OB-GYNE 1

BREASTFEEDING AND NEWBORN CARE

Lecturer: Dr. Ruby Anne Jandoc

TEN STEPS TO SUCCESSFUL BREASTFEEDING

1. Have a written breastfeeding policy that is routinely communicated to all healthcare staff.
2. Train all healthcare staff in skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of breastfeeding.
4. Help mothers initiate breastfeeding within half-hour of birth.
5. Show mothers how to breastfeed, and how to maintain lactation even if they should be
separated from their infants.
6. Give newborn infants no food or drink other than breastmilk unless medically indicated.
7. Practice rooming-in. Allow mothers and infants to remain together 24 hours a day.
8. Encourage breastfeeding on demand.
9. Give no artificial teats or pacifiers (aka dummies or soothers) to breastfeeding infants.
10. Foster the establishment of breastfeeding support groups and refer mothers to them
upon discharge from the hospital or clinic.

Role of OB-Gyne:
Step #3
 The ideal antenatal preparation is to use the time to discuss:
o The woman’s knowledge, beliefs, and feelings about breastfeeding.
o To build the woman’s confidence in her ability to exclusively breastfeed her baby.
 Exclusive breastfeeding for 6 mos
o To assure the woman that support is available for her.
 A pregnant woman needs to understand that:
o Breastfeeding is important for her baby and herself.
o Exclusive breastfeeding for 6 mos is recommended.
o Frequent breastfeeding continues to be important after complementary foods are
added.
 Even complementary food are given, breastfeeding should still be
continued.
Breastfeeding in HIV+ mothers
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 Risk of transmission – 5-15%

 Never mix food
o formula milk disrupts the integrity of the intestinal epithelial cell thereby allowing
the entry of the HIV through the baby’s GIT when breastfed.
 WHO DICTUM – DO NOT BREASTFEED
 ALL OR NOTHING
o Colostrum – coat the baby’s gut – promotes growth of good bacteria
 preventing entry of virus
o If cannot give formula milk exclusively, do breastfeeding exclusively
 AFASS
o Acceptable
o Feasible
o Affordable
o Safe
o Sustainable – most important
Roles of Clerks on Breastfeeding:
 Catch the baby
 Be with the mother as long as she is in the delivery room.
 Assist OB consultants
Relactation
 mother previously breastfed but would like to breastfeed again
 no timeframe
 Arugaan – group of women, NGO, requested to go to Leyte to augment after Typhoon
Yolanda for the help for relacatation
Induced lactation
 women who never breastfed but will breastfeed
 ability of a woman to breastfeed without undergoing pregnancy
 during pregnancy – body produces increasing amoutns of progesterone, estrogen (via
placenta), and prolactin (via pituitary)
 these hormones ready the breast for breastfeeding
 Protocol
o Oral contraceptive
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o Domperidone (anti-emetic)
o Breast pump or baby at the breast
Questions:
 How long to give domperidone, when do you stop when there is already lactation?
DISCUSSION OF BREASTFEEDING WITH PREGNANT WOMEN

 Most women decide whether or not to breastfeed before the baby is born (culture-
dependent).
 Health workers to educate women about breastfeeding as early as possible.
 Identify women who may be at risk for breastfeeding difficulties.

WHAT WOMEN NEED TO MAKE AN INFORMED DECISION ABOUT BREASTFEEDING

A. Information
 Accurate and factual about the importance of breastfeeding and the risk of
replacement feeding.
 Not the health worker’s personal opinion or marketing information from a formula
company.
B. Understanding
 Understanding of the information in her individual situation.
 Giving information in words that are suitable for the woman.
 Discussing the information in the context of her situation.
C. Confidence
 Building the woman’s confidence in her ability to exclusively breastfeed.
 If she is not breastfeeding, she needs to be confident that she can find a
replacement feeding method that is as safe as possible in her situation.
D. Support
 Support to carry out her feeding decision.
 Support to successfully feed her baby and overcome difficulties.

IMPORTANCE OF BREASTFEEDING

A. TO CHILDREN
 Action of breastfeeding helps the child’s jaw as well as muscles such as the
tongue and the muscles of the Eustachian tube.
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 Reduces ear infections.

