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Hello wise ones!

I just did my first consult and would appreciate your opinions/feedback.

My appologies for the long post!

Mom had difficult birth, SROM but no contractions & step b positive, therefore she had a pitocin induction with epidural and antibiotics.  She pushed for 3 hours,  the first OB did SIX attempts at a vaccuum extraction, before another OB was called who then performed an episiotomy and then a SEVENTH and successful Vaccuum extraction.  She was hooked up to IVs for more than 12 hours and consequently exprienced severe edema everywhere, including her breasts, causing nipple distention.

Baby suffered a severe hematoma, had 30 min of skin to skin with mom before going to the nursery for observation.  (This hospital generally does not separate moms and babies and is baby-friendly, but this was an exceptional case.)  Baby made no attempt to latch during the brief s2s.  In nursery, baby was fed formula via bottle teat 7-8 times over his 3 day hospital stay, 35ml each time.  Paediatrition ordered this because he was afraid of baby getting upset and crying due to the severe hemotoma.  Hemoglobin levels in baby were falling (from 210 to 163), Paediatrition was concerned about possible bleeding in baby's skull.  In hospital, due to the "flat" nipples (actually distended nipples due to excess fluids), nurse gave mom a nipple shield at 48 hours because baby was unable to latch on.  Nurse also suggested mom use pump to extract colostrum and bring out nipples and mom states her nipples became much flatter after.

Mom was released on day 2, baby stayed until day 3.

Mom called me on day 4, we spoke for 3 hours on the phone.  She reported that her nipples normally protruded but were now flat and her baby could still not latch without the shield.  I suggested RPS before nursing, manual extraction, so as to avoid more fluid in the breasts, reverse massage and cold application in between nursing to help reduce edema.  Also LOTS of skin to skin, anti-gravity positioning for all feeds.

I saw mom on day 6.  Observed some assymitry in baby's skull shape, not surprising given birth circumstances.  Parents report that it is greatly improved.  No "banana" posture or cocked chin to indicate torticolis.  Baby appears to be able to turn head equally to both sides.  I instructed parents how to continue to observe for this, since sometimes it takes a while to show up.  Baby still has some mild jaudice, but parents say they have noticed a reduction in the yellow colouring.  Oral exam:  baby clamped on my finger more than actually sucking.  very little tongue movement at all.  I did possible feel a bit of resistance under the tongue, but I will check again when I see them again soon.  Everywhere is closed for the holidays right now anyway, so I would not be able to refer for frenectomy.  I had mom get into a laid-back position and do skin to skin with baby for 30 min while he slept and we filled out the questionnaire.  Finally when he woke, mom first tried to nurse without the shield (after I did RPS), baby got angry and began to get frantic.  So we put the sheild on for breast #1.  Baby nursed actively for 10 minutes with obvious swallowing (gulping!), then fell asleep.  Remained in s2s while baby slept/rested, roused on his own for breast #2.  Again I did RPS, then offered baby bare breast (not really and assited latch, but just placed baby in the vicinity).  He latched without the shield!!!  He did not really nurse, but he gummed the nipple for about 3 minutes before growing frustrated and we put the shield on.  He then nursed actively with the shield for another 10 minutes.  While he did not really nurse, he did accept the bare nipple in his mouth for the first time, so I consider this a big step in the right direction.

Baby has copious diapers (mom reports 9 very wet and 5-7 yellow curdy stools per 24 hours), from exclusively nursing with the shield (no supplementation since day 3).

My training did not cover much about how to use or fit nipple shields, just when to use them.  I have learned how to apply them (turn almost inside out and stretch open and let it roll back down over the nipple).  When I applied it this way, mom said it felt like there was a lot more of her nipple in it than the way she had been doing it.  I have not, however found any resources as to how to fit them.  What does a properly fitting shield look like?  My client's nipple did not fill the teat of the sheild, despite my best efforts.  Can anyone point me to some info on fitting or photos of how to fit and what it is supposed to look like?

I have suggested to mom that she continue as much s2s as possible, RPS and reverse massage, offer a finger to baby with light pressure on the palate before offering the bare breast in hopes of stimulating the sucking reflex, and to continue to offer the bare breast using laid-back positioning, but not to let baby get frantic or too frustrated, switching to the shield if he won't take the bare breast.

I will go back soon to do another consult, when I observe for changes to the shape of his skull and apperance of any signs of torticollis and check again for ankyloglossia.

So what do you think?  Anything else I could have suggested?  Anyone have any resources for fit of nipple shields?


THANK YOU!!!

Jennifer Welch, IBCLC, LLLL (since 2006)
Still trying to find my footing and my confidence!

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