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(Outcome of Non-Protractile Nipple Correction with Breast รศ.นพ.พฤหัส จันทรประภาพ ภาควิชาสูติศาสตร- นรีเวชวิทยา ผลลัพธของการแกไขภาวะหัวนมสั้นในหญิงตงครรภั้ โดยใช ปทุมแกว: การศึกษาแบบสุมอําพราง (Outcome of Non‐protractile Nipple น.ส.จินดา ลัทธลาภกุล งานการพยาบาลสูตศาสตริ -นรีเวชวิทยา Correction with Breast Cups in Pregnant Women: A Randomized Controlled Trial) น.ส.สมประสงค ศิริบริรักษ คณะแพทยศาสตรศิริ ิิราชพยาบาล น.ส.ศรีสวาท บุณยวานิชกลุ มหาวิทยาลิ ัยมหั ิดลิ ที่มาและความสําคัญของปญหา ANC Lactation Clinic Data 2008 2009 2010 2011 1. ANC Patients 6,787 6,500 6,281 6,437 2. Number of patients 1,375 1,226 1,000 1,049 with nipple or areola 20.26% 18.86% 15.92% 16.30% abnormality underwent treatment หัวนมปกติ หัวนมผิดปกติ From: Siriraj OB/GYN Nursing Division วิธิ ีการแกี ไขห ัวนม Nipple puller Hoffman’s exercies Mothers with nipple length of >=7 mm of at least one side could succeed in BF of 4.38 times greater than those with shorter nipple Breast cups Preparing for breast feeding: treatment of inverted and non-non-protractileprotractile nipples in pregnancy. The MAIN Trial Collaborative Group. randomized controlled trial with a two treatment by two level factorial design. SETTING: in the UK, antenatal clinics in hospital and community settings in 10 centres and the antenatal network of the National Childbirth Trust; in Ontario, Canada, antenatal clinics in six hospital centres and one public health unit. PARTICIPANTS: 463 women with at least one inverted or non-protractile nipple and a singleton pregnancy, recruited between 25 completed and 35 completed weeks of pregnancy. PRIMARY OUTCOME MEASURE: rate of breast feeding as reported by postal questionnaire six weeks postnatally. FINDINGS: 107 out of 234 (46%) women allocated to use Hoffman's exercises compared with 100/229 (44%) women not allocated to use exercises were breast feeding at six weeks after delivery (difference 2%, 95% confidence interval -7% to 11%). One hundred and three out of 230 (45%) women allocated to use shells compared with 104/233 (45%) women not allocated to use breast shells were breast feeding at six weeks after delivery (difference 0%, 95% confidence interval -9% to 9%). CONCLUSIONS: in the light of the findings from this and a previous single centre trial, there is not basis for recommending the use of either Hoffman's nipple stretching exercises or breast shells as antenatal preparation for women with inverted and nonprotractile nipples who wish to breast feed. Given the lack of evidence to support these and other antenatal preparations there are no grounds for midwives to continue routine breast examination in pregnancy for this purpose Paper Review Review Paper Paper • Midwifery 1994; 10: 200-14. วัตถุประสงค เพื่อศึกษาเปรียบเทียบคาความยาวของหัวนมที่เปลี่ยนแปลง กอนและหลังระหวางกลุมที่ใชปทุมแกวและกลุมที่ไมไดแกไข หัวนมกอนคลอด เพื่อศึกษาดูความสําเร็จของการใหลูกดูดนมในระยะหลังคลอด วิธิ ีการศี ึกษาึ เพื่อศึกษาดูความพึงพอใจของผูปวยในการใชปทุมแกวเพื่อแกไข ภาวะหัวนมสั้น สถานที่ที่ ําการศึกษา ประชากรศึกษา Inclusion Exclusion ตั้งครรภเดี่ยว ไมทราบอายุครรภที่แนนอน มีอายุระหวาง 18-40 ปและมีอายุครรภไมเกิน