Baby Friendly Hospital Initiative

The Baby-friendly Hospital Initiative (BFHI) was launched by WHO and UNICEF in 1991, following the Innocenti Declaration of 1990.  The Innocenti Declaration is a document that outlines the optimal feeding of babies and children. Part of this declaration was a recommendation that all governments should develop national breastfeeding policies and implement systems to protect, promote, and support breastfeeding. The initiative is a global effort to implement practices that protect, promote and support breastfeeding.

So we know now that The BFHI was established to encourage maternity hospitals to implement the Ten Steps to Successful Breastfeeding and to practise in accordance with the International Code of Marketing of Breastmilk Substitutes.

The Baby Friendly Initiative works with the health-care system to ensure a high standard of care in relation to infant feeding for pregnant women and mothers and babies. Support is provided for health-care facilities that are seeking to implement best practice, and an assessment and accreditation process recognises those that have achieved the required standard.

Since its launching BFHI has grown, with more than 152 countries around the world implementing the initiative. The initiative has measurable and proven impact, increasing the likelihood of babies being exclusively breastfed for the first six months. Since the beginning of the BFHI, over 22,000 hospitals worldwide have become designated “Baby Friendly.  However, the vast majority of hospitals in the world have failed to implement the Baby Friendly Hospital Initiative in the 20 years since this agreement was signed.

In South Africa, the BFHI was launched in 1994 and St Monica's Maternity Hospital in Cape Town was the first hospital to be accredited Baby-Friendly. The Western Cape has 74 public and private hospitals with maternity wards, of which only 19 boasts the BFHI accreditation. 17 of the 19 are public hospitals. So we know now that nineteen hospitals in the Western Cape Province have received this accreditation. Alan Blyth Hospital celebrated its international Baby-Friendly Hospital Initiative (BFHI) accreditation by hosting a ceremony on Monday, 13 February 2012.

Nurses and midwives should take action. Advocate for Baby Friendly accreditation at your local hospitals.  Join breastfeeding organizations such as La Leche. If you are not already a member, I urge you to attend a La Leche League Group regularly and become a member. or become a member of International Baby Food Action Network.  Write letters to your local hospital administration, health minister, head of obstetrics, maternity ward, public health unit (health units can earn Baby Friendly accreditation as well), and health authority, advocating for a push to improve infant and maternal health via the Baby Friendly Hospital Initiative. Change the world, improve health, support women! One hospital at a time…

World Breastfeeding Week

World Breastfeeding Week is celebrated every year from 1 to 7 August in more than 170 countries to encourage breastfeeding and improve the health of babies around the world. It commemorates the Innocenti Declaration made by WHO and UNICEF policy-makers in August 1990 to protect, promote and support breastfeeding.The World Alliance for Breastfeeding Action (WABA) was formed in 1991 to act on the Innocenti Declaration (1990) to protect, promote and support breastfeeding. As part of its action plan to facilitate and strengthen social mobilisation for breastfeeding, WABA envisioned a glabal unifying breastfeeding promotion strategy. A day dedicated to breastfeeding was suggested to be markedin the calender of international events. The idea of a day's celebration was turned into a week.

The World Health Organization recommends that infants start breastfeeding within one hour of life, are exclusively breastfed for six months, with timely introduction of adequate, safe and properly fed complementary foods while continuing breastfeeding for up to two years of age or beyond. This has become to be known as World Breastfeeding Week (WBW) celebrated every 1-7 August commemorate the Innocenti Declaration. WBW was first celebrated in 1992. Now it involves over 170 countries and is endorsed by UNICEF, WHO, FAO and IPA.

Please read the WBW 2012 Calendar Announcement at www.worldbreastfeedingweek.org for more information.

