Assessment and Documentation of Feedings BBC 7: Assessment & Documentation Assessment and Documentation of Feedings Total Lesson Time: 40 minutes Refer to Session Plan for: Objectives- also listed on slide 2 Rationale Key Messages Toolbox - AV - Materials & Handouts - Equipment Activities Birth & Beyond California: Breastfeeding Training & QI Project Rev. April 2009

BBC 7: Assessment & Documentation Objectives Identify two signs of comfortable positioning List three signs of an effective latch Identify two latch problems in need of referral to a lactation consultant Overview A thorough assessment of the baby at breast is critical to providing safe care, appropriate interventions and referrals, as needed, for mother and baby Rev. March 2009

Signs of Comfortable Positioning BBC 7: Assessment & Documentation Signs of Comfortable Positioning Mother in physiological alignment Back straight, joints flexed, no straining Posture supported with pillows, foot rest Infant facing mother Head, chest, hips in straight line Ventral flexion Trunk and head supported Guidelines for Assessment Positioning Note to Trainer: refer to bullets on slide Begin with assessment of mother and baby comfort with their relative positions Evaluate physiological alignment of both mother and baby It is important that nurses share with the mother and other family members what they have observed - sharing observations provides education, information and increased awareness about breastfeeding Optional comment to participants: As nurses, early in Nursing Arts, we learned the importance of physiologic alignment Rev. March 2009

BBC 7: Assessment & Documentation Evaluate Positioning Photograph: baby improperly positioned at breast Breastfeeding Atlas 3rd edition, 2005, figure #85 Note to Trainer: Refer to slide photograph Presentation options for evaluating slides 4 & 5 Use each slide to explain how to assess OR Ask participants to evaluate this mother & baby’s positioning using the physiological alignment guidelines from previous slide (3) and Session 6 Putting Baby to Breast part 1: Positioning Assessment Baby Clearly not happy Not facing breast Hands in the way Mother Does not look comfortable - shoulders raised - wrist angle poor - placement of fingers on breast does not allow baby easy access to areola - working to keep baby’s hands away from mouth Intervention to correct the latch Both mother and baby need repositioning for an effective latch Rev. March 2009

BBC 7: Assessment & Documentation Evaluate Positioning Photograph: baby positioned incorrectly using cradle hold Breastfeeding Atlas 3rd edition, 2005, figure #88 Note to Trainer: refer to slide photograph Assessment: Baby’s right arm (lower arm) is awkwardly positioned - lower arm stress is probably uncomfortable for the baby - pain would be significant if baby had a fractured clavicle Backward rotation of shoulder creates strain on the neck and jaw affecting baby’s ability to latch and suckle Left hip is rotated out causing a bit of twist in torso Hips not supported Head, neck chest and hips not in a straight line Interventions to correct the latch Reposition baby Offer mother option of a pillow on her lap Rev. March 2009

Signs of Effective Latch BBC 7: Assessment & Documentation Signs of Effective Latch Wide angled mouth opening Chin deep into breast – head tilted back Much of areola taken into mouth Lips flanged back by breast Tongue visible under areola Repeat of slide 24 in Session 6: Putting Baby to Breast to reinforce elements of latch Guidelines for Assessment Latch Note to Trainer: refer to bullets on slide The bullets listed on slide 6 & 7 are a repeat of the slides presented in Session 6 Putting Baby to Breast These are the signs to assess to determine proper latch Rev. March 2009

Signs of Effective Latch BBC 7: Assessment & Documentation Signs of Effective Latch Gliding jaw movements Rhythmic sucking bursts with swallows Mother comfortable – baby relaxed Repeat of slide 25 in Session 6: Putting Baby to Breast to reinforce elements of latch Note to Trainer: Review the bullets listed on slides 6 & & signs of latch Ask: How do these sign translate to the documentation tool in use at this hospital? (the responses will vary according to venue) General statements related to documentation It is important that a close observation is done and the assessment findings are recorded These details may not be part of the hospital’s documentation tool - the assessment findings should be recorded in nursing notes in whatever form is used in this hospital - well known fact in medical records: “if it is not charted, then it was not done” Rev. March 2009

BBC 7: Assessment & Documentation Evaluate Latch Photograph: mother using scissor hold on breast, baby with swallow latch Note to Trainer: Refer to slide photograph Presentation options for evaluating slides 8, 9 & 10 Use each slide to explain how to assess OR Ask participants to evaluate the mother & baby’s latch attempt using guidelines from Session 6 Putting Baby to Breast part 2: Latch Assessment: Baby Narrow mouth opening Tension evident in pursed lips, naso-labial creases, frown Mother Using scissor hold with fingers covering areola The shallow latch suggests nipple pain and poor milk transfer Interventions to correct the latch Inform the mother of what has been observed Instruct her on how to remove baby, reposition and re-latch - goal:  wider mouth, deeper latch, better hand position for mother Observe for swallowing Rev. March 2009

