Vol. 9 Issue 9
Lactation nurses are following new models of care for new mothers, focusing on fewer interruptions
Nurse researchers at Case Western Reserve University in Cleveland recently published a study showing new mothers are interrupted a mean of 54 times in a 12-hour period on the first day postpartum (Morrison, B., et al. Journal of Obstetric, Gynecologic and Neonatal Nursing). In addition, those interruptions were perceived to negatively impact breastfeeding.
When Dawn Kersula, MA, RN, IBCLC, a perinatal educator and lactation specialist at The Birthing Center at Brattleboro Memorial Hospital, Brattleboro, VT, read the study results, she wasn't surprised.
"I'm on LACTNET, which is an online community of lactation consultants who are very lively and up-to-date with their discussions," she said, referring to debate on the Internet triggered by the study's results. "We all said, 'Well, those interruptions are coming from having too many visitors.' But then we looked closer and found that wasn't the case at all. The interruptions were coming from the nursing staff itself!"
A Paradigm Shift
Bonnie Henson, BS, RN, IBCLC, clinical operations manager for prenatal education and lactation support services at Memorial Care Center for Women at Miller Children's Hospital and Long Beach Memorial Medical Center, Long Beach, CA, affirmed the study's results.
"We did a similar look here by examining how often moms were interrupted when nursery nurses were responsible for the babies, and postpartum nurses for the mothers," she said. "We found numbers that were about the same as those in the research. We used this information as part of our decision to change to a mother-baby model of care with one nurse responsible for the family unit."
Whatever the model of care, the study certainly provides data for an important discussion around the topic of breastfeeding in the postpartum period.
"How do you start shifting a paradigm unless you know what's going on?" Kersula asked rhetorically. "We need to go back to the basics of good nursing care. How many times do you find yourself dropping into the patient's room only to realize you've forgotten something and running back out? We encourage our staff to think ahead of time about what they want to accomplish that day in terms of patient care and teaching, and to provide that care and education without excessive interruptions."
Annette Leary, BSN, RN, IBCLC, a lactation consultant at Winnie Palmer Hospital for Women and Babies in Orlando, FL, said her facility provides nursing staff a training course on lactation, I Can Help Mothers and Babies Learn to Breastfeed, which includes 3 hours of lecture and 12 hours of clinical time working with breastfeeding mothers. "The nurses tell me, 'I can't believe how many times that door opened and closed with people going in and out when I was in there helping the mom to breastfeed,' Leary said. "It's an eye-opening experience."
Added Bernadette Maloney, MSN, RN,C, IBCLC, women's health education coordinator at St. David's Hospital, Austin, TX: "Think of all the staff members who interact with the new mom over the course of a day – the postpartum and nursery nurses, obstetricians, pediatricians É registrars and photographer. We're certainly conscious of how overwhelming it can be for the new mom to interact with all those people."
The Golden Hour
Memorial Care's Henson believes new moms need uninterrupted private time with their babies from the very beginning. "It's tough to provide that uninterrupted time for mothers and babies to establish breastfeeding," she acknowledged.
"As soon as a baby is born, we put that neonate skin-to-skin with mom and give them an hour together uninterrupted. That allows mom and her significant other to hold the baby, gaze into the baby's eyes, and examine him," Henson continued. "The baby will innately move toward the breast and latch-on. If babies have that initial experience, they'll do better with breastfeeding, because they've realized, 'Ah-ha, this is where I get my food!'"
Delaying non-urgent nursing care for an hour after birth has boosted breastfeeding success rates, Henson added. "When we first tracked initiation of breastfeeding within the first hour of birth on vaginally delivered mothers, we had 25 percent of the moms breastfeeding within the first hour," she said. "Now we are seeing approximately 83 percent of the mothers initiating breastfeeding in that first hour."
Lactation experts agree empowering mothers is an important step in establishing successful breastfeeding.
"It's important we give the babies back to their mothers; we don't own these neonates," Kersula emphasized. "As a lactation specialist, I can't schedule a baby's eating, so I need to establish a relationship with the new mother. I'll tell her, 'Give a yell the next time he starts rooting around, and I'll come in to help you fine-tune your breastfeeding.'"
