Ok this is going to be long (and i have permission to post)

Mom is a good friend of mine and I'm serving as her lactation support/counselor. She is 
P4-G8. Baby boy was born at 12:30 tuesday. Mom was 38 weeks 5 days...  Mom is 32 
years old, African American, 296 lbs, 5'3". She had a breast reduction after baby #2 and 
produced milk for baby #3, although she supplemented from the beginning because no 
one advised her otherwise - so we don't know how much milk she will produce and 
whether it will be enough for her to exclusively breastfeed. She did note that her left 
breast seemed to produce more milk for baby #3 (nursed him for 4 months). She is a 
single mom with no family/friends support other than me and 1 lady from her church. 

Due to hypertension the OB (also mine) decided he could not induce her for a VBAC (last 
baby was a VBAC) and scheduled a c-section. After FIVE attempts to place a spinal, the 
OB told the anesthesiologist that he wanted to do a general anesthetic. Because of her 
size (very thick neck) they were unable to intubate her and the baby was delivered 
before she was intubated (very scary as a nurse came running out of the OR screaming to 
call another doctor STAT). Baby had 8/9 apgars and mom came out of the general in a 
normal amount of time. after that her blood pressure would not stabilize (178/108... and 
then some). I followed the baby to the nursery as I was the banded support person. The 
baby was not maintaining his oxygen saturation (88) and with supplemental oxygen did 
better, but it dropped when they would remove the mask. His respiration was too high 
and they ended up putting him under an oxygen tent. At one point he was up to 46% 
oxygen. They tested his blood sugar and he was at 37. This hospital's policy is anything 
under 50 requires supplementation and it is in their policy that breastfeeding can be the 
feeding, but i heard them outright deny a father's request to take his baby back to feed 
before they gave her formula. So baby boy was given half and ounce of good start 
(yummy!)

Later in the day they took a chest x-ray and started him on a D-10 IV (10cc's an hour). 
Mom was not stable enough to leave recovery until almost 12 hours after his birth and 
was not allowed to see the baby until the next morning. I had requested a breast pump 
for her room (this was done before her blood pressures spiked and she ended up staying 
in recovery longer than expected). 

Mom was able to hold the baby yesterday morning and attempted to get him to latch on, 
but he instantly fell asleep. We tried while I was there and he was still hooked up to the 
IV and was incredibly sleepy. I had to leave the hospital to pick my own children up from 
mother's day out . I called later to check with her and she said he had latched once and 
stayed on the breast for 7 minutes. She had been attempting to pump in her hospital 
room and the nursery and was getting nothing - not even any drops. She could manually 
express just a drop and nothing more. I attempted to express and also could get nothing. 

She understands the importance of pumping for stimulation and is trying to pump as 
frequently as she can. I evaluated the fit of the nipple flange last night and she is very 
close to needing a larger size in my opinion, but the hospital nurses don't have access to 
that equipment and the hospital LC works interesting hours. The LC actually discouraged 
the mom from pumping and told her that she'd rather save what milk she does have for 
the baby. (duh, she's going to feed it to him...) I was in the room as she was saying 
these things and I was the one who told her the day before what the mom's history was 
and she assured me that there were no problems and that everything would be great. 
(she is not aware that I am working toward my IBCLC or that I am currently a lactation 
counselor and educator). She assured my friend that if he didn't latch today she would 
teach her some secrets the next day and that "they'd have him on a schedule by the time 
they went home."

