**3.16 Post natal examinations**

First check up on discharge and second on sixth post partum week. Mother: general health, pulse, BP, temperature breasts, uterine fundus is

palpated per lower abdomen for normal involution.

Perineum is inspected and that of lochia.

Bladder and bowel functions are enquired.

Infant: weight, skin condition (jaundiced), eyes, condition of umbilical cord, feeding, stool, urination, any other problem are checked by referring to pediatric opd or paediatrician.

Second post natal check up on sixth week.

Mother and infant: duration of lochia, duration of first menses, sleep, bladder, bowel, perineal wound, breasts or bottle feeding.

Any problem of mother or baby is enquired.

Examination on mother: weight, BP, Pulse, anemia, breast, abdomen, perineum, pelvic organs.

Infants: weight, heart, lungs, umbilicus, Inj BCG are checked.

Advice on discharge: Food advices to mother, giving her a food chart and use of boiled water.

Rest, sleep, exercise and posture by mother.

Advice on contraceptives.

Breast feeding.

After delivery, the breasts start to secrete colostrum, which is a deep lemon yellow liquid usually by the second postpartum day. Compared with mature milk, colostrum is rich in immunological components and contains more minerals and amino acids, protein, much of which is globulin, but less sugar and fat. The colostrum content of immunoglobulin A (IgA) offers the newborn protection against enteric pathogens. Mature milk is a complex and dynamic biological fluid that consists of fat, proteins, carbohydrates, bioactive factors, minerals, vitamins, hormones and many other cellular products. The concentrations and contents of human milk change even during a single feed, but are affected by maternal diet and newborn age, health and needs.

A nursing mother usually produces 600 mL of milk daily. However, maternal gestational weight gain has little impact on the quantity or quality of milk. Milk is isotonic with plasma, and lactose alone accounts for half of the osmotic pressure. Essential amino acids in milk are derived from blood, and nonessential amino acids come from blood or synthesized in the mammary gland. Alpha-lactalbumin, betalactoglobulin and casein are some of the milk proteins. Fatty acids are synthesized in the breast alveoli from glucose and are secreted by an apocrine-like process. Though vitamins are found in human milk, but these are present in variable amounts. Vitamin K is virtually absent, and thus, an intramuscular dose is required to be given to the newborn [7].

Even the milk serum whey contains large amounts of interleukin-6. Human milk has a whey-to-casein ratio of 60:40 and that is considered ideal for absorption. Prolactin is also actively secreted into breast milk. Epidermal growth factor (EGF) found in milk is not destroyed by gastric proteolytic enzymes and hence may be absorbed to promote growth and maturation of newborn intestinal mucosa [8]. Lactoferrin, melatonin, oligosaccharides, and essential fatty acids are the other constituents of milk. The precise humoral and neural mechanisms involved in lactation are complex.

Progesterone, estrogen, and placental lactogen, as well as prolactin, cortisol, and insulin act in concert to stimulate the growth and development of the milksecreting apparatus in lactating breasts [9]. With delivery, the maternal serum levels of progesterone and estrogen decline abruptly and significantly. The falling progesterone and estrogen levels remove the inhibitory influence on alphalactalbumin production and thus stimulates lactose synthase in milk. Progesterone withdrawal also allows prolactin to act unopposed and stimulates production of alpha-lactalbumin in milk. The intensity and duration of subsequent lactation are controlled, in large part, by the repetitive stimulus of nursing and emptying of milk from the breast. Prolactin is essential for lactation and women with extensive pituitary necrosis— Sheehan syndrome—does not lactate. Although after delivery, plasma prolactin levels drop to levels lower than during pregnancy, each act of suckling causes a rise in levels [10]. Suckling curtails the release of dopamine, also known as prolactin-inhibiting factor, from the hypothalamus. That in turn, also transiently induces prolactin secretion. Oxytocin is known to be secreted by the pituitary in pulsatile fashion. This oxytocin stimulates contraction of myoepithelial cells in the alveoli and small milk ducts and hence helps in milk expression. Milk ejection or letting down, is a reflex initiated especially by suckling, which stimulates the posterior pituitary to liberate oxytocin. The reflex may even be provoked by an infant cry and can be inhibited by maternal fright or stress.

#### **3.17 Nursing**

Human milk is known ideal food for newborns for it provides age-specific nutrients, immunological factors, and antibacterial substances to the newborn. Milk also helps in promoting cellular growth and differentiation. For both mother and infant, the benefits of breastfeeding are long-term and unique. World Health Organization (2011) recommends exclusive breastfeeding for up to 6 months.

### **3.18 Advantages of breastfeeding**


The Baby Friendly Hospital Initiative is an international program to promote exclusive breastfeeding. It is based on the World Health Organization (1989) Ten Steps to Successful Breastfeeding. World wide, almost 20,000 hospitals are designated as "baby-friendly hospitals.

Ten Steps to Successful Breastfeeding (Baby Friendly Hospital Initiative):


#### **3.19 Contraindications to breastfeeding**

Nursing is contraindicated in some women who have intake of street drugs or alcohol abuse; have an infant with galactosemia; human immunodeficiency virus (HIV) infection; active, untreated tuberculosis; undergoing breast cancer treatment [11]. Breastfeeding has been recognized for some time as a mode of HIV transmission and is proscribed in developed countries in which adequate nutrition is otherwise available. Other viral infections do not contraindicate breastfeeding. Women with active herpes simplex virus may suckle their infants if there are no breast lesions and ifparticular care is directed to hand washing before nursing.

#### **3.20 Other issues with lactation**

With inverted and depressed nipples, nursing is very difficult. Here, lactiferous ducts open directly into a depression at the center of the areola. If the depression is not deep, milk can sometimes be expressed with the help of a breast pump. During the last few months of pregnancy, daily attempts can be madeto draw or "tease" the nipple out with the fingers.

Extra breasts—polymastia, or extra nipples—polythelia, may develop along the milk line or the former embryonic mammary ridge In some women, rests of accessory breast tissue may also be found in the mons pubis or vulva. In the general population, the incidence of accessory breast tissue ranges from 0.22 to 6 percent [12]. These accessory breasts are very small and are mistaken to be pigmented moles, lymphadenopathy or lipoma. However, polymastia has no obstetrical

significance. But, occasional enlargement of these accessory breasts during pregnancy or postpartum cause patient discomfort and anxiety.

Galactocele is another complication wherein a milk duct gets obstructed by inspissated milk secretions. The amount is ordinarily limited, but an excess may form a fluctuant mass—a galactocele. Galactocoele may cause pressure symptoms and also form an abscess. It might get resolved spontaneously or might require aspiration.

Among individuals, the volume of milk secreted varies markedly. This depends on breast glandular development rather than maternal health. Rarely, there is a condition with complete lack of mammary secretion—agalactia. Again, mammary secretion might be excessive—polygalactia.
