Dear Jennifer,
It sounds as if you did an excellent job with this mother and baby!
Nothing easy about this, your first consult. Here's a reference for applying a
nipple shield: _www.leron-line.com/updates/Nipple_Shield.pdf_
(http://www.leron-line.com/updates/Nipple_Shield.pdf)
It is not necessary nor recommended to get the nipple all the way to the
end of shield's teat. This could cause some of the nipple to be pulled
through the shield's holes which can cause damage. Nipple shield use should be
comfortable for mom and baby should be able to attach at the brim and not
just the teat.
What you provided this nursing dyad was well thought out despite your
apparent nervousness about *doing it right.* Skin-to-skin, biological
self-attachment, RPS, reading baby's cues of frustration all were helpful
approaches. I'd suggest mom and baby just recover for a bit and not stress about
whether shield is used or not. Mom can try removing the shield a few min
into the feed, once baby has fed a short time. Can also try walking with baby
and offering the breast in between feeds for ad lib nursing, for hiccups,
can't quite settle, etc. Co-bathing could be helpful to relax both mom and
baby and often baby then attaches as well as mom's nipples protracting
more. I would definitely recommend CST or some form of body work for this
baby and if that's not feasible, infant massage and whispered apologies to
baby for all he went through and his pain, both physical and emotional. (This
often helps mom deal with her pain, as well). Baby may not have the
ability to open widely if there's nerve impingement due to swelling from
hematoma at back of skull, or nearer the jaw due to long pushing stage and
forceful removal by vacuum.
In time, likely in the not too distant future, baby can latch to bare
breast and know what to do, that's the reassurance I often give moms. Looking
into other possible barriers, as you said about possible tongue-tie would
be warranted, too. Know you did a wonderful job and best to you and this
mommy and baby.
Barbara Latterner, BSN, RN, IBCLC
I just did my first consult and would appreciate your opinions/feedback.
My appologies for the long post!
Mom had difficult birth, SROM but no contractions & step b positive,
therefore she had a pitocin induction with epidural and antibiotics. She pushed
for 3 hours, the first OB did SIX attempts at a vaccuum extraction,
before another OB was called who then performed an episiotomy and then a SEVENTH
and successful Vaccuum extraction. She was hooked up to IVs for more than
12 hours and consequently exprienced severe edema everywhere, including
her breasts, causing nipple distention.
Baby suffered a severe hematoma, had 30 min of skin to skin with mom
before going to the nursery for observation. (This hospital generally does not
separate moms and babies and is baby-friendly, but this was an exceptional
case.) Baby made no attempt to latch during the brief s2s. In nursery,
baby was fed formula via bottle teat 7-8 times over his 3 day hospital stay,
35ml each time. Paediatrition ordered this because he was afraid of baby
getting upset and crying due to the severe hemotoma. Hemoglobin levels in
baby were falling (from 210 to 163), Paediatrition was concerned about
possible bleeding in baby's skull. In hospital, due to the "flat" nipples
(actually distended nipples due to excess fluids), nurse gave mom a nipple
shield at 48 hours because baby was unable to latch on. Nurse also suggested
mom use pump to extract colostrum and bring out nipples and mom states her
nipples became much flatter after.
Mom was released on day 2, baby stayed until day 3.
Mom called me on day 4, we spoke for 3 hours on the phone. She reported
that her nipples normally protruded but were now flat and her baby could
still not latch without the shield. I suggested RPS before nursing, manual
extraction, so as to avoid more fluid in the breasts, reverse massage and
cold application in between nursing to help reduce edema. Also LOTS of skin
to skin, anti-gravity positioning for all feeds.
I saw mom on day 6. Observed some assymitry in baby's skull shape, not
surprising given birth circumstances. Parents report that it is greatly
improved. No "banana" posture or cocked chin to indicate torticolis. Baby
appears to be able to turn head equally to both sides. I instructed parents
how to continue to observe for this, since sometimes it takes a while to
show up. Baby still has some mild jaudice, but parents say they have noticed
a reduction in the yellow colouring. Oral exam: baby clamped on my finger
more than actually sucking. very little tongue movement at all. I did
possible feel a bit of resistance under the tongue, but I will check again
when I see them again soon. Everywhere is closed for the holidays right now
anyway, so I would not be able to refer for frenectomy. I had mom get into
a laid-back position and do skin to skin with baby for 30 min while he
slept and we filled out the questionnaire. Finally when he woke, mom first
tried to nurse without the shield (after I did RPS), baby got angry and began
to get frantic. So we put the sheild on for breast #1. Baby nursed
actively for 10 minutes with obvious swallowing (gulping!), then fell asleep.
Remained in s2s while baby slept/rested, roused on his own for breast #2.
Again I did RPS, then offered baby bare breast (not really and assited
latch, but just placed baby in the vicinity). He latched without the shield!!!
He did not really nurse, but he gummed the nipple for about 3 minutes
before growing frustrated and we put the shield on. He then nursed actively
with the shield for another 10 minutes. While he did not really nurse, he
did accept the bare nipple in his mouth for the first time, so I consider
this a big step in the right direction.
Baby has copious diapers (mom reports 9 very wet and 5-7 yellow curdy
stools per 24 hours), from exclusively nursing with the shield (no
supplementation since day 3).
My training did not cover much about how to use or fit nipple shields,
just when to use them. I have learned how to apply them (turn almost inside
out and stretch open and let it roll back down over the nipple). When I
applied it this way, mom said it felt like there was a lot more of her nipple
in it than the way she had been doing it. I have not, however found any
resources as to how to fit them. What does a properly fitting shield look
like? My client's nipple did not fill the teat of the sheild, despite my
best efforts. Can anyone point me to some info on fitting or photos of how to
fit and what it is supposed to look like?
I have suggested to mom that she continue as much s2s as possible, RPS and
reverse massage, offer a finger to baby with light pressure on the palate
before offering the bare breast in hopes of stimulating the sucking reflex,
and to continue to offer the bare breast using laid-back positioning, but
not to let baby get frantic or too frustrated, switching to the shield if
he won't take the bare breast.
I will go back soon to do another consult, when I observe for changes to
the shape of his skull and apperance of any signs of torticollis and check
again for ankyloglossia.
So what do you think? Anything else I could have suggested? Anyone have
any resources for fit of nipple shields?
***********************************************
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