baby boy came off the IV and went to the room with his mom for the first time last night 
around 7 pm. When I was there at noon they told me his blood sugar was over 100 and 
he was doing great (still on the IV at this point). When mom called me they had just 
checked his sugar and it was at 62. When I got there at 8:45 p.m. the baby was very 
jittery and would not wake up to feed. The nurse had said she would check his sugar 
again at 10 p.m. and if it was 50 or lower mom would have to supplement with ABM. 
Baby would not wake up. ( MOM has been doing skin to skin since she was able to go see 
him in the nursery and is continuing to do it now). The baby had to be fed and we got 
nothing on the pump and he wouldn't latch, so we decided that we would syringe feed him  
15 ml of formula (5 ml slowly at a time - the nursery wouldnt give us a syringe as they 
prefer to bottle feed. I happened to have a sterile 5 ml BC? syringe at home so i brought 
that. I had previously asked about finger feeding, but was told they don't do that! I went 
on to ask about cup feeding and got blank stares...) The nurses also gave him a pacifier 
(soothie) without asking mom. When i put the first drops of ABM in his mouth he made 
the perfect bottle feeding mouth, but was not interested in opening wide enough to latch 
or attempt. It was just like he was expecting it to be put in his mouth so he wouldn't have 
to work for it! Even mom commented that it looked like he was trying to suck on a bottle. 
After 5mls I got a great belch out of him and he woke up all wide eyed. We immediately 
tried to put him to the breast and he fell back asleep. I gave him a few more drops of 
ABM at the breast trying to get him to start sucking again, but nothing. (the nurses said 
he needed to take at least half an ounce total) I fed him the next 5 mls and same thing - 
woke up after the belch and tried to latch and fell back asleep. After the final 5 mls I left 
with mom holding baby skin to skin. She said he didn't ever wake back up for her that 
night and that the nursery fed him at one point. (mom hurt herself trying to get to the 
bathroom and was in major pain in the middle of the night and unable to lift him out of 
the bassinet, so they put him back in the nursery.)

the dr. circ'd him this morning (much to my dismay as we have not successfully 
established bfing yet!). He's not wanting to wake up much still. Mom reports that she has 
not given him any formula since 5 a.m. and he's latched a few times, although still falls 
asleep. OB told her with the trauma she may not have lactogenesis II for 2 weeks. LC told 
her not to worry - everything would be ok. I say we have major concerns, but we're not 
giving up until she's ready to give up if she gets to that point. The pediatrician is ready to 
discharge the baby, but OB says mom needs to stay at least 1 more day maybe 2. 
Nursery says baby is jittery and even though he's essentially discharged they'll keep 
checking sugar if he's jittery. 

What have we not done? s2s, pumping, attempting frequent feeds, 

I expect her to have a delay in lactogenesis II - i'm prepared for that. I'm prepared and 
have discussed the possibility she may not make enough milk for this baby and will need 
to supplement. Mom is ok with that as long as he goes to the breast first. 

do we try fenugreek even though from what the LC I'm mentoring under has said - she's 
never seen it work pre-lactogenesis II. Do we give her a beer (as she's been requesting?) 
She's on a handful of meds to include procardia and tylox and a few others that I can't 
remember on the top of my head right now. Zyrtec and singulair... colace... 

Would a SNS be helpful? I feel that supplementation is going to be essential in the next 
week or two  - especially when he starts losing more weight. He will always go to the 
breast first - so if we supplement at the breast that would be better, right? This child has 
already imprinted on the bottle.

This is my first really tough, challenging case and because it's a personal friend who 
wants so desperately to breastfeed I feel compelled to help her even more. I've even 
offered my breastmilk if she needs to supplement so the baby isn't getting ABM, although 
my child is 7 mos old and the milk is not the same for what a newborn needs (any 
comments on this?)

We don't have access to domperidone as far as I know. Mom is on WIC and medicaid so 
funds are tight anyways. She would not be a good candidate for reglan because of a 
history of depression.

any comments are welcome either publicly or privately. If you do respond publicly could 
you please keep it under this subject (sleepy baby, frustrated mom)? This will ensure that 
I see all the responses as I often don't have the time to read all the posts and sometimes 
I've noticed people comment on a particular post but under a completely different subject 
line and it makes it hard to follow....

Thanks for advice. I hope I haven't forgotten anything, but I'm sure there are details I've 
overlooked. Please ask questions. 

Anne

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