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A Baby-Friendly Survey Perinatal Staff Preparation Handbook Q& A Ten Steps to Successful Breastfeeding Every facility providing maternity services and care for newborn infants should: 1. Have a written breastfeeding policy that is routinely communicated to all health care staff. 2. Train all health care staff in 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 should be separated from their infants. 6. Give newborn infants no food or drink others than 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 artificial teats or pacifiers to breastfeeding infants. 10. Foster the establishment of breast-feeding support groups and refer mothers to them on discharge from the hospital or clinic. The Ten Steps to Successful Breastfeeding form the basis of the Baby-Friendly Hospital Initiative, a worldwide breastfeeding quality improvement project created by the World Health Organization ( WHO) and the United Nations Children’s’ Fund. Baby-Friendly® hospitals and birth centers uphold the WHO International Code of Marketing of Breastmilk Substitutes by offering parents support, education, and educational materials that promote the use of human milk rather than other infant food or drinks, and by refusing to accept or distribute free or subsidized supplies of breast milk substitutes, nipples and other feeding devices. Q. When did you join the staff in the Perinatal department? A. Month date). Year (Perinatal hire Q. What is your position at UC Irvine Health? A. I am a . Note: If you are a Lactation Educator or Charge Nurse, be sure to mention this as well. Q. Have you received any training in breastfeeding and lactation management while you have been on the staff at this medical center? Have you had some on the job training? A. Perinatal RNs have had 20 hours of online training, including 4 hours of 1:1 training with the lactation consultant. Outpatient staff members have had 3 hours of training. MDs have had 3 hours of training. Note: If you did not attend the course here, please state when you took the course. If you are a lactation educator you should also state that you have attended 40 hours of lactation educator/ counselor training which also included 8 hours of clinical. Q. Do you teach or show mothers how to position and attach their infants for breastfeeding? A. Yes. 2 3 4 1 Q. When do you do this? A. Within the first hour of newborn’s life in Labor and Delivery, again within 6 hours of newborn’s life in Postpartum, and any time the mother requests assistance or has demonstrated that she needs assistance. Q. How do you do this? A. Find a position comfortable for both mother and infant. Turn the baby’s body towards his mother, stomach to stomach, keep close; head, shoulder and hip in line; mouth wide open, nose opposite nipple, lips flanged, chin deep into the breast; more of areola below nipple in mouth; cheeks full and rounded –no dimple; rhythmic burst-pause suckling and swallowing. Note: You may be asked to demonstrate positioning/latch by teaching a mother with a baby on the unit, or you may be asked to point one out that is positioned and latched correctly. Others have been given a doll and asked to position/ describe the key points of positioning/latch. You may be asked what constitutes a good latch. Q. Do you show or teach mothers how to express their breast milk by hand? Please describe the technique for expressing milk by hand that you teach to mothers. A. Yes. It is taught when we are assisting mothers with breastfeeding. Written information on hand expression is in the education packet. (Technique described on following page.) 5 6 7 TECHNIQUE - Thumb behind areola about an inch, 3-4 fingers opposite: press back towards chest wall, compress the breast (do not slide fingers on skin or pull nipple), release. Repeat press back, compress and release for several minutes to stimulate let down. Move from right breast to left and back again every few minutes. Rotate fingers to different positions around the nipple, to compress all milk ducts. (To review hand expression, go to https://newborns.stanford.edu/ Breastfeeding/HandExpression.html). Q. How does the feeding of extra formula and milk affect the success of breastfeeding? A. • The infant will have less desire to breastfeed because his stomach becomes too full. Flows preference and nipple confusion may occur if bottle is used. • Milk supply may be affected if the infant is not going to the breast as often to stimulate milk production. • There is an increased risk of allergy. • It may lead to mother feeling inadequate regarding her ability to nourish her baby. Q. What is the major cause of painful nipples? A. Poor latch, baby not taking enough breast tissue into the mouth. 