NUR244 TOPIC 3 LECTURE

Postpartum Emotional Wellbeing and Breastfeeding

Tiredness and Fatigue

Tiredness and fatigue have distinct definitions and emotional effects:

  • Tiredness is defined as a temporary state that can be alleviated through resting or sleeping.

  • Fatigue is described as an unrelenting condition that significantly impairs normal functioning.

  • Emotional effects reported by women experiencing fatigue include:

    • Difficulty in concentrating

    • Reduced patience

    • Frustration

    • Guilt

    • Resentment

    • Feelings of incompetence

    • Concerns about aggressive behavior towards the baby

  • Causes of tiredness and fatigue may include physical factors such as anemia, infection, thyroid disorders, or depression.

  • Women who undergo a cesarean section report higher levels of exhaustion and extreme tiredness.

  • Fatigue may also be linked to emotional distress.

Early Postpartum Emotional Wellbeing

Women often undergo considerable somatic and cognitive-affective changes following childbirth.

  • Mood Changes: These mood alterations may be a typical part of postpartum adjustment.

  • Debriefing: This is a psychological approach aimed at assisting individuals in coping with traumatic experiences; midwives offering labor care can debrief women after childbirth.

  • Attention must be given to the potential for women to suffer from post-traumatic stress disorder (PTSD) following childbirth, necessitating education about depression and available referral options.

Postpartum Affective Disorders

Postpartum affective disorders are differentiated into three categories:

  1. Postpartum Blues (Baby Blues):

    • Occurs in up to 84% of women.

    • Symptoms include mood lability, irritability, dysmorphic mood, crying, generalized anxiety, insomnia, and loss of appetite.

    • Typically peaks by days 4-5 and subsides by days 10-12 after giving birth.

  2. Postpartum Depression (PND):

    • NICE (2015) recommends assessment for PND if 'baby blues' do not resolve within 10-14 days.

  3. Postpartum Psychosis:

    • This is a rare but serious form of postnatal affective illness.

    • Characterized by rapid onset within the first two weeks post-birth, symptoms include quickly changing moods, disorganized behavior, delusions, and hallucinations.

Postnatal Depression (PND)

PND describes depression that can occur any time within the first year after childbirth.

  • Symptoms: These include irritability, anger, low energy levels, loss of interest, and feelings of guilt.

  • Risk Factors for PND:

    • Financial hardship

    • Being single

    • Migrating to an area where the mother’s primary language is not spoken

    • Association with three or more stressors

    • Social isolation

    • Poor partner relationships

    • Previous history of depression

  • The Edinburgh Postnatal Depression Scale (EPDS) is frequently used for self-reporting, despite some tool limitations.

Protective Factors Against PND

Protective factors that can mitigate the development of PND include:

  • Gentle exercise

  • Adequate rest

  • Assistance with baby care

  • Open dialogues regarding feelings

  • Access to social support networks

  • Optimism and self-esteem

  • Good partner relationships

  • Adequately preparing for the physical and psychosocial transitions of parenthood.

Anxiety

Anxiety is defined as a state of physiological arousal.

  • Recognized as a significant reaction during the postpartum period, which is identified as a stressful life event.

  • Antenatal anxiety predicts an increased risk of developing PND.

Management Strategies

Effective management forms include:

  • Self-help strategies

  • Non-directive counseling

  • Cognitive-behavioral therapy (CBT)

  • Interpersonal psychotherapy (IPT)

  • Antidepressant treatment

Post-Traumatic Stress and Childbirth

PTSD following childbirth is defined by the following characteristics:

  • Persistent re-experiencing of the traumatic event

  • Persistent avoidance of stimuli associated with the event

  • Numbing of general responsiveness

  • Symptoms of increased arousal

  • Studies show that 2%-6% of women meet diagnostic criteria for PTSD after childbirth.

  • Approximately 33% report their birthing experience as traumatic based on DSM-IV criteria, fearing severe damage to themselves or their babies.

  • Women who experience distress post-birth often reframing childbirth as frightening and dangerous; they may avoid having more children or opt for elective cesarean sections in future pregnancies.

  • Many women express a desire for increased support and guidance, yet often do not receive adequate mental health help.

Consequences of Poor Maternal Health

Postnatal distress correlates with a variety of adverse psychosocial consequences including:

  • Relationship difficulties

  • Poor family functioning

  • Impaired parenting

  • Children of mothers with mood disorders may experience both short- and long-term emotional, behavioral, and cognitive disruptions.

