- Email: [email protected]
Breastfeeding Conjoined Twins
C A S E
R E P O R T
Breastfeeding Conjoined Twins Elizabeth A. LaFleur, RN, BSN, IBCLC, Kathryn M. Niesen, RNC, MSN
The breastfeedingexperience of a mother and her preterm conjoined twins is described. Assisting the mother in achieving her breastfeeding goal presented unusual nursing-careproblems in securing, positioning, and comforting the twins. This case report emphasizes the individualized support provided to this mother and her infants,which was a critical factor in their breastfeeding success.JOGNN, 25, 241-244; 1996. Accepted: October 1994
A
ssisting a mother with breastfeeding conjoined twins is an experience had by few nurses. The incidence of conjoined twins ranges from 1 in 50,000 to 1 in 100,000births. Half of these are aborted spontaneously or die before delivery. One fourth of such twins delivered alive die within 24 hours. Only 5% of conjoined twins are discharged from the hospital after separation (Buyse, 1990). Breastfeeding multiple infants brings a challenge to new mothers. However, when the infants are conjoined, the challenge becomes even more complex. This case report describes the breastfeeding experience of omphalopagus conjoined twins and their mother. The nursing care provided to this family assisted them in overcoming seemingly insurmountable odds and in breastfeeding successfully.
Review of the Literature The word “omphalopagus” is derived by prefixing the anatomic area of the union to the Greek word “pagos” (that which is fixed). Conjoined twins are classified as omphalopagus, thoracopagus, pygopagus, ischiopagus, or craniopagus. In omphalopagus twinning, the conjunction extends from the sternum to and including the umbilicus (Buyse, 1990). Although there are several publications in the litera-
March/Aprill996
ture addressing the physical and emotional care of conjoined twins and their families (Bell, 1982; Hedrick, 1979; Jakobowski, Hagelgans, & Leson, 1989; Lipsky, 1982; Ramp et al., 1989), we could not locate any research publications addressing breastfeeding conjoined twins. Two studies addressing the management of breastfeeding multiple infants were located (Mead, Chuffo, Lawlor-Klean, & Meier, 1992; Saint, Maggiore, & Hartman, 1986). These studies support the adequacy of a mother’s breast-milk volume for multiple infants. Another clinical article by Sollid, Evans, McClowry, and Garrett (1989) outlines practical approaches to breastfeeding twins.
Case Report Mrs. M . R., a 21-year-old primigravida, was admitted to our medical center with a conjoined twin gestation of 32-’/, weeks. She was treated in our antenatal unit until 36-$weeks with modified bed rest and terbutaline for preterm labor suppression. Mrs. M. R. indicated that she had always planned to breastfeed her infants. Even when she learned she was to expect twins, and then conjoined twins, she did not reconsider her decision to breastfeed. Mrs. M. R. said that her hometown outpatient clinic nurses promoted breastfeeding during her early prenatal care and supported her decision to breastfeed her infants. When she was admitted to the medical center, the twins were both presenting cephalic. At 36% weeks, twin B was discovered to have rotated 90 degrees from a parallel position to twin A, and concerns of tortuous stress and damage to shared tissues and organs were pri-
When she learned she was to expect twins, and then conjoined twins, she did not reconsider her choice of breastfeeding.
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C A S E R E P O R T
feedings of 45 ml of breast milk every 3 hours, along with their breastfeedings. Initial Breastfeedings The neonatal intensive-care unit staff nurses and the lactation consultant assisted Mrs. M. R. and her infants with the initial breastfeedings. During the early feedings, Mrs. M. R. and the nurses were apprehensive yet determined to succeed. The physicians were interested and offered supportive suggestions, but essentially stood back while the nurses helped Mrs. M. R. begin the breastfeeding process. Because the twins were difficult to handle, it was comforting for Mrs. M. R. to have a nurse reassure her about her technique and provide an extra pair of hands. Through experimentation and instruction, Mrs. M . R. found that the cross-cradle position for the nursing infant was the best position. In the cross-cradle position, the infant is cradled across the mother’s chest with the infant’s abdomen tucked in tightly toward the mother’s abdomen. Pillows were placed across Mrs. M. R.’s abdomen to support the cradled infant. Additional pillows were used as needed under Mrs. M. R.’s elbows, lower back, and knees for support in bearing the infants’ weight. She preferred to sit in a recliner or rocking chair with armrests. Mrs. M . R.’s free hand (the one not cradling the feeding infant) supported the breast (see Figure 2). This helped the infant to latch on properlyand to maintain her hold. The twins’ conjoined position did not allow them Figure I. Conjoined twins Not. Reprinted wilh permission OJ‘Mu,voFoundation.