8 9 Q. What is the most common cause of insufficient milk supply? A. Infrequent feeding, improper suckling, poor latch, using bottles or pacifiers, or early supplementation. Q. Why is correct positioning and attachment important? A. • Ensures efficient milk transfer • Ensures sufficient milk supply • Prevents sore nipples Q. Why do we teach breastfeeding mothers how to express milk by hand? A. • Helps the baby attach well • Relieves engorgement • Relieves blocked ducts • Expresses colostrum • Better than a pump Q. Why is rooming-in important? A. • Mother learns and responds to baby’s feeding cues • Establishes feeding on demand • Baby learns to recognize his mother 11 12 13 10 Q. Do you have a written policy that establishes breastfeeding as the standard for infant feeding and addresses all of Baby-Friendly’s 10 steps? A. Yes, it can be found on the Intranet. From the home page: Clinician Tools Æ Policies/Compliance ÆPolicies & Procedures Æ Nursing Æ Women’s and Children’s Services Æ Women’s and Children Policies and Procedures Æ Infant Feeding. Note: Be prepared to show where it is located. Q. Are you aware of the “Ten Steps” and where they are posted? A. They are posted in English & Spanish in the following areas. • DH46: On bulletin board by nurse’s station • NICU: In hallway across from DH42 entrance • L&D: On wall next to entrance at bridge from DH, on wall next to OB Eval • 2Tower: Outside L&D Family waiting room • ED: On wall in ED waiting room next to brochures • In the lobbies of each of our clinics: Manchester, FHC- Santa Ana, FHC-Anaheim Q. What is the definition of “skin-to-skin?” A. At Birth (within 5 min) all mothers should be given their baby to hold skin-to-skin. The baby should be dried quickly and placed on mother’s bare chest. There should be nothing between them (other than a diaper on the baby, if preferred). However, a blanket over both of them must be placed to keep the baby warm and maintain privacy. If the baby is very small, a hat is recommended. 14 15 16 This period should last for until after the first feeding. Mother and baby should be encouraged to start the first feeding as soon as the baby is receptive. All necessary procedures can be done while baby is skin-to-skin. If skin contact is delayed or interrupted for maternal or newborn complications, we will start skin-to-skin again as soon as possible. If the baby is removed, we document it in the Newborn Assess/Intervent flowsheet. Q. Why is skin-to-skin important? A. • Promotes bonding • Regulates temperature • Regulates blood sugar levels • Regulates heartbeat and breathing • Calms mother and baby Q. When do mothers hold their babies skin-to-skin and initiate breastfeeding? A. They are placed skin-to-skin: • immediately (within 5 minutes after NSVD) or • For C/S births: - In Recovery, once the mother is responsive to the infant, we place her infant skin-to-skin and initiate breastfeeding - If the baby is sent to the Nursery, the mother’s partner/family member will be encouraged to initiate skin-to-skin contact until the mother can. • Breastfeeding is initiated within the first hour of life. • Document skin-to-skin on baby’s chart/newborn nursing flowsheet (Newborn Vital Signs). 18 17 Q. What do you do here that promotes or protects breastfeeding? A. We initiate Golden Hour skin to skin for all stable mothers and babies. We offer breastfeeding assistance and education throughout postpartum stay. Q. Are babies separated from their mothers for any reasons? A. Our goal is to keep mothers and babies together at all times. However, at times, special procedures may need to be performed in the newborn nursery. Our policy is to limit separation to 1 hour in every 24 hours. Q. What do you teach mothers regarding when they should feed their infants? What do you teach them about how long a feeding should last? A. Babies should be fed: • When they are showing feeding cues, such as lip- smacking, mouth opening, and moving their hands to their mouth. Crying is a LATE feeding cue. • A minimum of 8 times in a 24 hour period. Sleepy babies may need to be awakened if they are eating less frequently than this. • Infants may also “cluster feed” i.e. have a series of short, very frequent feeds. • The feeding should last as long as the infant continues to effectively suckle. Note: Do not say every 2-3 hours, 10 minutes on each side, etc. 19 20 21 Q. When do you encourage mothers with babies in the NICU to express their milk? Why is this important? A. No later than 6 hours after delivery with manual hand expression or an electric breastpump, and then pump 8- 12 times in 24 hours (including at night). Expression of milk at this time: • Provides colostrum to the baby • Stimulates milk supply Q. What do you teach regarding breastfeeding management? A. • positioning • proper latch • importance of exclusive breastfeeding • effective breastfeeding • second night – normal for baby to breastfeed very frequently, i.e. cluster feed • pain is not normal when breastfeeding • how to tell baby is getting enough - check urine and stool output. Minimums are: - Day 1 - 1 stool & 1 urine diaper in 24 hrs. - Day 2 - 2 stools & 2 urine diapers in 24 hrs. - Day 3 - 2 stools & 3 urine diapers in 24 hrs. - Day 4 - 3 stools & 4 urine diapers in 24 hrs. - Day 5+ - 3+ stools & 6+ urine diapers • no pacifiers or bottles • hand expression 22 23 Q. What do you teach about the benefits of exclusive breastfeeding for the first 6 months for babies? A. • Easy for baby to digest, matched to his nutritional needs • Baby receives skin-to-skin, eye, and voice contact • Filled with antibodies to protect against infection • Reduces