Source: www.who.int/features/factfiles/breastfeeding/facts/en/index.html
http://www.rnjournal.com/journal_of_nursing/the_importance_of_supporting_mothers_who_breastfeed.htm

Umbillical Cord Knots

The umbilical cord is about 30 to 60 cm in length at term. So at 36, 37 weeks it really is quite long. The important thing about it is, not only is it long, but it’s really thick. So it’s up to 2, sometimes 2 ½ cm thick, and not only does it contain two arteries and one vein. But it also contains a lot of jelly-like substance called Wharton’s Jelly that protects the blood vessels. So it really is encased in quite a thick covering and then the blood vessels have jelly around them. So that stops them getting twisted or occluded in any way.

Umbilical knots do happen occasionally when a foetus swims through a loop in the cord, but the structure of the cord makes it difficult for this to have any adverse effects.  Babies jump up and down, they turn over from head down to bottom down sometimes. There has to be a great deal of tension in order for the knot to compress the cord with any significance, and therefore, impede blood flow.

Here is a good review article on cord knots.

http://www.pediatricperinatalpathology.com/id27.html

Apparently, in some cases a cord knot is detected via ultrasound (but not all knots are found with prenatal exams). However, there are no specific treatments. Most of the time, a knot is not a problem, but a “true knot” can actually be so tight that it compromises blood flow through the umbilical cord to the baby. Probably what most people worry about when it comes to umbilical cords is that they will be wrapped around the baby’s neck. This is called a “nuchal” cord (from the Latin word for “neck”). This is much more common, occurring in up to 20% of all births, but only rarely causes problems. I've seen about a dozen true knots, none have been in babies with any problems.

Umbillical Cord

The Purpose of the Umbilical Cord

The umbilical cord is one of the most important things in an unborn baby's environment. The umbilical cord begins to form between four and six weeks as the embryonic disc takes a cylindrical shape. The proximal portion of the umbilical cord is in the lower third of the embryo, and begins to form and develops a sac. The proximal portion houses the guts until the tenth week of gestation. At this time the umbilical cord is short, usually shorter than the than the head-to-tail length of the embryo. By ten weeks the intestines leave the proximal cord and return to the stomach, the elongation of the cord begins and the location of the umbilicus positions in the middle third of the embryo.
 

Features

 

The umbilical cord is a unique tissue covered by a mucoid connective tissue called Wharton's jelly and a thin mucous membrane. The umbilical cord develops from two separate foetal origins. The yolk sack and the allantoses both compromise the umbilical cords. As a result both are formed from the foetal tissue and can be thought to be part of the foetus. The cord is usually 1-2 cm in diameter and 60 cm long according to Percy Malpas, a British obstetrician who studied cord length in the 1960s.

Wharton.s jelly is a specialized tissue serving many purposes for the developing fetus. Its specialized cells contain gelatin-like mucus that encases fibers. These properties give it elastic and cushion effect, which can tolerate the vibration, bending, stretching and twisting of an active fetus. In addition, it holds the vessels together, may regulate blood flow, plays a role in providing nutrition to the fetus, stores chemistry for the onset of labor, and protects the supply line. Umbilical cords without much Wharton’s jelly are more prone to compression, and complete absence is usually associated with fetal death. If an umbilical cord is twisted or knotted, it is more likely to tighten where there is less resistance, such as an area low in Wharton.s jelly. It is believed that males have more Wharton.s jelly content than do females and that good nutrition increases the amount. Wharton.s jelly tends to reduce with gestational age and can disappear when pregnancies go beyond 40 weeks.

Function

The umbilical cord contains three vessels and two arteries. About 1% of all infants are born with a cord that contains only a single vein and artery. A 15% of these infants are found to have accompanying congenital anomalies, particularly of the kidney and heart.

The umbilical cord has three functions: serves as a blood resource for the foetus, serves as a source of nutrients (calories, proteins, fats and vitamins) and transfers waste products. The umbilical cord carries blood in the opposite direction, from the baby to the placenta. This blood has been emptied of nutrients and oxygen and now carries the fetus' waste products back to the mother's bloodstream where she can dispose of them through her system. The blood in the arteries contains waste products, such as carbon dioxide, from the baby’s metabolism. Carbon dioxide is transferred across the placenta to the bloodstream and then into the lungs where it is breathed out. Oxygen is transported from the red blood cells in the circulation across the placenta to the baby in the umbilical vein. In addition to oxygen the umbilical cord transports nutrients from the placenta to the baby.

