A Two-Mom Co-Nursing Family Strategy and Humanized Care: Case Report in Public Health

Victoria Campos Dornelles, Julia Rossetto Dallanora, Artur Boschi, Fernando Pecis, Nadine De Souza Ziegler

**Victoria Campos Dornelles^*, Julia Rossetto Dallanora, Artur Boschi, Fernando Pecis, Nadine De Souza Ziegler**

Hospital Materno Infantil Presidente Vargas (Hmipv), Porto Alegre, Rs, Brazil.

Abstract

This manuscript explores the healthcare experiences of a two-mom family within the Brazilian public health system, elucidating the unique challenges faced by LGBTQ+ individuals in a predominantly heteronormative healthcare landscape. The study underscores the imperative for healthcare professionals to undergo training in delivering inclusive and affirming care. The case revolves around LN, a cis-gender pregnant woman, and EN, a non-pregnant cis-gender woman, advocating for co-nursing and a natural birthing process. Lactation induction employed a concise protocol involving levonorgestrel, domperidone, and mechanical breastfeeding stimulation, coupled with preterm labor prevention through a cervical pessary. Emphasizing family autonomy, immediate skin-to-skin breastfeeding was facilitated after each twin's birth, challenging conventional guidelines. The case highlights the absence of institutional LGBTQ+ guidelines, emphasizing the pivotal role of a supportive multidisciplinary team in fostering an inclusive healthcare environment. The study advocates for the formulation of evidence-based standards governing lactation induction, childbirth, and overall healthcare for LGBTQ+ families. By presenting this case, the manuscript contributes valuable insights, urging further research and the establishment of comprehensive guidelines to ensure respectful, humanized, and equitable healthcare for diverse family structures. Such initiatives are crucial for enhancing the well-being of LGBTQ+ individuals and fostering societal progress toward more inclusive and compassionate healthcare practices. Keywords: Obstetrics; Pregnancy; Sexual and Gender Minorities; Birthing Centers; Perinatal Care.

^*Corresponding Author: Victoria Campos Dornelles, ¹Hospital Materno Infantil Presidente Vargas (Hmipv), Porto Alegre, Rs, Brazil.

Received: 28 January 2025; Accepted: 03 February 2025; Published: 05 February 2025

Citation: Campos VD, Rossetto JD, Boschi A, Pecis F, De Souza NZ (2025) A Two-Mom Co-Nursing Family Strategy and Humanized Care: Case Report in Public Health. Glob J Med Biomed Case Rep 1: 006.

Introduction

LGBTQ+ is an inclusive term for defining individuals self considered as lesbian, gay, bisexual, transgender, queer or any other gender and/or sexual diversities. [1] Recent data reveals that, when considering 30 different countries worldwide in this study, 9% of the global population self-identifies as a member of the LGBTQ+ community, with a significant proportion hailing from Brazil. According to Brazil's local National Health Research data, this population represents 2.9 billion Brazilian adults.

Epidemiological research has indicated an increase in two-mom and two-dad families in recent times. This trend has led to a growing number of data publications on this subject, emphasizing the ongoing urgency for further research. [2] There is a well known disagreement among the sociology sciences authors regarding the possibility of the same-sex parenting being harmful for the raising of children, with recent data, supported by scientific evidence, indicating there is no harm at all. A growing number of studies have shown no differences regarding mental health, emotional well-being and education in children raised by LGBTQ+ families when compared with children raised by cisheteronormative families. [2-5]

Therefore, there is growing research on non-cisheteronormative families' improvement of healthcare assistance with more inclusive guidelines, such as the co-nursing possibility for two-mom couples. The lactation stimulation with galactogogues started for improving breastfeeding when pregnant mothers experienced difficulties. According to the American Academy of Breastfeeding Medicine (ABM) Protocol from 2018, domperidone and metoclopramide are the most commonly used galactogogues due to their dopamine antagonist effect, which increases prolactin production. However, the significant lack of high-quality evidence results in the absence of evidence-based standards. This is why, currently, non-pharmacological measures are the only recommended approach for enhancing milk production. [6] This knowledge was expanded for lactation induction practices aiming to enhance mother-child bond in cis-heteronormative families through adoption, becoming also a good alternative for co-participation roles in two-mom family cases; however, there is still little research and guidelines available in this subject and with this population. [1]

