Barbara, I agree:
< It would be great to alert the mom
pre-natally, if this could be done without alarming her and making her
less
inclined to even try, since she is not "built right" for the job.>
Yes. How sad. To me, this was the conclusion of the BMJ article on
prenatal preparation in a nutshell. But sensitivity to diversity is the
"in" thing! None of us has any control over our genetic heritage!
And the infertility clinicians have managed to develop sensitivity when
this is the case for pregnancy! And sometimes, it is a different
scenario. Not "built" but injured! Some mothers have had a forgotten
childhood injury that may have set up inflammation and caused minor
changes in the tissue.
And after all, everyone begins life with inverted nipples. It's normal
during certain stages of fetal life. I read a paper on embryological
development by Albert Raynaud that was very specific about how changes in
the fetal breast and nipple were very sensitive to hormones at certain
stages.
And the nipple eversion normally takes place the last 4 weeks of
gestation. We all really ought to begin asking questions of mothers in
regard to whether they were premature or not, because even 36 week
premies miss that hormonal milieu. I wonder if some graduate students
would choose this as a research topic to help us all learn more about it!
Unfortunately, in my personal experience with 5 pregnancies, 24 years in
hospital OB, and 20 years in public health prenatal care, all too often,
except in the context of hunting for pathology, the prenatal breast was
ignored.
It usually received no more attention from the obstetrical staff than the
spleen or a wart on the mother's nose. The breast is the postnatal
counterpart of the placenta, and the nipple's purpose is similar to the
cord. IMHO, there is room for improvement in our understanding of nipple
function in particular..
<I love the pontoon bridge analogy!>
And just as skill can be developed in foreseeing the need, planning and
engineering a pontoon bridge, skill can be developed in assessment and
sensitive care planning.
< The hospt. LCs and
nurses are there when the baby arrives,>
Yes, right there in the front lines. But there are plenty of us to
continue to work on two fronts at once!
< and sometimes you get lucky and get
a baby who is so robust they can make the nipples work even when they are
way sub-optimal in terms of elasticity. >
Also an important factor that we can point out to the mother prenatally
to ease our subject into the conversation! As yet, we have no idea what
her feeding partner will be like! Her nipple will "behave" differently
under different circumstances (e.g. a very vigorous nurser compared to a
"smaller, polite nurser", or an actual premature.)
And we ourselves need to remember that sometimes there are trade-offs in
pain and damage with the robust nurser and the "challenged" nipple. We
can alert her to expect distinct changes in the breast in a sort of bell
shaped curve in the first 7-10 days. Increases in tissue resistance may
be a side effect of labor interventions which have nothing to do with
"how she is built".
But the good news is that it's temporary, and that there is help if
needed, and encourage her to keep seeking, perhaps multiple opinions if
something is not working, because some situations benefit from expert
help.
Well, too much time on this soapbox today. Holiday preparations beckon.
K. Jean Cotterman RNC, IBCLC
Dayton, Ohio USA
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