Umbilical cord problems can be extremely scary to a pregnant woman. According to Dr. Jason H. Collins at The Pregnancy Institute, umbilical cord accidents leading to stillbirth occur in 1.5 of every 1000 births. An otherwise healthy fetus may suddenly develop a problem with the umbilical cord that needs to be carefully watched to make sure it doesn’t develop into an umbilical cord accident.

 Source: http://www.med.yale.edu/obgyn/kliman/placenta/articles/EOR_UC/Umbilical_Cord.html
              https://apps.who.int/rht/documents/MSM98-4/MSM-98-4.htm#IMPORTANCE
             
              http://www.pediatricperinatalpathology.com/id27.html

Oligohydramnios

Oligohydramnios is the condition of having too little amniotic fluid. About 8 per cent of all pregnant women are found to have low amniotic fluid at some point, usually in their third trimester. Among those still pregnant two weeks past their due date, 12 per cent have this condition. Amniotic fluid provides the fetus with fluid and nutrients, protects the fetus from trauma, has antibacterial properties and is necessary for the development of a healthy fetus. Studies have suggested that dramatic changes in amniotic fluid volumes can be a reflection of abnormalities in maternal or fetal status increasing the risk of perinatal morbidity and mortality.

The volume of amniotic fluid is ultimately determined by the volume of fluid flowing into and out of the amniotic sac. Fetal urination, lung fluid, and swallowing all make important contributions to fluid movement in late gestation, with minimal contributions from other sources. Fetal disorders that affect any of these processes.

What causes oligohydramnios?

Birth defects – Problems with the development of the kidneys or urinary tract which could cause little urine production, leading to low levels of amniotic fluid.

Placental problems – If the placenta is not providing enough blood and nutrients to the baby, then the baby may stop recycling fluid.

Leaking or rupture of membranes – This may be a gush of fluid or a slow constant trickle of fluid. This is due to a tear in the membrane. Premature rupture of membranes (PROM) can also result in low amniotic fluid levels.

Post Date Pregnancy - A post date pregnancy (one that goes over 42 weeks) can have low levels of amniotic fluid, which could be a result of declining placental function.

Maternal Complications - Factors such as maternal dehydration, hypertension, preeclampsia, diabetes, and chronic hypoxia can have an effect on amniotic fluid levels.

Medications - Certain drugs may cause oligohydramnios. Some drugs are used for management of high blood pressure, should be avoided in pregnancy as they affect the baby's kidney function. Certain drugs used to postpone premature labour such as indomethacin or even ibuprofen may also affect the kidney function of the baby. Talk to your doctor if you need to use these medications during your pregnancy.

An unusually large number of diagnoses seem to be made that "there is not enough amniotic fluid." It is important for parents to know that this is likely an inaccurate assessment. The diagnosis is confirmed by ultrasounds. An ultrasound examination during the second and/or third trimester of a pregnancy is a good tool to help detect the presence of oligohydramnios but it should not dictate to mothers that it is the only way. Ultrasound evaluations of amniotic fluid volumes are becoming a standard part of antepartum assessment of fetal well-being with variances in fluid levels leading to interventions that can increase the risk to both mother and baby. So, here's the point. If your doctor says, "Your fluid is low, we need to induce," don't blink blindly and say, "OK." The problem is that it is very often hard to determine "oligo" with certainty.

This measurement is commonly taken by using an ultrasound to determine the Amniotic Fluid Index (AFI). The AFI was introduced in 1987 to replace the 2 cm “pocket technique” of fluid assessment, and studies continue to question to what extent the AFI reflects actual amniotic fluid volume. The most recent studies say that the AFI is not a great predictor of the Amniotic fluid volume (actual amount of fluid. Doctors want to know the results of a Biophysical Profile to see what is going on. A biophysical profile is a simple, painless test that's performed during pregnancy to assess a foetus's well-being – specifically, whether he's getting enough oxygen inside the uterus or not.