mary. The twins were delivered by cesarean section. They were female, with a combined birth weight of 4325 g and a six-vessel umbilical cord. After birth, the twins were taken to the neonatal intensive-care unit for further evaluation. The twins were joined across the anterior abdomen from the sternum to the umbilicus facing each other (see Figure 1 ) . Twin B was located slightly superiorly in relationship to twin A. Portions of both livers were perfused individually and had shared perfusion. There was a small portion of shared abdominal cavity containing bowel lying inferior to the liver. Mrs. M. R. began pumping her breasts with a doublepump setup and electric pump. Pumping a minimum of eight times in 24 hours (including one night pumping) was recommended by the nurses. The goal for Mrs. M. R. was a 1080-1440-ml-per-daybreast milk supply to nourish her preterm twins. The twins were given orogastric
The twins were joined across the anterior abdomen from the sternum to the umbilicus facing each other.
242 J O C N N
Figure 2. Moiher holding conjoined !wins in cross-crudeprisition with infunt in lower position mrsing Note. Rgprintd with permisxion ofMu,vo Foundution
Volume 25, Number 3
Breastfeeding Conjoined Twins
to nurse simultaneously. Even by nursing the twins one at a time, Mrs. M. R. could not achieve the ideal “tummyto-tummy’’ position between infant and mother. The twins had to turn their heads slightly to latch on. While one twin nursed, the other lay perched on top with her head resting on her sister’s head and her hands often near her sister’s face. Mrs. M. R. found that because of the position in which the twins were joined, it was easier for her to nurse each infant exclusively on one side or to use the same breast for the same infant at each feeding. Problems Some problems were encountered. Mrs. M. R. expressed frustration that one infant cried while the other nursed. One twin was more impatient than the other. At times she would cry fussily and thrash out with her arms at her sister’s face while she awaited her turn. Lemon-glycerin swabs, a pacifier, and assisting her in sucking her own thumb were methods used in trying to comfort her. Finally, it was decided to tube feed one infant an hour before the planned breastfeeding of the other. This did seem to satisfy the more impatient infant. However, Mrs. M. R. and the nurses later acknowledged that the active, crying infant was more disconcerting to the nurses and to Mrs. M. R. than to her sister. Eventually, as Mrs. M. R. became more comfortable in assessing the infants’ behaviors, she was able to decide which twin to breastfeed first. She also would alternate breastfeeding and waiting between them in response to their expressed need.
Wrapping the twins made them easier to handle and prevented them from twisting and turning, which lessened the tortuous stress to their joined area.
Mrs. M. R. continued to need a second person for support and assistance. Looking for a solution, one of the nurses wrapped a woven elastic cloth bandage around the infants’ torsos to help secure them. Wrapping the twins helped to keep them from twisting and turning and lessened the tortuous stress to their joined area that concerned Mrs. M. R. The gentle but firm wrap also secured Mrs. M. R.’s independence by making the twins easier to handle. Progression of Feedings After the transition to independent breastfeedings, the progression of feedings advanced more rapidly. Increases in the 3-hour gavage volume were made on the 8th and 9th days. The breastfeeding advancement also began on the 9th day with early feedings in the progression done at 2-hour intervals. Mrs. M. R. soon was breastfeeding each infant four times per day and had gained confi-
dence in doing the feedings by herself. Within the next week, the twins were breastfeeding eight times per day, every 2-3 hours. As the twins moved toward being breastfed exclusively, breast pumping was reinforced after both were fed to ensure an adequate supply of milk. Mrs. M. R. was instructed to pump after every feeding from the first breastfeeding through hospital discharge of the infants to establish and maintain adequate milk production. When the infants gained weight at home, a slow, gradual weaning of pumping would occur. One pumping would be dropped every couple of days, and the infants would help their mother to create their own breast milk supply based on their demands. Initially, urine output of each conjoined twin was assessed as an individual determinant of breastfeeding intake. Twin A was a less vigorous nurser than twin B. However, a significant difference in urinary output was noted even when both were tube fed an identical volume. Twin A’s output was significantly