There are several studies on breastfeeding importance on newborn's health and its well known relation to decrease childhood mortality worldwide. [7,8] Nevertheless, the World Health Organization (WHO) and the Brazilian Health Minister still do not recommend cross breastfeeding practice due to contamination risks and to an assumed risk of discouraging breastfeeding when difficulties in breastfeeding are presented. These recommendations still haven't considered the potential co-nursing benefits for LGBTQ+ families and are still related to past experiences when women were enslaved to breastfeed other women's babies.[8] A recent review of literature publicated in 2023 have concluded co-nursing practice to be not only beneficial for newborn's health, but also for motherhood identity establishment and family bonding, with the lack of public health guidelines on this matter being mostly associated to the LGBTQ+ social invisibility. [8]

In 2016, Brazilian public health politics recommended the fatherhood inclusion in prenatal care, reinforcing the importance of active participation of the non pregnant parent during pregnancy and labor.Thus, the same should be encouraged for two-mom families for improving their both inclusion and roles during healthcare follow-up. It is also important to highlight that the available studies following two-mom couples included highly educated and wealthy families, leading to little evidence-based knowledge regarding socially vulnerable same-sex couples. [2-5]

In this scenario, the importance of more data publication in this topic is crucial for improving healthcare assistance for families not only in private health centers, but also in the public health system. This study's case report aims to highlight the two-mom co-nursing possibility and humanized care in a public health hospital located in Brazil, following the Case Report Guidelines (CARE). [9]

Case Presentation

Patients Information: LN, a 24 year-old artisan white cis-gender pregnant woman, married to EN, a 27 year-old woodworker white cis-gender woman, arrived at a municipal public health fetal medicine prenatal care service on April 26th, 2023, referred for dichorionic and diamniotic twin pregnancy follow-up. They were legally married for 4 years, and this current pregnancy was highly desired. It was conceived through home insemination, a process undertaken after thorough testing of the semen donor for diseases. This approach was chosen, as assisted reproduction, a predominantly private health service in Brazil, was financially unattainable for them. LN, the parturient, achieved pregnancy after four cycles of home insemination attempts, resulting in two babies. She presented at the fetal medicine specialized service with a gestational age (GA, weeks+days) of 10 weeks and 1 day, calculated from a 7-week and 1-day ultrasound exam conducted on April 5th, 2023, revealing a dichorionic and diamniotic twin pregnancy.

LN was already treating depression/anxiety symptoms with antidepressant (Sertraline 50mg/day) and had a positive family history of diabetes, systemic arterial hypertension and preeclampsia. EN had no chronic diseases or use of continuous medications, nor chronic diseases in her family history. The couple had no chemical dependence, no past medical interventions and no previous pregnancies. They also denied any previous history of allergies.

Main symptoms and clinical findings

In their first appointment, Ferrous Sulfate 300mg a day was prescribed as a gestational anemia prophylaxis and Folic Acid 5mg a day until 12 weeks of GA as a fetal neural tube defect prevention. In July's 27th, the ultrasound evaluation identified a 1.6cm cervix and, hence, the obstetrician in charge prescribed 200 mg of progesterone a day as a premature labor prevention.

On July's 31st, the couple presented at the service's obstetric emergency center with 23 weeks and 6 days of GA due to abdominal pain. In physical examination, vitals were stable and there were no uterine contractions, with regular uterine tone and a 1 centimeter (cm) dilated cervix. The abdomen was soft, symmetric, non-tender without any distention. After an observational period with no cervix modifications and regular laboratory tests, LN was admitted for pessary evaluation. A new cervix ultrasonography evaluation was performed identifying 1.4 cm. The patient was discharged after 2 days of fine pessary accommodation, advised complete bed rest at home and maintenance of progesterone therapy.

