I would be grateful for suggestions for a case I am struggling with. The 
problem is developing a practical plan of care for a mother of 6 days old 
twins who (the mom) happens to have hepatitis C infection .

A little history - it is a first pregnancy after IVF (no hormonal problems, 
infertility due to endometriosis and male factor). Uneventful pregnancy, 
baby boys born 38 weeks via (planned) cesarean preceded by 
spontaneous rupture of membranes and 4 hours of labor. Birth weight 
2800 gr and 2600 gr, no complications with the babies.

Mom got to see the babies for a brief second after delivery and again 
only after 36 hours have passed and she was brought to a normal 
postpartum room (it is the norm here, although I know that it is very 
different in your parts of the world). Mom has not expressed all this 
time, babies were being fed formula by bottles. She put both babies to 
breast immediately after she won the battle to get them brought to 
her - and almost immediately got her nipples cracked.

I saw them at their 3rd feeding after mom called me to seek help - 
normal breast and nipples, babies latch is very shallow. We tried 
everything and things improved a bit after 2 days - nipples are not 
terribly pinched anymore, but still lipstick-shaped. No improvement in 
this till now despite every effort made (I know I am not the most skillful 
lactation help, although I've been working with bf couples for 4 years 
now, but I reffered her to the - very skilled and the only one available - 
doctor that we work with and still latch is not optimal). Nipples are 
hurting, small cracks visible, but no bleeding - she applies lanolin and 
some type of nipple cream that the hospital provides.

Babies latch with a very open mouth, good latch technique - but still 
hurting the nipples. No TT visble (but neither myself, nor the doctor are 
able to discover a posterior TT), no palate issues visible. 

The bigger twin seems to suck efficiently with gulping (milk transfer on 
day 4 was 10 ml, weighed only at one feeding). I still suspect he has 
some lip weekness, because he sleeps with an open mouth and spills a 
lot of milk while bottle feeding despite proper pacing technique. 

The smaller one has a very disorganized suck, chomping and chewing 
action only, almost no gulping to hear or notice. 0 ml transferred at 
breast, although mom feeds them simultaneously and the bigger one 
triggers the MER for him. I am afraid he is not a good candidate for SNS-
feeding because of his ineffective suck - the doctor tried it with him, but 
it was no success and mom didn't like it. He feeds efficiently from the 
bottle. 

Mom is very nervous about bleeding nipples and is afraid she could 
pass the hep C infection to the babies if her nipples become more 
injured. So she is reluctant to put the babies to the breast more often 
than every 3 hours and her plan of action was to put babies to breast 
8x24h for 20-30 min and supplement with 10-20 ml formula afterwards. 

Milk came in yesterday (day 5), breasts fill fuller and hotter, a bit 
enlarged, but no uncomfortable engorgement. No additional breast 
stimulation with milk expression till today (day 6), just what the babies 
could do with their sucking issues.

I am really worried about milk supply with this lack of stimulation. Mom 
is very willing to put the babies to breast every hour and a half, but 
only after nipples are feeling good because of her fear of bleeding and 
infecting the boys. 

So the options here - as I see it - are working on the latch, nursing 
every 3 hours (as mom's wishes are) plus more frequent expression 
with the pump and giving expressed milk (or formula if breast milk 
unavailable) by bottle until the situation with the nipples improves. 

There are no hospital grade pumps available in our hospitals (and in 
fact not even one at all in the whole country), but today mom is going 
home with the babies and we talked about regularly expressing after 
each feeding with her Medela Swing (it is the best pump available 
here). She prefers the pump - I showed her hand expression, but she 
doesn't feel comfortable with it and thinks the pump is a better and 
faster way for her.

And I am not quite sure about the best way to organize the things - 
mom has 2 babies to care for and feedings could not last forever, so 
she has some time to not only pump and nurse, but get some sleep 
too. She will have help at home (grandma and husband will be home 
for some weeks), so it will be easier. In the hospital she was all alone 
with the babies and was not willing to leave them in the nursery (which 
I admire her for) although she slept only an hour or 2 a day for the 
past 4 days and is now totally exhausted.

What am I missing here - are there other things we could try? Think 
only the basics, we don't have most of the things I read on the list and 
we are the only lactation help available (and surely it is quite visible I 
am not an LC). 

Christina in Bulgaria,
BF Peer Counselor

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