1. Strengthening Reproductive Health Management and Service Delivery in West Bank and Gaza Strengthening Reproductive Health Management and Service Delivery in West Bank and Gaza National and Unified Obstetric and Newborn care Guidelines and Protocols

2. National and Unified Obstetric and Newborn care Guidelines and Protocols Guidelines 1.Normal delivery 2.Breastfeeding 3.Normal care to the newborn 4.High risk cases (1 : medical conditions) 5.High risk cases (2 obstetrical conditions) 6.Emergency Obstetrics 7.Newborn High Risk and Emergencies 8.Obstetrical procedures 9.Neonatal procedures 10.Quality assessment

3. National and Unified Obstetric and Newborn care Guidelines and Protocols Breastfeeding 1 1 st SECTION: Mother and foetus TOPIC 2 : Breastfeeding 3. Minor Breast Problems Complications during breastfeeding A Weak reflex B Flat nipples C Engorgement D Mastitis E Sore nipples 1 st SECTION: Mother and foetus TOPIC 2 : Breastfeeding 3. Minor Breast Problems Complications during breastfeeding A Weak reflex B Flat nipples C Engorgement D Mastitis E Sore nipples

4. National and Unified Obstetric and Newborn care Guidelines and Protocols Breastfeeding Minor Breast Problems Topic 2Breastfeeding Subtopic 32Minor Breast Problems A“Weak Suckling Reflex” Standard Statement All newborns with weak suckling reflex will be identified & their mothers will be assisted & guided properly.

5. National and Unified Obstetric and Newborn care Guidelines and Protocols Breastfeeding Minor Breast Problems Reassure the mother about this problem that may need her patience, time & observation Reassure the mother about this problem that may need her patience, time & observation “Weak Suckling Reflex”

6. National and Unified Obstetric and Newborn care Guidelines and Protocols Breastfeeding Minor Breast Problems Advise & demonstrate to the mother to help her newborn to strengthen this reflex by inserting her clean little finger between & before feedings into the baby’s mouth & allow him to suck for few minutes. Advise & demonstrate to the mother to help her newborn to strengthen this reflex by inserting her clean little finger between & before feedings into the baby’s mouth & allow him to suck for few minutes. “Weak Suckling Reflex”

7. National and Unified Obstetric and Newborn care Guidelines and Protocols Breastfeeding Minor Breast Problems Documentation: observations, assessment findings, teachings. folders, leaflets, …) “Weak Suckling Reflex”

8. National and Unified Obstetric and Newborn care Guidelines and Protocols Breastfeeding Minor Breast Problems Topic 2Breastfeeding Subtopic 32 Minor Breast Problems BFlat or inverted nipples Care GroupMothers complaining/having breast problems at any time during lactating period Standard Statement Women with inverted nipples should receive extra support and care to ensure successful breastfeeding

9. National and Unified Obstetric and Newborn care Guidelines and Protocols Types of Nipple Normal Flat Inverted Long and big nipples

10. National and Unified Obstetric and Newborn care Guidelines and Protocols Breastfeeding Minor Breast Problems Flat or inverted nipples 1.Antenatal treatment or immediately after delivery. 2.Keep mother and baby skin-to-skin contact after birth.  If the baby is unable to attach effectively Express the colostrum and feed the baby by spoon, cup or finger feeding. Expressing regularly 8-10 times in 24 hours may be necessary to establish lactation. Demonstrate effective hand expressing. Advise nipple massage & pulling several times before each breast feeding time. 1.Antenatal treatment or immediately after delivery. 2.Keep mother and baby skin-to-skin contact after birth.  If the baby is unable to attach effectively Express the colostrum and feed the baby by spoon, cup or finger feeding. Expressing regularly 8-10 times in 24 hours may be necessary to establish lactation. Demonstrate effective hand expressing. Advise nipple massage & pulling several times before each breast feeding time.

11. National and Unified Obstetric and Newborn care Guidelines and Protocols Breastfeeding Minor Breast Problems A nipple shield may be effective in enabling breast attachment. The Lactation Consultant or a midwife experienced in lactation issues should review feeding prior to using/introducing nipple shield. A nipple shield may be effective in enabling breast attachment. The Lactation Consultant or a midwife experienced in lactation issues should review feeding prior to using/introducing nipple shield. Flat or inverted nipples NIPPLE SHIELD USE

12. 12 طريقة المحقن الخطوة الثانية : أدخل المكبس من الطرف المقطوع الخطوة الأولى : اقطع هذا الجزء بشفرة على امتداد هذا الخط الخطوة الثالثة : اطلب من الأم أن تجذب المكبس برفق

