<Called to see a mother who had a Emergency Section 27/1/04. for failure to progress Mum is on antibotics for a wound infection another 3 days left to take.>
Red flag for thrush. Instruct her to be on the look out at both baby and mother, for further signs as one of several possible causes/potential problems.
<Mum is concerned about her breastfeeding. Baby has now gained her birth after 14 days weighed at birth 3880. length 56cms.
Mum has been told by someone that she needs to breastfeed 3 hourly so
has been doing this for the past 2 weeks.>
Even during the engorgement period?? If baby not signaling hunger or need for comfort more often, this leads me to suspect large storage capacity as one possible explanation.
<Her right breast felt lumpy (thats why I was called) she was concerned
that she had a plugged duct or mastitis. the lump disappeared after the
breastfeed. no redness.>
What bra size is she? Generally speaking, in my experience, longer tubings, more storage capaciy likely with C cups and beyond. Most secretory tissue is in upper half of breast, primarily in the upper outer quadrant. Gentle, steady breast compression in lumpy area when the baby slows down nursing would help in moving the milk forward. Also, if her incisional pain will allow it, if lumpiness is on right side, lie on left side with baby elevated on a pillow if need be, then roll over on her side as far as needed and nurse off of right (top) breast. Then gravity, plus a little breast compression, would help the RUQ drain more efficiently.
<Her right nipple is very sore>
'Sore' as in "tender", or 'sore' as in wounded? Or both? Grammar often gets ignored in using this word, and I find it helpful to clarify it with questions like "Can you see any redness or skin damage, or is it simply tender to touch?" Different interventions apply.
< at 2oclock>
I'm trying to guess the position. This would be the position in line with the middle of the upper lip if the baby were in football hold with the feet and legs lower than the rest of the body. Football position is more favorable for getting the lower jaw more fully on the areola. If "snug", then that might be expected to put less "drag" on the tissue in the upper part of the mouth. Perhaps using a different position, even if it were a modification of the football, by raising the baby's hips, by supporting lower extremities with a bigger pillow and clutching hips closer to her ribs might shift location where forces of the baby's mouth are applied and be less likely to "drag" on the breast.
< she has a small pin head size blister at the base.>
It's hard to tell from your description whether it's the blister that's at the 2 o'clock position, or just tenderness or possible nipple damage. By 'base', do you mean where the nipple junction with the areola occurs? If a blister is at the 2 o'clock position right at the joining of the areola and nipple, this reinforces the "drag" impression I described above, perhaps giving rise to friction with every suck-much the same as sucking blisters on a baby's lips might form.
< At 3oclock on the same breast it looks almost like a single mongomery gland is prominent.>
Could be a variaton of normal. Montgomery glands closer to the nipple are actually accessory lactiferous glands, while the closer to the edge of the areola they get, the more likely they are to secrete skin oils rather than milk. (Montagna) Visible leakage is often seen during MER for instance. If there is no redness or obvious sign of infection, it makes me think it's just producing more milk than the others.
<and when the baby comes (off) the nipple looks pinched which is on the same same side as the blister.>
Once again, I'm guessing then that it's the blister that's at 2:00. One more clue that the lower part of the latch is not off-center/deep enough, which would allow just one strip of the tip open to vacuum, but a much larger portion of the whole top of the nipple if the latch were more 'offcenter'. Have her try "leading with the chin" when she latches to get a larger part of the areola accessible to the tongue.
<she has previously had cracked and bleeding nipples she states that she dosent seem to be able to get the baby on as comfortably.on the right as well as the left side.>
Once again makes me suspect her latch hasn't been "off center and deep" enough in the area of the tongue.
<She feels also mentioned that she feels like a pulling sensation on the side of the breast. from under the axilla to the areola>
Goes along with my theory of "drag" as above, plus overfull ducts, which will be helped by breast compression while nursing.
<I advised her to rest her breast for 1 feed and to breastfeed on demand rather than wake baby every three hours.>
Which she did, and said baby doesn't wake up for 4 hours. Often points to a larger storage capacity. Is she using one breast at a feeding or both, and if so, is she letting the first side get as well drained as possible before switching? (Hind milk might satiate baby longer???) Does she understand about feeding cues? Is she offering the breast during early cues most of the time, or waiting till the baby actually cries vigorously? It might be more comfortable and more protective of her supply to nurse one side thoroughly but nurse oftener on early cues. Is she using much skin to skin time so that she is more aware of the cues? How many total feedings in 24 hours? More than 6 I would hope.
<could the nipple blister relate to the position of the baby lips/tongue?>
My guess is explained above.
< should I have done a suck assessment.>
Not necessarily, as long as you are visually sure there is no blatant tongue tie, in which case it would probably effect both sides, and probably wouldn't be improving today.
<She has a good supply but dosent feel any let-down.>
Not necessary to feel it. Listen to the baby's swallow/breathe pattern in the first few minutes of feeding. Or does she start to leak before a feed? Since baby is only 2 weeks old, she is still in the "calibration" phase" so frequent nursing and good supply is helpful to future production capability, but may benefit from "tamping down" any possible oversupply a little later (that's a whole different post)
<12/02/04> (Let's see, in New Zealand, that would mean the 12th of February, not Dec. 2, as in U.S.!)
<Spoke to Mum to-day, And she has had a better day, nipple still
sore, but she is working on the latch and postion. she has used a nipple shield, but its rubbing on the blister.>
Possibly the next size up would allow the inner ring leading into the nipple part of the shield to fall slightly beyond the blister?? Is the baby exposed to the feeling of the natural nipple at all, at least on the other side? Maybe switching completely from (my guess) football to other positions so as to rotate the position of the baby's mouth more frequently so that the 2 o'clock position would fall at the side of the baby's mouth???
<Baby is now feeding 4 hours and still needs to be woken.>
Check out hunger cues as above.
<output is good.>
Including poops???
<Mum feels she has more time to herself with the 4 hourly feeds.>
Understandable, and if she has a large storage capacity, OK for part of the day at least, as long as you explain to her the possible effect on her future supply. I would hope that the total # of feeds is at least 8 or more in 24 hours at this point in her calibration.
Hope my attempt at detective work helps you come up with some leads.
Jean
*****************
K. Jean Cotterman RNC, IBCLC
Dayton, Ohio USA
***********************************************
To temporarily stop your subscription: set lactnet nomail
To start it again: set lactnet mail (or digest)
To unsubscribe: unsubscribe lactnet
All commands go to [log in to unmask]
The LACTNET mailing list is powered by L-Soft's renowned
LISTSERV(R) list management software together with L-Soft's LSMTP(R)
mailer for lightning fast mail delivery. For more information, go to:
http://www.lsoft.com/LISTSERV-powered.html
|
