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From:
The Mullers <[log in to unmask]>
Reply To:
Lactation Information and Discussion <[log in to unmask]>
Date:
Tue, 30 Nov 2004 08:19:08 -0500
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I agree so thoroughly with Mardrey's answer that I had to take a second
look at who sent it. (I thought maybe I had done it in my sleep).
Basically, we could chart complexity "after the fact" but not "before"
Cheryl Muller RNC  IBCLC (hospital L.C.)





Date:    Mon, 29 Nov 2004 21:43:27 EST
From:    Mardrey Swenson <[log in to unmask]>
Subject: levels of patient complexity

Laurie asked about

My boss  will be giving me
further details on this soon, but I thought I would ask  now and if any
of you have such a system, would you be able to share it  with me? If
anyone else has any ideas as to how to describe the 4 levels,  feel free
to chime in. Thanks.



I don't know how your boss decided that there should be four levels,
Laurie.  I'm not saying that something along those lines might not be
developed. But I've seen too many psychological and just plain body
comfort/abilities/awkwardness issues that would make a particular
mother/baby  dyad hard to predict or categorize this way. And when would
these levels by  assessed?  Six hours
after birth/ Twelve hours after?   24?

It sounds like your boss wants to charge some mothers more because it
takes longer for her and the baby to achieve an acceptable comfortable
successful level of breastfeeding?? This does not sound like support
nor protection of breastfeeding.  I do see that that it could help to
know  that some mother/baby dyads might need more support more
frequently. And  want to use that for staffing purposes.  But at the
same time I just  don't see that you could proceed from Primip with no
risk factors to an assigned  management level.  Nor for a mother of her
second child with risk factors  for often the baby's makeup makes all
the difference.

 For instance, a particular mother might have soft breasts with  nipples
that are elastic and not flat, and a baby that is starting to open her
mouth and root well so assigned to a low management level. But the
mother might  be taking a long time to learn how to hold the baby so
that he doesn't slip  away from her, or she might keep on moving and
planting the baby firmly on the  crook of the elbow too far away from
her breast - no matter how softly and  gently you show her with a doll
model or describe to her what she is doing. Some mothers want to do it
themselves and resist teaching initially. This  type of mother may
eventually figure it out on their own or learn  what she specifically
needs help with on her own. Or may not.

Or given that same initial evaluation another baby might keep putting
her hands in the way just as she is brought onto the breast, blocking
her latch.  Or that baby might be doing something with her tongue so
that the latch looks "perfect' from the outside, but the tongue could be
thrusting, or held back in the mouth.  Another baby might get on the
breast so well and then  suddenly slide off to the side losing hold of
the breast.  [We figured  out by observing a baby doing this that he had
been pushing his tongue  against this finger tips most likely in utero
and after some sucks did the same  thing - pushed his tongue forward and
abruptly dislodged himself from the  breast!  It took days to change
this already established habit.]

 (By the way it's often the staff that tells a mom the latch looks
'perfect' and then I walk in, find out there is pain, some nipple trauma
and say something is going on and let's see what we can find out.)

I see a mother and baby progress at their own unique rate as each day
passes, learning in a way that isn't necessarily replicated by another
mother  and baby who initially might have the level of parity and exact
type of breast/nipple and baby who opens well. Can you predict which
mother is which at  the start? Are we giving the moms personality tests?
Myers-Briggs for instance?  One mother/baby dyad who on the first day
may be doing wonderfully on the  second, while the next dyad with the
same initial presentation may take three  days to get to a similar
place.  Will each level of these four have  subdivisions to map out the
myriad of subtle differences that occur?  Awkward mother not physically
comfortable, but slowly learning? Awkward mom with  a baby doing
something funny with tongue and mother experiencing pain and
frustration by the end of the first day?

Or a mother might have upright firm breasts, but a long trunk, and  long
baby who only achieves a comfortable latch with the mother leaning back
elongating her trunk and letting the baby's body angle down it rather
than  sitting upright when they latch. It might take a few days to
figure all that  out.

The baby's contribution can be a tremendous factor.  A mother with  flat
nipples might have struggled for days with her first 'slurper' baby  and
categorized at a different risk & managment level, but this second might
latch like a pro by the end of the first day.  Or with the help of the
type  of positioning in the "Follow Me Mum" video the mother might learn
a different  way of latching this baby that works well in one session or
in five.

I've seen too many mothers with no risk factors take longer to finally
say, "I think I've got it" than many mothers with risk factors.  So I
wonder if this style of evaluation would be at all effective, or just
one more thing the staff would have to chart without any real prediction
of outcome nor designated  management level.  Things change so fast in
the first two days.

I'll be interested to see what others have to say. You got me thinking
at any rate. Thanks,

Mardrey Swenson



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