Since their first obstetric appointment they had expressed the co-nursing parenting family desire, which had never been a fetal medicine service demand until this present case. They had also expressed a desire for vaginal delivery, with the least possible interventions, since their first obstetric appointment. Prenatal care was followed with no complications until the cervical pessary was removed in August, after GA of 36 and, afterwards, they evolved to post term spontaneous labor. The most important exams regarding this case are presented in (Table 1).

MOST RELEVANT US FROM THE CASE
DATING US	MORPHOLOGICAL US
(05 April 2023)	(01 August 2023)
Gestational sac with regular contours, two viable embryos and normal amniotic fluid. Conclusion: dichorionic and diamniotic twin gestation. Biometry consistent with 7 weeks and 5 days of gestational age.	Twin viable pregnancy with normal amniotic fluid in both sacs. Transvaginal cervical length measurement from internal to external cervical opening: 1.4 cm. Conclusion: Dichorionic and diamniotic twin gestation at 24 weeks, based on the previous US from April 05th. Short cervix.
NON-PREGNANT MOTHER LABORATORIAL EVALUATION
BEFORE BREASTFEED (09 November 2023)
Syphilis, hepatitis B, hepatite C, HIV, all negatives

Table 1: Most relevant exams of the presented case.

Interventions

Lactation induction for co-nursing
July 3rd: EN received a prescription of 0.25mg levonorgestrel + 0.05mg etinilestradiol for 6 weeks. Afterwards, 20mg of domperidone for every 6 hours was introduced. After 30 days, the birth control pill was suspended and breastfeeding mechanical stimulation was initiated.
Cervical pessary for preterm labor prevention in LN.
Twin vaginal delivery was perfomed respecting patients’ autonomy.

Follow-up and outcomes

At 38+2 of GA they reached the obstetrical emergency room after rupture of membranes in active labor and completed dilation of the cervix. They had previously devised a labor plan with multidisciplinary assistance and orientations, aiming for as few interventions as possible. Both fetuses were longitudinal and cephalic. Respecting the two-mom wishes and autonomy, they were transferred to the delivery room for vaginal birth in her preferred position.

The first baby was born on November 9th of 2023, at 12:12 am, male, with 3,145 g of birth weight (BW) and Apgar score 8/8. There was an immediate skin-to-skin and breastfed occurred with no difficulties in his first hour of life. There was no perineal laceration. At this moment, the spontaneous active labor stopped and, respecting their autonomy and supported by evidence based guidelines, no interventions were performed for delivery acceleration until November 10th 04:30 am. During this period between both labors, the parturient and fetal vitals were monitored frequently and, after almost 17 hours without spontaneous active labor, patients together with the obstetrical team decided to perform an artificial amniotomy for accelerating the second delivery. The amniotomy was performed with patients' consent and without any complications. The second baby was born on November 10th of 2023, at 04:43 am, female, 2,935 g of BW and Apgar score 8/8. There were no difficulties in co-nursing the second baby and skin-to-skin was also performed immediately after birth with both mothers. The placentas were discharged easily and no perineal lacerations were found during post labor physical examination.

After 48h of physiological puerperium observation with the two-mom co-nursing success, the family was discharged and took home their two healthy and well bonded babies. The induced lactation mother was discharged still in regular use of domperidone until this date, with a discontinuation plan to be aligned in further evaluation.