greater than twin B’s. This difference was also observed during breastfeeding. The difference in output may have been due to the vasculat transfer of fluid from twin B to twin A. Preparationfor Hospital Discbarge Mrs. M. R. began rooming-in overnight with the twins when they began breastfeeding exclusively. The dietitian instructed her about her own need for adequate calories, protein, nutrients, and fluids to meet the energy requirements for breastfeeding the twins. On dismissal at 20 days of age, the twins’ combined weight was 5065 g, an increase of 740 g since birth, for an average daily gain of 37 g. It was believed that when the twins returned at 2-f months of age for separation surgery, their combined weight would be considerably more. Each time Mrs. M. R. needed to attend to one infant, she would have to lift and carry them both. The nurses emphasized the importance of good body mechanics and adequate rest to provide the needed strength and energy for parenting and breastfeeding. Follow-up care was arranged with a pediatrician and a plastic surgeon. A public health nursing referral also was made. The parents were provided a toll-free telephone number to the neonatal intensive-care unit and were encouraged to use it after discharge for any questions or concerns. The family desired strict confidentialityuntil after the twins were separated surgically. Therefore, the number of health care providers involved in this family’scare after discharge from the medical center was kept to a minimum.
Discussioon Mrs. M. R.’s goal was to establish breastfeeding both infants before introducing bottle-feeding after discharge. She did begin some bottle-feedings after being home a few days. She then continued with a combination of breast- and bottle-feeding as well as pumping to maintain her milk supply. Because of her joined position, each twin continued to feed at only one breast, and Mrs.
JOG”
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M. R. continued using the same cross-cradle position with supporting pillows. As the twins’ combined weight increased, even this position became difficult. At 2 - i months of age, the twins were readmitted to the medical center for surgery and were separated successfully. Mrs. M. R. continued with breastfeeding.
Nursing Imptications This case shows the role of nurses in respecting and supporting the mother’s breastfeeding goals, even initially, when the challenge of breastfeeding seemed overwhelming. From early prenatal visits through hospitalization and discharge, the nurses encouraged Mrs. M. R. to follow through and succeed with breastfeeding. Although positioning for breastfeeding depends on the location of the conjoining, nurses can adapt practical information about positioning from information presented about twins. Helpful information about pumping also is applicable (Sollid, Evans, McClowry, & Garrett,
1989). Nurses solved the problem of handling the conjoined infants by wrapping them with an elastic cloth bandage. The mother’s concern about the infants’ injuring themselves by twisting and turning was alleviated, and she became independent in caring for them. Nurses secured the appropriate consultation for Mrs. M. R. A lactation consultant met with her before the twins were born and later assisted her with breastfeeding. A dietitian was consulted for maternal and neonatal nutritional requirements. Finally, a public health nursing referral and appropriate resources were provided for the family at discharge from the medical center.
Buyse, M. L. (Ed.). (1990). Birth defects encyclopedia. Dover, MA: Center for Birth Defects Information Services, Inc. Hedrick, G. (1979). Mothering conjoined twins. MaternalChild NursingJournal, 8,125-132. Lipsky, K. (1982). Conjoined twins: Psychosocial aspects. Association of Operating Room NursesJournal, 35(l ) , 58-61. Jakobowski, D. S., Hagelgans, N. A , , &k Leson, J. K. (1989). Assessment and management of conjoined twins. Journal of Perinatal a n d Neonatal Nursing, 3( l ) , 66-82. Mead, L. J., Chuffo, R., Lawlor-Klean, P., & Meier, P. (1991). Breastfeeding success with preterm quadruplets. Journal of Obstetric, Gynecologic, andNeonata1 Nursing, 21, 221226. Ramp, J. B., Baylor, J. R., Casamento, V. K., Gerald, A. L., Golczynski, D. C., & McComiskey, C. A. (1989). Conjoined twins: A multidisciplinary approach. Neonatal Network, 8(1), 29-39. Saint, L., Maggiore, P., & Hartman, P. E. (1986). Yield and nutrient content of milk in eight women breast-feeding twins and one woman breast-feeding triplets. British Journal of Nutrition, 56,49-58. Sollid, D. T., Evans, B. T., McClowry, S. G., & Garrett, A. (1989). Breast feeding multiples.Journal ofPerinata1 a n d NeonatalNursing, 3(1), 46-65.