 Assists with clear speech.
 Protects against dental caries and reduces the risk of orthodontic problems.
 Infants self-regulate their milk intake.
a. Effect on later appetite regulation and obesity (bottle fed – person feeding
the baby controls the feed).
 Human milk
a. Ideal nutrition to meet the infant’s needs for growth and development (no
preparation, no storage, readily available).
b. Protects against many infection (diarrhea and pneumonia), artificial
formula provides no protection from infection.
c. Reduces risks of allergies (eczema and atopic conditions) and of
conditions such as juvenile-onset diabetes.
d. Programs body systems that may assist in blood pressure regulation and
reduction of obesity risk in later life.
 Breastfeeding provides warmth, closeness, and contact, which can help in the
physical and emotional development of the child.
B. TO MOTHERS
 Reduce anemia and retained fat deposited during pregnancy.
 Less likely to become pregnant soon after birth (better child spacing).
 Reduce risk of breast cancer and other forms of ovarian cancer.
 More opportunity to get close to the baby.
C. TO FAMILIES
 Lesser family expenses and time dedicated to the purchase and preparation of
artificial feeds.
 Less worry about infant formula shortages or about an ill baby.
 Lesser absences of parents from work to take care of an ill child.
D. TO COMMUNITIES
 Healthy infants grow to become healthy, intelligent adults in the workforce,
contributing to the well-being of the community.

RECOMMENDATIONS FOR BREASTFEEDING

1. Exclusive breastfeeding for the first 6 months (no need for water, fluids, or food).
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2. Continues to be important after the first 6 months when other foods are given to the
baby.

IMPORTANCE OF BREASTFEEDING AND BREASTMILK

A. BREASTMILK
● Species-specific
o Calves – grow quickly with large muscles and bones.
o Humans – grow slowly with rapid brain development.
● A living fluid that actively protects against infection.
o Produces antibodies passed to the baby.
o Stimulates baby’s own immune system
o White cells are able to destroy bacteria
o Promotes growth of beneficial bacteria (lactobacillus bifidus)
B. COLOSTRUM
● Produced from 7th month - 1st few days after birth
● Thick, sticky, clear – yellowish in color
● “Coats” the baby’s gut (water or artificial feeds can remove the “coating”)
● Promotes growth of good bacteria in the gut
● Contains more protein and vitamin A than mature breastmilk (BM)
● Laxative – help pass meconium
C. PRETERM BREASTMILK
● Contains more protein and minerals
● More immune properties
D. MATURE BREASTMILK
● Contains all the major nutrients (protein, carbohydrates, fats, vitamins, minerals,
water).
E. NUTRIENTS IN BREASTMILK
● PROTEIN
o Easy to digest
o Artificial formulas – slow and difficult to digest; intolerance leading to
rashes, diarrhea, etc.
● FAT
o Digestive enzymes (lipase) in BM make fats readily.
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o Contains very long-chain fatty acids for brain and eye development.
o Foremilk – quenches thirst (level of fat is low)
o Hind milk – gives satiety (fat level high)
o Fat content varies from feed to feed
o Artificial formula – lack digestive enzymes
● CARBOHYDRATES
o Lactose – main CHO
o Aids in calcium absorption
o Fuel for brain growth
o Retards growth of harmful organisms in the gut
● IRON
o Low in amount but well-absorbed
o Artificial formula – high levels, not well absorbed
o Iron-deficiency anemia is rare in exclusively breastfed infants from 6 to 8
months
● WATER
o Does not overload the kidneys
o Does not retain unnecessary fluid
● FLAVOUR
o Affected by what mother eats.
o Variation help the baby get used to the tastes of food.
o Ease transition to these foods after 6 months of age
F. EXCLUSIVE BREASTFEEDING FOR THE FIRST 6 MONTHS
● No drinks/food other than breastmilk
● Vitamins, minerals, medicines can be given
● After 6 months – complimentary foods other than breastmilk
G. FACTORS THAT INTERFERE WITH EXCLUSIVE
● Drinks/foods other than BM
● Pacifier/dummy/soother
● Limit on number of breastfeeds
● Limit on suckling time or length of breastfeeds

PRACTICES FOR SUCCESSFUL BREASTFEEDING

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A. HOSPTIAL PRACTICES
● Have a companion during labor to help the mother be more comfortable and in
control.
● Have skin-to-skin contact immediately after birth, which keeps baby warm and
gives an early start to breastfeeding.
● Keep the baby beside the mother (rooming-in/bedding-in) so that baby is easy to
feed and safe.
● Avoid labor and birth interventions such as sedation and CS unless medically
necessary.
● Learn how to position and attach the baby for feeding.
● Learn feeding signs in your baby so that feeding is baby-led.
● Feeding frequently which helps develop a good milk supply.
● Breastfeeding exclusively with no supplements, bottles, or artificial teats.