The following criteria are assessed during a biophysical profile:

• Amniotic fluid index (AFI) – four pockets of fluid are measured; two pockets must measure 2 cm or more for a score of 2
• Fetal breathing – fetuses "practice breathing" by contracting and relaxing the diaphragm muscle; a score of 2 is assigned for fetal breathing lasting 30 seconds or more
• Fetal tone – the full extension and flexion of a limb such as opening and closing a hand
• Gross body movements – two or three episodes of movement such as squirming or kicking.

Pregnant women should ask questions such as can I get some fluids (IV, etc.) and retest? Here's some additional good info on AFI here esp relevant to "post-dates" pregnancy.

I have been seeing so many women who say their doctor wants to do a repeat ultrasound or just go ahead and induce on a certain day because it looks like the amniotic fluid is  low. These test can be sometimes so innaccurate and midwives should make people aware of this unnecessary intervention. Women should think twice before agreeing to the an induction. They should ask questions and every question posted should be answered by midwives and OB/GYN.


What I have found is most often, a woman will refuse induction on or around her due date. The doctor, for fear of liability, will order her to come in once or twice a week for non-stress tests (NST or CTG), in which they measure her amniotic fluid. These doctors will then tell the pregnant woman her fluid level is low, and they now have a medical reason to induce, and will promptly send her to the hospital. This tactic seems to be a way to convince a woman to do what the doctor tells her to by scaring her with medical jargon.

What treatment options are available for women with oligohydramnios?

A Cochrane systematic review by Hofmeyr and Gulmezoglu concluded that maternal hydration appears to increase amniotic fluid and may be beneficial in management of oligohydramnios. The amount of fluids a woman drinks daily directly influences the amount of fluid in your uterus. A 2009 study in the "Journal of Obstetrics and Gynaecology Research" demonstrated that pregnant women who had low amounts of amniotic fluid were able to increase the amount of amniotic fluid through oral hydration.

Since low amniotic fluid levels are more common during the summer, pregnant women should be advised careful to drink at least 10 cups of fluids daily, according to the Institute of Medicine. The majority of your fluids should be water, although you can also get fluids from decaffeinated tea, soup and fruit juices. Midwives should advise pregnant women to stay hydrated and monitor the baby's movements. Pregant women should take responsibility for the life they're carrying inside of them and should drink more water though I feel it is an effort for most of them.

Also, to improve the Amniotic fluid level Glucose, coconut water, water, fresh juices, etc should be consumed. Drinking tender coconut water in morning and evening will increase weight of baby also. Watermelon is also a good item to consumed during summer time when the water level in pregnant women decreases. Drink 1 glass of water every half an hour and pass urine at least once in a hour. Fluids will help with hydration. The body can't make fluid without it. Water is an important part of pregnancy. The fluid acts as the body's transportation system, and carries nutrients through the blood to the baby. This will help in preventing urinary infection also.

References
Boyd, R.L. & Carter, B.S. (2002). Polyhydramnios and Oligohydramnios. e Medicine.
Retrieved from http://www.emedicine.com/

Hofmeyr, G. J., Gulmezoglu, A. M. (2002). Maternal hydration for increasing amniotic fluid volume in oligohydramnios and normal amniotic fluid volume. In: The Cochrane Library, Issue 1,  Oxford: Updated Software.

Mozurkewich, E., Chilimigras, J., Koepke, E. et al. (2009).  Indications for induction of labour: a best-evidence review. BJOG. 116(5):626-36.

Phelan, J. P., Smith, C. V., Broussard, P., Small, M. (1987). Amniotic fluid volume assessment with the four-quadrant technique at 36–42weeks’ gestation. J Reprod Med. 32:540–542.

