Care for the Multicultural Family

ENHANCING CULTURAL SENSITIVITY

According to the United States Census Bureau (2001), ethnic and racial diversity in the U.S. population has reached new levels. At present, the population includes 77.1% Caucasians, 12.9% African Americans, 12% Hispanics, 4.2% Asians, 1.5% Native Americans/Alaska Natives, 0.3% Native Hawaiian/other Pacific Islanders, and 2.4% as persons who describe themselves as members of other races. Diversity in the population reaches into the health care sector and has prompted emphasis on cultural awareness in nursing education curricula and mandatory in service offerings for hospital staff.

Culturally competent care involves knowledge of the various dimensions of care, including moving beyond the biomedical needs of the patient. Rather, a holistic approach is one that expands knowledge, changes attitudes, and enhances clinical skills. To provide optimal care in a variety of clinical settings, it is important for health care professionals to conduct cultural assessments and expand their knowledge and understanding of culturally influenced beliefs, common health care practices, customs, and rituals (Taylor, 2005). In preparation for the cultural assessment, health care providers should:

• Assess their own cultural beliefs, identifying personal biases, stereotypes, and prejudices.

• Make a conscious commitment to respect and value the beliefs of others.

• Learn the customs and rituals of the common cultural groups within the community.

• Seek input from patients regarding health-related traditions and practices.

• Evaluate if what is about to be taught is really better than what the patient is already doing for herself.

• Adapt care to meet the special needs of the patient and her family, as long as standards of health and safety are not compromised.

• Include cultural assessment as a routine part of perinatal health care.

CULTURAL INFLUENCES ON THE PUERPERIUM

In certain multicultural populations such as India, Thailand, and China, the woman’s postpartum confinement lasts for 40 days. During this time, prolonged rest with restricted activity is believed to be essential. The postpartum period is an important time for ensuring future good health; thus great emphasis is placed on allowing the mother’s body to regain balance after the birth of a child.

During the 40-day confinement, support for the mother is provided by the female family members, usually the woman’s mother, sister(s), and mother-in law, who perform household chores such as cooking and caring for the siblings and new baby. The woman’s mother or older female relative often prescribes cultural remedies to aid in recovery and promote good health in the future. The female family members also provide the new mother with information on caring for herself and activities to avoid.

Lack of adequate rest and poor diet are believed to result in poor eyesight, varicose veins, digestive disorders, headache, and backache (Davis, 2001).

Certain beliefs regarding hot and cold exist among several multicultural groups. Blood is considered “hot,” and because the postpartum woman loses blood, she is considered to be in a “cold” state. To avoid illness, the mother must restore her health status by moving from a cold to hot state. The mother accomplishes this by:

• Adopting a diet that includes drinking/eating hot foods (foods such as black pepper, ginger, and garlic are believed to improve blood circulation). Sour foods such as lemons, grapefruits, and oranges are discouraged because they are thought to cause urinary incontinence later in life if eaten too early during the puerperium.

• Avoiding the consumption of ice water or cold water. These cold beverages are believed to cause weakness and delay healing.

• Avoiding cold temperatures, which are thought to be detrimental to the mother’s recovery. To maintain warmth, the mother dresses warmly and stays in bed for several days. Bathing, showering, and washing the hair is delayed for 40 days because water cools the body.

• Avoiding drafts by keeping doors and windows closed and avoiding fans and air-conditioning.

CLINICAL IMPLICATIONS OF CULTURALLY APPROPRIATE CARE

To provide sensitive, appropriate care, nurses need to adopt a flexible approach when caring for women who embrace non-Western health beliefs and practices. Inquiring about cultural beliefs, and, when possible, incorporating the beliefs into the plan of care are important strategies to help achieve this goal. For example, to demonstrate sensitivity to beliefs regarding hot and cold, the nurse may offer a warm sponge bath instead of a shower, adjust the thermostat in the room and provide extra blankets for warmth; offer warm drinks instead of cold beverages; and allow female family members as much access to the mother as possible.

Now Can You— Provide culturally sensitive postpartal care?

1. Identify at least five ways that health care providers can enhance cultural sensitivity before conducting a cultural assessment? 2. Describe several cultural beliefs concerning “hot” and “cold” and identify specific nursing interventions that allow women to adhere to these beliefs?

