1. Post Partum Concerns, Breastfeeding, Breast Health
OBgyn Week 11
Post Partum Concerns,
Breastfeeding, Breast Health

2. Post Partum Complications
Postpartum hemorrhage
Defined as blood loss over 500ml (about 2 cups)
5% of births end up in a hemorrhage
Maternal hemorrhage accounts for 25% of maternal deaths perinatally
Bleeding to death can occur in 7 minutes
Most likely occurs immediately post-partum but it can happen later
Early pp hemorrhage occurs in first 24 hours
Late pp hemorrhage occurs within 1-6 days; usually dt retained fragments; more likely to be complicated by DIC
This is the biggest post partum concern. This is why you want all birth products to leave the uterus. Hemmorhage is the leading cause of maternal death at birth.
DIC is a result of hemorrhage – all clotting factors are used up.

3. Hemorrhage Can be due to retained tissue
Signs/ symptoms of retained secundines: (products of conception that are not the baby)
Abdominal tenderness
Slight non-involution (return to prePG state) of the uterus
Post-partum involution refers to the gradual return of the reproductive organs back to their non-pregnant state
Fever or temperature over 99.4 degrees F

4. Hemorrhage Risk factors for hemorrhage Twins (uterine distention)
Long labor
Precipitous labor
Abnormal placental placement
Psychological factors
Decreased Hgb (hemoglobin)
Fibroids
Grand multip (>5 births)
Partial separation
Lacerations
Anesthesia
Forceps
Anything distending the uterus more than normal, basically, as well as low hemoglobin,

5. Hemorrhage Characteristics of hemorrhage:
Can gush or be slow trickle bleed
Non-visible: clots inside uterus
Bright red blood or pulsating: artery ruptured Surgery required.
Some women can tolerate blood loss better than others; depends on:
Quantity of blood loss
Hgb levels – higher levels = less shock
Self awareness– psychological factors
Blood volume
Body weight

6. Hemorrhage
Hemorrhage may be stopped by achieving uterine contractions/ clamping down. These will help expel all contents:
Nipple stimulation
Uterine massage/ bimanual compression
Methergine: causes large uterine contraction
Pitocin: usually used to stimulate labor, causes contractions
O2 administration and Trendelenburg position (on back with feet above heart level) help prevent shock / shut-down of rest of body
Make sure all birth stuff is out of the uterus. Above are ways to do that.

7. Shock
Shock
CV system fails to provide sufficient circulation, tissues eventually suffer from a lack of oxygen
Compensatory mechanism designed to keep brain well oxygenated during CV insufficiency
Brain remains oxygenated by:
Peripheral vasoconstricion of circulation so blood is pulled to internal vital organs
Increased HR to increase blood to brain
Increased respirations to maximize oxygen in blood
Hypovolemic shock – shock from low blood volume. Loss of blood plus vomiting makes danger higher.

8. Types of Shock
Hypovolemic: decreased blood volume due to internal or external hemorrhage; main type in deliveries
May also be dt dehydration (sweating, diarrhea, vomiting)
Cardiogenic: heart failure
Neurogenic/vasogenic: decreased vascular tone leads to anaphylactic shock (over release of histamine) which leads to vasorelaxation of parasympathetic NS
Sepsis, blood poisoning, bee sting, etc.
Psychogenic: fainting dt vasorelaxation then vasoconstriction

9. Shock S/SX Shock signs/ symptoms Restlessness Anxiety “Spaciness”
Foreboding feeling
Rapid, shallow respiratory rate
Increased HR but weak and thready
Skin cool, clammy pale
Nausea/ vomiting, pupils dilated
Change in BP of 10mm Hg from normal, or systolic < 80

10. Shock Tx To treat shock, stop hemorrhage May require ER
Many western and Chinese herbs can help with shock and hemorrhage
Trendelenburg position to increase brain O2
Acupuncture (from Dr. Fritz)
Sp 10, Lr 1, Sp1, Sp 6, CV4, Sp 9, moxa
Dizziness after delivery: CV 7, GV 20, Sp 6
Shock: CV 24, K 1, Pc 5, Pc 6, Pc 7, Lu 9, ST 36

11. PP Complications - Hematoma
Rupture of blood vessel causing extravasation of blood into tissue – pools between tissue layers. Enough of this can cause shock. Can be painful as well as tissues are stretched.
Predisposing factors:
Prolonged second stage – in birth canal for longer
Excessive use of perineal stretching
Instrumentation – forceps i.e.
Macrosomia – large baby

