Sunday, July 31, 2011

What every doula should know about breastfeeding: Tip #2: When to refer, how to refer

Preface: Often as a doula, before I became an LC, I would encounter situations in the hours after the baby was born, or at postpartum visits, where I wasn't quite sure what to suggest; or looking back, I realize I could have done something differently. I've decided to share some tips with other doulas about things that I wish I had known long ago! Today is Tip #2: Referring to advanced support.

Knowing when to refer and how to refer mothers to advanced breastfeeding support is a vital part of a doula's role in supporting breastfeeding.

WHY to refer:

As doulas, we spend hours, sometimes days with our clients through one of the most intense experiences of their lives. You often end up very bonded and very invested, and when breastfeeding issues arise you're ready to jump in and do everything to make it work.

Resist the temptation to solve everything for your client!

On doula listservs I sometimes see questions like, "My client's baby's weight is down 12% and she's having to supplement with formula. What can I do to help her?" or "My client's baby just won't latch, should I suggest she do a lot of skin-to-skin?" You can give so much to a client in this situation: compassion, practical support, a listening ear at 2 a.m.; but the most important thing you can give her is a referral to a lactation consultant and the encouragement to call ASAP. She has a problem that needs quick professional help; it will probably not be helpful to her for you to come back in a couple days with tips from people who have never met her.

A 3-5 day CLC/CLE/CBE etc. course is wonderful (as is years of experience breastfeeding your own babies, helping friends, etc.) but KNOW YOUR SCOPE and be careful about venturing slowly into deeper and deeper waters where suddenly you discover you're in way over your head. It is so easy to get drawn into helping beyond your expertise. I speak from experience! I have written about how the more I learn, the more I realized I didn't know. I say this knowing that I, myself, would sometimes get in over my head when helping clients in AmeriCorps; our supervisor was a midwife who could help out when we were stuck, but she wasn't always available and I was trying to fix things knowing the patients might not be able to come back for a follow-up visit. I honestly cringe at some of the advice I used to give! It wasn't terrible or harmful, but it was probably really unhelpful.

In general, think of yourself as a "breastfeeding emergency first responder". You should provide the same services as any emergency first responder - do what you can at the moment to help the patient, offer them comfort and support, and then get them to advanced care. So absolutely suggest that the mom whose baby isn't latching do lots of skin-to-skin - and then help her find an LC who can assess why this is happening and how to fix it.

In the meantime, support the mother and remember the rules:
Rule 1) FEED THE BABY (in whatever way is necessary; sometimes bottles and formula ARE necessary);
Rule 2) Protect the milk supply (through pumping and/or hand expression if the baby is not feeding effectively at the breast).

WHEN to refer:

Not sure if your client is having just some normal latch pain and things are going to get better? Not sure if the weight is a real concern or just a temporary dip?

Here's a (partial) list of situations in which your client should DEFINITELY be referred to an LC (do not pass Go, do not collect $200):
  • Painful nipples throughout the feeding...
  • ....especially with any signs of nipple trauma (cracking, bleeding, blisters)
  • ....especially if the mother tells you she "dreads" feedings, that she cries from pain during the feeding, that she puts off feedings or limits their length because of pain, or that she is exclusively pumping because of latch pain
  • Excessive weight loss or poor weight gain in the baby, or any concern for weight that leads the baby's doctor to recommend supplementation
  • A mother who was sent home from the hospital supplementing the baby (via any method, not just bottles) without clear further instructions about when/how to stop supplementing
  • A baby who refuses to latch or does not latch consistently; the mother may describe feedings as "battles" or "fights" that drag out, sometimes for over an hour
(Does anyone have additions or modifications for this list?)

HOW to refer:

To refer your clients, you need to know about the lay of the land in your community. Who are the lactation consultants? Where are they based - pediatric offices, hospitals, private practice? Does the mother have to go to them, or do they do home visits? What do they charge and how do they bill the mother's insurance? (For example, at our hospitals outpatients' insurance is billed for a nurse visit and the mother has a small co-pay; a private practice LC will generally be paid up front and the mother must apply for reimbursement.) For lower-income mothers, is there a WIC breastfeeding support program that has an IBCLC?

