I know our list mothers have called a moratorium on posting about the SOP  
but as one of the 3000 silent lactnetters I feel a need to weigh in  this once.
 
First of all I'm not sure how a credentialing body  can even delineate a 
scope of practice. At one time I was an RNC which  means that I was certified in 
my area of specialty -- high risk neonatal. I  studied like mad and then took a 
pretty difficult exam. This is what I was  certified to do--absolutely 
nothing beyond what I was licensed to do as an  RN.  What it did provide is evidence 
to my current or subsequent employer  that I took the time and spent the 
money to prove that I was a competent test  taker. Hopefully it also conveyed that 
I had a fairly complete body of knowledge  in high risk neonatal nursing. It 
did not enlarge my scope of practice in any  way, however.
 
I never thought about my international board certification in lactation in  
the same way, but indeed is it any different?  Can anyone think of any  other 
credentialing body which delineates a scope of practice for its  credentialees? 
  When we look at the scopes of practice for PT's,  psychologists, etc. these 
come from licensing boards not credentialing  organizations.  Even a 
physicians who is not board certified in a  particular specialty can still, for the 
most part,  practice in that  specialty. Is it not the physician's licence which 
outlines the scope of  practice?  (I would love to have any physicians on 
Lactnet let me know if I  am on track about this.)
 
As far as our current SOP it is neither realistic nor  possible to  practice 
without recommending alternative therapies, not that the board has even  
attempted to define what it means by "alternative". 
 
As far as diagnosing it is very possible for us to do our job without  
diagnosing--nurses have been doing this for years. As in, "you have all the  signs 
and symptoms of mastitiis. You need  to call your HCP right  away. It is 
important for you to continue to breastfeed your baby. The  milk is perfectly safe. 
If the pain is too great on the affected side for your  baby to nurse you will 
need to pump since milk stasis will make the  infection worse and will reduce 
your milk supply. I would also advise you  to try to get someone to help you 
so you can be on bedrest. Most mothers begin  to feel better within 24-48 hr. 
of starting antibiotics, but it is important for  you to take all of the 
antibiotics prescribed so no resistant bacteria will be  left. If your HCP has any 
questions please have him/her give me a call.  If  you are not feeling better 
within 48 hr. or you get worse please give your HCP a  call."
 
Now by stating "you have all the signs and sx of mastitis" I have not  
diagnosed, just described what I am seeing or hearing." It's a matter of  semantics.
 
And as far as treating a medical condition, as someone said I don't have  one 
of those little pads with my name and medical license on it, so I definitely  
cannot prescribe a medication. And I would never presume to treat a medical  
condition because this would be construed as practicing medicine without a  
license and would jeopardize my nursing license. 
 
The final tenet of the SOP states that "contradicting or ignoring  the advice 
of a client's health care provider" is outside of the SOP of an  IBCLC. I'm 
pretty sure that most of us in little ways get around  this  almost every day 
we work. I'm very careful, however, not to put my nursing  license in jeopardy. 
There are times that I cannot contradict a physician's  advice even though it 
kills me to have to go along with it. If it endangered the  life or safety of 
a pt. I would and could refuse to carry out an order. But it  is  seldom that 
clear cut. When an HCP tells a new mother she has no  milk, I gently but 
thoroughly explain that she has sufficient newborn  milk for her baby, called 
colostrum, and that  frequent breastfeeding  without supplementation will insure 
that her breasts make the amount of milk the  baby needs.  When an HCP orders 
formula after every breastfeeding,  without assessing the infant's ability to 
breastfeed effectively, because  the infant's bilirubin is in a high risk zone 
it's a little bit more of a  slippery slope.  As the dyad leaves the hospital 
I cannot advise them to  ignore this advice. If that baby goes home and does 
not bf well, loses more wt.  and jaundice increases my license is on the line 
for advising them to ignore  their doctor's advice. What I can do is advise the 
mother to rent a hospital  grade pump, to pump after every breastfeeding so 
she can protect her supply and  to arrange for lactation follow up so she can 
get her baby back to full  breastfeeding as soon as possible. 
 
Finally, I'd like to share an example of a pretty dramatic instance when I  
had to contradict a physician's advice. I was working in an outpt. lactation  
clinic. A mother who had been exclusively breastfeeding for 5 or 6 months was  
referred to me by her OB office.  She had recently been treated for  mastitis 
and had returned to the OB because her breast did not look at all  normal.  He 
told her it was a plugged duct and the lactation consultant  could help her. 
The entire outer aspect of her left breast was red, swollen and  looked to me 
almost like a cellulitis. It was painful to the touch but she had  no fever or 
systemic sx of mastitis.  I told her it did not look like any  plugged duct I 
had ever seen and that I was going to call her OB to discuss what  I was 
observing (fearing that it was cellulitis or an abscess). I spoke to  the OB's 
nurse who told me that the OB did not want to speak to me. He  told the RN that 
he had diagnosed a plugged duct and that was  what it was. He also refused to 
see or speak to the patient again. I now  had a dilemma. I knew this was not a 
plugged duct but something more  serious. Luckily, there was a breast surgeon 
who worked in the same complex  of offices as ours and she also had recently 
breastfed her own baby. We had  referred pts to her in the past. I asked the 
mother, who luckily had a  PPO so she could self refer, if she would see the 
surgeon and she readily  agreed. I then called the surgeon who was able to fit 
the pt. in and drained a  1/4 of a cup of pus from an abscess. The surgeon 
called me back to let me know  that within a day this mother would have been very 
sick and would have  required hospitalization.  The surgeon subsequently sent a 
letter to me  and the OB thanking me for the referral and the OB for the  
privilege of treating his pt. describing the situation she encountered and  her 
tx.  I hope he got the point.  So in this instance the mom's  well-being 
dictated I contradict the physicians findings.  If the  mother had not been well 
insured and had not been able to self refer I guess I  would have had to send her 
to the ER.
 
So-- I'm not sure having a SOP for a credential helps us. I do think this  
whole issue points to the need for a specified educational tract  culminating in 
licensure for our profession. In the mean time I hope the board  removes 
ambiguities from the SOP because at this time we have little choice if  we are to 
provide good care except to ignore them.
 
Kathy Boggs, RN, IBCLC

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