MOTHER BABY

FRIENDLY CARE
PRACTICES
practices that assist breastfeeding
Essential
Intrapartum Care
Maternal

Newborn
Objectives
Describe how the actions during labor and birth can
affect early breastfeeding.
Discuss the evidence for recommended practices
during labor and delivery
Explain how certain practices during labor and delivery
hinder breastfeeding

The special role of

maternity services
“The care that a mother experiences during Labor
and Birth can affect breastfeeding and how she cares
for her baby.”

Poor practices interfere with BF and contribute to the

spread of artificial feeding
Good practices support BF

The special role of maternity services

”Solid scientific evidence shows that returning to birthing
practices that preserve normalcy can accomplish many
things:
- faster, easier births
- healthier, more active and alert mothers and newborns
mother-baby pairs physiologically and optimally ready to
breastfeed.“

Mary Kroeger, Impact of Birthing Practices on Breastfeeding,

2004
The special role of maternity services
”Solid scientific evidence shows that returning to birthing
practices that preserve normalcy can accomplish many
things:
- faster, easier births
- healthier, more active and alert mothers and newborns
mother-baby pairs physiologically and optimally ready to
breastfeed.“

Mary Kroeger, Impact of Birthing Practices on Breastfeeding,

2004
ten steps to successful breastfeeding
Critical management procedures:

1a. Comply fully with the International Code of Marketing of

Breast-milk Substitutes and relevant World Health Assembly
resolutions.
1b. Have a written infant feeding policy that is routinely
communicated to staff and parents.
1c. Establish ongoing monitoring and data-management
systems.
2. Ensure that staff have sufficient knowledge, competence
and skills to support breastfeeding.
Ten steps to successful breastfeeding
Key clinical practices:

3. Discuss the importance and management of breastfeeding

with pregnant women and their families.
4. Facilitate immediate and uninterrupted skin-to-skin contact
and support mothers to initiate breastfeeding as soon as
possible after birth.
5. Support mothers to initiate and maintain breastfeeding and
manage common difficulties.
6. Do not provide breastfed newborns any food or fluids other
than breast milk, unless medically indicated.
Ten steps to successful breastfeeding
7. Enable mothers and their infants to remain together and to
practise rooming-in 24 hours a day.

8. Support mothers to recognize and respond to their infants’

cues for feeding.

9. Counsel mothers on the use and risks of feeding bottles, teats

and pacifiers.

10. Coordinate discharge so that parents and their infants have

timely access to ongoing support and care.
 4. Facilitate immediate and uninterrupted skin-to-
skin contact and support mothers to initiate
breastfeeding as soon as possible after birth.

•Place babies in skin-to-skin contact with their mothers

immediately following birth for at least an hour and
encourage mothers to recognize when their babies are
ready to breastfeed, offering help if needed.
INTRApartum care
 4. Facilitate immediate and uninterrupted skin-to-
skin contact and support mothers to initiate
breastfeeding as soon as possible after birth.

•Place babies in skin-to-skin contact with their mothers

immediately following birth for at least an hour and
encourage mothers to recognize when their babies are
ready to breastfeed, offering help if needed.
•The Intrapartum care recommendations are based on
the CPG on intrapartum care developed by the POGS in
2012 using the GRADE methodology, in consultation
with different stakeholders (the “Panel) (private and
govt midwives, nurses, generalists and specialists, and
hospital administrators.) Developed in collaboration
with the DOH and WHO Philippines, it is an update of
the DOH CPG on facility based delivery and the POGS
CPG on Normal delivery.
 1. Admit to Labor Room when the patietn is already in the
ACTIVE phase

ACTIVE PHASE labor

- there are 3-4
contractions in 10
minutes
Cervix is 4-5 cm dilated
2. Allow Companion Of Choice To Provide Continuous
Maternal Support

Maternal support can be provided by the health

worker, however this may not be continuous one on
one intrapartum support.

One-to-one intrapartum support

Health provider
Companion of choice - ante
Having a LABOR COMPANION can result in:

LESS USE OF PAIN RELIEF DRUGS → Increased alertness

of baby
• Baby less stressed , uses less energy
– Reduced risk of infant hypothermia
– Reduced risk of hypoglycemia
• Early and frequent breastfeeding
• Easier bonding with the baby
Provide Emotional Support

Good communication - use + words,

explain/update the progress of labor to
boost confidence
Respect for privacy
Non­supine position/Position of
choice/Mobility - encourage to move
No routine IVF - Allowing food & drink
during labor -
Adequate and timely pain relief
INFORMATION, Informed
consent & refusal and
RESPECT for her CHOICES and
PREFERENCES including
COMPANIONSHIP during
maternity care
PRIVACY and
CONFIDENTIALITY
3. Allow position of
choice during 1st stage
of labor, as upright as
possible. Allow mobility
during labor.

Most women admitted to

labor are placed in a the
supine position, which
according to studies is the
worst position to be in
during labor. Women should
be allowed to move freely
during labor.
In the absence of complications, women should be
encouraged to change to positions or move around
during labor.
4. Give Oral Fluids and Food during Labor

Withholding food and drink during labor is

an outdated practice that has been shown to
negatively affect birth outcomes. 
No evidence exists that putting the
parturient on NPO benefits the course of a
normal labor
Intrapartum mothers should be allowed to
determine for themselves what they wish to
eat or drink and when they choose to do so.

5. NO ROUTINE IVF

•A mother eating and drinking in labor will not require

intravenous
•No evidence exists that suggests the placement of an
IV in the low-risk intrapartum client prevents poor
outcomes
Elkins, Kerise, Neilson, Crowther, Duley, & Hotnett, 2000
•IV fluids need to be used only for a clear medical
indication
•Prophylactic placement of IVF is considered
unnecessary

IVF DURING LABOR

Advantage is to have ready access for

emergency meds
Disadvantages:
Interferes with the natural birthing process
restricts woman’s freedom to move
Not as effective as food and fluids in labor
to treat/prevent dehydration, ketosis or
electrolyte imbalance

6. RELIEVE Pain & Discomfort during Labor

OFFER NON-MEDICATION METHODS OF PAIN relief

before offering pain medications.
Labor companion
Verbal and physical reassurance
Laboring and birth positions of mother’s choice
Massage, warm water
Quiet environment/no bright lights

6. RELIEVE Pain & Discomfort during Labor

acupressure, use of birthing ball,
A supportive health worker massaging the back of
patient who preferred the “on all fours” position
Pain Medications:Risks
7. Monitor progress of labor using the
WHO PARTOGRAPH
7. Limit total number of IE to 5 or less.
9. Upright position during delivery
10. Encourage pushing only when the mother has the
urge to push
 11. SELECTIVE Episiotomy

Posterior perineal trauma by 12%

2nd-4th degree tears by 33%
Need for suturing by 29%
Anterior perineal trauma by 84%

No difference in infection rate w/ or w/o episiotomy

11. SELECTIVE Episiotomy

Episiotomies can have a negative impact on the

mother's comfort and therefore her ability to initiate
and continue breastfeeding.
It is associated with more pain, incontinence and
sexual problems than spontaneous tearing of the
perineum (Goer et al., 2007).
Episiotomies heal slower than spontaneous perineal
tears.
12. Perineal Support and Controlled Delivery of the Head

During delivery of the

head, encourage
woman to stop pushing
and breathe rapidly
with mouth open
12. Perineal Support and Controlled Delivery of the Head

Keep one hand on the

head as it advances
during contractions
while the other hand
supports the perineum.

13. Active Management of the Third Stage of Labor

(AMTSL

1. Administration of uterotonic oxytocin within

one min of delivery of the baby. (exclude a
second baby)
2. Controlled cord traction with counter
traction on the uterus (to avoid inversion of
uterus)
3. Uterine massage (to maintain contracted).

AMTSL and Breastfeeding

1. Bolus of oxytocic is necessary to achieve the

strong contraction that helps separate
placenta and establish good uterine tone
2. AMTSL helps achieve uterine tone
3. Ongoing breastfeeding helps maintain
uterine tone
4. Breastfeeding is an essential
maternal/newborn care practice, but not
sufficient for AMTSL
BIRTH PRACTICES that
SUPPORT BREASTFEEDING

1. Emotional support during labor

2. Attention to the effects of pain medication
on the baby
3. Offering light foods and fluids during labor
4. Avoidance of unnecessary cesarean sections
5. Early mother-baby contact

 BIRTH PRACTICES that HINDER

BREASTFEEDING
1. Supine position during labor
2. Lack of support
3. Withholding foods and fluids during early labor
4. Pain medications that sedate mother or baby,
episiotomy, IV lines, oxytocin augmentation,
continuous electronic fetal monitoring and
other interventions
5. Wrapping the baby tightly after birth
6. Separating the mother and baby after birth
4 Core Steps in IMMEDIATE
NEWBORN CARE
 Delivery Routines & Breastfeeding

Infant is most receptive to self-attachment

to the breast and breastfeeding after
delivery

One factor influencing whether a mother

breastfeeds during the immediate
postpartum period is standard hospital
practices that separate the mother and
infant
 Standard Hospital Birthing Practices
NOT conducive to maternal–infant bonding
and attachment or breastfeeding
These practices include:
Suctioning
Infant physical exam
Vitamin K injection
Application of eye ointment
Swaddling
Maternal–infant separation immediately
following birth and during the recovery period
 Essential Intrapartum Newborn Care
The Four Core Steps are included in the
package of interventions that comprise
Essential Intrapartum and Newborn Care (EINC)
To derive the maximum
benefit for newborns, the
immediate newborn care
interventions should be
delivered not just as a
package of interventions,
but sequenced
methodically. These time-
sensitive interventions
should not be preempted
nor undermined by other
interventions.
1st Core Step: Immediate and Thorough Drying

Immediate drying:
Stimulates breathing
Prevents hypothermia
1st Core Step: Immediate and Thorough Drying

Hypothermia can lead to

Infection
Coagulation defects
Acidosis
Delayed fetal to newborn
circulatory adjustment
Hyaline membrane
disease
Brain hemorrhage
1st Core Step: Immediate and Thorough Drying
If baby is not breathing, STIMULATE by DRYING!
Do not ventilate unless the baby is floppy/limp
and not breathing.
Routine suctioning not recommended unless the
mouth/nose are blocked

Vigorous suctioning can

create oral aversion (the
baby protects himself by
keeping his mouth
closed)
 2nd Core step: Skin-to-Skin Contact
General perception is that it is purely for mother-
baby bonding

Skin-to-skin contact between

mother and baby at birth reduces
crying,
improves mother-baby
interaction,
keeps the baby warmer,
and helps women breastfeed
successfully
 2nd Core step: Skin-to-Skin Contact

Other benefits:
B – breastfeeding success
L – lymphoid tissue system
stimulation
E – exposure to maternal skin
flora
S – sugar (protection from
hypoglycemia)
T - thermoregulation
 2nd Core step: Skin-to-Skin Contact

Baby’s frontal contact with mother’s body stimulates both

maternal and baby’s breast-seeking behaviors

Preterm infants exposed to their mother’s milk odor—a

natural byproduct of skin-to-skin care—suckle for longer
periods of time at each feeding, and consume more milk at
each feeding when they reach 35 weeks post-conceptional
age.
 2nd Core step: Skin-to-Skin Contact

Touch is the primary

sensory trigger for
breast-seeking
behavior (along with
sight, smell and
hearing) à Breast
crawl
 3rd Core Step: Properly Timed Cord Clamping

Reduction in anemia (fewer

babies need blood transfusion)
By 80% in term newborns
By 51% in preterm
newborns
Reduction in brain hemorrhage
by 41% in preterms
Better circulatory stability
reduced risk neonatal
enteroclitis
reduced late onset sepsis
 4th Core Step: Non-separation for the
Early Initiation of Breastfeed

An early first breastfeed seems to

help with increased milk supply in
the first days of life
There is earlier passage of
meconium
There is a greater likelihood of
continued breastfeeding
Delay in the first feed can lead to:
Issues of poor milk supply
Greater odds of discontinuing
breastfeeding
 4th Core Step: Non-separation for the
Early Initiation of Breastfeed

Leave the newborn between the

mother’s breasts in continuous
skin-to-skin contact
The baby may want to rest for
20-30 mins and even up to 120
minutes before showing signs of
readiness to feed
First breastfeeding episode
typically occurs around the 1st
hour of life
 4th Core Step: Non-separation for the
Early Initiation of Breastfeed

The timing of initiation of

breastfeeding is important as
there is a higher risk of death
among infants with longer delay
in the initiation of breastfeeding.
9 Instinctive Stages after Birth
Breastfeeding Cues/ Feeding Reflexes

Head lifting and bobbing

alertness, movements of arms
and legs (stepping, crawling)
Tossing, turning or wiggling
Mouthing, licking, tonguing
Rooting
Hand to mouth
Changes in facial expression
Squeaking noises or light fussing
Breastfeeding Cues/ Feeding Reflexes
6. Do not provide breastfed newborns any food
or fluids other than breast milk, unless
medically indicated.

SHOULD NOT:
touch the newborn unless there is a medical
indication
give sugar water, formula
give breastmilk substitutes
give bottles or pacifiers
throw away colostrum
 Newborn Procedures
done after uninterrrupted skin-to-skin contact
which last for at least one hour after birth or until
after the first breastfeed.
 Newborn Procedures

Eye care,
weighing,
examinations,
injections including the birth dose of the
Hepatitis B vaccine should be done only after
the first full breastfeed is completed.
 Not Waiting for the 1st Breastfeed
Overstimulating the baby (multiple assessment
examinations, suctioning, weighing and measuring,
glucose checks, eye treatment,injections) causes the baby
to “shut down”
Leads to a sleepy baby that is difficult, if not impossible,
to nurse.
Routinely separating babies from their mothers for
evaluation and bathing during the minutes and hours
after birth disrupts the baby's ability to find the breast
and self-attach
 Harm of Early Bathing

Removes vernix
Vernix is a protective barrier to E.coli and
Group B Strep
Hinders crawling reflex
Can lead to hypothermia, infection, coagulation
defects, acidosis,
delayed fetal to newborn circulatory
adjustment,
hyaline membrane disease, brain hemorrhage
 Summary
Appropriate hospital routines
greatly affect the
establishment of effective
breastfeeding
The Four Core Steps in
immediate newborn care lead
to early initiation of
breastfeeding
Health care worker’s
knowledge and appropriate
management of newborns in
special cases is essential