Ten Steps to Successful Breastfeeding

Prepared by: IBALI, Jarliequeen A. BSN3G Group29

STEP 1: Breastfeeding policy

Have a written breastfeeding policy that is routinely communicated to all health care staff.

The health-care facility should  Have a breastfeeding policy that covers all Ten Steps to Successful Breastfeeding and prohibits the display or distribution of materials that promote breast milk substitutes, feeding bottles, teats and dummies.  Ensure that the policy is communicated to pregnant women and parents; they should be able to access a copy of the full policy if they wish to do so.  Audit compliance with the policy at least every year. Assessment  A breastfeeding policy that covers all the Baby Friendly best practice standards.  A written description of the mechanism for ensuring that the policy is communicated to pregnant women and parents in an appropriate and effective manner.  The mechanism for auditing the breastfeeding policy.

STEP 2: Staff Training Train all health-care staff in the skills necessary to implement the breastfeeding policy Standards

The health-care facility should  All new staff should be orientated to the breastfeeding policy within their first week of employment and then fully trained to implement the breastfeeding policy according to their role within six months.  Written curricula that cover the Baby Friendly best practice standards should be available for all staff training.  Breastfeeding training should be mandatory for all staff, and accurate records of attendance should be kept.  Staff should be able to answer questions on basic breastfeeding management correctly. Assessment  A written description of the mechanism for orientating new staff to the breastfeeding policy.  The written curricula for all staff training.  A written description of the mechanism for allocating staff to attend training and for recording attendance at training.  Records to confirm that all new staff has been orientated to the policy and that all staff has received training.  Staff to answer correctly a range of questions on basic breastfeeding management.

STEP 3: Antenatal information

Inform all pregnant women about the benefits and management of breastfeeding Standards

The health-care facility should  Before 34 weeks of pregnancy all pregnant women should receive full and clear information about the health benefits of breastfeeding and the importance of: - keeping their baby close - avoiding supplements and teats - feeding when their baby shows signs of wanting to feed - effective positioning and attachment - skin contact after delivery.  All written materials intended for pregnant women should be accurate and effective, and free from the promotion of breast milk substitutes, bottles, teats and dummies.  Antenatal parent education classes (where these are provided) should provide good quality and effective information to supplement that provided during one to one discussion. Routine antenatal group education should not include instruction in how to prepare a bottle of infant formula. Assessment  The written minimum standard of information provided to all pregnant women.  A description of how, where and when all pregnant women are to be informed of the benefits and management of breastfeeding.  An outline of antenatal parent education (where this exists)  Written information intended for pregnant women must be accurate and effective, and free from the advertising of breast milk substitutes, bottles, teats and dummies.

STEP 4: Initiating breastfeeding

Help mothers initiate breastfeeding soon after birth

Standards  All mothers should be given their baby to hold with skin-to-skin contact in an unhurried environment for at least one hour or until after the first breastfeed.  All mothers should be offered help to initiate a first breastfeed when their baby shows signs of readiness to feed. Assessment  New mothers to confirm that they were given the opportunity to hold their baby in skin-to-skin contact as soon as possible after birth.  New mothers to confirm that they were able to hold their baby in skin contact for at least one hour or until after the first breastfeed.  New mothers to confirm that they were offered help with a first breastfeed.

STEP 5: Teaching breastfeeding

Show mothers how to breastfeed and how to maintain lactation, even if they should be separated from their infants

Standards  All breastfeeding mothers should be offered help with a further breastfeed within six hours of delivery. (NB: the baby does not have to breastfeed again within six hours, but an offer of help should be made.)  All breastfeeding mothers should be shown how to effectively position and attach their baby for breastfeeding.  All breastfeeding mothers should be shown how to express their breast milk by hand.  All breastfeeding mothers should receive information, both verbally and in writing, prior to transfer home about how to recognize effective feeding. In addition, a breastfeeding assessment will be carried out at around day 5.  All mothers with a baby on the neonatal unit should be offered help to initiate lactation as soon as possible after delivery, taught how to express by hand and by pump, and advised to do this at least 8 times in 24 hours, including at night.  All written materials intended for new mothers should be accurate and effective, and free from the promotion of breast milk substitutes, bottles, teats and dummies.  All health-care staff with primary responsibility for supporting breastfeeding mothers should have the necessary skills to teach mothers how to position and attach their baby for breastfeeding and how to hand express breast milk.

