episiotomies or perineal lacerations (3rd or 4th degree) are usually prescribed stool softeners to take a t home. Pain medications (opioid and non opioid) may be prescribed, esp for those who had cesareans. Nurse should make sure woman knows route, dosage, frequency, and common side effects. Written info usually included with discharge instructions.

Resuming Sexual Activity After Birth

  • Unless health care provider indicates otherwise, can safely resume sexual activity by 2nd-4th week after birth, when bleeding has stopped and perineum is healed. Most women resume by 5-6 weeks after birth, although this varies and is often related to perineal discomfort. Perineal lacerations or episiotomy increases chances of discomfort w intercourse. For first 6 weeks – 6 months, vaginal lubrication might be decreased, esp among breastfeeding women. Physiologic reactions to sexual stimulation for 1st 3 months may be slower and less intense. Strength of orgasm may be reduced
  • Water-soluble gel or contraceptive cream or jelly might be recommended for lubrication. If some vaginal tenderness is present, your partner can be instructed to insert one or more clean, lubricated fingers into the vagina and rotate them to help the vagina relax and identify possible areas of discomfort. A position in which you have control of the depth of the insertion of the penis also is useful. Side by side or female on top position may be most comfortable.
  • Presence of baby influences sexual activity and enjoyment. Parents hear every sound made by the bay; conversely you may be concerned that baby hears every sound you make. Any phase of sexual response can be interrupted by hearing bay cry or move, leaving both of you frustrated and unsatisfied. The amount of psychologic energy expended in child care activities can lead to fatigue. Newborns require a great deal of attention and time.
  • Some women report feeling sexual stimulation and orgasms when breastfeeding. This is not abnormal. Breastfeeding moms often interested in sexual activity before non breastfeeding moms.
  • Do Kegels to correctly strengthen pubococcygeal muscle. This muscle is associated with bowel and bladder function and vaginal feeling during intercourse.

Follow-Up After Discharge

Routine Schedule of Care – women who have experienced uncomplicated vaginal births commonly scheduled for 6 week postpartum exam. Women with cesareans often seen within 2 weeks. Date and time should be included in discharge instructions.

Parents need to make newborn apptmt following discharge if haven’t already done so. Breastfeeding infants seen 3-5 days after birth or 48-72 hrs after discharge and again at ~ 2 weeks. Formula feeding infants may be seen for first time at 2 weeks.

Perineal Trauma and Postpartum Sexual Function:

  • Sexual dysfunction can affect more than half of all women at 2-3 months after birth. One major cause is dyspareunia (painful intercourse) after perineal trauma, esp 3rd and 4th degree lacerations requiring repair. Other causes may include decreased libido and lower estrogen resulting from breastfeeding, postpartum depression and fatigue
  • Both episiotomy and 2nd degree lacerations w repair are associated with lower libido, orgasm, sexual satisfaction, and greater dyspareunia than in women with intact perineums
  • Warm compresses and perineal massage during 1st & 2nd stage birth significantly decrease 3rd and 4th degree tears
  • Evidence is still mixed for whether to suture 1st and 2nd degree lacerations. Although small studies show little difference between groups for pain and wound complications, despite slower wound healing the unsutured group still experiences greater satisfaction

Nurses:

  • Antenatal perineal massage should be taught to minimize perineal damage
  • Perineal management at birth should include limited use of instrumental delivery, esp forceps and avoiding episiotomy, along w careful assessment and repair of anal sphincter lacerations with synthetic, absorbable sutures
  • Before hospital discharge, initiate discussions regarding pain, dyspareunia, resumption of intercourse and contraception. Women should known the hypoestrogenic and sensitivity changes that they can experience as a result of breastfeeding and the need for additional lubrication
  • At postpartum visits assess urine, bowel and sexual function; inspect perineum and assess and discuss mood and intimacy challenges such as fatigue and timing issues. Suggesting alternate positions may help increase comfort during intercourse. Evaluation satisfaction with contraceptive method.

Home Visits – w in a few days can help bridge gap between hospital care and routine visits (only available for some as in cases of midwives). Some families hire postpartum doulas to help. Support by nurses and other trained workers can enhance parent-infant interaction and parenting skills; home visits also help to promote mutual support between mom and partner. Breastfeeding outcomes can be enhanced.

