Nancy,
    Have you thought of using a *mirror*?  What I mean is, setting the mother's breastfeeding chair where she can be in front of a mirror, both for latching and for pumping.  That way she can see where the nipple and areola are in relation to her baby's mouth, and for pumping she can see that she is centering the nipple in the pump flange.
   Regarding pumps and carpal tunnel:  is an electric one a possibility?   I know rheumatoid arthritis (RA) is not carpal tunnel syndrome, but this might help. Back in 1998 when I had my worst-ever flare-up of RA in my hands and wrists, I tried out several manual pumps - a good time to try them to see which might suit Mums with hand problems.  The one which colleagues have thought would definitely not be usable, was actually the one that I could continue the hand movements on, without soreness.  It was the one-handed pump by Ameda (Hollister). The only problem with this pump that I found was learning to assemble it.  Once again, each individual woman will have slightly different needs and I can't say if this pump would suit this mother.  [I hope it is okay to mention a brand - no I don't sell them, nor any other pump.]  My hands are really good now, and so I can't retest the pumps!
    Any responses to the list and to me privately (as I've gone NOMAIL).
      Virginia
      in Brisbane

On Sat, 8 Mar 2003 Nancy Holtzman wrote:
     In fact just this morning I was secretly marvelling this very thing- I was helping a mom with very, very, *very* large breasts/areola's express milk (using a combination of hand expression and the 30mm extra large flanges for the Lactina) and she had lovely droplets of milk from several different spots on her areola, which was the diameter of a small saucer. She is such a challenging case so I'd welcome any suggestions:  single-by-choice- 40-something mom, first baby, very super-plus sized woman with extremely large breasts.  Complicated by: c/section birth, severe edema (taking HCTZ), very large nipple faces the size of a quarter, with thick meaty tissue there, and the nipples, unfortunately, are completely flat.  Baby is willing to try, but cannot grasp and form a teat.  Have tried all the usual tricks (manual expr., pumping, RPS) to bring out the nipple and shape something graspable to no avail. It is like trying to latch to the flat side of a balloon. So mom needs to pump, BUT (see, it gets worse) this mom has *severe* Carpel Tunnel syndrome and her hands go numb and painful after a few minutes of holding the flanges.  Ayiyi.  I tried positioning her so the pump bottles could rest on a nursing pillow on her lap, but her breasts are so large that she cannot see the nipples to properly position to double pump.  This was my second visit to her home and both times I could help her position and latch the baby using a nipple shield, but it literally took me standing there holding him in place and helping him latch. Of course mom is completely overwhelmed.  I also brought 3 pillows to try: a my brest friend, (too high and stiff), a nojo "dog-bone" type- worked pretty well for the football hold, and a boppy, which was useful for her to rest her arms and wrists on while pumping.
Please, any suggestions at all? I am going back on Monday for a third visit.

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