Thanks to all who have sent suggestions so far.

On Friday, day 5, I took the opportunity to do a home visit, as I am
learning a lot from observation, and consider this a challenge. The baby
is scheduled to see a local osteopath skilled in CSA on Monday, and I
hope to be there for my first chance to observe. I can see the sutures
still overlapping, and the TMJ still s/w limited, perhaps from the speed
of the labor and birth. I think it's important that it be checked out,
doubly so for the reasons below.

Something that I obviously missed, or perhaps hoped I wasn't seeing in
previous visits. 2+ inch wide space over breastbone, between breasts.
Those "A to B cup" breasts are not tubular, or asymmetrical, or oddly
shaped, just no signs of engorgement on 5th day, although she reports she
had "a little swelling" the 4th day, and I can clearly feel full milk
sinuses, even larger than many I have felt. I hoped some of this lack of
engorgment was due to no IV's, early, frequent nursing, etc., but she
also says she didn't notice obvious breast enlargement in the first
trimester. Red flags I missed before by focusing so much on her issue,
that of fear of nipple pain. I doubt the two are connected. Though it is
only the 5th day, she has passed one walnut sized clot, and I told her
what color changes in the lochia to expect and to keep me posted if there
were still bright red bleeding next week, in case there might be some
retained placental fragments as well.

No nipple damage seen. Tiny 1/8 x 3/16 inch of blanched swelling at tip
after release of latch, that resolved within a minute or two. Amazingly,
the color of the nipple and the entire areola are no longer an even
bright reddish pink, which I had attributed to pigmentation. The entire
area is now much paler, like many of the nipples I see on blonde,
caucasian women. No vasospasm type color changes/pain, though.

Nipple pain seems somewhat less to me as I watch mother's body language,
though mother still fearful of latching. I persuaded her to allow me to
teach her to nurse lying down with the baby supported on her upper arm so
she wouldn't be afraid of falling asleep while nursing in that position.
It will require her husband's help till they have it down pat, but it
worked well and she appears to be resting more.

I didn't intrude again into baby's mouth that day. I saw alertness
between feedings, wider jaw excursions, and heard eager swallows. Skin
turgor is good, fontanels not sunken, and only a very faint suggestion of
yellow skin cast. I taught her to do breast compression more effectively.
During first side nursing, a large creamy droplet appeared on tip of
other side, and as I watched as she nursed the second side, lo and behold
pretty soon, another large creamy droplet slowly appeared on the surface
of the side previously nursed. To build her confidence, I drew her
attention to this as a good sign, for MER to cause leaking just after the
breast was well nursed. She says she experienced a small amount of
leakage on day 4.

But I was gently frank with her about the red flags, and said frequent
weight checks were very important, and that some mothers who seem to have
less milk making tissue still get the hormonal rewards and give plenty of
immunities, and compensate to gain volume by more frequent feedings,
"third breast" feedings, and/or even whatever supplement is necessary to
support weight gain, by supplementer or other means they choose. I
explained the situation originates in a mother's own embryological and
fetal developmental period, but there is some evidence that every mother
can still add somewhat to the amount of milk making tissue in the first
4-6 weeks by the hormonal stimulation of frequent nursing.

I think I delivered the news tactfully and with sufficient alternatives
as she took it smoothly and without apparent disappointment. The news may
have actually  answered the question both she and her husband had: "It
seems like so many of her friends just 'start off and go right on with
success'. What is the difference in her situation?" Till we see what
comes of the CSA Monday, I decided not to suggest the introduction of any
"insurance pumping" . Though the husband has taken 3 weeks off work, I
think this family has enough on the plate what with a 2 y.o., a clamping
baby and the mother's heightened need for reassurance. It came out that
"she likes a lot of structure, so the 2 y.o. knows what to expect" as far
as scheduled toddler meal times, etc.

The couple is using common sense, has supplemented twice, so far, with
one ounce of formula each time. They were going that p.m. to the MD for a
weight check, after having called him concerned over few wet diapers and
only one large dark stool with flecks of yellow by 4th day. He advised
them not to go to ER due to all the sickness to be encountered there. The
weight (though on a different scale) was 4 ounces more than the discharge
weight, 4 ounces less than birth weight. I'd like to have seen more, but
I'm glad it wasn't continued loss.

I'm sure further thoughtful observation will help me learn more from
"clinical practice" as events unfold. It's breaking many of my "routine"
suggestion patterns. One size does not fit all! And what the mother
reports is not always what I can see if I but look and listen well
enough!

Jean
************
K. Jean Cotterman RNC, IBCLC
Dayton, Ohio USA

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