Antepartum Intrapartum and Postpartum Pearls August 10 2016 Lauren Hanley MD IBCLC FACOG Department of Obstetrics and Gynecology Massachusetts General Hospital No conflicts of interest to disclose ID: 935077
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How Obstetricians Can Best Support Breastfeeding Dyads: Antepartum, Intrapartum and Postpartum Pearls
August 10, 2016Lauren Hanley, MD, IBCLC, FACOGDepartment of Obstetrics and GynecologyMassachusetts General Hospital
Slide2No conflicts of interest to disclose.* I was formula fed. This was recommended as optimal way to feed by my pediatrician in 1971.
Slide3ObjectivesTo review how Obstetricians can support women to achieve their breastfeeding goals during the following timeframes:-Antepartum
/Prenatal-Intrapartum-PostpartumTo review how and why Skin to Skin supports normal newborn physiology and enhances breastfeedingTo review medication usage during lactation and resources to check safetyTo review available Resources
Slide4Breastfeeding is a public health issue.
Even in developed countries, infants who are not breastfed face higher risks of infectious and chronic diseases, and mothers who do not breastfeed face higher risks of cancer and metabolic disease.
Slide5Slide6Slide7ACOG RecommendationsThe American College of Obstetricians and Gynecologists strongly encourages women to breastfeed and supports each woman’s right to breastfeed.
The College recommends exclusive breastfeeding for the first 6 months of life, with continued breastfeeding as complementary foods are introduced through the infant’s first year of life
, or longer as mutually desired by the woman and her infant.
Committee Opinion No. 658
Photo: Massachusetts Breastfeeding Coalition
Slide8Mother’s breastfeeding goals
Breastfeeding success!
Baby friendly maternity care
Supportive family and friends
Informed
medical providers
Adequate leave, workplace support
Slide9Your care directly affects a woman’s breastfeeding success.
Both observational and randomized trials demonstrate that routine health care practices can enable mothers to meet their infant feeding goals – or derail breastfeeding and increase health risks for mother and child.
Slide10Global initiative of the WHO and UNICEFImplemented in the USA by “BFUSA” (designating body)Based on “The Ten Steps to Successful Breastfeeding: The Special Role of Maternity Services” 1989Adherence to the Ten Steps decreases racial, ethnic, and sociocultural
disparities in Breastfeeding Rates in the US.HP 2020 goal (births in BF hospital): 8.1%, we are at 18%!!What is Baby Friendly?
Slide111. Have a written breastfeeding
policy.
2. Train all health care staff.
3. Inform all pregnant women about the benefits and management of breastfeeding.
4.
Help mothers initiate breastfeeding within one hour of birth
.
5. Show mothers how to breastfeed and 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 - that is, allow mothers and infants to remain together 24 hours a day.
8. Encourage breastfeeding on demand.
9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.
10.Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.
The Ten Steps
Slide12Slide13Lind et al (2014).
MMWR Morb Mortal Wkly Rep 63(33): 725-8.
Slide14The World Health Organization’s “Ten Steps to Successful Breastfeeding” should be integrated into maternity care to increase the likelihood that a woman achieves her personal breastfeeding goals.
Committee Opinion No. 658
Slide15DiGirolamo
, A. M. et al. Pediatrics 2008;122:S43-S49
FIGURE 1 Among women who initiated breastfeeding and intended to breastfeed for >2 months, percentage who stopped breastfeeding before 6 weeks according to the number of Baby-Friendly Hospital Initiative practices they experienced
Maternity care directly affects a woman’s breastfeeding success
Slide16Patient-Centered Care60% of women do not meet THEIR OWN breastfeeding goals.
CDC/FDA Infant Feeding Practices Survey II, 2008
Slide17Antepartum Education:Why is it important?
1997 JHL study found that 23% of expectant mothers received counseling from
OB.
1998 JHL study associated antenatal advice associated with intent to BF (61% vs 35
%).
2007 Cochrane
review: professional
support was effective in prolonging any breastfeeding.
2011
BMJ
review:breastfeeding
promotion interventions increased exclusive and any BF @ 4-6
wks &
6
mos.
Slide18Antepartum Education: Is it happening?
12/2013
Demirci
J,
Bogan
D,Holland
C et al.
Breastfeeding discussion @ initial OB visit
172 recorded encounters
BF discussion @ 29% of visits for mean 39 sec.
CNM more likely to initiate discussion than OB residents.
