One typical busy morning coming on shift, one of the couplets I received report on was a 3 day post-op C/S mom and baby who were scheduled for discharge this same morning. She had been a long 3 or 4 day failed attempt to induce a vaginal delivery for fetal macrosomia (big baby) at 40 5/7 weeks before the C/S. Lots of IV’s, lots of Pitocin… all before the birth.
Her baby weighed 10 lbs 4 oz at birth. We got in report that his glucose sticks had all been over 60 initially so they were stopped early on. His exams were normal. His total bilirubin this AM was 11.3 at over 72 hours of age. He was “breastfeeding only” (*sigh*from the nurse giving me report). She then expressed a concern that he was down 10% from birth weight weighing 9 lbs 4.5 oz today. When I asked her about the feedings, she said he’s been nursing beautifully all the time but nobody’s had time to stay in the room and watch him feed. I asked about the output and she reported he’s been voiding, the last stool was a couple shifts ago. Then the nurse added “We told her you were here today, Melissa, she has a lot of questions for you. ”
I was able to juggle some things around, have staff cover some of my other responsibilities temporarily to make this a priority. Since I am a general staff nurse, there are often more pressing situations. Fortunately, today I was able to manage the time to see her right away.
- Good independent maternal positioning, holding and offering of the breast
- Nipples erectile, breast tissue soft, pliable, small amts colostrum expressed–> mom reports her breasts were “swollen first 2 days”
- Latch fairly adequate but not optimal-> improved greatly with football position and instruction on asymmetrical latch approach (I’d like to say here that I have a” if it’s not broke don’t fix it” attitude. I don’t correct a latch for a mom who has no pain and good milk transfer, we talk about it in case it may come up for though)
- Mikey very sleepy at breast, difficult to maintain latch, no milk transfer observed–>breast massage during feed tried without improvement
- Due to continued low energy level (suspected caloric deprived state causing sleepy ineffective feeding behaviors) a bedside glucose was checked. Result was 49.
- Diaper dry–> the previous concentrated void was only his 2nd in last 24 hrs No stool last 20 hrs and that one was dark.
- Cup feed formula now while she pumped –>Mikey would not cup feed so we used a syringe, 18 cc, repeat glucose 62
- Pumping round the clock, double pumping –> Meg rented a hospital grade pump for home use
- Keep close eye on feeding cues, put Mikey to breast in football w/ latch process discussed earlier
- Closely watch signs for milk transfer, correct feeding activity while at breast, sucking rythym 1 or 2 sucks /swallow ( Brad was very involved in this process of learning the observation techniques)
- Use breast massage/ compression while baby @ breast through feed to increase milk transfer
- Goal of min 8 effective feeds in 24 hr..wanted to try for 10 –>agreed to feed expressed milk or formula 1/2 to 1 oz after each feed first 24 hrs until re-weighed next day
- Have as 1st 24 hr goal: to see 3 -4 increasingly wet/clearer diapers and at least 2-3 good sized stools
- Return to MD for F/U bili and wgt check next day
- Call IBCLC for eval in next few days if weight not adequate and not independently breastfeeding/output within safe parameters for age
The follow up reports:
- DAY 1 (In hospital) Mikey fed 3 more times in the hospital at 2 hour intervals. Each time he had about 15 to 20 cc of formula by syringe. Each feed was improved but not adequate quality of milk transfer. Meg pumped 4 times before discharge not getting much first 3 times but 4th time she got almost 10 cc! Mikey had 1 conc wet diaper and a med sized dark stool. We re-weighed Mikey prior to discharge and he was 9 lbs 5.5 oz. Meg left the hospital late that afternoon while I had been called to a STAT C/S. She was determined to go home after all the time she had been there! I called her later and she was on target with her plan.
- DAY 2 (first 24 hrs home) Seen at Peds office. (reported to me from MD) Bilirubin 10.6, weight–> 9 lbs 7.5 oz! Baby more energetic, better quality feeds reported. Meg still power pumping, now getting 1 -2 oz per pumping and giving to baby with syringe and only used formula occassionally if no breastmilk. Had 3 wet and 2 stools since discharge, stools lighter in color. MD arranged F/U weight visit for 2 days, will arrange IBCLC if no strong improvement before 2 more days
- AGE 6 1/2 days Seen at Peds office. (reported to me from MD) Weight–> 9 lbs 11 oz !!! Meg having fairly same routine but not always pumping if she feels Mikey had good milk transfer. She reported increased breast fullness, 6 wetter, lighter urines and 4 mostly yellow stools in each of the previous 24 hr periods.
- AGE 2 weeks I don’t have MD office reports but Meg called me to tell me Mikey was 1o lbs 7 oz at his 2 week check up and nursing a lot better EVERY feeding!! She was still attached to her pump, gradually decreasing the sessions, just felt safer to keep going with that. If she gets milk she was still giving it to him. This was her security blanket and she was happy doing it. She was very proud of herself and crying happy tears! 🙂
Meg’s case was a beautiful example of HOW a situation can turn around quickly. An individual mother’s determination coupled with a productive plan can produce these results. All situations are different.
Every mother and baby deserve our best!