I would appreciate some input on a case.  I have mom's permission to post.
I hope everyone is not at ILCA so that someone is around to respond.  :-)

Baby was born Monday evening, Mom called me Thursday night, about 8pm,
concerned that her milk was not coming in.  Mom described breasts that felt
like they were "full of rocks", baby would nurse for an hour at a time and
was sleeping alot (still mom's description), baby was having wet diapers but
no soiled diapers since midnight the previous night.  Mom also reported that
she had implants under the muscle.  At that time, I advised mom to use warm
compresses for 5-10min, massage and then nurse.  If baby was not nursing
well, then pump (mom has a PIS double pump), followed by cold compresses.
Mom called back one hour later to say she had only expressed a few drops of
milk while pumping and that her breasts were becoming more uncomfortable,
but not unbearable, still felt lumpy.  I encouraged mom to continue
alternating warm/cold compresses with nursing the baby, hand expression in
hot shower, and have her husband massage her back between her shoulder
blades.  I also encouraged her to give the baby any milk she expressed using
a spoon (I was concerned about the lack of soiled diapers for almost 24hrs).
I asked the mom to call me if the situation got worse and also suggested
that she might send her husband to the store for some cabbage to be used if
the engorgement got worse.  The mom called at 8am Friday morning and said
that her breasts were extremely hard and uncomfortable and baby was refusing
to latch, still no stool, two wet diapers overnight with what looked to be
an "orangish powder".  Mom had tried to give baby a bottle of fomula but mom
reported baby sucked but did not trnasfer any milk.  At this point mom
requested a home visit and I was there by 9am.  I advised the mom to apply
cabbage leaves to the breast and ice packs over that and discontinue heat.
The baby was noticeably jaundiced and very difficult to rouse, mom was
extremely engorged.  Baby would not suck on a gloved finger or rouse to take
the breast.  Dad called the pediatrician and was advised to take the baby to
have bloodwork to check bili levels.  We gave baby approx 1/3oz of formula
by dropper (baby still would not suck but was swallowing the formula.  Baby
did not appear to be dehydrated, but was lethargic.  Dad left with baby to
go to the hotspital for blood work and from there to the pediatrician.  Mom
stayed so that we could address the engorgement.  After about 2 hours of
cold compresses alternated with massage and pumping we were able to express
about 3/4oz of milk and the breasts were beginning to soften in places.  Mom
was exhausted and had not slept at all the night before.  I sent the mom to
bed with cabbage in her bra with instructions to lay flat on her back and
sleep for at least 2 hrs (mom was too exhausted to function at this point)
and then get up and massage and try to nurse (if baby was back from the
doctor) or pump.  Dad brought baby back home after bloodwork and before
going to the pediatrician and gave the baby the 3/4oz of expressed milk via
bottle.  I returned at 6pm and mom was still doing ice packs and cabbage in
the bra for 2hrs on,1hr off.  Mom reported that baby's bili was 12,
pediatrician instructed mom and dad to nurse baby every 2-3hrs, followed by
1/2-1oz expressed milk via fingerfeeding, cup or spoon.  Baby had stooled at
the pediatricians office and had 2 wet diapers during the afternoon (total
of 4 since midnight).  Mom took a warm shower and we were able to get baby
to latch for about 5 min on the left breast (vigorous swallowing observed)
and then she pulled off and refused to relatch.  We got her latched well on
the right and she nursed well for 15-20min.  Moms breasts were noticeably
softer on the lower inner quadrants on both breasts, but still very firm in
all other areas.  After breastfeeding we used the pump and massaged, got
approx 1oz and moms breasts were softer and more comfortable,  except for
the upper outer quandrant on the left breast.  I advised mom to continue
nursing the baby, followed by pumping if the breasts were not softened after
feeding, then apply ice if needed to control swelling, spend as much time as
possible lying flat on her back and continue applying cabbage to the area
that was still engorged (1hr on, 1hr off).  The next afternoon (Saturday
now) mom reported breasts were softer but still not getting more than 1/2oz
total while pumping and baby was refusing the breast and all feeding were
being given by finger-feeding.  Baby's bili was now at 15 and peidatrician
advied supplementing each feeding with 1.5-2oz formula.  I reviewed
positioning with mom and encouraged lots of skin-to-skin contact.  Mom was
extremely exhausted again, tearful and anxious, had barely slept again the
night before.  At this point, I advised the mom to try to pump, not looking
at the bottles or worrying about output while her husband massaged her feet,
shoulders, back or whatever, then she was to go to bed and sleep for at
least 4 hrs (I figured we didn't have much to lose by this point, mom was
ready to quit and I had hoped that getting an adequate amount of rest would
improve her output of milk and give her more patience to work on baby's
latch).  This morning mom reported that she felt more rested, but she had
offered the baby the breast during the night and baby continued to refuse
and at this point is getting all formula via bottle.  Mom still wants to
continue working at it so I have her doing constant (or as constant as
possible) skin to skin contact with baby in bed, nursing if baby shows
interest and pumping every 3hrs if baby will not latch.  Mom is still
getting minimal amounts from the pump (1/2oz at best at this point), she
reports that her breasts feel firm, but not extremely engorged with a hard,
tender lump under the left arm.  I will return in about an hour to continue
working with the mom.  I plan on trying an SNS to get the baby at the breast
and to stimulate mom's supply.  I will also start her on fenugreek.  I don't
plan on advising her to pump because she doesn't seem to respond well to it
( I have a Classic, I may take that though and let her try it).  I would
appreciate any input on what I could have done differently to make the
situation easier (I am particularly worried that either I was too agressive
with the cabbage and it decreased her supply too much or that the
engorgement was so severe that it inhibited her supply) and what else I
might do to get things turned around from here.  Other facts to know:  Mom
was formerly an A cup and increased to a D with implants.  The areaola was
not moved, mom reports full nipple sensation.  Baby latched really well when
I observed her and mom has no soreness of the nipples.  Baby's birth weight
was 7#5oz, down to 7# at d/c, 6#11oz at day 5.  The "orangish powder" turned
out to be vaginal discharge.

Thanks for any input,
Mellanie Sheppard
Arlington, TX
sitting for THE EXAM in 8 days!

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