เคยผาตัดบริเวณเตานมหรือหัวนมมากอน 20 สัปดาห มีความผิดปกติของหัวนมชนิดหัวนมบุม ไมเคยเลี้ยงลูกดวยนมแมมากอน หรือเคย (inverted nipple) ทั้งกอนและหลังทําการ กระตุนหัวนมดวยการคลึงหัวนม (nipple Antenatal Lactation Clinic เลี้ยงลูกดวยนมแมแตไมตอเนื่องถึง 6 สัปดาห มีความยาวของหัวนมขางใดขางหนึ่งตั้งแต rolling) เปนเวลา 5 วินาที และหัวนมบุมเมื่อ 0 ซม. จนถึงนอยกวา 0.7 ซม. ทั้งนี้ตอง ทําการตรวจดวยวิธี Pinch test ตรวจวัดภายหลังกระตุนหัวนมดวยวิธีคลึง มีประวัติเคยคลอดบุตรกอนกําหนด หัวนม (nipple rolling) เปนเวลา 5 วินาที มารับการตรวจติดตามไดไมถึงอายุครรภ แลว 36 สัปดาห และหรือนอยกวา 5 ครั้ง ยินยอมและไดลงนามเขารวมในการศึกษา ไมสามารถติดตามผลการคลอดได ครั้งนี้ Withdrawal Labor Room Postpartum Ward หญิงที่ไมสามารถทําตามคําแนะนําหรือหญิงที่คลอดกอนกําหนดจะถูกถอนออกจากการศึกษา หญิงตั้งครรภที่มาฝากครรภใหม @ GA 20 wk 1 2 Expectant หัวนมขางใดขางหนึ่งมีความผิดปกติ กลุมที่ ใชปทุมแกว กลุมที่ หัวนมสั้น <7 มม.(หลังคลึง 5 วินาที) หัวนมไมบุม ( -ve Pinch test) นัด F/U เพื่อประเมินความยาวหัวนม ทุก 4 สัปดาห จนถึง อายุครรภ 36 สัปดาห ( 4 ครั้ง) คุณสมบัติตรงตามเกณฑการคัดเลือก คุณสมบัติไมตรงตามเกณฑการคัดเลือก ประเมินความยาวหัวนมในวันที่มาคลอด ลงชื่อยินยอมเขารวมการวิจัย กลุมที่ 1 ใชปทุมแกว (48) ประเมินความสําเร็จในการเล้ี้ยงลูกดวยนมในวันท่ี่1, 3 ประเมิน LATCH score ในวันที่ 3 หลังคลอด ซํํกประวป ััติิ บัันทึึกขอมูลพื้ื้นฐาน (Blocked randomization) ประเมินความสําเร็จในการเลี้ยงลูกดวยนม สัปดาหที่ 6 และ 12 หลังคลอด ทางโทรศัพท ตรวจวัดความยาว ความกวางหัวนมและลานหัวนม (96) กลุมที่ 2 Expectant (48) วิธีการศึกษา วิธีการศึกษา Ta bl e 11.. Demographic data of sample population (N = 90)90) Breast Cup Group Expectant Group Characteristic p-value (n = 43)* (n = 47)* 25.24 +/-4.97 25.21 +/- 5.63 .984 Age (y) 59.36 + /-12.99 55.80 + /-12.38 .188 ผลการศึกษาวิจัย Weight (kg) 158.47 +/- 4.99 157.60 +/- 6.72 .486 Height (cm) 16.94 +/- 1.16 16.67 + /-1.13 .259 Initial GA (wk) 38.60 +/- 1.33 38.81 + /-1.34 .554 GA at delivery (wk) The statistical significance was analyzed by independent T test *Exclude: Non pregnancy outcome, Abortion, Pseudo inverted nipple, Lost F/U, GA @ delivery < 36 wk. Ta b l e 3.3 . The number of women who had converted from very short Ta bl e 2.2 . Pre and post treatment of the nipple length and diameter or short nipple to normal nipple after treatment in both groups between 2 groups (N = 90)90) (N = 9090)) Group Post-treatment Very short nipple Short nipple Normal nipple Breast Cup Group Expectant Group Mean Difference + 95% CI of the m Data p-value (<4.0 m .) (4.0 mm. - 6.9 mm.) (>7.0 mm.) (n = 43)** (n = 47)** Std. Error Difference Difference Pre-treatment Nipple Length (NL) Breast cup Very short nipple 2 13 5 Pre-treatment NL (mm) 4.19 + 1.08 4.41 + 1.29 -0.22 + 0.25 -0.71, 0.28 .387 (n = 43)* (<4.0 mm.) (10.0 %) (65.0 %) (25.0 %) 21 Post-treatment NL (mm) 6.56 + 1.77 6.25 + 1.59 0.31 + 0.35 -0.39, 1.02 .379 Short nipple 1 6 (48.84%)16 NL improvement (mm) 2.37 + 1.29 1.84 + 0.98 0.53 + 0.24 0.05, 1.01 .032* (4.0 mm. - 6.9 mm.) (4.3%) (26.1%) (69.6%) Nipple Diameter (ND) Expectant Very short nipple 4 19 1 Pre-treatment ND (mm) 12.05 + 1.58 11.72 + 1.43 0.34 + 0.32 -0.29, 0.97 .858 (n = 47)* (< 4.0 mm.) (16.7 %) (79.2 %) (4.2 %) 13.67 + 2.10 13.23 + 1.96 