Discussion

Strengths and limitations for lactation induction

The lactation induction shown in this reported case was requested by this family instead of being a health professional explained option during prenatal care. This is an important limitation to be mentioned, since this practice is still not well known even by healthcare providers hence, non-pregnant mothers should always be advised about the possibility of breastfeeding induction. However, when considering diverse family structures within the LGBTQ+ population, these orientations should be approached with care, recognizing that not every individual with breasts may desire a breastfeeding experience. Also, while explaining the lactation induction possibility, it is important to counsel the family on the time and effort needed for success and the emotional distress that may be involved, since the little available evidence about the frequency of this practice's success and parental stress is already shown to harm children's neurodevelopment. Accordingly, it is a decision to be made individually and together with the family involved after extended orientations, discussion of expectations, goals and proper follow-up arrangement. [1]

The absence of local institutional guidelines for lactation induction was a significant limitation in managing this case. However, despite the lack of prior experience, the multidisciplinary local team successfully examined guidelines from other institutions to adopt an evidence-based approach. This deficiency is not only an institutional issue but also reflects a failure in public health in Brazil. The local Health Minister still does not endorse cross-nursing, LGBTQ+ families are still invisible in public health policies and most existing prenatal care guidelines are developed with a focus solely on cis-heteronormative families. [8] Despite the still little evidence on this subject, there are growing studies showing the lactation induction practice to bring large benefits for parents and babies, with low risks involved if performed by a multidisciplinary team following evidence-based protocols with appropriate follow-up. This practice is associated with a more successful experience of exclusive and prolonged breastfeeding, preventing early weaning and the need for supplemental formula feeding. Moreover, it has been emphasized that the emotional and bonding benefits of this approach surpass nutritional advantages. [8,10]

The ABM Protocol published in 2018 showed galactogogues risks and benefits, demonstrated in (Table 2). [6] In a more recent publication, they considered LGBTQ+ families and the lactation induction possibilities and concluded the urgent need for more research in this field for further evidence-based standards guidelines and recommendations. [1]

	DOMPERIDONE	METOCLOPRAMIDE
Action	Dopamine antagonist	Dopamine antagonist
Side effects	Dry mouth Headache Abdominal cramps Psychomotor withdrawal symptoms in > 160 mg/day Prolonged QTc interval have been reported if past history of ventricular arrhythmias	Reversible central neural system effects with short-term use including sedation, anxiety, depression/agitation, motor restlessness, dystonic reactions and extrapyramidal symptoms; Rare reports tardive dyskinesia irreversible
Interactions	Fluconazol Macrolide antibiotics grapefruit juice Cannabinoids Antipsychotics	Antihistamines Antidepressants

Table 2: Galactogogues for lactation induction in high-quality evidence-based. Souce: elaborated by the authors, based in ABM Clinical Protocol 9, 2018.

In this case, the prescription was based on the lactation induction guidelines from Albert Einstein Hospital, a well-referenced institution located in São Paulo, the southeast of Brazil. Their guideline, which affords regular and short prescription options described in (Table 3), was developed with the following main objectives: allow breastfeeding experience for non-pregnant people, such as two-mom families, transgender mothers, surrogate mothers, adoption; achieve equal tasks in parenthood; stimulate bonding and improve the nutritional offer for twin babies. Therefore, this case aligns with all these objectives, featuring not only a non-pregnant mother in a two-mom family but also a twin pregnancy.

Furthermore, this brazilian lactation induction guideline was based in the Canadian Newman-Goldfarb Protocols, 2022, which are based in Jack Newman and Lenore Goldfarb research that started in 1999 with the Lenore's lactation induction experience for her son conceived by gestational surrogacy. Dr. Newman developed it combining a birth control pill, for its breast changes side effect, with domperidone, for its higher prolactin levels side effect, aiming to achieve milk production. Additionally, the breast pump plays a crucial role in sustaining the breastfeeding process by promoting elevated oxytocin levels and, consequently, increased prolactin production. Following this initial success in non-pregnant breastfeeding, they collaborated on publications and assisted over 500 non-pregnant mothers in breastfeeding, continuously refining their protocols to the present day. The protocol emphasizes the importance of physician prescription, follow-up, and/or competent lactation consultants. (Table 3) also provides details on their regular and abbreviated prescription options, along with significant side effects and contraindications. [10]

