strengthening reproductive health management and service delivery in west bank and gaza...

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


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


Breastfeeding 1

1st SECTION: Mother and foetus

TOPIC 2 : Breastfeeding

3. Minor Breast Problems Complications during breastfeeding

A Weak reflex B Flat nipples C Engorgement D MastitisE Sore nipples

1st SECTION: Mother and foetus

TOPIC 2 : Breastfeeding

3. Minor Breast Problems Complications during breastfeeding

A Weak reflex B Flat nipples C Engorgement D MastitisE Sore nipples


Breastfeeding Minor Breast Problems

Topic 2 Breastfeeding

Subtopic 32 Minor Breast Problems

A “Weak Suckling Reflex”

Standard Statement

All newborns with weak suckling reflex will be identified & their mothers will be assisted & guided properly.



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”



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.




Documentation:

• observations, • assessment findings, • teachings. folders, leaflets, …)





Subtopic 32

Minor Breast Problems

B Flat or inverted nipples

Care Group Mothers complaining/having breast problems at any time during lactating period

Standard Statement

Women with inverted nipples should receive extra support and care to ensuresuccessful breastfeeding


Types of Nipple

Normal Normal

Flat Flat

Inverted Inverted

Long and big Long and big nipplesnipples



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.



• 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.


NIPPLE SHIELD USE

12

المحقن طريقة

دخل المكبس أالخطوة الثانية: من الطرف المقطوع

الخطوة األولى: اقطع هذا الجزء بشفرة على امتداد هذا

الخط

الخطوة الثالثة: اطلب من األم أن تجذب

المكبس برفق




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




Subtopic 32


C ENGORGEMENT / FULL, LUMPY BREASTS


Standard Statement

Same as above. The woman with any breast problem during lactating period should be investigated, diagnosed and managed properly



Do not REST the breastDo not REST the breast

Breast Engorgement



To prevent irreversible trauma to the breast tissue caused by unresolved engorgement

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.


12

National and Unified Obstetric and Newborn care Guidelines and Protocols 18

الثدي تشريح

الداعمة (1 األنسجة supporting والدهنيات

tissue & fat muscle cells عضلية خاليا 2 )

األوكسيتوسين بفعل تتقلص oxytocin makes them

contract

اللبن إخاليا (3 فراز

milk secreting cellsتفرز البروالكتين يجعلها prolactin makes اللبنthem secrete milk

القنوات (4 ducts

الثدى ( 5 areola هالةيتجمع هنا milk collects اللبنhere

الجيوب ( 6 lactiferousاللبينة

sinuses الحلمة( 7

nipple

مونتجمرى ( 8 غددMontgomery’s gland

alveoliحويصالت ال( 9

19

الجيد التعلق

12

20

السيئ التعلق12



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



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



Before feed to stimulate oxytocin reflex

Warm compress on breasts or warm showerMassage to neck and backLight massage of breastStimulate nipple skinHelp mother to relax

After feed to reduce oedema

Cold / ice compress on breastsEncourage 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 showerMassage to neck and backLight massage of breastStimulate nipple skinHelp mother to relax

After feed to reduce oedema

Cold / ice compress on breastsEncourage 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



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



Build the mother confidenceBuild the mother confidence

Breast Engorgement




Subtopic 32


D Blocked duct and Mastitis


Standard Statement

The woman with any breast problem during lactating period should be investigated, diagnosed and managed properly



Blocked duct/non Infective Mastitis

Blocked duct/non Infective Mastitis

Mastitis

Infective Mastitis

Breast abscess



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.



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



Blocked duct and Mastitis

If any of these :

measures are ineffective

Refer for Physician check up & management



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



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

Drug Dose Instructions

Flucloxacillin 250 mg oraly6 hourlyfor 7-10 days

Take dose at least 30 minutes before food

Erythromycin 250-500 mg orally6 hourlyfor 7-10 days

Cephalexin 250-500 mg orally6 hourlyfor 7-10 days

For mother is allergic to penicillin



Analgesics that can be taken are:-Analgesics that can be taken are:-

Drug Dose Instructions

Ibuprofen 400 mg oraly8 hourly

This should not be taken by women who suffer from stomach ulcers, or are allergic to aspirin

Paracetamol 500mg *2 orally6 hourly



Topic 8 Minor Breast Problems

E Sore Nipples and Nipple Fissure


Standard Statement

The woman with any breast problem during lactating period should be investigated, diagnosed and managed properly



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.



5. Encourage continuation of breast feeding. 6. Wash breasts only once a day & dry very well, and avoid

using soap7. 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 soap7. 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




No improvement after 24 hours

or more severe symptoms

Refer for Physician check up & management





Look for a cause:

1. Check attachment2. Examine breasts-

1. engorgement, 2. fissures, 3. Candida

3. Check baby for Candida, and tongue-tie

Look for a cause:

1. Check attachment2. Examine breasts-

1. engorgement, 2. fissures, 3. Candida

3. Check baby for Candida, and tongue-tie




Give appropriate treatment:

1. Build mother's confidence2. Improve attachment, and continue breast-feeding3. Reduce engorgement-suggest feed frequently,

express milk4. 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 confidence2. Improve attachment, and continue breast-feeding3. Reduce engorgement-suggest feed frequently,

express milk4. Treat for Candida if skin red shiny, flaky; if there is

itchiness, or deep pain, or if soreness persists.



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-feedsContinue 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-feedsContinue 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


Breastfeeding

End of module 2 Breastfeeding

strengthening reproductive health management and service delivery in west bank and gaza...

Documents

newborn care guidelines

protocols guidelines

minor breast problems

minor breast problems

successful breastfeeding

minor breast problems

breastfeeding subtopic

normal care