13. National and Unified Obstetric and Newborn care Guidelines and Protocols Breastfeeding Minor Breast Problems Flat or inverted nipples For the first – two week : Build mother's confidence-breasts will improve and become softer Explain & assist the baby to suckle BREAST not nipple (correct Latch on) If difficult Latch on, be patient, & try again. Let baby explore breast, skin-to-skin contact Help mother to position baby to breast feed within the first hour after birth. Help her to make nipple stand out more before a feed Build mother's confidence-breasts will improve and become softer Explain & assist the baby to suckle BREAST not nipple (correct Latch on) If difficult Latch on, be patient, & try again. Let baby explore breast, skin-to-skin contact Help mother to position baby to breast feed within the first hour after birth. Help her to make nipple stand out more before a feed

14. National and Unified Obstetric and Newborn care Guidelines and Protocols Breastfeeding Minor Breast Problems Topic 2Breastfeeding Subtopic 32 Minor Breast Problems CENGORGEMENT / FULL, LUMPY BREASTS Care GroupMothers complaining/having breast problems at any time during lactating period Standard Statement Same as above. The woman with any breast problem during lactating period should be investigated, diagnosed and managed properly

15. National and Unified Obstetric and Newborn care Guidelines and Protocols Breastfeeding Minor Breast Problems Do not REST the breast Breast Engorgement

16. National and Unified Obstetric and Newborn care Guidelines and Protocols Breastfeeding Minor Breast Problems To prevent irreversible trauma to the breast tissue caused by unresolved engorgement AIM Preventive Measures Unrestricted breastfeeding or expressing from birth i.e. feeding 8-12 times in 24 hours. Correct positioning, attachment and good sucking action is vital for good milk transfer. A complimentary feeds should not be used. Unrestricted breastfeeding or expressing from birth i.e. feeding 8-12 times in 24 hours. Correct positioning, attachment and good sucking action is vital for good milk transfer. A complimentary feeds should not be used.

17. National and Unified Obstetric and Newborn care Guidelines and Protocols 1 2

18. 18 تشريح الثدي 1) الأنسجة الداعمة والدهنيات supporting tissue & fat muscle cells خلايا عضلية 2) تتقلص بفعل الأوكسيتوسين oxytocin makes them contract 3) خلايا إفراز اللبن milk secreting cells يجعلها البرولاكتين تفرز اللبن prolactin makes them secrete milk 4 ) القنوات ducts 5) هالة الثدى areola هنا يتجمع اللبن milk collects here 6 ) الجيوب اللبينة lactiferous sinuses 7) الحلمة nipple 8) غدد مونتجمرى Montgomery’s gland 9) الحويصلات alveoli

19. 19 التعلق الجيد 12

20. 20 التعلق السيئ 1 2

21. National and Unified Obstetric and Newborn care Guidelines and Protocols Breastfeeding Minor Breast Problems If baby able to suckle Feed frequently, help with positioning, use different positions. Start feeding from the engorged breast. If baby not able to suckle or suckling is not enough to empty the breast: Express milk by hand after each feeding. If baby able to suckle Feed frequently, help with positioning, use different positions. Start feeding from the engorged breast. If baby not able to suckle or suckling is not enough to empty the breast: Express milk by hand after each feeding. Breast Engorgement

22. National and Unified Obstetric and Newborn care Guidelines and Protocols Breastfeeding Minor Breast Problems 1. Check the above prevention measures and correct if necessary. 2. Gentle stroking of the breast promotes the let down reflex to encourage milk flow. 3. It is often necessary to hand express the breast to soften the areola to enable the baby to attach effectively. 4. Ensure the baby drains the first breast before offering the second side. If the first breast is still full, hard, red or has lumps (blocked ducts) after the baby has fed, it will need to be completely drained. 4. If the baby refuses the second side and it is hard, red or has lumps (blocked ducts) it will also need draining. Use gentle stroking and an electric breast pump.. Ensure the correct size shield is used. 5. Cool packs may encourage milk flow if there is vascular engorgement 1. Check the above prevention measures and correct if necessary. 2. Gentle stroking of the breast promotes the let down reflex to encourage milk flow. 3. It is often necessary to hand express the breast to soften the areola to enable the baby to attach effectively. 4. Ensure the baby drains the first breast before offering the second side. If the first breast is still full, hard, red or has lumps (blocked ducts) after the baby has fed, it will need to be completely drained. 4. If the baby refuses the second side and it is hard, red or has lumps (blocked ducts) it will also need draining. Use gentle stroking and an electric breast pump.. Ensure the correct size shield is used. 5. Cool packs may encourage milk flow if there is vascular engorgement Management

