Supporting exclusive breastfeeding from birth to discharge requires a very specific skillset. Much of what is written online today for lactation professionals skims over this critical juncture of a mother and baby’s breastfeeding journey. There are model breastfeeding policies, protocols, guidelines, etc. There are recommendations for physicians caring for newborns and postpartum women. There are nursing protocols to help nurses keep their patients safe as they recover. But for those whose specific duty it is to ensure breastfeeding is successful, the instruction manual is broadly painted and depends largely on the institution in which they work. The daily objectives can vary, the support of other staff can confound the practice, and the long-term recommendations for babies to be exclusively breastfed for at least 6 months can easily be lost in the chaos of the lightning-fast discharge process. Keeping it simple is always the best course, and applying The First 100 Hours© strategy ensures consistency among staff and patients.
– Consider each dyad from the perspective of how many hours postpartum they are. By thinking specifically about how many hours it has been since the birth, rather than how many days or nights it has been, you can form an estimate or vision of what *should* be happening right now.
– Know the indicators and assess the dyad thoroughly. What is happening with their breastfeeding situation, what has already happened, what should be coming up next?
– Provide appropriate clinical care and education based on the exact timeframe of the dyad. A 6-hour old baby who hasn’t latched needs far different clinical care than a 24-hour old who hasn’t latched. A dyad being discharged home at 28 hours postpartum needs different teaching than a dyad being discharged home at 56 hours and in Stage II Lactogenesis.
Let’s play with the strategy here with some fictional examples:
– Dyad 1, the Washingtons: still in postpartum unit, 50 hours old, baby born at 39 weeks + 5 days after induction of labor and with epidural pain management. Now exhibiting a high intermediate jaundice level and physician is recommending supplementation after every feeding. To this point, baby has been exclusively breastfeeding. Mrs. Washington reports to nursing staff that breastfeeding is going well, she is experienced (nursed her previous baby past one month) and denies pain with latch or nipple trauma. When I focus on this dyad through my First 100 Hours© lens, the first thing I think, without knowing any other information, is that at this time there is a strong likelihood that Mrs. Washington is in Stage II Lactogenesis. When I speak to her, that is the primary factor I want to research because it will determine whether she will be supplementing with her own milk or with formula. If she has copious amounts of colostrum or if her breasts are already feeling fuller or (hopefully not!) engorged, these factors mean she is unlikely to need to interrupt breastfeeding or breastmilk-feeding. *(In facilities where policies or physician practice dictate automatic additional feeds with formula in cases of jaundice, The First 100 Hours© strategy addresses the importance of teaching the mother to protect and manage her milk supply until she can resume exclusive breastfeeding.)
– Dyad 2, the deOliveiras: 9-hour old, healthy baby born at 38 weeks in a very fast labor and birth process with minimal pushing effort, has breastfed 3 times since birth, has not had a bath yet, and has had 2 stools. Baby is sound asleep, skin-to-skin on his mother’s chest. What do we need to do to help? Nothing. They’ve got this. There are No Indicators of Problems here. When this baby is ready, he will easily let his mama know. If he were wrapped in 3 receiving blankets and being passed around to visitors, it would be wise to intervene and resume skin-to-skin contact.
Dyad 3, the Garcias: a 35-week, 5 lb 10 oz girl born by cesarean due to breech presentation, now 80 hours old. Baby has mild jaundice, has lost 9 oz since birth, and mother has had difficulty waking her and keeping her awake during feeds. When you ask Ms Garcia, she says her breasts do not feel “different” yet; you can see her swollen feet sticking out from her blankets and her hands are so puffy she has trouble changing the baby’s diaper. She started giving the baby formula every 3 hours yesterday because she knew the baby was not eating enough, and she has been breastfeeding as often as the baby is willing. My first thought: if her breasts don’t feel different, are her areolas puffy like her hands from all the excess fluids? Or is she experiencing Delayed Onset of Stage II Lactogenesis? Either way, her milk supply needs intervention quickly. If we don’t address it now, it may be compromised permanently, rendering her unable to ever fully breastfeed if that is her intention, or creating complications for her such as plugged ducts or severe engorgement, mastitis, or even abscess.
Now that we have examined some narrative examples, let’s look at some documentation. These forms were developed as part of The First 100 Hours© strategy to facilitate thorough, efficient assessment of the breastfeeding dyad within or just after the first 100 hours postpartum. As above, the dyads are not based on real patients but represent common situations recognizable to any hospital-based IBCLC in 2014.
This type of documentation tells a story. In this example, the story is that breastfeeding has been interrupted by non-medically indicated formula use, and the mother has not even reached Stage II Lactogenesis yet. This mother needs a great deal of education and support at this point, an observation of breastfeeding with specific attention to helping the mother to observe signs of milk transfer, and a really good follow-up plan. This mother can likely resume exclusive breastfeeding rather quickly – some timely teaching may just be what motivates her to do so.
Here we read the story of Jennifer and her 4th child, Jayden, who are experiencing breastfeeding difficulties even though she has plenty of experience. Note that in this example, Jennifer and her son have passed the First 100 Hours© landmark already. She knows that something is not right, and the fact that she is only able to pump right now when she really intended to breastfeed tells us that this dyad needs a face-to-face consultation as soon as possible. It’s really helpful to have the information about how things unfolded during this baby’s first days of life because it tells the story of how much this mother already understands basic breastfeeding management.
Ooh, look, an easy one! The biggest challenge we can predict for Tameika is avoiding the engorgement she experienced with her previous baby. We’ll give her lots of tips on preventing engorgement, and we’ll talk about exactly who to call if she runs into a problem. Most of us who work in hospitals wish more of our patients were like Tameika and Ashantae – straightforward, uncomplicated, basic breastfeeding management.
However, a lot of our time is actually spent with dyads like the next one:
These cases can be overwhelming. When we have a really complicated case like this one, it’s easy to think: where do we even start? Well, when the relevant information is listed out like a story this way, it’s a bit easier to go step-by-step through all of the interventions this situation demands. Since this mother is calling on the phone to get help, the first priority based on all of this information is to determine when, what, and how the baby last ate. Once we know the baby has recently had a feeding, we can begin addressing the gaps: Alexis needs a really specific plan for keeping her baby feeding regularly and for regular milk expression, and she needs to understand her baby’s individual needs as a Late Preterm Infant who has not been feeding well overall since birth. Finally, Alexis needs to know who will be there to help her in her breastfeeding journey, and that it’s not over just because she came upon some early challenges.
Caring for breastfeeding dyads in the hospital during the first postpartum days is really challenging work. Hospital-based IBCLCs as a group are accustomed to not getting feedback from the majority of their patients. The relatively few mothers who do call us back with questions or come back in for more help are the ones who educate us, inspire us, and strengthen us for our future patients.
Copyright 2014 by Christine Staricka, BS, IBCLC, CCE