At Brattleboro, each new mom is given a set of four magnetic signs to place on her door. "We let her know, 'You're in charge of your environment,'" Kersula said. "There's 'Visitors Welcome,' 'No Visitors,' 'Mother and Baby Sleeping,' and 'Mother and Baby Feeding.' We also have room service available so the mother can order what she wants to eat and have it delivered anytime between 7 a.m. and 5 p.m."
For the sake of the mother, Kersula encourages nurses to take an unhurried approach to newborn care and lactation. "It's important for them to feel they have a friend in the birthing center who is interested in the well-being of both mother and baby, instead of thinking, 'Oh no, here comes that nurse again who's in such a big hurry,'" she said.
Just Say 'No'
First-time mothers in particular may be reluctant to speak up, Leary said. "We tell them it's OK to say 'no' to an interruption, as long as the baby isn't compromised." That includes the birth registrar, lactation consultant, casual visitor or virtually anyone else who might interrupt breastfeeding, she added.
Martha Lasley, BSN, RN, IBCLC, manager of maternal education at Winnie Palmer Hospital, encourages nurses to advocate for new mothers establishing breastfeeding. For instance, "if a pediatrician is making rounds, and the new mom has just started breastfeeding her baby, it's OK to ask if that interruption can wait," she said.
Ensuring a new mom's privacy is another important role of the nurse advocate, said Diane Bolin, RN, IBCLC, obstetrics coordinator at Provena United Samaritans Medical Center in Danville, IL. "We encourage visitors to arrive after 10 a.m.," she said. "And if moms are shy about breastfeeding, we'll ask visitors to step down to the waiting room and maybe offer them a cup of coffee."
Sometimes it can be a challenge providing needed nursing care while ensuring privacy for new moms, Maloney said.
"Our nurses try to bundle their care to reduce interruptions, but this can be difficult with the frequent assessments needed to detect hemorrhage or other complications," she said. "And with the C-section rate up, those assessments go well beyond the first 24 hours. The postpartum nurses do a good job of saying to the mothers, 'Let me take care of these things now so you can rest.'"
Provena's Bolin has found hourly rounds can reduce the number of interruptions. "We make hourly rounds at the top of the hour [going in to see if the moms need anything] so they know when to expect us," she said. "At that time, we can take care of any planned nursing care and address any of the mom's concerns."
Coordination & Collaboration
As a lactation consultant, Maloney works with other staff members to coordinate care.
"If a nurse is in the room doing an assessment when I knock on the door, I'll wait outside for a bit so I can go right in when the nurse is done," she said. "That way, I'm not coming back for yet another interruption."
At Winnie Palmer, nurses collaborate with the new moms to reduce interruptions. In fact, new mothers even have the number for their nurse's wireless phone written on a board in the room, Leary said. That way, nurses don't need to drop in and out of the room to see if the mother needs anything.
"The nurse or the nursing assistant should say to the mother, 'Is there anything else I can do for you before I leave the room?'" she added. "We also encourage mothers to write down their questions as they come up, so they can ask when [a nurse] is in the room."
Rather than scheduling special teaching sessions, nurses should incorporate education into the ongoing care of the mother and baby.
"Instead of asking about the baby's pees and poops at one visit, and then coming back for well-baby instructions, include information about the number of wet diapers in that first visit," Leary said. "Likewise, when you're handing the mother pain medication, teach her about pain management after discharge right on the spot."
Janet Johnson-Yosgott, MPH, a childbirth educator and breastfeeding expert with Health Net of California in Rancho Cordova, said nurses need to be sure new mothers anticipate being left alone at times.
"There needs to be a plan to educate these women about this goal of providing private time, so they don't feel the nurses are ignoring their healthcare needs," she cautioned. "Nurses can talk about this goal and encourage women to use their call lights whenever they need assistance.
"Reassure them that efforts will be made to provide them with quiet time to bond with their baby and establish breastfeeding, but that nurses will respond whenever their assistance is requested."
Morrison, B., et al. (2006). Interruptions to breastfeeding dyads on postpartum day 1 in a university hospital. Journal of Obstetric, Gynecologic and Neonatal Nursing, 35(6), 709-716.
Sandy Keefe is a frequent contributor to ADVANCE.