LACTATION INDUCTION PROTOCOLS
PREPARE
Breast/chest physical examination (search for active herpes and/or lumps)
Laboratory tests: screening for infection diseases (syphilis, hepatitis B/C, HIV, cytomegalovirus, HTLV, Chagas disease)
Counseling and orientation
Are there any contraindications?
CONTRAINDICATIONS
Prolonged QTc interval, aura migraine; previous thrombosis, undiagnosed uterine bleeding; Suspicious breast lump; decompensated hypertension and diabetes
ACCELERATED PROTOCOL	REGULAR PROTOCOL
Birth control pill > 35?g etinilestradiol during 4 weeks	Birth control pill > 35?g etinilestradiol during 4-6 months
Domperidone 20mg 4x/day	Domperidone 20mg 4x/day
Start with half dose for 1 week	Start with half dose for 1 week
Start breast pumping after 4 weeks	Start breast pumping 6 weeks before birth
Stop birth control pill when start pump	Stop birth control pill 6 weeks before birth
Baby stimulation as soon as possible	Baby stimulation as soon as possible
POSSIBLE SIDE EFFECTS
Extrapyramidal symptom, hypotension, diarrhea, hyperprolactinemia
Increased blood pressure, depression, nausea, edema, weight gain, exhausts, mastalgia, melasma, candidiasis, thrombosis
IMPORTANT NOTES
? If 35 years old or more and/or birth control pills contraindicated: replace it for either Provera 2.5 OR Prometrium 100mg
? Domperidone should be taken ½ hour before meals
? Addition of oatmeal regularly in diet were noticed to increase milk production by some of patients followed by Dr Newman
? If possible, 6-8 water glasses a day are recommended
? In women maintaining intercourse with men: an alternative contraception method should be prescribed
? It is expected that serum prolactin levels increase between 1 am and 5 am: pumping during night can be an advantage for milk production
? Pumping instructions: 5-7 minutes on the low or medium setting, than massage, stroke, shake and afterwards pump again for 5-7 minutes
? It is suggested pumping every 3 hours - at least once during the night
? Despite lack of evidence, Herbs Thistle (390 mg per capsule) and Fenugreek seed (610 mg per capsule): take 3 capsules of each 3 times a day with meals can be considered
? Continue Domperidone 20 mg 4 times a day after delivery until she achieves substantial milk supply or after wean
DISCONTINUING DOMPERIDONE
1. Drop one pill (instead of 9 pills a day, use 8) for 5-7 days
2. If no change in milk supply afterwards, drop another pill for 5-7 days
3. Continue like that until no pills a day, if no decrease in milk supply
4. If the milk supply diminishes: return to previous effective dose and do not drop any pills (for at least 2 weeks, afterwards go back to item 1)
5. Following steps 1-4 above may get the patient's lowest effective dose
IF DISCONTINUATION AFTER WEANING OF BREASTFEED
1. Decrease domperidone to 20 mg 3 times a day for 2 weeks
2. Decrease it to 10 mg 4 times a day for more 2 weeks
3. Continue to decrease it to 10 mg 2 times a day for another 2 weeks
4. Decrease it to 10 mg once a day for 2 weeks
5. Stop the used afterwards

Table 3. Lactation induction evidence-based protocols. Source: elaborated by the authors, based on Newman-Goldfarb Protocols, 2002-2019, and Albert Einstein Hospital Protocol, 2022.

