Dear Jen:
Re: << A friend, who is one of our labor and delivery nurses, conceived triplets with IVF. They were born today, unfortunately, at 25 weeks 4 days, due to preterm labor and chorioamnionitis. They are all very sick, and on high-frequency ventilators. They are girl, boy, girl - 680 gm, 720 gms, and 780 gms. >>
Looks like a long and probably bumpy road ahead for this mother of multiples (MOM) and her family. I hope the babies do well and, as a L&D nurse, this mother knows the risks for each. Hope she is doing well – physically re: recovering from the infection/birth and mentally.
Just an aside – I know the babies were probably listed by gender in the post due to privacy issues, so I hope no one minds that I throw in the suggestion to always ask a MOT/MOM the names of her babies and then use them as appropriate when working with her. It is especially easy for MOT/MOM to fall into the practice of referring to babies by gender, e.g. “the girls,” “the boy”; pronouns –“she,” “he,” “them”; or “baby A,” “B,” or “C.” Calling multiples by name can help a mother (and possibly a HP) think in terms of each baby as a unique individual vs. simply part of a set. This may be especially important when morbidity and mortality risks are higher; most mothers seem to appreciate the acknowledgement of each baby’s personhood.
<< I talked to mom this afternoon, and she was feeling shell-shocked,
but has started pumping and is hoping to provide milk for these babies. She
had pumped twice when I talked to her, but got just drops each time, not
even enough to collect with a syringe.
What can I tell her to expect as far as production with this early a
gestation?… Can she expect a decent milk supply, or does being this
early affect supply? >>
I can only imagine how “shell-shocked” she must be feeling. It says a lot that in spite of the shock, she thought to get started pumping. As per others, I’ve also seen a lot of variation in production when babies are born mid-20 weeks gestation, although getting only a few drops with pumping in the first days after delivery is not unusual. And she’ll probably get a (little) bit more with each pumping, so those frequent/regular sessions are important. In addition to the very preterm delivery, does she have other risks for delayed or decreased copious production, e.g. PCOS, DM –GDM, IDDM, DMII, etc.? Did she have much in the way of breast change early in pregnancy?
Although many of these MOM produce well, I’d want her to feel encouraged if that doesn’t happen for her. In the last few years, I’ve talked to directly or been in touch with a number of MOM who experienced extreme delays in copious production – and not all were related to preterm delivery or other identifiable factors. Were getting volumes of 250-500ml (and some even less) with what I’d consider good pumping management (8+ sessions early on, using a hospital-grade pump and good technique) by 10-14 days. Even with galactogogues production did not increase appreciably, although it generally decreased more if whatever an individual mother was using was stopped. (Several alternated galactogogues, finding production would dip after 10-14 days on one but would go back to “stable” with the intro of something different.) For those that kept plugging away at the regular pumping, most experienced a significant increase in production at some point about 9-15 weeks post-delivery. It was not always full production for 2 or more infants, but much better than prior. The 1998 JHL case report (Auer & Gromada) is one such about a mother of quads…
If copious production is somewhat delayed and she doesn’t continue with regular pumping, then for sure she won’t ever get there. I like Barbara Wilson-Clay’s metaphor of priming a water pump – one moves the handle up and down and, if minutes go by, it may seem that nothing will ever come out of that pump. Then suddenly one is rewarded with a steady stream for one’s work. However, if the person had stopped priming the pump, she may think there was no water there and she definitely would never have gotten any water.
<< And would she be better off to hand express early on, or pump,
or both maybe? >>
Can’t hurt to do both! Sometimes colostrum is obtained more easily via the compression of manual expression, and some mothers obtain much with pumping. Evidence indicates that breast massage prior to or during pumping is helpful; perhaps, it supplies the compression factor. I also find some mothers initially find single-sided/sequential pumping more effective for the first days, as they’re learning to use the breast pump and/or feel a bit cloudy from meds, shell-shock situations, maternal complications, etc. When feeling “cloudy” or with pendulous breasts, it can be difficult to monitor both breasts for double pumping and flanges can “slip” off or the seal around the breast is broken. A move to double-pumping as soon as able probably is a good idea, but in the meantime, mother can usually massage while pumping with single-sided pumping. (Can also do so with double pumping, but I find many mothers have difficulty achieving this when first learning to pump.)
Others have already mentioned the 8-10 pumpings in 24 hours. Even though she has multiples and probably will need to add pumping sessions later, mother’s physical and mental condition should be taken into account. A lot of new MOM are overwhelmed with their own conditions, plus the pumping. Sure, 10 pumping sessions and no 5-hour night break would be great, but a lot of these women really need that break for personal recuperation from a stressful pregnancy and often a surgical delivery. I find most MOM opt for the 8 sessions with a break during the night for uninterrupted sleep, and they then add sessions (if able) as babies’ nutritional needs increase.
I think it helps a mom to keep a daily pumping log – keeps her “honest” about the number of sessions, since it’s so easy to put one off or miss one entirely when recuperating, visiting babies, etc. I have such a log on my web site (www.karengromada.com/; under “articles”) and we have a nice one for NICU moms where I work. It also allows her to monitor volume obtained for pattern, progress, etc.
<< I spoke also to the neonatology fellow who was very glad mom was planning to pump, but I don't know how much support she'll get there. >>
Does this NICU make it “easy” for her to maintain pumping when she visits her babies? There should be breast pumps available there, so all she has to do is bring her pump kit with her to the NICU. That says a lot in terms of support.
If this MOM is interested, there are several mothers of twins and triplets on the Yahoo group AP Multiples who’ve initiated pumping and breastfeeding under similar circumstances. They are very supportive…
Karen Gromada
(author of Mothering Multiples: Breastfeeding and Caring for Twins or More)
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