As you're getting to know the lactation support resources in your community, please read Best for Babes' Is Your Lactation Specialist an Imposter? Not all lactation "helpers" are lactation consultants; and sad to say, not all lactation consultants are supporting moms the way they should. This is true of every profession; hopefully, you would not refer your doula clients to a midwife just because she had "CNM" or "CPM" after her name, assuming she provided optimal midwifery care, because not all midwives practice in ways that are consistent with a compassionate, evidence-based midwifery model of care. You would want to talk with other doulas, mothers, and providers - or work with the midwife directly - to know that she provided the kind of care you were comfortable recommending. I have worked with midwives I would refer my clients to, and midwives I would warn them away from; the same goes for LCs. You help your clients by finding trusted people you can refer to.

Ask local La Leche League leaders, mothers, doulas, midwives, doctors, and other community resources who they trust and recommend. Listen for specifics of how they deal with different issues, and whether the mothers who use them found them to be sympathetic and helpful. And, while this is a little delicate, keep your ear to the ground for the people who are not recommended or who you hear about giving questionable advice. Of course, even the best provider will have some dissatisfied patients (again, you may have an absolute favorite midwife and meet someone who had a bad experience with her - maybe it just wasn't a good personality fit, or a bad day.) But when you hear the same poor feedback over and over about somebody, it could be a sign to have your ears perked if your client mentions working with that person. (And if you know a hospital doesn't have LCs on staff, and the mother says "But the lactation consultant in the hospital said her latch was perfect!" skeptical.)

If you develop a relationship with an LC, or a few LCs, that you consistently refer to, you may also develop a referral system. Many LCs will welcome a phone message or e-mail from a doula or other professional working with the mother, who can offer an outside perspective on what has been happening and why the mother is being referred. Talk to the LCs you work with about whether this would be helpful.

Even when you've helped your client find a great LC, your client may be hesitant to pay for a lactation consultant - especially since with a private practice LC they will need to pay up front. Help her think through the cost of formula, or even of exclusive pumping (which some women seem to regard as a quick solution for any breastfeeding problem, without understanding that it brings its own distinct challenges.) Talk to her about how she saw the value in hiring a trained labor support person; hopefully she will see the same value in finding professional breastfeeding support.

A lot of women seem to feel guilt or frustration for needing to turn to someone for help at what is supposed to be "natural" (I say "it might be natural, but it doesn't always come naturally!") You can discuss some women's need for lactation support with your client at prenatal visits, so your clients who need LCs know in advance that they're not "failing" or somehow strange for needing an LC. You can include information about LCs you recommend in your prenatal information packets.

If you can, follow up with the mother about the LC visit, how it went, and how things are progressing; or encourage her to call you if things are still not going well. If the mother did not feel helped by the first LC she sees, offer to help her find someone else, especially if you are not sure about that LC's qualifications. And of course, support and empower her in whatever challenges she is facing, and listen to and validate her concerns.

Note for community-based and/or volunteer doulas:
If you are working with low-income women, they may be in a very difficult situation. We confronted this issue a lot when I was working in AmeriCorps. Ask around for low-cost resources like WIC, LCs who are willing to do pro bono work (especially if it is referred by a doula who knows the mother's financial situation), LCs working at hospital-based clinics that may take Medicaid, and free mother-to-mother support groups that the mother would be comfortable attending (keep in mind some women may feel out of place in settings like La Leche League meetings). Be proactive about helping the mother get in touch with these resources.

If you are the only help available to a mom, ask around for LCs/LLLLs/other resources who might be willing to talk you through problems or offer suggestions, and again be very careful about not overstepping your boundaries. While it's hard to see a situation go down the tubes, and you want to throw every idea you have at the problem to fix it, it is actually better for a mother to give up breastfeeding than for her or her baby to be harmed by poor advice... and it's hard to know what's poor advice if you're stepping outside your scope of practice.


I loved the feedback on the last post, and welcome comments on this one! More tips to come!

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