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SDMS ID: P2010/0696-001 WACSClinProc7.

1/09 WACS Title: Replaces: Description: Target Audience: Key Words: Policy Supported: Lactation Consultant: Practice and Referral Guidelines Lactation Consultant: Practice and Referral Guidelines 7.1/07 Practice and referral guidelines for LGH Lactation Consultants Midwives, registered nurses, medical officers, LGH Lactation P2010/0299-001 Breastfeeding Policy P2010/0300-001 Breastmilk: Safe Management P2010/0299-003 Breastfeeding Protocol

International Board Certified Lactation Consultants (IBCLC) Lactation Consultant/s employed by the Launceston General Hospital are required to be registered midwives (RM) with a current practicing certificate with the additional qualification as a current board-certified Lactation Consultant (IBCLC). The primary purpose of International Board Certification is to benefit the public by setting standards for the care of the breastfeeding mother and her child. The IBCLC credential identifies a member of the healthcare team who can provide substantive breastfeeding assistance and skilled technical management of breastfeeding problems. After initial certification, IBCLCs are required to maintain competence and recertify every five years. Professional associations world-wide acknowledge the IBCLC credential as the professional credential for lactation consultants. There is no other recognised pathway for becoming a lactation consultant. IBCLCs are required to comply with a Code of Ethics for IBCLCs and to work within ILCA Scope or Standards of Practice. Scope of Role: Responsible and accountable for the effective co-ordination and standard of patient care in relation to lactation services provided in the hospital. Provides direct nursing care to patients requiring complex lactation intervention when appropriate. Acts as a clinical resource person, makes recommendations and provides advice on matters relating to lactation services and issues. In conjunction with other health professionals provides breastfeeding and lactation education for individuals and groups of health professionals and patients as indicated clinically and by LGH policies and protocols. Responsibility for quality improvement activities that relate to infant feeding and breastfeeding. Specifically, this involves: o In conjunction with Co-director and Baby Friendly Hospital Committee, provides professional support for the co-ordination of the Baby Friendly Hospital Initiative (BFHI)

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Involvement in activities and committees to assist processes towards ACHS accreditation within the Womens & Childrens Services and the Launceston General Hospital. Facilitates Outpatient Breastfeeding Clinic for clients requiring additional and specialised support to two weeks post discharge. Objectives: Co-ordinate the planning, implementation, evaluation and promotion of lactation services within Womens & Childrens Service (WACS) and the Launceston General Hospital (LGH). Collaborate with members of the multi-disciplinary healthcare team to ensure the delivery of an optimal lactation service. Provide lactation education to medical, nursing and midwifery staff. Maintain LGH Baby Friendly Hospital Initiative accreditation, supporting all 10 Steps to Successful Breastfeeding and the WHO Code for the Marketing of Breastmilk Substitutes Organisation: Provides clinical support for the management of complex lactation issues in conjunction with other WACS clinical staff. Works autonomously, liaising as appropriate with Nurse Unit Managers and Clinical Nurse Educators within WACS and within the LGH Guidance and support is given through the Co-Director (Nursing & Midwifery). 1.5 FTE Lactation Consultant positions (Registered Nurse Level 3) exist within the LGH. Case management model to be utilised as appropriate. Flexibility is required, together with a sharing of the education and administration roles, and collection of infant feeding statistics. Additional DHHS-employed IBCLCs may be required for holiday relief & study leave. Management Plan for Referrals: Referral forms are available through the imprest system: Order form no. 114065. A referral form is required for all Womens & Childrens Services patients. The original form must be stored in the medical record. Feedback eg Discharge/ Referral form 16E, will be sent to Child Health and Parenting Service and / or referral agency directly from Lactation Consultant. Referral Guidelines: At all times, the mother must have requested or agree to the referral. All antenatal referrals should be encouraged to attend an Antenatal Breastfeeding Workshop. Appointments can be made via computer system into an allocated Antenatal appointment slot, and a referral sent via internal mail. All postnatal mothers referred to the Lactation Consultant should be inpatient or a maximum 2 weeks post discharge. Referrals from all other LGH areas eg DEM, 4K are on a requested or needs basis Referral form can be given directly to Lactation consultant during working hours, left in Lactation Consultant folder in ward 4O out of hours, or faxed to Lactation Consultant office from other areas (internal no 8924), with a phone call informing of same. The original referral form to be left in patient history. Those mothers who self-refer or are referred through other sources and are greater than 2 weeks postnatal may be assisted via the telephone as time permits the Lactation Consultant and if required be referred on to the Family & Child Health Service.
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Patients with the Extended Midwifery Service (EMS) may be provided with consultation via the telephone or in the Outpatient Breastfeeding Clinic if EMS midwives request. Mothers who are discharged from care, but are within 2 weeks post-birth may be provided with consultation via the telephone or in the Outpatient Breastfeeding Clinic. The mother should be encouraged to make contact with the Child Health Nurse at all times. Women experiencing symptoms of mastitis, whether self referred, via community health service or physiotherapy referral will be seen in Outpatient Breastfeeding Clinic as an urgent case, and an exception to the two week post discharge guideline. Tasmanian Aboriginal Centre health worker may refer clients during the antenatal or early postnatal period, education sessions may be conducted at the TAC as requested. CALD women may benefit from individual antenatal education to increase comprehension Referral Criteria
CRITERIA FOR REFERRAL TO LACTATION CONSUSLTANT INPATIENT MATERNAL CRITERIA INFANT CRITERIA Antenatal support where previous breastfeeding Has not attached to breast difficulty or specific issue Previous breast surgery - reduction, augmentation, Attachment / suck difficulty other Nipple trauma, pain or abnormalities Weight loss at or greater than 10% of birth weight Nipple shield use and follow-up Premature / sick infant: maternal expressing support Low supply and/or galactagogue use-Domperidone Supplementary feeds indicated or requested Over supply issues Infant diagnosed with congenital disorder (cleft lip and/or palate, Down Syndrome) where mother wishes to breastfeed or express breastmilk. Breast: pain, flushed, engorged, mastitis, other Breastfed infant admitted to 4K where nursing and / or medical staff consider referral will be beneficial. Difficulty with positioning of infant due to maternal health, disability or well-being. Breastfeeding mother admitted to LGH for medical or surgical issue, where nursing and / or medical staff consider referral will be beneficial.

