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NAPS Prenatal Lactation Consultation Note
Date Of Visit
*
MM
DD
YYYY
Start Time
Hour
Minute
Second
AM
PM
End Time
Hour
Minute
Second
AM
PM
Location of Visit
In-home
In-office
Telehealth
Client Name
*
First Name
Last Name
Client's Date of Birth
*
MM
DD
YYYY
Baby's Name
*
First Name
Last Name
Baby's Date of Birth
*
MM
DD
YYYY
Birth Weight
Lactation Consultant
*
First Name
Last Name
Pediatrician Name
*
First Name
Last Name
OB or Midwife Name
*
First Name
Last Name
Reason for Visit
*
Pre-Feed Weight
*
Post Feed Weight
*
Latch Assessment
Positioned belly to belly
Infant Body Alignment
Gape Response Present
Lips Flanged
Rocker Motion
Wide angle in corder of mouth
Audible Swallows
Pain Free throughout feeding
Global Health Media on Latching: https://www.youtube.com/watch?v=wjt-Ashodw8&t=6s
Breast Assessment
cracked nipples
nipple pain
engorgement
clogged ducts
Breast and Oral Assessment
Corrections made to latch and/or positioning
Recommendations
Breastfeed 8-12 times in 24 hours
Pump both breasts at same time for 10-20 minutes
Supplement with breastmilk or formula as outlined
Take herbal supplements as recommended
Feed baby every 2-3 hours during the day
Feed baby every 3-4 hours overnight until baby has regained birthweight
Apply nipple ointment after every feed
Use nipple shield as recommended
Other (see below)
Teaching provided
Safe storage of breastmilk (Rule of 4's: https://www.cdc.gov/breastfeeding/recommendations/handling_breastmilk.htm)
Proper setup/use/cleaning of breast pump
Use of nipple shield including how to wean
Warning signs for baby and when to call pediatrician
Warning signs for mom and when to call OB
Paced bottle feeding (https://vimeo.com/797799187/26d3ba022e?share=copy)
5 s's (1. swaddle 2. side lying 3. swinging 4. shushing 5. sucking)
Proper preparation of infant formula
Other (see below)
Plan following this visit
*
Follow Up
Follow-up appointment recommended (contact to schedule)
Follow-up appointment scheduled
Follow-up phone call recommended (contact to schedule)
Follow-up phone call scheduled
Outside-referral made (see below)
Other (see below)
Additional notes or education
Recommended Referrals
Recommended Products
Additional Opportunities for Learning & Support
Free Breastfeeding Support Group: offered weekly virtually and in person
Unswaddled: The Truth About Parenting Podcast. Listen here: https://podcasts.apple.com/us/podcast/unswaddled/id1560213381
Nurture by NAPS Membership
*
Already a member: ask your follow up questions on the "ask a nurse" message board and receive a response within 24 hours.
New Member offer will be sent in email follow up.
Signed and Accepted by
*
Enter lactation consultant's name and credentials
Date Signed and Accepted
*
MM
DD
YYYY
Thank you!