From MIDWIFERY MATTERS, Issue No. no 78, Autumn 1998
by S Brown
I WORK AS A breastfeeding liaison midwife with a special interest in ill or premature infants and in this role I learn much from the women and their babies. As women we tend to question our breasts' ability to meet the feeding needs of our babies, yet we know that the simple yet intricate supply and demand mechanism of breastfeeding works. One of the commonest reasons why women stop breastfeeding is a perceived lack of breastmilk (Foster et al, 1997) and for women breastfeeding twins or more then this uncertainty often increases (Rushworth, 1988; Bolting et al, 1990; Fiducia, 1995). Fortunately midwifery textbooks no longer state that in the case of breastfeeding twins supplementary feeds are 'inevitable' (Thomas, 1953) but we still need to continue to develop our skills and knowledge in supporting women through their breastfeeding.
This is the story of a mother, Stephanie, her husband, Chris and their three babies. Stephanie had become pregnant following fertility treatment. The pregnancy was obstetrically uneventful but Stephanie had spent three weeks in hospital ';resting' prior to delivery. During these three weeks Stephanie had to spend some time in a maternity unit many miles from her home as the local special care baby unit did not have three cots available. Chris therefore found himself very busy commuting between home and hospital. Stephanie's babies were finally delivered at 35 weeks gestation by caesarean section. The three healthy premature infants, one girl (Evangeline 1.70 kg) and two boys (Alex 1.92 kg and Maxwell 1.80 kg) did not need any active resuscitation but were transferred to the special care baby unit for observation.
All the triplets had been put the breast from the first day but none were showing any interest in feeding as yet so feeding commenced by nasogastric tube and cup. A mixture of colostrum and low birthweight formula feed was given. Stephanie had started to use a Egnell SMB electric breastpump within hours of delivery and was expressing six times a day.
By the third post natal day, when I first met Stephanie, she was feeling very tired. Her right nipple was cracked and bleeding from using the electric breastpump at too high a pressure in an attempt to obtain a larger volume of colostrum and her milk was showing no signs of coming in. On top of this all the babies were showing signs of physiological jaundice and were very sleepy and not interested in feeding.
Fortunately the problem of Stephanie's sore cracked nipple was solved within 24 hours with the use of hand expression prior to the use of the electric breastpump on a lower pressure. Primary lactation occurred as well during this time which enabled her to express larger volumes of breastmilk very easily. The triplets remained sleepy and unresponsive to any feeding stimulation but they did not require phototherapy.
I was impressed by the knowledge Stephanie and Chris had accrued during the pregnancy on breastfeeding, especially breastfeeding triplets. There seem to be few published personal accounts of feeding triplets but Stephanie had many of them. Stephanie initially thought that her wish to breastfeed may have ended when she found out she was expecting triplets, she had also become dismayed at the reaction of others when she mentioned the possibility of breastfeeding until she finally met another mother of triplets who encouraged her to go ahead with her original decision. This background knowledge on breastfeeding and Stephanie's nursery nursing background, enabled her to conclude that scheduled feeding was probably the only way she could cope. Stephanie just hoped her babies would feel the same way.
By the fourth postnatal day all of the triplets had attempted at least one breastfeed which had followed on very naturally from skin-to-skin contact. From the sixth postnatal day the triplets no longer required their nasogastric tubes as they were breastfeeding with complements by cup when necessary. Stephanie continued to use the breastpump when complementary feeds were given. One member of the neonatal unit staff become very important to Stephanie and Chris at this time and her encouragement and support and continued care during the three nights when the triplets were beginning to breastfeed proved to be the turning point in enabling successful feeding.
The triplets were beginning to develop their own characteristics. Alex was always eager and usually the first to breastfeed. Evangeline, although the smallest, was the quickest at becoming fully breastfed and did so in a very quiet understated way. Maxwell was the best at latching on and feeding and was able to attach himself at an early stage.
The triplets had their own room on the newborn unit. This enabled Stephanie and Chris to become used to the demands of their infants but also ensured a helping hand if needed. For the short break between feeds Stephanie would rest in her room. A pattern of care was becoming familiar to all concerned. The first two to wake would be nursed together and the third infant fed, while Chris settled the first duo.
At this time the special care unit became very busy and the tantalising thought of transferring the triplets back to the maternity unit was considered. Stephanie knew she was coping with the present situation but felt that 24-hour care would be too much for her at present. When she expressed these concerns the unit staff became aware of how tired Stephanie was and how important the all too brief rests in her own room were. In retrospect Stephanie realised she had probably been perceived to be coping too well while holding on to concerns and anxieties about her three premature babies. Evangeline was also found not to be fit enough for discharge from the unit and a planned discharge home was finally arranged when the triplets were twelve days old. At discharge all infants were over their birthweight and totally breastfed.
My interest continued in their wellbeing following their discharge. Over the next week Stephanie and Chris coordinated the night time feeds so well that in 60-90 minutes all of the babies were fed and back to sleep again. Chris had to return to work after a fortnight at home and this night-time routine continued, with his help, for the next four months. Fortunately the babies maintained the routine feeding pattern most of the time, the downside of this was that all three would wake together.
Stephanie and Chris did have help from friends and relatives but Social Services offered one hour a day, twice-a week. Other help was obtained from nursery nurse students on placements and a wonderful neighbour. Stephanie's health visitor was also a local breastfeeding coordinator which helped with continuity of support on feeding issues.
The only feeding problem that occurred was that Maxwell was very slow to gain weight. When a feed was observed he breastfed very well, almost playing to the audience, but at other times Stephanie would notice he waited for his brother or sister to initiate the let-down reflex and then fed quite passively. Maxwell's weight became static for a week and then dropped slightly. As his weight was under 2 Kg it was decided that cup feeds of expressed breastmilk would be offered after the daytime breastfeeds. After a weekend of these complimentary feeds Maxwell had gained 3 oz. Stephanie decided to continue with the complementary cup feeds but at six weeks Maxwell went on to bottle feeds since one set of the grandparents were staying and could help.
Over the next few weeks Maxwell managed fewer and fewer breastfeeds but Stephanie insisted he had at least one breastfeed or a feed of expressed breastmilk each day. When discussing Maxwell's feeding pattern later on, Stephanie thought that it had changed following the introduction of dummy when he was three weeks old.
The triplets are now eight months old. All were introduced to a weaning diet at four months. Alex and Evangeline are still breastfeeding and Maxwell continues to have his daily feed of expressed breastmilk. All infants are well with just one episode of ';snuffles' during the entire winter and Maxwell has very mild eczema.
When I first met Stephanie, she told me that she did not have any plans about how long she would breastfeed but now she is planning to breastfeed for as long as possible. Another local woman is expecting triplets later on this year, Stephanie is hoping she will get in touch and that she will be able to offer that wonderful mother-to-mother support which convinced her that breastfeeding triplets is both possible and also very satisfying.
Source: This article was originally published in Midwifery Matters - issue no 78, Autumn 1998, pp 8-9
Botling B, Macfarlane A and Price F (1990). Three, Four or More - A study of triplets and higher order births, HMSO, London
Fiducia A (1995). 'Breastfeeding three babies at once', (abstract) MIDIRS Midwifery Digest, 6, 3, 346-347.
Foster K, Lader D and Cheesbrough S (1997). Infant Feeding, Office for National Statistics, HMSO, London.
Rushworth F (1988). 'Supply and demand, demand, demand!' New Generation, March, 33-34.
Thomas F (1953). Mayes' Handbook for Midwives, Baillière, Tindall and Co, London.
AH updated 16 July 2001