12. Hematoma Hemotoma signs/ symptoms Hematoma management:
Swelling, bruising
Signs of shock: increased pulse, hypotension
As much as 1500cc can accumulate in broad ligament hematoma
Displacement of uterus
Pain
Hematoma management:
Apply pressure
Stop bleeding– mb necessary to open and ligate vessel
Prevent infection

13. PP Complications - thromboses
Thrombosis: presence of a thrombus (blood clot still attached at the site of its formation) in a blood vessel
5X more likely in the pregnant and parturient patient
In the parturient patient high risk of pulmonary embolism (embolus is the same as a thrombus but it’s been dislodged); still a major cause of maternal death
(parturient = in labor)

14. Thromboses Thrombosis predisposing factors:
Caesarian section – many clotting factors used
> 35 yo (increased age)
High parity
Obesity
Smoking (esp combined w/oral contraceptives)
Immobility
Trauma to legs

15. Thromboses Thrombosis signs/ symptoms
Superficial thrombophlebitis: tenderness, very hard, feel a lump, red, and warm
Deep vein thrombosis: pain swelling, + Homan’s sign (lay ‘em down, raise the knee, quickly dorsiflex the foot = pain then that’s a positive Homan’s sign)
Diagnosed with ultrasound, venography
Homan’s maneuver under question – might dislodge the thrombus and make it mobile.

16. PP Complications - Emboli
Pulmonary embolism signs/ symptoms
Severe chest pain – causes necrosis in the fx’d part of lung
Dyspnea – esp SOB. Compromises O2 xchg.
Shock sx
Slight hemoptysis
Mb asymptomatic if clot large enough; death may occur without warning. Seems counter-intuitive.
Collapse
Cyanosis
Hypotension (look for dizziness)

17. Emboli Amniotic fluid embolism
Definition: amniotic fluid entering maternal circulation. May cause obstruction of pulmonary vessel but seems to more often cause anaphylaxis
Predisposing factors:
Precipitous labor
Multiparity
Excessive use of oxytocic drugs or prostaglandins
Uterine trauma: rupture, Caesarian, catheter insertion
Trauma to the vasculature – lets amniotic fluid into the blood stream. Doesn’t dissolve – forms oil droplets which can occlude the lungs.

18. Emboli
Amniotic fluid embolism signs/ symptoms Same sx as other embolism
Dyspnea
Rapid, shallow respirations
Pulmonary edema
Tachycardia
Hypotension
Convulsions
Hemorrhage dt DIC
Mortality rate up to 86%
25% of deaths occur in first hour

19. PP Complications - Puerperal Fever
Septicemia usu due to strep bacteria
Usu accompanied by fever
Infxn route: traumatized birth canal tissues
Includes infections of genital tract: perineum, vagina, cervix, uterus, adnexae as well as breast infxn and UTI

20. Puerperal Fever Predisposing factors PROM Prolonged labor Trauma
Intrauterine manipulation
Hemorrhage
Anemia
Malnutrition/ low socioeconomic status
Retained parts
Because closed area is now open to the environment.

21. Puerperal Fever Signs/ symptoms Management Temperature > 100.4 F po
Chills
Pain
Foul discharge
Body aches
Management
Rest and hydration
Determine source of infection
Simple meals: bone broth
Antibiotics may be necessary, but should be avoided if possible (esp if breast feeding)
Source of infection can be from anywhere, even birth attendants. Attendants can be carriers for all the crap they are exposed to – strep, MRSA, etc.

22. PP Complications - Depression
Post partum depression
Approximately 10% of new moms experience PPDep
Due to sudden change in hormones (hormones are a main cause of depression)
Mild form: “baby blues:
Mood swings
Anxiety
Sadness
Irritability
Crying
Decreased concentration
Difficulty sleeping

23. PP Depression
Post partum depression: signs and symptoms more intense and longer lasting than “baby blues” (>6 weeks)
Loss of appetite
Insomnia
Intense irritability and anger
Overwhelming fatigue
Loss of interest in sex
Lack of joy in life
Feelings of shame, guilt, or inadequacy
Severe mood swings
Difficulty bonding with baby
Withdrawal from family and friends
Thoughts of harming self or baby
The main cure is sleep….which moms don’t get to do much.

