OBgyn Week 11Post Partum Concerns,

Breastfeeding, Breast Health

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

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

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

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

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

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

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

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

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

PP Complications - Hematoma

• 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

Hematoma• Hemotoma signs/ symptoms

– 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

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)

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

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

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)

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

Emboli

• Amniotic fluid embolism signs/ symptomsSame 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

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

Puerperal Fever

• Predisposing factors– PROM– Prolonged labor– Trauma– Intrauterine manipulation– Hemorrhage– Anemia– Malnutrition/ low socioeconomic status– Retained parts

Puerperal Fever• Signs/ symptoms

– 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)

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

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

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

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

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

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

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

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

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!!

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

Dysparunea

• DysparuneaAlways 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

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

Breasts• Breast Health

• Breastfeeding

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-riskRecently 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.

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

Breast Self Exam

Breast Self Exam - Visual

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

Breast Changes• Change in size, firmness, tenderness

nodularity normal with monthly cycle

Nipple discharge should be investigated, esp if one sided, bloody.

Clinical Breast Exam• Inspection

– 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

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)

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

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

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

Benign Breast Conditions• Fibrocystic change

– Most common lesion of the breast– Covers a spectrum of clinical signs, symptoms,

and histologic change– Common in 35-55 year old women– Estrogen is thought to promote clinical symptoms– Cysts arise from breast lobules– Rare after menopause, common during

perimenopause

Fibrocystic Change• Clinical findings

– 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

Tx of Fibrocystic Change• Conventional treatment

– Supportive bra night and day

– Bromocriptine – 2.5 mg BID X 3-6 months

– Danazol – 100-200 mg BID

– Tamoxifen

– Analgesic agents - NSAIDS

– Diuretics

– Progestogen

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

Tx of Fibrocystic Change– Eliminate methylxanthines, arachidonic acid– Vitamin B-6 200-800 mg/day– Evening primrose oil – 1,500 mg omega-6 EFA BID– Vitamin E 150-800 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 – 40-80 mg isoflavones/d*– Intravaginal progesterone – 4 grams/d 2.5% prog cream

days 19-25*

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

Benign Breast Tumors• Fibroadenoma

– Most common benign tumor of the breast– Account for up to 50% of breast biopsies– Usually occur in 20-35 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

Fibroadenoma• 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

Other Benign Breast Conditions

• Nipple discharge – in non-lactating women– Is usually benign (>96%)– Most common causes

• Intraductal papilloma• Papillomatosis• Fibrocystic change• Carcinoma

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

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

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

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

Breastfeeding

• Anatomy– Breast has 15-20 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

Breastfeeding

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

Breastfeeding

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

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

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 / SpecialistsDatabases to locate LCs:http://www.breastfeeding.com/directory/states/texas.html

http://www.ilca.org/i4a/pages/index.cfm?pageid=3337

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

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

Newborns use hands and mouth to stimulate oxytocin after birth

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

Establishing Baseline

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

Breastfeeding

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

Milk Volume

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

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)

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

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)

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

Effects of Analgesia• Epidural or other pain meds (IV or IM)

Effects on newborn:– Decrease alertness– Lower neurobehavioral scores– Inhibit suckling– Delay effective feeding

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)

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

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

(this is not a good latch)

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

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

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)

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

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; 300-

500 calories over pregnancy level (generally 2500-3000 calories/ day)

– Drink to thirst, but at least 10-12 glasses/day

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

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

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

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

Bottle Feeding– 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

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

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

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

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)

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

Mastitis

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

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

Breastfeeding - Improving Milk Supply

• What if supply is inadequate?– Improve nutrition– Increase fluids– Pump – Herbs: galactogogues

• Hops• Fenugreek• Borage• Raspberry

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

Review for Final

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?

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?

THANK YOU!

Good Luck in your endeavors!