Promoting Recovery and Self-Care in the Puerperium

ACTIVITY AND REST

In the postpartum period, it is important for the new mother to begin ambulating as soon as her condition permits. Despite recent advances in diagnosis and treatment, deep vein thrombosis after birth continues to constitute a leading cause of maternal morbidity and mortality. Venous stasis and hypercoagulation, conditions that exist in pregnancy, are continued into the postpartum period. Early postpartum ambulation is key in preventing maternal thromboembolic events.

The type of birth and overall health status determines how soon the patient is allowed to resume exercise. The woman should be taught to begin with mild exercises, such as Kegel exercises, to strengthen the pelvic floor muscles. Non ambulating patients may begin with leg exercises. All exercise methods should be increased gradually.

Many women enter labor fatigued from the discomforts of pregnancy and lack of satisfying sleep associated with the third trimester. The length of labor and demands of the new mothering role further increase the feelings of exhaustion. During the hospital stay and later at home, all patients should be encouraged to obtain adequate sleep and frequent rest periods to help facilitate an optimal recovery.

NOURISHMENT

A weight loss of approximately 10 to 12 lbs. (4.5 to 5.5 kg) occurs immediately after childbirth, and this amount is directly related to the collective weights of the baby, placenta, and amniotic fluid. An additional 5 lbs. (2.3 kg) is lost over the following week as a result of puerperal diuresis and uterine involution. How quickly the woman returns to her pre-pregnancy weight depends on her physical activity level, eating habits, and lifestyle. Olson, Strawderman, Hinton, and Pearson (2003) noted that women whose weight increase was within the recommended limit of 25 to 30 lbs. (11.4 to 13.6 kg) during pregnancy could anticipate a return to the pre-pregnancy weight by 6 to 8 weeks postpartum. Factors associated with weight changes during the postpartum period include gestational weight gain, frequency of exercise, dietary intake, and breastfeeding for longer than 1 year.

Because of the restriction of food during labor, most patients demonstrate a hearty appetite after childbirth. All parturient women should be encouraged to eat a balanced, nutritious diet with multivitamin supplements. Iron is recommended only if the patient’s hemoglobin is low.

ELIMINATION

Voiding should occur within 4 hours of childbirth. Patients should be encouraged to empty the bladder every 4 to 6 hours and to expect to excrete large volumes of urine. In addition to the extra- to intravascular fl uid shift that follows childbirth, there is a decrease in the production of the adrenal hormone aldosterone. Declining levels of aldosterone are associated with a decrease in sodium retention and an increase in urinary output.

An intake and output record should be maintained to monitor the volume of urine passed during the first 24 hours. The woman who has recently given birth is prone to urinary stasis and retention. Incomplete bladder emptying or urinary retention may result from trauma to urethral tissue sustained during the “pushing phase” of a vaginal birth. Also, patients who were catheterized or who received regional anesthesia during childbirth sometimes experience an absence of the sensation to void. Bladder hypotonia during labor may also lead to postpartal urinary retention or stasis, factors that increase the risk of infection.

Incomplete emptying of the bladder is suspected when the patient experiences urinary frequency and passes 100 to 150 mL of urine with each voiding. The nurse’s assessment includes careful palpation of the lower abdomen to identify a distended or displaced uterus. The uterine fundus is felt above the symphysis pubis with a lateral displacement of the uterus. The nurse also notes an increase in the amount of lochia since the uterus is unable to contract effectively. The bladder is displaced, bulges above the symphysis pubis, and feels “boggy” on palpation. Patients experiencing urinary retention due to absence of the urge to void can be helped by assisted early ambulation to the toilet and other measures such as running the water from the lavatory faucet. If ambulation is not possible, the nurse can pour warm water over the vulva and perineal area to help relax the urethral sphincter. Owing to the risk of urinary infection associated with urinary stasis, catheterization may be necessary if the patient is unable to void.

Constipation commonly occurs because of slowed peristalsis associated with pregnancy hormones and childbirth anesthesia. In addition, perineal discomfort, fear of suture separation at the episiotomy site, and incisional pain (after a cesarean birth) may contribute to decreased frequency in bowel movements. To prevent constipation, nurses should encourage patients to consume foods high in fiber and roughage. Adequate fluid intake that includes drinking at least six to eight glasses of water or juice daily is another important strategy to prevent constipation. Early ambulation is also encouraged to improve peristalsis and relieve abdominal gas pain. If these measures are not effective, the primary care provider may prescribe a stool softener, suppository, or enema to alleviate the symptoms.

PERINEAL CARE

The perineum is susceptible to infection because of impaired tissue integrity resulting from bruising, laceration, or an episiotomy. The proximity of the perineum to the anus increases the risk of the incision becoming contaminated with fecal material; continuous drainage of blood creates a favorable medium for the proliferation of bacteria. To minimize infection, patients should be taught about perineal hygiene. A teaching approach that incorporates a return demonstration, encouragement, and positive reinforcement is most likely to be successful. Instructions should be given about properly cleansing the perineal area and the value of sitz baths, which not only cleanse but also provide relief from discomfort during the first

24 to 48 hours postpartum.

Patients should be educated about the importance of cleansing the perineum after each voiding and bowel movement. Hand washing before and after perineal care (“pericare”) is essential for the prevention of infection. The nurse instructs the patient to gently rinse her perineum with fresh warm water after use of the toilet and before a new perineal pad is applied. The patient is taught to fill the peri-bottle (hand-held squirt bottle) with warm tap water and gently squirt the water toward the front of the perineum and allow the water to flow from front to back. Consistent use of the peri-bottle is soothing, cleansing, and helps to relieve discomfort. Peri-pads should be changed often and secured in the underwear to allow for free drainage of the lochia. Tampons are contraindicated due to the risk of infection.

The nurse provides pericare for patients recovering from cesarean births until they are ambulatory and able to perform personal self-care. To provide pericare for the bedbound patient, a plastic-covered pad is placed under the patient’s buttocks to protect the bed during the procedure. With the woman in a supine position, the nurse carefully removes the perineal pad in a front-to-back direction. This prevents the portion of the pad that touched the rectal area from sliding forward and contaminating the vagina. Next, a bedpan is positioned under the buttocks. The movement associated with lifting the buttocks helps to expel clots and/or pooled blood in the vaginal canal. This also serves as a good time to assess the fundus for tone. Uterine palpation may be beneficial in helping the patient expel additional blood or clots. The nurse uses a peri-bottle fi lled with warm water (or other solution used according to hospital policy) and gently squirts the perineum from front to back while allowing the water to collect in the bedpan. The labia are not separated because they prevent the solution from entering the vagina. The perineal area is then gently dried and a clean peripad is applied from front to back.

Optimizing Outcomes— Teaching about perineal care

To enhance the patient’s understanding about proper perineal care, the nurse provides the following instructions: 1. Fill the squeeze/peri bottle with tap water. The water should feel comfortably warm on your wrist. 2. Sit on the toilet with the bottle positioned between your legs so that water can be squirted directly on the perineum. Aim the bottle opening at your perineum and spray so that the water moves from front to back. Do not separate the labia and do not spray the water into your vagina. Empty the entire bottle over the perineum— this should take approximately 2 minutes. 3. Gently pat the area dry with toilet paper or cotton wipes. Move from front to back, use each wipe once, then drop it in the toilet. 4. Grasping the bottom side or ends of a clean perineal pad, apply it from front to back. 5. Stand before flushing the toilet to prevent the water from the toilet from spraying onto your perineum.

Ice Packs

To reduce perineal swelling and pain that result from bruising, ice packs may be applied every 2 to 4 hours. Application of cold is beneficial because of its vasoconstriction and numbing effects. The ice pack should always be covered and applied from front to back. It should be left in place for no longer than 20 minutes to minimize the complications associated with prolonged vasoconstriction. Patients obtain the most relief when ice packs are applied within the first 24 hours after childbirth.

DISCOMFORT RELATED TO AFTERPAINS

Afterbirth pains describe intermittent uterine contractions that occur during the process of involution. In general, the pains are more pronounced in patients with decreased uterine tone due to overdistention. Uterine overdistention is associated with multiple gestation, multiparity, macrosomia, and hydramnios. Afterpains also tend to be more intense in breastfeeding women because infant suckling and/or pumping the breasts triggers an endogenous release of oxytocin, the hormone that initiates the milk-ejection reflex. Oxytocin causes powerful uterine contractions. Afterbirth pain maybe severe for 2 to 3 days after childbirth. Mild analgesics should provide relief.

SPECIAL CONSIDERATIONS FOR WOMEN WITH HIV/AIDS

Women who have the human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS) require special precautionary care during the puerperium. All personnel who come in close contact with the patient should wear latex gloves (unless the patient has a latex allergy). In that situation, nonlatex gloves are used, as well as safety glasses to prevent the transmission of blood and body fluids. Patients need to be taught to avoid contact of personal body fl uids with the infant’s mucous membranes and open skin lesions. Breastfeeding is not advised due to the risk of transmission of HIV to the infant.

Now Can You— Promote recovery and self-care in the puerperium?

1. Identify factors that determine how quickly patients should return to the pre-pregnant weight? 2. Describe the essential components of patient teaching about perineal care? 3. Describe special precautions that should be taken for postpartal HIV-positive women?

Care of the PostpartalSurgical Patient

PERMANENT STERILIZATION (TUBALLIGATION)

A postpartum tubal ligation is a procedure that blocks the fallopian tubes to prevent the woman from becoming pregnant. When requested, the procedure, called a minilaparotomy, is performed after childbirth while the mother is still hospitalized. The size and position of the uterus during the early puerperium facilitates the surgical procedure. When a cesarean birth has been performed, the tubal ligation may be done at the same time. Patients need to be informed that while it is typically considered to be a permanent form of fertility control, there is a small chance that a future pregnancy may occur.

Patients scheduled for a tubal ligation are NPO before the surgical procedure. If epidural anesthesia was used for childbirth, the catheter is often left in place so that the patient can be re-anesthetized easily. When no epidural was previously placed, general anesthesia will most likely be used during surgery.

CARE OF THE PATIENT AFTER A CESAREAN BIRTH

Nursing care of the postoperative postpartum patient is similar to the care provided to all postoperative patients. The nurse must complete the BUBBLE-HE assessment previously discussed. Because the woman is confined to bed until full sensation has returned to the lower extremities, interventions for the prevention of deep vein thrombosis (DVTs) must be implemented. Preventive strategies include leg exercises (flexion and extension of the knee) and application of compression boots as ordered by the physician.

How the patient reacts to her surgery is often tied to the circumstances surrounding the birth—that is, whether the cesarean section (“c-section”) was a planned procedure or an emergency event. Women who experience an emergency or unplanned cesarean birth may suffer from extreme disappointment, feelings of inadequacy, guilt, and personal failure. They may also harbor hostilities directed toward the medical and nursing staff.

After a cesarean birth, especially when unplanned, nurses must be aware of the myriad of potential psychological issues that may arise. Research suggests that women may perceive cesarean birth to be a less positive experience than a vaginal birth. Vaginal birth has been shown to be associated with enhanced maternal satisfaction and perceptions of greater personal control over the birth. Women who experience vaginal birth describe feelings of empowerment, elation, and achievement (Lavender, Hofmeyr, Nielson, Kingdon, & Gyte, 2007). Particularly for unplanned or emergent cesarean deliveries, the experience of cesarean birth may be associated with more negative perceptions of the birthing experience. However, research regarding the psychological outcomes associated with cesarean birth remains mixed (Patel, Murphy, & Peters, 2005).

The benefits of maternal–child interaction during the early postpartal hours are well documented. The first few hours after childbirth constitute a critical time for the initiation of a healthy maternal–infant interaction. For most mothers, a successful vaginal birth is psychologically better tolerated and avoids the need for additional recovery time that is necessary after a cesarean birth. In addition, early breast feeding (for those who wish to breast feed) is more easily implemented after a vaginal birth.

Additional challenges faced by patients during recovery from a cesarean birth include recovery from the anesthesia,a need to cope with incisional and gas pain, and slow ambulation. Mother–infant bonding may be delayed and patients are at an increased risk for hemorrhage, surgical wound infection, urinary tract infections, and DVT.

CARE OF THE INCISIONAL WOUND

The surgical incision requires ongoing nursing assessment after a cesarean birth. The nurse should assess for approximation of the wound edges, and make note of any redness, discoloration, warmth, edema, unusual tenderness, or drainage. If a dry sterile dressing has been applied, the surrounding tissue should be carefully evaluated for evidence of a reaction to the tape used to secure the dressing.

Assessing for and effectively treating incisional pain is also of paramount importance.