HOW CAN A HEALTH WORKER FIND OUT IF A PREGNANT WOMAN KNOWS ABOUT
THE IMPORTANCE OF BREASTFEEING OR HAS QUESTIONS?

A. HEALTH WORKER’S APPROACH

● Start with an open question
o What do you know about breastfeeding?
 Opportunity to reinforce a decision to breastfeed
 Discuss barriers a woman may see about BF
 Discuss problems about previous breastfeeding
o Vs. Are you going to breastfeed your baby?
 Difficult to continue discussion if the woman says she is not going
to breastfeed.
B. ANTENATAL BREAST PREPARATION
● Reassure her that most women breastfeed with no problems
o Breasts and nipples can look different and still work perfectly, except in
very rare cases.
o Antenatal practices such as wearing a bra, using creams, performing
breast massage or nipple exercises, DO NOT assist in breastfeeding.
C. ADDITIONAL INFORMATION FOR THE HEALTH WORKER
● Breast examination during pregnancy can be HELPFUL if used to:
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o Point out to the woman changes in the breasts and how these are signs
that her body is getting ready to breastfeed.
o Check for previous chest or breast surgery or other problems (lump)
o Talk about regular breast self-examination and its importance.
● Breast examination during pregnancy can be HARMFUL if used to:
o Judge if a woman’s nipples or breasts are suitable or unsuitable for
breastfeeding.

WOMEN WHO NEEDS EXTRA ATTENTION

A. Who among pregnant women may need extra counseling and support in feeding
their babies?
● Had difficulty breastfeeding a previous baby and gave up and started formula
feeding quickly.
● Must spend time away from the baby due to work or school.
● Family difficulty – non-supportive family members
● Depressed
● Is isolated, without social support
● Young or single mother
● Has an intention to leave baby for adoption
● Previous breast surgery or trauma that interfere with milk production
● Has a chronic illness or needs medication
● High-risk of her baby needing special care after birth or twin pregnancy
● Is tested and shown to be HIV+
B. Breastfeeding women who became pregnant
● No need to stop breastfeeding an older baby during the succeeding pregnancy
● History of premature labor or experiences uterine cramping – discuss with doctor
● Needs to take care of herself, eating well, and resting
● Breast may feel more tender or milk seems to decrease in the mid-trimester of
pregnancy, continue breastfeeding
● Breastmilk is a major part of a young child’s diet.
● If breastfeeding stops, young child may be at risk, especially if there are no
animal foods in the diet.
● Abrupt cessation of breastfeeding should be avoided.
C. Antenatal Discussion with Women who are HIV+
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● Risk of transmission via BR – 5-15%

● Never mix feed
o Formula milk disrupts the integrity of the intestinal epithelial cell thereby
allowing the entry of the HIV through the baby’s GIT when breastfed.
● ALL OR NOTHING
● AFASS
o Acceptable
o Feasible
o Affordable
o Safe
o Sustainable
● Information on HIV testing
o All pregnant women are offered voluntary and confidential HIV testing.
o Risk of transmission of HIV to baby through breastfeeding (5-10% of
babies or 1:20 to 1:7)
o Individual counseling to give mothers information to make informed
choices about how to feed their babies in their own situation.
o The risk of illness and death from NOT exclusively breastfeeding is higher
than risk of HIV transmission from BF.
o Modified breastfeeding
 HIV+ mother’s own expressed milk is heat-treated to kill HIV virus.
 Expressed breastmilk from another woman and heat-treated.
● If after counseling, a woman who is HIV+ decides NOT to breastfeed
o Replacement feeding options
o Needs in order to use the method she chooses
o If commercial formula, differences and type suited for infant.
o If home-prepared formula, available sources of milk that are suitable and
safe.
o Safe water supply
o Preparation and cleaning of equipment
o Avoidance of mixed feeding and care of her breasts until milk is gone.

IF REPLACEMENT FEEDING IS NOT SUITABLE

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 Can consider “SAFER BREASTFEEDING,” – exclusive breastfeeding followed by safe

transition to exclusive replacement feeding is the method becomes AFASS (need
guidance and support)
 Express milk and heat-treat to kill the HIV
 Exclusive breastfeeding reduces transmission of HIV by about half.

