Hope
Sorry to send this late reply. I've worked with two mothers with
Sheehan's (over the quota I know ...)
The first was a second-time LLL mom, who was very committed to
breastfeeding, successfully nursed her first baby for well over 18
months. I saw her just after hospital discharge, on about Day 4, on
referral from the paediatrician since the mother was worried about
the baby getting enough, and he had assumed that her fears were
unjustified. They were not! She had suffered an horrendous
second-stage labour, ending in a C/sec, and severe haemorrhage. The
baby had lost a lot of weight and was unhappy and jaundiced in spite
of frequent and exclusive "breastfeeding". Manual expression of the
breasts revealed just tiny glistens of fluid. Formula supplements
were started immediately, and the mother put the baby to the breast
for every feed before supplementing. She also took sulpiride as a
galactogogue (very effective in normal circumstances). I was able to
follow this mother up very closely for the first few days and weeks,
and less closely for several months. In the first days I kept
expecting the milk to come in, the mother did all the right things,
absolutely by the book, but Lactogenesis II simply just never
happened. Eventually we had to conclude that this was a real case of
Sheehan's, and that formula-feeding would be essential for the
duration. The mother was absolutely heart-broken. Several months
later, she realized that she was suffering other symptoms (loss of
public and underarm hair, abdominal weight gain, extreme fatigue, dry
skin). A check-up with her GP revealed that adrenal function had
been affected, low cortisol levels, and I think she was treated as
something of an emergency for a while. She was told at that time it
was unlikely that she would ever be able to have more children, which
added to the heartbreak. A terrible case.
The second case was a first-time mother who'd had severe haemorrhage
because, unbelievably, her OB had accidentally hit an artery while
doing an episiotomy. I also saw this mother just after hospital
discharge because the milk didn't seem to be coming in. The symptoms
were so similar to the first case that I recognized what might be
happening. There was simply no milk production, ever. Again the baby
had to be exclusively formula-fed in spite of everyone's best
efforts, and there were later predictions of infertility and hormonal
issues, but not so severe because the GP had been involved from the start.
I've recently worked with a mother who, as part of her history,
described similar events to your case Hope. Severe haemorrhage
resulting in hysterectomy. However, she breastfed just fine. I've
also worked with other cases where there had been severe postpartum
haemorrhage, and full milk production was delayed until about 6
weeks. In these cases there was some milk, but just not enough in
spite of really good breastfeeding management and formula supplements
were really necessary. However, milk production did slowly increase,
the formula could be reduced, and exclusive breastfeeding was finally
achieved. So each case is different and I think just needs to be
handled very much with a wait-and-see attitude. It seems as if the
diagnosis of Sheehan's can only really be made retrospectively.
It sounds like you are making the best recommendations in what are
very difficult circumstances. If you are able to focus on the best
possible breast stimulation/drainage, at least 8-10 times in 24
hours, accompanied by a galactogogue to encourage high prolactin
levels (Domperidone or Sulpiride might be better than Reglan?)
supplementation of the baby until you see whether the breastmilk is
really coming in. Lots of empathetic support for the mother
including repeated assurances that doing the best she can will give
the best possible outcome, but that this is not her fault, may help
her emotional state. I don't think more can be done. I would not be
bothering with the oxytocin nasal spray for now, and I would
encourage breast massage and hand-expression instead of a pump until,
or unless, the quantity of milk produced becomes plentiful enough to
justify its use, or until the baby can be put to the breast. If
you see any milk at all in the next few days - even just drops
- then there will be a chance that it will increase even more,
particularly as the mother's Hb levels rise. However, if there's no
milk production with these methods over a period of 3-4 weeks, while
Hb levels return to normal, then I think you could probably conclude
that this really was Sheehan's. Anticipatory care for true Sheehan's
should include on-going check-ups for the mother to head off later
other health difficulties - failed lactogenesis is only one symptom.
Hope this helps. Please let us know how this turns out.
Pamela Morrison IBCLC
Rustington, England
-------------------------------------------
At 22:28 29/02/2008, you wrote:
>Date: Fri, 29 Feb 2008 10:53:55 -0800
>From: Hope Overholt <[log in to unmask]>
>Subject: Sheehan's syndrome
>
>I was called from a local hospital by a sobbing mother. She suffered
>severe hemorrhage 7 days post cesarean resulting in hysterectomy.
>The were no hospital grade pumps available to her, she was not
>allowed to pump untill about 12 hours post surgery. The husband
>purchased a small electric pump from Walmart, I'm unsure of the
>brand, not hospital grade is all that matters. Her first pumping=
>5oz; 2 nd=3oz; 3rd= drops.
>The blood loss was severe and she was still receiving blod as of yesterday.
>She appears to be at risk for Sheehan's syndrome. I found in
>Lawrence that they mention successful treatment with Oxytocin nasal
>spray and use of nursing supplementation at the breast for about two
>weeks that restored the milk supply.
>My questions:
>1. How do I determine if this in fact a Sheehan's episode?
>2. Do I proceed and ask the doctor to order the oxytocin nasal spray now?
>3. Would oral Reglan be of benefit?
>The baby was nursing well at home prior to the hemmorrhage by
>mother's report. Unfortunately the hospital will not allow children
>< 12yrs. onto patient care areas due to RSV precautions so mother
>has no access to baby until discharge home Sat. or Sunday. She will
>have a hospital grade pump today however.
>What else should I be doing?
>Hope Overholt RN, IBCLC
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