I want to report on the mom who is becoming an example of interdisciplanary cooperation and community effort.
First, I found out she lives a good hour East of Austin and is on Medicaid. This automatically qualifies her for WIC. I had already encouraged her to contact Anna Swisher or Barbara Wilson Clay, but her WIC status makes her a good candidate to go to Mom's Place: WIC Breastfeeding Clinic, where she can be helped with follow-up and WIC resources. I wanted to be sure Mom's phone call wasn't lost as a simple case of engorgement, so I called Mom's Place to expect her call.
Yesterday, I visited with the mother just as the OB was explaining risk of mastitis and breast abscess. The doctor said she had come up with very little in her internet search the night before about this condition. She was thrilled that I provided her with a copy of the Leaven article here:
http://www.lalecheleague.org/llleaderweb/LV/LVJunJul05p62.html
I also shared the contact information for Dr. Craig and possible use of bromocriptine. The doctor made a couple of phone calls (not sure what she was checking out or with whom) and then prescribed bromocriptine for the mom to take. She also wants to see mom in one week to ensure overall breast health and reevaluate.
Mom was even larger on Wednesday than the day before, and her pumping was beginning to look more like transition milk at 48 hours postpartum. She said she tried the RPS but didn't find it very helpful. I attempted myself and found very little shifting in the edema. The pump flanges are the largest available through Hollister, and left significant dents in her skin after pumping. The nipples were barely drawn out. She is pumping increasing amounts of transition milk, 13 mls combined at last pumping.
Mom had been using ice packs throughout the night. I encouraged her to sleep and nap on her back where her heart would be below her breasts and hopefully her heart can help pump the extra fluid away. I repeated all instructions again looking directly at Dad to be sure the message was understood.
Dad is mixing mom's milk with a little formula up to 10-15 mls. When she finishes that, he puts in another 10-15mls of formula and lets baby tell him when she's done. Mom desperately wanted to breastfeed, so I helped her with the next feed. We used a 16ml nipple shield. By turning it halfway out and stretching it over her areola, we were able to get a little bit of suction and it drew the nipple up about 1/3 into the shield. It didn't "tap the keg", however, and didn't stimulate any leaking.
Baby at breast had a very weak suckle, but managed to stay latched for 7-8 minutes. When she stopped making any suckling effort, I took her off. There was no milk in the shield. I encouraged mom to give baby breast time, not with every feed, but a few times a day, follow with a bottle. When she starts seeing milk filling the shield, she can start reducing the supplement and putting baby to breast more often. Mom wanted reassurance that she can stop using formula when she pumps enough for the feed. Dad asked the same question again later, so they are both very committed to breastfeeding.
I encouraged parents to rent a hospital grade breastpump for one month to carry them through this period before she gets WIC set up. I repeated the OB's caution to watch for mastitis, breaks in the skin or plugged ducts. Poor mom became very teary, but I felt it was important for her to be vigilant and keep the breasts healthy so the milk can flow. She was very happy to hear that Mom's Place is expecting her phone call.
The pediatrician was very helpful throughout. He asked for a copy of the Leaven article which I was happy to share. He encouraged Mom to supplement with formula until her own milk was sufficient for baby's intake and encouraged her to follow up with Lactation to get the baby directly breastfeeding.
As it happened, Mom was cared for by a student nurse who was fascinated with the information and course of action. She shared the Leaven article with her whole class at the end of the day. The instructor told me she did a good job and now the whole class has learned something new (although the young men were a little horrified).
My fellow nurses have also been very interested in this Mom's progress. None of us have ever seen anything so drastic, nor so potentially harmful to mom. We are used to seeing breasts as the givers of life, and engorgment as a normal process that signals the abundance of milk. They will all want to know the outcome of this mom's story.
We sent Mom home at 48 hours postpartum (shamefully with a 37 week baby and engorgement blocking the milk flow) with 4 ice packs to use for the journey. I sincerely hope we haven't lost her.
Things I wish I had done differently:
I wish I had asked her for permission to call her at home and kept her phone number. I can still get it through medical records if she doesn't contact Mom's Place.
I wish I had a digital camera that I could have used to take pictures day 1 and day 2.
I wish we could have kept her one extra day given the double whammy of having a Near Term baby, and blocked milk.
Knowing this is something that happens only once in 100,000 women, I now understand how I could have counseled mothers for 25 years without ever seeing it "up close". I appreciate everyone's quick and positive responses. The internet has brought an interconnectedness we couldn't have achieved a generation ago.
Thank you, everyone.
Jeanne Mitchell, RN IBCLC
Austin, TX
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