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

             ***********************************************

Archives: http://community.lsoft.com/archives/LACTNET.html
To reach list owners: [log in to unmask]
Mail all list management commands to: [log in to unmask]
COMMANDS:
1. To temporarily stop your subscription write in the body of an email: set lactnet nomail
2. To start it again: set lactnet mail
3. To unsubscribe: unsubscribe lactnet
4. To get a comprehensive list of rules and directions: get lactnet welcome