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4.0 Case Study D (Sally)

Key Points - Case Study D

Sally is 29 years old and presents to see you two and a half weeks postpartum with her first baby. Emily was born at T+7 days and weighed 4060 grams. Sally had a normal delivery but had a postpartum haemorrhage and a retained placenta that required a general anaesthetic and manual removal. They were discharged on day three fully breastfeeding, with Emily weighing 3770 grams and Sally's Hb 92 g/L. Sally has no other significant medical or surgical history, is well educated and has a supportive partner. Emily is a "good" baby: she is sleeping at least six hours at night and seems content. What questions would you ask Sally, and what additional information would you gather to assess whether breastfeeding was progressing normally?

Topic 4.1: Initial assessment
To assess the adequacy of breast milk intake ask about: number and length of feeds; elimination patterns; general infant behaviour; breast and nipple concerns; and maternal confidence. Also check: infant weight gain; jaundice and general infant wellbeing.

Sally is confident with her breastfeeding and her breasts and nipples are fine. Her breasts feel a little fuller early in the morning, but she has not had problems with engorgement like some of her friends. Emily is feeding approximately six times a day and feeds for 15-20 minutes before falling asleep. She is having four wet nappies a day – two of which are damp. She is having a bowel motion every three days or so. Emily weighs 3800 grams. On examination, she is not dehydrated. You are concerned that Emily is not getting enough breast milk.

Topic 4.2: Milk production
Oxytocin and prolactin are the main hormones necessary for the initiation of lactation. Factors such as diabetes, primiparity, caesarean section, stress and pain in labour, obesity and preterm delivery can interfere with the onset of lactation. Once lactation is established, milk removal is the main determinant of milk production.

What may cause inadequate growth in breastfed infants such as Emily?

Topic 4.3: Causes of inadequate infant growth
The main reasons for inadequate growth in a breastfed infant are: reduced milk intake due to suboptimal feeding patterns or routines; low milk supply; difficulty transferring milk; and increased energy expenditure in the infant.

How could Sally increase her milk supply?

Topic 4.4: Increasing milk supply
To increase a mother's milk supply correct any underlying problems, if possible, and increase breast drainage. Encourage adequate rest and a balanced diet. Some women require galactagogues. Some infants who are malnourished at presentation, or do not respond to effective, frequent feeding, may need supplementation with donor breast milk or infant formula.