Oxford Handbook of Midwifery (145 page)

• • If lethargic when awake the baby may not be receiving adequate nutrition
    
  • Baby is ill.
    

    Actions
    

    The first two actions should be addressed with all babies and the following actions acted upon as relevant to the history.
    

  • A breastfeeding history should be taken to see if the reason can be identified.
    
  • A breastfeed should be observed and positioning and attachment improved.
    

    •
    If necessary wake the baby and give additional feeds (EBM or colostrum if possible) until the situation has improved.
    

  • If the baby is jaundiced encourage the baby to feed as frequently as possible.
    
  • Feed the baby when he or she is half asleep.
    
  • Encourage the baby to stay awake whilst feeding by keeping the baby cooler during feeds.
    
  • Switch feed—that is change the baby from one breast to the second as the baby becomes sleepy.
    
  • Change the baby’s position while feeding to stimulate the baby to suckle more vigorously.
    
  • Encourage mother to adopt skin-to-skin as much as possible—do not offer the breast let the baby find it.
    
  • Change nappy to wake the baby.
    
  • Bath the baby.
    
  • Sit in a warm bath to feed the baby.
    

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  Sore/cracked nipples
  

  Breastfeeding should be comfortable and pain-free although some mothers may experience some discomfort at the beginning of the feed for the first few days. This usually resolves spontaneously. However, 24% of mothers who discontinue breastfeeding in the first week postnatally do so because of sore or cracked nipples.
  ²
  It is very likely that the majority of sore nipples could be prevented and treated by correct positioning and attachment of the baby at the breast.
  

  The causes of sore and cracked nipples include:
  

Action

the baby to attach easier. It may be appropriate to refer the baby for

separation of the frenulum.

Inverted nipples

Nipples usually protrude but appropriately 10% of pregnant women who wish to breastfeed have inverted or non-protractile nipples. Currently there is no evidence that any antenatal nipple treatment or prepara- tion contributes to successful breastfeeding. No prediction of success of breastfeeding should be made on antenatal inspection.

CHAPTER 24
Breastfeeding

692

Action

• The mother should be reassured that the baby breast feeds not nipple feeds.
  
• Skilled help with attachment is important for these women in the first few days postpartum.
  
• If difficulty is encountered attaching the baby, expressing a small amount of milk to soften the area around the areola can sometimes be helpful.
  
• Lactation can be initiated and sustained with a breast pump and further attempts made at attaching made when the milk has ‘come in’ and the breasts are softer.
  
• Dummies and nipple shields should be avoided as they require a different action and may confuse the baby.
  
• Mothers with inverted nipples can be as successful breastfeeding as mothers with protractile nipples.
  

  Engorgement
  

  There are two types of engorgement:
  

• Milk arrival engorgement
  
• Secondary engorgement.
  

  Milk arrival engorgement
  

  This occurs usually around the 2–4th days postnatal as the milk ‘comes in.’ It can result from poor attachment, restricting feeds in the early days, or not waking the baby enough. It is caused by increased blood supply to the breasts and extra lymph fluid. The mother will have red, painful, and swollen breasts. She may also have a mild pyrexia and flu-like symptoms. If action is not taken it may result in mastitis.
  

  Secondary engorgement
  

  The mother presents with the same symptoms of painful, swollen breasts but this can occur at any time and is due to the ineffective drainage of the
  

  breasts. It may result from a variety of causes including:
  

• The mother missing a feed
  
• Reduced appetite in the baby
  
• Over-stimulation of the supply
  
• Too rapid weaning
  
• Baby sleeping through the night.
  

  Action
  

  The actions taken are the same in both types of engorgement:
  

• Warm flannels can be used to aid the milk flow
  
• Expressing a small amount of milk will also help to get the milk flowing and make it easier for the baby to attach
  
• Improve positioning and attachment
  
• Encourage the baby to feed frequently
  
• Analgesia may be required (paracetamol is usually the drug of choice). Reassure the mother that it is a temporary situation.
  

  Blocked duct/s
  

  The woman will generally feel well but she will present with a localized tender lump or a feeling of bruising. It usually occurs in one breast and can
  

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  occur at any time during the breastfeeding period. The woman’s tempera- ture is not usually raised.
  

  Actions
  

Mastitis

Mastitis means inflammation of the breast. The term should not be regarded as synonymous with ‘breast infection’ because although inflammation may be the result of infection, in over 50% of cases of mastitis it is not. Mastitis can be the result of milk leaking into the breast tissue because of a blocked duct or engorgement. The body’s defence mechanism reacts in the same way as it would for infection by increasing the blood supply, which in turn is responsible for the redness and inflammation. Therefore antibiotics may not be required if self-help measures are initiated promptly.

Signs

Predisposing factors

There are a number of factors that may make non-infective mastitis more
likely; these include: