Madison Birth Center Offers Breastfeeding Support
by Aszani Kunkler CNM, MSN, CLC
One of the great pleasures of midwifery practice at the Madison Birth Center is our ability to offer quality breastfeeding support to our clients. In our fragmented health care system, the model we promote is truly unique. Each member of our midwifery team holds a lactation credential, and we work closely, through home and birth center visits, to ensure the breastfeeding success of our clients. Our care philosophy reflects our deep belief in the benefits of breastfeeding, and begins even before pregnancy with breastfeeding education.
Once the baby is born, she is placed skin-to-skin with her mother under warm blankets for an extended period of time. All vital signs are performed with the baby in her mother's arms, and she is not removed for weighing or measuring until she's had a good nursing session. Signs of readiness to nurse are pointed out to the parents, and the infant is encouraged to latch onto the nipple. When necessary, the new babe is assisted with the first latch, but we do not impede the infant's own process, which we know leads to a stronger instinct to suckle. At home visits, both the newborn and new mother are carefully assessed, and breastfeeding support is an important part of the visit.
When we see breastfeeding problems, birth center midwives visit the mother-baby dyad more frequently until nursing is well established and the mother and baby are thriving.
Riley and Anna (their names have been changed to protect their privacy) are one example. Little Anna was born in the birth tub at the birth center one beautiful spring day. She nursed well before discharge and her mother was well versed in how and when to offer the new baby the breast. At the first home visit, Anna's weight had dropped 8 percent. All babies lose some weight as their mother's milk comes in, but a 10 percent weight loss is the point at which intervention needs to occur, and an 8 percent loss in the first day bodes careful monitoring. In Anna's case, she was nursing well and often, but was fussy. One of Riley's nipples was a little more flat than the other, and this was a challenge for both mother and baby. The home visit focused on soothing the baby so she would nurse, and working on a good latch, especially on the flatter nipple. The plan was to see the pair in two days unless things didn't go well overnight.
The next morning Riley called with an urgent appeal for another home visit, the sooner the better. It had been a rough night, and Anna had been screaming unceasingly for two hours, despite being offered the breast several times. After finishing another home visit, I made my way to their home. Anna's mucus membranes were dry, she was more jaundiced than the day previous, and she was obviously hungry. She was 10 percent under her birth weight and Riley's flatter nipple was cracked and painful. I sent Riley's husband out to buy formula and taught the family how to syringe feed Anna with it. So what, you may be asking, is a midwife doing encouraging the use of formula?
In general, lactation consultants eschew the use of non-human milk supplements, and we are no exception. In days gone by, other lactating women helped each other through periods of breastfeeding difficulty by allowing infants other than their own to nurse. In our day and age, we are often isolated from other lactating mothers, and the use of formula is an accepted way to supplement when needed. The difference between our practice and many others is that we see formula as a way to get the infant back to the breast, and not a substitute for breastfeeding. We have encountered many practitioners who urge a complete switch to formula feeding when breastfeeding problems occur. This disregards the mothers wish to breastfeed and the obvious benefits of doing so to both mother and infant.
In addition to teaching syringe feeding, this home visit included demonstrating the use of the breast pump and making a plan for nursing, syringe feeding and pumping.
Breastfeeding research and theory provided the foundation for the plan developed. The use of a syringe and finger to feed the formula was to prevent any chance of Anna developing "nipple confusion." Although this happens rarely, once a breastfeeding baby becomes used to the faster flow and very different suck patterns needed for bottle feeding, it is difficult to get the baby back to breast.
Syringe feeding also allows the parents to reward the infant for sucking more strongly, and helps the parents continue to think of their baby as one who breastfeeds with a temporary supplement of formula. The pump was used after nursing sessions to provide more breast stimulation and encourage the milk to come in faster. Generally, the small serving size of colostrum, or the first milk, is plenty for the baby until the milk comes in.
In Anna's case, there was a negative spiral occurring-her suck wasn't the strongest, and she had difficulty latching on to the flatter nipple. Because she wasn't suckling strongly, she wasn't stimulating the breast well. Adequate breast stimulation signals the body to produce essential hormones for milk production, and the signals were weak. I reassured Riley that once her milk came in, Anna's suck would improve and feeding would not be painful. In the meantime, we had to keep Anna from further weight loss and dehydration, stimulate the hormonal signals for milk production, and rest the cracked nipple. With complicated interventions such as these, communication about the reasons behind the plan and detailed instructions and demonstrations are necessary.
At the home visit the next day, Anna's weight was up 2 ounces, she was well hydrated judging by voids, stools and mucus membranes and she had settled in to her life of nursing and syringe feeding. Riley's milk was beginning to come in and she was adding whatever colostrum she pumped to the formula in the syringe. Her flatter nipple was healed to the point where she could tolerate latching the baby. Anna's bilirubin level, drawn by me the previous day, was not abnormally high. I called Anna's pediatrician to update her on my assessments, the bilirubin level and the plan for the next 24 hours. I reassured Riley and her husband that things were looking up and promised to come back the next day.
At postpartum day four, Riley's milk was in and Anna was nursing like a champ! Anna had gained more weight, her color was pink and all other assessments were normal. Pumping and syringe feeding was discontinued and a plan was made for Riley and Anna to see the pediatrician the next day. Birth Center midwives checked on the pair by phone and by the time Riley and Anna came back for their two week visit, Anna was 1 1/2 pounds over her birth weight! The goal is to be back to birth weight by two weeks, and this chunky baby was an example of how a little timely intervention can make all the difference in the world.
Despite this success story, this kind of continuity of care in support of healthy mothers and babies is the exception and not the rule. In fact, most home visits are not covered by insurance companies.
Madison Birth Center includes most of them in our global OB fee, but we always struggle with collection when we have to bill for them. Although lactation consultants are available through hospitals, a trip to see one is an ordeal of parking ramps and elevators, all with a healing body and heavy car seat in tow. If we are ever to become a breastfeeding culture again, we need to make the support women and babies need accessible and affordable.
Aszani Kunkler, CNM, MSN, CLC, is the founder and director of Madison Birth Center, Wisconsin's first nationally accredited free-standing birth center. She can be reached at (608) 821-0123 or through our Web site www.madisonbirthcenter.com
Madison Birth Center recently participated in a national benchmarking process through the American College of Nurse-Midwives. They were named one of the three best midwifery practices in the nation for the percent of clients breastfeeding at 6 weeks. Congratulations MBC!
