Abstract
Background:
Patients who are lactating at the time of a procedure requiring anesthesia benefit from specific education and care coordination to support continued lactation and avoid complications. Before design and implementation of a comprehensive care pathway for this patient population at our institution, we sought to elicit the patient perspective.
Methods:
We conducted semistructured qualitative interviews with eight patients by phone regarding their experience as a lactating patient presenting for a procedure with anesthesia care at our institution. These were analyzed for predominant themes regarding their experiences.
Results:
The patients we interviewed reported receiving conflicting information and feeling a sense of uncertainty. Some patients experienced preventable health effects such as mastitis, and prior experience with breastfeeding was protective. The interviewed patients endorsed a desire for structured support and improved education resources.
Discussion:
This qualitative study of lactating patients undergoing anesthesia and surgery demonstrates a need for coordinated perioperative lactation care. A structured pathway for this patient population with access to updated care guidelines and patient education would be welcomed.
Introduction
The health and societal benefits of providing human milk to infants are numerous and well described. 1 Lactating individuals are ubiquitous in society and health care, and yet remain understudied. 2 Hospitals and health systems spend time, money, and effort to acquire Baby Friendly designations for lactation initiation strategies, yet do not invest comparable resources into maintaining lactation.3,4 Maternal illness and medications have been cited as major reasons that women do not meet their desired breastfeeding goal. 5
For mothers undergoing surgery under general anesthesia or sedation, physicians and perioperative staff may still give outdated recommendations to “pump and dump” (express and discard milk for varying time intervals after anesthesia or sedation). This is contrary to current evidence that breastfeeding-compatible plans for pain management, anesthesia, and treatment of medical conditions are almost always possible.6–8 Current recommendations are that patients continue to feed their infant or express breast milk on their usual schedule during their perioperative encounter and should not be told to discard milk routinely.6–8
Before implementing a project to improve the perioperative care of lactating patients within a large health care system, we sought to examine the current experiences of lactating patients. The purpose of this qualitative study was to determine the beliefs, experiences, and perceptions of breastfeeding mothers with respect to their lactation experience during a recent surgical encounter.
Methods
This investigation was approved by the Mayo Clinic Institutional Review Board, and written informed consent was obtained from all participants. All patients between January 1, 2017, and March 30, 2018, who had presented for a surgical procedure at Mayo Clinic Hospital within 12 months of delivery and had evidence of lactation or breastfeeding at the time of their procedure were identified from the electronic medical record. Patients were eligible for inclusion if they had a surgical procedure while lactating, were of age 18–50 years, and their child was <12 months of age at the time of the surgical procedure.
Patients were excluded if they had an American Society of Anesthesiologists (ASA) physical status classification IV or V or had declined research authorization to examine their medical record to determine eligibility. Eligible patients were contacted through phone and invited to participate in the study. Patients were selected to be invited with the intention of representing a variety of surgical procedures and departments, routine and urgent surgery, and varied infant age. Data including type of procedure, type of anesthetic, length of procedure, ASA physical status classification, admission type, and age of child were abstracted from the medical record for all participants.
A semistructured qualitative interview guide was developed through consensus of study investigators (Table 1). This guide was used by a professional qualitative research analyst to perform interviews by telephone in March 2020. Each interview proceeded until all guide questions were asked, including a final question soliciting any further general comments. The interviews were recorded and transcribed.
Semistructured Interview Guide
Predominant themes (i.e., issues, feelings, or opinions repeated/common across multiple participants) were identified and agreed on by two of the coauthors, who developed a coding strategy and independently coded all interviews using methods of content analysis (i.e., systematic process of sorting and coding information based on themes). Independent coding results were compared, and important themes and representative quotes were identified. Consensus was obtained from data-based discussion that included returning to complete interview texts as necessary to reconsider the context of participant's comments. The number of participants was determined a priori based on the estimation of the study team of the number needed to reach saturation in terms of identifying themes.
Results
Three hundred forty-six patients presented for an operating room procedure within 12 months of delivery. Sixty-three patients had documented evidence of breastfeeding in the medical record within 1 month of their procedure. These 63 patients had 79 procedures within the study period. Categories of surgical procedures included gastroenterological (14, 18%), orthopedic (8, 9%), and general surgery (15, 19%). The most frequent anesthetic technique was general anesthesia (34, 43%); other types of anesthesia included monitored anesthesia care (16, 20%), moderate sedation provided by registered nurse (10, 13%), regional anesthesia (4, 5%), and local anesthesia without sedation (15, 19%).
Eight patients were invited to participate and all consented. These 8 participants had 10 surgical procedures. Patient, surgical, and anesthetic characteristics of interviewees are summarized in Table 2.
Patient and Procedure Attributes
Four main themes were identified in the interviews: (1) patients received conflicting information and felt uncertain, (2) some patients experienced preventable health effects, (3) patients with prior knowledge of breastfeeding seemed protected, and (4) patients desired perioperative education about lactation.
Patients received conflicting information and felt uncertain
Most patients reported receiving conflicting instructions regarding management of their lactation around the time of their surgery or procedure. None of the patients recalled being offered a discussion with a lactation professional as part of their preoperative planning.
“I got reamed by one of the doctors telling me I couldn't (breastfeed)…then I had a doctor come in and say ‘no, no, they don't know what they're talking about. We've done studies and very little gets in there.”
