Strengthening Reproductive Health Management and Service Delivery in West Bank and Gaza

1. National and Unified Obstetric and Newborn care Guidelines and Protocols Strengthening Reproductive Health Management and Service Delivery in West Bank and Gaza

2. Guidelines • Normal delivery • Breastfeeding • Normal care to the newborn • High risk cases (1 : medical conditions) • High risk cases (2 obstetrical conditions) • Emergency Obstetrics • Newborn High Risk and Emergencies • Obstetrical procedures • Neonatal procedures • Quality assessment National and Unified Obstetric and Newborn care Guidelines and Protocols

3. Breastfeeding 1 • 1st SECTION: Mother and foetus • TOPIC 2 : Breastfeeding • 3. Minor Breast Problems • Complications during breastfeeding • Weak reflex • Flat nipples • Engorgement • Mastitis • Sore nipples National and Unified Obstetric and Newborn care Guidelines and Protocols

4. Breastfeeding Minor Breast Problems Topic 2 Breastfeeding Subtopic 32 Minor Breast Problems A “Weak Suckling Reflex” Standard Statement All newborns with weak suckling reflex will be identified & their mothers will be assisted & guided properly. National and Unified Obstetric and Newborn care Guidelines and Protocols

5. Breastfeeding Minor Breast Problems “Weak Suckling Reflex” • Reassure the mother about this problem that may need her • patience, • time • & observation National and Unified Obstetric and Newborn care Guidelines and Protocols

6. Breastfeeding Minor Breast Problems “Weak Suckling Reflex” Advise & demonstrate to the mother to help her newborn to strengthen this reflex by inserting her clean little finger between & before feedings into the baby’s mouth & allow him to suck for few minutes. National and Unified Obstetric and Newborn care Guidelines and Protocols

7. Breastfeeding Minor Breast Problems “Weak Suckling Reflex” • Documentation: • observations, • assessment findings, • teachings. folders, leaflets, …) National and Unified Obstetric and Newborn care Guidelines and Protocols

8. Breastfeeding Minor Breast Problems Topic 2 Breastfeeding Subtopic 32 Minor Breast Problems B Flat or inverted nipples Care Group Mothers complaining/having breast problems at any time during lactating period Standard Statement Women with inverted nipples should receive extra support and care to ensure successful breastfeeding National and Unified Obstetric and Newborn care Guidelines and Protocols

9. Types of Nipple Normal Flat Inverted Long and big nipples

10. Breastfeeding Minor Breast Problems Flat or inverted nipples • Antenatal treatment or immediately after delivery. • Keep mother and baby skin-to-skin contact after birth. • If the baby is unable to attach effectively • Express the colostrum and feed the baby by spoon , cup or finger feeding. • Expressing regularly 8-10 times in 24 hours may be necessary to establish lactation. • Demonstrate effective hand expressing. • Advise nipple massage & pulling several times before each breast feeding time. National and Unified Obstetric and Newborn care Guidelines and Protocols

11. Breastfeeding Minor Breast Problems Flat or inverted nipples NIPPLE SHIELD USE • A nipple shield may be effective in enabling breast attachment. • The Lactation Consultant or a midwife experienced in lactation issues should review feeding prior to using/introducing nipple shield. National and Unified Obstetric and Newborn care Guidelines and Protocols

12. طريقة المحقن الخطوة الأولى: اقطع هذا الجزء بشفرة على امتداد هذا الخط الخطوة الثانية: أدخل المكبس من الطرف المقطوع الخطوة الثالثة: اطلب من الأم أن تجذب المكبس برفق

13. Breastfeeding Minor Breast Problems Flat or inverted nipples For the first – two week : • Build mother's confidence-breasts will improve and become softer • Explain & assist the baby to suckle BREAST not nipple (correct Latch on) • If difficult Latch on, be patient, & try again. • Let baby explore breast, skin-to-skin contact • Help mother to position baby to breast feed within the first hour after birth. • Help her to make nipple stand out more before a feed National and Unified Obstetric and Newborn care Guidelines and Protocols

14. Breastfeeding Minor Breast Problems Topic 2 Breastfeeding Subtopic 32 Minor Breast Problems C ENGORGEMENT / FULL, LUMPY BREASTS Care Group Mothers complaining/having breast problems at any time during lactating period Standard Statement Same as above. The woman with any breast problem during lactating period should be investigated, diagnosed and managed properly National and Unified Obstetric and Newborn care Guidelines and Protocols