In this present case, the decision for the short prescription protocol was performed due to the short time interval between the patients' request and the estimated delivery date, since the evidence-based protocols reinforce the need of breastfeeding as soon as possible after birth for better maintenance of the lactation induced process. According to Newman-Goldfarb Protocols publication in 2019, the breast pump must be performed for lactation induction for at least one month before delivery, as well as the need to stop the birth control pills when starting pumping, as its use is widely not recommended during breastfeed. Also, the birth control pill and domperidone combination must be continuously used for at least 30 days before being stopped 6 weeks before delivery, for this method's success, reinforcing that the longer the use, the better the results. [10] Besides that, the birth pill control used in this case had a lower estrogen dose in comparison with the high-dose recommendations and still presented a satisfactory response in lactation. Thus, more studies and reported cases publications should be performed for revising the real need of high-dose birth pill control for proper lactation induction response and for elaborating more evidence-based guidelines.

After delivery, the use of domperidone is recommended to be continued during breastfeeding for better maintenance of milk production, according to the available protocols; however, this drug’s safety for the baby is still controversial in the literature. [10] The American Food and Drug Administration (FDA) still does not approve domperidone use for lactation induction in any country due to the lack of established evidence regarding milk supply increase and its benefits over risks, with FDA having published a warning in 2004 regarding this use. In a 2023 publication, however, the FDA recommended cautions regarding exposing the baby to unknown risks and provided evidence on the association of neuropsychiatric adverse events when sudden discontinuation of the medication. (FDA, 2003) Since the amount of domperidone into the milk was already shown to be small, its use during breastfeeding is currently approved by the American Academy of Pediatrics e there is growing evidence showing its benefits over risks with rare long-term side effects observed in the last 2 decades worldwide experience of use. [10] As with any medication prescription, these all should always be extensively oriented to patients for shared decision making, and more studies should be performed in order to improve high evidence-based domperidone use for lactation. The discontinuation recommendations are still under study and should be always performed with caution, never suddenly and the decision of when to stop should be always performed together with patients in use after the extensive orientations of the lack of well-established recommendations. [10]

Given the overall duration required for successful lactation induction, the importance of health professionals' counseling is emphasized and should be initiated promptly. Therefore, the optimal protocol decision should be guided by the expected delivery time, as successfully implemented in this case [10] The good response on the Newman-Goldfarb protocol prescription shown in this reported case was also shown in 3 lactation inductions cases reported for in southeast Brazil, with one of the patients receiving the same short protocol prescription as this case and the other 2 receiving the regular protocol.

In agreement with the available evidence, tests for transmissible infections were also evaluated in the non-pregnant mother, as the risk of the baby's contamination through breastfeeding is one of the reasons why the cross-breastfeeding practice is not widely recommended. [1] In this case, this could have been performed together with the pregnant mother in the first prenatal evaluation for improving the non-pregnant mother inclusion in prenatal care, as it is already recommended in Brazil for father’s co-participation. [1,8] Also, as it was properly performed in this case, the non-pregnant parent should always have their breasts/chests examined for improved guidance and for any signs of active infections, such as herpes virus, which would be a breastfeeding contraindication. [1]

Strengths and limitations for delivery

Twin pregnancies are associated with a higher risk of preterm labor, as well as the short cervix diagnosed during pregnancy. It is important to highlight that, in this present case, the preterm delivery was well prevented through cervical pessary from GA 23+6 to 36, leading to spontaneous labor only at GA 38+2. The cervical pessary is a rubber tool introduced into the patient's vagina that has controversial literature results in reducing preterm labor in concomitant short cervix cases (CL< 2.5 cm), with some studies showing positive outcomes, while others found no significant data. [11-13] On its turn, progesterone prescription is also associated with good outcomes in preterm labor prevention; however, there are still little studies analyzing this use in association with the cervical pessary. Nonetheless, this practice is considered safe for preventing preterm labor, as observed in this reported case, despite the absence of current evidence-based recommendations. The cervical cerclage is also an option for avoid prematurity in cervical incompetence cases, supported by evidence-based protocols; nevertheless, it is only recommended until GA 24 and it is not a routine for all twin pregnancies. [14] Considering that this patient's case involved a short cervix diagnosis very close to the gestational age limit for cervical cerclage, the obstetric team decided to employ the cervical pessary with progesterone supplementation approach.

