Dear Cherie - your descriptions of the post-partum engorgement which happens
to your client were very eloquent.  IMHO severe, unrelieved, post-partum
engorgement is the single worst thing which can happen to a new mother
because of the pain/suffering and damage to the milk-producing cells which
occurs at the time,  and most especially because of the long-term
implicaations - the domino effect of lactation failure - which can severely
compromise what should have been a good breastmilk supply far into the
future.  I believe you are quite right - a mother who wishes to produce
sufficient breastmilk to exclusively breastfeeding for 6 months needs to
avoid any possibility of damaging those milk producing cells in the
postpartum period, and the first week or so does seem to be criticical.

It's my observation that some women just produce more milk than others at
the time that the milk "comes in", (I joke with the mom that some mothers
just have enough milk for sextuplets) and that the milk may come in for a
second or subsequent baby *sooner* than for a first baby so that you cannot
afford to dither!  I also find that one of the biggest difficulties to
overcome is the mother's belief that if she relieves the engorgement by
extra manual expression or pumping (over and above nursing the baby) then
she will *go on* producing more and more milk and that this will only
exacerbate the engorgement, while in fact the opposite is true - the
engorgement needs to be relieved by draining the breasts by whatever means
(baby. manual expression, pumping) whenever they start to feel even slightly
over-full or tight and this needs to be maintained for as long as it takes.
The potential for engorgement usually lasts from Day 4 - Day 9 postpartum.
My care plan for your client (and any mom anywhere who wishes to *prevent*
engorgement) would be:

1.  Nurse the baby within 1 hour of delivery and "on demand" thereafter if
baby is "demanding", waking to breastfeed three hours after beginning of the
last breastfeeding if baby seems sleepy.  Allow baby to "finish the first
breast first" (i e do not change breasts unless the baby spontaneously
unlatches).

2.  LC to check mom/baby positioning/latching techniques within 24 hours of
delivery to ensure potential for excellent milk transfer and breast drainage
during nursing - show mom breast compression and how to maximize baby's
intake during each breastfeeding.

3.  Daily follow-ups to check breasts.  Mom to be shown techniques for
breast drainage at the *first* signs of over-fullness or tightness of the
breasts (prevention of engorgement is *so* much easier than cure), i e wake
the baby to feed, or use manual expression or use an effective breast pump.
Encourage mom to drain breasts to comfort before breastfeeding, after
breastfeeding and between breastfeeds - as often as it takes - to maintain
the breasts in a comfortably soft condition.  This may mean taking off 150
ml from each breast if she has been asleep and wakes up feeling full, or it
may mean taking off 20 - 30 ml from unused breast after feeding the baby, it
should be subjective, there are no "rules".  Show mom how to use gentle
massage and kneading over any lumpy areas and how to express or pump *again*
until the lumps have resolved.  Impress upon the mother the need to keep
this up even though it can be demoralizing and tedious, and the dangers of
just leaving it.

4. Save the milk in the fridge "just in case" (message being that EBM is far
too precious to throw away.  If the baby is consistently sleepy, feed EBM to
baby by spoon, finger, easiest method, until he perks up and becomes demanding.

5. If mom consistently over-produces she could tuck cabbage around the
breasts, changing every two hours, but *stop* using it as soon as things
seem under control so as not to suppress lactation too far.

6.  By about Day 9 postpartum two things have usually happened: 1) because
the milk-producing cells have stayed a *little* too full, they have
gradually been persuaded to produce a *little* less and a *little* less
milk, so milk production appears to be calming down, and 2) the baby's
appetite has increased, and he is now much more competent.  So baby's intake
and mom's output are more likely to be in synchrony. Occasionally I have
worked with mothers who go on over-producing at this time, but by now they
can take care of it competently and easily as and when they need to.  A mom
still over-producing at about 3 weeks could deliberately allow the breasts
to stay a little over-full which would cause a reduced rate of synthesis
within 3 - 4 days.

I hope this helps.  Best wishes to your client this time around.

Pamela Morrison IBCLC, Zimbabwe

             ***********************************************
The LACTNET mailing list is powered by L-Soft's renowned
LISTSERV(R) list management software together with L-Soft's LSMTP(TM)
mailer for lightning fast mail delivery. For more information, go to:
http://www.lsoft.com/LISTSERV-powered.html