I have permission to post. 

My client is a 35 yr. old first time mother. Her daughter was born 8-9 days 
early. The mother had been in labor 20 hours and had been given pitocin to 
speed up her labor. She was then given 2 doses of epidural medications to help 
manage the pain. She experienced quite a bit of edema. 
 
The mother tried to latch the baby in the first hour after birth, but the 
mother was shaking too much and the baby was crying. The baby didn't latch 
successfully until about 24 hours later. 

The mother felt that although the baby was sleepy, she appeared to be nursing 
appropriately until engorgement set in.  However she was taught 
finger-feeding at the hospital, as the baby didn't nurse well until the fourth day and then 
that evening engorgement set in. She had experienced 24 hours of engorgement 
when she called me the evening of the fifth day. She was using 
Reverse-pressure softening, all the usual engorgement measures and was pumping and 
finger-feeding, while continuing to attempt to latch the baby. I encouraged her to 
continue what she was doing until I could see her the next day.
 
The mother reported that after a weight check at her pediatrician's office 
indicated that the baby had lost about a pound, she was advised to give 1 oz. of 
pumped milk at each feeding. Because the parents were not feeding the baby as 
often as they had thought, the baby had only received about 6 oz. of milk in 
the last 12 hours.
 
When I arrived, the mother's breasts were still very firm and the baby had 
not eaten in over 4 hours, so I encouraged the mother to pump and the father to 
finger-feed the baby a little before we attempted to latch. The mother had 
been limiting pumping to 10-12 minutes for fear of increasing the engorgement. 
She was producing about 1 ½ - 2 oz. per pumping.

Although the breasts were still quite firm even after pumping, the areola and 
breast appeared soft enough to latch. The nipples were soft and well everted. 
 

I asked the mother to show me how she was attempting to feed. She had been 
pushing on the baby's head.  I showed her how to hold her hands on the baby's 
back and neck and use an asymmetrical latch.  

The baby was very alert and patient, but she would not latch. She would put 
her mouth on the breast but not close down. We tried using the syringe and tube 
at the breast. We tried different holds, but the baby's tongue was usually at 
the roof of her mouth and even when it was down, she would not close her 
mouth or attempt to suckle. it seemed to take her a while to organize her suck 
during a suck assessment. 

I encouraged the parents to increase the frequency and amount of feeding, 
watching for early feeding cues. I suggested they try giving a syringe full of 
milk by finger-feeding to help her to organize her suck and then attempt to feed 
her. After a reasonable amount of time, they should finish the feeding by 
finger-feeding and try again at the next feeding. 

I encouraged them to continue the skin-to-skin contact that they were already 
doing.

I encouraged the mother to continue engorgement treatments and to pump her 
breasts thoroughly.

I suggested that they might explore CST, but they weren't interested. I then 
suggested that they could try to relax her oral musculature by massaging the 
baby's TMJ, jaw line and around her mouth.

When I talked to the mother the following day, nothing had changed. They did 
admit that they had had visitors and had not been as diligent with either 
pumping or feeding. I encouraged them again to increase the number of pumpings and 
feedings. They had been spending a tremendous time attempting to latch, so I 
encouraged them again, to try for 15-20 minutes and then stop, feed the baby, 
and try again at the next feeding.

When I talked to the mother today she was very discouraged.  They had 
increased the feedings and the baby now had an appropriate amount of yellow, seedy 
stools, but nothing else had changed. Her breasts were still quite firm and the 
baby showed no interest in latching. 

We switched to an SNS to make finger-feedings and enticing to the breast 
easier, but I am at a loss. I said I would post here for other ideas to try.

Thanks!

Kathy
 
Kathleen Fallon Pasakarnis, M.Ed. IBCLC
Nurturing Family Lactation and Parenting Services

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