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OUT-PATIENT MATERNAL CRITERIA INFANT CRITERIA Extended Midwifery Service (EMS) patients with Infants requiring monitoring of weight related breastfeeding difficulties. to breastfeeding issues. Antenatal patients with: Infant with suck difficulty Previous breastfeeding difficulty Previous breast surgery eg reduction Existing breast anomaly, eg inverted nipples Pre-existing condition where breastfeeding may be affected or antenatal expressing may be of benefit - diabetes, thyroid, pituitary, allergy, anxiety, disability Known foetal anomaly which may impact on breastfeeding. Multiple or preterm birth expected Boarder mother requiring breastfeeding review Premature infants transferred to 4N at Home requiring breastfeeding follow-up. Mother using breastfeeding aides such as: Jaundice with associated breastfeeding difficulties (low supply) or breastmilk jaundice Nipple shield Supply line or finger feed Breast or nipple condition, e.g., nipple trauma, EMS patient with feeding difficulty or weight mastitis, infection or injury. loss greater than 10% Galactagogue use (e.g., domperidone) Postnatal patients at discharge with history of breast surgery or other complex breastfeeding needs. Community referral for treatment of breast signs or symptoms, where physiotherapy ultrasound appears to be indicated.

The Lactation Consultant will consult with medical staff in any of the following situations: As required to assist collaborative decision-making. Medication or pathology appears to be indicated. Maternal or infant health may be compromised. If infant observations and health status indicate and/or weight loss is continuing above 12.5% (Macdonald et al 2003). Re-admission appears to be indicated. Premature or sick infants in 4N or 4K, where a change of feeding regime is indicated. Clinical Decision Making: The Lactation Consultant will consult with midwife, medical staff, physiotherapist, dietician, social worker and other health professionals as indicated, for the purposes of collaborative decision-making and for consultation. Where possible, the midwife or nurse caring for the referred inpatient, will be involved in assessment, planning, implementation and evaluation of care planned. The patient is a partner throughout the assessment, planning, implementation and evaluation process. The family, when available, will be included in this process No plan should be commenced without the patient understanding the risk and benefits of the chosen plan and alternatives. Documentation should reflect this informed consent.
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The Lactation Consultant will work within the policies and procedures of the Launceston General Hospital. Follow up Planning: Implementation of any clinical plan will require adequate instruction to the patient and staff caring for that patient. A documented time-line for review (e.g., 24 hours) should be given. Consideration of the need for a written plan for patient and staff should always be made. Notes on assessment, plan, implementation and evaluation are written following each consultation in the progress notes. Where more complex management plans are required for inpatients eg use of lactation aids, the Lactation Consultant will discuss with the CNC to ensure adequate staffing. A follow up appointment in the Outpatient Breastfeeding Clinic should be made for any patient being discharged using a lactation aid or more complex feeding plan. Phone contact to the local Child Health Nurse should be made prior to the discharge of a patient with more complex needs or requiring prompt follow-up, making them aware of any LC follow up arranged. Always consult with the local Child Health Nurse prior to any referral to Walker House Parenting Centre. Lactation Consultants in private practice are available in the northern region. A mother may be referred to a private practitioner for follow-up care if she requests or agrees to same. Australian Breastfeeding Association (ABA) information should be available for all breastfeeding mothers. Parentcraft / Antenatal Education: The Lactation Consultant will: Provide expert advice and input into the curricula for antenatal education regarding infant feeding. Have responsibility for conducting accessible and appropriate Breastfeeding Workshops for antenatal women. Collate and review patient handouts and literature for antenatal and parent education on infant feeding. Staff Education: The Lactation Consultant will: Provide regular breastfeeding education to registered