RECOVERY FROM ANESTHESIA

Ambulation is encouraged as soon as the patient’s vital signs are stable. If a spinal or epidural anesthesia was used, ambulation is delayed until full sensation has returned to the lower extremities. Common side effects of anesthesia include paresthesias (sensation of pins and needles in the legs) and headache. Assistance is required when the patient gets out of bed for the first time. Nurses should administer pain medication 30 minutes before the patient attempts ambulation. To minimize dizziness from orthostatic hypotension, the nurse should instruct the patient to sit on the side of her bed for several minutes before moving into a standing position.

Respiratory Care

Incisional pain and abdominal distension often cause patients to adopt shallow breathing patterns that can lead to decreased gas exchange and a reduced tidal volume. To facilitate adequate lung functions, patients should be taught how to perform pulmonary exercises. After being placed in a high Fowler’s position, the patient is shown to use a pillow to support her incision and instructed to take a deep breath and cough. Respiratory therapists are often included in the team approach to care for postoperative patients. Expectoration of secretions and deep breathing help prevent common complications including atelectasis and pneumonia. The nurse should administer pain medication 15 to 30 minutes before the patient begins her respiratory exercises.

Abdominal distension and gas pains are common after abdominal surgery and result from delayed peristalsis. Breakdown of digested food in the colon produces a buildup of gas that results in distension and discomfort. Anesthesia also causes a delay in the return of peristalsis and it usually takes several days for the intestinal function to return.

Until bowel sounds are present, the nurse should offer the patient ice chips and small sips of water only. The diet is slowly advanced as tolerated. To minimize gas pains and stimulate the return of peristalsis, frequent ambulation is encouraged.

An indwelling Foley catheter connected to a closed drainage system remains in place for approximately 24 hours after a cesarean birth. While the catheter is in place, the nurse must assess for urine output of at least 150 mL/hr and maintain appropriate perineal care to reduce the risk of urinary tract infection. Once the catheter has been removed, the patient is at risk for urinary retention and her output must be closely monitored. The nurse can help facilitate the return of normal voiding patterns by encouraging early ambulation to the toilet, ensuring privacy, allowing water to run in the lavatory, and pouring warm water on the perineum. If the patient is unable to void within 6 hours, a diagnosis of urinary retention should be considered and catheterization may be necessary.

Now Can You— Provide nursing care for the surgical postpartal patient?

1. Identify nursing assessments appropriate for the postoperative postpartum patient? 2. Describe maternal psychological issues that may accompany a cesarean birth? 3. Discuss nursing interventions to facilitate ambulation and lung expansion?

Facilitating Infant Nourishment: Educating Parents to Make Informed Choices

Holistic care during the puerperium includes educating women and their partners about infant nutrition and providing support to facilitate success with the feeding method chosen. By the time they enter the postpartum phase of childbearing, most women have already made a decision about infant feeding. Providing current, evidence based information, offering clinical guidance, and identifying appropriate resources when needed empowers patients to achieve success in nourishing and nurturing their newborn.

Breastfeeding has long been established as the optimal method of infant feeding and current trends are reflective of the public’s awareness of its value. Today, more women in the United States are breastfeeding their babies than at any time in modern history. While the rate of breastfeeding has increased in all demographic groups, certain populations of women are less likely to breastfeed. These include women younger than 25 years of age; those with a lower income; primiparas; African Americans; those who participate in the special Supplemental Nutrition Program for Women, Infants, and Children (WIC); those with a high school education or less; and those who are employed full time outside of the home (Johnston & Esposito, 2007).

Human breast milk is the ideal infant food choice. It is bacteriologically safe, fresh, readily available and balanced to meet the infant’s needs. According to the American Academy of Pediatrics, “human milk is species-specific, and all substitute feeding preparations differ markedly from it, making human milk uniquely superior for infant feeding” (Gartner et al., 2005). When discussing infant feeding options with parents, nurses can share factual information about the physiological and psychological benefits of breastfeeding (Box 15-3). There are economic benefits as well: breastfeeding reduces the cost of feeding and preparation time. Providing such information may reinforce the mother’s decision to breastfeed or help women and their partners in the decision-making process. The partner’s level of support with the infant feeding method is an important factor in the woman’s decision and success. There are only a few situations in which breast feeding is contraindicated:

• Infants with galactosemia (due to an inability to digest the lactose in the milk)

Box 15-3 Selected Breastfeeding Benefits

FOR MOTHERS • Decreased risk of breast cancer • Lactational amenorrhea (LAM) (although breastfeeding is not considered an effective form of contraception) • Enhanced involution (due to uterine contractions triggered by the release of oxytocin) and decreased risk of postpartum hemorrhage • Enhanced postpartum weight loss • Increased bone density • Enhanced bonding with infant

