Kathy D., you wrote:

<The problem I have with any video for Third World women that suggests
they
not touch their breasts is that . . . . . . . . lots of women in Mali (my
only real Third World experience) have 3-4 foot long breasts.  Yes, you
read that right.  If they don't hold up the end of the breast and place
the
nipple in the baby's mouth, then they're going to have to have the baby
out
at the very end of their laps, or even on a chair, and do some pretty
bizarre manipulating of the baby.  I've seen toddlers standing *behind*
their mothers, nursing, with the breast either thrown over the mother's
shoulder, or pulled around the side underneath her arm.  I've seen a
child
standing several feet away from the mother, holding the breast and
nursing.>

Kathy, I agree with the rest of your post about the hand washing. But
please enlighten me on the above-fascinating piece of information  like a
missing piece of the puzzle always going on in my mind about anatomy and
physiology of the breast.

As a child, I had seen similar illustrations in National Geograpic. I've
seen video(s) or photos of women of other cultures grasping behind the
nipple, stretching their subareolar tissue upward/forward for an inch or
two, with the heavy breast tugging below it.

I don't know if this was in the immediate context of getting ready to
feed, or express or what. But I have always wondered whether young women,
having seen it done openly, might not attempt imitation and
experimentation prenatally,  amounting to a certain degree of prenatal
preparation for breastfeeding.

As a 5'6" woman with enough droop that I picked the center of my breast
bone as a certain point of reference,  36" reached midway between my knee
and my ankle, and 48" came to the joint of my big toe. I can't imagine
what my life would be like with breasts that long!

Is it just the difference in clothing (lack of bra/support) all of their
reproductive life that results in this? Or is it some sort of inbred
thing among the women, and what is the progression from menarche to
menopause? Native women elsewhere stretched neck, ear lobes etc. Do they
stretch their breasts in some special way?

I am working with a mother now with what I term "functional retraction of
the nipple" (also, their circumference was the size of a nickel)  with DD
cup breasts and a "pithy, doughy, edematous texture" of her subareolar
tissue, and I was unable to palpate milk sinuses or express even a drop
of colostrum when I first saw her at 34 weeks g.a.

25-30 years ago, I would have suggested she use aggressive (per old
Egnell references) prenatal vacuum intervention from at least 37 weeks on
till term, and then postpartum if necessary. I am convinced that it gave
the mothers with severely non-protractile nipples the advantage of a more
even playing (feeding) field, though I have not yet figured out a way to
prove this.

That was way back when we had general anesthetics, routine delayed and
timed feedings and nothing but a bicycle horn pump and 2 kinds of
shields- thick rubber, or plexiglass and rubber, and no real postpartum
followup past 4-5 days in the hospital for most mothers. (Clandestine)
medicine droppers were the only "assistive feeding tools" I had besides
rubber nipples. Spoons and cups would have been unthinkable.

Someone referred her for shells. But in light of the worldwide
disagreement over the subject, along with the shells and my suggestions
for reverse pressure tissue softening at bathtime (Hoffman, essentially),
I gave her the BMJ article that concluded that rather than take the
chance of discouraging a mother from trying to nurse, it was better not
to examine the function of the nipples, let alone suggest any
intervention.

I told her my past experience gave me a strong difference of opinion
about their conclusions.  I offered to come for home visits after
delivery till nursing was well established,  no matter what she chose to
do prenatally. It was agreed that I would do this in exchange for my own
clinical education to follow the results. She chose essentially to do
nothing, wearing the shells "occasionally for 20 minutes" she said, and
massaging the breast itself at bathtime. I loaned her Renfrew/Fisher/Arms
"Bestfeeding" to read.

At 42 weeks g.a., she had a midwife-attended birth in a hospital, of a
6#9 oz. boy (no circ),  with what I would call a minimum of labor,
delivery and nursery intervention COMPARED to MOST women in our city.

The tight frenulum was recognized, but the pediatrician said "Wait and
see", but also ordered a small supplementation with glucose water (to
avoid dehydration). Unfortunately, the nurses fed/provided the parents
with a rubber nipple.

Her perception was that the baby had been "latching fine" and eagerly
until the rubber nipples. My question is whether milk sinuses were being
reached. (What the pediatrician had not seen were the mother's nipples.
Due to the size of the baby's mouth, It was a classical case of
"oroboobular disproportion" even without the frenulum problem.)

I first saw her on the evening of day 4, a Saturday. No wet diapers for
preceding 16+ hours. No severe engorgement, but obvious firmness in the
lobules, indicating beginning milk production to me.  She understands
what a good latch is supposed to be and she is coordinating nicely. The
frenulum was clipped on Monday, day 6. Better nursing attempts followed.

Being as encouraging as I can and as conservative as I feel it safe to
be, so far, I have felt it necessary to have her use an electric pump, a
plastic medicine dropper at the breast with formula, then finger feeder
(mostly by dad while she pumps), and now breast compression with an SNS.
About all the "fiddly stuff" available. Even tried a nipple shield.
Nipple wouldn't fit inside it, and baby wouldn't take it anyway.

On my last visit  on the 8th day, though pumping  was only yielding 45-60
cc after 20 minutes, I was pleased to see how little compression it took
to at least express a "steady ooze" of colostrum from the nipple,
Despite the disproportion between the nipple and the mouth, the baby
appeared to be latching as well as possible,  and I thought we were "on
our way". I was ready to eat "humble pie" about my prenatal assessment of
potential for problems.

The baby is now 12 days old, and I can tell she is very discouraged.
In retrospect, re the finger feeding sessions, especially by dad, I may
not have cautioned enough about not being too aggressive. The baby is
refusing all attempts at the breasts with clamped lips and turns the head
away. I am supplying plentiful encouragement and will take over a copy of
Diane W's "The Labor of Nursing" tonight.

I have encouraged her to drop direct attempts to latch for a while, and
hold the baby skin to skin at the breast while feeding with a finger
feeder till I can observe them tonight, and to check for possible thrush
in his mouth.

In retrospect, I'm now sorry I chose to approach it this way prenatally.
Surely, primitive women somewhere in the world have not been "skittish"
about handling the breast and the areola prenatally? Or has good genetics
and loose/no clothing and/or other factors made this unnecessary? Else
how has the human race survived? I know. Many babies haven't. And "wet
nursing" etc. probably saved many. I will continue to "doula" this
mother, but I would appreciate comments.

K. Jean Cotterman RNC, IBCLC
Dayton, OH USA

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