Most commonly scheduled on woman’s 2nd day home, depending on individual family’s situation. Additional visits planned throughout first week, as needed.

Conducting assessment in private area of home provides an opportunity for mom to ask questions on potentially sensitive topics such as breast care, constipation, sexual activity or family planning.

Blood sample may be drawn by home care nurse if baby was discharged before 24 hours.

Telephone Follow Up – many providers are implementing 1 or more follow up calls. Frequently used as follow up to postpartum home visits to reassess woman’s knowledge about sign/symptoms of adequate intake by breastfeeding infant or regarding equipment complications.

Warm Lines – help line or consultation service, not a crisis intervention line. Appropriately used for dealing w less extreme concerns that seem urgent at time the call is placed but not actual emergencies. Calls commonly related to infant feeding, prolonged crying or sibling rivalry.

Support Groups – women adjusting to motherhood may desire interaction and conversation with other women who are having similar experiences. Members of childbirth classes may decide to extend relationship during 4th trimester. Fathers or partners also benefit.

Inexperienced partners can imitate behavior of others in group whom they perceive as particularly capable.

Referral to Community Resources – nurse should have effective referral system for needs of women and family and community resources available. Locating and compiling info contributes to development of referral system. Also develop resource file of local and national services frequently useful.

Key Points:

  • Common nursing interventions in postpartum period focus on preventing excessive bleeding, bladder distention, infection; providing nonpharmacologic and pharmacologic relief of discomfort associated with episiotomy, lacerations or breastfeeding and instituting measures to promote/suppress lactation.
  • Early discharge classes, telephone follow up, home visits, warm lines, and support groups are effective means of initiating physiologic and psychologic adjustments in postpartum period.
  1. Sex and contraception

 

  1. Working outside the home

Returning to Work: Single parents may have to. Some parents love their jobs or have financial obligations. Some may choose to have only 1 parent return to work. If the last option interests you, discover if its possible for your family by visiting www.PCNguide.com. Other questions: can you or partner delay returning to work; can either of you work part time or job share? Work from home? Costs of returning to work: clothing, transportation, child care, convenience foods, and more visits to baby’s caregiver (may become sick more often from exposure to ill children in child care); will income exceed total costs of working outside the home and making working worthwhile; how will person who works feel about other’s staying at home?   Make sure you and your partner support each other to accommodate the change.

Finding Child Care for Your Baby: Best time to arrange for childcare is well before the birth, but sometimes that isn’t possible. If can’t make arrangements before birth, try waiting 3-4 months after birth before returning to work. When start your search, allow at least a month to find childcare that best suits your needs. Ask coworkers or other working parents about their arrangements. Contact local agencies that can help you find licensed child-care facilities, homes or providers such as nannies. See if can share nanny or babysitter with another family. If don’t want a stranger, consider asking family members or friends. Or thing about staggering you and partner’s work schedules. In some work settings, it may be possible to bring baby to work – some have on site child care. Saferchild.org and childcareaware.org have advice on evaluating child care providers. Visit the facilities/homes with baby. How do they deal with babies? With patience/and gentleness or impatience and detachment? How do they deal with crying babies? What do they do when a baby becomes ill? How do they support breastfeeding mothers? How will they feel about your visiting when you can? Check hours and holiday/vacation schedules and ask to see current licenses. Pay attention to how providers respond to you and your baby and trust your instincts. Interview nannies in your home. Ask how they plan to handle duties if they become sick or go on vacation. Request references and contact them. Once begin a relationship, offer compliments and acknowledge their valuable service by giving appropriate holiday gifts. If you feel it isn’t right at any time, find someone else to ensure baby is getting best care.

Returning to Work: by 3 months after giving birth, 60% of employed, 1st time mothers in U.S. return to work. During pregnancy, a 3 month leave from work after birth may seem reasonable however, by 3rd postpartum month, most moms getting to know babies. Need to figure out how to get child to and from child care. Breastfeeding mothers must determine how much to pump and store. If mother or baby has health complications, feeding difficulties, PPMD or stressful/unsupportive job, returning to work can be a challenge. Once back, many worry how sleep deprivation will affect job. If child care option unacceptable or work situation unbearable, try to negotiate delayed return, shorter or flexible hours or work part time or from home. Should you quit? Try to find another? Can family function without your income? Devote energy to workplace’s attitude toward new parents? MomsRising seeks to change public policy on maternity and family leave and other benefits for mothers and families.

