2/2/2017
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Preventing Breastfeeding Problems:
Critical Thinking and Assessment
Rose deVigne-Jackiewicz, RN, MPH, IBCLC
Kaiser Permanente: Department of Pediatrics
Happy Healthy Moms & Babies
San Diego Breastfeeding Coalition: Board Member
619-992-1933
Rose’s Clinical Background
Loma Linda University
High Risk Labor and Delivery
Nurse Clinician
Labor & Delivery, Postpartum, Nursery, NICU
Lactation Consultant (started their lactation program)
Sharp Mary Birch
Lactation Consultant (started their lactation program)
Kaiser Permanente (2000 to current)
Outpatient Lactation Consultant (started outpatient lactation program)
University of California
Clinical Instructor
Lactation Consultant Experience
34 years (40 as RN)
“Subspecialties”
Premature babies
Induced/adoptive nursing
- Additional areas of interest/focus
- Postpartum depression
- Perinatal Hospice
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Care of the Lactating Mom
and Breastfeeding Baby
Introduction
Objectives
Critical Thinking
Critical Thinking and
Lactation
Risk Factors for mom and
baby
Q & A
Disclosure
No financial relationship
with anyone or any
company for the
presentation today
Common Breastfeeding
Issues/Concerns
Mother/Baby Issues
Basics “how do I”
Sleepy baby, fussy baby, and latch issues
Sore Nipples
Engorgement
Cultural Differences and concerns respected”
Mother/Baby separation
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Critical Thinking
Clinical skills are obviously important, but critical
thinking is at the core of being a good nurse
lactation consultant
Critical thinking skills are very important in the
nursing lactation field because they are what you
use to prioritize and make key decisions
Lactation consultants/professionals DO give
“critical care”. It is these critical thinking skills can
really mean the difference between someone
being successful or failing with breastfeeding*.
* specific details later in presentation
Critical Thinking for
Nurses/Lactation Consultants
Critical thinkers need to be:
Precise
Complete
Logical
Accurate
Clear
Fair
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Key Critical Thinking Skills
Interpreting – Understanding and explaining the
meaning of information, or a particular event.
Analyzing – Investigating a course of action, that is
based upon data that is objective and subjective.
Evaluating – This is how you assess the value of the
information that you got. Is the information relevant, reliable and
credible? This skill is also needed to determine if outcomes
have been fully reached.
Key Critical Thinking Skills Explaining – Clearly and concisely
explaining your conclusions. The nurse needs to be
able to give a sound rationale for her answers.
Self regulating – You have to monitor your
own thinking processes. This means that you must
reflect on the process that lead to the conclusion.
You should self correct in this process as needed.
Be on alert for bias and improper assumptions.
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Critical Thinking Pitfalls
Illogical Processes
Bias
Closed Minded
Social and Cultural
Trends/Issues
Cultural assessment
Common cultural behaviors
Historical and Social Trends
Learn from your patients!
Learn from your patients
families!
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Happy, Healthy
Moms and Babies
Factors that Influence
Successful
Breastfeeding
Establishment
&Management
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Baby Friendly Breastfeeding
10 Steps 1. Have a written breastfeeding policy that is rout8nely communicated to all health care staff
2. Train all healthcare staff in the skills necessary to implement this policy
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 how to maintain lactation, even if they are separated from their infants
6. Give infants no food or drink other that breast-milk 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 pacifier or artificial nipples to breastfeeding infants.
10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or birth center
Applying Critical Thinking Skills to the
Management of the Breastfeeding Mom and Baby
Must Know Basics of Mothers
and Babies
Labor & Delivery
Postpartum mom
Newborn baby
Infants
Breast Anatomy and Physiology
Breastfeeding Process
Common Breastfeeding
concerns/problems and plan of care
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BREASTFEEDING: WITH ALL WE KNOW AND TEACH, WHY DO SO MANY MOTHERS STILL FAIL
“Wellness Bias”
Serious pitfall – especially in telephone triaging
Assumptions
High risk vs. Low risk
Expect Low risk/normal, assess for high risk
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Basic Breastfeeding
Education(Per Rose)
What ALL new breastfeeding mothers
need to be taught, demonstrated,
reviewed.
First baby, 5th baby, it shouldn’t
matter.
