Access KeysSkip to MenuSkip to ContentSkip to Footer

6.6 Discharge planning

The goal of discharge planning is two-fold


It is the duty of care of the health professionals caring for the mother-baby dyad to ensure that all mothers know how to recognise wellness in their baby and adequate transfer of milk and to react quickly when anything abnormal occurs.

Preventing common problems

Timing of follow-up

Routine follow-up with a qualified health care provider must be confirmed with the parents prior to discharge. A suggested Clinical Practice Guideline recommends the following appointment schedule:2

Age of infant at discharge Should be seen by
Before 24hr old 72 hrs (3 days)
From 24 - <48 hrs 96 hrs (4 days)
From 48 - 72 hrs 120 hrs (5 days)
For some newborns discharged before 48 hours, 2 follow-up visits may be required, the first visit between 24 and 72 hours and the second between 72 and 120 hours.

Critical warning signs

The 3 Red Flags!

Optimal birth circumstances and good postnatal breastfeeding care will significantly reduce the incidence of infant problems. Each of these signs is an indicator that there may be a breastfeeding problem or something more serious.
Any of these signs need immediate medical attention.

#1. Baby's output is less than expected.

Review the output table in 6.2 Breastfeeding Messages

Do all mothers have a copy of that table to take home?

Output is a direct indicator of intake - ensure that you can accurately describe normal urine and stool output of the breastfed infant. There are visual aids available to show parents what to expect.

Ask about the pinkish/rusty stain on a nappy/diaper which is urates in urine. This is normal until baby is 72 hours old (3 completed days). Secretion of urates in urine is a direct function of the serum uric acid concentration (ie blood levels). It is normal to see urates on a nappy/diaper with a scant volume of urine until Day 4. As the milk intake increases on Day 4 urates should no longer be seen.

A note of caution to health professionals who provide only telephone consultations ... your image of a wet nappy/diaper, or a reasonable bowel action may not match the mother's impression. Urine should be clear and each nappy/diaper heavy. Although not a pleasant image, it is helpful to describe a 'handful' size as being a good volume of stooling. This is a very clear picture and will help the mother understand that scant frequent stainings are inadequate.

If there is any doubt at all you must organize for the baby to have medical review urgently.

#2. Breastfeeding is painful.

Breastfeeding should not be painful.

Pain during feeding, misshapen or damaged nipples or pain continuing after the feeding are all indicators that baby is poorly latched and milk transfer will be compromised. A hot or inflamed painful breast is a sign of severe engorgement, or mastitis with reduced milk transfer as a result. Painful breastfeeding is abnormal!

Immediately seek help from an expert in breastfeeding.

#3. Increasing jaundice

Jaundice is a physiological state and is an expected developmental state for the majority of breastfed babies. Jaundice peaks at about Day 3 then gradually fades over the next few weeks. Jaundice should not be seen below the level of the umbilicus.

Increasing jaundice causes sleepiness and poor feeding; conversely, poor feeding causes increased jaundice.

Teach parents to check for jaundice by observing their baby in natural daylight and putting finger pressure on their baby's forehead, upper chest, arms, abdomen and upper legs, and observe for blanching.

Instruct parents that increasing jaundice or jaundice at or below nipple line is to be reported immediately to their baby's health professional.

Return for immediate assessment

  • Urine and stool output less than normal or urates persist after the 3rd completed day
  • Nipple damage, pain; painful or inflamed breasts
  • Increasing jaundice

Workbook Activity 6.6

Complete Activity 6.6 in your workbook.

These signs or symptoms are the most important for the parents to remember and seek help with if they develop.

Some instructions are very complicated and often confuse education about breastfeeding with Red Flags, for example, telling parents to count a minimum number of feeds per day, or to be concerned about sleepy babies. If these markers become a problem then one or more of the Red Flags will also be evident.

Succinct instructions will more likely be remembered by parents. Ensure they know how to seek urgent review from their health care provider whenever any one or more of those points are abnormal.

Contraception

Preventing an unwanted pregnancy is important to women, and adequate child-spacing is important to the mother's health and the health of the new baby. Breastfeeding is also of paramount importance to the health of both mother and baby.