BBC 7: Assessment & Documentation Evaluate Latch Photograph: mother using scissor hold on breast, baby with swallow latch, face buried Breastfeeding Atlas 3rd edition, 2005, figure #122 Note to Trainer: refer to slide photograph Assessment: Baby Baby has neck flexed onto chest Can not make wide jaw excursions Suggests poor milk transfer Mother Mother is pushing baby’s head into breast - nose first to touch breast Interventions to correct the latch Inform the mother of what has been observed Instruct mother on how to reposition herself and her baby so mother’s palm is over scapula, baby’s head tilted back. Latch with chin and lower lip to areola first Rev. March 2009

BBC 7: Assessment & Documentation Evaluate Latch Photograph: baby with shallow latch, narrow mouth opening Breastfeeding Atlas 3rd edition, 2005, figure #125 Assessment Baby very narrow angled mouth opening taut upper lip deep naso-labial creases. minimal areola in mouth Mother Note: Due to photo cropping- we can’t see if mother is supporting the baby’s trunk Baby’s head resting on mother’s wrist Increased risk for nipple pain / trauma Suggests decreased milk transfer Interventions to correct the latch Inform the mother of what has been observed Instruct her on how to remove baby from breast - place her finger along side nipple, into baby’s mouth and use as a wedge between gums to break the suction and protect the nipple Help her to reposition in cross cradle and follow latch steps Rev. March 2009

BBC 7: Assessment & Documentation Evaluate Latch Photograph: Close up view of baby on breast and properly latched Breastfeeding Atlas 3rd edition, 2005, figure #129 Ask participants to assess this photograph Assessment Questions Baby Does baby have a wide gape? Are the lips flanged ? How much of the of areola is in baby’s mouth? What signs of milk transfer need to be observed? Mother Inform mom of these observations Ask the mother if she is comfortable? No nipple pain? Can she feel baby tugging on her nipple? Does she appear relaxed? Summary of assessment findings: Overall this baby appears to be well latched Rev. March 2009

Nipple Appearance After Feeding BBC 7: Assessment & Documentation Nipple Appearance After Feeding Photographs: 1) Undistorted nipple after feeding 2) Pinched nipple after feeding Breastfeeding Atlas 3rd edition, 2005, figure #130 Mother should be instructed to observe the shape of her nipple during a feeding session it should look round (like the tip of her finger) it should not be flattened or creased Undistorted Nipple Pinched nipple Rev. March 2009

Breastfeeding Assessment Tools BBC 7: Assessment & Documentation Breastfeeding Assessment Tools A psychometrically sound neonate feeding assessment tool has not yet been empirically validated Clinicians who use these tools for clinical and research purposes should take into account this lack of evidence of psychometric soundness and interpret results of assessment with precautions Well-designed research is needed to study the scientific integrity of these instruments for program evaluations in neonatal care Overview of assessment tools Many different feeding assessment tools are available - per the literature, none of them is perfect It is important to know how to use the assessment tool Equally important is the need to provide education to the mother and implement a plan of action to help those couplets who do not score well - any mother-baby dyad can have a low scoring feeding, especially in the beginning - over time they should improve - if a trend in the opposite direction is observed it needs to be addressed, prior to discharge, with a plan for assistance and referral to a more experienced practitioner, either in-house or in the community Note to Trainer: Identify what tool is used to document breastfeeding at this hospital Ask: How many are familiar with it? - How many have used it? - What do you think of it ? - Is it Useful? User friendly? Identify the Lactation Team / LC at this hospital Ask: How does staff nurse contact lactation team? Ask: What is the mechanism for referral to community resources? Howe, Lin et al. JOGNN, 2008. Rev. March 2009

BBC 7: Assessment & Documentation LATCH Reporting Latch Audible Swallowing Type of Nipple Comfort Hold 0 Sleepy reluctant no latch 1 Attempts to hold nipple in mouth, sucks with stimulation 2 Grasps breast deeply, tongue down, lips flanged, rhythmical sucking 0 None 1 Few - A few with 2 Spontaneous and Intermittent <24hrs, Spontaneous and frequent, > 24 hrs 0 Inverted 1 Flat 2 Everted (afte4 stimulation) 0 Severe Pain: engorged, cracked, bleeding, blisters bruises, 1 Moderate Pain: reddened, bruises 2 No pain Comfortable 0  Full Assist (staff holds) 1 Minimal assist teach one side, mom does other, staff holds mom takes over 2 No Assist mom able to position/hold baby Chart: the LATCH tool is an example of a tool that is used in lactation charting Samples of other tools available include the: IBFAT, MBA & NOMAS Note to Trainer: This slide may be hidden if the LATCH Tool is not used by this hospital OR The content on this slide can be discussed as it relates to the assessment tool this hospital is currently using Overview of Tools The use of a standardized tool within an institution to chart lactation assessments is going to vary by institution Some may have no standardized tool at all If this hospital does use a tool: briefly discuss it’s elements and how to record assessments - detailed training in the use of the tool should be planned for those not familiar with it Nurse/ Staff responsibility Nurses need to learn to make accurate, detailed assessments of breastfeedings Nurses need to record those findings on the baby’s and / or mother’s chart Additional nurses notes may need to be recorded to accurately document some feedings Rev. March 2009