FOR INFANTS • Enhanced immunity through the transfer of maternal antibodies; decreased incidence of infections including otitis media, pneumonia, urinary tract infections, bacteremia and bacterial meningitis • Enhanced maturation of the gastrointestinal tract • Decreased likelihood of developing insulin-dependent (type 1) diabetes • Decreased risk of childhood obesity • Enhanced jaw development • Protective effects against certain childhood cancers 490 • Mothers with active tuberculosis or HIV infection • Mothers with active herpes lesions on the nipples • Mothers who are receiving certain medications, such as lithium or methotrexate • Mothers who are exposed to radioactive isotopes (e.g., during diagnostic testing)

Despite knowledge of the benefits of breastfeeding some women choose to formula feed. Concerns about convenience, opportunity to involve the father in the baby’s care, and modesty and embarrassment may be factors that influence the mother’s decision. An unsuccessful breastfeeding experience during a previous pregnancy may also play a role. Some women anticipate that breastfeeding will interfere with plans to return to work. Whatever the reasons, the nurse must provide information and support in a caring, non judgmental manner. Postpartal women who planned to bottle feed may still benefit from education about the benefits of breast milk over formula (Miller, Cook, Brooks, Heine, & Curtis, 2007). The nurse’s offer of breastfeeding support and assistance may encourage some women to change their chosen feeding method. The importance of the nurse’s role in the promotion of breastfeeding has been underscored in an AWHONN clinical position statement (1999; available at http://www.awhonn.org/awhonn/content.do?name=05HealthPolicyLegislation/ 5HPositionStatements.htm).

Optimizing Outcomes— Supporting women in their infant feeding choice

Although breast milk provides the best nutrition choice for infants, the decision to breastfeed is always one that must be made by the woman. She should make the choice based on what pleases her and makes her feel most comfortable. If the woman is pleased and comfortable with her choice, the infant will also be pleased and comfortable and both will benefit from the experience.

ENHANCING UNDERSTANDING OF THE PROCESS OF LACTATION

Normal Structure of the Breast

The breast is composed of glandular, connective, and fatty tissue. The lactating breast contains lobes that house the milk production cells called aveoli (alveolus), fatty tissue, and a series of small and main ducts. The ducts converge into 9 to 10 duct openings in the nipple (Fig. 15-5).

According to most published literature, each breast contains 15 to 20 lobes although recent ultrasound studies have demonstrated variations that range from 4 to18 lobes per breast (Ramsay, Kent, Hartmann, & Hartmann, 2005). Each lobe has a small duct that unites with others to form a main duct. The lobes are connected by areolar tissue and blood vessels. The ducts function to collect milk from the alveolus and transport it toward the nipple. The Cooper’s ligaments, along with the fatty adipose tissue, give shape to the breasts and provide support to the ductal system (Fig. 15-6).

The areola, a 15- to 16-mm circular pigmented structure, darkens and enlarges with pregnancy. The Montgomery tubercles are small sebaceous glands in the areola that enlarge during pregnancy. They secrete a waxy substance that acts as a lubricant and contains anti-infective properties that protect the nipples. The nipple, a mass of conical erectile tissue, is located in the center of the areola and projects a few millimeters from the center of the breast. Circular smooth muscles surround the areola and cause the nipple to become erect with stimulation. The main ducts converge and open into the nipple (Riordan, 2005).

Blood and Nerve Supply and Lymphatic Drainage

There is an abundant vascular supply to the breasts. Approximately 60% of the blood supply to the breasts comes from the internal mammary artery. The remainder is supplied by branches of the intercostal, subclavian, and axillary arteries (Lawrence & Lawrence, 2005). Branches from the mammary arteries anastomose around the nipples and areolae and provide blood to those structures.

The fourth, fifth, and sixth intercostal nerves provide innervation to the breasts. The fourth nerve enters into the posterior aspect of the breast (anatomically, in the position of 4 o’clock on the left breast; 8 o’clock on the right breast) and provides maximum sensation to the nipple and the areola. The areola is the most sensitive area of the breast; the nipple itself is the least sensitive area. Damage to the intercostal nerves can result in some loss of sensation to the breast (Riordan, 2005). Loss of sensation may prevent the nipple from protruding and becoming erect in preparation for a baby’s latching-on to breastfeed.