Breastfeeding & Working Outside the Home: breastfeeding possible with planning and support; nursing baby during workday or expressing/storing milk keeps up milk supply, provides baby with nourishment that can protect him from acquiring infections in day care and maintains the closeness with your baby that comes with breastfeeding. Most industrialized countries provide mothers with maternity leaves that last a year or more, allowing time for babies to naturally reduce their need to nurse and better adjust to long breaks between feedings. In U.S, usually less than 12 weeks. Before returning to work, research workplace’s policy and attitudes (and legal rights) about breastfeeding.

Let employer know breastfeeding moms take less time off because kids get sick less often. If work close, arrange to work longer so you can have longer breaks during day. If in daycare, choose one that supports breastfeeding.

Ask employer to arrange a time and privacy to express or pump milk at work. Mothers who can’t pump at work can still breastfeed by feeding frequently when at home. Many babies will go on a “reverse feeding” schedule – nurse infrequently during day and feed mostly in evenings and at night.

Can breastfeed at home and supplement with formula while away as long as you continue to nurse frequently when with baby, you should produce enough milk. If supply begins to dwindle, increase number of feedings. Check out La Leche League for more information.

  1. Siblings

Parental Sensory Impairment

Visually Impaired Parent – does not seem to have negative effect on early parenting experiences. Perform differently: prep of infant’s nursery, clothes and supplies. Some parents put entire outfit together and hang it in closet rather than keeping separately in drawers. Some develop a labeling system of infant’s clothing and place diapering, bathing and other care supplies where they will be easy to locate. Can tell when baby is facing them because of baby’s breath.

One of major difficulties is skepticism, open or hidden, of health care professionals. Materials for perinatal education available in Braille.

Eye contact important in U.S. Culture, which will be missed in parent-child attachment process, but visually impaired parent does not miss it. Infant will need sensory input form other parent. Infant will be unaware that eyes are unseeing. Problem may arise if visually impaired parent has little facial expression. Infant, after making repeated unsuccessful attempts to engage in face play, will abandon behavior with her and intensify it with other partner or people in household. Nurses can help mother learn to nod and smile while talking/cooing to infant.

Hearing-Impaired Parent – devices that transform sound into light flashes can be placed in infant’s room to permit immediate detection of crying. Even if parent is not speech trained, vocalizing can serve as both a stimulus and response to infant’s early vocalizing. Deaf parents can provide additional vocal training by use of recordings and TV so that from birth child is aware of full range of human voice. Young children acquire sign language readily and first sign used is as varied as first word.

DHS requires hospitals to have certified interpreters proficient in sign language. Ex: having nurses stand where parent can read their lips. Creative approach is for nursing unit to develop videos on postpartum care, infant care and parenting issues signed by an interpreter and spoken by a nurse. Video recording in which a nurse signs while speaking is ideal. Many resources available with help of internet.

Nursing Approaches for Working with Visually Impaired Parents

  • Visually impaired parent needs orientation to hospital room that allows the parent to move about the room independently. “Go to left of bed and trail wall until feel first door; that is bathroom”
  • Parents need explanations of routines
  • Parents need to feel devices – portable sitz bath equipment, breast pump and to hear descriptions of devices
  • Need chance to ask questions
  • Need opportunity to hold and touch baby after birth
  • Nurses need to demonstrate infant care by touch and to follow with “Now show me how you would do it”
  • Nurses need to give instructions such as “I’m going to give you the baby. The head is to your left side”

Sibling Adaptation – addition of new family member affects everyone in the family. Parents often face the task of caring for the neonate while also attending to the needs of other children, and attempting to distribute their attention equitable. When newborn is preterm o=r has special needs, this task can be difficult.

Reactions of siblings result from temporary separation from mother, changes in mom/dads behavior or infant coming home. Positive behavioral changes include interest in and concern for baby and increased independence. Regression in toileting and sleep habits, aggression towards baby, and increased seeking of attention and whining are examples of negative behaviors.

Parents attitudes toward arrival of baby can set stage for other children’s reactions. Because baby absorbs time and attention of important people in other children’s lives, jealousy (sibling rivalry) is common once initial excitement of having a new baby in the home is over.

