This presentation is my presentation for the GP, lactation specialists in the Benha University lactation diploma it includes steps of support for the pregnant women and how to counsel patients about breast feeding to prepare pregnant women for breast feeding after delivery it includes the following objectives: Breast feeding promotion during antenatal care Point of care ultrasound during pregnancy Breast feeding support during child birth Breast feeding promotion during antenatal care includes Health education 1st trimester topics of interest 2nd trimester topics of interest 3rd trimester topics of interest Antenatal counselling in preparation for delivery Point of care ultrasound during pregnancy Breast feeding support during child birth includes advice and counselling about breast feeding benefits prior to labor and discussion about impact of different practices done during labor on breast feeding acceptance by the mother

1. Breast feeding support in the
perinatal period
By
Dr. Ahmed Mohamed Amin Nasef
Assistant lecturer in obstetrics& gynecology department
Benha University

2. Objectives
• Breast feeding promotion during antenatal care
• Point of care ultrasound during pregnancy
• Breast feeding support during child birth

3. Breast feeding promotion during antenatal care

4. Breast feeding promotion during antenatal care
• Health education
• 1st trimester topics of interest
• 2nd trimester topics of interest
• 3rd trimester topics of interest
• Antenatal counselling in preparation for delivery

5. Health education

6. Health education
Educational interventions have an impact on the health of the pregnant
woman and on the health and wellbeing of the next human generations
• To the woman, her husband, family & society
• By obstetrician, lactation specialist, nurses, midwives & GP
• Benefits of health education
Antenatal breastfeeding education is beneficial in preparing women for
effective breastfeeding by
promoting their confidence level, knowledge, and skills

7. 1st trimester topics of interest

8. 1st trimester topics of interest
• Physiologic changes of pregnancy which may cause discomfort include:
a. Pain and tingling
b. Nausea and vomiting (morning sickness)
c. Urinary frequency
d. Fatigue & Mood swings
• Warning signs that should be reported include:
a. vaginal bleeding
b. abdominal cramping
c. Severe and prolonged vomiting

9. 1st trimester topics of interest
• Health teaching should be scheduled with the return visits for routine prenatal care and include
topics on:
a. general hygiene
b. comfort measures for trimester-related discomforts and their duration
c. counseling on the importance of breastfeeding and its management
d. sexual activity
e. safety issues as auto safety including proper use of seatbelts and avoiding getting overtired—
schedule rest/relaxation periods, avoid cancerous chemicals in the home and the workplace,
comfortable shoes and clothes
f. physical activity including mild to moderate exercise is encouraged, adequate hydration
g. nutritional guidance, weight gain, and dieting
h. Pregnant women should be counseled on avoidance of alcohol, hazards of smoking and second
hand smoke as well as self-medication with over-the-counter drugs, herbal remedies, and even
unnecessary vitamins.

10. 1st trimester topics of interest
• Nutrition guidance
(a) Theoretically the nutritional needs of a woman carrying more than one
fetus should be greater to support extra blood volume and
placental/fetal tissue
(b) Total weight gain recommendations are between 18.2 and 20.5 kg (40
and 45 pounds) for twins and 20.5 and 22.7 kg (45 and 50 pounds) for
triplets
(c) General dietary recommendations include the following:
Follow all dietary recommendations of non-risk pregnancy
Eat nutrient-dense foods
Increase protein and calcium intake as necessary
Eat small, frequent meals

11. 2nd trimester topics of interest

12. 2nd trimester topics of interest
• Physiologic changes with resulting discomforts as:
a. enlargement of abdomen
b. skin pigmentation
c. striae gravidarum
d. vascular spiders
e. Constipation
f. Heartburn
g. leg cramps
h. groin pain from round ligament stretching
i. Leukorrhea

13. 2nd trimester topics of interest
• Warning signs that should be reported as follows:
a. vaginal bleeding
b. burning or painful urination
c. signs of fever
d. reduction in or absence of fetal movements
e. nausea and vomiting
f. abdominal pain or cramping
g. swelling of face or fingers, headaches, visual
disturbances, and/ or epigastric pain

14. 2nd trimester topics of interest
• Health teaching
a. reinforcement and reiteration of previous teaching
b.comfort measures specific to trimester-related discomforts
c. benefits of breastfeeding to mother and baby, economic benefits, early initiation of breastfeeding
and importance of exclusive breastfeeding, techniques and practices for successful breastfeeding
and gradual weaning off breast only after two years of age
d.choices of prenatal education classes (avoidance of formula milk sponsored classes; e. signs and
symptoms of preterm labor

15. 3rd trimester topics of interest

16. 3rd trimester topics of interest
• Physiologic changes with resulting discomforts:
these include dyspnea, leg and foot cramps, constipation, indigestion,
heartburn, pedal edema, fatigue, vaginal discharge, urinary frequency
and Braxton Hicks contractions
• Warning signs that should be reported:
these include visual disturbance, headache, hand and facial edema,
fever, vaginal bleeding, abdominal pain, uterine contractions,
premature rupture of membranes, decreased or lack of fetal movement

17. Antenatal counselling in preparation for delivery

18. Antenatal counselling in preparation for delivery
a. signs and symptoms of labor/preterm labor
b. when to call the health care provider, when to go to the hospital or
birthing place
c. early first hour and labor plan for having baby roomed–in and given
to bottles or pacifiers except for medical indication consented by
parents and its benefits to mother and baby
d. optimal practices that lead to successful breastfeeding including
early intrapartum skin-to-skin contact until first breastfeed, and
frequent suckling in postpartum period and exclusive breastfeeding
(no prelacteals, bottles of pacifiers)

