Maternal Conditions and Breastfeeding

Maternal Conditions and Breastfeeding

dr. Muhammad Ilham Aldika Akbar SpOGMaternal Fetal Medicine Division

Dept Obgyn RSUA-RSUD Dr. SoetomoFaculty of Medicine Universitas Airlangga

Surabaya

dr. M. Ilham Aldika A, SpOG - FK UNAIR

LactogenesisThe changes that occur between pregnancy and

lactationTwo stages:

Lactogenesis I: during pregnancy, initiation of the synthetic capacity of the mammary glands

Lactogenesis II: after delivery, initiation of plentiful milk secretion

Lactation• Physical and

mental health• Past

experiences• Intention

related to breastfeeding

• Body image

• Socioeconomic factors

• General physical environment

• Family support• Hospital and

clinician support

• Maternal conditions

Internal Environment External Environment


Lactogenesis IIChanges in milk

constituentsFeeling of breast fullness 30-40 hours following birthInfluenced by complex hormonal milieu• Reproductive hormones (E, P,

HPL, Prolactin, Oxytocin)• Metabolic hormones

(glucocorticoid, growth, insulin, thyroid)


Problems in Lactogenesis II

DELAYED FAILEDLonger than usual interval between the colostrum phase and copious milk production

The mothers able to achieve full lactation but an extrinsic factor has interfered with the process

One or more factors result in failure to attain adequate milk production

Primary Secondary


Delayed or failed achievement of

Lactogenesis 2 is a result of various

maternal and infant factors

Early recognition of these factors is critical for

clinician


Risk Factor for Delayed or Failed Lactogenesis II

Primiparity Psychosocial stress/pain

Maternal Obesity Diabetes

Hypertension Stressful labor and delivery

Unscheduled Cesarean Section

Delayed first breastfeed episode

Low perinatal breastfeeding

frequencyBreast

surgery/injuryRetained placental fragments

Cigarette Smoking

Hypothyroidism,

hypopituitarismPCOS Post partum

hemorrhageInsufficient mammary

gland tissue

Hormonal and metabolic problems

Diabetes, Hypothyroidism, Obesity, PCOS, SLE

Delay breastfeeding initiation

Preterm labor, CS Complication pregnancy

Gestational DM, preeclampsia

Problem related to labor and delivery

Post partum haemorrhage, Hysterectomy, Sheehan

Anatomic breast abnormalities

Post breast surgery, breast implants, reduction mammoplasty

Maternal medication

Pseudoephedrine, birth control

Maternal Condition causing Delay/Failed Lactogenesis II


BREASTFEEDING AFTER A CESAREAN DELIVERY


CS rate is dramatically increasing in recent years

CS is strongly associated with delayed lactogenesis, delayed in early breastfeeding, decrease in success of

breastfeeding, poorer infant suck, more suplementation, and shorter duration breastfeeding

(Dewey et al, 2002; Smith, 2010)

Different breastfeeding experience with vaginal delivery


Caesarean Section

Delay/FailureLactogenesis

Post operative

pain

Pain Relief drugs

Supress Breastfeedin

g

Stress/Fatique

Decreased milk

supply

Blood loss

Anemia

StressHormone

Infant Problem

s

RDS NICU

Admission

Separation from mother

IMD

BF difficulties

Inhibit oxytocin


Benefits of Breastfeeding after Caesarean

Faster uterine involution

Endogenous oxytocin release by breast stimulation Less postpartum bleeding Weight loss more quickly

Risk of immobility after caesarean Decreases incidence of infant infection

Risk of infection from longer hospitalisation Prevent hypoglycemia, jaundice Bonding


Breastfeeding After CSEpidural or spinal anesthesia is ideal (pain free

post operative)Need extra support by hospital staff and familyCommon position: cradle hold, football hold

and side-lying position IMDRooming in


BREASTFEEDING IN WOMEN AFTER POST

PARTUM HAEMORRHAGE

Many Factors Contributed to Breastfeeding Failure in Women with PPH

Maternal condition(unconsious,

fatique, severe anemia)

ICU Admission (mother baby separation)