Assessment  The method used for recording whether breastfeeding mothers have been given all relevant support and information.  The mechanism for ensuring that all new breastfeeding mothers receive information, both verbally and in writing about how to recognize effective feeding.  The mechanism for ensuring that a feeding assessment is carried out on or around day 5.  The training curriculum for staff with primary responsibility for supporting breastfeeding mothers. This should show how these staff is educated to acquire the skills needed to teach mothers to position and attach their babies for breastfeeding and to hand express breast milk.  Written information for new mothers must be accurate and effective, and free from advertising of breast milk substitutes, bottles, teats and dummies. Staff with primary responsibility for supporting breastfeeding mothers to demonstrate correctly how they would teach a mother to position and attach her baby for breastfeeding and to hand express breast milk.  Breastfeeding mothers to confirm that they have: - been offered further help with breastfeeding within six hours of delivery - been shown how to position and attach their baby effectively for breastfeeding - been shown how to hand express breast milk - been given information, both verbal and in writing about how to recognize effective feeding - had a breastfeeding assessment with a midwife or other member of staff.  Mothers with a baby on the neonatal unit to confirm that they have been: - offered help to initiate lactation as soon as possible after delivery - shown how to express breast milk by hand and by pump - advised to express at least 8 times in 24 hours including at night.

STEP 6: Avoid supplementation

Give newborn infants no food or drink other than breast milk, unless medically indicated Standards

Standard  No food or drink other than breast milk should be given to breastfed babies unless: - there is an acceptable clinical reason, the baby is unable to breastfeed and there is no/insufficient breast milk available - the mother has made a fully informed choice to feed her baby other than from the breast.  No promotion for infant food or drink other than breast milk should be displayed or distributed to mothers or staff in the facility. Assessment  The head of service to provide written confirmation that there is no promotion of infant food or drink other than breast milk allowed in the health-care facility.  Hypoglycemia guidelines and reluctant feeder guidelines to be provided. These guidelines to be evidence based, safe and protective of exclusive breastfeeding.  Breastfeeding mothers to confirm that their baby was given no food or drink other than breast milk unless this was clinically indicated or the result of a fully informed maternal choice.  All policies and guidelines underpin good practice.  No promotion of infant food or drink other than breast milk to be found anywhere in the un

STEP 7: Practice rooming-in

Practice rooming-in: allow mothers and infants to remain together 24 hours a day

Standard  All mothers should be enabled to stay with their baby 24 hours a day. Separation should only occur for acceptable clinical reasons or as a result of a fully informed choice by the mother. Assessment  All mothers to confirm that they have been able to stay with their baby 24 hours a day and that separation has only occurred for acceptable clinical reasons.

STEP 8: Encourage breastfeeding on demand

Encourage breastfeeding on demand

Standards  There should be no restrictions on the frequency or length of breastfeeds.  Mothers should be encouraged to breastfeed on demand unless regular feeds are required for acceptable clinical reasons. Assessment  Breastfeeding mothers to confirm that no unnecessary restrictions have been placed on the frequency or lengths of breastfeeds and those they have been advised to observe for feeding cues.  Breastfeeding mothers to confirm that they have been encouraged to feed on demand.

STEP 9: No artificial teats or dummies

No artificial teats or dummies

Standard  No teats or dummies to be given to breastfeeding infants during the establishment of breastfeeding.  It remains a strong recommendation that dummies and teats are used with caution in the neonatal unit setting particularly when the baby is learning to breastfeed. This standard will not, however, be assessed formally as part of the Baby Friendly assessment process. Assessment  Breastfeeding mothers to confirm that their baby has not been given a teat or dummy except in cases where the mother has made a fully informed choice.

STEP 10: Support groups

Identify sources of national and local support for breastfeeding and ensure that mothers know how to access these prior to discharge from hospital

Standard  All breastfeeding mothers to be informed of both professional and voluntary support available to them in the community, including contact details of community midwives, voluntary counselors and any breastfeeding support groups. Assessment  The written information given to mothers about the breastfeeding support available after discharge from hospital.  Breastfeeding mothers to confirm that they have been informed of how to contact both professional and voluntary help with breastfeeding after discharge from hospital.

Placenta

Placenta
The word placenta comes from the Latin for cake. The placenta is an organ that connects the developing fetus to the uterine wall to allow nutrient uptake, waste elimination, and gas exchange via the mother's blood supply. The placenta develops from the same sperm and egg cells that form the fetus, and functions as a fetomaternal organ with two components, the fetal part (Chorion frondosum), and the maternal part (Decidua basalis).