It is preferable for the mother to recover her nutritional status following the demands of pregnancy and lactation. Recovery of these stores prior to a subsequent pregnancy is important for her health - a recuperative period of less than 6 months between the end of breastfeeding and the next pregnancy is associated with depletion of maternal nutrient stores.3

Mothers therefore require counselling on selection of a contraceptive method that is

  • highly effective in preventing pregnancy, and
  • does not interfere with breastfeeding.

The Lactational Amenorrhea Method (LAM) of contraception has been extensively studied and found to be more effective than the progestin-only contraceptive pill. Additionally all forms of hormonal contraceptive have the potential to adversely affect breastfeeding.

Using the Lactational Amenorrhea Method of contraception

Using the Lactational Amenorrhea Method of contraception.
Graphic © Health e-Learning


Contraception for breastfeeding mothers

To read more about other contraceptive methods during lactation click on the icon on the left, print the page and file it with your course notes. From this page you'll find further links and references.

The quality of contraceptive/fertility counselling given to a woman significantly influences its effectiveness. When giving advice about any contraception ensure you understand it completely.

Workbook Activity 6.7

Complete Activity 6.7 in your workbook.

Consolidating learning

Practical skills should be reinforced by educational materials which must be

  • accurate,
  • consistent within themselves and with previous verbal teaching,
  • written at an appropriate reading-age, and
  • free from commercial advertising.

Resource materials for mothers

Form a group to look at ALL the materials that are given to mothers. Each one should be discussed and explained to the mother as it is given. Are all the materials necessary? Are all staff familiar with the materials?

"The critical warning signs" handout is the most important - does it stand out from the brochures? Perhaps you could start a working group to design/update this vital parent information page?

Discharge packs DO influence actions, particularly in regard to breastfeeding. Artificial formula company sponsored packs reduce the likelihood of exclusive breastfeeding4 and therefore for the health and safety of mother and baby they should not be distributed by any health care facilities.

Referral to mother-to-mother support network

Baby Friendly Step 10 and Point 7

Step 10 of the Ten Steps to Successful Breastfeeding, and Point 7 of the Seven-point Plan for Sustaining Breastfeeding in the Community state:
Step 10: Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.
Point 7: Promote co-operation between health care staff, breastfeeding support groups and the local community.

Attendance at mother-to-mother support groups or follow-up by peer counselors has demonstrated significant increases in maintaining exclusive breastfeeding.5,6 7 Strategies that depend mainly on face-to-face support appear more effective than those that rely primarily on telephone contact. 8 Parents should be given information about the location and availability of these services with encouragement to use the services.

How is the information provided?

Does your Unit have a list of all the available breastfeeding support groups and networks in your area? Is it up-to-date with current phone numbers and meeting places and dates? Are representatives from these groups welcome to meet with mothers in your Unit?


© Australian Breastfeeding Association

What should I remember?

  • The 3 critical warning signs that indicate potential infant danger.
  • The consequences of these warning signs if left unattended.
  • The contraceptive choices and actions which can be offered safely for breastfeeding mothers.
  • How to contact your local mother-to-mother support group.

Self-test Quiz

Assessment Quiz

When you are happy that you've understood all the information in this topic you will be ready to complete the Module 6 Assessment. To do this, go to the course opening page, scroll down to the Assessment section and choose Module 6.

Notes

  1. # Friedman MA et al. (2004) Discharge criteria for the term newborn.
  2. # AAP Subcommittee on Hyperbilirubinemia (2004) Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation
  3. # Merchant K et al. (1990) Maternal and fetal responses to the stresses of lactation concurrent with pregnancy and of short recuperative intervals.
  4. # Donnelly A et al. (2004) Commercial hospital discharge packs for breastfeeding women
  5. # Thomson G et al. (2013) Callers\' attitudes and experiences of UK breastfeeding helpline support.
  6. # Sudfeld CR et al. (2012) Peer support and exclusive breastfeeding duration in low and middle-income countries: a systematic review and meta-analysis.
  7. # Hoddinott P et al. (2006) Effectiveness of a breastfeeding peer coaching intervention in rural Scotland
  8. # Sikorski J et al. (2004) Support for breastfeeding mothers