20. Antenatal counselling in preparation for delivery
• Nipple preparation or treatment of flat or retracted nipples is no
longer recommended as
They may have negative effects on the psychological status of mother’s
in breastfeeding
They may also induce preterm labor in some women
Frequent rubbing and pulling of the areola and nipple may injure the
Montgomery glands which are important in lubricating the skin and
preventing cracks and fissures

21. Point of care ultrasound during pregnancy

22. Point of care ultrasound during pregnancy
Point of Care ultrasound (POCUS)
refers to the practice of trained health professionals using portable ultrasound machines to
diagnose problems wherever a patient is being screened, treated, whether done in a
modern hospital, an ambulance, or a remote village
“Bedside Ultrasound” is an older term that describes the sonographic assessment of
patients, usually in a medical facility, at the patient’s bedside
The use of portable ultrasound allows radiological exam to detect or monitor conditions
that may need referral or immediate attention
POCUS is increasingly being used to reduce waiting time and has become the replacement
for stethoscopes in cardiology and pulmonology, fetoscope in obstetrics and radiology for
other systems or organs
POCUS for diagnosing pregnancy There are two methods to perform POCUS for the pelvis
to diagnose pregnancy:
the transabdominal ultrasound (TAS) and transvaginal ultrasound (TVS

23. Breast feeding support during child birth

24. Impact of Child Birth Practices on
Breastfeeding
• Normal labor can become a cascade of interventions which can affect breastfeeding
outcomes
• Evidence supported by the UNICEF/WHO recommendations shows that lack of
continuous support at birth especially for primiparous mothers can result in
poor coping
exacerbate anxiety and pain
slow the progress of labor
This may necessitate “augmentation” by synthetic oxytocin intravenous (IV) drip to bring
stronger contractions
This reduces endogenous oxytocin decreases the anti-stress effect and bonding
responses induced by endogenous oxytocin
• Narcotic analgesia can lead to slowed/dysfunctional labor and thus increase in the need
for more synthetic oxytocin which prolongs labor, leading to more exhaustion of the
mother and placing the unborn baby at risk.

25. Impact of Child Birth Practices on
Breastfeeding
• withholding oral fluids “in case cesarean is required” places the mother at risk of
dehydration and the IV fluids she receives restrict her movement and later lead to
more weight loss and increase the risk of jaundice to her newborn
• Poor breastfeeding outcomes are linked to prolonged labor and interventions as
the mother becomes exhausted and drained of her own endogenous oxytocin,
thereby deprived of their effect on increasing tolerance and reducing stress and
anxiety
In the same time the baby may have been exposed to asphyxia or breathing
problems that necessitate resuscitation and thus immediate SSC is interrupted or
postponed
• Compelling evidence shows that continuous labor support through support
companions whether in middle or high income settings, reduces the need for the
unnecessary build-up of labor interventions and improves outcomes of labor and
breastfeeding

26. Impact of Child Birth Practices on
Breastfeeding
• Upright position at second stage of labor is beneficial
It leads to
faster deliveries
fewer instrumental deliveries
less perceived pain
fewer episiotomies and thereby preventing their effects on
breastfeeding
Hence women should be encouraged to use upright positions for labor
and delivery to facilitate breastfeeding

28. Impact of Child Birth Practices on
Breastfeeding
• There is no evidence to support that continuous electronic fetal
monitoring that restricts movement of mother, has any effect on
improving maternal or fetal or newborn outcomes
• Strong evidence exits that meperidine (Demerol, Pethidine) as a labor
drug leads to CNS depression in the fetus and newborn and negatively
impacts breastfeeding. Timing and dose are correlated with effects

29. Impact of Child Birth Practices on
Breastfeeding
• Many randomized clinical trials (RCTs) shows that epidural anesthesia can lead to
poor progress of labor (particularly in primipara mothers, longer second stage
(need for augmentation by IV oxytocin), slower rate of spontaneous vaginal
delivery, increased maternal fever, and increased evaluation and treatment of
newborns for suspected sepsis
• Non-pharmacological labor pain relief should be encouraged as shown by
research based on RCT
These include
Continuous support labor support
Baths
Touch and massage
Maternal movement and positioning
Intradermal water blocks for back pain relief

30. Impact of Child Birth Practices on
Breastfeeding
• Episiotomy
It is no longer recommended as a routine obstetric procedure and there is
no evidence that it decreases perineal damage and may even increase later
reproductive tract complications
It also causes mothers discomfort during breastfeeding
Episiotomy may affect women’s sex life during the second year postpartum
with more frequent pain and vaginal dryness at intercourse
It increases risk of later tears and especially third and fourth degree tears
that affect the rectal muscle leading to rectal incontinence
Mothers with no or minimal perineal trauma will be more comfortable and
relaxed breastfeeding in the first hours and days of life

31. Impact of Child Birth Practices on
Breastfeeding
• Cesarean section delivery (CSD) is a life-saving procedure when used
appropriately, but it requires greater support to ensure breastfeeding
success
Motivation of these mothers undergoing CSD is invariably important
Mothers with no or minimal perineal trauma will be more comfortable
and relaxed breastfeeding in the first hours and days of life

32. Impact of Child Birth Practices on
Breastfeeding
• Labor medications
Including epidural anesthesia, block the normal secretion of maternal
beta-endorphins during labor
Beta endorphins are found in high concentrations in colostrum in
vaginal delivery and may play a role in newborn adaptation to extra-
uterine stress

33. Impact of Child Birth Practices on
Breastfeeding
• Early suckling immediately after birth through prolonged SSC
All stimulate oxytocin production in the mother and are likely to play a
role in reducing postpartum bleeding
However, more research is needed to document the role of early
immediate breastfeeding on reducing postpartum bleeding