Polyhydramnios

Polyhydramnious or hydramnious is as an abnormally large volume of amniotic fluid. There is a range of 'normal' fluid volumes and an abnormally large volume may raise suspicion of a problem with the pregnancy. Greater deviations from the norm are more strongly associated with abnormality. The definition of "too much" is generally considered to be more than 2 liters; the average amount is about 1 liter, see  "Assessment of amniotic fluid volume".). Most cases of polyhydramnios are mild and involve less than 3 liters of amniotic fluid. So, in many cases, a diagnosis of polyhydramnios means that you're on the high side of normal for amount of amniotic fluid and presents only minor secondary concerns.

Polyhydramnios occurs in about 1 pregnancy out of 100; 95% of those are considered mild to moderate. The symptoms of hydramnios can include rapid growth of the uterus, discomfort in the abdomen, and possibly uterine contractions, but more often than not, there are no symptoms at all.

Pathogenesis

Physiologically, the volume of fluid increases with gestation to a maximum of 800-1,000 ml at 36-37 weeks. It has a number of purposes, including protecting the fetus from trauma and infection, allowing lung development and facilitating the development and movement of the limb and other skeletal parts. Fetal swallowing causes a reduction in the volume of fluid and absence of swallowing or a blockage of the fetal gastrointestinal tract may lead to polyhydramnios. Polyhydramnios is therefore linked to fetal abnormality.

Most women diagnosed with the condition deliver healthy babies. Most of the time, a little extra amniotic fluid is nothing to be concerned about. Such extra fluid is likely to be reabsorbed without any treatment. But when fluid accumulation is severe, it may signal a problem with the baby such as a central nervous system or gastrointestinal defect, kidney or bladder malfunction, or a problem with the baby's ability to swallow.

What causes polyhydramnios?

The causes of polyhydramnios are not completely understood. In many cases it's difficult to say what causes polyhydramnios but there are a few circumstances that make the condition more likely:

■Multiple / twin pregnancies - you're more likely to have abnormal amniotic fluid levels if you're carrying twins or other multiples. The cause of this is often twin-to-twin transfusion syndrome, where one twin has too little amniotic fluid and the other has too much.

 ■Gestational diabetes - greatly increases the likelihood of polyhydramnios. Around one in ten pregnant women with diabetes will develop some degree of excess amniotic fluid. If diabetes is uncontrolled or poorly controlled in pregnancy, there is a much higher incidence of polyhydramnios and the excessive amount of amniotic fluid is a direct result of the unstable diabetes.

 ■Infection - certain infections such as rubella, toxoplasmosis and syphilis may lead to polyhydramnios. These can be checked for with blood tests.

 ■Fetal abnormalities - in about a fifth of cases, excess amniotic fluid may build up when the baby has difficulties swallowing or digesting the amniotic fluid, preventing the fluid from being recycled. This could be caused by an obstruction in the baby's throat (such as cleft lip or palate) or gastrointestinal tract, or by a neurological problem. Polyhydramnios is also associated with problems with the baby's heart, kidneys and with chromosomal abnormalities.

Risk factors

In addition, too much amniotic fluid can put your pregnancy at risk for premature rupture of your membranes, premature labour, placental abruption, breech baby presentation, postpartum haemorrhage or umbilical cord prolapse.

Polyhydramnios increases the risk of postpartum haemorrhage simply because the uterus has been distended more than is usual for a singleton pregnancy.

Polyhydramnios increases the risk of placental abruption because of the mechanical forces at work in separating the placenta from the uterus. Polyhydramnios increases the risk of cord prolapse for several reasons. First, because the baby's presentation is unpredictable, the baby may be in an unfavorable position when the membranes rupture, and the presenting part may not fit into the pelvis well enough to keep the cord from falling out below. Second, because there is so much fluid, there is more pressure on the movable umbilical cord to move it out past the presenting part. If your waters do break before the start of labour you will be advised to lie down and stay reasonably still before going to hospital to reduce the likelihood of a prolapsed umbilical cord.

