1 Welcome Back Birth and Beyond California Day 2

2 Assignments Observe a newborn placed skin to skin with mother for 20 minutes Observe an infant breastfeeding and listen for sucks and swallows Observe the cluster feeding pattern of the breastfeeding newborn

3 Objectives Demonstrate three positions mothers may use to breastfeed List at least three signs of an effective latch Identify two signs of milk transfer from the breast to the infant Identify three in-hospital strategies for early breastfeeding management

4 Putting the Baby to Breast Positioning and Latch Birth & Beyond California: Training and QI Project

5 Factors Influencing Positioning & Latch Infant –Is baby alert and searching? –Are there any underlying medical issues? –Birth trauma? Birth medications?

6 Factors Influencing Positioning & Latch Maternal –Is mother alert and comfortable? –Level of breastfeeding education/ familiarity? –Is she desirous of learning the skill?

7 Breastfeeding in Delivery Room

8 Recumbent Positions Side Lying Gives mother more rest Less discomfort on perineum Post-op C-Section Baby may be more alert Colson, Early Human Development, 2008

9 Side Lying - Variation

10 Recumbent Positions Baby Prone on Breast Instinctive position Helpful for mother with large breasts Post spinal headache where mother must lie flat Managing overactive milk release which overwhelms baby

11 Under The Arm Position Football/ Clutch Hold Gives infant good trunk and head support Mother can support shoulders and buttocks so the baby’s lips can find the nipple more easily Baby approaches from under breast Good visibility of latch Good for preterm/ low tone baby Provides ventral flexion

12 Position Hands Over Shoulder Blades

13 Under the Arm Position Variation More comfortable for post-op or mothers with large breasts Pillow used for support of breast and baby Baby approaches from side Could be used for twins

14 Cross Chest Positions Cross Cradle / Transitional Gives baby good trunk and head support Head, neck, chest, hips in straight line Hips in flexion Mother can guide head to nipple easily Easier for women with large breasts & short upper arm Easier than football hold for many women

15 Cradle or Cuddle Hold Hold most mothers want to try – familiar Difficult to control head of newborn and guide to nipple Awkward for mothers with large breasts and short arm Eventually becomes easier

16 Cradle Hold

17 Cradle Hold

18 Suck, Swallow, Breathe Activity

19 Latch to the Breast Nose opposite nipple Support upper back and base of skull Move baby forward at shoulders; allow head to tilt back slightly Hug the baby’s buttocks in close

20 Latch to the Breast Chin touches breast first Let nipple touch lips WAIT for wide gape with tongue down

21 Latch to the Breast Baby takes in more of lower areola than upper Teat lays on tongue and head comes forward Asymmetrical latch If not deeply latched, remove and start again Cheeks should be rounded, no dimpling

22 Latch 1,2,3 Troubleshooting Breastfeeding in the Early Weeks The Healthy Children Project

23 Breast Holds

24 Signs of Effective Latch Wide angled mouth opening Chin deep into breast – head tilted back Much of areola taken into mouth Lips flanged back by breast Tongue visible under areola

25 Signs of Effective Latch Rhythmic sucking bursts with swallows Mother comfortable – baby relaxed Gliding jaw movements

26 Signs of Milk Transfer Swallowing by infant can be seen / heard for much of feeding Mother’s breast is firmer before feeding, softer after feeding Evidence of milk in baby’s mouth Pre and post feeding weights

27 The Nurses’ Role: Assisting with Latch-on Position the mother Position the baby Guide the mother’s hands as needed Have her give a return demonstration Assess and document Develop a care plan

28 Early Breastfeeding Management In Hospital –First feeding within first hour –Encourage 24 hour rooming in –Teach early feeding cues; goal is at least 8 or more feeding attempts per 24 hours –Avoid supplementation unless medically indicated –Do not put formula bottles in crib for mother to use

29 Early Breastfeeding Management Early Weeks at Home –Continue feeding 8–12 times per 24 hours; wake infant if necessary; lots of skin-to-skin –Feeding should be at least 20–30 minutes of active suck/ swallow –Watch for normal breast fullness at 48–72 hours post partum; shift from colostrum to transitional milk –Watch for normal stooling and voiding patterns

30 Early Breastfeeding Management Early weeks at home –Support network for mother & breastfeeding referral for help if needed –Rest and good nutrition –First well baby visit at 2-3 days post discharge per AAP recommendations –Second well baby visit at 2 weeks –When mature milk appears (by day 5) baby should gain 1 oz./day

31 Summary Varied nursing positions allow couplet to find the most comfortable and effective Good positioning facilitates an effective latch An asymmetrical latch promotes better milk transfer and maternal nipple comfort Observed swallowing during a feeding and adequate urine and stool output are reliable markers of intake

32 Photo Credits Slide 4 – Die Kinderstube des Kunstlers by Daniel Chodowiecki c Slide 5 – courtesy R. Gonzalez-Dow Slide 6 – courtesy R. Gonzalez-Dow Slide 7 – courtesy Slide 9 – by Roni Chastain