Address for correspondence: Elizabeth A . LaFleur, RN, Mayo Foundatton Hospttals, Department of Nursing, Neonatal Intensive Care Unlt, Rochester, MN 55905.
Elizabeth A . LaFleur Is a neonatal intenslve care staff nurse at Mayo Foundation Hospitals, Rochester, MN.
References Bell, A. N. (1982). Separating conjoined twins: A care plan. Association of Operating Room Nurses Journal, 35 (I), 4757.
Kathryn M . Niesen Is a perlnatal clhtcal nurse specialist at Mayo Foundation Hospitals, Rochester, MN, and an assistant professor of nursing at Mayo Medtcal School, Rochester, MN.
244 J O C N N
Volume 25, Number 3
R E P O R T
Breastfeeding Conjoined Twins Elizabeth A. LaFleur, RN, BSN, IBCLC, Kathryn M. Niesen, RNC, MSN
The breastfeedingexperience of a mother and her preterm conjoined twins is described. Assisting the mother in achieving her breastfeeding goal presented unusual nursing-careproblems in securing, positioning, and comforting the twins. This case report emphasizes the individualized support provided to this mother and her infants,which was a critical factor in their breastfeeding success.JOGNN, 25, 241-244; 1996. Accepted: October 1994
A
ssisting a mother with breastfeeding conjoined twins is an experience had by few nurses. The incidence of conjoined twins ranges from 1 in 50,000 to 1 in 100,000births. Half of these are aborted spontaneously or die before delivery. One fourth of such twins delivered alive die within 24 hours. Only 5% of conjoined twins are discharged from the hospital after separation (Buyse, 1990). Breastfeeding multiple infants brings a challenge to new mothers. However, when the infants are conjoined, the challenge becomes even more complex. This case report describes the breastfeeding experience of omphalopagus conjoined twins and their mother. The nursing care provided to this family assisted them in overcoming seemingly insurmountable odds and in breastfeeding successfully.
Review of the Literature The word “omphalopagus” is derived by prefixing the anatomic area of the union to the Greek word “pagos” (that which is fixed). Conjoined twins are classified as omphalopagus, thoracopagus, pygopagus, ischiopagus, or craniopagus. In omphalopagus twinning, the conjunction extends from the sternum to and including the umbilicus (Buyse, 1990). Although there are several publications in the litera-
March/Aprill996
ture addressing the physical and emotional care of conjoined twins and their families (Bell, 1982; Hedrick, 1979; Jakobowski, Hagelgans, & Leson, 1989; Lipsky, 1982; Ramp et al., 1989), we could not locate any research publications addressing breastfeeding conjoined twins. Two studies addressing the management of breastfeeding multiple infants were located (Mead, Chuffo, Lawlor-Klean, & Meier, 1992; Saint, Maggiore, & Hartman, 1986). These studies support the adequacy of a mother’s breast-milk volume for multiple infants. Another clinical article by Sollid, Evans, McClowry, and Garrett (1989) outlines practical approaches to breastfeeding twins.
Case Report Mrs. M . R., a 21-year-old primigravida, was admitted to our medical center with a conjoined twin gestation of 32-’/, weeks. She was treated in our antenatal unit until 36-$weeks with modified bed rest and terbutaline for preterm labor suppression. Mrs. M. R. indicated that she had always planned to breastfeed her infants. Even when she learned she was to expect twins, and then conjoined twins, she did not reconsider her decision to breastfeed. Mrs. M. R. said that her hometown outpatient clinic nurses promoted breastfeeding during her early prenatal care and supported her decision to breastfeed her infants. When she was admitted to the medical center, the twins were both presenting cephalic. At 36% weeks, twin B was discovered to have rotated 90 degrees from a parallel position to twin A, and concerns of tortuous stress and damage to shared tissues and organs were pri-
When she learned she was to expect twins, and then conjoined twins, she did not reconsider her choice of breastfeeding.