Growth restriction (IUGR) resulting in skeletal malformations

Stillbirth occurs in about 4 in 1000 pregnancies that suffer from polyhydramnios vs. about 2 in1000 pregnancies with normal fluid levels.

Signs and symptoms

Women might complain of abdominal girth, shortness of breath, oedema of ankles, tense abdomen.  The woman might be restless, abdominal skin might look shiny, difficult to palpate, malpresentation and abnormal lie of the foetus

Management

The first step is to identify any underlying cause. Mild polyhydramnios can be simply monitored and treated conservatively. Pre-term labour is common due to overdistension of the uterus, and measures should be taken to minimise this complication. This includes regular antenatal checks and inspection of the uterus, and bed rest towards the latter stages. Polyhydramnios during pregnancy does not have a harmful effect on the development of the baby or on the woman after delivery, and there is no evidence to suggest that it will recur in a subsequent pregnancy. Bedrest is needed.

Mbilu, J. N. K. (2002). Essentials of Obstetrics and Gynaecology for Clinical Officers and Midwives. Volume 1. Writers Club Press. Lincoln. NE.

Beloosesky, R., Ross, M. G. (2010). Polyhydramnios. UpToDate.

Yeast J. (2006). Polyhydramnios: etiology, diagnosis and management. Neoreviews. 7: 6 e300

Meconium

Meconium comes from the Greek word "meconi" which means poppi juice or opium. Meconuim is composed of all the substances that have built up in the baby’s gut during pregnancy. Meconuim is a sterile compound and is mostly water (70-80% and a number of other interesting ingredients: small bile pigment, bile acids, residue of intestinal secretions, mucus glycoprotein’s, lips and proteases etc. About 15% of babies are born with meconuim stained liquor (MAS).

Meconuim stained liquor occurs when the baby inhales meconuim during labour, birth or immediately following birth. You can see a simple explanation of MAS in utero here. Many theories have been proposed to explain the passage of meconium in utero; however, the precise mechanisms remain unclear. The fetal bowel has little peristaltic action and the anal sphincter is contracted. It is thought that hypoxia and academia cause the anal sphincter to relax, whilst at the same time increasing the production of motilin, which promotes peristalsis.

Risk factors that may cause stress on the baby before birth include:

• Aging" of the placenta if the pregnancy goes far past the due date
• Decreased oxygen to the infant while in the uterus
• Diabetes in the pregnant mother
• Difficult delivery or long labour
• High blood pressure in the pregnant mother
• Smoking
• Direct pushing
• Lack of antenatal care
• Cord involvement
• Natural therapies
• Rupture of membranes early

Induction of labour is a strong risk factor. We know that we see more meconium in induced babies. A logical guess may be that we see more meconium in postdates babies simply because postdates babies are far more likely to be induced than are 40 week.

A careful review of the recent literature indicates clearly that a policy of non-suctioning is as safe as routine suctioning at the perineum for infants born with meconium-stained amniotic fluid. Risks of intrapartum suctioning include causing the fetus to “gasp,” and causing vagal stimulation and postnatal fetal depression and / or bradycardia. Instead, the baby should be transferred quickly to the neonatal team, who will initiate  management of the neonatal airways as indicated. Evidence of the effectiveness of intrapartum suctioning comes from the results of a single retrospective cohort study indicating a non-significant trend towards improved outcomes. The results of that study have been subsequently contradicted by two other studies showing equivalent outcomes with no intrapartum suctioning.

If meconium is present during labour and birth, the pregnant should be watched more closely for signs of fetal distress. Alone, meconium staining of the amniotic fluid does not mean that a baby is suffering from fetal distress. However, since it is one sign, the labour and birth team will look for others signs and continue with the pregnancy as normal as possible without causing any discomfort.

Unsworth, J., Vause, S. (2010). Meconuim in Labour. Obstetrics, Gynaecology & Reproductive Medicine, Volume 20, Issue 10, October 2010, Pages 289-294