Development of the Newborn & Care of the mother in the First 72 Hours Kittie Frantz, RN, CPNP-PC...
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Transcript of Development of the Newborn & Care of the mother in the First 72 Hours Kittie Frantz, RN, CPNP-PC...
Development of the Newborn & Care of the mother in the First 72
HoursKittie Frantz, RN, CPNP-PC
Clinical Instructor in PediatricsKeck School of Medicine at
The University of Southern CaliforniaLos Angeles, California
American Academy of Pediatrics/American College of Obstetrics & Gynecology Perinatal
Guidelines says…
“Healthy infants should be placed & remain in direct skin-to-skin contact with their mothers
immediately after delivery until the 1ST feeding is accomplished.”
2American Academy of Pediatrics, American College of Obstetrics & Gynecology: GUIDELINES FOR PERINATAL CARE, 6th ed. AAP & ACOG, Elk Grove Village, IL 2007.
Attachment Right at Delivery
3
Delivery Room Attachment• Place baby on mom’s body• Dry baby while skin-to-skin• Apgars done while skin-to-skin• Baby will rest for 20 minutes• Crawls to attach by 50 minutes• Process disturbed if removed for weight,
measuring, etc. Righard, L, Alade, M. (1990) Effect of delivery room routines on success of first breast-feed, LANCET 336: 1105-07
• American Academy of Pediatrics says tasks to be done after the complete first breast feed
4
Brimdyr, K. SKIN TO SKIN THE FIRST HOUR AFTER BIRTH; PRACTICAL ADVICE FOR STAFF AFTER VAGINAL OR CESAREAN BIRTH. [DVD]The Healthy Children Project, Inc., 2010, www.healthychildren.cc
Watch Baby do it
5© 1995 Righard, Frantz “Delivery Self Attachment” film Licensed by Geddes Productions, LLC
Several Studies Looked at This
• Dr. Lennart Righard in The Lancet Righard, L, Alade, M: (1990) Effect of delivery room routines on success of first breast-feed. THE LANCET; 336:1105-1107
• Ann Marie Widstrom in Sweden Widstrom, A.
et al (2011) Newborn behavior to locate the breast when skin to skin: a possible method for enabling early self regulation. ACTA PAEDIATRICA Jan;100(1):79-85
• Varendi in England Varendi, H., Porter, R.; Breast odour as the only maternal stimulus elicits crawling towards the odour source, ACTA PAEDIATRICA, 2001, 90:372-5.
6
The first two hours baby is very alert to do this
7
Baby gets A LOT of colostrum this first long feed! (Sometimes 1 hour)
8
© Welda Hoerst
Many Baby Procedures can be done while on Mom
9
© Debi Bocar
Formula feeding moms can do skin-to-skin too!
10
Gift from Family
Best to do the bath and measurements before he goes into his transition sleep
11
BUT AFTER THE 1ST BREAST
FEED
© Kay HooverAmerican Academy of Pediatrics, American College of Obstetrics & Gynecology: GUIDELINES
FOR PERINATAL CARE, 6th ed. AAP & ACOG, Elk Grove Villiage, IL 2007.
Then baby goes into a deep sleep for four to six hours because he is in transition
12© 2001 Nils Bergman
This is the best place to sleep while in transition! Skin-to-skin on mom
13
Mom and baby are then transported together to their post partum room
14
© LAC+USC Medical Center
© LAC+USC Medical Center
Rooming-in means baby with mom 23 out of 24 hours
15
© LAC+USC Medical Center
World Health Organization, UNICEF Baby Friendly Hospital Initiative
Transition is the baby’s first 12 hours.
What occurs in transition?
16
Skin-to-skin is the best place to spend transition even when awake
17
© LAC+USC Medical Center
Where would you want to be in this transitional
period?
18
© 2001 Nils Bergman© Kittie Frantz
45 degree reclining position with baby prone is comfortable for them both
19© LAC+USC Medical Center
Do we need to worry that he is not eating?
• No, he is in transition & may not feels like eating if awakened
• Remember we are discussing full term normal newborns
• Explain to family that he will eat when he awakens
20
When baby wakes after this deep sleep, he will go to the breast again
21
© Helen Quimby
He may falter a bit but it is normal for him to lick, try and learn
22
© 2001 Nils Bergman
The baby who was skin-to-skin at delivery does better
23© LAC+USC Medical Center
Baby-led latch works best here
24
© 2009 Smillie, Frantz, Makelin “Baby-led Breastfeeding: The Mother-baby Dance” DVDLicensed by Geddes Productions, LLC
© 2007.2010 Smillie, Frantz, Makelin “Baby-led Breastfeeding: The Mother-baby Dance” licensed by Geddes Productions, LLC www.geddesproduction.com
Baby will reach with his tongue and draw the breast in
25© 1980,1990 Kittie Frantz
Baby will place his mouth in an asymmetrical latch
26
© 2006 Geddes Productions, LLC
What does baby need this first day?