15. Breastfeeding Minor Breast Problems Breast Engorgement Do not REST the breast National and Unified Obstetric and Newborn care Guidelines and Protocols

16. Breastfeeding Minor Breast Problems AIM To prevent irreversible trauma to the breast tissue caused by unresolved engorgement Preventive Measures • Unrestricted breastfeeding or expressing from birth i.e. feeding 8-12 times in 24 hours. • Correct positioning, attachment and good sucking action is vital for good milk transfer. • A complimentary feeds should not be used. National and Unified Obstetric and Newborn care Guidelines and Protocols

17. 1 2

18. 1) الأنسجة الداعمة والدهنياتsupportingtissue & fat muscle cells خلايا عضلية2) تتقلص بفعل الأوكسيتوسين oxytocin makes them contract 3) خلايا إفراز اللبن milk secreting cells يجعلها البرولاكتين تفرز اللبنprolactin makes them secrete milk 4)القنواتducts 5) هالة الثدىareola 6) الجيوب اللبينةlactiferous sinuses هنا يتجمع اللبنmilk collects here 7) الحلمةnipple 8) غدد مونتجمرى Montgomery’s gland 9) الحويصلات alveoli تشريح الثدي

19. التعلق الجيد 2 1

20. التعلق السيئ 2 1

21. Breastfeeding Minor Breast Problems Breast Engorgement If baby able to suckle Feed frequently, help with positioning, use different positions. Start feeding from the engorged breast. If baby not able to suckle or suckling is not enough to empty the breast: Express milk by hand after each feeding. National and Unified Obstetric and Newborn care Guidelines and Protocols

22. Breastfeeding Minor Breast Problems Management 1. Check the above prevention measures and correct if necessary. 2. Gentle stroking of the breast promotes the let down reflex to encourage milk flow. 3. It is often necessary to hand express the breast to soften the areola to enable the baby to attach effectively. 4. Ensure the baby drains the first breast before offering the second side. If the first breast is still full, hard, red or has lumps (blocked ducts) after the baby has fed, it will need to be completely drained. 4. If the baby refuses the second side and it is hard, red or has lumps (blocked ducts) it will also need draining. Use gentle stroking and an electric breast pump.. Ensure the correct size shield is used. 5. Cool packs may encourage milk flow if there is vascular engorgement National and Unified Obstetric and Newborn care Guidelines and Protocols

23. Breastfeeding Minor Breast Problems Breast Engorgement Before feed to stimulate oxytocin reflex Warm compress on breasts or warm shower Massage to neck and back Light massage of breast Stimulate nipple skin Help mother to relax After feed to reduce oedema Cold / ice compress on breasts Encourage wearing a supportive bra to hold the breast in position. There is a new recommendation to apply cabbage leaves on the engorged breast that might relieve engorgement. National and Unified Obstetric and Newborn care Guidelines and Protocols

24. Breastfeeding Minor Breast Problems Breast engorgement If any of these : measures are ineffective after more than 24 hours Refer for experienced midwife / lactation consultant or Physician check up & management National and Unified Obstetric and Newborn care Guidelines and Protocols

25. Breastfeeding Minor Breast Problems Breast Engorgement Build the mother confidence National and Unified Obstetric and Newborn care Guidelines and Protocols

26. Breastfeeding Minor Breast Problems Topic 2 Breastfeeding Subtopic 32 Minor Breast Problems D Blocked duct and Mastitis Care Group Mothers complaining/having breast problems at any time during lactating period Standard Statement The woman with any breast problem during lactating period should be investigated, diagnosed and managed properly National and Unified Obstetric and Newborn care Guidelines and Protocols

27. Breastfeeding Minor Breast Problems Mastitis Blocked duct/non Infective Mastitis Infective Mastitis Breast abscess National and Unified Obstetric and Newborn care Guidelines and Protocols

28. Breastfeeding Minor Breast Problems Blocked duct • Prevention and self help measures • It is important to check that the baby is well positioned and attached at the breast correctly. • Do not stop feeding from the affected breast, as this is the best way to remove any blockage. • Feed from the affected side first, and try different positions. • Express any remaining milk after a feed to ensure the breasts are kept well drained. • Aim to empty the affected breast by giving frequent feeds. • Applying warm water before a feed and/or a cold compress after the feed to the affected area will also give the mother relief and may help to reduce the inflammation. National and Unified Obstetric and Newborn care Guidelines and Protocols

