I need to bang my head against the wall a few times, amongst friends/peers/
cohorts.  This is not meant to be a bash of my hospital, which has long promoted and supported breastfeeding and the mother/infant relationship, at least at the surface and in some ways.  It is a vent of frustration.  I feel I need to put in the above disclaimer, since priorly someone informed my boss that I was "badmouthing" my institution in a public forum, for which I was cautioned and reprimanded.

As many of you all know, I work for an urban hospital/HMO which has a tertiary care perinatal unit fed by several OB clinics both in and out of the City itself.  The clinics offer prenatal and breastfeeding classes.  Our hospital has an LC in- house four hours a day, seven days a week, seeing patients both in postpartum and in the NICU (we have no well-baby nursery -- except for sick or significantly premature babies, all our babies room-in.)   Our range of patients runs the entire gamut of ethnicities and economic backgrounds,  from highly educated to   uneducated and/or illiterate, and sometimes not too bright either, and from confirmed bottlefeeders to highly motivated breastfeeders -- a typical range of patients for an urban hospital.

Generally, I am quite proud of how much our staff nurses have learned in the last 1-1/2 years, to promote, support, and nurture breastfeeding rather than deliberately or unwittingly sabotaging it.  But there are still some very frustrating instances that arise when what I know and can teach as an IBCLC are outside my scope of practice within the hospital.   Particularly, when breastfeeding is not being completely successful and infant needs supplementation,  and we can only give the baby a bottle -- staff nurses are not allowed to even use, much less teach, alternative methods of providing nutrition, such as syringe feeding, cup feeding or fingerfeeding. 

How do we protect or enhance the mother/infant bond, or the nursing relationship when 

1)  a pedi decides supplementation should be offered --  13 ounces, fractionally more than 10%, weight loss at 48 hours; 

2)  the baby that has just started to nurse well -- for first 36 - 40 hours was disorganized as well as sleepy at breast and was still having varying success at each feed; 

3)  mother voiced concerns over potential for nipple confusion or development of a preference for the bottle nipple, and the pediatrician said he doesn't believe a couple of bottles will disrupt breastfeeding -- and after the very first bottle baby   "forgot" how to breastfeed, did not breastfeed again successfully for  8 hours (had two more bottles in the meantime).   

Mom, who has given permission to share this story, BTW, feels very frustrated.
She has done a lot of reading both regarding childbirth and breastfeeding, attended classes at our clinics which told her about how totally the lcs and staff nurses would work to help her establish good breastfeeding, and learn the tricks to getting there.  Yet when she asks about using any of these methods she read or heard about --  she is told we can't teach her those while she is in the hospital, since they are not in our protocols.  She feels very strongly that every time she gives the baby a bottle (and so far it is formula in the bottle, since she was getting no colostrum with pump at first), she undermines the baby's interest in and ability to breastfeed.  On the other hand, she knows that if baby continues to lose weight (he lost another ounce in the next 12 hours after supplementation was started - a total of an ounce supplemented formula in that time), she may have to stay longer in the hospital, and give even more bottles, further undermining breastfeeding,  before she can go home and hire someone who is allowed to teach her an alternative method of getting food into her baby.

What did I do?  Among other things:  I worked with her to sort out her information, emotions and priorities.  By the end of my shift she had decided to feed the baby and get out of there as fast as she could.  She was also on the phone to the outside world to find referrals to private LCs for once she gets home.  (Our home health nurses do not go out to her area, her local clinic does not have LCs in it, and she would have to come into the City from a suburb for hands-on LC support and teaching -- and she just had a c-section, making a lot traveling uncomfortable, as well as an unreasonable expectation).  I also referred her back to her breastfeeding books and talked about some of the methods that could be used to help wean her baby back to the breast, once she goes home, if problems continue.  I was able to reassure her, to some extent, that these methods would work.  I also encouraged her to get in touch with her local LLL, at the very least for some mother-mother support, and as a possible source for referrals to LCs in her neighborhood.

But I don't feel good about having to convince her to use a bottle, even for this short period of time, especially since her baby seems not to be one of those who can switch easily back and forth from breast to bottle and back again.

Perhaps the weight loss was enough to make formula "medically" indicated --
the pediatrician at least thought so, and our hospital generally does intervene if babies get to more than 7-8% weightloss by 48 hours.  But a bottle was NOT medically indicated -- there are other acceptable methods for feeding babies, and it doesn't even take an RN or MD to teach those methods in the outside world.  In fact, if my patient were fore-armed, she would already have had a private LC lined up, who could come into the hospital and teach her alternative methods of feeding.  Why are we making it so difficult for RNs to use these methods in our hospital, especially when we are advertising ourselves as breastfeeding supportive?  Especially, why are we making it so difficult at my particular hospital, when others of our hospitals, both in our geographical region and in other regions, already have protocols in place, and do use and teach these methods?  And why, when we are our own HMO, are we setting up situations where our clients/patients have to pay outsiders, out-of-pocket, for help we should be giving them?

The "why"s are rhetorical, of course.  But I would appreciate some feedback as to how others make their minds more at ease about the conflict between what they know and what they are allowed to teach within given settings.

Also, as I requested in another short post, if anyone has references or protocols for finger-feeding at their fingertips, I would appreciate getting them.  What would you suggest I look under in our archives, besides finger-feeding, those of you who are practiced at using Lactnet's SEARCH facilities?

TIA,  Chanita, San Francisco