Hello Colleagues.  Ellen Vojta, here, making my introduction.

I am currently living and working in Sheboygan, WI. (4 yrs.) but spent
almost all of my life in the Milwaukee area.  I have over 20 yrs. of
experience as a hospital RN in obstetrics, 15 yrs.  as a childbirth
educator, and have always worked with breastfeeding mothers.  I became an
IBCLC in 1987 and have worked in two hospitals as a lactation consultant
since.  Also have two children, 23 yrs. and 13 yrs.  Love the ILCA
conferences and especially at SCOTTSDALE--will be there this summer.

I am not directly on the internet yet, but using my husband Jan's address.
My responses will 1-2 days delayed for now, but we hope to be connected at
home in the next couple of weeks.
I have accumulated lots of comments to what all of you have written thus
far.  I will be brief, and here they are.

Getting hospitals to pay for LC services:  Use the fact that hospitals are
now competitive.  Offer them an added care feature that their
competetion doesn't offer.  Any client that has been happy with any
breastfeeding service that you have provided is your best mouth piece--
ask them to write constructive letters to the HOSPITAL
ADMINISTRATOR (don't even bother with anyone lower) explaining
that services from a certified lactation consultant are important to them,
were absent during their stay at his or her hospital, and that the
availability of these services will be an extremely important determiner
of not only where their next birth will occur, but also where their entire
family will choose to go for their future health care.  Then ask them to
comment on what they liked about your (now your name gets in there)
services.  It very often works-takes time, but works.  I learned it from
my OB instructor in 1965 and have resorted to it frequently since then.
Clients can often be charged for in house LC services if you figure out
how to do it, either please the insurance company or fake them out--I
haven't figured out which it is yet.  May need to call services "special
teaching"-that works sometimes.  Be sure medical record states what it is
that you specially taught in case insurance questions it--that's happened
to me and they have consequently paid.

Staffing-no matter how you cut it, an LC functioning on an OB unit
saves staff time.  What does a baby need in order to survive when
discharged from the hospital?--It needs to be FED, loved, kept warm and
secure.  It does not need to be bathed 13 times, circ'd, etc.  I have no
knowledge of any baby that failed to thrive due to an intact foreskin or
from lack of bathing in the first week of life.  Perhaps these thought
might help your hospital shift prioities.

Regarding the sagging uterus and bladder from breastfeeding.  Amazing!
When the Dr. provides the resources for that info., please share them
with us.  For some reason two words just keep floating through my mind
every time that I think about this case---f-o-r-m-u-l-a  c-o-m-p-a-n-y----
but I don't know why.  Did anyone else experience any unexplainable
thoughts after reading this case?

Yeast--please help.  Our local task force attempted to culture and study
the presence of yeast on the nipple.  Had labs from two hospitals
collaborate as well as input from many experts on how to do cultures.
MDs wanted verification of presence of yeast before they would treat.
Had to abandon study.  Couldn't successfully culture--but cases did
respond when treated (we were sure we were dealing with yeast-mostly
NB).

Prenatal breastfeeding classes--Agree that more than one class needed
and hospitals usually won't provide.  A class on "Infant Feeding-A
Parenting Issue"--discusses the differences between feeding methods,
infant capabilities.  Frank discussion on the difference between being OK
and optimum health--works very well to motivate parents to think
seriously about this issue.  I've had good success with this approach and
now parents are beginning to request this info. during hospital
breastfeeding classes.  Takes me about 1&1/2 hrs. and there isn't time to
cover in the breastfeeding how to's class, so I will be proposing this as
an additional class, intended for mid-trimester.  We charge $10 per
couple.

Early discharge-I fell into something at my current place of employment
that is perfect for breastfeeding and for bottle feeding probably as well.
They call it "out patient feeding assessments".  Peds or fam. practice
order mom and baby to return in 24-48hrs. post discharge for a one-on-
one look see at how things are going.  Done by me when I'm there, staff
when I'm not there.  We do a complete feeding, check infant's weight,
color, breast integrity, parental coping, questions, etc., etc.  It has on
occasion included everything from teaching circ care to watching an
insecure mom bathe her baby.  And family members that come along get
hints on what they can do to help mom.  Average assessment takes 1 hr.
20min.  Current charge is $53.00 no matter how long or short the visit.
Done in office in OB which allows staff to do and allows use of all of
medical center's facilities if needed.  Four years ago approx 50
assesments were done per year.  In Dec. of '94 I did 30 alone and the
staff did about a dozen additional.  We readmit infant as out patient and
bill insurance company.  Usually they pay.  Phone report to ped before
mom and baby leave if ped desires--eases their concern about early
discharges. Ped also gets carbon copy of written report of visit for their
files--they love it.  It's a great service, cost effective, and rarely does a
mom not want to come--in fact many come more than once.  of course
home visits are needed for those who are too ill to come back.

JHL topics--most urgent need is specifics on how to get third party
reimbursement.  Becomes more and more critical as insurance companies
continue to tighten their belts and most of us cannot continue to practice
if we cannot get paid.  Kathy Auerbach, I'm working on that study on
the use of nipple shields that I wrote to you about.  We did increase the
number of mothers studied to 50, instead of 30, on your suggestion.
Hopefully I can complete it in time for the JHL issue on same.

Sorry for the length of this one, but I had some catching up to do.
Ellen Vojta, RN, IBCLC, CCE