Parents, esp mothers, spend much time and energy promoting sibling acceptance of new baby. Sibling preparation classes can help children adjust.   Older children may be actively involved in preparing for infant, and this involvement can intensify after the birth. Parents have to manage the feeling of guilt that older children are being deprived of parental time and attention and monitor behavior of older children toward the more vulnerable infant and divert aggressive behavior.

Siblings demonstrate acquaintance behaviors with the newborn. The acquaintance process depends on the info given tot eh child before the baby is born and on the child’s cognitive and developmental levels. Initial behaviors of siblings with newborn include looking at infant and touching the head. Initial adjustment of older children to a newborn takes time, and parents should allow children to interact at their own pace rather than forcing them to interact. To expect a young child to accept and love a rival for the parent’s affection assumes an unrealistic level of maturity. Sibling love grows as does other love, that is, by being with another person and sharing experiences. The bond between siblings involves a secure base in which 1 child provides support for the other, is missed when absent, and is looked to for comfort and security.

Strategies for Facilitating Sibling Acceptance of a New Baby

  • Take older child (or children) on a tour of your hospital room and point out similarities between this birth and his or her birth.
  • Have a small gift from the baby to give to your older child each day he/she visits
  • Give older child a t-shirt that says “I’m a big brother”
  • When older child visits for first time, make sure you are not holding the new baby. arms need to be open and available for older child. Instruct person accompanying older child to call ahead or give a warning knock to give you time to lay baby down or have someone else hold baby
  • Plan individual time with each child. Father or partner can spend time with older siblings while mother is taking care of baby and vice versa. Siblings like to have time and attention from both parents.
  • Give preschool and early school-age sibling a newborn doll as “their baby”. give sibling a photograph of new baby to take to school to show off “his” or “her” baby, the newborn, such as learning how to give the baby a bottle or change a diaper. Remember to supervise interactions between the sibling and new baby.

Including Your Child at Birth: most home births and birth centers allow, as well as some hospitals. Only you and your partner can decide if child should be there (can get bored, bother staff, who will care for etc). assess child’s physical health, emotional readiness, personality and maturity.

If plan to have child attend birth:

  • Take childbirth preparation classes or review what you learned in previous classes. To make child feel comfortable, you’ll have go be confident in ability to cope with labor.
  • Choose birth setting that allows child’s inclusion – ample space and flexibility to come and go if child becomes bored or uncomfortable. B ring toys and comfort items
  • Arrange for someone to look after child during birth and help explain what’s going on to her (other than partner or labor support person)
  • Let your child know what to expect. Prepare for sights and sounds. Suggest things she can do – like bring you juice, cool cloth, walk with you, play music, take photos with a disposable camera, be quiet when asked. Prepare her for baby’s appearance after birth. Children’s books/DVDs
  • Let child know some circumstances may make it so she can’t come (illness, school, asleep or complications)
  • Don’t expect her to be different (will still want restroom breaks, to be cuddled, say no to requests etc)

If child won’t be at birth:

  • During last weeks of birth, let child know you’ll be leaving to have baby. Let him know time can be a surprise and who will be taking care of him (someone he knows and trusts ideally)
  • Help him pack bag with favorite toys
  • Let him know when in labor you may leave while he’s asleep
  • Prepare for possibility of separation anxiety
  • Plan to have child visit
  • Have realistic expectations – child may ignore you and baby, cling excessively or cry uncontrollably when time to leave. Healthy for him to see you rather than be separated for a longer time
  • Consider a gift for your child to open when he visits or when you phone him to tell baby arrived and say it’s a gift from the baby
  • If hospital trip longer than expected, try to talk to child on phone and provide pictures

Books for Children about babies and siblings: I’m a big brother, I’m a big sister by Joanna Cole and Maxie Chambliss (ages 2-6). My New Baby by Annie Kubler. The New Baby by Mercer Mayer. The New Baby by Fred Rogers.

Helping Child Adjust to New Baby: child may have mixed feelings, tantrums, withdrawn, change eating/sleeping habits, revert to outgrown behavior such as sucking thumb or wanting pacifier, feeding from bottle or breast or wetting herself. Child younger than 3 tents not to fully resent a new arrival’s presence until baby begins crawling and interfering in her play. A child at least 3 often immediately recognizes the impact a baby has on her relationship with her parents and typically has little difficulty showering her displeasure. Even preteens can feel resentment, although they may hide feelings.