Slide19When should we discuss breastfeeding during prenatal care?As soon as possible! Unless there is a question of miscarriageDuring the breast examOpen ended questions
Decisions are often made prior to pregnancy or in first trimester
Slide20Open ended questions that may facilitate a discussion about feeding:Have you ever thought about how you will feed your baby?Are you interested in learning about why breastfeeding is the healthiest option for you and your baby?
Do you have any family members or friends that breastfed their baby?What are your plans regarding work outside of the home after the birth?
Slide21History/Anticipatory Guidance Breastfeeding History Did she breastfeed in the past? How long?
Why did she wean?Other relevant medical/surgical historyInvolving partner/other family /social supportsReview resourcesClasses, Hospital Support (Lactation, nursing, OB/CNM/pedi)Community SupportReview hospital practices that will support breastfeeding
Slide22History of Breast Injury or SurgeryReduction MammoplastyAugmentation MammoplastyLumpectomy or BiopsyEspecially if significant ducts or nerves are severed/removed
Greatest concern are periareolar incisionsPrevious Treatment for Breast CAHx of Trauma, Burns, or Chest Tube (childhood)Nipple Piercings with Infection or Scarring
Slide23Patients listen to what their doctors say…
DiGirolamo et al. Birth 2003;30:94-100
Send a clear message to patients:
‘I recommend breastfeeding.’
Slide24Summary of Antenatal EducationDiscuss breastfeeding early and oftenReview benefits for mother and childReview practices in the hospital that will enhance successRooming In, Feeding on Demand, Skin to Skin
Unnecessary supplementation, Avoid pacifiersSupport groups and Community ResourcesReview how to combine working and breastfeeding/ pumping and how to work with employers.
Slide25Slide26Breastfeeding Friendly OfficePosters/Art depicting breastfeeding throughout the office, multicultural women and childrenNO formula marketing/coupons
Sign to remind patients that breastfeeding is welcomed in the waiting roomMother’s room for patients and staffPatient and Staff EducationCommunity Based Resources/Printed materialsPrenatal Classes
Slide27Families should receive noncommercial, accurate, and unbiased information so that they can make informed decisions about their health care.
Obstetric care providers should be aware that personal experiences with infant feeding may affect their counseling. In addition, pervasive direct-to-consumer marketing of infant formula adversely affects patient and health care provider perception of the risks and benefits of breastfeeding.
Committee Opinion No. 658
Slide28Step 4: Help mothers
initiate breastfeeding within 1 hour of birth
Skin-to-skin supports normal physiology of breastfeeding
Contact in first hour of life, when infant is awake and alert, is a “critical period” for nursing success
Slide29Step 4: Initiate feeding within one hour
Slide30What about Cesarean Delivery?
Slide31AAP Guidelines 2005, revised 2012
Healthy infants should be placed and remain in direct skin-to-skin contact with their mothers immediately after delivery until the first feeding is accomplished.Skin-to-skin supports normal physiology of breastfeedingContact in first hour of life, when infant is awake and alert, is a “critical period” for nursing success
Remember: a gown, blanket, or bra between baby and mother is NOT skin to skin!
Slide3230 studies, 1925 dyads, 29 RCT, diverse populationsImproved infant glucose levelsImproved rates at 1 & 4 months and total duration of breastfeeding
Rooming in also increased durationSkin to skin improved temp and CV stability Improved maternal attachmentNo adverse effectsCochrane Database Study, 2007, Moore et al.
Slide33Skin to Skin MGH Cesarean Section: February, 2014 started as a PDSATracking rates and working on documentationStaff / patient satisfaction
Safety: “Speak Up” modelAnesthesia, OB, Pedi “buy in”Discuss in preop huddle and postop debriefClear drapeBaby to chest after 5 minute APGARTEAM effort
Slide34Skin to Skin buttons for staffActual Size of a Term Newborn’s Stomach
Teaching tool for learning to understand the new baby’s needs
Slide35www.massbreastfeeding.org
Slide36Slide37What is the usual protocol in the L&D unit for skin to skin?Change takes time, but introducing the idea and working with staff to accomplish this goal has excellent science behind it and makes a difference!Patient(s) are more satisfied when baby not “taken away” for weight, exam, injection, eye ointment etc. (MOM and BABY)
What we do really matters!
Slide38Postpartum Considerations
Slide39Where Providers lack confidence
Peds/OB providers polled about where deficiencies lie:Referral servicesReturning to work/PumpingLow Milk SupplyBreast Pain
Teaching Basic Skills/Evaluating Latch
Taveras, E. M., R. Li, et al. (2004). Pediatrics 113
(4): e283-90.
Know when, and to whom, to refer – make use of lactation consultants.
