Background: Persistent nipple pain is one of the most common reasons given by mothers for ceasing exclusive breastfeeding. We aimed to determine the frequency of nipple pain as a reason for consultation, the most common attributed aetiologies, and the effectiveness of the advice and treatment given. Methods: All consultations at the Breast Feeding Centre of Western Australia (WA) were audited over two six-month periods in 2011 (n = 469) and 2014 (n = 708). Attributed cause(s) of nipple pain, microbiology results, treatment(s) advised, and resolution of pain were recorded. Results: Nipple pain was one of the reasons for consultation in 36% of cases. The most common attributed cause of nipple pain was incorrect positioning and attachment, followed by tongue tie, infection, palatal anomaly, flat or inverted nipples, mastitis, and vasospasm. Advice included correction of positioning and attachment, use of a nipple shield, resting the nipples and expressing breastmilk, frenotomy, oral antibiotics, topical treatments, and cold or warm compresses. Pain was resolving or resolved in 57% of cases after 18 days (range 2–110). Conclusion: The multiple attributed causes of nipple pain, possibly as a result of a cascade of events, suggests that effective early lactation management for prevention of nipple pain and early diagnosis and effective treatment are crucial to avoid early weaning.

A perception of insufficient milk supply (PIMS) is associated with early discontinuation of breastfeeding. Ideally, an objective measure of milk supply would either dispel or confirm this perception and provide reassurance or guide professional advice. Clinical signs of sufficient milk intake (steady growth, sufficient elimination, infant alertness and breasts feeling full before breastfeeds and soft after breastfeeds) should provide confidence in milk supply. We surveyed 423 mothers in early lactation who had breastfeeding problems to determine the proportion that had PIMS and to determine if the mothers with PIMS relied on these clinical signs or other perceptions of their infants' behaviour as indications of insufficient milk supply. By 3 weeks after birth, we found that the rate of PIMS among mothers with breastfeeding problems was 44%. Supplementary infant formula was being given to 66% of the infants, so the clinical indications were that milk intake was sufficient, but 74% of the mothers with PIMS cited concerns that their infants did not appear satisfied after breastfeeds. After targeted advice from lactation consultants, mothers with PIMS showed positive changes in their perceptions of their milk supply, underlining the value of professional guidance soon after birth. We conclude that an appearance of infant dissatisfaction is the major cause of PIMS in Western Australia.

Background Caesarean section(CS) rates in Scotland have increased from 8.6% in 1976 to 25.4% in 2010.1 Aims & Objectives In this study, we appraised the management of caesarean section against NICE and local guidelines,2 with a view to target any areas of improvement. Specific objectives included a review of operative technique, type of anaesthetic and fetal distress parameters. Materials & Methods Retrospective data collection of caesarean sections during a 2 week period. The audits were carried out in June 2005, November 2006 and January 2011. Results All women received thromboprophylaxis. 95 % of CS were performed under regional anaesthetic. Umbilical cord pH performed in 75% of emergency CS. Decision to delivery times for the most urgent CS have reduced from a median of 33 (range 20-60) to 26 minutes (range 20-36 minutes)}, syntocinon use for third stage has increased from 91% to 98% and the rate of double-layer uterine closure has increased from 63% to 93%). Conclusion There is evidence of improving care in this audit spiral as manifest from the results. However, compliance with guidelines is lower with regards to consultant involvement in decisions to perform emergency CS but this may reflect inadequate notekeeping rather than lack of communication with senior staff. The use of an operative proforma was shown in audit 2 of this spiral to be useful in improving surgical documentation.