This is my first time to post, so introductions are in order. I am a
hospital based LC and live in the same community as Gail Hertz. We are so
happy to have her enthusiasm, knowledge and support! I have been lurking and
learning for months, Gail even posted for me once. We have 2.7 FTE's for
lactation and  5 IBCLC's. I am trying to post  again, with a new
concern.....I have been in practice for 11 years and recently had a mom who
totally perplexed me.

She was a gr 1, hx of augmented labor, prolonged second stage and vaginal
birth with epidural. In reality a "typical" American birth - with no
observed complications.  She is Korean and had very taut breast tissue and
somewhat flat nipples. Discharged at day 2 - LC in hosptial answered many
questions, felt mom would be ok - LATCH  apparently normal.
Mom called on Day 4 for a consult and baby was seen with weight loss of 13.5
% and bilirubin of 20.5. At that time she rated engorgement a 5 out of 5 -
very firm, no s&s of mastitis. She had iced once prior to appt. Attempted
pumpiing with a hospital grade pump - only drops obtained. Feeding observed
- nipples scabbed bilat, no audible swallowing, obviously little to no milk
transfer. She was sent home pumping, and began supplementing at breast with
syringe. She continued to ice and or cabbage. The following day the mother
reported 5 mls with pumping, a few swallows with the baby at breast, less
engorgement, still no appreciable milk. She denied previous breast surgery
or injury and strongly desired to breast feed. She did not appear unduly
anxious or stressed.

Two days later we tried Reglan with slight increase to about 8 mls with
pumping. Breasts were become softer yet. We also attempted to get a pharmacy
to reconstitute oxytocin spray, which we were able to do, but it took us a
whole week to get it in and so it was quite too late to help. Can anyone
suggest what we missed? Or what prompted this response.

She is now about 2 weeks postpartum and has never gotten a good supply or
letdown. I did think perhaps the nipple pores were blocked due to slight
scabbing, but really don't think this was it. Is it possible to have
congenital  obstruction or constriction and is this is something you could
ultrasound for?  She wants to know if this will happen again....and I don't
want to give false hope, but rather come up with some type of answer for her
so she can be successful next time.

Sorry for the length, interesting case.

TIA,
LuAnn Smith RN, IBCLC
Lactation Coordinator
Wellspan Health
York, PA
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