Robin, I'm glad this reinforced for you the importance of listening to the
patient.

That said, I don't think the compress had anything to do with possible low
supply on day seven, since there was a five-fold increase in the amount of
milk transferred at a single feed the next day, before the compress was
discovered or removed.  The woman was afebrile, suggesting that her body was
not using a lot of energy to mount an inflammatory response, certainly not
so much that it should affect milk supply.  I've removed several compresses
more than a week post partum and this case sounds typical.  Usually it takes
a few days for them to get in enough contact with air to start really
smelling, and the reason they get forgotten is that whoever did the suturing
at birth and used a compress rather than a special tampon to absorb blood,
will have placed it so high in the fornix that it just disappears in the
folds of the upper vagina, esp when soaked with blood.  As the vagina also
involutes, the compress moves toward the outlet.  In all the cases I have
seen, this has been the case.  None of them have been associated with any
disturbances in breastfeeding, nor would I expect them to, since compresses
do not restrain the secretion of prolactin.  

This baby was jaundiced and lethargic when first seen.  You didn't mention
what the care plan was after the first visit, nor did we learn what the
baby's birth weight and weight on day seven were.  We also did not hear
about stool and urine output.  I assume you got data on all these things as
part of the routine assessment.  If the diagnosis of low supply was made
after determining that the baby's weight was far below what is to be
expected at one week, and not simply on the basis of a single pre- and
post-feed weighing, I would put more store by it.  Otherwise I would reserve
judgment about whether there was really low supply at all.  Maybe it was low
transfer because the baby was too lethargic to feed well, because the mother
hadn't learned how to detect or correct an ineffective latch.  Maybe it was
just a small feed.

Our postpartum clinic is staffed only by midwives, so we don't have to call
anyone else in order to examine a woman.  In cases of forgotten compresses,
by the time they are causing the kind of symptoms described here, they are
lying just inside the introitus and can be easily removed with no equipment
other than exam gloves, which then can be used to double-wrap and seal the
compress so you can toss it without having to fumigate the room afterwards.
 Unless there are other indicators of systemic infection, we go straight to
writing the incident report after removing the compress and apologizing
profusely to the woman, and she has an uneventful further course.

For the record, what helped most at our hospital was the active use of the
quality assurance system.  Every case came from the same practitioner, and
after a brief but effective reprogramming session, that person now uses
tampons like everyone else, instead of compresses.  Tampons have a huge
string, more like a rope, really, that hangs out right in your work field
while you're suturing, so you can't forget them.  :-)

Rachel Myr
Kristiansand, Norway

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