Jenny,

<She showed me her left nipple, which was very large, probably larger
than a quarter in diameter.  It was cracked vertically & scabbed over,
looked really raw.  The entire breast was engorged, as she had not nursed
on it for about 36 hours, just finding the pain unbearable.  Her other
nipple is much, much smaller, and baby is nursing there just fine>

6 days postpartum- + not having nursed in 36 hours = much engorgement,
about 50% of which could well be interstitial tissue fluid.

Before any pumping, shield, or nursing attempts, I would use Reverse
Pressure Softening. (Mom could use 6-8 bent fingertips directly on the
areola touching the base of the nipple, pressing firmly but gently inward
for 60 seconds to make 6-8 temporary "dimples" in the edema. If HCP doing
it, use flats of 2 thumbs applied 60 seconds each in opposite quadrants.)


I think you are on the right track to think of using a larger size pump
flange, as the milk reservoirs might well be quite a bit deeper on that
side. However, I am wary that vacuum on an open wound and on already
edematous flesh at this point might be counterproductive.

Perhaps RPS and frequent fingertip extraction and breast massage might be
the better route to go for 48 hours or so. Also, once you have the areola
softened up and the milk flowing, have you thought of trying the
large-nipple size of thin silicone shield?

As long as the baby is apparently accepting and doing OK on the mother's
natural nipple on one side, I don't think it would be a matter of
confusion to use a shield until some future month when the baby's mouth
will have grown and a transition can be tried.

(We have all seen plenty of babies who will accept both mother's nipple
and an artificial nipple without complaint, especially if they imprinted
well on the mother's nipple to start with.)

I saw a term on LN last week that I like better than "nipple confusion".
I think it is more "flow rate confusion", or better yet, "flow rate
disparity" that causes so many of the problems labeled nipple confusion.
I don't think that would apply here, as flow rate would probably be
similar on both sides, especially with a little breast compression.

This is precisely what I referred to in my post about prenatal nipple
exams. Surely, if this is not just because of the engorgement, the
disparity in nipple size could have been seen well beforehand!

Referral to a knowledgeable person could have identified the comparative
locations of the mother's two sets of milk sinuses and allowed some
planning for a different type of management on the very large one.

Example: pure pumping on the large-nipple side for the first day or so
till the baby got really good with imprinting on the normal sized nipple,
then use of a pump (to avoid severe engorgement) and a shield, right from
the very next day on the overly large nipple, until such time the baby's
mouth grew bigger!

Just my $.02. Hope some of it helps.

Jean

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