When health professionals are not well prepared to work with LGBTQ+ families, the delivery experience can be significantly traumatic, with existing data demonstrating discrimination experiences and substandard care. Breastfeeding on demand stimulation and skin-to-skin immediately after birth should be performed whenever possible as any other cis-gender family, and this presented case has performed it successfully. In a recent ABM protocol, it was recommended immediate birth skin-to-skin to be performed with one of the parents that should be determined before delivery. [1] Unlike this recommendation, the immediate birth skin-to-skin breastfeeding was performed with both mothers in an equal amount of time, respecting their wishes. Considering the WHO (2020) skin-to-skin recommendations, this practice is stimulated for improving breastfeeding, vital parameters' stabilization and healthy microbiota establishment. [17] There isn't enough evidence contrary to performing this practice in a two-mom co-nursing scenario, in which those benefits would be the same, as this reported case has shown. Hence, the breastfeeding guidelines should be expanded with including non-pregnant parents in their recommendations, stimulating human milk availability as much as possible and skin-to-skin practice whenever feasible.

Furthermore, the ABM protocol recommends family privacy and birth plans always to be respected, as well as lactation assistance in a hands-off approach also always to be preferred. [1] In this case, the majority of the multidisciplinary team, despite its lack of training and institutional protocol, employed their best efforts and patients were discharged well satisfied with both delivery and breastfeeding experiences and assistance received.

According to WHO recommendations, which are supported by the Brazilian Health Minister, every birth should be provided with respect, maintaining privacy, confidentiality and allowing patient's well informed autonomy. Also, there are no interventions stimulated for the acceleration of labor, such as amniotomy or oxytocin, when the patient and fetus are healthy and stable [7] Furthermore, respecting patients' autonomy on delivery route decisions is also supported by the Code of Medical Ethics as an important bioethical principle always to be respected in the absence of maternal and/or fetal life threatening conditions. Also, this choice should not be influenced by any external philosophical, religious or political opinions. [15]

Regarding vaginal delivery in twin pregnancies, the evidence-based support this preferred route in diamniotic both cephalic fetuses, with the cesarian birth being preferred for non-cephalic presentations in diamniotic twin pregnancies, monoamniotic twins or if any standard obstetric indications presented herein. Moreover, in uncomplicated diamniotic twin pregnancies, delivery should be planned between GA 38-38+6 in delivery centers able to perform immediate cesarean section if necessary, due to its higher risks. [18,19]After the first birth, the evidence-based recommendations support the possibility of waiting with no interventions for the second baby, after confirming cephalic presentation and if the patient and fetus are well and stable. Besides, there is no maximum interval of time for waiting for spontaneous second vaginal delivery if the patient and fetus presents stable vitals. (Chasen, 2023) The brazilian Health Minister guideline for high risk pregnancies also support this approach and highlight the importance of fetal monitorization during this time between deliveries, with attention to possible complications of prolonged labor such as placental abruption, uterine atony and fetal gloving. (MS, 2022) It is important to reinforce that unnecessary interventions are also associated with higher complications rates, such as acute fetal suffering, tachysystole, chorioamnionitis, umbilical cord accidents and emergency cesarean section indications, evaluated the severe acute maternal morbidity in twin pregnancies regarding delivery route, showing it to be higher in cesarean section for both twins and also if only performed in for the second twin, highlighting the importance of avoiding the elective surgical delivery indication. [21]

Considering all the possible risks and benefits of waiting for the second twin's spontaneous labor and of performing any interventions in order to accelerate it, the more suitable management should be chosen with a shared decision making, after extensive orientations for the patients involved. Thus, this reported case performed respectful delivery assistance, respecting patients's autonomy and in agreement with updated evidence-based literature.