Slide40What do I tell my patients?
Skin to skin at delivery, early initiation of breastfeeding and not using supplementation without a medical indication can be helpful in improving breastfeeding success
What happens in the hospital
matters
to helping mother’s meet
their
intended breastfeeding goals.
Slide41Hospital Practices TipsFacilitate skin to skin
Initiate breastfeeding/pumping in delivery roomRoom in, demand feedingAvoid supplementation unless medically indicated
Avoid early introduction of pacifiers (except for procedures) and bottle nipples
Slide42Medications and BreastfeedingPearls for making the best choices
Slide43Golden Rules:Reaffirm mother’s goalsTry to enable a scenario where mother is appropriately treated and no interruption of feeding occursOnly rare circumstances where breastfeeding needs to temporarily or permanently cease
Consult your resources adequately/quickly
Slide44Meds: Golden Rules: continuedMothers with depression symptoms should seek treatment. Most of these meds are safe or can choose one that is safe.Most drugs are safe in breastfeeding mothers
If drug is not safe, can TEMPORARILY discontinue until the drug is metabolized. Not always necessary to stop altogetherChoose drugs with short T1/2, high protein binding, low oral bioavailability or high molecular weight.
Slide45Resources for Medication compatibility with breastfeedingLactmedWebsiteAppMedications and Mother’s Milk, Hale,
2014Infantrisk.orgAppAAP Committee on Drugs document (more general)PDR (NO!!) Compiles all packages inserts standard recs are NOT to take—Poorest source of information
Slide46http://lactmed.nlm.nih.gov
Or Google “LactMed”
Slide47Lact MedFREE!
Slide48Medications and Mothers’ MilkTom Hale, PhD
Slide49Hormonal Methods: General rule is to avoid estrogens if possibleCombined OCP, Patch, Ring: all can decrease milk supplyProgesterone methods have less impact on milk supply
Progesterone Implant (3 year)Progesterone IUD (5 year)POPMedroxyprogesterone Injection (3 months)*Sometimes they can alter milk supply as well
Slide50Progesterone Only MethodsTheoretical risk of introducing too early may impact full supply being establishedPostdelivery decrease in progesterone part of the physiologic cascade to
start lactogenesis II.Most experts recommend delay initiating these methods until full supply is established (4-6 weeks minimum)Rarely patients see a drop in supply even with Progesterone IUD.
Slide51Progesterone Methods Failure RatesDepot Medroxyprogesterone (IM q 3 months) Typical failure rate: 0.3%Progesterone Only Pill: 8-10% (Typical use) Perfect use: 1%Implant (Etonorgestrel Rod) Typical use <1%Also helpful for medically complicated patients that are not estrogen candidates
Slide52Postpartum Checkup: How can we help enhance breastfeeding duration and exclusivity?Have referral/resources for community support readily available with staff for phone calls and during appointmentsRemind patients to call the office with questions or problems relating to breast health at ANY time postpartum even after the PP exam
Review transition of return to workforce and plans to highlight the law and offer support and advice re: expressing at work.
Slide53ACA Supporting Breastfeeding and LactationThe Affordable Care Act (ACA) has two major provisions:
Coverage of comprehensive lactation support and counselingCoverage of costs of renting or purchasing breastfeeding equipment for the duration of breastfeeding.
Slide54Support of continuation through first yearOffer to provide a letter for employer reviewing the medical and economic benefits for an employee to continue to breastfeedBetter employee retention
Less absenteeism due to sick childFinancially advantageous to retain breastfeeding employees rather than hire new employeeBetter work satisfaction
Slide55Resources/Links
Slide56http://
acog.org/breastfeeding
Slide57Academy of Breastfeeding Medicine
http://www.bfmed.org/
Protocols:
Hypoglycemia
Discharge
Supplementation
Mastitis
Peripartum management
Cosleeping
Model Hospital Policy
Human milk storage
Galactogogues
Near-term infant
Ankyloglossia
NICU graduate
Contraception
The breastfeeding-
friendly physician’s office
Anesthesia and analgesia
The hypotonic infant
Slide58Resources for Black Families
Slide59ACOG/AAP/ABM
Slide60Know Your Local Resources and the LawLactation consultants – ILCA.orgCommunity support
– LLLI.org– WIC– Local hospital groupsFrenotomy providersBreast specialistsBreastfeeding in Public/Employment Laws
Slide61Happy National Breastfeeding Month!
Slide62Thank youKathy Hartke, MD and Paul HartkeCresta Jones, MDGE
Questions?