J O C N N
241
C A S E R E P O R T
feedings of 45 ml of breast milk every 3 hours, along with their breastfeedings. Initial Breastfeedings The neonatal intensive-care unit staff nurses and the lactation consultant assisted Mrs. M. R. and her infants with the initial breastfeedings. During the early feedings, Mrs. M. R. and the nurses were apprehensive yet determined to succeed. The physicians were interested and offered supportive suggestions, but essentially stood back while the nurses helped Mrs. M. R. begin the breastfeeding process. Because the twins were difficult to handle, it was comforting for Mrs. M. R. to have a nurse reassure her about her technique and provide an extra pair of hands. Through experimentation and instruction, Mrs. M . R. found that the cross-cradle position for the nursing infant was the best position. In the cross-cradle position, the infant is cradled across the mother’s chest with the infant’s abdomen tucked in tightly toward the mother’s abdomen. Pillows were placed across Mrs. M. R.’s abdomen to support the cradled infant. Additional pillows were used as needed under Mrs. M. R.’s elbows, lower back, and knees for support in bearing the infants’ weight. She preferred to sit in a recliner or rocking chair with armrests. Mrs. M . R.’s free hand (the one not cradling the feeding infant) supported the breast (see Figure 2). This helped the infant to latch on properlyand to maintain her hold. The twins’ conjoined position did not allow them Figure I. Conjoined twins Not. Reprinted wilh permission OJ‘Mu,voFoundation.
mary. The twins were delivered by cesarean section. They were female, with a combined birth weight of 4325 g and a six-vessel umbilical cord. After birth, the twins were taken to the neonatal intensive-care unit for further evaluation. The twins were joined across the anterior abdomen from the sternum to the umbilicus facing each other (see Figure 1 ) . Twin B was located slightly superiorly in relationship to twin A. Portions of both livers were perfused individually and had shared perfusion. There was a small portion of shared abdominal cavity containing bowel lying inferior to the liver. Mrs. M. R. began pumping her breasts with a doublepump setup and electric pump. Pumping a minimum of eight times in 24 hours (including one night pumping) was recommended by the nurses. The goal for Mrs. M. R. was a 1080-1440-ml-per-daybreast milk supply to nourish her preterm twins. The twins were given orogastric
The twins were joined across the anterior abdomen from the sternum to the umbilicus facing each other.
242 J O C N N
Figure 2. Moiher holding conjoined !wins in cross-crudeprisition with infunt in lower position mrsing Note. Rgprintd with permisxion ofMu,vo Foundution
Volume 25, Number 3
Breastfeeding Conjoined Twins
to nurse simultaneously. Even by nursing the twins one at a time, Mrs. M. R. could not achieve the ideal “tummyto-tummy’’ position between infant and mother. The twins had to turn their heads slightly to latch on. While one twin nursed, the other lay perched on top with her head resting on her sister’s head and her hands often near her sister’s face. Mrs. M. R. found that because of the position in which the twins were joined, it was easier for her to nurse each infant exclusively on one side or to use the same breast for the same infant at each feeding. Problems Some problems were encountered. Mrs. M. R. expressed frustration that one infant cried while the other nursed. One twin was more impatient than the other. At times she would cry fussily and thrash out with her arms at her sister’s face while she awaited her turn. Lemon-glycerin swabs, a pacifier, and assisting her in sucking her own thumb were methods used in trying to comfort her. Finally, it was decided to tube feed one infant an hour before the planned breastfeeding of the other. This did seem to satisfy the more impatient infant. However, Mrs. M. R. and the nurses later acknowledged that the active, crying infant was more disconcerting to the nurses and to Mrs. M. R. than to her sister. Eventually, as Mrs. M. R. became more comfortable in assessing the infants’ behaviors, she was able to decide which twin to breastfeed first. She also would alternate breastfeeding and waiting between them in response to their expressed need.
Wrapping the twins made them easier to handle and prevented them from twisting and turning, which lessened the tortuous stress to their joined area.
