such as narcotics; Epidural; Caesarian birth; and Vacuum extraction and forceps delivery. Discussion of Evidence Infants born to mothers who received narcotic and/or epidural medication during labour may experience sucking difficulties in the early postpartum period. From a review of studies (AWHONN, 2000), the effects of intrapartum medications on the breastfeeding experience will vary according to the timing and the quantity of the medication administered. After a caesarian birth, breastfeeding should be initiated as soon as the mother is physically able. With a local anesthesia, initiation of breastfeeding should not be delayed. With a general anesthesia, breastfeeding should be initiated when the mother regains consciousness (Gonzales, 1990; WHO, 1998). Currently, there is insufficient evidence on induction, forceps delivery and other related factors such as length and difficulty of labour on breastfeeding. Nurses need to assess and consider how these factors might affect the early breastfeeding experience. 44 Breastfeeding Best Practice Guidelines for Nurses When to Seek Help (Level of Evidence III) Nurses must provide families with key verbal and written information on when they should seek help. It is important to emphasize to families that the presence of individual signs is not necessarily a problem, but that the identification of a pattern indicates a need for intervention by a health care professional. Information provided to families should include the following: INFORMATION FOR FAMILIES – WHEN TO SEEK HELP Weight loss greater than 7% and/or continued weight loss after Day 3 Nurses need to identify to families that the baby’s weight should ideally be taken on the same scale at each assessment. Scales have a level of variability, and taking the measurement on a consistent scale provides a means of accurate comparison. It is not expected, or encouraged, that families should be calculating this weight loss, but nurses should be familiar with the necessary calculations. Less than 3 bowel movements in a 24 hour period Meconium stool after Day 4 Less than 6 wet diapers in a 24 hour period after Day 4 Discuss with families the difference between soaked diapers and stained diapers. This is often difficult to assess with super-absorbent disposable diapers. Infant is sleepy, restless or irritable No audible swallowing while breastfeeding Refusal to feed No change in maternal breast size or milk volume by Day 5 Sore nipples Engorgement unrelieved by feeding No infant weight gain by Day 5 Birth weight has not been achieved by approximately 2 – 3 weeks Discussion of Evidence Nurses need to work with the family’s primary care provider to ensure that parents are able to identify the signs indicating the need for immediate help and further breastfeeding assessment. These signs include: weight loss greater than 7% (taken from consistent scales); continued weight loss after day 3; less than 3 bowel movements in 24 hours; meconium stool after day 4; less than 6 wet diapers in 24 hours after day 4; irritable, restless or sleepy infant; no audible swallowing; refusal to feed; no change in maternal breast size or milk volume by day 5; sore nipples; engorgement unrelieved by feeding; no infant weight gain by day 5; and infant has not returned to birth weight by 2 to 3 weeks (Huggins & Billon, 1993; Humenick, Hill & Wilhelm, 1997; Merlob, Aloni, & Prager, 1994; Neifert, 1998; Nyhan, 1952; Powers & Slusser, 1997; Righard & Alade, 1990; Shrago, 1996). 45 Nursing Best Practice Guideline Where to get additional information and resources (Level of Evidence III) Breastfeeding women and their families need to be aware of where they can access additional assistance and information regarding breastfeeding. Nurses need to be familiar with various breastfeeding resources available in the local community. These resources include, but are not limited to: lactation consultants; La Leche League; Public Health Units; community support nurses; physicians; breastfeeding clinics; and midwives. Appendix I provides a list of recommended educational resources, while Appendix J provides a framework for identifying local breastfeeding support services. Women and their families need to be aware of the importance of support for successful breastfeeding experiences. Partners will often share household tasks, but it is the frequent positive reinforcement and sensitivity to the mother’s feelings of frustration and discouragement that has been shown to be most helpful. Partners should be encouraged to explore, prior to the birth of the infant, their sources of support, including each other, family, friends and their community. The support of health care providers is essential to successful breastfeeding (CICH, 1996). Discussion of Evidence Support services have been associated with an increase in duration for breastfeeding (AWHONN, 2000). Recommendation • 5 Small, informal group health education classes, delivered in the antenatal period, have a better impact on breastfeeding initiation rates than breastfeeding literature alone or combined with formal, non-interactive methods of teaching. (Level of Evidence I) Nurses may offer breastfeeding information early during pregnancy (first trimester) through: Group classes (Duffy et al., 1997; Kistin et al., 1990; Pugin et al.,1996; Wiles, 1984); Peer groups (Caulfield et al., 1998; Long et al., 1995; Morrow et al., 1999); and