24. Psychosis Postpartum psychosis
Rare, develops within first two weeks after delivery
Symptoms as with PP Depression, but more severe and also include:
Confusion, disorientation
Hallucinations and delusions
Paranoia
Attempts to harm self and/or baby

25. PP Depression Etiology:
Rapid drop in estrogen, progesterone, possibly thyroid hormones
Emotional factors: anxiety, sense of identity, loss of control
Sleep deprivation
MOMS SHOULD GET SLEEP WITHIN 6 HOURS OF DELIVERY TO HELP PREVENT PPD
Lifestyle influences: demanding baby or older siblings, financial problems, lack of support
Progesterone use discussion:
Hormone use in general should be avoided, but our society in general is estrogen dominant – we are exposed to xenoestrogens like crazy. It’s in a lot of plastics and it mimics estrogen. The ratio between progesterone and estrogen is important to support and maintain a PG. Chronic miscarries esp at about the same stage can implicate low progesterone. It’s possible that women in this time period in history should get low levels of progesterone to counter the estrogen dominance. Not a lot of information on dosing however.

26. PP Depression PPD Risk factors
May happen after the birth of any child, not just the first
History of depression
PPD after a previous pregnancy
Stressful events in past year
Marital conflicts
Weak support system
Unplanned or unwanted pregnancy
Risk of PP psychosis higher for women who have bipolar disorder
Prevent if possible. Easier than treatment!

27. PP Depression Post partum depression
Important to warn new moms about signs and symptoms of PPD, explain not to get embarrassed, that it is important to seek help especially if having difficulty taking care of baby
Seek immediate help if thoughts of wanting to harm self/ baby
If untreated, can last up to a year or longer or may become a chronic depressive disorder
Increases a woman’s risk of future episodes of major depression

28. PP Depression Treatment may include: Counseling
Antidepressants – common in biomedicine
Hormone therapy (thyroid; careful with HRT while breastfeeding!), check hormone therapies
Acupuncture, herbal therapy, qi gong
Getting support network involved

29. PP Depression Prevention Sleep within 6 hours after delivery
Healthy lifestyle choices that include physical activity (preferably outdoors) and good nutrition
Set realistic expectations
Mommy time
Avoid isolation

30. Post Partum - Resuming Sexual Activity
Pelvic rest is indicated for 6 weeks PP
Immediate risk: air embolism, infection, perineal trauma, thrombus, embolism
Later risks: infection, perineal trauma
If episiotomy/ laceration, pelvic rest recommended for up to 8 weeks
~1/3rd of women resume sex by 6 weeks
Also, No Tampons!!

31. Resuming Sexual Activity
Resuming sex is often difficult for postpartum moms
Low libido
Decreased interest (normal for a few weeks to months); focus is on baby
Oxytocin in the system can satisfy her, so she doesn’t really want sex.
Decreased enjoyment
Kegels, pelvic weights to increase vaginal tone

32. Dysparunea Dysparunea Always a bad sign
40% women report pain/ discomfort with intercourse at 3 months PP
Evaluate healing of tissue
Evaluate hormonal effect on mucosa
Evaluate for infection

33. Resuming Sexual Activity
Other factors affecting resuming sex
Episiotomy or laceration
Hormonal imbalance
Fatigue
Post partum depression
Complications of labor or postpartum
Breastfeeding: may lower libido initially; high prolactin levels give a greater sense of contentment
It’s important to listen to your patients – they can’t talk to their family about it and may not be willing to go to a counselor. May have to schedule sex!

34. Breasts
Breast Health
Breastfeeding

35. Breast Exam Self Exam - starting age 20
Clinical Exam - ages 20-39, every 1-3 years, usu done same time as Pap exam. Timing depends on results from Pap.
Screening Mammogram - yearly starting age 40 or 50, earlier if high-risk Recently changed to age 50, but there’s a lot of disagreement in the groups who decide these things. And there general guidelines don’t apply if there’s a family hx, etc.

36. Breast Self Exam May be taught by practitioner during first exam
Do same way, same time each month
Feeling for changes, asymmetry, lumps
Looking for skin changes, discharge, asymmetry
May be done in shower – soap makes it easier
Be sure to examine entire breast, including area towards axilla
Palpation with fingertips plus visual inspection as well
Most breast cancers are detected first by patient
Normal for breast tissue to change with hormone changes during the month.
Cancer has a central fixed mass with fingers that reach out to other tissues. Fixed with rough edges more likely to be cancer.
Most breast cancers happen in the axilla, the tail of the breast.