  • Give child a doll so she has a “baby” to care for too
  • Have a party to celebrate birth of baby and birth of big sister or brother. Encourage her to make a gift for baby. Let child open present for baby
  • Have partner do more of child’s daily care before birth – giving bath, story time
  • Schedule time to be alone with child and let her decide what you’ll be doing together
  • Respond to child’s requests, comments and actions. Ignoring her when busy may upset her at a vulnerable time. Instead of saying “we can’t go to park now because I’m feeding baby” say “lets go later when its sunnier”
  • Correct negative behavior as always.
  • If she wants to avoid baby, let her
  • Let her help with baby
  • Use feeding time to read, talk or share a snack with child

ICEA Teaching Paper – Siblings

Parents need to know that a Sibling Class will not change how the child has been living for eight months. Sibling preparation is a long-term parental responsibility. The child comes to a Sibling Class with prior learning from the family, media, peers and school. A Sibling Class can: confirm accurate information; correct misconceptions; provide information and experiences not readily available elsewhere; and stimulate questions and subsequent at-home learning.

Suggest that before the class the sibling:

  1. Attend a prenatal exam with mom
  2. Visit and/or help babysit for a newborn
  3. Observe breastfeeding (if the mother plans to breastfeed) at La Leche meetings or elsewhere
  4. Look at own baby pictures
  5. Collect baby pictures from catalogs or magazines to make a scrapbook
  6. Help prepare baby’s clothing and room
  7. Look at children’s books about having a new baby in the family.

Logistics – Schedule classes when there are few conflicts with children’s naps and activities—Saturday morning? Sunday afternoon?

Ages – Children younger than 3 have trouble sitting still and focusing on lecture and activities in class. You might want to divide classes among younger (3-6 years) and older (6 and older) siblings. However, limiting attendance on age alone is not always appropriate. Maturity levels differ drastically and children process what is appropriate for their level. Parents should come with their children to the class so they can participate in the learning and remove bored or disruptive children, if necessary.

Invitations—Prepare simple invitations enhanced with stickers or cartoons for the siblings. In the invitation ask each child to bring:

  • A picture of themselves to make a “birth day” card for the baby
  • A doll or stuffed animal to practice diapering and holding, unless you have a collection of dolls for this purpose.

Name tags for each child and adult—Print children’s names and ages on their name tag. The ages will help gauge more accurately what might be expected from each child. Adding bright stickers to the name tags make them appealing and fun to the children.

Learning Activities

  1. Give each child a paper newborn foot and hand print; ask the siblings to outline their own hands and feet on the same page and make comparisons with the newborn prints.
  2. Have a variety of bright stickers, crayons, scissors, glue sticks, and large blank index cards or poster boards for backing available. The siblings can cut out their photos and arrange stickers around them to make “birth day” cards; precut laminating material to make the cards more durable is also a good thing to have available. The completed cards can be placed near the new baby’s bed or on a string hanging over it.
  3. Show Injoy Videos films for sibling preparation.
  4. Place fetal development charts around the room so the children can look at them; put on the ICEA fetal model t-shirt and talk about the uterus, placenta, and cord.
  5. Lead a role play of being a baby in utero; gather the children in a circle, have them cross their legs, close their eyes, and listen as you play placental sounds and a mother’s heart beat.
  6. Use a large mother doll with an open-bottomed pouch sewn on to demonstrate labor and birth; help the doll have at least fifteen minutes of labor contractions, breathing techniques, grunting, and pushing. Between the contractions, talk about the length of labor and where it will take place.
  7. Talk about the hard work of labor, the pain the mother will experience, and the blood.
  8. Give children disposable doctors’ hats, masks, and booties to show how the doctors, nurses, and midwives dress for birth.
  9. Talk about the work of pushing a baby out; have children push a heavy object to show how hard it can be.
  10. Use a life-size newborn baby doll to show what babies look like.
  11. Have children practice diapering and holding their dolls/stuffed animals.
  12. Place the children’s diapered dolls/animals one at a time in a borrowed hospital bassinet; talk about where babies who stay overnight in the hospital might sleep.
  13. Have parents provide refreshments for a mid- class break
  14. Show a video of labor and birth
  15. Encourage children to vocalize responses to: “Let me hear how babies tell you they are hungry? Lonely? Sad? Wet? Hot? Cold?” Play a recording of a baby crying as a clue to the children.
  16. If possible, take a quick tour of the labor and delivery and postpartum area; show the electric beds and medical equipment
  17. Ceremoniously call each child up to receive a Big Brother/Sister tee shirt or diploma at the end of the session.