Helping a New Mother to Breastfeed BBC 7: Assessment & Documentation Helping a New Mother to Breastfeed Royal College of Midwives Refer to Session Plan for DVD Instructions for Use DVD: Helping a New Mother To Breastfeed- Royal College of Midwives Activity 1: Assessment of latch on DVD Refer to Session Plan for Activity time and instructions Background For DVD Training video for British midwives Clip will show a baby 36 hours old who still has not yet taken a good feeding For Activity: During the DVD clip the Trainer will pause the action 3 times and participants will be asked to assess the mother and baby at each pause Observations– suggest participants note: - baby’s quiet alert state and feeding cues - the repeated attempts to latch before an effective latch is accomplished - baby was not stressed and crying - the suck/swallow pattern before and after letdown reflex - baby gets on and off breast by herself - the calm nurse/midwife as the helper - the nurse/midwife is sitting while helping, not leaning over and hurting her back Debrief Activity Ask: What did you learn about assessment with this activity? Rev. March 2009

BBC 7: Assessment & Documentation ACTIVITY Breastfeeding Assessment Documentation Activity 2: LATCH Scoring Refer to Session Plan for materials, time and instructions Note to Trainer: Modify this activity depending on the tool that is used at your hospital Hide this slide if not used Background If LATCH is the tool at this hospital, Activity 2 can be used to demonstrate its use Trainer will read assessment findings for Day 1,2 & 5 and ask the group to score the findings Goal: to determine how complete a picture of the breastfeeding assessment does it allow you to record? Debrief Activity Ability to latch is often more difficult after a few days but not for same reasons - the mother/baby dyad can have favorable score one day and not the next - follow-up is essential It is the nurse’s responsibility to observe, assess, intervene, and document for each patient If breastfeeding difficulties occur one of the goals of this training is that there will be additional resources available to both the staff nurse and the patient for consultation and referral - identify the in-patient lactation team and LC - identify the post-discharge follow up services including out-patient clinic, support groups and community resources - Note: any gaps in services should be recorded on the QI Team wall/ flip chart Rev. March 2009

Mother Reported Assessments BBC 7: Assessment & Documentation Mother Reported Assessments Several feedings should be directly observed by a nurse in each 24 hours Mother self reported assessments may be used between nurse observations Reporting of breastfeeding assessment findings: Staff reporting It is important to acknowledge staff responsibilities in terms of patient acuity, assignments and staffing issues It is not always realistic to expect staff to observe every feeding A direct observation by staff should be made at least once each shift - policy guidelines should include the parameters for a direct observation - during this observation staff can begin to teach the mother how to assess her baby’s latch once she is home Maternal self reporting This is an assessment technique and an education tool A mother should learn how to assess a feeding prior to discharge Note to Trainer: Ask: What kind of questions will you ask the mother to gather the information you need? Discussion points include: - Have students verbalize some typical questions and responses given by mothers - Remind participants about the importance of using open ended questions - L : How did your baby latch? How was your baby’s latch during the last feeding? - A :Now that you know what swallows sound like, what did you notice while baby fed? - T : No need to ask about this as type of nipple doesn’t change normally, however, if you have taught her how to stimulate a flat nipple you can ask how she did with the technique - C: How did your nipple feel during the feeding this time? How is your nipple feeling now? - H: Were you able to latch baby yourself or did / was your partner (mother, sister…) able to help you? In the early postpartum period the nurse should observe the feeding and listen to the mother’s assessment - assessment of breastfeeding is a learned skill: if the nurse and mother’s assessments are congruent then it is more likely that the mother’s assessments are valid Rev. March 2009

Latch Problems in Need of Referral BBC 7: Assessment & Documentation Latch Problems in Need of Referral Refusal to latch after 24 hours Poor/inconsistent latch after 24 hours No audible swallowing Inverted nipples Unresolved pain, >3 in the 10-point pain scale Assessment findings needing referral for lactation consultation and follow up Rev. March 2009

Plan of Care: Ineffective Breastfeeding BBC 7: Assessment & Documentation Plan of Care: Ineffective Breastfeeding Refer to lactation consultant Feed the baby Supplement appropriately Protect mother's milk supply Mechanical & hand expression Develop a Plan of Care Note to Trainer: Supplementation and milk expression will be covered in later sessions Rev. March 2009

BBC 7: Assessment & Documentation Summary Feedings need to be observed by a nurse on each shift Assessments need to be shared with the mother and documented on patient chart and progress notes Maternal self reported assessments may be used between nurse observations Couplets will be referred to a more experienced lactation professional as needed Read summary slide Rev. March 2009

BBC 7: Assessment & Documentation Photo Credits Slide 1 – Winter Nursing by J. Kirk Richards Rev. March 2009