I'm about to leave for work at my post partum unit, where I realized
yesterday about an hour before my shift ended, that on my team with 10
mothers, we had four mothers who each would have benefited from one-to-one
help for at least one hour, uninterrupted, due to significant start
difficulties with breastfeeding.  I felt more frustrated than usual about
this since one of those mothers is a very close friend of mine, and I was
her midwife for the birth as well, and her baby had still not opened his
mouth enough to latch, and he was over 24 hours old.
All the other mothers had other reasons for their difficulties, like
reduction surgery, twins, newly started treatment for congenital hip
dislocation, discovered on day 3, when mother was already extremely sore due
to oroboobular disproportion and overcrowded ward so not enough helt, and a
small, barely 37-weeker who hadn't quite figured out the mechanics of
feeding and was more than 10 per cent below birthweight on day 3.
I don't know the full details of the other births, but I can tell you about
my friend.  Labor started spontaneously at term with waters breaking.  One
hour later we arrived at the hospital, her preferred venue for the birth, me
riding with them in their car, and she was nearly completely dilated.  We
settled in to a labor room on a ward so busy that they would have had to
call in extra staff had I not accompanied my friend myself.  She was
examined twice, by me, on admission, and once more about 70 minutes later,
to confirm that the  vertex was in the AP diameter and on the pelvic floor,
and she proceeded to push the baby out with the gentlest of encouragement
from two people who care deeply for her.  She was free to move as she liked,
and there was no one present but her husband and me, until an aide slipped
into the room at my request just before baby was born, virtually unnoticed
by my friend.  Baby was not suctioned, nor was he removed from skin-to-skin
for many hours, right from the start even as we took steps to stop her
surprising post partum hemorrhage and suture her perineum, and then only
briefly was he held in father's arms so she could empty her bladder.  He got
a Vitamin K injection as per our protocol, and showed no reaction whatsoever
to that.  Still, he only made half-hearted attempts to latch.  He stayed
skin-to-skin for most of the first 24 hours and most of the next day as
well.  Mother didn't even shower until afternoon the day following the
birth.  Finally, at 36 hours, he took the breast into his mouth and seemed
to suckle, at which point I went home, 4 hours after my shift on the ward
ended.  
I don't know what makes some babies less quick to catch on than others.  I
do know that this baby slowly calmed down and his repeated attempts to latch
became longer-lasting and more organized over the 36 hours it took him to
figure it out.  Often we remove babies from mother when they get so
frustrated that they cry inconsolably, and I think this makes it even worse.
I've never seen one of those slow to latch, frustrated souls become more
able to latch after a separation.  In this case I had the satisfaction of
knowing that my friend is going to manage to breastfeed no matter what, and
she wanted nothing more than to keep her baby with her all the time anyway.
Her first baby showed the same behavior, and while that labor was augmented
with a pitocin IV, there were no other medical interventions - no drugs for
analgesia, no manipulations of the baby, no nothing.  That was 8 years ago,
before I was quite as acutely aware of the significance of skin to skin,
though I have always practiced it.  The other thing I didn't know about back
then was RPS, and as my friend was quite edematous in late pregnancy, we
have found RPS to be invaluable in keeping her breasts soft enough to
express colostrum right into the baby's mouth, so that he has gotten a
significant amount of that already, and by the time he did latch, she was
leaking enough to make large wet spots on her shirt.
I have to wind this up so I can go to work now.  It's been nuts for the past
week, and we were evaluated for baby-friendliness in the middle of a huge
baby boom, which hasn't eased up yet.  We'll know in a matter of weeks
whether we met the criteria.  I hope so, because it gives us a great
platform from which to keep moving forward.  
I agree with Jennifer that the accreditation process has many problems, all
of which can serve to weaken the certification.  But we don't have anything
better at the moment.  It takes people like Jennifer, and many others here
on Lactnet, to keep nudging us all in the direction of even better care -
keep raising that bar, and never give up.
Rachel Myr
Kristiansand, Norway, where this is the Sunday we celebrate Mother's Day,
which I will do by serving as many of them as I can manage, from 3 to 11 pm
:-)

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