Appendix E
Education Checklist for Mothers of Sick or Preterm Infants who Choose to Provide Breastmilk for Their Infant(s)
Dear Mother: Please initial this form after receiving/understanding each of the following:
1. Breastfeeding benefits discussed with my baby's doctor |
(date__________) | _____ |
| 2. Began assisted pumping by nursing staff | (time/date______) | _____ |
| 3. Began pumping independently | (time/date______) | _____ |
| 4. Learned how to record in diary my pumping frequency (minimum 8 times/day) | _____ | |
| 5. Learned how to clean pump and collecting equipment | _____ | |
| 6. Learned about labeling, storage and transport of my milk (including small vials for colostrum) | _____ | |
| 7. Toured the NICU and saw pumping facilities | _____ | |
8. Learned what to expect when milk comes in |
_____ | |
9. Learned about breast massage and manual expression |
_____ | |
10. Received my own copy of the video: A Premie Needs His Mother, First Steps to Breastfeeding Your Premature Baby (for mothers of preterm infants only) |
_____ | |
11.My rental pump for home use will be available the day of discharge If no, please give date of rental __________ (rental site _________________ ) |
_____ |
Signature of discharge nurse assisting mother complete her educational objectives:
____________________________________________ (name/date)