29. Breastfeeding Minor Breast Problems Mastitis • Encourage to continue breast feeding unless there is bloody discharge from the nipples • Measures that can be taken to avoid mastitis include:- • Ensure correct positioning and attachment and efficient drainage of breast. • Avoid long gaps between feeds. • Avoid any compression on the breast e.g. tight fitting bras/clothes or may be • pressure from fingers if supporting the breast National and Unified Obstetric and Newborn care Guidelines and Protocols

30. Breastfeeding Minor Breast Problems Blocked duct and Mastitis If any of these : measures are ineffective Refer for Physician check up & management National and Unified Obstetric and Newborn care Guidelines and Protocols

31. Breastfeeding Minor Breast Problems Blocked duct and Mastitis In case of infection, prescribe antibiotics & analgesics. In case of breast abscess, advise surgical treatment (drainage from a specialist). In case of fungal infection, prescribe anti-fungal treatment National and Unified Obstetric and Newborn care Guidelines and Protocols

32. Breastfeeding Minor Breast Problems Antibiotics Treatment for infective Mastitis The commonest bacterium found in breast is staphylococcus aureus. Therefore it is necessary to treat breast infections with a penicillinase-resistant antibiotic National and Unified Obstetric and Newborn care Guidelines and Protocols

33. Breastfeeding Minor Breast Problems Analgesics that can be taken are:- National and Unified Obstetric and Newborn care Guidelines and Protocols

34. Breastfeeding Minor Breast Problems Topic 8 Minor Breast Problems E Sore Nipples and Nipple Fissure Care Group Mothers complaining/having breast problems at any time during lactating period Standard Statement The woman with any breast problem during lactating period should be investigated, diagnosed and managed properly National and Unified Obstetric and Newborn care Guidelines and Protocols

35. Breastfeeding Minor Breast Problems Sore Nipples and Nipple Fissure • Observe & assess the position, latch on & removing the baby from breast. • Teach correct latch on. • Teach to break down suction before taking off the baby off the breast. • Reduce engorgement-suggest feed frequently, express milk. National and Unified Obstetric and Newborn care Guidelines and Protocols

36. Breastfeeding Minor Breast Problems Sore Nipples and Nipple Fissure • Encourage continuation of breast feeding. • Wash breasts only once a day & dry very well, and avoid using soap • Expose the breast to air after massaging a drop of breast milk on the nipple. • Avoid medicated lotions and ointments Rub hind-milk on areola after feeds National and Unified Obstetric and Newborn care Guidelines and Protocols

37. Breastfeeding Minor Breast Problems Sore Nipples and Nipple Fissure No improvement after 24 hours or more severe symptoms Refer for Physician check up & management National and Unified Obstetric and Newborn care Guidelines and Protocols

38. Breastfeeding Minor Breast Problems Sore Nipples and Nipple Fissure • Look for a cause: • Check attachment • Examine breasts- • engorgement, • fissures, • Candida • Check baby for Candida, and tongue-tie National and Unified Obstetric and Newborn care Guidelines and Protocols

39. Breastfeeding Minor Breast Problems Sore Nipples and Nipple Fissure • Give appropriate treatment: • Build mother's confidence • Improve attachment, and continue breast-feeding • Reduce engorgement-suggest feed frequently, express milk • Treat for Candida if skin red shiny, flaky; if there is itchiness, or deep pain, or if soreness persists. National and Unified Obstetric and Newborn care Guidelines and Protocols

40. Breastfeeding Minor Breast Problems • Treatment of Candida of the Breast • Gentian violet paint: • To baby's mouth: 0.25% apply daily or alternate days for 5 days or until 3 days after he lesions have healed. • To mother's nipples: 0.5% apply daily for 5 days • OR • Nystatin cream 100,000 IU/G: • Apply to nipples 4 times daily after breast-feeds • Continue ti apply fir 7 days after lesion s have healed • Nystatin suspension 100,000 IU/ml: • Apply 1 ml by dropper to child's mouth 4 times daily after breast-feeds for 7 days, or as long as mother is being treated. • Stop using pacifiers, teats, and nipple shields National and Unified Obstetric and Newborn care Guidelines and Protocols

41. Breastfeeding End of module 2 Breastfeeding National and Unified Obstetric and Newborn care Guidelines and Protocols