Are breast checks by a pediatrician appropriate? Babble.com’s Parental Advisory.
Should pediatricians do breast checks at prenatal visits?
Hello, I’m a pediatrician who has been practicing for many years. I have taught many breastfeeding classes and enthusiastically promote the practice in our small city. At prenatal visits I often will briefly check a mom-to-be’s breast to make sure that we know what we’ll encounter postpartum (e.g., inverted nipples). There’s no touching involved, and the check just takes a few seconds. But I recently had a pregnant woman complain that it was inappropriate. This was the first time in over twenty-five years of practice anyone has complained. I later found out that she was sexually abused as a youngster. What are your thoughts on these screenings? I have spoken to several lactation consultants who think what I do is entirely appropriate. Thank you. – Old Doc
Dear Old Doc,
We think it’s really terrific that you’re a pediatrician with knowledge about breastfeeding. As we have complained in this column, before, many women turn to their doctors for advice and support about breastfeeding and don’t get it, or maybe even get outdated or incorrect information. It sounds like your experience and knowledge have been helpful to many of your patients. It also sounds like this particular patient was a little freaked out.
The transition to motherhood can bring up all kinds of issues when it comes to body and sex. If this is true for a person with a healthy sexual history, imagine how much more intense or even traumatic it can get for someone who’s been abused. Pregnancy, birth and breastfeeding can all trigger complicated feelings for survivors: Aside from a general feeling of loss of control, the sensations of having and feeding a baby can bring up terrible memories or associations. Women who were abused as children might feel especially afraid or upset by the idea of “loosening up” or “surrendering” during labor, feel invaded by needles or aggressively restrained by monitors. Breastfeeding may make a woman feel that her body has been taken over, or “owned” by someone else. Night feeding and public feeding can be especially hard for a woman who feels very protective of her boundaries.
Since a woman’s sexual history can have an impact on birth and childcare, OBs and midwives are trained to screen for abuse.
The Nurse-Midwifery Handbook: A Practical Guide to Prenatal and Postpartum Care by Linda Wheeler outlines the protocol for abuse screening. It’s very sensitively written with lots of information for how to talk to patients and direct them to appropriate support when necessary. You might want to check out the book, but that brings us to the next question: Does an inquiry into sexual abuse fall under your jurisdiction or the prenatal caregiver’s? We’re not entirely sure of your arrangement with patients, so we can’t make that call. Our hunch is that you’re simply being a really thoughtful pediatrician by meeting with pregnant women ahead of the birth to discuss breastfeeding – an important aspect of infant care. If that’s the case, and you’re not directly involved in prenatal care, it would be inappropriate for you to delve into a full Q&A about sexual history.
Still, if you’re discussing breastfeeding with a mother-to-be and feel that an examination of her breasts would be helpful, you need to be very clear about your role and the purpose of what you’re doing. We can imagine a patient being a little taken aback by the somewhat unusual scenario of having a doctor – who isn’t even ostensibly treating her – ask to see her breasts. While such a request makes sense to someone with breastfeeding expertise, it might not to a first time mom. Primiparas are at the very beginning of a long learning curve about what it’s like to consider their breasts in a non-sexual context. Some women are very comfortable with this; others – even those without a history of abuse – need more time and space to adjust. So, if you’re concerned about future patients who might have similar issues, here are a few thoughts to consider:
– Ask before you look or touch. The big issue here is boundaries; by asking first, you are immediately respecting them. Kathleen Kendall-Tackett, in her article, “Breastfeeding and the Sexual Abuse Survivor” writes, “If a mother might be a sexual abuse survivor, always ask permission before touching her. This gives her the chance to control the amount of contact.”
– Then as you move forward – if you have gotten permission – continue to respect the woman’s boundaries by explaining precisely why you need to do what you are going to do. And narrate as you go: “I am going to do this; I am going to that; I will look for this; all done; great.”
– If the woman is not comfortable being examined, it’s probably best to leave it at that. Let her know you’ll be there for her as a resource for breastfeeding and perhaps give her some literature or avenues for support.
If sexual abuse ever directly comes up in a meeting with a patient, you could use of the questions Linda Wheeler offers midwives: “‘Is any of this unfinished for you?’ [This] can help you decide whether a referral for counseling should be suggested.” You may also want to look into support services in your area so you’re able to refer patients who could use some help.
The job of a good caregiver encompasses not only acting appropriately but also acting sensitively to the patient’s needs and responses. Your concern about this incident suggests that you’re interested in doing both, and we commend you on that.
Have a question? Email parentaladvisory@babble.com
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Was just thinking that I might be alarmed if a MALE pediatrician asked to see my breasts unless my child was under his care and there were breastfeeding issues.
Couldnt tell if this question was by a woman or a man. SHouldnt matter but somehow it does.
I wish I had dealt with someone this sensitive when I had my son. Instead I dealt with a nurse in the hospital that, when I asked about help, instead of asking to see anything, reached over and grabbed my breast, explaining in a rather insulting tone that I wasn’t getting a good latch, and then showed me how. Why the information was helpful, the delivery of it was horrid. At least this doctor asked first!
How is this practioner coming in contact with these women? Where are these “exams” being conducted? How many women do YOU know would go to a pediatrician with concerns about breast feeding? And why was the HIPPA law violated? Hippa is a national law that prohibits the discussion of a client’s medical history unless the discussion is DIRECTLY related to patient care. That pediatrician has NO RIGHT to know anything about the woman’s sexual history. I have been an RN for over ten years, and do not know ANY pediatricians who want to “examine” a mom to be’s breasts. Nor do I know any lactation consultants who would encourage this. Good for the woman who stood up to this pervert.
While I understand the benefit of having a medical professional check a pregnant woman’s breasts for things like inverted or flat nipples that may be a pose a problem for breastfeeding I don’t think it is within the realm of the pediatrician. The mother-to-be is not the patient of the pediatrician. Perhaps it would be different if the pediatrician is also a certified lactation consultant but I still think a prenatal breast check fits more appropriately into the scope of practice of the pregnant woman’s midwife or OB.
Weird story: I had a labor and delivery nurse pinch my nipple before inducing me, telling me breastfeeding would go just fine. I appreciated the head’s up, but was she really the appropriate person? Also, if someone could’ve warned–no ASKED–me first, that would’ve been great. I felt totally skeeved.
She was right though. Breastfeeding was fine.
Thank you Nurse G. As a health professional (Family Nurse
Practitioner) there is so much I find wrong about this article. For example- how does this pediatrician assess
for things like flat nipples (which are not always obvious on observation) without actually touching the
woman? Also the pregnant women who are at the prenatal appointment
ARE NOT the patient of the pediatrician so it is completely
inappropriate for the pediatrician to do a medical assessment and give
advice. And most prenatal pediatrician “appointments” are actually
meet and greet sessions- so the new parents can meet the physician and
ask questions about care philosophy, etc and not the place for a breast
exam.
I highly doubt that this story is true- I can’t imagine in 25
years of doing breast exams on pregnant women at prenatal appointments
only 1 woman felt uncomfortable (I would have to wonder how many women just never came back to that practice!). If the pediatrician I interviewed had
wanted to do that I would never have gone back. Maybe I live in a more conservative area than this physician practices in but I can’t imagine the
vast majority of my friends would have felt comfortable in this
situation either. While prenatal breast checks can be valuable tool to
assess for conditions that might interfere with breastfeeding the most
appropriate health care provider to do them is the woman’s OB or
Midwife NOT a pediatrician.