27
© Neil
American Academy of Pediatrics and The Joint Commission says 8-12 feedings per
each 24 hours
Can he do it thisfirst day?
28
© Kittie Frantz
American Academy of Pediatrics, American College of Obstetrics & Gynecology: GUIDELINES FOR PERINATAL CARE, 6th ed. AAP & ACOG, Elk Grove Village, IL 2007.
The first 24 hours• He breastfed at delivery once
• If he doesn’t feed during the transition sleep (8 hrs) then…,
• The next 16 hours he will need to do 7 feedings
• That is about every 2.25 hours until he is 24 hours old. It works!
29
The problem with saying “every 2-3 hours”…
• Parents choose the 3 hours
• Smaller babies need 10-12 feeds
• Parents try to schedule the baby and ignore baby’s feeding cues
• Parents try to get the baby to sleep longer with swaddling and pacifiers
30
Best to say feed as often or as long as baby wants to or when baby shows feeding cues
31
© Helen Quimby
Brazelton infant states
• Deep sleep (nothing moves)• Rem sleep (eyes closed but move)• Quiet/semi-awake (eyes, mouth, hands move)• Alert awake (eye contact, quiet)• Active alert (moving a lot, arm cycling)• Crying
32
Brazelton, TB, Nugent, JK (2011) Neonatal Behavioral Assessment Scale, 4 th ed. CLINICS IN DEVELOPEMENTAL MEDICINE, #190, Wiley, Hoboken New Jersey
Which infant state is best for feeding?
• Deep sleep (nothing moves)• Rem sleep (eyes closed but move)• Quiet/semi-awake (eyes, mouth, hands move)• Alert awake (eye contact, quiet)• Active alert (moving a lot, arm cycling)• Crying
33
Teach mom the feeding cues and states
• Babies feed best in REM sleep or Quiet/semi-awake states
• Crying disorganizes the baby• Teach mom what to look for in cues
and states• Baby should be skin-to-skin, loose in
a blanket or in a sleep sack blanket
34
Swaddling prevents baby from waking – can’t arm cycle – and doesn’t fully awake
35
Franco, P, Seret, N, Van Hees, J, Scaillet, S, Groswasser, J, Kahn, A: Influence of Swaddling on Sleep and Arousal Characteristics of Healthy Infants. PEDIATRICS, 115(5):1307-1311, 2005.
Your responsibility is to be sure baby breastfeeds 8-12 times each 24 hours
This is an American Joint Commission Sentinel Alert
36
..
Joint Commission on Accreditation of Health Care Organizations. Revised Guidance to help Prevent Kernicterus, SENTINEL EVENT ALERT, Issue 18, April 2001.
Pacifiers not recommended by the American Academy of Pediatrics until
breastfeeding is well established Why?
37
American Academy of Pediatrics, American College of Obstetrics & Gynecology: GUIDELINES FOR PERINATAL CARE, 6th ed. AAP & ACOG, Elk Grove Village, IL 2007.
What about the length of the breastfeed?
• Parents don’t like being told a different number of minutes per breast by different nurses or doctors
• 10-15 minutes per breast is too short for colostrum!
• The American Academy of Pediatrics says no time limits for each feed. Feed until the baby falls asleep and lets go of the nipple
• We found our babies take 45 to 60 minute feedings the first two days!
38
American Academy of Pediatrics, American College of Obstetrics & Gynecology: GUIDELINES FOR PERINATAL CARE, 6th ed. AAP & ACOG, Elk Grove Village, IL 2007.
What about the length of the breastfeed?
• We told the moms let him feed on the first breast till he spits it out
• Then feed on the second breast till he comes off by himself asleep
• Be sure baby is in a nice asymmetrical latch to protect the nipples
39
Colostrum suckling takes a LONG time
40
© Welda Hoerst
Mom feels like doing this because we get her
comfortable in laid-back positioning !
41Gift from Family
But, doesn’t he need to eat during transition???
42
Term babies are born with a “backpack”
• Tissue edema• Subcutaneous fat stores• They use this fat & urinate out the edema
constitutes the weight loss:– 5.5 -6/6% Between day 2 & 3 – 7-8% IN 1ST Week– No more than 12% in the first week
43
American Academy of Pediatrics, American College of Obstetrics & Gynecology: GUIDELINES FOR PERINATAL CARE, 6th ed. AAP & ACOG, Elk Grove Village, IL 2007.
But, doesn’t he need to eat???