Strengths and limitations for a respectful environment

Due to the large societal discrimination and LGBTQ+ population invisibility, there is an important lack of health professionals training for provision of inclusive and affirmative care, which was an important limitation in this presented case. Lesbophobia can be explicit or a result of unpreparedness in health services, leading to traumatic experiences and impaired care follow-up. Brazilian data has already shown 40-60% of lesbian women feeling discomfort in health care services and 13-70% avoiding it due to previous traumatic experiences. [1] Also, it is important to reinforce the Code of Medical Ethics statements against any kind of discrimination during any patient care, which should always be remembered.

Since the service had no guidelines including this population, the unpreparedness was present and could have been prevented with proper training. The health care services should be trained in order to understand how to use pronouns, open questions, using different parenting terms instead of mother and father, with no cis-heteronormative assumptions. The patient/provider relationship should always be maximized for healthcare improvement. [1]

Equity stands as a paramount principle within Brazil's public health system, emphasizing the recognition of societal disparities among vulnerable populations to enhance their access to public health services. The commitment to equity promotion involves acknowledging and respecting these differences. Although local government laws endorse individualized assistance for LGBTQ+ patients among health providers (SES, 2020), the existing reality reveals a gap in the training of most local public institutions for fostering an inclusive environment. Unfortunately, cases of LGBTQ+ phobia persist among health providers, underscoring the need for comprehensive efforts to address and rectify this issue.

Despite the lack of institutional training and difficulties found in the management of this case, the health professionals who were able to improve the environment care for these patients were a strength to be highlighted. Aiming to diminish the limitations experienced in this case report, a good-practice evidence-based guideline for future cases is suggested in (Figure 1).

Figure 1: Healthcare improving assistance suggestions for future cases.

Conclusion

In conclusion, the lactation induction prescription for the non-pregnant mother in this case achieved a good amount of milk production that led to breastfeeding success from the first hour after birth of each twin baby. This presented case may contribute to the literature in order to allow refinements in the available protocols, highlighting the good response possibility even in lower birth pill control doses.

Furthermore, humanized evidence based delivery assistance was successfully performed respecting patients' autonomy, with the breastfeeding bonding experience being allowed for both mothers, as well as a more equal parent role for this family since prenatal care to delivery ?s assistance. This case also reflects the urgent need of more publications in this subject and more institutional guidelines for achieving a more equal healthcare assistance for the LGBTQ+ population, respecting all family compositions possibilities. The healthcare assistance equality and improvement for this marginalized population could be the start of more respectful new societal generations.

Thus, this case presentation showed a lactation induction success for a two-mom family in the public health service and presented suggestions for a local institutional guideline evidence base elaboration for future cases.

Acknowledgments

The authors are widely grateful for the patients involved in this case for allowing their data to be used for research and for demanding their rights in public healthcare - this may lead to assistance improvements in further cases.

A special thanks to Dr Fernando Pecis, Dr Artur Boschi and Dra Nadine de Souza Ziegler for the stimulation in this writing and validation of this subject’s importance.

To all the multidisciplinary healthcare professionals who performed their best efforts, in spite of the lack of proper institutional training, to provide the most welcoming environment as it was possible: thank you very much. The healthcare providers are some of the people who can actually improve the visibility of societal marginalized populations.

Ethics and Consent Informed Signed Term

The patients involved in this reported case agreed to this publication and signed an Informed Consent Term (ICT) allowing this manuscripts’ elaboration. This study was submitted and approved for the local Research Ethics Committee (Hospital Materno Infantil Presidente Vargas, Porto Alegre, Brazil, CAAE 74383123.8.0000.5329, purport 6.504.728, approved in November, 2023).

Conflicts of Interest: The authors declare no conflicts of interest.

Authors Contribution

V.C.D. performed the study design, collection of data, consent term signatures and was the major manuscript and critical discussion writer; J.R.D. performed manuscript contributions with critical discussion; A.B. and N.S.Z. performed critical discussion and final manuscript approval. All authors have read and approved the final version of this manuscript.

Case Report