Questions to ask and/or clarify the answers to at various times during the class:

  • How many of you are expecting new babies in your families?
  • How do you feel about having a new baby in your family?
  • Where is the baby now? (Solicit answers from the younger children first)
  • How long will labor take?
  • Where will you go when your mom goes to the hospital to have the baby?
  • Has the baby grown bigger inside your mom?
  • How does the baby get food in there?
  • How will the baby get out?
  • What is a newborn baby like?
  • What do babies wear when they are born?
  • Do new babies have teeth? Hair?
  • What can babies eat?
    · Can new babies see? Can they hear?
    · What can newborn babies do?
    · What songs can you sing to a newborn baby?

Sibling Classes can provide a challenge to experiment with a variety of teaching methods. Working with children in this way can also be an antidote to educator burnout. Though sibling classes require a great deal of meticulous preparation, they are never dull and most often are fun and energizing.

  1. Teaching Ideas
  2. Breastfeeding

ICEA YouTube channel members minute: Is baby ready to eat? Breastfeeding awareness(1:47)

Baby gives cues when ready to eat – rapid eye movement – 1st sign (eyes closed but moving), rooting, wiggling, crying is a late sign – a sign of frustration

Pg 69 of handbook – correct latch. Class 1) changing body, supportive partner. Class 2) nutrition, weight loss benefits Class 3) Breastfeeding grab bag   Class 4) skin to skin contact immediately after birth and rooming in. Place on mother’s chest and let baby move. Class 5) possible effects of interventions and medications on early breastfeeding. Breastfeeding easier for cesarean mothers than artificial feeding. Class 6) DVD – Amazing Talents of the Newborn. Effective latch, early feeding cues, how to know baby is getting enough milk, support for mother. Checklist – You know breastfeeding is going well when…

DVD that comes with book

Videos on web: www.breastfeedingmadesimple.com

http://breastcrawl.org/breastcrawl-default.mp4

Breastfeeding Grab Bag

  1. Postpartum

 

Class 1) benefits of exercise and relaxation. Good communication. Class 2) Nutrition.

Class 3) massage for newborn and family members

Class 4) appearance of baby at birth/Apgar score. Immediate skin to skin. Baby remaining in room.

Class 5) effects of interventions/medications on postpartum recovery.

Class 6) Book Your Amazing Newborn. DVD Amazing Talents of the Newborn.

Postpartum Mood Disorders – include PTSD. DVD – healthy mom, happy family.

Reunion class from previous series to final class.

Handouts – Time Sharing – pg 112 in Family Way handbook. Postpartum Support Inventory.

Newborn Care – newborns can’t be spoiled. Harmful effects of scheduled feedings and sleep training, especially if breastfed. Swaddling. Cosleeping.

Wear “baby” during class.

Postpartum grab bag- breast pads, panty liner, baby sleeping sign, shower srubby, cell phone, baby sling, baby product catalog, sexy nightie, water bottle, back to sleep sign, tucks, baby lotion, box of tissues, plate with serving sizes, peri-bottle, feather duster, eye mask, movie tickets

Ways to soothe crying baby – Happiest Baby on Block.

 

  1. Perinatal Loss

 

VII. Other references to read

  1. Papers on Infant Feeding
  2. ICEA Position Paper on Infant Feeding
 www.ICEA.org
  3. Innocenti Declaration of 1990

Innocenti Declarations of 1990 and 2005: Call to Action – in 1990, WHO, UNICEF and other key health funding agencies convened a high level consensus meeting of global policy makers in Innocenti, Italy to set up operational targets for “protection, promotion, and support of breastfeeding.” Outcome was Innocenti Declaration of 1990, which sets a global goal for optimal maternal and child health and nutrition.

