Lactation — structured oral station (12 minutes)

Opening prompt — "What are you going to do?"

Model response — say it in this order: ^[1]

• "I will watch a whole feed before I change anything. The four problems — cracked nipples, engorgement, weight loss and the suggestion of formula — usually share one cause, which is shallow attachment, and I can fix most of it in twenty minutes if I confirm that."
• "I assess positioning and attachment, the breasts, the mother and the infant. Weight loss of 9 per cent is approaching the threshold for intervention, so I want a formal weight plotted against birth weight and a feeding and output plan today."^[1][2]

Examiner is listening for: the offer to observe a feed before prescribing or supplementing; the attachment signs; and the recognition that the four problems are linked. ^[1]

Probe 1 — "Explain the physiology of why her milk came in and why a stressed mother can struggle."

• "Secretory activation happens at 30 to 72 hours after birth, triggered by the progesterone withdrawal that follows placental delivery — prolactin, high all pregnancy, is finally unopposed."^[1]
• "Two reflexes run the feed: prolactin from the anterior pituitary makes the milk, and oxytocin from the posterior pituitary ejects it. Oxytocin is the reflex that pain, anxiety and embarrassment inhibit — which is the physiological reason a woman 'has no milk' in a busy four-bed bay and plenty at home. Protecting that reflex is part of the treatment."^[1][2]

Probe 2 — "The right breast turns red and she is febrile at 48 hours. Walk me through your management."

• "I place it on the mastitis spectrum. Early erythema with systemic symptoms but no fluctuance is inflammatory mastitis — ice hourly, ibuprofen 800 mg every 8 hours and paracetamol 1000 mg every 8 hours, continued feeding to the infant's needs, and review at 24 hours before antibiotics."^[1]
• "If it is worsening or failing to improve at 24 hours, I start dicloxacillin or flucloxacillin 500 mg four times daily for 10 to 14 days — first-line, low relative infant dose. Cephalexin 500 mg four times daily is the alternative; clindamycin 300 mg four times daily for penicillin allergy."^[1][3]
• "If a fluctuant mass appears or fever persists despite 48 hours of the right antibiotic, I ultrasound and drain — ultrasound-guided aspiration or a drain — and she continues to feed from that breast; the milk fistula rate is under 2 per cent."^[4]

Probe 3 — "She asks whether the antibiotic means she has to stop feeding her baby. Answer her."

Demonstrate it with actual words and the principle. ^[5]

• "No — flucloxacillin is safe while feeding. Very little reaches the baby in the milk, well under the 10 per cent relative infant dose we use as our reassurance threshold, and no adverse effects are expected. The risk of stopping — engorgement, worsening mastitis, loss of supply — is greater than the drug risk."^[5]
• "If you are ever unsure about a medicine, the right move is to look it up — the Australian Medicines Handbook, Therapeutic Guidelines, the NZ Formulary, or LactMed — rather than guess. Most drugs are compatible."^[5]

Probe 4 — "She is overwhelmed and mentions stopping altogether. What do you say?"

• Acknowledge first, in plain words: "This has been really hard, and you're doing more than you think. The problems we're seeing are fixable, and fixing them is my job, not a test of you."
• Give the plan and the timeline: "If we sort the latch, most of the pain goes in a day or two, the weight picks up, and you have options. Stopping is always your choice — but let's fix the cause first so it's a choice, not a relief."
• Protect the oxytocin reflex practically: privacy, warmth, a drink, skin-to-skin, and a partner or support person who is helping rather than hovering.^[1][2]

Probe 5 — "She had a stillbirth last year and is now weighing whether to suppress if feeding fails. How is that done?"

• "Non-drug measures — a firm supportive bra, cold packs, simple analgesia, avoiding nipple stimulation, and expressing only the minimum for comfort — suffice for many women."^[6]
• "If medication is needed, cabergoline 1 mg orally as a single dose, given early after birth, has the highest success rate; it is contraindicated in preeclampsia or uncontrolled hypertension, which she does not have. Bromocriptine is superseded because of serious cardiovascular and psychiatric adverse events."^[6]