0.38 + 0.43 -0.48, 1.24 .378 15 Post-treatment ND (mm) (31.9 %) ND improvement (mm) 1.62 + 1.50 1.57 + 1.19 0.52 + 0.29 0.48, 1.01 .858 Short nipple 0 9 14 The statistical significance was analyzed with independent T test (4.0 mm. - 6.9 mm.) (0%) (43.3%) (60.9%) * statistical significant ** Exclude: Non pregnancy outcome, Abortion, Pseudo inverted nipple, Lost F/U, *Exclude: Non pregnancy outcome, Abortion, Pseudo inverted nipple, Lost F/U, GA @ delivery < 36 wk. GA @ delivery < 36 wk. Ta bl e 44.. The number of successful breastfeeding cases Ta bl e 55.. Infant feeding type on the 3rd day, 6th and 12th week after (LATCH score > 77)) on day 3 after delivery in both groups delivery in both groups (N = 90)90) Postpartum Period Infant Feeding Type Breast Cup Group Expectant Group p-value (%) (%) Day 3 Exclusive breastfeeding 11 23 (65 cases) (37.9) (63.9) Breast Cup Group Expectant Group .037* LATCH score Pearson Chi-Square) Mixed feeding 18 13 (24) (31) (62.1) (36.1) > 79 7 6th week Exclusive breastfeeding 19 20 (57 cases) (67.86) (66.6) (37.5%) (22.6%) Mixed feeding 9 9 .182* .62 < 7 15 24 (32.14) (30.0) Infant formula feeding - 1 (62.5%) (77.4%) (3.33) 12th week Exclusive breastfeeding 17 15 (56 cases) (65.39) (50.0) * no statistical significance Mixed feeding 8 11 .35 (30.77) (36.67) Infant formula feeding 1 4 ** Exclude: Non pregnancy outcome, Abortion, Pseudo inverted nipple, Lost F/U, GA @ delivery < 36 wk. (3.85) (13.33) * statistical significance (by Pearson Chi-Square) Ta bl e 66.. The percentage of treatment satisfaction Ta bl e 6.6 . The percentage of side effect in the breast and side effect in the breast cup group cup group and the expectant group Satisfaction (41 cases) Number % BC Exp Excellent 16 37.2 ( N = 30 ) ( N = 29 ) 41 Good 17 39.5 (95.1%) Uterine Contraction 14 28 Fair 6 14.0 32.6% 59.6% Poor 2 4.7 Uncomfortable 18 3 41.9% 6.4% Skin rash 6 2 14% 4.3% บทเรียนที ี่ไดี่ ร ับจากการทั ําวํ ิจิ ัยั 1. วิธีการทํางานเปนทีม 2. วิธีการบริหารจัดการทรัพยากรตาง ๆ อยางเหมาะสม 3. วิธีการบริหารจัดการบุคลากรในการทําหนาที่ตาง ๆ อยาง เหมาะสม ความเปลี่ยนแปลงภายหลังงานวิจัย 4. วิธีการจัดเก็บขอมูลที่ดีและมีประสิทธิภาพ 5. วิธีการติดตอสื่อสารระหวางทีมผูวิจัยอยาง ANC RN 1 min Normal 48 min 1 2 Booking SANA Nipple & Breast 4 min Activity Care Advice Assessment RN 30 min Abnormal 3 BF Education for ALL 5 min 6 10 min at 7.30 a.m. everyday Nipple correction RN RN & Advice @ ANCL 4 VDO presentation 30 min Make an appointment 2 min RN for the next F/U RN 5 Summary then 20 min Q & A RN Abnormal Nipple Normal nipple : Total Process = 6 Total Process = 5 TAT = 150 min TAT = 138 min Value Added Time = 72 min Value Added Time = 60 min % Value Added = 48 % % Value Added = 43.47% คําแนะนํ ํานมแมํ ระหว างรอตรวจ คําแนะนํ ํานมแมํ หน าห องตรวจ กอนงานวิจัยยหลหลังงานวั ิจิ ัยั หองตรวจเตานม คําแนะนํ ําการแกํ ไขห ัวนมในหั องตรวจ กอนงานวิจัยยหลหลังงานวั ิจิ ัยั หองการเร ียนการสอนี หองการเรียนการสอน (ตอ) Innovation Siriraj Breast cups 2 in 1 (SBC 2 in 11)) Siriraj Breast cups 2 in 1 (SBC 2 in 11)) Nipple Ruler Miracle Breast Madonna Jacket Booby Gaga Siriraj Breast Cups 2 in 1 (SBC 2 in 11)).
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