23. National and Unified Obstetric and Newborn care Guidelines and Protocols Breastfeeding Minor Breast Problems Before feed to stimulate oxytocin reflex Warm compress on breasts or warm shower Massage to neck and back Light massage of breast Stimulate nipple skin Help mother to relax After feed to reduce oedema Cold / ice compress on breasts Encourage wearing a supportive bra to hold the breast in position. There is a new recommendation to apply cabbage leaves on the engorged breast that might relieve engorgement. Before feed to stimulate oxytocin reflex Warm compress on breasts or warm shower Massage to neck and back Light massage of breast Stimulate nipple skin Help mother to relax After feed to reduce oedema Cold / ice compress on breasts Encourage wearing a supportive bra to hold the breast in position. There is a new recommendation to apply cabbage leaves on the engorged breast that might relieve engorgement. Breast Engorgement

24. National and Unified Obstetric and Newborn care Guidelines and Protocols Breastfeeding Minor Breast Problems Breast engorgement If any of these : measures are ineffective after more than 24 hours Refer for experienced midwife / lactation consultant or Physician check up & management

25. National and Unified Obstetric and Newborn care Guidelines and Protocols Breastfeeding Minor Breast Problems Build the mother confidence Breast Engorgement

26. National and Unified Obstetric and Newborn care Guidelines and Protocols Breastfeeding Minor Breast Problems Topic 2Breastfeeding Subtopic 32 Minor Breast Problems DBlocked duct and Mastitis Care GroupMothers complaining/having breast problems at any time during lactating period Standard Statement The woman with any breast problem during lactating period should be investigated, diagnosed and managed properly

27. National and Unified Obstetric and Newborn care Guidelines and Protocols Breastfeeding Minor Breast Problems Blocked duct/non Infective Mastitis Blocked duct/non Infective Mastitis Mastitis Infective Mastitis Breast abscess

28. National and Unified Obstetric and Newborn care Guidelines and Protocols Breastfeeding Minor Breast Problems Blocked duct Prevention and self help measures It is important to check that the baby is well positioned and attached at the breast correctly. Do not stop feeding from the affected breast, as this is the best way to remove any blockage. Feed from the affected side first, and try different positions. Express any remaining milk after a feed to ensure the breasts are kept well drained. Aim to empty the affected breast by giving frequent feeds. Applying warm water before a feed and/or a cold compress after the feed to the affected area will also give the mother relief and may help to reduce the inflammation. Prevention and self help measures It is important to check that the baby is well positioned and attached at the breast correctly. Do not stop feeding from the affected breast, as this is the best way to remove any blockage. Feed from the affected side first, and try different positions. Express any remaining milk after a feed to ensure the breasts are kept well drained. Aim to empty the affected breast by giving frequent feeds. Applying warm water before a feed and/or a cold compress after the feed to the affected area will also give the mother relief and may help to reduce the inflammation.

29. National and Unified Obstetric and Newborn care Guidelines and Protocols Breastfeeding Minor Breast Problems Mastitis Encourage to continue breast feeding unless there is bloody discharge from the nipples Measures that can be taken to avoid mastitis include:- Ensure correct positioning and attachment and efficient drainage of breast. Avoid long gaps between feeds. Avoid any compression on the breast e.g. tight fitting bras/clothes or may be pressure from fingers if supporting the breast Encourage to continue breast feeding unless there is bloody discharge from the nipples Measures that can be taken to avoid mastitis include:- Ensure correct positioning and attachment and efficient drainage of breast. Avoid long gaps between feeds. Avoid any compression on the breast e.g. tight fitting bras/clothes or may be pressure from fingers if supporting the breast

30. National and Unified Obstetric and Newborn care Guidelines and Protocols Breastfeeding Minor Breast Problems Blocked duct and Mastitis If any of these : measures are ineffective Refer for Physician check up & management

31. National and Unified Obstetric and Newborn care Guidelines and Protocols Breastfeeding Minor Breast Problems In case of infection, prescribe antibiotics & analgesics. In case of breast abscess, advise surgical treatment (drainage from a specialist). In case of fungal infection, prescribe anti-fungal treatment In case of infection, prescribe antibiotics & analgesics. In case of breast abscess, advise surgical treatment (drainage from a specialist). In case of fungal infection, prescribe anti-fungal treatment Blocked duct and Mastitis

32. National and Unified Obstetric and Newborn care Guidelines and Protocols Breastfeeding Minor Breast Problems Antibiotics Treatment for infective Mastitis The commonest bacterium found in breast is staphylococcus aureus. Therefore it is necessary to treat breast infections with a penicillinase-resistant antibiotic Antibiotics Treatment for infective Mastitis The commonest bacterium found in breast is staphylococcus aureus. Therefore it is necessary to treat breast infections with a penicillinase-resistant antibiotic DrugDoseInstructions Flucloxacillin 250 mg oraly 6 hourly for 7-10 days Take dose at least 30 minutes before food Erythromycin 250-500 mg orally 6 hourly for 7-10 days Cephalexin 250-500 mg orally 6 hourly for 7-10 days For mother is allergic to penicillin