Structure
In humans, the placenta averages 22 cm (9 inch) in length and 22.5 cm (0.81 inch) in thickness (greatest thickness at the center and become thinner peripherally). It typically weighs approximately 500 grams (1 lb). It has a dark reddish-blue or maroon color. It connects to the fetus by an umbilical cord of approximately 5560 cm (2224 inch) in length that contains two arteries and one vein. The umbilical cord inserts into the chorionic plate (has an eccentric attachment). Vessels branch out over the surface of the placenta and further divide to form a network covered by a thin layer of cells. This results in the formation of villous tree structures. On the maternal side, these villous tree structures are grouped into lobules called cotyledons. In humans the placenta usually has a disc shape, but size varies vastly between different mammalian species.

Developmental
The placenta begins to develop upon implantation of the blastocyst into the maternal endometrium. The outer layer of the blastocyst becomes the trophoblast which forms the outer layer of the placenta. This outer layer is divided into two further layers: the underlying cytotrophoblast layer and the overlying syncytiotrophoblast layer. The syncytiotrophoblast is a multinucleate continuous cell layer which covers the surface of the placenta. It forms as a result of differentiation and fusion of the underlying cytotrophoblast cells, a process which continues throughout placental development. The syncytiotrophoblast (otherwise known as syncytium), thereby contributes to the barrier function of the placenta. The placenta grows throughout pregnancy. Development of the maternal blood supply to the placenta is suggested to be complete by the end of the first trimester of pregnancy (approximately 1213 weeks

Function
1. Nutrition and immunity The perfusion of the intervillous spaces of the placenta with maternal blood allows the transfer of nutrients and oxygen from the mother to the fetus and the transfer of waste products and carbon dioxide back from the fetus to the mother. Nutrient transfer to the fetus is both actively and passively mediated by proteins called nutrient transporters that are expressed within 2. Endocrine function In humans, aside from serving as the conduit for oxygen and nutrients for fetus, placenta secretes hormone that is important during pregnancy. 3. Human Chorionic Gonadotropin (hCG) The first placental hormone produced is hCG, which can be found in maternal blood and urine as early as the first missed menstrual period (shortly after implantation has occurred) through about the 100th day of pregnancy. This is the hormone analyzed by pregnancy test; a false-negative result from a pregnancy test may be obtained before or after this period. Women's blood serum will be completely negative for hCG by one to two weeks after birth. hCG testing is proof that all placental tissue is delivered. hCG is only present during pregnancy because it is secreted by the placenta, which of course is present only during pregnancy. hCG also ensures that the corpus luteum continue to secrete progesterone and estrogen. Progesterone is very important during pregnancy because when its secretion decreases, endometrial lining will slough off and pregnancy will be lost. hCG suppresses the maternal immunologic response so that placenta is not rejected.

Function
4. Human Placental Lactogen (hPL [Human Chorionic Somatomammotropin]) This hormone is lactogenic and growth-promoting properties. It promotes mammary gland growth in preparation for lactation in the mother. It also regulates maternal glucose, protein, fat levels so that this is always available to the fetus. 5. Estrogen It is referred to as the "hormone of woman" because it influences the female appearance. It contributes to the woman's mammary gland development in preparation for lactation and stimulates uterine growth to accommodate growing fetus. 6. Progesterone This is referred to as the "hormone of mothers" because it is necessary to maintain endometrial lining of the uterus during pregnancy. This hormone prevents preterm labor by reducing myometrial contraction. This hormone is high during pregnancy. 7. Other functions The placenta also provides a reservoir of blood for the fetus, delivering blood to it in case of hypotension and vice versa, comparable to a capacitor.

Placental Abnormalities

1. Placenta Previa
Placenta previa is defined as implantation of the placenta in the lower uterine segment in advance of the fetal presenting part. The placenta either totally or partially lies within the lower uterine segment. Placenta previa complicates approximately 0.3%-0.5% of pregnancies or about 4.8 per 1,000 deliveries. The risk of recurrent placenta previa is as high as 4% to 8%. The risk of placenta previa increases with the number of prior cesarean sections, rising to 10% with four or more. Although some distinctions in outcome may be made among the different degrees of true placenta previa, all are potentially associated with life-threatening hemorrhage during labor. The degree of placenta previa cannot alone predict the clinical course accurately, nor can it serve as the sole guide for management decisions. Thus, the importance of such classifications has diminished.

Traditionally, placenta previa has been categorized into 4 types (1): 1. Complete placenta previa: where the placenta completely covers the internal os; 2. Partial placenta previa: where the placenta partially covers the internal os. Thus, this scenario occurs only when the internal os is dilated to some degree; 3. Marginal placenta previa: where placenta just reaches the internal os, but does not cover it; 4. Low-lying placenta: where placenta extends into the lower uterine segment but does not reach the internal os.

