Oxford Handbook of Midwifery (140 page)

Support may sometimes be required to assist good positioning. This may be in the form of cushions to support a comfortable position for the mother or to raise the baby to the level of the breast.

The following should be avoided:

Biological nurturing

This is a new, non-prescriptive, mother-centred breastfeeding approach that refers to a range of semi-reclined maternal breastfeeding postures and innate feeding behaviours.
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The positions used are similar to those used in skin-to-skin contact. The baby is held instinctively and cuddled in a natural way. This can be done with the baby held long ways, sideways or slanting. The baby always has close contact with the breast and can have unrestricted access to the breast for feeding. This is a useful approach for many mothers and especially those encountering problems with latching on. The Baby Friendly Initiative (BFI) recommends that those working towards BFI accreditation should inform themselves about biological nur- turing and to look for ways to incorporate this information within a frame- work of care that provides women with a range of skills to enable them to adapt their breastfeeding to a variety of situations.
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Attachment of the baby at the breast

Attachment is the term used to describe how the baby’s mouth fits around

the mother’s nipple and areola to suckle at the breast.
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The three main reflexes required for a baby to attach effectively are:

If any of these reflexes is absent, the baby will not be able to attach and feed effectively. Premature babies frequently are unable to coordinate the reflexes.

Process of attachment

In order to attach correctly, the baby needs to:

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CHAPTER 24
Breastfeeding

Fig. 24.1
The baby should be encouraged to open their mouth widely.

Fig. 24.2
Baby correctly attached at the breast.

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Recognizing correct attachment

Exaggerated attachment at the breast

This is useful if:

How to attain an exaggerated attachment

If the mother is going to feed from her left breast, she needs to cup the breast underneath with her left hand, keeping her fingers well away from the areola. There is always a tendency to want to move the fingers up, but this will affect the success of the attachment. The thumb should tilt the nipple back so it looks like it is pointing away from the baby. This will have the effect of making the breast under the nipple bulge forwards. The

baby’s bottom lip should make contact with the breast well away from the
base of the nipple.

Pattern of sucking

Normally once the baby is attached he or she will take a few quick sucks at the breast which will initiate the oxytocin reflex. As the milk begins to flow and fills the mouth, the baby’s sucks will become slower and deeper. The baby will pause occasionally. If a baby continues to take frequent short sucks or there are audible ‘smacking’ noises as the baby sucks, this is a good indication that the attachment is incorrect.

Recognizing incorrect attachment

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Breastfeeding

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• The cheeks are drawn in as the baby sucks.
  
• The breast tissue is puckered.
  
• The breast tissue moves in and out of the baby’s mouth as he feeds.
  
• The baby makes little sucks as if he is sucking a dummy.
  
• There is no change in the rhythm of feeding.
  
• The baby will show frustration at not having his hunger satisfied, by either becoming sleepy and ceasing to suck or by coming off the breast and crying.
  
• The colour of the stools may change back to green/brown from yellow.
  

  Results of ineffective attachment
  

  The mother may:
  

• Feel pain when feeding
  
• Experience sore nipples, especially cracks across the tip of the nipple or at the base of the nipple
  
• Experience engorgement of the breast. The baby may:
  
• Appear unsatisfied
  
• Cry a lot and want frequent feeds, or may feed for protracted lengths of time
  
• Receive insufficient milk and fail to gain or even lose weight
  
• Become frustrated and refuse to feed
  
• Receive adequate nourishment for the first few weeks by feeding frequently if the oxytocin reflex works well but then will fail to thrive.
  

  Measures shown to enhance breastfeeding success
  

  A comprehensive systematic review conducted by NICE
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  has identified what practices enable a mother to breastfeed for longer, and these should be used in conjunction with the following information.
  

  Baby-led feeding
  

  

  Baby-led feeding, or demand feeding, simply consists of feeding the baby whenever he or she wishes and for as long as he or she wishes.
  

  There is substantial evidence that the timing and duration of breastfeeds should be responsive to the needs of the baby.
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  Babies will feed at the breast for very different lengths of time if left undisturbed, and it is thought that the length of a feed is determined by the rate of milk transfer between mother and baby.
  ¹⁰
  

  Limiting the duration of the feed or removing a baby from the breast before they finish spontaneously, may prevent the baby from receiving adequate calorific intake causing failure to gain weight despite frequent feeds and an apparently good milk supply.
  

  Unrestricted frequency of feeds is also advocated. Observation studies have demonstrated that the frequency of feeds in the first few weeks appears to be unpredictable and random, varying between 1h and 8h. Babies who regulate the length and frequency of feeds gain weight more quickly.
  

  Advice to the mother to restrict or limit suckling time or frequency at the breast will not only do no good, but could do harm. However, a baby that has protracted feeds without coming off spontaneously, or a baby that feeds very frequently, may be attached to the breast incorrectly.
  

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  A baby that is poorly attached can also cause nipple trauma, which may give rise to engorgement and/or mastitis.
  ¹¹
  

  Night feeds
  

  The advantages of night feeds include: