5                                                     Baby friendly                                                     ca...
BABY FRIENDLY CARE          67term parental caring of a child. Therefore,         resistance with parents, health workers ...
68    MOTHER AND BABY FRIENDLY CARECARE OF THE INFANT                                    3. The artery forceps need not be...
BABY FRIENDLY CARE      69single midwife, giving the infant to the mother      5-16 Should mothers give Kangarooallows her...
70   MOTHER AND BABY FRIENDLY CARE4. Make the nursery environment as relaxing           record and identification labels. ...
BABY FRIENDLY CARE   71that the infant is their own and does not             5-28 What is cluster care?simple ‘belong to t...
72    MOTHER AND BABY FRIENDLY CARE5-31 Can noise be a problem in the nursery?             This is often very reassuring f...
BABY FRIENDLY CARE       73with visiting family members. Only one or two        windows by using curtains or blinds or byp...
74   MOTHER AND BABY FRIENDLY CAREpamphlets (e.g. on low birth weight infants            5-44 What can be done to reduce p...
BABY FRIENDLY CARE      755-46 How can the parent’s anxiety and                 CARE OF INFANTS IN THEstress be lessened? ...
76    MOTHER AND BABY FRIENDLY CAREunfounded. The infant should be bathed in the          weeks when the infant is till be...
BABY FRIENDLY CARE       77BABY FRIENDLY HOSPITAL                              7. Allow mothers and their infants to remai...
78    MOTHER AND BABY FRIENDLY CARE                                                      NOTE  Research into the ‘biology ...
BABY FRIENDLY CARE     79after delivery. Placing the infant on the breast    CASE STUDY 2after birth is the best way of en...
80   MOTHER AND BABY FRIENDLY CARE4. How should a nursery be decorated?               1. Should a neonatal intensive care ...
BABY FRIENDLY CARE     81     measurements when there is not a good          needs of the hospital and staff. Baby friendl...
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Mother and Baby Friendly Care: Baby friendly care

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Newborn Care was written for healthcare workers providing special care for newborn infants in level 2 hospitals. It covers: An essential tool in the initial and ongoing training and teaching of any healthcare worker – Miriam Adhikari, South African Journal of Child Health, Primary Newborn Care was written specifically for nurses, midwives and doctors who provide primary care for newborn infants in level 1 clinics and hospitals. It covers: Mother and Baby Friendly Care describes gentler, kinder, evidence-based ways of caring for women during pregnancy, labour and delivery. It also presents improved methods of providing infant care with an emphasis on kangaroo mother care and exclusive breastfeeding. It covers: mother-friendly care in pregnancy, a modern approach to normal labour, skin-to-skin care of infants, encouraging breastfeeding, a baby-friendly nursery.

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Mother and Baby Friendly Care: Baby friendly care

  1. 1. 5 Baby friendly care Objectives Baby friendly care is good for the infant, parents and health workers. When you have completed this unit you 5-2 Why is baby friendly care important? should be able to: • Describe baby friendly care. Because it is believed to be the best method • List the advantages of baby friendly care. of caring for infants in both poor and industrialised countries. Many routines of • Give examples of baby friendly care. observation and management in infant care • Describe the Baby Friendly Hospital have been developed for sick or high risk Initiative. infants and are not necessarily needed for • Promote touch therapy. well infants. These routines may even be harmful or dangerous to healthy infants. Each infant should be given the best and most appropriate care.INTRODUCTION TO BABY Baby friendly care is also important becauseFRIENDLY CARE it promotes bonding between parents and their infant.5-1 What is baby friendly care? 5-3 What is mother-infant bonding?This is the care of newborn infants where the This is the special, strong, emotional bond orneeds of the infant and mother are placed attachment, which develops between a motherbefore those of the hospital or clinic staff. Baby and her newborn infant. A similar bond isfriendly care is also an attempt to look after the developed between the infant and father asinfant in a way that is as natural and humane well as other close family members. Bondingas possible. As with mother friendly care, baby also occurs between an infant and the clinicfriendly care is good, evidence based care. The or hospital staff, especially when a small infantinfant, parents and health workers all benefit spends many weeks or months in the nursery.from baby friendly care. Bonding is essential to ensure the good long
  2. 2. BABY FRIENDLY CARE 67term parental caring of a child. Therefore, resistance with parents, health workers andevery effort must be made to encourage and administrators. Many people do not likesupport this bonding process. change, even if the change is to everyone’s benefit. Therefore, the main problem with the introduction of baby friendly care is to Baby friendly care must be promoted at every convince and support those who need to opportunity. change. This is not always easy. Introducing baby friendly care requires vision, time, dedication and a lot of effort.5-4 Is baby friendly care new?Although the principles of baby friendly care Introducing baby friendly care is often difficulthave been known and practiced in someplaces for many years, it is only been recently as health care workers have to change theirthat the importance of baby friendly care attitudes, beliefs and practices.has been appreciated and actively promoted.Unfortunately, many hospitals and clinics stilldo not provide baby friendly care. 5-8 Should baby friendly care only apply to well infants?5-5 Is baby friendly care expensive? No. Baby friendly care should be given to all infants as the principles of baby friendly careAlmost all aspects of baby friendly care can can be used for both well and sick or highbe introduced at no or very little extra cost. risk infants.Expensive equipment is not needed to providebaby friendly care. Because infants thrivewith baby friendly care, hospital expenses and 5-9 When should baby friendly care beservice costs are often reduced. Baby friendly used?care is cost effective because it is both good Baby friendly care should be used, at alland cheap. All levels of care, from primary to times. Baby friendly care has changed the waytertiary, can be made baby friendly that infants are cared for immediately after delivery, in the nursery and postnatal ward,5-6 Why has baby friendly care not always and after discharge home. All levels of carebeen used? should be made baby friendly.Because of ignorance, selfishness or an inabilityto change. In the past it was not understood 5-10 What are examples of baby friendlywhat was the best method of caring for care?newborn infants. Often staff and parents Whenever possible, the following examples ofchose methods that were easiest for them. baby friendly care should be practiced:Even if better methods of caring for infants 1. Keeping the mother and infant togetherwere known, it is difficult to change old habits after delivery.and routines. Research studies have helped to 2. Immediate and exclusive breastfeeding.identify which methods of care result in the 3. Discharging the mother and infant homebest outcome for infants and their families. as soon as possible. 4. Using kangaroo mother care for low birth5-7 What are the problems with baby weight infants.friendly care? 5. Allowing open visiting by parents in theSome old routines and practices have to nursery.change if we are to give better care. Anychange causes uncertainty, insecurity and
  3. 3. 68 MOTHER AND BABY FRIENDLY CARECARE OF THE INFANT 3. The artery forceps need not be immediately replaced by a cord clamp.IMMEDIATELY AFTER 4. Bathing the infant is not needed straightDELIVERY after delivery. Allow the mother to hold and breastfeed her5-11 Why should infants be given to their infant before the routine procedures are done.mothers straight after delivery?Because it is kind, sensible, practical and the If the infant has problems and must to bebest way of promoting bonding between a taken directly to the nursery, the mothermother and her newborn infant. In the past it should visit her infant as soon as possible afterwas incorrectly believed that the mother was delivery. Take a Polaroid photograph of thetoo tired to hold her infant immediately after infant for the mother.delivery. The staff also believed it was easier forthem and the parents if the infant was moved 5-13 Should the mother and infant beaway to the nursery for a few hours until separated when the mother is moved fromthe delivery was completed and the mother the labour ward?had a chance to sleep. Mothers usually werenot asked what they wanted. It seemed more No. Not only should the infant be givenconvenient for the staff if the infant was not to the mother immediately after birth, butkept in the labour ward or theatre. they should also be kept together if possible when the mother is moved out of the labourAfter all the excitement, pain and effort of ward. If the mother and her infant have to belabour and delivery, the mother has every separated, because either needs medical care,right to hold her infant. As soon as the infant they must be brought together again as soon asis delivered, dried well, briefly assessed, and possible. Ideally the parents should be allowedthe cord cut, the infant should be given to the some private time to spend together with theirmother unless there is a medical indication infant once the delivery has been completed.not to do so. Most mothers want to hold their This is a very special time for them.infants after delivery. Whenever possible, the mother and infant should Most mothers want to hold their infant as soon as be kept together after delivery. possible after delivery. 5-14 Why is it important to breastfeed as5-12 Should the infant stay with the soon as possible after birth?mother after delivery? Because it is a very effective method ofYes. There is no need for most infants to promoting successful breastfeeding. Itbe moved away for routine observations, also encourages bonding and helps tomeasurements or procedures: stimulate uterine contractions and delivery1. An Apgar score at five minutes is not of the placenta. If a woman chooses not to indicated in normal infants who have a breastfeed, she should still hold her infant normal score at one minute. after delivery. Many women want to put their2. Routine identification, weighing, eye infant to the breast immediately after birth. care and vitamin K can be given once the It is not important that most women have mother has had a chance to see and hold very little milk on the first day after delivery. her infant. When a delivery is being attended only by a
  4. 4. BABY FRIENDLY CARE 69single midwife, giving the infant to the mother 5-16 Should mothers give Kangarooallows her to concentrate on the safe delivery Mother Care to their infants after delivery?of the placenta. Yes. Once the infant has been well dried, it should be placed skin-to-skin between the Mothers should be allowed to hold and put their mother’s breasts. She can now keep her infant infant to the breast immediately after birth. warm and they can get to know each other. Infants receiving KMC are less stressed thanThe choice of breast or formula feeding must be infants placed alone in cribs.carefully considered before delivery in womenwho are known to be HIV positive. If the 5-17 When should the mother and infantmother decides to exclusively formula feed, she be discharged home?should be given her infant to hold but not to If both are healthy and normal, they canput to the breast. Baby friendly care can still be usually be discharged home after six hours.practiced if a mother decides to formula feed. Most of the serious complications after delivery (e.g. post partum haemorrhage in the5-15 What are the benefits of exclusive mother or respiratory distress in the infant)breastfeeding? will have presented before this time.1. For the first six months of life, breast milk meets all the nutrition needs of most 5-18 What are the advantages of early infants. discharge?2. Exclusive breastfeeding is the most 1. Usually the mother wants to be at home effective method of preventing infections with her family and away from the clinic or in the infant, especially serious hospital. gastroenteritis. 2. It allows the mother to relax, sleep and3. It reduces the risk of allergy in infants born establish breastfeeding at home. into a family with a history of allergies. 3. At home she is familiar with the routines4. It is cheap and does not require bottles or and has her family to help and support her. cups. 4. The mother and infant are less likely to5. It reduces the chance of the mother falling develop infections at home. pregnant again soon. 5. It saves staff and expenses and helps to6. It helps the mother lose the normal weight avoid overcrowding in hospital. gained during pregnancy. Most of the fat built up during pregnancy is to support months of breastfeeding after delivery.7. Exclusive breastfeeding reduces the risk CARE OF THE INFANT IN of mother-to-child transmission of HIV THE NURSERY (compared to mixed breastfeeding) if the HIV infected mother chooses to breastfeed her infant. 5-19 How can care in the nursery be made baby friendly?Mothers should be encouraged to exclusivelybreastfeed for the first six months and then Many changes can be made in a newborncontinue to breastfeed for as long as possible nursery to provide better care for infants:after other feeds are introduced. 1. Recognising infants as individuals. 2. Encouraging mothers and family to spend There are many benefits of exclusive time with their infant. breastfeeding for both mother and infant. 3. Improve communication between parents and staff.
  5. 5. 70 MOTHER AND BABY FRIENDLY CARE4. Make the nursery environment as relaxing record and identification labels. Staff should be as possible. encouraged to refer to infants by their names.5. Promote nesting, cluster investigations and handling, and quiet times. 5-23 How can name labels easily indicate whether the infant is a boy or a girl?5-20 Why should infants be recognised as This is simply done by colour coding withindividuals? blue labels for boys and pink labels for girls.As with adults and older children, it is Either a coloured card can be used or a whiteimportant that each infant be recognised as card with a coloured stripe added with aan individual with his or her own personality crayon or highlighter. Identifying the genderand needs. This improves both staff and parent (sex) of the infant helps to give him or herbonding with the infant which improves care. some individuality. It is also very usefulWhenever possible, care should be tailored to when staff speak to parents. At a glance onemeet the individual needs of infants. knows the gender of the infant if the coloured label is clearly displayed. It improves staff communication with parents to know the Every effort must be made to make infants gender of their infant. recognisable as individuals.Many simple steps can be taken to make Each infant in the nursery should have a clearlyinfants recognised as individuals. One of the visible label giving the infant’s name and gender.most important ways is to give infants names. 5-24 How should infants be dressed?5-21 When should infants be given names? Infants usually wear nappies (diapers), to makeAs soon as possible. Parents often decide on nursing easier, and are partially dressed to avoida name or short list of possible names during heat loss. Woollen caps and cotton jackets arethe pregnancy. Most infants can be given a first worn. However, other clothes can be worn toname within the first week, even if it is only a individualise infants and promote bonding.‘nick name’. Often an infant is only recognised Mothers should be encouraged to bring theiras an individual when a name is chosen. own clothes for the infant. Booties, leggingsHowever, some parents need to consult distant and ‘baby-grows’ are popular. Different andfamily before a name can be given. Failure to attractive colours also help to make infants lookname an infant may be a sign of poor bonding. different from one another. Some parents bring NOTE In many cultures an infant has no rights and a small cover or even a duvet. is not accepted as a member of the community Do not bath all infants in the same place as until it is formally named. this increase the risk of spreading infection. Infants are usually bathed in their plastic5-22 How should the infant’s name be bassinettes. Dry infants immediately after adisplayed? bath to prevent hypothermia.Usually the mother’s first name and surnameare given on the infant’s records and on a 5-25 Should messages and toys be allowedcard attached to the overhead radiant heater, in a nursery?incubator or cot. The name is also on the Parents should be encouraged to bring writtenidentification tag on the infant’s wrist and or drawn messages and cards for their infants.ankle. As soon as an infant is given a first They can be placed inside or outside a closedname, this should be added to the infant incubator. Some parents bring toys, especially a doll or teddy bear. This makes parents feel
  6. 6. BABY FRIENDLY CARE 71that the infant is their own and does not 5-28 What is cluster care?simple ‘belong to the hospital’. It is safe to have Whenever possible, investigations andtoys in an incubator. However, toys must not handling of infants should be clusteredbe moved from one infant to another as this together so that they can be done at thecan spread infections. same time. This is preferable to repeatedly disturbing the infant. For example, the5-26 How can infants be handled more routine observations, nappy change and bloodgently? sampling for glucose measurement can all beInfants are often alarmed when handled, done together rather than each at a differentespecially if they are handled roughly and with time. As a result the infant is disturbed oncecold hands. They get a fright, cry and become and not many times. This requires planningjittery. Often they display the startle reflect and organisation. Cluster care is not alwayswith outstretched arms and open hands. easy with a shortage of staff but every effortRough handling may even precipitate apnoea, should be made.vomiting or cyanosis. 5-29 What is the importance of quiet times?Infants must always be handled gently, slowlyand with warm hands. Do not suddenly It is important that both well and sick infantsturn the infant over. Infants must always be be allowed quiet times when they can resthandled with respect. Simply because an and sleep. This is important for growth andinfant cannot always express pain, fear and recovery. Being continually stimulated andanxiety, does not give careers the right to disturbed is very stressful. During sleep theignore an infant’s feelings. oxygen and energy needs of infants fall.5-27 How can stressful procedures be best Infants should be allowed time to sleep.managed?Some stress is unavoidable such as needlesticks. Gentle handling helps. The procedure 5-30 Should the nursery always beshould be done quickly and expertly. Holding, brightly lit?touching and talking soothingly after the Remember that infants can see well. Sometimesprocedure reduces the duration of crying. a good, bright light is needed to examinePutting the infant to the breast is very helpful an infant or perform a difficult procedure.in reducing the stress. A small feed of milk or However, at most times the lighting in theglucose water also helps. Only do procedures nursery does not have to be bright. Curtainsthat are necessary and not simply because they or blinds can also be used to prevent directhave been done routinely for years, e.g. blood sunlight reaching infants. With the wider useglucose or serum bilirubin measurements on of electronic monitoring, bright lighting inall newborn infants. the nursery at all times is not necessary. ManyOften parents are asked to leave the room nurseries now reduce the lighting at night.when stressful procedures are performed. Under phototherapy, the infant’s eyes shouldHowever, some parents prefer to remain with be covered. This is done for comfort. Theirtheir infant so that they know what is being eyes can be uncovered during feeding times. Adone. They will also be there to comfort the screen may be needed to shield other infantsinfant during and after the procedure. Parents from being disturbed by phototherapy lights.should be given the option.
  7. 7. 72 MOTHER AND BABY FRIENDLY CARE5-31 Can noise be a problem in the nursery? This is often very reassuring for the parents. A mother will often sit for a long time, beside theThe nursery must not be a noisy place as infants incubator, touching and talking to her infant.have good hearing and are easily disturbed. Like Unmarried fathers should also be allowedbright lights, noise is stressful to infants, parents to visit their infants if the mother agrees.and staff. Frequently sounding, loud alarms are Everyone, including patents, must always washparticularly stressful. Incubator motors can also their hand with soap, or spray them with abe very loud, especially if they are not routinely disinfectant (e.g. chlorhexidine in alcohol),serviced. Telephones can also be too loud. Staff before touching an infant.should not speak loudly, shout or laugh loudlyin the nursery. It is not appropriate to have atelevision set in a nursery as it distracts the staff It is important that parents touch their infant.and parents.5-32 Should both the mother and her 5-34 Should siblings be allowed into thepartner be allowed to visit an infant in the nursery?nursery? Yes. It is important for the siblings to also visitIt is essential that both parents visit their and touch their newly born brother or sister.infant in the nursery as soon as possible after The siblings are always interested in the newbirth. Not only is this very important for addition to the family and need to bond withbonding but it is the parents right to see their the infant. Visiting children in the nurseryinfant. Strict visiting hours should not be kept must always be accompanied by a parent, theyin the nursery. Parents are encouraged to visit must be closely supervised and well behavedtheir infant whenever possible and to spend as and must always wash their hands beforemuch time as they can with their infant. Often touching the infant. Siblings who are sick (e.g.working fathers can only visit in the evening. a common cold) must not be allowed into the nursery. The risk of siblings infecting anIn some nurseries, parents are asked to infant is no greater than that of the parents orwait outside during ward rounds. This may staff. Anyone who has an infectious illness,be needed to keep the diagnosis of infants especially a viral illness, should not be inconfidential. They may also be asked to leave contact with small infants.if an infant needs resuscitation or if an infanthas died. Siblings should be allowed to visit an infant in the nursery. Parents should be encouraged to spend as much time as possible with their infant in the nursery. 5-35 Should other family members be allowed to visit the infant?5-33 Should parents be allowed to touchtheir infants? Usually grand parents are also allowed to visit an infant in the nursery. This is very importantYes. Parents must be encouraged to touch if the mother does not have a partner or if thetheir infant, as this is a very important part grandparents are going to help look after theof bonding. Many parents are afraid of infant. Bonding between grandparents and thetouching and possibly hurting a very small or infant is especially important when the mothersick infant. However, even very ill infants in is very young and still living at home. Unlessintensive care can be gently touched. under exceptional circumstances, other familyUsually parents touch the infant’s hands and members and friends are not usually allowedfeet first before they touch the head and trunk. into the nursery. The nursery cannot be filled
  8. 8. BABY FRIENDLY CARE 73with visiting family members. Only one or two windows by using curtains or blinds or bypeople are allowed to visit an infant at one time. double-glazing the windows. Avoid direct sunlight in the nursery. Curtains may become5-36 How should the nursery be decorated? dusty but do not collect bacteria. They should be washed regularly.The appearance of the nursery affects themood and behavior of all that work or visit 5-40 What is nesting?there. The nursery and intensive care unitshould not look like a stark hospital ward with The unborn infant is ‘nested’ safely in a warm,white walls and no decorations. A light colour, dark and quiet intra-uterine environmentsuch as blue or pink, makes the nursery appear where the infant is enclosed in a small space.gentler and less threatening. It also makes The infant can touch the uterine walls.the work environment less stressful to the Newborn infants also need to feel securestaff. Curtains should have restful colors and in a closed space. The ideal closed space ispatterns. Pictures or posters can be hung on provided by kangaroo mother care. A similarthe walls. Breastfeeding mothers and young environment can be created in a closedanimals are favourite topics. incubator or overhead radiant heater by ‘nesting’. A towel or small cotton blanket is5-37 What clothes should staff wear in the rolled up and placed on the mattress aroundnursery? the infant to form a circle or horse-shoe. Infants are often nested on their side which helps toNot only does light, attractive, comfortable keep their back flexed. It is important that theclothing make the working conditions more infant’s head does not lie on the towel as thisenjoyable for the staff but improves the will flex the neck, which can obstruct breathing.environment for everyone. Formal uniforms Infants are usually nursed on their back or sideare often threatening to parents. All staff must as this reduces the risk of ‘cot death’. However,wear name tags so that they can be identified infants with respiratory distress or reflux areby parents. Doctors need not wear white coats. often nursed on their abdomen.Long sleeves should always be rolled up toavoid spreading infection. Clothing should be 5-41 How can communication with parentspractical and clean but not provocative. Usually be improved?wedding or engagement rings can be worn. Every effort must be made to improve5-38 Should music be allowed in the communication between health workersnursery? and parents. Parents should feel able to ask questions and be given clear, honest and easy-Soft, gentle background music is soothing to to-understand answers. Although both doctorsstaff and parents and makes the atmosphere in and nurses must speak to parents, the nursesthe nursery more relaxed and less stressful. If are often better at communicating. Nursesa radio is to be used, loud music or the spoken spend more time with the infants and get tovoice should be avoided. Recorded classical know them well. Good communication is babymusic is best. The volume of the music should friendly as it promotes parent-infants bonding.be turned down during quiet times. 5-42 How can parents be given information5-39 Are windows recommended in a about their infants?nursery? Information is best given directly to parentsA view to the outside world reduces working by the staff. A simple, honest explanationstress. Efforts must be made, however, to of the problems, risks and management ofreduce excessive heat loss or gain through the infant is needed. However information
  9. 9. 74 MOTHER AND BABY FRIENDLY CAREpamphlets (e.g. on low birth weight infants 5-44 What can be done to reduce pain inor infants being ventilated) are very useful as newborn infants?parents can read them again and again. Often 1. Avoid unnecessary investigations.what is told to parents is not remembered 2. Be aware of painful complications such asbecause of the stressful situation. Booklets, fractures.videos, CDs, notices and photographs (even 3. Handle infants gently, especially if they arethe internet) can help provide specific in pain.information. The names and uses of different 4. Allow the infant to suckle at the breastpieces of equipment used in the nursery can be during painful procedures such as a heelexplained by means of pictures. prick. 5. Use local anaesthetic (e.g. lignocaine) when indicated, e.g. if a chest drain isCARE OF INFANTS IN AN inserted.INTENSIVE CARE UNIT 6. A general analgesic, e.g. morphine, should be used in infants with severe pain, e.g. postoperatively. Paracetamol can be used5-43 Do newborn infants feel pain? for lesser pain. 7. Gentle touch can be used to reduce pain.In the past it was often incorrectly believedthat newborn infants do not feel pain. Infantsshow all the stress responses seen by children Pain and discomfort in newborn infants shouldand adults who are in pain. They cry, frown, be actively managed.actively move their arms and legs, increasetheir heart rate, blood pressure and bloodglucose concentration, and have raised levels 5-45 What causes stress to newborn infants?of stress hormones in their blood (adrenaline Factors other than pain can cause stress inand noradrenaline). newborn infants:Every effort must be made to reduce the 1. Separation from the mother. Every effortpain experienced by infants during medical must be made to keep mothers and theirprocedures such as taking a sample of blood infants together.or starting an intravenous infusion. Effective 2. Excessive handling and stimulation. Dolocal or generalised analgesia must always be not handle small, ill infants unless it isused for major procedures such as inserting necessary. It is best to cluster handling, e.g.a chest drain. Special scoring systems (pain change nappy and take heel prick bloodassessment scores) are available to measure an sample for glucose measurement at theinfant’s stress response to pain and discomfort. same time rather than at different times.The score helps to monitor pain and guide 3. Lack of sleep. It is important that infantspain management. In order to reduce stress, are allowed time to sleep.infants being ventilated are often sedated, e.g. 4. Excessive light and noise. Intensive carewith morphine or midazolam (Dormicum). units are usually noisy and brightly lit. NOTE After repeated painful procedures an infant Reduce the noise of loud voices and alarms learns what to expect and starts crying before the and ringing telephones when possible. Soft procedure is started. This is commonly seen when background music is preferable. Reduce repeated arterial punctures are necessary. The lighting when infants are asleep. possible long term emotion effects are not known.
  10. 10. BABY FRIENDLY CARE 755-46 How can the parent’s anxiety and CARE OF INFANTS IN THEstress be lessened? POSTNATAL WARDPart of good infant care includes thinkingabout the needs of the parents. It is verystressful to have your infant in an intensive 5-48 How can the postnatal ward be madecare unit. Open and honest communication more ‘baby friendly’?is the best way to reduce parental stress.Bereavement counselling is particularly Almost all the changes that can be made in theimportant when infants are dying or have nursery can also be made in the postnatal ward:died, or are born with severe congenital 1. Each mother and her infant should be keptabnormalities. A follow-up phone call to together.bereaved parents is greatly appreciated by 2. The ward should be comfortably warm.the family. Photographs of the infant, a lock 3. It should be painted in pleasing colours.of hair, foot print or name tag are helpful for 4. The lighting must not be too bright. Avoidbereaved parents as keep-sakes. direct sunlight.The concept of mother friendly care is also 5. Loud noises must be avoided.important as kinder, gentler, more considerate 6. It should have a homely feel rather than acare of parents visiting a neonatal ICU must hospital appearance.be promoted. A special, private room for 7. Comfortable chairs for feeding arecounselling parents is very useful. This space important.can also be used by parents who want to spend 8. Some privacy is essential.private time with their dying or dead infant. 9. Staff must be gentle, supportive, kind and friendly. 10. Visitors should be allowed in a controlled5-47 Can the developmental outcome fashion.of infants receiving intensive care be 11. Mothers in the postnatal ward, who stillimproved? have small or sick infants in the nursery,There is good evidence that gentler, more should be given every assistance to visit‘humane’, baby friendly care can improve the their infants whenever they want to. If theymental development and behaviour of small are too ill to visit their infant, or have theirinfants who are managed in an intensive care infant with them, they should be given aunit. Modern, scientific care of newborn Polaroid photograph of the infant. Thisinfants (which improves survival) should, helps bonding.therefore, be modified to ensure the bestoutcome of survivors. 5-49 What care should be given to infants NOTE NIDCAP (Newborn Individualised in a postnatal ward? Developmental Care and Assessment Program) Most infants in a postnatal ward are normal, is a method of caring for very small infants health and born at term. Therefore, care where the optimum environment is provided for normal brain development. It is based on the should be aimed at promoting bonding, theory that sensory input influences the function encouraging and supporting exclusive and structure of the developing brain. Research breastfeeding, and the routine management shows a better developmental outcome after such as cord care and recording weight gain. using NIDCAP in neonatal ICUs. The infant may be nursed in bed with the mother, carried around in the KMC position or allowed to sleep beside her bed in a crib (bassinet). Sharing a bed is not dangerous and does not increase the risk of cot death. The fear of the mother rolling onto the infant is
  11. 11. 76 MOTHER AND BABY FRIENDLY CAREunfounded. The infant should be bathed in the weeks when the infant is till being breastfedplastic crib and not at a common site where frequently. Help with routine household tasks,cross infection may occur. This is a good such as cleaning and cooking, are neededopportunity to help the mother learn about most. The father should support the mothercaring for her newborn infant. Mothers often when she arrives home with her infant.help, and learn from, each other. Grandmothers are particularly important with young, inexperienced mothers.If the infant requires phototherapy, this canusually be given in the postnatal ward. As soonas possible, the mother and her infant should 5-52 Should neighbours and distant familybe discharged home together. visit the infant? Once the mother and infant are at home, visits5-50 Should the infant be kept with the by neighbours, friends and family are common.mother all the time? However, anyone who has an infectious illness, especially an upper respiratory tract infection,If possible the mother and her infant should be should be kept away from the infant. Youngkept together. Infants should not be routinely parents often need a lot of help and supportmoved to the nursery at night so that they do from family and friends. Isolation and a lacknot disturb the mothers’ sleep. Mothers should of support is a main factor in the neglect andbe encouraged to demand feed both day and battering of infants.night. If an individual infant cries a lot or if themother is not well, the infant may be movedout of the ward for a few hours. However, the 5-53 Is it safe to kiss infants?infant must be brought back for feeds. It is normal for a mother to want to hugWhat is no longer acceptable is for the mother and kiss her infant. However, some seriousto watch television, entertain her friends and infections, such as herpes, can be spread torest most of the day while her infant is taken to infants by kissing. Anyone with fever blistersthe nursery to be bottle fed. (recurrent herpes infection) must never kiss an infant, as herpes infection in a young infant can be fatal. It is best if other family and friendsCARE OF THE INFANT AT do not kiss the infant, especially on the mouth.HOME 5-54 Should all infants be taken to the well baby clinic?5-51 How can the home be made more Regular visits to the local well baby clinic are‘baby friendly’? an important part of good primary health care. Weight gain and feeding should beAs with the nursery and postnatal ward, many monitored, routine immunisations given,small but important changes can be made at minor problems managed and educationhome to improve the care and well being of and support given to the mother. When thethe newborn infant. The question of the infant weather is cold, KMC can be used to keep thesleeping in the same bed as the parents remains infant warm on the way to and from the clinic.controversial. However, there are many benefits Every effort should be made to ensure that theto this practice for the first few months after well baby clinic is baby friendly.delivery, especially with poor, cold housing.Looking after a newborn infant at home is verydemanding and mothers often feel exhausted.Every assistance should, therefore, be givento the mother, especially during the first few
  12. 12. BABY FRIENDLY CARE 77BABY FRIENDLY HOSPITAL 7. Allow mothers and their infants to remain together all the time from delivery toINITIATIVE discharge. 8. Encourage breastfeeding on demand. 9. Discourage the use of dummies, teats and5-55 What is the Baby Friendly Hospital nipple shields.Initiative? 10. Promote the formation of breastfeedingThe Baby Friendly Hospital Initiative (BFHI) support groups and refer mothers to theseis an international programme of the World groups on discharge from hospital or clinic.Health Organisation (WHO) and the United The Baby Friendly Initiative also includes HIVNations Children’s Fund (UNICEF) that was infected mothers who choose to formula feedintroduced in 1991. The BFHI is based on their infants as this is a medical indication.the Ten Steps to Successful Breastfeedingand aims to promote, introduce, protect andsupport breastfeeding. The BFHI recogniseshospitals which have taken steps to create the TOUCH THERAPYbest possible conditions for breastfeeding.These hospitals, after a detailed inspection, are 5-57 What is touch therapy?awarded Baby Friendly status if they meet allthe criteria. More and more state and private Touch is one of the five important senses.hospitals and delivery centres in South Africa By touching we communicate with others.are being given this award. All hospitals with Touching is one of the most important waysmaternity facilities should be encouraged to a mother and infant bond with each other.achieve Baby Friendly status. Touch therapy teaches mothers to use touch as a way of getting to know their infant better. Physical contact is one of the basic needs of The Baby Friendly Hospital Initiative aims infants (and adults) and is essential for normal to promote, introduce, protect and support emotional and interpersonal development. breastfeeding. Infants like being touched. Many young, inexperienced mothers are reluctant to have a lot of physical contact with their infant,5-56 What are the ten steps to successful especially if they were not touched a lot bybreastfeeding? their own parents. They may also not have a1. Have a written breastfeeding policy that is close physical relationship with their partner. frequently communicated to all the health Touching one another is often not encouraged care staff. in some cultures.2. Train all the health care staff in the NOTE Clarissa Estes in her book Women who run skills needed to implement successful with wolves states that ‘hands laid upon another breastfeeding. can sooth, comfort, remove pain and heal’.3. Inform all pregnant women about the benefits and management of breastfeeding. 5-58 What are the advantages of touch4. Help mothers to start breastfeeding within therapy for infants? an hour of delivery. 1. Touch therapy (or massage therapy) helps5. Show mothers how to breastfeed and teach many mothers bond more closely with them how to maintain lactation even if their infant. they are separated from their infants. 2. Touch therapy has been shown in a6. Do not give newborn infants formula, number of studies to decrease crying and water or other food unless this is indicated increase the weight gain of preterm infants. for medical reasons.
  13. 13. 78 MOTHER AND BABY FRIENDLY CARE NOTE Research into the ‘biology of touch’ shows Touch therapy is very useful in helping some that massage therapy reduces the level of stress mothers bond with their infant. hormones (cortisol, adrenaline and noradrenaline) and promotes vagal stimulation. This helps digestion and absorption, immune responses5-59 How is touch therapy given? and sleep patterns. Touching or rubbing an area of skin helps to reduce pain originating fromMost mothers will naturally touch, stroke the same dermatome (the gate theory of pain).and gently rub their infants without formal Mothers intuitively ‘rub the pain better’.guidance or instructions. However, somemothers need encouragement, support andhelp to develop meaningful physical contact CASE STUDY 1with their infant. Mothers often use oil ortalcum powder for massaging. At the same A young woman delivers her first born infanttime they usually also talk, sing or make ‘baby at a rural hospital. The infant appears wellsounds’. Eye contact is important. Slow, gentle and healthy when assessed immediately afterstroking is a way of expressing love and care. birth. She is not given her infant to hold asTouch or massage therapy is a method of the labour ward is cold. It is routine practicesystematically stroking an infant, usually to move all infants to the nursery straightstarting with the face and then moving to the after delivery so that their mothers can rest.chest, arms, stomach, legs and back. Mothers The staff find it easier if infants are weighed,are best taught how to give massage therapy given vitamin K and prophylactic eye care inby a touch therapist. Massage should be firm, the nursery. Only after 6 hours is the infantslow and rhythmical. Fathers can also benefit brought to the postnatal ward so that thefrom learning how to give touch therapy. Many mother can breastfeed.cultural practices include some form of infantmassage. It is best to use a commercial ‘baby 1. What is the problem with theoil’ or simple carrier oils only as additives can management of this infant?be absorbed through the infant’s thin skin. The mother and her infant should not be separated after delivery. No medical reason has5-60 How does touch therapy work? been given to move the infant to the nursery.Touching and stroking induces relaxation,reduces stress behaviour and promotes a 2. How should this infant have been keptfeeling of well-being. Numerous studies on warm?both humans and animals have demonstratedthe many benefits of touch. It is a powerful The labour ward should not be cold. Thisway of improving mother-infant bonding. infant should have been given to the mother soMassage may reduce the pain of infant colic. that she could keep the infant warm by giving kangaroo mother care. Both the mother andTouch therapy is being used more and more infant could be covered with a blanket to keepin children and adults with severe or chronic them warm if the room was cold.illnesses, such as AIDS. Simply being touchedmakes people feel better. 3. Why should mothers not be allowed timeTouch therapy is being used in some neonatal alone after delivery, without their infant, sointensive care units as part of the management that they can rest?of small or sick infants, especially infants The time immediately after delivery is veryin pain or receiving painful or stressful important to start both the bonding processprocedures. Touch plays an important part in and to begin breastfeeding. Most mothersthe skin-to-skin care of KMC. want to hold their infant as soon as possible
  14. 14. BABY FRIENDLY CARE 79after delivery. Placing the infant on the breast CASE STUDY 2after birth is the best way of ensuring that themother establishes successful breastfeeding. When a new nursery was opening in a regionalSeparating mother and infant is stressful to hospital, it was decided to write protocolsthem both. for routine care in order to establish high standards of management. The mother’s name4. Is it not important that the infant was clearly displayed on each crib or incubatoris weighed and given vitamin K and to help identify infants. Both parents wereprophylactic eye care as soon as possible allowed to visit during strictly controlledafter birth? visiting hours but only the mother was allowedThese routine procedures can be postponed to touch her infant. Siblings had to remainuntil the mother has had a chance to hold in the waiting room outside the nursery.her infant and place the infant on the breast. The walls were painted white and curtains,Early breastfeeding may even speed up the pictures and posters were not allowed. Radiosthird stage of labour. The routine procedures and television sets were strictly prohibited.can best be done once the placenta has safely All nurses wore uniforms and infants worebeen delivered. regulation hospital clothing. Toys were banned.5. Is it not easier for the staff to care for the 1. Is it helpful to have the mother’s nameinfant in the nursery than keep the infant on each infant crib or incubator?with the mother? Yes, as it is important to identify infants.With baby friendly care, it is important to do However, it is also helpful to add the infant’swhat is best for the mother and infant rather own name as this allows infants to bethan what is easier for the staff. The mother can recognised as individuals, which promoteshold and care for her infant while the midwife bonding. Colour coding labels, pink for girlsor doctor manages the delivery of the placenta. and blue for boys, should be used.6. If an infant has to be taken to the 2. Who should be able to visit infants in anursery, when should the infant be nursery?brought back to the mother? Both parents and siblings. UsuallySometimes either the mother or infant are ill grandparents are also allowed to visit.and the infant cannot stay with the mother. However, some control over visiting isThe mother should then visit the infant in the important as the nursery cannot be filled withnursery, or the infant should be taken to the visitors. The visitors may have to take turns.mother in the ward, as soon as possible. There It is important that siblings are not excludedis no medical reason for all healthy infants from this important family occasion.to be taken to the nursery for ‘observations’for the first 6 hours after birth. Most infants 3. Is it important that parents only visitdelivered by caesarean section can also stay during fixed visiting hours?with their mother. Photographs of the infant Parents should be able to visit at any time andcan promote bonding if the mother and her stay as long as they want. Often working fathersinfant have to be separated. cannot visit during formal visiting hours. . They may only be able to visit in the evenings. Parents of small infants should be encouraged to spend time giving KMC to their infants.
  15. 15. 80 MOTHER AND BABY FRIENDLY CARE4. How should a nursery be decorated? 1. Should a neonatal intensive care unit have good lighting?Every effort must be made to make the nurserylook as less stressful as possible. White walls Lighting is important and this is best achievedwith no decorations are cold and threatening. with windows. They allow natural light inLight coloured walls with attractive curtains and also reduce stress if the staff can look out.and pictures or posters make the nursery However, bright lighting disturbs infants andappear more like a home and creates a restful can prevent them sleeping. Bright lights aremood. A nursery should not look like a only needed during specific procedures. Ideallytypical, traditional hospital ward. there should be quiet times with dim lighting.5. Should radios and television sets be 2. What is ‘nesting’?allowed in a nursery? With nesting, a towel or small cotton blanketTelevision is a distraction and should not be is rolled up and placed on the mattress aroundallowed. A radio playing soft, relaxing music the infant to form a circle or horse-shoe. Infantshelps to reduce stress, especially among the are often nested on their side. In this way thenursing staff. infants can feel the limit of their immediate environment rather than move around the6. What clothing is best for staff and infants incubator until they can lie against the side wall.in the nursery? 3. What are the advantages of ‘cluster care’?Nurses clothing should be comfortable,attractive and not threatening. Formal nursing When using cluster care, investigations (e.g.uniforms are not recommended. All staff taking blood for glucose measurement) andmust wear name tags for easy identification by handling (e.g. nappy changes or feeds) ofparents. Infants in incubators should always infants are clustered together so that theyhave warm caps and nappies. They may also can be done at the same time. This reduceshave coloured cotton or woollen tops. Families the frequency that an infant is disturbed andoften bring clothes for their infants which help allows for longer periods of rest and sleep.to give the infants an identity of their own.Soft toys are safe as long as they are not shared 4. How can parents be given easier accesswith other infants. to information about their infant’s health problems?CASE STUDY 3 It is important that parents understand what is wrong with their infant, the risks and the management. Careful, simple and repeatedIn a large hospital, attempts are being made explanation is most important. However,to make a neonatal intensive care unit more giving parents written information in the‘humane’ and baby friendly. As there are only form of pamphlets is also useful as they cana few windows it is suggested that better, read and reread the information at home.brighter lights should be installed. One of In addition, booklets, videos, notices andthe nurses has read about nesting and cluster photographs can be used.care and is keen to introduce these newpractices. The senior doctors want to improve 5. What are the principles of paincommunication with patients and give them management in newborn infants?easier access to information. The question ofcorrect pain management is also discussed at 1. Infants do feel and express signs of pain.a staff meeting. 2. Unnecessary painful procedures must be avoided, e.g. routine blood glucose
  16. 16. BABY FRIENDLY CARE 81 measurements when there is not a good needs of the hospital and staff. Baby friendly indication. care is good, evidenced based care which3. Always handle infants gently. promotes bonding and breastfeeding.4. If possible, allow infants to suckle at the breast during painful procedures. 3. What is the Baby Friendly Hospital5. Use a local anaesthetic (e.g. lignocaine) or initiative? a general analgesic (e.g. morphine) when a painful procedure is done (e.g. inserting a This is an international programme supported chest drain). by the World Health Organisation and based6. Touching and stroking an infant may help on the ‘Ten steps to successful breastfeeding’. to relieve stress. Hospitals and clinics are formally inspected and, if successful, awarded BFI status.CASE STUDY 4 4. What are the ten steps to successful breastfeeding?In a postnatal ward all infants are nursed in These are practical steps that can becribs next to their mother’s beds. Sharing a bed implemented in order to promote, supportis not allowed because of the fear of the mother and manage successful breastfeeding in arolling onto the infant in her sleep. When maternity service.infants are discharged home, mothers areadvised to get the infant used to sleeping alonein a cot in a separate room. A newly appointed 5. Why is there sometimes resistance tonurse suggests that the hospital should become hospitals or clinics becoming baby friendly?‘baby friendly’. The older members of staff Any change in managing mothers andare unhappy to change routines which ‘have infants causes uncertainty, insecurity andworked well for many years’. They get angry resistance with parents, health workers andwhen touch therapy is suggested. administrators. Many people do not like change, even if the change is to everyone’s1. Is it safe to allow mothers and infants to benefit. With the introduction of babyshare beds in hospital and at home? friendly care it is important to convince and support those who need to change fromFor many years mothers have shared beds with previous ideas and habits.their infants at home without any side effects.In poor communities it may be the mostpractical way of keeping infants warm at night. 6. What is touch therapy?The risk of cot death is not increased. The risk It is a method of teaching mothers to touchof mothers rolling onto and smothering their and gently stroke their infant. It buildsinfants is also very small. In many baby friendly confidence in anxious, inexperienced mothershospitals infants sleep with their mothers. and promotes bonding. Touch therapy soothes crying infants and can increase weight gain.2. What is a baby friendly hospital?This is a hospital (or clinic) which places thecare of the mother and her infant ahead of the

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