37. Breast Self Exam

38. Breast Self Exam - Visual

39. Breast Changes
Change in size, firmness, tenderness nodularity normal with monthly cycle
Nipple discharge should be investigated, esp if one sided, bloody.

40. Clinical Breast Exam Inspection Palpation
Symmetry, contour, skin appearance (peau d’orange)
Palpation
Performed with patient sitting, supine (w/hands under head), or both
Palpate in strips or concentric circles
Don’t forget tail of Spence
Palpate axillary and clavicular nodes
Assess for
Temperature, texture, density, nodularity, tenderness, asymmetry, mass, nipple discharge
Anything receiving more circulation will be warmer – cancer included since it makes it’s own circulation.

41. Breast Imaging Techniques
Mammography
Current standard for screening and diagnosis
Ultrasonography
Used in conjunction with mammography, can distinguish solid from cystic masses
Magnetic resonance imaging
May be useful in certain situations, no radiation
New evidence emerging about benefits of MRI for Dx of DCIS (ductal in situ cancer)
Thermography is up and coming – photograph that is temp sensitive so you can see circulation differences in the tissues.
Mammo is gold standard, then biopsy.

42. Imaging Techniques Positron emission tomography
Assesses metabolic activity of tumors
Technetium-99m sestamibi
New technology, still being evaluated
Thermography
Not shown to be useful for screening or diagnosis
May be useful in specialized situations

43. Breast Imaging
Mammography and ultrasonography are the most reliable and common imaging techniques for the early detection of breast lesions
Slowly growing breast cancers can be identified by mammography at least 2 years before the mass reaches a size detectable by palpation
~35-50% of early breast cancers can be discovered only by mammography, and 20% can be detected only by palpation

44. Breast Biopsy
The diagnosis of breast cancer is made by examination of tissue removed by biopsy
Biopsy should be performed on all patients with a dominant or suspicious mass found by PE, and on all suspicious lesions shown by mammography, even with a negative PE
Mammography is not a substitute for biopsy
Typically, biopsy is performed by needle or excision techniques
Take MCP (modified citrus pectin) prior to biopsy, post biopsy, and continue if you get a positive cancer result. This minimizes the risk of metastasizing due to biopsy….which can totally make it spread. MCP binds to circulating cancer cells. Take ½ tsp 2ce daily in water before and after biopsy (or a comparable amt in capsules). Decreases metastasizing and size of met tumors.
Met tends to be along the track of the needle if comes from a biopsy. That’s nice. More hospital/doctor induced poor health.

46. This is cancerous – central mass with the fingers reaching out.

47. Benign Breast Conditions
Fibrocystic change
Most common lesion of the breast
Covers a spectrum of clinical signs, symptoms, and histologic change
Common in year old women
Estrogen is thought to promote clinical symptoms
Cysts arise from breast lobules
Rare after menopause, common during perimenopause

48. Fibrocystic Change Clinical findings DDX
Pain and tenderness, often premenstrual
Occasionally painless
Fluctuation in size, rapid appearance and disappearance common
Cyclic breast pain most common symptom
Usually multiple and bilateral
DDX
If a dominant mass is palpated, carcinoma must be ruled out with mammography, ultrasonography, and biopsy if appropriate
Cancer usually isn’t a painful lump. Fibrocystics are.

49. Tx of Fibrocystic Change
Conventional treatment
Supportive bra night and day
Bromocriptine – 2.5 mg BID X 3-6 months
Danazol – mg BID
Tamoxifen
Analgesic agents - NSAIDS
Diuretics
Progestogen

50. Tx of Fibrocystic Change
Naturopathic treatment
Strategies
Decrease inflammatory activity in breast
Reduce relative estrogen excess and sensitivity to estrogen – consume soy and other phytoestrogens as they binds with the estrogen receptors and reduces production internally…unless px has estrogen sensitive/induced tumors.**
Provide diuretic activity
**Avoid canned foods, storing foods in plastics, any plastic/food related containers. BPA free cans are OK. Some paper to-go boxes, ‘paper’ cups from food places, even plastic shower curtain liners.

