greetings,

i come to you all for your collective wisdom - thank you in advance for any
thoughts or words of advice.  i have been asked by an acquaintance to be
present (outside the OR and throughout recovery, etc.) for the cesarean
delivery of her 36.5 or so week baby.  the c-section is due to complete
placenta previa.  this is her second child, and she is nurisng her 3 year
old, so tht may bear upon how quickly her milk comes in, and how
effectively she will be able to express colostrum in the early days if
necesary.  She is extremely concerned that she will not be allowed to keep
her baby with her, and that breastfeeding will go awry due to unauthorized
pacifiers, bottles, formula, or glucose in the nicu or transitional nursery
- hence her request that i come and follow the baby wherever he goes, and
advocate for mother-baby togetherness and kangaroo care.  She has a written
post-delivery plan, and she has contacted the head nurse of the NICU to ask
about routine procedures, etc.  The nurse left her feeling very
discouraged, indicating that NG tubes, pacifiers for "painful procedures"
such as heel sticks, etc., WOULD be likely with a 36 weeker.

I have little experience with hospitalized/premature babies.  I understand
that this baby may very well be big, healthy and nurse beautifully, thus
avoiding many of these issues.   I have read the chapter on prematurity in
Jack Newman and Teresa Pitman's wonderful book, which answered many
questions, and raised many more.  so i am wondering:

- In jack's book, he talks about risks of hypoglycemia with preterm babies,
saying the smaller the baby the higher the risk.  this baby will be pretty
big on the pre-term spectrum, but it seems routine procedure is a heel
stick immediately after birth to test for glucose levels and red blood
cells.  Jack mentions that that is an unreliable method of testing,
producing many false low readings for glucose.  he also says real concern
over glucose levels in preterms needs to be addressed with IV glucose not
oral glucose, oral colostrum, or anything oral - as it is difficult to
predict how fast baby's blood glucose levels will rise when given
orally.   If it is not an emergency, then it is of coruse preferable to
express and feed colustrum.  So what exactly is the established appropriate
blood glucose level for a newborn 36.5 weeker?  At what level is it
considered an emergency?  if the hospital staff is insisting on oral
glucose, can we presume it is not an emergency, and insist back that mom
express colostrum and feed the baby with an alternative feeding device
(assuming of course that baby is too sleepy to breastfeed . .. ).  Would it
be appropriate to insist on NO heel stick, but just a venal blood draw to
test bllod glucose levels?

  - my second question is about NG tube feeding.  In your collective
experience, how often does a 36 weeker really need an NG tube?  If this
baby is 5-6 pounds and just sleepy, is it safe to be baby-led NPO for 24
hours as it generally is with a full-term healthy newborn?  Should blood
glucose be regularly monitored in this case, and if  so, how?  Are most 36
weekers at least able to take small colostrum feedings with a syringe or
cup, even if not ready to nurse at breast?  What scenarios would require an
NG tube, and at what point would a baby legitimately be designated "too
sleepy or pre-term to feed" and require an NG tube?  Clearly it would be
great to avoid that intrusive procedure if at all possible!

I  am being asked to help support the breastfeeding, which i am fully
capable of doing - however the pieces that are missing for me, not being an
RN or MD, are the pieces that affect breastfeeding, but are not always
viewed as such by hospital personnel.  I am sorry for the length of this
post, but it does seem from past discussions on Lactnet that these issues
are of interest to many, and responses vary so much from hospital to
hospital, so hopefully this discussion will be of interest to more than
just me.  If not, feel free to respond to me privately instead of on-list.

Thanks so much for any suggestions you can give me about how to advocate
for this mom and baby with hospital personnel, including good references
for these issues that we might share in the event that we encounter
resistance to mother's wishes at the hospital.

Lyla Wolfenstein
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