I went and saw a mama (Z) today for her 1 week postpartum visit. I went and did the visit solo (without my preceptor).
The last time we saw her was 5 days ago at the 3 day visit. At that visit, we asked how nursing was going, and Z said it was going fine. This was her 4th baby, and has nursed all of her kids. He looked sleepy, but not out of the range of normal for a 3 day old baby. Near the end of the visit, Z said that everything was going great, she just wanted to make sure he was nursing enough. We asked how often he nurses.
Every 8 hours.
We asked about how many times had he nursed since birth.
OMG!!!!! It was all we could do to contain our shock.
We told her to offer her breast to him at least every 2 hours, or more often if he wants it.
I think what was/is happening is that because he just sleeps and doesn't cry to nurse, Z just lets him sleep because she is pretty overwhelmed by her 3 other young kids. Sometimes I think demanding, fussy babies are better off, esp when they have lots of older siblings. So, we left her with instructions to nurse him often, to wake him up at least every 2 hours to nurse if he is sleeping. Z said she would.
So, today I go and see her. She says baby is still sleeping lots, but now waking up every 4 hours or so, and she nurses him then. I asked how many times in a 24 hour period is he nursing. She says 6 times. How many wet diapers? 4 really soaked ones, but she said probably more because she isn't changing him as often as she could/should. (So, if this is true, in my head I am stretching her wet diaper count to 5). Then we weigh him. We expect babies to loose some weight in the 1st few days, and we like to see them gain their birth weight back by 2 weeks. This little guy was 7 lbs, 1 oz at birth. Today, at one week, he is 6 lbs, 6 oz. That is slightly over a 10% loss. Pretty borderline.
Now, what I wanted to tell Z was this: 'please, please wake him up in the daytime at least every 2 hours and try to get him to nurse, and when you do nurse him, when he is 'done' on one side, offer him the other breast. This is so important because it ensures he is getting enough milk and to ensure you have a full milk supply.'
What I told her was that at this age, baby should be nursing at least 8-12 times in a 24 hour period. But, if she felt like he was getting enough, and he keeps wetting 5-6 diapers (disposable, and she said they always had poop in them) in a 24 hour period, maybe that is fine for him. After all, all babies are different.
So... WHY didn't I say what I felt? 2 things. 1st, this is a 4th time mom. She has done this before. I don't want to undermine her own mother instinct about her own baby. I know she is a caring mother (though overwhelmed with not much help). She said she really feels like he is getting enough milk. And, we did already tell her this 5 days previous...and we made it clear how important it is, too. 2nd, this isn't my client. I know it sounds silly (at least, to me it does!) but I have a hard time being assertive and sure of myself with clients knowing that they didn't hire me and that I don't want to say something that might contraindicate something that my preceptor might say.
This in no way is the result of my preceptor's sentiments. She strongly encourages me to do solo care and be the person her clients come to with questions. It is my own sensitivity.
I really need to work on trusting in myself and my thoughts. I need to be more assertive about what I believe is best (while still respecting the client's own wishes).
I volunteered to go out and visit Z again in a few days to weigh baby again (to make sure he is back on the way to gaining) and to really talk to her more about getting him to the breast more often. I feel pretty guilty about not being clearer to her today about how very important it is for her to be nursing him much more often...for both the baby's sake and for establishing a good milk supply. I know all of this, and I let my insecurities get in the way of this mama and baby's breastfeeding relationship.