Traumatic maternal

stress

Severe blood loss/hypotension

Ischemia/infarct pituitary glands

Altered prolactin level

Sheehan Syndrome


Management of Breastfeeding in Women After PPH

Collaboration care by lactation consultant, obgyn, pediatrician, nurse, patient and family

Maternal condition stabilisationEducate mothers about potential problemsStimulate maternal lactation potentialCarefull infant feeding plan, supplementation

needed Partial BF complete BF

BREASTFEEDING IN WOMEN WITH

PREECLAMPSIA



PREECLAMPSIA2nd leading cause

direct maternal mortality

70-80.000 maternal and 500.000 perinatal death annually

> 99% South Asia & Sub Saharan Africa

Incidence 29.7% (RSUD DR. Soetomo)


Breastfeeding in Women with Severe

Preeclampsia

Maternal Condition

Magnesium Sulphate

administrassion

Prematurity

ICU admission

NICU admission

Early Separation

Obesity

Delay initiation of Breastfeeding


Study of Breastfeeding in women with PE, Cordero L et al, Breastfeeding Medicine vol 7, number 6, 2012

2007-2010, USA281 women with Severe Preeclampsia81 term and 200 late preterm infants

• All mothers and infants survive

• 54% infants were admitted to NICU

• 51% sucessfully initiated breastfeeding

• Factors associated with Breastfeeding initiation failure:• African american race• Young age• Lower education• Multiparity• Smoking• Obesity

Magnesium Sulphate

Prevent EclampsiaFetal neuroprotectantNo effect on Apgar Score

Transfer trans placentallyRisk neonatal

hypermagnesemia?Decrease in sucking rate?Decrease breast stimulation?

Benefit Risk

Breastfeeding


Is not expected to affect breastfeed (not increasing magnesium level significantly in milk)Decrease in sucking rates decrease in breast stimulation Need to feed more frequently, need more stimulation to suckling

Manual expression or breast pumping

Magnesium Sulphate on Breastfeeding

Retained Placental

Fragments



RETAINED PLACENTAL FRAGMENTS DELAY/FAILED LACTOGENESIS II

Causing haemorrhagic post partum Sheehan Syndrome

Inhibit decrease of progesterone level inhibit action of prolactin to stimulate milk production

Management: removing placental fragments

DELAYED LACTOGENESIS RELATED TO GESTATIONAL

DIABETES



GESTATIONAL DIABETESHigh blood glucose level in pregnant women who

have never had diabetes9.2% (CDC) 7x more likely to develop permanent Diabetes type

2


BREASTFEEDING IN GESTATIONAL DIABETES WOMENDelay onset of lactation by 15-28 hDecrease milk volume over 3 first daysHypoglycemia may reduce glucose availability to

lactocytes reduce lactose synthesis & ability to initiate lactation

Women with GDM are less likely to breastfeed (cross sectional study, 2038 women, 2005-2007)

Longer duration of breastfeeding showed a correlation with reduction in risk of developing type

2 diabetes

Kaiser prospective cohort study, 1010 women who breastfeed 2 month vs several month.

RESULT:• After 2 years, 11.8% women developed DM• 35% to 57% reduction in two years diabetes incidence

associated with longer duration of breastfeeding (< 2 vs > 10 month)

Why Mothers with GDM should Breastfeed?


Another Benefit of Breastfeeding in Gestational Diabetes

MothersBetter overall health Less insulin need during

lactation

InfantHelp adjust glucose levelProtection against

malnutrition during early childhood

Lower risk of developing obesity, diabetes, hypertension and cardiovascular disease later in life


Study of womens experience with early breastfeeding after gestational diabetes

Barriers to breastfeeding:BF challenges and supportMilk supply challengesConcern for infant health

A need for consistent breastfeeding education as well as strategies for

addressing BF challenges and milk supply issues


MATERNAL OBESITY


MATERNAL OBESITY Delay increase prolactin

after breastfeeding > 2 days

Low milk transfer at 60 hours post birth

High Leptin inhibit milk ejection

1 unit increase in BMI ~ 0.5 hour delay in lactogenesis

Maternal BMI ~ shorten BF duration

Developmental Origins of Health and Disease

Warner MJ, Ozzane SE, 2010

Fetal Programming


DELAY LACTOGENESIS RELATED TO POLYCYSTIC

OVARIAN SYNDROME

High Androgen down regulate prolactin receptor Insulin resistance Low progresterone poor breast tissue development



