There are good days and not-so-great days. Last month, I got a bit of a shock when two of the mothers I had counseled admitted their kids to the Neonatal ICU (NICU) for dehydration, hyperbilirubinemia and excessive weight loss. Of course, all these are direct causes of inadequate breastfeeding.
I had seen one of them once briefly and the second one, about whom this post is about, I had counseled extensively and multiple times, along with her whole family. To say that I was dismayed to see her in the NICU with a sick baby would be an understatement.
Sometimes issues with language, understanding, culture etc are vast, or they seem so. This lady came from a very poor family. That per se doesn't mean anything. Intelligent, capable women are found everywhere, regardless of their family situation.The language of communication was Hindi, not my strong point; the differences in education, financial situation, family stability etc were of course clearly present. But these I have been able to overcome before, but somehow was not able to do so in this case. There was no rapport. Usually, if I find it difficult to communicate with the patient, I turn to her mother since she will be the one who's helping the new mom. Speaking to this patient's mom was just as difficult. There was a brother as well, and he was actually easier to talk to. Very interested in his sister's ability to breastfeed and the suckling ability of the baby. Usually when a male family member interests himself in the breastfeeding process, it's the father of the new mother or the father of the baby. Having a brother so keenly asking questions was surprising, but who am I to judge? I actually was grateful that someone in the family seemed to understand and respond to what I was saying. Many times I wondered if I was getting through to them, despite the head nods and the smiles, but then I dismissed my concerns, assuming that everything would be fine. She had an inverted nipple, but was feeding the baby through a nipple shield. She seemed comfortable, the baby appeared to be feeding well, was peeing well and there was a slight weight gain by the time she and the kid were discharged.
And then of course, a week later, she turned up with her little baby to the NICU.
Anyway, counseled her again in the NICU; she was defensive, not willing to think that there was a problem; and then all of a sudden, burst into tears about her father... she sobbed and spoke through her tears. I was unable to understand if her father had recently died or had abandoned them, or if all these events were in the past which she was still grieving over. At the back of my mind were all these questions: where was her husband? What was the brother's role? What was going on?!
Very confusing. And it happened right in the middle of the NICU; all the sisters stopped, stared, exchanged bemused glances, whispered among themselves and I was trying to console this lady and was wondering what I had said that set her off.
After some time, and a lot of coaxing and fake cheerful-talking, things returned to normal, or as normal as they could get. Turned out she wasn't eating properly- they were keeping her on rice and dal because she had had a cesarean section (were they punishing her or were they simply misinformed? Usually maternal diet after childbirth forms a pretty key part of my standard spiel... did I somehow miss talking about this with these guys?), she was not eating or drinking properly. Imagine- 3 meals of just rice and dal; not even with ghee. Restricted water. How is anyone to survive on this nonsense, let alone make enough milk to feed a newborn?
Later I found her brother in the vicinity and questioned him. And he said, "Yes doctor, you had told us about what to give her and what she should eat" (ok. good. so at least I hadn't missed that) and then I reiterated again about what she should be eating and how important that was.
God knows what happened after her discharge from the NICU. I hope she doesn't turn up again at the NICU and that baby grows a bit and this whole breastfeeding thing resolves without any more issues.
Ideally, I should have asked her to come meet me on an OPD basis to follow up with the lactation. But I was frankly very reluctant. I am a simple lactation counselor, that too with no qualifications other than an LCCE, a bit of experience and a true desire to do this stuff. All the psychiatric stuff, the financial stuff (they might feel obligated to come see me, but may not be able to afford the OPD fees), and most importantly, the getting-through-to-them stuff was too overwhelming for me. So I gave her my card with my number on it and asked her to get in touch in case of any issues, but didn't set a time.
Reading this account over makes me realize how out of control I felt. Most of my decisions were made based on a desire to get out of the situation rather than meet it head on. This is something I will probably come across again. So I must learn to become more aware of these obstacles. I must talk to Rk and other doctors about how they handle difficult cases.
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