  • Possible maternal experiences include continuing anxiety and panic attacks, depression, suicidal thoughts, feelings of rage, marital instability, sexual dysfunction, and emotional detachment from their babies and other children.

Breastfeeding

WHO Recommended Feeding Choices for Infants

The World Health Organization (WHO) recommends various feeding options for infants, which include:

  • Breastfeeding

  • Expressed breastmilk

  • Donor breastmilk

  • Formula

  • It is crucial to understand that breastfeeding may not be a feasible option for all mothers due to medical reasons.

Exclusive Breastfeeding Recommendations

The WHO endorses exclusive breastfeeding for the first six months of life, with continued breastfeeding recommended into at least the second year to ensure optimal immunological protection against illness, disease, and allergy.

Breast Structure and Function

The breast is described as a dynamic organ comprising glandular tissues within a branching duct structure, supported by a loose connective and adipose tissue framework.

  • Variations in breast size, color, and shape exist among women and between each breast.

  • Breast size, which correlates with the amount of adipose tissue present, is not a reliable predictor of breastfeeding success.

  • Each breast contains around 15-20 lobes, which reach out sporadically from the nipple, and each lobe consists of 10-100 alveoli, the glandular tissue responsible for breast milk production.

  • Alveoli comprise mammary secretory epithelial cells (lactocytes) that are encircled by myoepithelial cells, facilitating milk expulsion during the milk ejection reflex (let-down).

  • Each alveolus connects to a ductule that transports milk from the lobes, ultimately merging into lactiferous ducts that lead to terminal ducts at the nipple.

Composition of Breast Milk

Breast milk exhibits dynamic characteristics, with slight variations in composition according to feeding frequency, duration, diurnal rhythms, and lactation stages.

  • Colostrum:

    • Produced starting at 16 weeks gestation and persists in transitional milk for up to 14 days.

    • Appears concentrated and viscous, yellow, white, or orange in color, low in volume and calories.

    • High in proteins, sodium, and minerals but low in lactose, carbohydrates, fats, and vitamins.

    • Promotes gut flora growth and assists in meconium excretion due to its mild laxative properties.

    • Contains substantial amounts of immunoglobulins, macrophages, lymphocytes, neutrophils, antibodies, and immune cells that safeguard against microbes and viruses.

  • Transitional Breast Milk:

    • Produced following a rapid drop in progesterone, occurring approximately 60 hours after delivery.

    • Retains immunological properties of colostrum while adopting nutritive qualities of mature milk.

    • Contains decreased protein and immunoglobulin levels but increased lactose, carbohydrate, and fat concentrations.

  • Mature Breast Milk:

    • Synthesized roughly two weeks postpartum, reaching full maturity after 4-6 weeks.

    • This rich milk consists of 90% water and 10% proteins, carbohydrates, fats, vitamins, and minerals, appearing bluish in color and with an alkaline pH of 7.0-7.45, and providing an average calorie count of 65 kcal/100 mL (272 kJ/100 mL).

    • Geographical location and dietary habits influence both compositional and immunological characteristics of mature milk.

Foremilk and Hindmilk

The frequency of breastfeeding and breast fullness can affect the protein and fat content in the milk.

  • The fat and protein levels may vary across different ducts within the same breast.

  • As the infant suckles, fat content in the milk tends to increase as the breast empties more fully.

Milk Volumes According to Stage of Lactation

The following volume measurements are indicative of milk production according to the stage of lactation:

  • Post-Vaginal Birth:

    • Day 1: 21 ml/24h

    • Day 2: 87 ml/24h

    • Day 3: 231 ml/24h

    • Day 4: 371 ml/24h

    • Day 5: 430 ml/24h

    • Day 6: 483 ml/24h

  • Post-Cesarean Section:

    • Day 1: 14 ml/24h

    • Day 2: 45 ml/24h

    • Day 3: 154 ml/24h

    • Day 4: 287 ml/24h

    • Day 5: 388 ml/24h

    • Day 6: 451 ml/24h

  • At one month and beyond, average milk production is around 800 mL/day.