2. Abruptio Placentae

The term abruptio placentae denote separation of a normally implanted placenta prior to the birth of the fetus. The diagnosis is most commonly made in third trimester, but the term may be used after the 20th week of pregnancy when the clinical and pathologic criteria are met. This is uniquely dangerous condition to both the mother and the fetus because of its pathologic sequelae. Placental separation is a serious complication of pregnancy. The reported incidence varies from 0.49% to 1.29% with a mean incidence of 0.83% or one per 120 deliveries.

3. Vasa Previa
Vasa previa refers to fetal vessels running through the membranes over the cervix and under the fetal presenting part, unprotected by placenta or umbilical cord. The condition usually results either from a velamentous insertion of the cord into the membranes rather than the placenta or from vessels running between lobes of a placenta with one or more accessory lobe. It is a condition which, if undiagnosed is associated with a perinatal mortality of approximately 60%. The condition is important because, when the membranes rupture, spontaneously or artificially, the fetal vessels running through the membranes have a high risk of concomitant rupture, frequently resulting in fetal exsanguination and death. The incidence of vasa previa is approximately 1 in 2,500 deliveries. Risk factors for the condition include a second-trimester low-lying placenta (even if the "low lying" placenta or placenta previa resolves in the third-trimester), pregnancies in which the placenta has accessory lobes, multiple pregnancies, and pregnancies resulting from in vitro fertilization.

Fetal Circulation

Special Structures in Fetal Circulation

Placenta
Where gas exchange takes place during fetal life

Ductus Venosus
Carry oxygenated blood from umbilical vein to inferior vena cava, bypassing fetal liver

Umbilical Arteries
Carry unoxygenated blood from the fetus to placenta

Ductus Arteriosus
Carry oxygenated blood from pulmonary artery to aorta, bypassing fetal lungs.

Umbilical Vein
Brings oxygenated blood coming from the placenta to the fetus

Foramen Ovale
Connects the left and right atrium. It pushes blood from the right atrium to the left atrium so that blood can be supplied to brain, heart and kidney

Heart
Is to pump blood through blood vessels to the body's cells

How does the fetal circulatory system work?

During pregnancy, the fetal circulatory system works differently than after birth:

The fetus is connected by the umbilical cord to the placenta, the organ that develops and implants in the mother's uterus during pregnancy. Through the blood vessels in the umbilical cord, the fetus receives all the necessary nutrition, oxygen, and life support from the mother through the placenta. Waste products and carbon dioxide from the fetus are sent back through the umbilical cord and placenta to the mother's circulation to be eliminated.

Inside the fetal heart:

Blood enters the right atrium, the chamber on the upper right side of the heart. Most of the blood flows to the left side through a special fetal opening between the left and right atria, called the foramen ovale. Blood then passes into the left ventricle (lower chamber of the heart) and then to the aorta, (the large artery coming from the heart).\From the aorta, blood is sent to the heart muscle itself in addition to the brain and arms. After circulating there, the blood returns to the right atrium of the heart through the superior vena cava. About one-third of the blood entering the right atrium does not flow through the foramen ovale, but, instead, stays in the right side of the heart. This blood enters the right ventricle from the right atrium, then exits the right ventricle to end up in, eventually flowing into the pulmonary artery. From there, some of the blood will travel to the lungs. The majority of the blood in the pulmonary artery, however, enters the descending aorta through a special artery called the patent ductus arteriosus (PDA). It then travels through smaller vessels to reach back into the placenta. Because the placenta does the work of exchanging oxygen (O2) and carbon dioxide (CO2) through the mother's circulation, the fetal lungs are not used for breathing. Instead of blood flowing to the lungs to pick up oxygen and then flowing to the rest of the body, the fetal circulation shunts (bypasses) most of the blood away from the lungs. In the fetus, blood is shunted from the pulmonary artery to the aorta through the patent ductus arteriosus.

Blood circulation after birth:

With the first breaths of air the baby takes at birth, the fetal circulation changes. A larger amount of blood is sent to the lungs to pick up oxygen. Because the patent ductus arteriosus (the normal connection between the aorta and the pulmonary artery) is no longer needed, it begins to narrow and close off. The circulation in the lungs increases and more blood flows into the left atrium of the heart. This increased pressure causes the foramen ovale to close and blood circulates normally.

The End