“Efforts should be made to increase women’s confidence in their ability to breastfeed. S uch empowerment involved the removal of constraints and influences that manipulate perceptions and behavior towards breastfeeding, often by subtle and indirect means. This requires sensitivity, continued vigilance, and a responsive and comprehensive communications strategy involving all media and addressed to all levels of society. Furthermore obstacles to breastfeeding within the health system, the workplace and the community must be eliminated”

  1. Innocenti Declaration of 2005

IBPB Pgs 23-24
 the 2005 meeting called on government organizations, manufacturers of products, and public interest groups to strengthen and renew their commitment to the 1990 goals. 5 target goals were added, supporting 6 months of exclusive breastfeeding, improving appropriate complementary feeding, addressing infant feeding in extraordinary circumstances and considering legislative implementation of the International Code of Marketing of Breastmilk substitutes.

Calls for removal of obstacles within the health system, which include reducing use of birthing practices that compromise breastfeeding outcomes. Evidence based care of mother clearly improves breastfeeding outcomes and also preserves mothers self esteem, sense of being in control, and empowerment throughout her pregnancy, birth and breastfeeding experience.

  1. Global Strategy for Infant and Young Child Feeding

BFHI: Policies That Protect, Promote and Support the Birth-Breastfeeding Continuum

Breastfeeding, esp exclusive breastfeeding, is central to achieving the WHO/UNICEF Millennium Development Goal (MDG) for child survival. BFHI emerged out of 1989 WHO.UNICEF statement. BFHI, designed to reverse early undermining of breastfeeding in maternity facilities, was launched internationally in 1991 in response to Innocenti Declaration’s call for action, considering that there were very few countries that had dedicated national level breastfeeding support activities and breastfeeding protection, promotion and support was needed at facilities providing maternity services.

Millennium Development Goals – MDGs are 8 goals to be achieved by 2015 that respond to world’s main development challenges. Adopted by 189 nations; signed by 147 heads of state and gov during UN Millennium Summit in Sep 2000. Break down into 21 quantifiable targets measured by 60 indicators

  1. Eradicate extreme poverty and hunger
  2. Achieve universal primary education
  3. Promote gender equality and empower women
  4. Reduce child mortality
  5. Improve maternal health
  6. Combat HIV/AIDS, malaria and other diseases
  7. Ensure environmental sustainability
  8. Develop a global partnership for development

As of 09, >20,000 hospitals and birth facilities worldwide have been designated Baby-Friendly Hospitals. Many hospitals have reported that process of making improvements with such positive outcomes became addictive and caused them to think about what other improvement processes they could implement to further mother/baby health. Healthy children project recently collaborated on a new research methodology with pilot project to implement and sustain skin to skin from birth until completion of first feeding.

  1. WHO Baby-Friendly Hospital Initiative (BFHI)

The Baby Friendly Hospital Initiative (BFHI)- in 1989, UNICEF and WHO issued joint statement “Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services” in which maternity hospitals were targets for strengthening breastfeeding in the prenatal and early postnatal periods. It recommended 10 principles, came known internationally as “Ten Steps to Successful Breastfeeding”

They launched the Baby Friendly Hospital Initiative in 1991, putting forth these steps as international best practices. BFHI was launched in response to Innocenti Declaration’s call for action, considering that there were very few countries that dedicated national-level breastfeeding support activities.

Ten Steps to Successful Breastfeeding (see below)

Among priority facilities targeted were large government, university and teaching hospitals, with intention to influence academic health sector and assist in influencing practice, education and policy at country level.

1989 Joint Statement discusses importance of maternal nutrition and health during pregnancy and the impact of labor and delivery management, noting that “a woman’s experience during labor and delivery affects her motivation towards breastfeeding”

According to WHO, “Breastfeeding, esp exclusive breastfeeding, is central to achieving the Millennium Development Goal (MDG) for child survival. Today, after nearly 17 years of WHO endorsement and UNICEF country-level support, most countries have breastfeeding or infant and young child feeding (IYCF) authorities or BFHI coordinating groups.

In 2006, added sections on HIV and infant feeding, mother-friendly childbirth practices and support for women who aren’t breastfeeding. As of mid-2009, >20,000 hospital and birth centers in 136 countries had been designated as Baby Friendly, including 80 in U.S.

