I have permission to post.  Just a bit of background-

Tough birth.  Planned homebirth, Premature rupture of membranes, no labor
after 48 hours so began caster oil induction.  Lots of contractions, but no
cervical changes.  After another few days started pitocin induction in the
hospital.  After 50 hours of pitocin, plus foley bulb dilation attempt still
no cervical change.  Had c-section.

Mom reports she was very swollen (her ankles looked like her thighs, she is
not a thin woman, so this is quite a bit of edema).      LC's attepted to
latch her on with a shield without success (according to Mom never even
suggested she try to latch without a shield).  Due to the large breasts with
very flat nipples, no attempt was made to latch the baby on without the
shield.  Baby lost more than 10% in first 24 hours.  Was told she needed to
supplement in order to go home.  Started supplementing with syringe and 8
french ng tube at finger, and pumping every two hours except for a 4 hour
block at night.  Did not get any milk.  Continued trying to latch baby on
with shield, no success.

Developed an infection in the incision.  

At two weeks postpartum, felt like she was having an asthma attack (no
history of asthma) so she went to the emergency room.  Found out she was
actually in congestive heart failure due to fluid overload during her
induction.  Was in the hospital about a week on lasix and fluid restriction.
 Baby brought to mom periodically for Mommy time.  Nurse suggested trying
to, latch baby on without shield.  Baby latched and nursed periodically if
offered breast.  Mom continued to pump round the clock without much milk. 
Baby bottle fed at home with a mixture of donated milk and organic ABM with
a variety of nipples.

The swelling subsided and she started to get some milk- max 1oz.  Mom was
single pumping with 27mm flange.  At five weeks, baby refused to latch.

This is where I get the call for help with a three day nursing strike.

Breast exam- large, pendulous breasts, can palpate good breast tissue in
there;  the breast just seems a bit buried in a fatty layer.  Mom is on the
heavy side.  The flange is way too small, the nipple is not being drawn into
the funnel of the flange at all (the niupple is flat and the streams of milk
are being sucked out with no tissue movement).  We go up to the 30mm size,
better but still no increase of milk.  Mom has used symphony, pump in style
and thinks her current pump (lactina select) is the best of the lot.  Baby
still refusing to latch, hysterical if even close to the breast.  Mom has
been trying to hand express.  I am a hand expression queen, so I teach her
to hand express, nothing seems to move the milk by hand.


I recommend trying larger flanges 36mm, and stop trying to latch baby on for
a little bit.  Lots of skin to skin, co-bathing, feed cheek to breast with
finger or bottle.  Teach paced bottle feeding for non-finger feeds.  Mom
continues to pump every 2 hours during the day (8am-11pm with one pumping at
night around 1-2 am).

Follow-up consult three days later- baby latched that morning (shallow but
latched for 15 minutes).  Happy again with mom near breast.

Mom still pumping with all sized flanges (27, 30 and 36), milk supply
continues to dwindle to 1/4 oz from each breast every two hours.  The breast
is softer today, the 30mm flange looks best to me (a little tight) the 36
looks a bit big, but not too big), but mom still thinks she gets more milk
with the 27mm.  Mom said the baby was taking in less milk (from 4 oz at
bottle to 2.5 and seemed happy and content with that amount, still lots of
pees and poops).  Latched baby onto nipple tip for a bit, refused to latch
more deeply.  Tried with expressed breast milk in curved tip syringe,
started to get stressed out (pulling head away, pushing away pushing nipple
out with tongue.  Finger fed with curved syringe cheek to breast 1/4 oz of
breastmilk.  Fell asleep.

Baby looks great, and the suck assessment is optimal.  Good tongue movement,
tongue goes over gum line, no evidence of tongue tie.  Good suck, great
tongue movement.  Mouth opens wide, and she drops her head back when set
tummy to tummy with mom and nose to breast.

Baby is fine on the AMB, no s/sx (signs or symptoms) of milk allergy, is
happy and gaining well.  Mom is heartbroken at the loss of her homebirth and
nursing relationship.  

Important loose ends-

Mom shared with me that she had a "nodule" on her pituitary and lactated
(dripped milk from her breasts) from age 16 until 25 when it stopped.  She
declined any medications and did not have surgery on her pituitary.  Denies
any History of PCOS.

Mom is still bleeding 5 weeks post c-section.  Went lighter for a while and
then got heavy again at the beginning fo the 5th week, clotty, with
cramping.  Nurses at the hospital think it is her period, Mom thinks so too.
 I am not convinced.

here is our plan-
Mom is a chiropractor so she knows quite a few acupuncturists, so is going
today for acupuncture to see if it could help her milk supply.

She is going to pump every 3 hours as she is just too exhaused to do more
right now and is very discouraged.  Will go back to q 2 hours as soon as
possible.  She is going back to finger feeding cheek to breast as she thinks
the latch is better at the finger.  Has large syringe with 5 french feeding
tube attached.  Will try baby at breast as long as baby is not too stressed
out and continue lots of skin to skin.  Will try with and without nipple
shield as desired. 

Once we can get the baby to latch we are going to feed at the breast with a
tube. 

We talked about the possibility of adding some domperidone.  I have some she
could try for a few days to see if it helped, but am unsure given the
pituitary history if it is a good idea.  

So here are my questions-

Any thoughts as to the pituitary?  did it "burn out"?  

What lab tests might be helpful at this point?..I have done prolactin level
draws but in the hospital setting, so they could be drawn multiple times. 
How would you suggest an out patient draw?  Would it be worth while to check
some other hormonal levels (rule out retained placenta)?

How do we get more milk out with pumping?  The breasts are very, very large
and soft.  The pump just seems to pull the tissue without getting to the
breast structure.  Any tips?  Tricks of the trade?  She has a hands free
pumping bra, but it did not help.  She is single pumping because in order to
get the flange to stay on she needs to manipulate the breast with the other
hand.

I am this woman _sixth_ lactation consultant and have developed a good
rapport with her.    She is willing to do just about anything for the next 6
weeks to get a better breastfeeding relationship so throw out any and all
thoughts.

Warmly,

Charity   

     

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