51. Tx of Fibrocystic Change
Eliminate methylxanthines, arachidonic acid
Vitamin B mg/day
Evening primrose oil – 1,500 mg omega-6 EFA BID
Vitamin E iu/day
Aqueous iodine – 3-6 mg/day*
Botanical diuretics – taraxicum, celery, juniper
Support liver function, treat constipation
Soy protein – 34 g/d*
Red clover – mg isoflavones/d*
Intravaginal progesterone – 4 grams/d 2.5% prog cream days 19-25*
* Clinical trials

52. Fibrocystic Change and Breast Cancer
Fibrocystic change is not associated with an increased risk of breast cancer unless there is histologic evidence of epithelial proliferative changes
In women with FC who underwent breast biopsy, 70% had non-proliferative changes, and 30% had proliferative changes
Those with proliferative changes have a 5 fold higher risk of breast cancer than the non-proliferative group

53. Benign Breast Tumors Fibroadenoma
Most common benign tumor of the breast
Account for up to 50% of breast biopsies
Usually occur in year old women
Occur rarely after menopause, but calcified ones can be found
Thought to be responsive to estrogen stimulation
Transformation into cancer is rare

54. Fibroadenoma *all = opposite of cancerous Clinical findings
Young patient usually notices a mass while showering or dressing
Physical exam findings
2-3 cm firm, smooth, rubbery mass*
Non-tender, discrete borders, unilateral, mobile*
No inflammation, no skin retraction
DDX – R/O malignancy
Mammography and ultrasonography
Needle or excision biopsy – partial or complete
Treatment
None necessary, ND’s may want to reduce estrogen exposure
*all = opposite of cancerous

55. Other Benign Breast Conditions
Nipple discharge – in non-lactating women
Is usually benign (>96%)
Most common causes
Intraductal papilloma
Papillomatosis
Fibrocystic change
Carcinoma

56. Nipple Discharge Evaluation of nipple discharge
Serous, bloody, or milky
Associated mass
Uni or bilateral
Single or multiple ducts
Spontaneous or provoked
Relation to menses
Pre or postmenopausal
Hormonal medications

57. Nipple Discharge
Unilateral, spontaneous, bloody or serosanguinous discharge from a single duct is usually caused by an intraductal papilloma or intraductal cancer
Diagnostic testing – for persistent, spontaneous d/c
Cytology – negative does not rule our cancer
Mammography, ultrasonography, ductography
Excisional biopsy
Prolactin level with bilateral milky discharge to R/O pituitary adenoma

58. Fat Necrosis
Rare
Caused by trauma, but patient may not report an injury
Unilateral breast mass that may be accompanied by skin or nipple retraction, may see ecchymosis near mass
May be tender or painless
DDX – must R/O CA
Imaging plus needle or excision bx
Untreated, will gradually disappear

59. Erosive Adenomatosis of the Breast
Rare, mimics Paget’s dz of the breast
Sx’s – pruritis, burning, painful nipple, can be enlarged during menses
PE – nipple can be ulcerated, crusting, scaling, indurated, and erythematous
DDX – squamous cell CA, psoriasis, contact dermatitis, seborrheic keratosis, adenocarcinoma mets to the skin, Paget’s dz, other primary nipple tumors
DX – biopsy
TX – local excision
This slide not on the test.

60. Breastfeeding Anatomy
Breast has lobes of glands arranged circularly which secrete milk
Lobe is made up of alveoli and alveolar ducts that are surrounded by myoepithelial cells
Alveoli drain into a lactiferous duct
Lactiferous ducts underneath the nipple form milk sinuses and open onto the surface of the nipple

61. Breastfeeding

62. Breastfeeding Breast changes of pregnancy:
Increase in ductal sprouting and branching and lobular formation from luteal and placental hormones
Estrogen stimulates ductal growth
Progesterone stimulates the branching and
Prolactin stimulates alveolar growth

63. Breastfeeding

64. Breastfeeding Breast tissue also contains: Fat Connective tissue
Montgomery glands: large sebaceous glands surrounding the areola that secrete an antibacterial lubricant
Nipple and areola have smooth musculature that is responsive to tactile, sensory or autonomic stimulation

