Fundamentals of Midwifery: A Textbook for Students (93 page)

Learning and developing practical skills to support effective breastfeeding are considered to be a fundamental part of the midwives role in supporting infant feeding. Boxes 10.1 and 10.2 outline the key principles to teach mothers using a hands off approach as recommended by UNICEF Baby friendly Initiative.

Box 10.1 Key principles for positioning and attachment

The baby is held close to the mother’s body.

The baby’s head and body are in alignment making sure the baby has freedom to tilt the head back.

The baby’s shoulders are supported, not the back of the head.

The baby’s nose starts opposite the nipple.

The position is sustainable.

When the baby’s mouth opens wide the baby is brought towards the breast quickly.

Chin and tongue leading, nipple goes towards the junction of soft and hard palate.(UNICEF 2008)
Box 10.2 Recommendations for recognising effective attachment to enable sufficient milk transfer

The baby’s mouth is wide open with the bottom lip curled back.

The baby has a large mouth full of breast.

Cheeks look full and rounded.

The baby’s chin touching the breast.

More of the darker skin of the areola is visible above the baby’s top lip than below the baby’sbottom lip – lower portion of areola is not visible.

Feeding is pain free. Initially mothers may feel some discomfort at the start of the feed.(UNICEF 2008)
Baby’s nose starts opposite the nippleBaby’s head and body are in alignment – baby is free to tilt head backBaby’s219shoulders aresupported – not the back of the headBaby is skin to skin and held close
Figure 10.5
Demonstrates key principles of effective positioning as outlined in Box 10.1. Source: Reproduced with permission from Philip Batty, www.ibreastfeed.co.uk.
Baby’s mouth is wide openLower lip is curled down/outChin touches the breastLower portion of the areola is not visible
Figure 10.6
Demonstrates key signs of effective attachment as outlined in Box 10.2. Source: Reproduced with permission from Philip Batty, www.ibreastfeed.co.uk.
Activity 10.4 ‌Visit the Baby Friendly Initiative website and view the online resources designed to help healthprofessionals support mothers in achieving effective positioning and attachment at the breast. [Available online] http://www.unicef.org.uk/BabyFriendly/Health-Professionals/Care-Pathways/ Breastfeeding/First-days/Positioning-and-Attachment/220
Different positions for breastfeeding
Adopting different positions for breastfeeding allows sustainability of the breastfeed and can be used as part of a feeding plan to manage different breastfeeding challenges, e.g. breast engorgement. Some of the different positions used by mothers may include the underarm hold shown in Figure 10.7 or the cross cradle hold shown in Figure 10.8 using the same key principles (outlined in Boxes 10.1 and 10.2) for initially positioning the baby at the breast for effective attachment.
Breastfeeding pattern
When the baby is attached effectively there is a characteristic pattern of sucking and swallow- ing. When the baby first goes to the breast, rapid short sucks can be observed to stimulate the MER and get the milk moving through the lactiferous ducts. Once the milk is flowing the feeding
Figure 10.7
Underarm hold. Source: Reproduced with permission from Philip Batty, www. ibreastfeed.co.uk.
Figure 10.8
Cross cradle hold. Source: Reproduced with permission from Philip Batty, www. ibreastfeed.co.uk.
221pattern changes to longer, more rhythmical sucks with audible swallowing of the milk and pauses. The sucking/swallowing ratio should be approximately 1 : 1 or 2 : 1 indicative of sufficient milk transfer (UNICEF 2008). Four or more sucks per swallow can be an indication the baby is not attached effectively to the breast or there is insufficient milk transfer.At the end of the feed, the sucking pattern can be less vigorous and flutter sucking can be observed whereby swallowing may be less frequent. This is indicative of the baby receiving higher fat content in the breastmilk (UNICEF 2008).
Biological nurturing – a different breastfeeding approach
Babies are born with an innate ability to smell, locate and latch onto a food source (Porter andWinberg 1999). With the rise of formula feeding in developed countries, it is argued by Colson (2010) that we have lost faith in a baby’s natural ability to find the breast itself. UNICEF (2008) recommends using conventional practical skills to teach mothers positions to support the tran- sition to effective breastfeeding as outlined in Boxes 10.1 and 10.2. It is challenged by Colson (2010) that upright positions of the mother apply pressure to the baby’s back, which counteracts gravity, decreasing primitive neonatal reflexes that assist in helping the baby to establish suc- cessful breastfeeding. Colson’s research argues that babies are ‘abdominal feeders’ and that mothers may benefit from neither sitting upright or laying on their sides, but by adopting a semi-recumbent position leaning back and encouraging the baby to lie prone in close frontal apposition with maternal body contours. It is argued that these positions encourage primitive neonatal reflexes pivotal to the establishment of breastfeeding (Colson et al. 2008).
Box 10.3 Assessing sufficient milk transfer‌