The American College of Obstetricians and Gynecologists WOMEN’S HEALTH CARE PHYSICIANS Pertinent Medical and Surgical History: Ask about breast surgery (including reduction or augmentation and significant trauma or radiation to the chest wall), which could affect breastfeeding performance. Medications: For chronic medications, ask what the patient knows about drug safety in lactation. Consult LactMed for long-term medications and provide her with printed resources, such as LactMed monographs or MotherToBaby fact sheets, for information on safety of medications she anticipates taking after giving birth. Anticipatory Guidance: Begin conversations about lactation early in prenatal care using three-step counseling: 1) Ask the patient an open-ended question and listen to her response, 2) Summarize her response in your own words, and 3) Educate, addressing her concerns. What have you heard about breastfeeding? • Health effects: Breastfeeding is different from formula feeding. Discuss benefits for the woman and the baby. • Pain: Many women experience discomfort with latching in the early days as the baby draws the nipple and areola into its mouth. Pain lasting more than 20–30 seconds is a signal to adjust the baby’s position, sometimes simply by shifting the baby’s torso to face the woman’s body. Hospital staff will help with positioning too. • When to feed: The baby has a fuel gauge––elbows flexed and fists near the mouth means “empty” and arms relaxed means “full.” One arm flexed means “I might want dessert.” • Making enough milk: To make lots of milk, put the baby to the breast early and often. The breasts are stimulated to make more milk by having colostrum or milk removed from them. The woman will make as much milk as her baby removes. Acknowledge that although breastfeeding works for most women, it may not work for everyone. • Nursing in public: Discuss how to nurse discreetly, and review that the woman has a legal right to breastfeed in public. Consider timing outings and using an infant sling, a breastfeeding cover, and a breastfeeding bra. Empower women to request a private space for nursing. What have you heard about how long to breastfeed? • Review recommendations for 6 months of exclusive breastfeeding, continuing for 1 year or longer if mutually desired by the woman and the baby as new foods are introduced after the first 6 months. How does your family or partner feel about breastfeeding? • Offer to consult with unsupportive family or partner. • Concerns about sexuality: Explore the partner’s cultural values; explain the primary role of breasts as nourishment. What are your plans for returning to work or school in the first few months after birth? • Discuss opportunities for expressing milk at work or school. If there are none, the woman and her baby will adapt to more frequent nursing in off times. Express milk when at home for the next day’s supply. The Affordable Care Act requires most employers to provide breastfeeding women with breaks to express milk in a place other than a bathroom. Find out more at Multiparous women: How did feeding go with your older child or children? • Praise the patient for any previous breastfeeding. Ask about challenges she encountered and strategies for overcoming them. Offer a prenatal consult with an International Board Certified Lactation Consultant for anticipatory guidance. If the patient formula fed, explore reasons for her decision. Ask if she has considered breastfeeding. Some questions and suggestions for education:* *Questions & guidance adapted in part from Appendix A: Intervention Protocols, Bonuck K, Stuebe A, Barnett J, Labbok MH, Fletcher J, Bernstein PS. Effect of primary care intervention on breastfeeding duration and intensity. Am J Public Health. 2014;104 (suppl):S119–27. Physician Conversation Guide on Support for Breastfeeding

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