65. Who Can Breastfeed?
Size of breasts does NOT determine ability to breastfeed
Inverted nipples may make feeding more difficult at first, but does not usually prohibit feeding (surgery possible if severe)
Some surgeries affect breastfeeding ability
Mastectomy
Breast reduction - may damage ductal system
Augmentation - nerves may be severed, implant may impede milk flow

66. Breastfeeding Support
Women who are encouraged and supported in breastfeeding:
Are more likely to breastfeed
Are more successful with breastfeeding
Breastfeed longer on average
Have more satisfaction with process
Lactation Consultants / Specialists
Databases to locate LCs:

67. Breastfeeding Support
Primary caregiver is extremely important to success of breastfeeding
Provide education
Referrals as appropriate
Provide breast-feeding area in waiting room
Help troubleshoot problems that may arise

68. Breastfeeding Breastfeeding physiology Prolactin
Starts to rise about 8 weeks gestation; increase in estrogen suppresses dopamine, which stimulates pituitary prolactin secretion
Stimulates breast growth and colostrum production
Progesterone inhibits lactation during pregnancy
Oxytocin
Contracts myoepithelial cells (uterine and breast)
Empties alveoli and allows alveoli refilling
Release is stimulated by suckling (let-down reflex), infants hand mvmts, and psychologic stimuli

69. Newborns use hands and mouth to stimulate oxytocin after birth

70. Breastfeeding Post partum
Takes about 3-4 days for E and P levels to fall to let prolactin circulate
Suckling stimulates nerve endings in the nipple to release prolactin, oxytocin, and TSH (plays a role in prolactin secretion)
Milk supply usually equal to demand
Breast will store milk for about 48 hours, after which the supply diminishes
Important to set maternal breastfeeding baseline within first week after birth, else milk supply can be insufficient or dry up

71. Establishing Baseline

72. Breastfeeding Advantages of breastfeeding: Bonding
Prolactin stimulates relaxation
Prolactin and oxytocin promote attachment
Mother feels she is truly nourishing the baby
Nutrition (more later)
Milk composition changes to accommodate infant’s nutritional needs
Immune support for infant
Decreased allergies, illnesses, and hospitalizations for infant

73. Breastfeeding Incidence (on average): 65% breastfeed at birth
45% at 2 months
35% at 3 months
20% at 6 months
<10% at 1 year

74. Milk Volume

75. Breastfeeding - Nutrition
Colostrum:
Can be expressed from 12 weeks gestation
10-40mL day
Thick, yellowish pre-milk
Lower calorie, fat, and volume than milk but higher in minerals, protein, and fat-soluble vitamins; high in Ig and antibodies
Important to establish bifidus acidophilus in gut; babies without colostrum don’t establish good gut flora
Laxative: aids baby in passing meconium
Helps clear bilirubin from body
Has high levels of endorphins (2x mom’s blood level)
Helps with postnatal adaptation and development

76. Nutrition Nutrition in breast milk
Increased lactose, water, and fat content during baby’s first week (lower protein and minerals)
Contains lactoferrin (milk source of iron); nursing babies do not require iron supplementation
Bioavailability of iron in milk is 50% vs. 7% formulas and 4% in infant cereals
Bioavailability of
Calcium: 75% vs. 50% in formula
Zinc: 60% v. 35% cow milk formula, 14% soy formula
90% water; baby does not need plain water
Contains cholesterol (removed from infant formula)

77. Breastfeeding Benefits
Decreases allergy to cow and soy milk
Provides immunologic protection
No IgA protection for first year in newborn
Full antibody response not mature until age 2
Inhibits and kills harmful bacteria (IgA component)
Breastfed babies given formula for more than half their feedings don’t have the immunological advantage of the exclusively breastfed baby
Decreases colic, otitis media, pneumonia, bacteremia, meningitis, respiratory infections, asthma, UTIs, atopic eczema, Crohn’s disease, insulin-dependent diabetes, lymphoma

78. Breastfeeding Nutrition Immunologic component
sIgA: highest immunoglobulin present in milk
IgG: rises rapidly after birth then declines around 2 weeks
IgM: same as IgG
IgE: absent in human milk
Several other and proteins and components that provide immune function: mucins, lysozyme, bifidus factor
Enzymes: anti-infective, digestive
Hormones (thyroid, prostaglandins, insulin-like growth factor)

