Lactation Clinical Skills Day

History Taking and Assessment Tool

  1. Basic Information:
  2. Name of mom and baby, age of baby
  3. Reason for call or presenting concern/issue
  4. Birth Information, gestational age, Gravida Para (G/P), birth weight, discharge weight, last weight
  5. Obtain weight before a feeding, with a dry diaper on baby
  6. Take weight of baby after a feeding, with same diaper; do not change diapers between pre and post feed weights.
  7. Feeding Information:
  8. “Tell me about baby’s feedings”- how often, how long, any bottles and how much per bottle, when was last feeding.
  9. Output – wet and dirty diapers, amount, consistency, color
  10. Baby’s behavior – wakes self to feed, sleepy baby, short feedings, long feedings, fussy baby, “good” baby.
  11. Head to Toe assessment of mom:
  12. Overall, how does mom look, how is her health, breastfeeding history, birth story
  13. Breasts assessment, this can be done at the time you are observing a feeding at the breast, any breast changes during the pregnancy, injuries, surgeries,
  14. Medication, vitamins, herbs, supplements used by mom; any birth control given/using
  15. Post partum bleeding – amount and type of flow, clots, menses returned
  16. Head to Toe assessment of baby:
  17. Overall, how does baby look: skin color, tone, hydration, fat pads, any known health issues
  18. Watch mom latch baby and feed baby.
  19. Assess positioning and latch and how that impacts baby’s ability to suck/swallow or actively eat at the breast.
  20. Upper body evaluation of baby: Cranial bones, facial symmetry, ability to move head from side to side, muscle tone of arms and neck area
  21. Oral assessment: Rooting, lips, tongue, roof of mouth, ability and desire to suck

SOAP – This is a way to chart, yet it is also a way to collect information and draw a conclusion about the feeding issue.

S:Subject Information – Things mom tells you

O:Objective Information – Things you observe

A:Assessment or analysis of the information you have observed and collected. Draw a conclusion and share it with mom. Tell her what is going on; give her a name for the issue.

P:Plan, what is the plan to address the issue. Use the Feeding Plan tool so mom has a written document of the plan.

May 2016