SUMMARY

 A pregnant woman needs to understand that:

o Breastfeeding is important for her baby and herself.
o Exclusive breastfeeding for 6 months is recommended
o Frequent breastfeeding continues to be important after complementary foods are
added.
 Following practices are BENEFICIAL and can assist in establishing breastfeeding:
o Early skin-to-skin contact after birth
o Early initiation of breastfeeding
o Rooming-in
o Frequent baby-led feeding
o Good positioning and attachment
o Exclusive breastfeeding without supplements.
 The IDEAL ANTENATAL PREPARATION is to use the time to discuss:
o The woman’s knowledge, beliefs, and feelings about breastfeeding
o To build the woman’s confidence in her ability to exclusively breastfeed her baby
o To assure the woman that support is available for her.

ESSENTIALS IN NEWBORN CARE

 4 TIME-BOUND INTERVENTIONS
o Immediate drying
o Skin-to-skin contact followed by clamping of the cord after 1-3 minutes
o Non-separation of baby from mother
 Incidence of sepsis is higher when baby is separated from the mother
immediately.
o Breastfeeding initiation
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ESSENTIAL NEWBORN CARE PROTOCOL

 World Health Organization Standard

 Millennium Development Goal 4: Decrease Child Mortality

UNANG YAKAP

 PREPARATION
o 3 pairs of surgical gloves
 2 for the Obstetrician
 1 for the Pediatrician
o 2 blankets
o 1 bonnet
o Cord care
o Eye care
o Vitamin K
o Hepatitis B vaccine shot
 WITHIN FIRST THREE MINUTES
o Call out time of birth
o First linen -> towel dry the baby
 Dry baby the first 30 seconds
 To stimulate the baby to breathe
 Do not wipe off vernix
o Vernix – natural protective cover of the baby
o Do not wash the baby within the first 6 hours
 Washing may lead to hypothermia and infection
o Do a rapid assessment while drying the baby.
o Remove the cloth
o Initiate skin-to-skin contact
 ALL IMPORTANT
 Place the baby prone on the mother’s abdomen or between her breasts
o Cover the baby’s back and head
 Bonnet – for the baby’s head
 Second linen – for the baby’s back
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o Remove first pair of gloves prior to handling of the cord.

o Handling of the cord
 Do not cut the cord immediately
 Allow to stop the pulsations of the cord without milking the cord
 Clamp the cord at 2 cm from the umbilical base
 Apply second clamp 5 cm from the base of umbilicus
 Cut the cord
 Wait for 1-3 minutes or until the cord pulsations have stopped
 Prevents anemia
 Lower rate of intrauterine hemorrhage
o Check on the mother’s condition and deliver placenta
 Inject 10 IV oxytocin into the mother’s arm to avoid uterine atony
 Check how heavy her bleeding is and examine perineum, vagina, and
vulva for tears
 Clean the mother and keep her comfortable

BENEFITS OF SKIN-TO-SKIN CONTACT

 Promotes bonding between mother and child

 Overall success of breastfeeding/colostrum feeding
 Colonization of maternal skin flora
 Protection from hypoglycemia

30 MINUTES TO 1 HOUR AFTER BIRTH

 Baby will start licking, rooting, and tonguing movements

o cues ready for breastfeeding
 Engage the crawling reflex to seek out the nipple
 Counsel on positioning and attachment

AFTER BREASTFEEDING

 Carry out eyecare procedure

 Administer vaccines
 Keep the child in mother’s arm
 Rooming-in of mother and newborn
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EXCLUSIVE BREASTFEEDING STARTS AT BIRTH WITH COLOSTRUM FEEDING AND

CONTINUES FOR SIX MONTHS

 Global Infant and Young Child feeding strategy recommends giving nothing but
breastmilk for 6 months.
 After 6 months, appropriate complementary solids are started while breastfeeding
continues until two years or beyond.

SUMMARY

 Immediate and thorough drying at least 30 seconds with rapid assessment of breathing
and tone.
 Early skin-to-skin contact
 Properly timed cord clamping
 Non-separation for early breastfeeding
o Carry out eye care and immunization procedure after first breastfeed
o Rooming-in
o Exclusive breathing for 6 months