79. Breastfeeding Maternal advantages
More rapid uterine contraction back to normal
Protection against ovarian cancer
Decreased risk of premenopausal breast cancer esp. if first lactation is before age 20 and is for 6 months
Less risk of osteoporosis as bone loss during nursing is replaced and mb to levels above baseline
Cost-effective
Convenient
May suppress ovulation – space children apart

80. Effects of Analgesia Epidural or other pain meds (IV or IM)
Effects on newborn:
Decrease alertness
Lower neurobehavioral scores
Inhibit suckling
Delay effective feeding

81. No analgesia or given less than 1 hour before birth 6.4 hours
Time to Successful Breast Feeding by Analgesia Use and Time of First Feed
Journal of Nurse Midwifery
To breast within 1 hour
To breast after 1 hour
No analgesia or given less than 1 hour before birth
6.4 hours
(n = 8)
49.7 hours
(n = 19)
Analgesia given more than 1 hour before birth
50.3 hours
(n = 9)
62.5 hours
(n = 7)

82. Advantages of Early BF Establishment
Earlier establishment of effective sucking and feeding
Temperature stability
Higher blood sugar
Increased stooling, decreased jaundice
Longer duration of breastfeeding

83. Breastfeeding
Timing
Best to have first nursing within 1 hour of birth, baby is alert and eager and ensure adequate blood sugar
Good for bonding
Environment important: relaxed and private, sit up straight, have water readily available for mom
Use of pillows to support baby and mom’s arms
Lactation coach can assist with position and latch

84. (this is not a good latch)

85. Breastfeeding Intervals
Mom should nurse on demand as long as baby is nursing 8-12 times per day
Maximum interval 4-6 hours in one 24 hour stretch
During the day every 2 hours and every 3-4 h at night if baby allows during first 2 weeks
If baby does not wake within 6 hours to nurse there is likely a problem with his blood sugar– needs to be woken up

86. Advantages of On-Demand Feeding
Less engorgement
No increase in nipple soreness
Less jaundice
Stable blood sugar
Faster onset of mature milk
Less weight loss, faster weight gain

87. Breastfeeding Duration: 15-25 min average per feeding
Cues that baby is hungry:
Increased alertness
Arm and leg movement
Rooting
Hand to mouth movements
Tonguing
Lip smacking
Crying (late sign)

88. Breastfeeding Signs of an adequate milk supply
Baby is satisfied at end of feeding
Comfortable baby for 2-4 hours
Appropriate weight gain
6-8 wet diapers/ day
Bowel movements
Moist mucous membranes and good skin turgor
Milk changes from colostrum to milk
Mother experiences contractions and thrist when baby feeds

89. Breastfeeding Maternal nutrition
Mom should stay on prenatal vitamin while nursing
Most vitamins increase in milk as maternal intake increases (except vitamins C, B1 and K)
Increased need for protein, vitamin D, B6, calcium, zinc, vitamins A, C and folate
More calories needed than when pregnant; calories over pregnancy level (generally calories/ day)
Drink to thirst, but at least glasses/day

90. Breastfeeding Dieting Most breastfeeding moms lose about 1-2#/month
If breastfeeding for over 1 year, they lose more weight in second set of 6 months
Not recommended to lose more than 4#/month
Food choices affect weight gain and loss!
Aerobic exercise does not affect quantity or composition of milk as long as caloric intake is adequate

91. Breastfeeding and Cigarettes
Maternal substance use
Cigarettes
More nicotine is absorbed by infant through the respiratory tract than via breastmilk
Breastmilk is protective against SIDS which has higher incidence in smokers; smoking mothers should therefore still breastfeed

92. Breastfeeding and Alcohol
Alcohol should be discouraged
Affects taste of milk
Diminishes ejection let-down reflex
Infants whose mothers drank heavily were behind in gross motor skills at 1 year of age
Unclear whether dt drinking during PG or lactation
One beer high in hops (IPA) may help with milk production– ok once in a while
Only small % of alcohol gets into milk, but remember infant has low body weight

93. Breastfeeding - Colic
If infant colicky or fussy, look into mom’s diet. Many foods are harder for infants to tolerate when very young (may be able to tolerate better later if avoided early on)
Dairy
Gluten
Caffeine
Chocolate
Onions
Garlic
Strong spices
Legumes
Brassicacea family