The breasts contain an extensive lymphatic network. The skin covering the breasts houses superficial lymph channels that serve the chest wall and are continuous with the superficial lymphatics of the neck and abdomen. A rich network of lymphatics is also present deep in the breasts. The primary deep lymphatics drain laterally toward the axillae.

Figure 15-5 Cross section of a lactating breast.

The Physiology of Lactation

MILK PRODUCTION AND LET-DOWN.

Lactogenesis, the process by which the breasts secrete milk, is dependent on the release of the hormones prolactin and oxytocin. The process of milk synthesis begins after the delivery of the placenta. This event results in a dramatic decrease in plasma progesterone and estrogen and an increase in the secretion of prolactin from the anterior lobe of the pituitary gland. Prolactin stimulates the alveoli, or milk producing cells, to secrete milk. Stimulation from infant suckling or pumping the breasts triggers the release of oxytocin from the posterior lobe of the pituitary gland.

Oxytocin prompts contraction of the smooth muscle myoepithelial cells surrounding the alveoli to eject milk from the alveoli into the lactiferous (main) ducts (Fig. 15-7). Movement of milk into the large lactiferous ducts for removal is called the “milk ejection reflex” or the “letdown” reflex. Lactating mothers describe “let-down” as a tingling or pins and needles sensation that occurs immediately before or during breastfeeding. Frequent stimulation and release of milk from the breasts are necessary for the continued release of prolactin.

The initiation of milk production is divided into three stages. Stage 1 occurs in late pregnancy and is characterized by the maturation of the alveoli, the proliferation of the secretory alveoli ductal system, and the increase in size and weight of the breast. Stage 2 begins during the postpartum period. Reduced plasma progesterone levels lead to an increase in prolactin levels that cause a copious milk production by the fourth to fifth postpartal day. Stage 3, the establishment and maintenance of the milk supply, is governed by a principle of “supply and demand” and continues until breastfeeding ceases. The “weaning” stage, sometimes referred to as “Stage 4,” begins when breast stimulation ceases. This stage is characterized by a significant reduction in milk volume.

A lack of breastfeeding (in breastfeeding or non breastfeeding mothers), or a failure to empty the breasts by pumping, results in an accumulation of inhibiting peptides, or hormones released from the hypothalamus. Inhibiting peptides act on the breast secretory cells, causing a gradual decrease in milk volume and the eventual death of the epithelial cells.

ASSISTING THE MOTHER WHO CHOOSES TO BREASTFEED: STRATEGIES FOR BREASTFEEDING SUCCESS

The most important information that the nurse can give to a mother is that breastfeeding should not be painful. When the baby is feeding at the breast, the woman should experience a strong tugging sensation and occasional mild discomfort. However, pain associated with breastfeeding is not a normal finding. The nurse should refer women who experience breastfeeding pain or other difficulties to a board-certified lactation consultant (IBCLC) for help and assistance. Although the pediatrician is responsible for the health care of the infant, the IBCLC is a lactation expert who offers the most current, up-to-date, accurate information on breastfeeding using a “hands-on” approach. Mothers should be encouraged to consult with an IBCLC when they have any questions, are having difficulty with the latch-on process, or express concerns about their milk production. Ideally, all breastfeeding mothers should be discharged with an appointment to an IBCLC.

Collaboration in Caring— Partnering with an IBCLC and other community resources

An IBCLC is a health care professional who specializes in the clinical management of breastfeeding. IBCLCs are certified by the International Board of Lactation Consultant Examiners Inc. under the direction of the US National Commission for Certifying Agencies. IBCLCs work in a variety of health care settings including hospitals, pediatric offices, public health clinics, and private practice. The IBCLC credential is primarily an add-on qualification that brings together health professionals from different disciplines who share a common knowledge base in human lactation. Among those who become IBCLCs are midwives, nurses, family practitioners, pediatricians, obstetricians, educators, dietitians, and occupational, speech, and physical therapists. Most of these health care professionals have spent at least 4 years acquiring the experience and education required for certification. Costs for services provided by IBCLCs depend upon the environments in which they work. Charges for inpatients are typically incorporated into the hospital stay. Follow-up visits in a hospital-based lactation department may or may not be included as a benefit for giving birth at that facility. Other consultations are fee-for-service. Most insurance companies do not pay for lactation services unless the service is provided within a physician’s office under the supervision of the physician. Under these circumstances, the office visit charges may apply. Many government sponsored health programs such as the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provide breastfeeding support services that are staffed by breastfeeding peer counselors. A mother who indicates that she is breastfeeding and is part of the WIC program will be provided with a special food package for herself and for her newborn. The La Leche League, an international support organization for breastfeeding mothers, is another resource that may be available in the community.