• Stomach is marble (5-7cc) sized at birth and initially not very elastic
• Stomach can stretch to take 20 CCs on the 1st day
• Frequent slow drip of colostrum is kind
• Is colostrum so thick so it won’t come too fast?
44
But, doesn’t he need to eat???
• Nurses know that if you give more than 20ccs that first feed that it might come back up!
• We don’t do baby a favor by forcing the stomach expansion those first few days
45
We need to explain this to the parents
• Show them a visual
• Tell them that their baby’s stomach is about the size of his fist when full
• Stress frequent refills!
46
We need to explain this to parents• Formula in the first week alters baby’s immune
system Host,A 1991 Importance of first meal on the development of cow’s milk allergy & intolerance ALLERGY
PRAC. 12(4):227-32
• Overfeeding in the first week sets baby up for future obesity
Stetler, N 2005 Weight gain in the first week of life and overweight in adulthood. CIRCULATION,111:1897-1903
47
What to do when she insists on a bottle
• Nurse to solve any problems, educate her and chart the interaction
• If she still insists on a bottle, get a doctor’s order. Chart the reason for the formula
• Offer formula not in a bottle with nipple. We choose the feeding tube device (SNS) at the breast as that is breastfeeding
48World Health Organization, UNICEF The Baby Friendly Hospital Initiative
What to do when she insists on a bottle
• Take ONE bottle into the room
• Always OPEN that bottle
• Educate her that formula is only good for one hour after opened
• If she just breastfed, pour out all but 10-15 ml so he doesn’t spit it up!
49
Academy of Breastfeeding Medicine (2013) Protocol #5 Peripartum breastfeeding management for the healthy mother of a term infant, BREASTFEEDING MEDICINE 8(6):469-73
How much does the full term baby need?
20 mls the first post partum day30 mls the second post partum day30-40 mls the third post partum day90 mls the fourth postpartum day
50
According to Scammon and Doyle, the amount baby takes doesn’t reach
120K/cal per Kg until day four….if he feeds 12 times a day for the first four
days
51
Scammon, R., Doyle,L, Observations on the capacity of the stomach in the first ten days of postnatal life. AMERICAN JOURNAL OF DISEASES IN CHILDREN, 20:516-38, 1920.
FIRST 12 HOURS
• What if he sleeps too much this first 12 hours?
• Remember, baby is in transition
52
Baby has blunted feeding cues if he is swaddled all the
time
53
How long can baby go without food?
• At risk for hypoglycemia?
• Skin to skin reduces energy loss
• If can’t maintain temperature skin to skin, consider sepsis
54
No energy loss here
55
Gift from Family
Mom’s feelings of inadequacy
• “What I do doesn’t matter”
• “He is getting nothing from me”
• “He feeds again and again and again”
• Knowledge that baby is bringing in the milk could be helpful
56
Suggestions for managing her rest
• Close your eyes and sleep between feeds
• Manage your visitors wisely
• Turn off or turn down the TV volume
• Turn your cell phone ringer off
57
Gift from Family
Anticipatory Guidance
• Tell her baby will feed every 2 – 2½ hours this first night
• If she knows this is coming, she may not view it as a problem and panic
• Can Dad or Grandma stay to watch her so she can sleep while baby breastfeeds?
58
Wet diaper minimum should be 1 for each day of the week
59One wet diaper is fine this first 24 hours
© 1996 Kittie Frantz
THE SECOND 24 HOURS
• American Academy of Pediatrics says baby is to feed 8 -12 times this next 24 hours
• But …… babies are night people!
60
American Academy of Pediatrics, American College of Obstetrics & Gynecology: GUIDELINES FOR PERINATAL CARE, 6th ed. AAP & ACOG, Elk Grove Village, IL 2007.
Night people???• They sleep a lot in the
day
• They do most feeds between 6pm to 6am
• Prolactin is the highest from 1-5am
• This is the pattern for the first THREE weeks and is normal
61
© 1996 Kittie Frantz
We need to teach this or parents try to “fix it”
• Pacifier• Swaddled all the time• “Shushing” a crying baby• Waking baby in the day time• Parent finger in mouth to hold him off• Asks to send baby away at night• Grandma or dad asks to give baby a bottle
62
Too many visitors in the day tires mom so that she has no energy to care for the baby at
night
63
Gift from Family
What to do to ensure her rest in the day??
• Mornings are baby’s sleepy time and ideal for mom to sleep too
• No visitors until 11:00 am
• Classes or visits by ancillary staff suggested for the afternoon when dad can attend
64
The second night feeding frenzy!
• Baby will want to breastfeed A LOT this night
• We don’t really know why?
• We see it happen even with moms tandem nursing a toddler
• Doubt it is lack of milk but perhaps a rhythm in the baby
65
Get the mother comfortable
66
Gift from Family
Gift from Family
Baby is perhaps bringing in the milk!
