Intraoperative Care of Lactating Patients Guideline (Mayo Clinic Internal Guideline January 2023)

Scope

Provision of appropriate and patient-centered care according to our values will be possible only with the thoughtful construction of a standardized system for supporting lactating patients in intraoperative care.

Purpose

When duration of an operation or procedure is expected to exceed the interval that a lactating patient would typically feed their infant or express milk, providers may need to arrange for milk expression intraoperatively. This will guide the care team in discussing, planning, and performing this activity.

Guideline

  • The possibility of intraoperative milk expression should be discussed preoperatively with all lactating patients who undergo surgery with a reasonable chance of being prolonged to a duration longer than the patient's typical feeding or pumping interval.
  • Patients should express milk or feed infants as close to OR start time as possible, as this may decrease the number of intraoperative sessions. The infant may be present in the preoperative area with a caregiver (other than the patient). OR start time may be affected.
  • The team should discuss at briefing the timepoint at which plans for milk expression will be put in motion. This should not be repeatedly delayed.
    • It is reasonable to target a time range so that it can be performed at a point that is not disruptive to a critical or challenging part of the operation. A small amount of patient movement is to be expected during milk expression.
    • In positions that the team deems the chest completely inaccessible for a prolonged period, pumping should be performed preoperatively and in the operating room after they are returned to supine position.
  • Milk expression should be performed by a provider with experience in milk expression and ideally familiar with the hospital grade pump (Medela Symphony).
  • In the anesthetized patient, we recommend discarding the milk pumped intraoperatively. For regional or MAC cases, this is at the discretion of the covering anesthesiologist in consultation with the patient and lactation consulting.
    • If the milk is to be saved, it should be labeled, and refrigeration should be discussed with patient's floor RN (registered nurse) or PACU.
  • If an operation is unexpectedly prolonged in a lactating patient, consider contacting a surrogate decision maker to discuss whether pumping should be initiated.

Intraoperative Adjustments

  • Breasts should be free of pressure and accessible for periodic evaluation and intraoperative milk expression if applicable.
  • Iodine-based preparation solutions should be avoided to prevent thyroid suppression in the infant.
  • Consider allowing patients to wear a wire-free supportive bra (nursing or sport-type) for comfort in appropriate operations.
  • When an incision is in the chest or breast area, increased blood flow should be expected.
  • If intraoperative pumping is planned, breasts should be accessible or a plan for temporary access should be in place. Consider a trial run for provider access before and after final draping prior to incision to limit disruption during operation.

Equipment/Supplies

  • This section should be site-specific. Example information from Mayo is included below.
  • The team should contact the preoperative RN or preoperative charge RN to order a hospital grade pump and supply kit to accompany the patient to the operating room. If the pre/post area is closed for the day, the OR nurse should order the materials to be brought to the operating room.
  • Breast pump information:
    • Breast pump (Central Service): CS-Distribution Item number CSPUM12 PUMP, Breast
    • Pumping kit: Distribution PBAR #370725
    • Additional bottles: Distribution PBAR Item#392210 80 ML bottles

Communication

  • Whiteboard communication: RN will write estimated scheduled for pumping times, including last preoperative feeding or milk expression.

Resources

Additional training in intraoperative milk expression is under development and will be offered broadly to operating room care team members interested. More information will be announced later.

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Sarah Dodd, M.D. (C)
January 2023