Advantages of Breastfeeding

Various health outcomes benefit from breastfeeding for both infants/children and mothers, as categorized by levels of evidence:

  • Convincing Evidence:

    • Gastrointestinal illnesses

    • Otitis media

    • Respiratory tract infections

    • Necrotizing enterocolitis (NEC)

  • Probable Evidence:

    • Asthma and allergy

    • Cognitive development/intelligence

    • Some childhood leukemias

    • Urinary Tract Infections (UTI)

    • Inflammatory bowel disease

    • Coeliac disease

    • Sudden Infant Death Syndrome (SIDS)

  • Possible Evidence:

    • Insulin-Dependent Diabetes Mellitus (IDDM)

    • Obesity

    • Premenopausal breast cancer

    • Decreased period of postpartum infertility

    • Slow maternal recovery from childbirth

    • Postmenopausal breast cancer

    • Ovarian cancer

    • Rheumatoid arthritis

    • Bacteraemia

    • Meningitis

    • Dental occlusion

    • Ischemic heart disease (IHD)

    • Atherosclerosis

    • Risk factors for cardiovascular diseases, type II diabetes, obesity, and metabolic syndrome

    • Maternal depression

    • Endometrial cancer

    • Osteoporosis and bone fracture

    • No or slow return to pre-pregnancy weight

    • Impaired maternal-infant bonding.

The Ten Steps to Successful Breastfeeding

The following ten steps outline essential practices and policies hospitals can adopt to support mothers in breastfeeding:

  1. Hospital Policies: Hospitals should refrain from promoting infant formula, bottles, or teats.

  2. Staff Competency:

    • Health professionals should be trained to assist and support mothers with breastfeeding.

    • Health workers’ knowledge and skills need regular assessment, and breastfeeding care should become standard practice.

    • Facilities should maintain records of breastfeeding support initiatives.

  3. Antenatal Care: Hospitals must discuss the importance of breastfeeding for both infants and mothers with expectant mothers.

  4. Care Right After Birth:

    • Encourage skin-to-skin contact between the mother and infant immediately post-birth.

    • Educate mothers on how to initiate breastfeeding as soon as possible.

  5. Support with Breastfeeding:

    • Hospitals should monitor the mother's positioning, attachment, and suckling of the baby during breastfeeding.

  6. Supplementing:

    • Only breast milk should be provided unless medical conditions compel supplementation, prioritizing donor human milk when needed.

    • Address common breastfeeding problems and provide practical support for mothers.

  7. Rooming-In:

    • Mothers and babies should be allowed to share rooms day and night, ensuring that mothers of ill infants can stay near their child.

  8. Responsive Feeding:

    • Assist mothers in recognizing when their baby is hungry, and do not restrict breastfeeding durations.

  9. Bottles, Teats, and Pacifiers:

    • Counsel mothers regarding the pitfalls associated with the use of bottles, teats, and pacifiers.

  10. Discharge Recommendations:

    • Provide mothers with resources to aid in breastfeeding, including information on community support services.

Protecting, Promoting, and Supporting Breastfeeding

An overview of several initiatives and strategies aimed at improving breastfeeding practices:

  • International Code of Marketing of Breast-milk Substitutes:

    • This Code offers a set of guidelines from the World Health Assembly (WHA) to secure safe and adequate nutrition for infants through breastfeeding and appropriate use of substitutes.

  • International Baby Food Action Network (IBFAN):

    • Established in 1979, consisting of public interest groups focused on reducing infant and young child morbidity and mortality.

    • IBFAN promotes protective measures for breastfeeding and optimal feeding practices through rigorous implementation of the International Code and WHA resolutions.

  • The Ten Steps to Successful Breastfeeding (1989):

    • A collaborative WHO/UNICEF declaration aimed at enhancing standards of care for mothers initiating breastfeeding in healthcare settings.

  • Innocenti Declaration:

    • This declaration endorses exclusive breastfeeding for infants and acknowledges its significant health benefits.

  • WHO/UNICEF Baby Friendly Hospital Initiative (BFHI):

    • Launched in 1991 to support breastfeeding practices, with implementation in over 152 countries and nearly 20,000 health facilities.

  • Breastfeeding Friendly Community Initiative (BFCI):

    • The BFCI seeks to strengthen breastfeeding support in communities based on the principles derived from the Ten Steps.

  • Australian Breastfeeding Strategy (2019 and Beyond):

    • Aims to provide comprehensive support to mothers, fathers, and infants across Australia regarding breastfeeding.

Breastfeeding and the Law

In Australia, the right to breastfeed in any public or private space is protected under the Sex Discrimination Act 1984.

  • All states have laws ensuring that women can combine breastfeeding with paid employment; it is unlawful to discriminate against a woman for breastfeeding or being a parent.

Selling and Sharing Breast Milk

According to Australian legislation, it is illegal to sell or purchase human body parts, which includes breast milk.

  • Informal sharing options and donor milk from sources such as hospitals or organizations like Mothers Milk Bank Charity exist to facilitate sharing of breast milk when necessary.