NEVER ASSUME
Basic principles need to be
individualized to each mom
The “Old Norm”
Pregnancy the “old fashioned way”
Mom goes into labor “on her own”
Baby delivers at 38-41 weeks gestation
Several days in hospital
Family help and support
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The “New Norm”
Assisted pregnancy
Advance maternal age
Increased multiple
births
Surrogacy
Increased C/S
deliveries
Increased inductions
Deliveries before EDC***
More maternal problems
Larger Premature
babies staying with
moms on postpartum
unit (not going to NICU)
Treated as “dyad
couple”
Followed with SOC
for term/healthy dyad
Anatomy and Physiology
Breast and Nipples
Changes during pregnancy
Internal/External structures
Nipples
Prolactin
Oxytocin
Establishing a good milk supply
Baby’s mouth
Suck assessment
Anatomy
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Review Anatomy & Physiology
Breast Changes during pregnancy
Internal/External structures
Nipples – Everted, flat,
1. Chest wall
2. Pectoralis muscle
3. Lobules
4. Nipple
5. Areola
6. Milk ducts
7. Fat
8. Skin
Psychological Factors
Hormones of Lactation
Factors affecting mother’s decisions
Families/fathers/significant others
Breastfeeding attrition
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Review Anatomy & Physiology
Physiology of Lactation
Progesterone
Prolactin
Oxytocin
Cortisol
Review Anatomy & Physiology
Physiology of Lactation
Progesterone
Produced in the ovaries, adrenal glands, and
placenta
High levels maintain pregnancy and
suppress milk production by inhibiting
prolactin
When baby is born and the placenta is
delivered, progesterone levels decrease
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Review Anatomy & Physiology
Physiology of Lactation
Prolactin: hormone responsible to making milk
Produced in the anterior pituitary gland
Inhibited by progesterone
Stimulated by infant suckling
Increased prolactin = milk production
Levels vary depending on time of day
– Highest at night, lowest midmorning
NO PROLACTIN = NO MILK
A LITTLE PROLACTIN = A LITTLE MILK
Review Anatomy & Physiology
Physiology of Lactation
Oxytocin: Milk Ejection Reflex– releases milk
Stimulated by:
– Baby at breast
– Pumping breast
– Psycho-social: Hearing infant/thoughts of Baby
Signs of Milk Ejection Reflex
– Audible swallowing
– Leaking
– Uterine cramping
– Breast sensations
Inhibited MER – “Performance anxiety”
Also referred to as the cuddle hormone
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Review Anatomy & Physiology
Physiology of Lactation
Cortisol
Produced in the adrenal glands
Released in response to stress
High levels of cortisol can delay
Lactogenesis (so low levels and decreased
stress improve breastfeeding quality)
Breastfeeding Management for
Healthy Mothers and Newborns
Maternal Education Antepartum
Postpartum
Informed decision and choices
Anticipatory guidance
When things go wrong
Maternal Assessment and Counseling
Infant Assessment
Breastfeeding Basics
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Maternal Physical Assessment
Maternal Health History
Medical & Health History
Obstetric History
Labor & Delivery [“Birth Story”]
Breasts
Nipples
“Red Flags’ for BF Problems
Maternal Risk Factors
History of BF problems
Breast surgery
Breast abnormality
No breast changes with problems
Teen
Many others
Prenatal
Intrapartum
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Breasts -Visual Assessment
Infant Risk Factors
Premature
Borderline Premature
Poor latch
No latch
Small baby
Oral anatomically prob
Many others
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Infant Assessment
Gestation
Size
“Birth Story”
Suck Assessment
“Red-Flags”
Factors that Influence
Successful Breastfeeding
Mother/Baby Issues
Sleepy baby, fussy baby, and latch issues
Hunger vs.... suckling needs
Sore Nipples
Engorgement
Cultural Differences and concerns respected
“No tiene leche” “I have no milk”
“Breast AND Bottle”
Mother/Baby separation
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Baby Feeding/Latch Problems
Sleepy/not interested
Latches but doesn’t maintain latch
Latches incorrectly
Actively refuses to latch
“Nurses all the time”
Breastfeeding Basics
Mechanisms of Milk Production
Milk supply is baby driven
Frequency of feeds regulates milk supply
Law of demand and supply
Getting Successful Milk Transfer
Newborn Sucking/feeding “Styles”
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Evaluation of Feedings
Parameters Beyond the Breastfeeding
Interaction
Urine Output
Stool Output
Weight gain/loss
Growth Spurts
Breastfeeding Management
Under Difficult Circumstances
Premature
Near term/”Borderline” Premature
Compromised newborn
Establishing lactation/milk
supply is critical
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Happy, Healthy Moms and Babies
Plan of Care
Plan A
Plan B
Etc.
Some breastfeeding better than No breastfeeding
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Telephone Triage
Very Difficult and Challenging
“Wellness” Bias
Red Flag Comments
Key Questions to ask
Common Call in Concerns & Problems
Early Postpartum (1st 2 weeks)
Late Postpartum (2 – 4 weeks)
After 4 Weeks
Requirements for Telephone
Triage
Knowledge & understanding of:
Basic BF techniques
Basic Lactation physiology
Normal newborn
Normal postpartum
Clinical management of common basic
problems
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Requirements for Telephone
Triage
Needs to be:
Empathetic/Sympathetic
Non-judgmental
Needs to know:
Not to discuss person preferences/beliefs/person feelings
BF Risk factors/Red Flags
Key Questions to Ask
AGE of infant
How often is infant eating (frequency)
How long does infant nurse at feeding (duration)
# wet diapers & stools – color of stools
Birth weight
Discharge weight (if newborn)
Last/current weight
Last/next visit with Lactation/Pediatrician
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Here’s the question (again)
BREASTFEEDING: WITH ALL WE KNOW
AND TEACH, WHY DO SO MANY
MOTHERS STILL FAIL ??
SUMMARY &
RECOMMENDATIONS
Know the basics
Know how to establish effective
breastfeeding
Know how to address the common
problems that moms and babies have
Know what you don’t know
Refer