Several countries have implemented the 5 recommended Mother-Friendly practices specifically to improve breastfeeding outcomes. BFHI has been called UNICEF’s single most successful initiative.

Significant changes in clinical practice worldwide have occurred in handling of newborns at birth, in early initiation of breastfeeding, in encouraging minimal or no separation of newborns from mothers and in longer periods of exclusive breastfeeding. However, same emphasis on mother’s health, her emotional integrity, her sense of empowerment and her participation in decisions about her care still falls short around the world.

The BFHI’s 10 Steps to Successful Breastfeeding:

  1. Have a written breastfeeding policy that is routinely communicated to all healthcare staff.
    1. A facility-wide evidence-based policy establishes a consistent philosophy, attitudes and culture surrounding all personnel in the facility and thereby supports mothers
  2. Train all healthcare staff in skills necessary to implement this policy
    1. Training, education and skills development allow all staff to become competent in the knowledge and practical action that supports breastfeeding mothers. Every staff member can become competent in basic skills, so all mothers have access to support. The 20 hours educational framework includes knowledge, skills practice and info on supportive birth practices
  3. Inform all pregnant women about the benefits and management of breastfeeding
    1. Prenatal teaching of how and why of breastfeeding now includes informing women of 5 birth related practices that influence breastfeeding that were added to BFHI in 2006: having a companion during labor; freely moving about; eating and drinking during labor; nonpharmaceutical pain relief; and avoidance of unnecessary interventions
  4. Help mothers initiate breastfeeding within 1 half hour of birth
    1. Place babies in skin to skin contact with moms immediately following birth for at least an hour and encourage moms to recognize when babies are ready to breastfeed, offering help if needed. This is the first and most important postbirth management strategy
  5. Show mothers how to breastfeed and maintain lactation, even if they should be separated from their infants
    1. If baby is unable to feed due to prematurity, illness, injury or another factor, milk expression should be started within 6 hours
  6. Give newborn infants no food or drink other than breastmilk, unless medically indicated
    1. Exclusive breastfeeding means just that – nothing is given to baby by mouth other than mom’s own milk. List of medical reasons for supplementation update in 2009
  7. Practice rooming in-that is, allow mothers and infants to remain together 24 hrs a day
    1. Babies are kept in same room with moms for at least 23/24 hours and in skin-to-skin contact for many of those hours. Safe bed sharing should be assured for mom and baby
  8. Encourage breastfeeding on demand
    1. Breastfeeding on cue is a fundamental principle for long, comfortable breastfeeding. Scheduled feeds (length and/or frequency) are undermining to most breastfeeding relationship
  9. Give no artificial teats or pacifiers to breastfeeding infants.
    1. If direct breastfeeding is ineffective, expressed milk should be fed by cup,, spoon, or other non-teat device. Pacifiers interfere with breastfeeding, esp in early weeks
  10. Foster establishment of breastfeeding support group and refer moms to them on discharge from hospital
    1. Mother support groups and peer support are well-documented strategies that increase exclusivity and duration of breastfeeding.

 

Public Health Implications – bad news is global maternal mortality rates are rising, despite increasing use of technology in birth. Infant mortality rates are key determinants of health in all public health agencies, and these rates are still high and increasing even in some industrialized countries.

Good news is BRHI has been shown to positively impact breastfeeding initiation, exclusivity and overall rates of breastfeeding at 3, 6 and 9 months. Evidence is now very strong that even in industrialized countries, formula-fed babies are at significantly increased risk of morbidity and mortality.

Over 18,000 International Board Certified Lactation Consultants support breastfeeding worldwide. LLL has more than 7000 leaders in 68 countries, conduction over 3000 support groups in 8 or more languages. Similar mother-support organizations thrive in other nations.

Childbirth education and labor support organizations that acknowledge importance of breastfeeding have not yet rallied BFHI’s Mother-Friendly Module in a unified fashion in the way diverse health agencies and professionals have rallied around BFHI with such powerfully positive results.

Practices unsupported by evidence should be discontinued.

  1. International Code of Marketing of Breastmilk Substitutes
  1. Other relevant certifying programs
  2. ICEA Postpartum Doula

2. ICEA Dr. Sears Certified Health Coach

  1. ICEA Early Lactation Care Specialist

About The Author

Jessica