risk for gastrointestinal disturbances, ear and lower respiratory infections, allergies, and SIDS • Can reduce the risk for atopic dermatitis, asthma, obesity, diabetes, childhood leukemia later in life Q. What about the benefits to the mother? A. • Convenient and economical • Helps the uterus return to its normal size faster • Helpful with weight loss • Reduces risk of breast, uterine, endometrial, and ovarian cancers • Reduces the risk for osteoporosis • Reduces the risk for diabetes and obesity 24 25 Q. Where do you document teaching and care given on skin-to-skin, breastfeeding, supplementation, pacifier and bottle use? What do you teach? A. • Each teaching is documented in the mother’s chart (OB Teaching Plan – Perinatal). • Breastfeeding, supplementation, pacifier, and bottle use are documented in the infant’s chart (Intake & Output). • Skin to skin is documented in Newborn Vital Signs. • Pacifiers are discouraged for the first 3-4 weeks until breastfeeding is established. They may be used for painful procedures and are thrown away after. • We avoid pacifiers because they can - make it more difficult for babies to latch - interfere with cue-based feeding - lead to decreased milk supply 26 Q. What are the medical indications for supple- menting concerning your breastfeeding policy? A. When management of breastfeeding does not improve the following conditions, supplementation may be indicated (according to Joint Commission standards). Infant: • Clinical and lab evidence of dehydration • Asymptomatic hypoglycemia documented by laboratory blood glucose tests • Weight loss of 8-10% with delayed lactogenesis II (by day 5 or later) • Delayed bowel movements or continued meconium stools on day 5 • Insufficient intake despite adequate milk supply • Hyperbilirubinemia Maternal: • Delayed lactogenesis II (day 3-5) • Retained placenta • Sheehan syndrome (postpartum hemorrhage followed by absence of lactogenesis) • Primary glandular insufficiency (primary lactation failure), as evidenced by poor breast growth and minimal clinical indications of lactogenesis (occurs in <5% of women) • Breast pathology or prior breast surgery resulting in poor milk production • Intolerable pain during feedings unrelieved by interventions 27 Q. What do you teach mothers who must formula feed for medical indications? A. • Safe storage and handling • Appropriate measurement and reconstitution • Good hygiene and cleaning of equipment • Appropriate feeding methods (i.e. paced feeding) Q. How do you intervene when a mother requests for formula supplementation? A. • Discuss with the mother her reasons for wanting formula supplementation and encourage supplementing with her own milk • Educate to her concerns • Discuss risks of formula & benefits of breastmilk • If she still requests formula, we suggest using alternate feeding method per our policy: finger feeding, supplementing at breast, cup feeding • This is documented on the mother’s chart Q. How do you evaluate medication that may impact breastfeeding? A. • We consult “Medications and Mothers Milk” by Thomas Hale. We have one on each unit, in the medication room or at the nurses’ station. • Lactmed: medications and breastmilk – expert opinions accessible via the Intranet home page from the Sharepoint directory Æ Pharmacy Æ under “Links”. 30 28 29 Document! Document! Document! This booklet was adapted from the Perinatal Staff Preparation Handbook of Pomona Valley Hospital by Patty Carlton, RN BSN IBCLC and Nicole Balagtas, SN UCI with the help of Marra Williams, CHES 24 hrs. - Day 5+ - 3+ stools & 6+ urine diapers • no pacifiers or bottles • hand expression 22 23 Q. What do you teach about the benefits of exclusive breastfeeding for the first 6 months for babies? A. • Easy for baby to digest, matched to his nutritional needs • Baby receives skin-to-skin, eye, and voice contact • Filled with antibodies to protect against infection • Reduces risk for gastrointestinal disturbances, ear and lower respiratory infections, allergies, and SIDS • Can reduce the risk for atopic dermatitis, asthma, obesity, diabetes, childhood leukemia later in life Q. What about the benefits to the mother? A. • Convenient and economical • Helps the uterus return to its normal size faster • Helpful with weight loss • Reduces risk of breast, uterine, endometrial, and ovarian cancers • Reduces the risk for osteoporosis • Reduces the risk for diabetes and obesity 24 25 Q. Where do you document teaching and care given on skin-to-skin, breastfeeding, supplementation, pacifier and bottle use? What do you teach? A. • Each teaching is documented in the mother’s chart (OB Teaching Plan – Perinatal). • Breastfeeding, supplementation, pacifier, and bottle use are documented in the infant’s chart (Intake & Output). • Skin to skin is documented in Newborn Vital Signs. • Pacifiers are discouraged for the first 3-4 weeks until breastfeeding is established. They may be used for painful procedures and are thrown away after. • We avoid pacifiers because they can - make it more difficult for babies to latch - interfere with cue-based feeding - lead to decreased milk supply 26 Q. What are the medical indications for supple- menting concernin