MANAGEMENT OF DELAY/FAILURE OF

LACTOGENESIS II


MANAGEMENT PLAN for DELAY-FAILURE LACTOGENESIS II

Provide adequate infant nutrition

Maximizing breast stimulation, and complete breast

emptying

Strategies to measure milk intake during BF

Writen record of progression on feeding

plan

Recognition when maternal lactation

potential is reached


PROVIDE ADEQUATE INFANT NUTRITION

An infant who is malnourished will not have energy to BF effectively

Recommending the mother simply increase frequency BF will not improve this situation when failed lactogenesis II is suspected


Determining the need for supplementation is essential in provide adequate infant nutrition

Expressed breast milk/formula should be given as a complement (immediately following BF session) rather than full suplement (replace BF)

To maximize maternal breast stimulation and maintain infant BF ability

Determining suplementation feeding methods need carefull consideration

Bottle, cup, syringe, or feeding tube device



MAXIMIZE BREAST STIMULATION AND COMPLETE BREAST EMPTYINGAny potential infant sucking problems should be

correctedBreast problem should be correctedBreast pumping following each BF should be initiatedGalactagogues


OBJECTIVE MEASUREMENT OF MILK INTAKE DURING BREASTFEEDINGSubjective estimation is inaccurateTest weighing procedure are important

diagnostic tool for delayed/failed lactogenesis II 1 g ~ 1ml milk intake

Weekly provider visit to asses BF paterns, vol of supplement, and post feeding pumping vol

MAINTAINING FEEDING or PUMPING RECORDHaving mothers maintain a

simple record of daily feeding, pumping and infant stooling and urinary patterns is useful to monitor progress

Guide plan of care for modification as BF improves or not



RECOGNIZING When MATERNAL LACTATION POTENTIAL Has Been Reached

This is a challenge!

Asses proportion of daily BF, supplements, and expressed breast milk volume information to determine lactation potential has been reached

Refference Anderson AM, 2001. Case Report: Disruption of Lactogenesis by Retained Placental Fragments. J Hum Lact.

17(2), 2001.

Chapman DJ, 2014. Risk Factors for Delayed Lactogenesis among Women with Gestational Diabetes Mellitus. Journal of Human Lactation 2014, Vol. 30(2) 134-135.

Cordero L, Valentine CJ, Samuels P, Giannone PJ, Nankervis CA, 2012. Breastfeeding in Women with Severe Preeclampsia. Breastfeeding Medicine Vol 7, Number 6, 2012.

Hurst NM, 2007. Recognizing and Treating Delayed or Failed Lactogenesis II. Journal of Midwifery & Women's Health.

Kair LR, Colaizy TT, 2015. When Breast Milk Alone is Not Enough: Barriers to Breastfeeding Continuation among Overweight and Obese Mothers. Journal of Human Lactation 1-8, 2015.

Sema Kuguoglu, Hatice Yildiz, Meltem Kurtuncu Tanir and Birsel Canan Demirbag (2012). Breastfeeding After a Cesarean Delivery, Cesarean Delivery, Dr. Raed Salim (Ed.), ISBN: 978-953-51-0638-8, InTech, Available from: http://www.intechopen.com/books/cesarean-delivery/breastfeeding-after-a-cesarean-delivery

Marasco L, Marmet C, Shell E, 2000. Polycystic Ovary Syndrome: A Connection to Insuficient Milk Supply? J Hum Lct 2000;16(2):143-148.

Neville MC, Morton J, 2001. Physiology and Endocrine Changes Underlying Human Lactogenesis II. J Nutr. 131: 3005S-3008S, 2001.

Riordan J, Hoople KG, Angeron J, 2005. Indicators of Effective Breastfeeding and Estimates of Breast Milk Intake. J Hum Lact. 21(4):406-412, 2005.


Thank You!

Maternal Conditions and Breastfeeding

Health & Medicine

Transcript of Maternal Conditions and Breastfeeding