Optimizing Outcomes— Care of the breasts during lactation

The nurse should teach breastfeeding mothers to wash the nipples with warm water. Soap, which can have a drying effect and cause cracked nipples, should be avoided. Breast creams are also to be avoided. They may block the natural oil secreted by the Montgomery tubercles on the areolae; others contain alcohol, a drying agent. Creams or oils that contain vitamin E should also be avoided because the infant may absorb toxic amounts of the fat-soluble vitamin.

Initiating the Feeding

The optimal time to breastfeed is when the baby is in a quiet alert state. Crying is usually a late sign of hunger and achieving satisfactory latch-on at this time is difficult.

Latch-on is proper attachment of the infant to the breast for feeding. The neonate is most alert during the first 1 to 2 hours after an unmedicated birth, and this is the ideal time to put the infant to the breast. Bathing the neonate before the first breastfeeding should be avoided. The smell of the amniotic fluid on the infant matches the smells of the mother and serves as a “homing device” for the baby.

Cesarean deliveries and medicated births, including those with epidural anesthesia, may require more mother–infant skin to skin contact before a successful latch-on occurs.

To assist the breastfeeding mother, the nurse must understand that a baby latched on to the breast is not necessarily transferring milk. A baby that breastfeeds effectively cues (shows readiness) for feedings, is in a good feeding position, latches-on (attaches) deeply at the breast, and moves milk forward from the breast and into the mouth. When the infant is properly latched-on to the breast, the tip of his nose, cheeks and chin should all be touching the breast (Fig. 15-8).

To feed effectively, the infant must awaken and let his mother know that he wants to eat. When possible, mother-baby rooming-in creates an optimal situation for breastfeeding. When the infant is in the mother’s room at all times, she is able to observe “feeding-readiness cues” that signal the infant’s readiness to feed (Box 15-4).

“What to say”— To assist the mother whose infant won’t awaken to breastfeed

During hospitalization, nurses provide much information and coaching regarding breastfeeding. One new mother expresses her concern that her infant is too sleepy to breastfeed. The nurse may ask: • Have you tried to unwrap the baby’s swaddling? Doing this will increase skin-to-skin contact and help to awaken the infant and promote feeding. • Have you tried to rest with the baby by your breast? Doing this may allow the infant to feel and/or smell the breast, which may promote feeding. • Are you familiar with feeding cues? Watching for feeding cues may help you to recognize when your baby is ready to breastfeed. Examples of infant feeding cues are vocalizations, movements of the mouth, and moving the hand toward the mouth. Hunger-related crying is a late sign of hunger and should not be used as the cue for feeding.

An optimal breastfeeding experience begins with the mother’s prompt response to her infant’s feeding readiness cues (Cadwell et al., 2006). The mother should hold the baby so that his nose is aligned with the nipple and watch for an open mouth gape. At the height of the gape, when the mouth is open widest, the mother should aim the bottom lip as far away as possible from the base of the nipple.

With this action, the infant’s chin and the lower jaw meet the breast first and the nipple is pointed to the roof of the mouth. To facilitate a proper latch-on, it is desirable that the nipple be aligned with the baby’s nose. This position allows the baby to tilt his head upward slightly so that the chin and lower jaw drops, creating the wide open gape desired. Next, the infant’s mouth should be placed 1 to 2 inches beyond the base of the nipple. Depending on the areola size, most of the areola should be visible from the infant’s top lip but not from the bottom lip. The top and bottom lips should be flanged outward. When properly positioned, there should be no slurping or clicking sounds or dimpling of the cheeks. Also, the mother should report a tugging sensation but no pain or pinching. If any of these are present, the infant should be removed from the breast by instructing the mother to insert her finger into the corner of the baby’s mouth to break the seal. As an alternative, the mother can gently lift up and push back on the baby’s upper lip (Fig. 15-9).

Figure 15-8 When properly latched-on, the tip of the infant’s nose, cheeks and chin should all be touching the breast.