33. National and Unified Obstetric and Newborn care Guidelines and Protocols Breastfeeding Minor Breast Problems Analgesics that can be taken are:- DrugDoseInstructions Ibuprofen 400 mg oraly 8 hourly This should not be taken by women who suffer from stomach ulcers, or are allergic to aspirin Paracetamol 500mg *2 orally 6 hourly

34. National and Unified Obstetric and Newborn care Guidelines and Protocols Breastfeeding Minor Breast Problems Topic 8Minor Breast Problems ESore Nipples and Nipple Fissure Care GroupMothers complaining/having breast problems at any time during lactating period Standard Statement The woman with any breast problem during lactating period should be investigated, diagnosed and managed properly

35. National and Unified Obstetric and Newborn care Guidelines and Protocols Breastfeeding Minor Breast Problems Sore Nipples and Nipple Fissure 1. Observe & assess the position, latch on & removing the baby from breast. 2. Teach correct latch on. 3. Teach to break down suction before taking off the baby off the breast. 4. Reduce engorgement-suggest feed frequently, express milk. 1. Observe & assess the position, latch on & removing the baby from breast. 2. Teach correct latch on. 3. Teach to break down suction before taking off the baby off the breast. 4. Reduce engorgement-suggest feed frequently, express milk.

36. National and Unified Obstetric and Newborn care Guidelines and Protocols Breastfeeding Minor Breast Problems 5.Encourage continuation of breast feeding. 6. Wash breasts only once a day & dry very well, and avoid using soap 7.Expose the breast to air after massaging a drop of breast milk on the nipple. 8.Avoid medicated lotions and ointments Rub hind-milk on areola after feeds 5.Encourage continuation of breast feeding. 6. Wash breasts only once a day & dry very well, and avoid using soap 7.Expose the breast to air after massaging a drop of breast milk on the nipple. 8.Avoid medicated lotions and ointments Rub hind-milk on areola after feeds Sore Nipples and Nipple Fissure

37. National and Unified Obstetric and Newborn care Guidelines and Protocols Breastfeeding Minor Breast Problems No improvement after 24 hours or more severe symptoms Refer for Physician check up & management Sore Nipples and Nipple Fissure

38. National and Unified Obstetric and Newborn care Guidelines and Protocols Breastfeeding Minor Breast Problems Sore Nipples and Nipple Fissure Look for a cause: 1.Check attachment 2.Examine breasts- 1.engorgement, 2.fissures, 3.Candida 3.Check baby for Candida, and tongue-tie Look for a cause: 1.Check attachment 2.Examine breasts- 1.engorgement, 2.fissures, 3.Candida 3.Check baby for Candida, and tongue-tie

39. National and Unified Obstetric and Newborn care Guidelines and Protocols Breastfeeding Minor Breast Problems Sore Nipples and Nipple Fissure Give appropriate treatment: 1.Build mother's confidence 2.Improve attachment, and continue breast-feeding 3.Reduce engorgement-suggest feed frequently, express milk 4.Treat for Candida if skin red shiny, flaky; if there is itchiness, or deep pain, or if soreness persists. Give appropriate treatment: 1.Build mother's confidence 2.Improve attachment, and continue breast-feeding 3.Reduce engorgement-suggest feed frequently, express milk 4.Treat for Candida if skin red shiny, flaky; if there is itchiness, or deep pain, or if soreness persists.

40. National and Unified Obstetric and Newborn care Guidelines and Protocols Breastfeeding Minor Breast Problems Treatment of Candida of the Breast Gentian violet paint:  To baby's mouth: 0.25% apply daily or alternate days for 5 days or until 3 days after he lesions have healed.  To mother's nipples: 0.5% apply daily for 5 days OR Nystatin cream 100,000 IU/G:  Apply to nipples 4 times daily after breast-feeds  Continue ti apply fir 7 days after lesion s have healed Nystatin suspension 100,000 IU/ml:  Apply 1 ml by dropper to child's mouth 4 times daily after breast- feeds for 7 days, or as long as mother is being treated. Stop using pacifiers, teats, and nipple shields Treatment of Candida of the Breast Gentian violet paint:  To baby's mouth: 0.25% apply daily or alternate days for 5 days or until 3 days after he lesions have healed.  To mother's nipples: 0.5% apply daily for 5 days OR Nystatin cream 100,000 IU/G:  Apply to nipples 4 times daily after breast-feeds  Continue ti apply fir 7 days after lesion s have healed Nystatin suspension 100,000 IU/ml:  Apply 1 ml by dropper to child's mouth 4 times daily after breast- feeds for 7 days, or as long as mother is being treated. Stop using pacifiers, teats, and nipple shields

41. National and Unified Obstetric and Newborn care Guidelines and Protocols Breastfeeding End of module 2 Breastfeeding