“I was told ‘no’ that was not accurate information, and you are able to breastfeed.”
For some that led to feelings of uncertainty and led at least one to make unnecessarily restrictive decisions for their lactation management.
“I guess there was very little known about it.”
“They said they thought it would be ok…I ended up pumping and dumping for a couple days after, just to be safe because I didn't know.”
Some patients experienced preventable health effects
Multiple patients experienced difficulties that impacted their perioperative health that were potentially preventable with coordination of lactation status.
“I also had mastitis…and had an allergic reaction to the antibiotics.”
“After my nerve block wore off, I had a pain crisis. I was in such bad pain that I ended up being readmitted to the hospital… Until I could get back down to the 5 mg of oxycodone every four hours, my daughter had to have formula.”
One patient felt that her medical condition may have contributed to earlier than desired weaning.
“I think I stopped pumping right after my second surgery. It's hard to say because I didn't really get a chance to start doing it at work, so I don't know how that would have played a part.”
Prior personal or professional experience with breastfeeding was helpful
Patients who had breastfed prior infants or who had professional knowledge of breastfeeding reported advocating for themselves despite not having a formal perioperative pathway.
“I think it definitely would've been harder if it was my first baby. I mean I knew I was not gonna give up and I was gonna breast-feed my baby [laughs]. So I breast-fed all my kids for two years. I was not gonna give up. I think it could've derailed the whole thing if this was my first baby.”
“I'm a physician and had… access to some of those resources that say, it's a common misconception that you need to pump and dump for such-and-such period of time after most anesthetics. It's pretty rare to actually need to discard any milk. So I had been aware of that through other resources.”
Patients desired perioperative education about lactation
When asked what they would like to see change, responses centered around improving the structured support and education processes for this group of patients.
“I just don't want any moms to have to go through what I did. It'd be nice if there was a process or resource since it's not a common thing.”
“I think if my doctor would have explained things to me or even if they would have reassured me that ‘it's okay, you're doing just fine, even through all this, you can still pump or whatever and it will still be fine,’ but I didn't have that reassurance.”
They also understood that this may be outside of the expected knowledge for their surgeon or surgical care team and seemed to welcome additional expertise.
“I think having a lactation discussion be a part of the preoperative teaching and scheduling and a clear, validated part of that. Like ‘Are you lactating? Do you need any support for that?’ And then ‘If yes, here's the lactation consultant visit.’”
“He's a wonderful surgeon and a great doctor, I'm not questioning that. Maybe he needs a little more information on lactation around surgical services.”
Discussion
This qualitative study provides insight into the perioperative experience of lactating surgical patients and suggests lactating patients desire a better perioperative experience. Although this study was formative and conducted within a single health system, the themes invite physicians, allied health staff, and health care systems to evaluate the way they care for and educate lactating surgical patients.
The Academy of Breastfeeding Medicine recently described the ideal approach to coordinated care of lactating patients as an important objective for providers caring for hospitalized patients and their infants. 9 They recommend hospitals create policies to support lactating patients and the breastfeeding child including keeping mothers and infants together, using evidence-based safety recommendations for medications, and providing necessary lactation equipment. Professional societies have also updated or created new guidelines to summarize recommendations on this topic, including the Association of Anaesthetists 6 and the ASA 10 who both recommend patients can resume breastfeeding after surgery as soon as they are alert and able to feed.
Rieth et al. described the implementation of a perioperative lactation program at Memorial Sloan Kettering Cancer Center, outlining an approach to identify, educate, and care for lactating surgical patients. Lactating patients represented a small but consistent percentage of their overall population, with 80 patients identified over a 30-month study period. 11
At our institution, a comprehensive perioperative lactation pathway is in development and the information from this study has been used in planning and needs assessment. It was important to our team that patient experience be the cornerstone of the baseline and ongoing evaluation process. The themes identified in this study will be used in assessment of performance in the areas of providing accurate and clear information, patient impact, and satisfaction with lactation management as a part of their perioperative care. This topic is clearly of interest to lactating women, who expressed a need for it to be better addressed. Although we studied only a small sample, at least two experienced adverse consequences related to perioperative lactation management, highlighting the significance of this area.
Limitations of our study include its single-center study design, limiting generalizability. Furthermore, the number of patients identified in the 15-month time period is likely an underestimation as the documentation of a patient's lactation status was not routinely captured in the electronic health record. In addition, all patients interviewed except one had outpatient surgery, limiting the conclusions that can be drawn for patients being admitted after their surgical procedure.
In summary, this qualitative study highlights that lactating women undergoing surgery have needs related to their lactation that are not being adequately addressed and can have significant consequences. Anesthesiologists, surgeons, and proceduralists should anticipate that they will encounter lactating patients, recognize that supporting a patient's goal to continue breastfeeding has individual and societal impact, and make an action plan for how patients can be provided appropriate care and education at their facility or institution.
Footnotes
Acknowledgments
We thank Anesthesia Clinical Research Unit study coordinator Nicole Andrijasevic, RRT, LRT for her help with data extraction. We thank Kern Center for Science of Health Care Delivery Research Analyst Dawn Finnie, MPA. for her help with interview guide development and conduct of interviews.
Disclosure Statement
No competing financial interests exist.
Funding Information
This publication was made possible by the Mayo Clinic CTSA through grant number UL1TR002377 from the National Center for Advancing Translational Sciences (NCATS), a component of the National Institutes of Health (NIH).