To all Lactnetters:
Having subscribed since January, and since then enjoyed the  posts immensely,
I decided it was time for an intro and my first question.  I am an IBCLC
(since 1988) in private practice in State College, PA, home of Penn State, in
Central Pennsylvania.  The breastfeeding population is a varied one, ranging
from  international students to a rural community in the surrounding areas,
from a very well educated professional competitive group of  thinkers to a
"that's the way it is and always will be" mind set.  Some days it's the
routine questions, quick "solves" where everyone feels pretty good pretty
quickly and others, well, others are where I find out it's one thing to be
the person referred to  because I can do it very well on my own, but quite
the other thing when a situation presents the need for collaboration and
intervention beyond the scope of an LC.  Then I feel like I've hit the
proverbial brick wall and a mind set that "oh,well there's always ABM."

I would like to input from you all for this situation:

Primip, no hx of infertility or problems during pregnancy, delivers 8#5 girl
vaginally, 20 hours of labor, plus 4 hours (!) of pushing, on Tuesday, May
14.  Uses interthecal fentanyl as pain relief (most of our deliveries use
this at our hospital). On Friday, May 17,  at routine ped check, baby is 7#2,
parents are directed to *feed* the baby.  When they called me over the
weekend, they presented with no evidence of milk coming in, but a fist sized
clot passed Saturday afternoon; they had a willingness to continue to
breastfeed the baby and felt that of the options I presented,  that they
would feed the baby supplement with dropper at breast and some bottles. By
Monday, 5/20, the baby had gained 8 ounces. However, still no signs of milk
coming in.  Due to extenuating circumstances, I could not see the baby until
Wednesday, May 22, 8 days old, however, on Monday, after hearing that she had
again passed two large clots, and had throbbing twingy heaviness feeling and
pain in her uterus,  I instructed the parents to call their OB with all the
info, especially to notify them that milk had not yet come in and
descriptions of uterine activity. There was no concern about any of the info
from the OBs.  When I saw the baby on Wednesday, she exhibited wonderful
behavior at the breast, with definitely improved swallowing with starter tube
feeder in place.  Breast examination shows:  Less than an A cup breast
fullness, however, both parents said that this was an enlargement from prior
to pregnancy and had noticed changes and tenderness at the start of the
pregnancy.  One great nipple, the other misshapen, with inversion that was
starting to pull out due to nursing and pumping. Upon exam and expression,
milky fluid (drops) could be expressed from each nipple, no feeling of any
glandular enlargement, no firmness or fullness at all.

What would you do now?  Nipple stimulation is there (she has been using a
good pump for extra stim) and baby is doing her job. How else can you rule
out or prove retained placental fragment? Blood work- what levels would we be
looking at ? Would this mom's baseline mammogram show basic glandular
development to "see" if we are working with the rare  insufficient glandular
tissue here? This mom is understandably anxious and disappointed that the bf
is not working as planned, and yet will jump through a hoop if I tell her to,
so compliance is not an issue. What would you say to docs to go the next step
if there is one? (I couldn't get past the nurse yesterday when I called.)

Most of the time you don't get a mom willing to keep going- in previous
situations, either baby behavior or family support has made these questions a
moot point. I've had a couple of these resolve favorably (one with
Syntocinon, the other who knows why?) , but I'm stuck on this one. Ideas?
Suggestions?

I hope to meet many of you at the ILCA conference! TIA.

Karen Foard