midwifery and nursing staff eg Professional Development Day, on ward in-service, access to online learning packages. Provide breastfeeding education to student midwives and medical students as required Provide supervised clinical practice time for registered nurses, student midwives and medical students (BFHI requirement is a minimum of three hours for nursing staff) Provide new staff to WACS with supervised clinical practice time as part of their orientation eg Pool staff three hours, WACS staff eight hours Provide orientation to the LGH Breastfeeding Policy to all staff working within WACS eg catering and cleaning; and the wider LGH community as appropriate eg Onboarding for new staff, DEM, Theatre, Dieticians, Physiotherapists etc Professional Development: Lactation Consultant should: Attend a conference or seminar at least annually Participate in appropriate professional organisations
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Receive and review professional journals and other sources of evidence based practice and current research. Hospital financial support for the above will be decided by consultation with Co-Director (Nursing & Midwifery), Womens & Childrens Services on an as need basis. Lactation Consultant Participates in the Following: Launceston General Hospital internal committees Baby Friendly Hospital Initiative (BFHI) Working Group as Chair Nursing and Midwifery Reference Group CHAPS & QVMU Liaison meeting Statewide Committees representing Launceston General Hospital Baby Friendly Hospital Initiative Tasmania Committee Tasmanian Breastfeeding Coalition. Collection of Infant Feeding Statistics: Infant feeding statistics will be collected on all babies who are born in the Queen Victoria Maternity Unit, or the baby is admitted to the LGH during the early postnatal period. Statistics collected will be as per BFHI requirements or for Quality Activity purposes The midwife at the time of discharge is requested to ensure completion of appropriate section of the Neonatal Clinical Pathway and Infant Feeding Statistics Form. The Lactation Consultant, or delegated person, will collate statistics into designated computer system. Monthly summaries will be available and disseminated through the LGH-BFHI committee and other committees as appropriate. Maintenance and Supplies: The Lactation Consultant will: Collect and maintain records of Miele Thermo-Disinfecting Dishwasher situated between Ward 4O and 4N. Act as a resource person to work with CNC and other persons responsible for the maintenance and ordering of supplies concerned with lactation aids and infant feeding. Store additional equipment or lactation aids required for complex referrals. Maintain knowledge of current and recent developments in regard to lactation aids and disinfection requirements of infant feeding equipment. Together with CNCs, liaise with external company representatives and Launceston General Hospital Purchasing and Stores personnel, where procurement of infant feeding equipment and lactation aids for the Launceston General Hospital is required. Work within the World Health Organisation (WHO) International Code of Marketing of Breastmilk Substitutes and subsequent relevant resolutions, and ensure others within the LGH comply with LGH Policy regarding this. Order office requirements from Supply Department through Ward 4O. Glossary: IBCLC International Board Certified Lactation Consultant ILCA International Lactation Consultant Association IBLCE International Board of Lactation Consultant Examiners

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Performance Indicators: Review Date: Annually verified for currency or as changes occur, and reviewed every three years. Registered nurses, midwives and medical officers, LGH Jill Hanson and Dianne Howarth, Lactation Consultant

Stakeholders: Developed by:

Helen Bryan Director of Nursing Launceston General Hospital Date: 18 June 2009

Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

References: Code of Ethics for IBCLCs, 2006, www.iblce.edu.au ILCA Standards of Practice for IBCLC, 2006, www.ilca.org/files/resources/Standards-of-Practice-web.pdf Scope of Practice for IBCLCs, 2008, IBLCE, www.iblce.edu.au/downloads/ScopeofPractice2008.pdf McDonald PDM, Ross SRM, Grant L, Young D (2003) Neonatal weight loss in breast and formula fed infants, Arch Dis Child Fetal Neonatal Ed, 88: F472-F47 Lactation Consultant Referral Form (stores code 114065) Discharge/ Referral QVMU Form (stores code 13540)

Lactation Consultant: Practice and Referral Guidelines May-11

WACSClinProc7.1/09