Dear wise ones, I am looking for answers to some questions I have in
relation to PPH and lactation insufficiency.

I am seeing a mother tomorrow in our Breastfeeding centre, who's baby was
day 14 yesterday and >10% below birth weight. Baby has not had a bowel
action since Day 2! Urine pale and infant not clinically dehydrated.This
baby is obviously calorie deprived.
 I saw this baby at home yesterday during a 'hospital in the home' visit and
started her on a more intensive program of expressing 8xday with an electric
pump and cupping (or spooning as mum preferred to do, her choice) with at
least 60 mls each feed after a breastfeed (using breast compression), at
*least* 3 hourly BF's.
Oral examination normal and sucks ok on my finger and looks ok on the
breast, but only 1 swallow to about 4-6 sucks on the breast, i.e. very poor
milk transfer. Yet mum's breasts did feel sl softer post feed so some
transfer is going on.
Prior to my visit she was expressing by hand and giving 30 mls after each
breastfeed in the daytime only, so I feel this was not meeting this baby's
requirements nor protecting her lactation sufficiently.
Positioning not too bad although I did suggest she hold her in closer and
extend the baby's head back a bit more to drive in that chin. (i.e. a more
asymmetrical latch)
Mum has successfully BF her previous child for 11 months.
Mum had a PPH of approx 800 mls this time which I wonder if this is the
explanation for her lactation failure. No retained products or other medical
problems. Breast normal other than large nipples. Do not know her
haemoglobin, will find out tomorrow.
Plan tomorrow is start a lactation aid, and domperidone if no improvement in
lactation. (and I guess some crude lactoengineering too is worth a thought
if not much gain in 2 days!)

So my questions are in relation to PPH and lactation failure:
How *much* of a PPH does it take to cause ischaemia to the pituitary? If it
is not a severe PPH then is a moderate one enough to cause a temporary
insufficiency, and if so how temporary?
What tests should I be asking for? Thyroid function test, Prolactin.
Anything else? Do I need to do these tests or should I just assume that that
is the cause?
With prolactin, is this both pre (for baseline) and post feed levels or just
post feed,and what levels should I be concerned about?

I have searched the archives and goggle but not come up with what I am
looking for. I did find Lisa Amir's post referencing:
J Hum Lact 1995 Jun;11(2):123-6
Infant insufficient milk syndrome associated with maternal postpartum
hemorrhage.
Willis CE, Livingstone V.
and
Birth 1995 Jun;22(2):86-92
Anemia and insufficient milk in first-time mothers.

I will try to get these articles tomorrow.
(only have my old texts here at home as my books are out on loan to an exam
candidate. My 1993 Auerbach and Riordan has a little bit on Sheehan's
Syndrome, which says "milder cases of pituitary disruption may occur with
less severe symptoms and a delay in milk synthesis")

Any comments much appreciated! (Or am I looking for zebras and missing the
horses!!)
Cheers
Karen Clements
IBCLC
Melb Aust

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