Early breastfeeding learning scenario

(February 2017)

Something a little different today. There is a scenario which many midwives may be familiar with. It is constructed from my imagination/experience and so no fears about confidentiality though I suspect you may feel you recognise it. Have a read and then consider my questions at the end.

A woman has a normal vaginal birth of her first baby around mid afternoon. She is absolutely over the moon and desperate to breastfeed; it was in her plan and she really feels it is the best thing for her baby having been to antenatal classes and done a bit of reading. She is thrilled when her little boy latches on first time and assures you that it doesn’t hurt. You can see that baby has a good latch, he stays on for a good 20 minutes before dozing off and she is transferred to the postnatal ward. You hand over to the midwife that the baby has fed well and they are both for routine postnatal care including feeding support.

The following day you are assigned to the postnatal ward and on seeing the woman’s name on the board, choose her bay as it will be lovely to have some continuity. After handover you go to say hello to everyone and she is tired but well and baby fed loads which she is really happy about. However she tells you that her nipples are extremely sore and despite loads of support overnight she feels they are ‘shredded’ (or words to that effect) and asks you to take a look. They both look pretty bad, her skin is naturally very pale and you reflect inwardly that very pale skinned women often suffer a bit more with sore nipples. Her baby is stirring and so you offer to give her some support to latch the baby on. Her technique is really good and the baby latches on but it is immediately apparent that the pain is excruciating and after about 10 seconds of no improvement you encourage her to unlatch the baby to avoid further damage. The nipple is red and a bit misshapen and now she is reluctant to put the baby back to the breast and tells you that she will express colostrum as she has loads and give that to the baby. She manages to express nearly 3mls and gives that straight to her little one who settles nicely.

The baby is not yet 24 hours old and has no risk factors for hypoglycaemia, is responding normally and has passed meconium as well as a wet nappy in the early hours of the morning. Everything is telling you that this baby is normal, with normal reserves. You say that you are not worried about the health of her baby at the moment and suggest that staying another night would probably help so she gets some support to establish an improving latch. Her partner seems supportive and simply says that she must do what she feels is best.

Fast forward 7 or 8 hours, the woman has not yet put the baby back to the breast due to the pain and has been expressing similar amounts of colostrum and requested a 15 ml top up of formula milk which she was given. She has now informed you that she is worried that the baby isn’t getting enough milk from her, she is tearful, doesn’t want to stay any longer in the postnatal ward (no offense she says!) and wants to go home. It is about 5pm and the baby is now just over 24 hours old.

Over to you…
How would you write the end of this story?
What is your plan? What are you thinking? What are you wondering? What do you WANT to say? What WILL you say? What are your fears? What do you imagine might happen?