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

12Rosebuds@gmail.com

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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Baby- Visual Assessment

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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

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Inspected by……