Thanks to everyone for the wonderful collective knowledge on this site.
I subscribed a few weeks ago, but this is the first time I have posted.
I am a hospital based LC, and new to the field (taking the exam this summer!),
having previously worked as a birth center RN.
I am completely stumped about a patient, and the CNMs are looking to me for
advice...
A patient came back in last week, 2 weeks post partum, with extreme nipple pain.  At
that point she was complaining of constant burning pain, worsened by any touch.
She had been given topical nystatin by her midwife in clinic the day before, but was
unable to tolerate wiping it off.  She was still nursing baby, although reported
burning that shot back into breast with nursing.  She said that nursing had been
painful since the infant's birth.  Her nipples and areolas looked a tender pink, with a
shallow fissure noted in the side of one nipple.  The breasts were soft and nontender
to palpation. The infant had no signs of thrush.  Infant latched well.  When the infant
came off the breast the nipple was blanched.  I noticed similar blanching after she
nursed on the other breast.  She denied any particular pain when she took baby off
the breast, but did state that the pain was worse on cold days.
The CNM prescribed PO nystatin for both mother and baby, with instructions to call
back if situation did not improve.
Patient did not call back, and I left messages for her at the end of last week, but was
unable to reach her until today.
Today she says that while the continual pain has gotten better (she is now able to
tolerate a towel or clothing rubbing gently on breast), she is no longer able to
tolerate the baby nursing.  She says that she has also noticed some itching in the
last few days, both internally and externally. She is pumping and feeding expressed
milk.   I asked about the blanching, and she says her nipples blanch whenever they
get wet, such as during a shower, but that it is not associated with pain.
The patient is scheduled to be seen tomorrow.  Does anyone have any
suggestions?  Am I being thrown off by the blanching, since it doesn't sound like
what I've read as classic Raynaud's?  Could it be a tenacious yeast?
Thanks in advance!
Maya Vasquez, RN
San Francisco General Hospital

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