Fio has some concerns and questions about a friend.

My answer is from long OB nursing, but not up-to-date, experience:

<retained placental fragments: how is it diagnosed/treated?>


Some symptoms would be bleeding irregularities, excess bleeding or "normal amounts" but with continued bright red color, small or large clots continuing for days, and sometimes weeks, after birth. If really indicated, physical exam, blood tests for placental hormone levels and/or ultrasound might be various ways to diagnose or rule it out if the physician thinks it necessary. IME, late onset of Lactogenesis 2 is seldom near the top of a physician's list for suspecting retained placenta, especially if <she said her lochia is down to just brown stains> This sounds very much in the normal range to me.


<I have a friend whose baby is 6?-ish days old. Milk hasn't come in, baby down to fewer than
1 pee i think she said, so they started formula supplementing. Baby very
lethargic. I know she had an epidural and a "more complicated than she had
hoped" vag delivery but I don't know details.> 


This is a "sketchy" intrapartum history that may have other factors that could effect the timing of Lactogenesis 2.


The question that came to my mind was whether, because of the various complications, she may have had extra "third-stage management" to prevent hemorrhage. I am referring to the use of IV pitocin for 12-48 hours or so after the birth of the placenta. 


I have observed that many hours of IV pitocin combined with the IV's that accompany any regional anesthesia-if making her total fluid intake (Oral + IV) over 2000-2500cc. in any one 24 hour period, often contributes to tissue edema. If this amount of IV fluid, (especially if it includes hours of pitocin for induction or augmentation), is given before the birth of the placenta, some edema usually begins to show up in the first 48 hours after birth, while the mother is still in the hospital. If she receives the IV fluid/pitocin after the birth of the placenta, the swelling may not become really obvious till after she leaves the hospital, and could easily still be present on day 6. 


It is my observation that excess interstitial fluid collects not only in the extremities, but in the breast, especially if it is pendulous. Edema in itself can interfere with an effective latch, especially if the baby is growing weak from lack of fluid and calories. Promptly follow Rule #1: Feed the baby. Beyond interfering with effective latching, edema "dilutes" the normal chemistry of interstitial fluid, and can conceivably delay transfer of hormones and raw materials to the cell walls of the milk-making cells in the appropriate proportions necessary for Lactogenesis 2 to begin and get into "high gear".


Latch help, either verbal review and directions, or better yet, direct observation, and perhaps hands-on assistance if she is willing, sounds as if it is important. If edema is present, reverse pressure softening before each latching can help a vigorous well-nourished, well hydrated baby get a better latch. Pumping at this stage often serves mainly to permit edema to push forward toward the flange area, so I hope she has not been pumping. RPS followed by fingertip expression would be a much better way to get colostrum to supplement the baby's nursings. But absent that, prompt feeding of artificial baby milk is the next easiest-to-get alternative. 
<she tore but not at the perennium nor the cervix...somewhere in the vagina I am guessing...says she
thinks the stitches may be infected?> 


Bad odor and/or swelling would be some possible signs that she needs to report to her OB doctor, the one who is most qualified to diagnose and treat infection.


By day 6, most babies in our geographic area would have already been in for a check-up by their pediatric team. 
Fio, since you do not state any possible credentials, and while your concern and support is valuable to your friend and her baby, in regard to the feeding issues, it appears that at the very least, she and her baby need experienced and skilled help of a hospital, private or WIC LC, or possibly a LLLL or experienced postartum home visit nurse, and/or a visit to the pediatrician's office ASAP, before the ER becomes the next alternative. 


K. Jean Cotterman RNC-E, IBCLC
WIC Volunteer LC  Dayton OH









 

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