Passion grows with
knowledge
67
Gift from Family
Hand express to show her what is really there
68
© LAC+USC Medical Center
Baby is preventing engorgement if he is allowed to nurse a lot this night!
• If you explain this process
• She will respect your tips because it worked!
69
UNICEF
Engorgement can be caused by:
70
• Giving bottles of formula
• Using a pacifier
• Keeping baby swaddled
• Scheduling the feedings by parents
• Taking the baby away at night
Parents need to know what will happen this second night so they don’t panic!
71© Geddes Productions, LLC
Wet diaper minimum should be 1 for each day of the week
72
Two wet diapers are the minimum for this second day
© 1996 Kittie Frantz
THE THIRD 24 HOURS
73
Milk is in before 48 hours if baby got to feed 8 – 12 times/24 hours for long feedings in the first two
days
• She needs to see success!
• Show her and praise her!
74
If baby is not suckling well, then:
• The milk coming in may be delayed
• Or she might get engorged even if feeding 8 – 12 times/24 hours
75
The length of the feeding may change because the milk is in
• When the milk comes in, the feedings shorten
• Still feed the baby till he falls asleep
• Help her resist others who tell her how long baby should sleep
76
Cluster feedings: a few feedings really close together usually in the evening
• Well documented cluster feedings for the normal newborn Why?
• Baby was fed continuously in the womb
• Is this a gradual transition to more spaced out feedings?
77
Use feeding chart to teach
Simplify any charts they may use
Circle clusters to show they occur every day
78Gift from Family
Milk coming in means a faster flow and now baby has to coordinate his
suckle & swallow with breathing
79
This challenges some newborns and they may balk a bit!
• Baby-led latch really helps here
• Let him sleep with mouth near the nipple so he can wake to suckling
• Pump if engorged to slow the initial flow
80
Watch as baby dances at the nipple knowing a flow is coming!
81
© 2007,2010 Smillie, Frantz, Makelin “Baby-led Breastfeeding:The Mother-baby Dance.” Licensed from Geddes Productions, LLC
© 2007,2010 Smillie, Frantz, Makelin “Baby-led Breastfeeding:The Mother-baby Dance’. Licensed from Geddes Productions, LLC
www.geddesproduction.com
The flow of the milk organizes the suckle
The baby who did not suckle well, may now improve rapidly!
82
The faster flow may organize the suckle and sore nipples may vanish
83© 2007,2010 Smillie, Frantz, Makelin “Baby-led Breastfeeding:The Mother-baby Dance” licensed from Geddes Productions, LLC www.geddesproduction.com
© 2007,2010 Smillie, Frantz, Makelin “Baby-led Breastfeeding:The Mother-baby Dance” licensed from Geddes Productions, LLC
Get mom excited to know her milk is in!
• Teach the new sound of consistent swallows
• Have her watch the wide jaw openings as baby swallows
84
It is an art to send the parents home confident in the breastfeeding!
85
How will I know my baby is getting enough?
Do wet diapers or stools gauge the milk intake the best?
86
Shrago says stools are a better indicator of milk intake
• More stools indicate more colostrum ingestion
• The magic number is 4 stools within the fourth 24 hours
Shrago,L. (2006) Pediatric Nursing;32(3):195-201
87
American Academy of Pediatrics says yellow stools should be seen by day 4-5
88
© Ross Abbott
American Academy of Pediatrics, American College of Obstetrics & Gynecology: GUIDELINES FOR PERINATAL CARE, 6th ed. AAP & ACOG, Elk Grove Village, IL 2007.
Wet diaper minimum should be 1 for each day of the week
89What is he peeing out? 3 wet diapers for this 3rd day
© 1996 Kittie Frantz
The very best measure for parents is to listen for consistent swallowing
90
© Helen Quimby
Turning her fears into proactive steps
• Feed often
• Feed long
• No bottles, pacifiers, swaddling so he does feed often and long
• Hand express to store as insurance
91
DISCHARGE SUPPORT
92
Many moms quit in the first week without these questions addressed
93
Family that she trusts tells her she has no milk and they want to feed the baby
a bottle!
94© Ross Abbott
We all know that formula at discharge can encourage that fear and families will use it
95
© Kittie Frantz
World Health Organization UNICEF Baby Friendly Hospital Initiative
Her family is an important information source
• Encourage the 30-40 days of rest but with the baby cuddled up and nursing
• Explain how this is the secret to milk making success
• Try to get grandma in on the conversation
96
She needs someone she can call if worried
97© Kittie Frantz
Where to call?
98
And cheer for her when her baby gains weight and is at birth weight at the 2 week visit!
99Gift from Family
Questions?
100