94. Bottle Feeding Storage of breast milk
Best to use breast milk in bottle
Bottle nipple is larger and has larger hole
Baby doesn’t need to use tongue (work as hard) to feed
Introduce at six weeks; hold bottle horizontally
Don’t give to baby while flat on his back
If wait longer than 3-6 months, often baby won’t take it
If doing bottle and breast, need to pump for missed feedings or breast will produce less
Storage of breast milk
Refrigerate immediately– up to 24 hours
Up to 6 weeks in regular freezer
Up to 3 months in deep freezer

95. Breastfeeding Weaning
Begins at around 6 months when begin to introduce solid foods
Look for cues baby is ready
Sits upright alone
Getting teeth
Trying to eat food (watching parents eat)
Can swallow without spitting out food
Often babies/toddlers wean themselves
Toddlers: usually nurse for comfort, still beneficial
WHO: recommends breastfeeding x 2 years

96. Breastfeeding -Complications
Sore nipples
Check technique: latch, nursing position
Topical: lanolin,herbal salves, cabbage leaves, expressed breast milk, vitamin E
Nipple shields (can alter flow)
Nurse more often, dry nipples after each feeding
Enhance let down by nursing less sore breast first
Breast engorgement
Usu due to combination of high milk production and decreased feeding frequency
Treatment is hand expression, pumping, or BFing
Hydrotherapy: alternating hot and cold to breast

97. Breastfeeding - Complications
Milk blister: blister on end of nipple due to plugged nipple pore covered by epidermis
Treat by placing warm compress, then baby immediately to breast
Open blister treated with analgesics, ice, antibacterial ointment or herbal salve, breast shields
Time off if mom in too much pain; use breast pump and feed baby by dropper, spoon or cup (to prevent nipple confusion) for 24 hours

98. Breastfeeding - Complications: Mastitis
Mastitis: an infection of the breast tissue that causes pain, swelling and redness of breast
Bacteria enter breast through a break or crack in nipple or through opening of milk duct
Most often occurs in the first 6 weeks postpartum
May occur in non-breastfeeding women (rare)

99. Mastitis Mastitis Symptoms: Breast tenderness or warmth to the touch
General malaise or feeling ill
Swelling of the breast
Pain or a burning sensation continuously or while breast-feeding
Skin redness, often in a wedge-shaped pattern
Fever of 101 F (38.3 C) or greater

100. Mastitis

101. Mastitis Mastitis risk factors:
Sore or cracked nipples (can develop without broken skin)
Previous bout of mastitis while breastfeeding
Using only one position to breast feed, which may not fully drain breast
Wearing a tight-fitting bra (underwire can contribute to breast compression) that restricts milk flow

102. Mastitis Mastitis treatment
Hydrotherapy: alternating hot/cold compresses
Herbs: western and Chinese: take care not to include herbs that may dry milk supply
Try compresses/ poultices before using herbs internally
Acupuncture: points?
Modify risk factors
Antibiotics when absolutely necessary
Avoid tetracycline and sulfa drugs

103. Breastfeeding - Improving Milk Supply
What if supply is inadequate?
Improve nutrition
Increase fluids
Pump
Herbs: galactogogues
Hops
Fenugreek
Borage
Raspberry

104. Breastfeeding - Complications
Thrush
Candida infection in baby’s mouth
Teach mom to keep nipples dry
Bathe nipples in 1 tsp vinegar in cup water
Decrease simple sugars in mom’s diet
Give mom probiotics, can give baby also

105. Review for Final

106. Review Questions Where does fertilization usu take place?
How long is normal human gestation?
At what week of gestation does fertilization occur (approx)?
What are normal early SX of pregnancy?
What are later changes of pregnancy?
What causes these S/SX?
What symptoms would need investigation?
What is Rh incompatibility? Who is at risk?
Which weeks of gestation are embryonic stage?
At approx which week is fetus viable if born?
What is the role of the placenta?
What role(s) do oxytocin play in birth? After birth? In breastfeeding?

107. Review Questions
What are the categories and types of contraceptive methods?
Which are most effective? Cheapest?
What are CIs to OCP use? SEs?
What are some ways to increase fertility and chance of conception?
What are S/SX of SAB? Ectopic PG?
What is Preeclampsia? Eclampsia?
What is PROM? What risks are associated?
How many cms is full cervical dilation?
What are some methods of labor induction?
What does VBAC stand for?
What is meconium?

108. Good Luck in your endeavors!
THANK YOU!
Good Luck in your endeavors!