Mrs. M. R. continued to need a second person for support and assistance. Looking for a solution, one of the nurses wrapped a woven elastic cloth bandage around the infants’ torsos to help secure them. Wrapping the twins helped to keep them from twisting and turning and lessened the tortuous stress to their joined area that concerned Mrs. M. R. The gentle but firm wrap also secured Mrs. M. R.’s independence by making the twins easier to handle. Progression of Feedings After the transition to independent breastfeedings, the progression of feedings advanced more rapidly. Increases in the 3-hour gavage volume were made on the 8th and 9th days. The breastfeeding advancement also began on the 9th day with early feedings in the progression done at 2-hour intervals. Mrs. M. R. soon was breastfeeding each infant four times per day and had gained confi-
dence in doing the feedings by herself. Within the next week, the twins were breastfeeding eight times per day, every 2-3 hours. As the twins moved toward being breastfed exclusively, breast pumping was reinforced after both were fed to ensure an adequate supply of milk. Mrs. M. R. was instructed to pump after every feeding from the first breastfeeding through hospital discharge of the infants to establish and maintain adequate milk production. When the infants gained weight at home, a slow, gradual weaning of pumping would occur. One pumping would be dropped every couple of days, and the infants would help their mother to create their own breast milk supply based on their demands. Initially, urine output of each conjoined twin was assessed as an individual determinant of breastfeeding intake. Twin A was a less vigorous nurser than twin B. However, a significant difference in urinary output was noted even when both were tube fed an identical volume. Twin A’s output was significantly greater than twin B’s. This difference was also observed during breastfeeding. The difference in output may have been due to the vasculat transfer of fluid from twin B to twin A. Preparationfor Hospital Discbarge Mrs. M. R. began rooming-in overnight with the twins when they began breastfeeding exclusively. The dietitian instructed her about her own need for adequate calories, protein, nutrients, and fluids to meet the energy requirements for breastfeeding the twins. On dismissal at 20 days of age, the twins’ combined weight was 5065 g, an increase of 740 g since birth, for an average daily gain of 37 g. It was believed that when the twins returned at 2-f months of age for separation surgery, their combined weight would be considerably more. Each time Mrs. M. R. needed to attend to one infant, she would have to lift and carry them both. The nurses emphasized the importance of good body mechanics and adequate rest to provide the needed strength and energy for parenting and breastfeeding. Follow-up care was arranged with a pediatrician and a plastic surgeon. A public health nursing referral also was made. The parents were provided a toll-free telephone number to the neonatal intensive-care unit and were encouraged to use it after discharge for any questions or concerns. The family desired strict confidentialityuntil after the twins were separated surgically. Therefore, the number of health care providers involved in this family’scare after discharge from the medical center was kept to a minimum.
Discussioon Mrs. M. R.’s goal was to establish breastfeeding both infants before introducing bottle-feeding after discharge. She did begin some bottle-feedings after being home a few days. She then continued with a combination of breast- and bottle-feeding as well as pumping to maintain her milk supply. Because of her joined position, each twin continued to feed at only one breast, and Mrs.
JOG”
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C A S E R E P O R T
M. R. continued using the same cross-cradle position with supporting pillows. As the twins’ combined weight increased, even this position became difficult. At 2 - i months of age, the twins were readmitted to the medical center for surgery and were separated successfully. Mrs. M. R. continued with breastfeeding.
Nursing Imptications This case shows the role of nurses in respecting and supporting the mother’s breastfeeding goals, even initially, when the challenge of breastfeeding seemed overwhelming. From early prenatal visits through hospitalization and discharge, the nurses encouraged Mrs. M. R. to follow through and succeed with breastfeeding. Although positioning for breastfeeding depends on the location of the conjoining, nurses can adapt practical information about positioning from information presented about twins. Helpful information about pumping also is applicable (Sollid, Evans, McClowry, & Garrett,
1989). Nurses solved the problem of handling the conjoined infants by wrapping them with an elastic cloth bandage. The mother’s concern about the infants’ injuring themselves by twisting and turning was alleviated, and she became independent in caring for them. Nurses secured the appropriate consultation for Mrs. M. R. A lactation consultant met with her before the twins were born and later assisted her with breastfeeding. A dietitian was consulted for maternal and neonatal nutritional requirements. Finally, a public health nursing referral and appropriate resources were provided for the family at discharge from the medical center.
Buyse, M. L. (Ed.). (1990). Birth defects encyclopedia. Dover, MA: Center for Birth Defects Information Services, Inc. Hedrick, G. (1979). Mothering conjoined twins. MaternalChild NursingJournal, 8,125-132. Lipsky, K. (1982). Conjoined twins: Psychosocial aspects. Association of Operating Room NursesJournal, 35(l ) , 58-61. Jakobowski, D. S., Hagelgans, N. A , , &k Leson, J. K. (1989). Assessment and management of conjoined twins. Journal of Perinatal a n d Neonatal Nursing, 3( l ) , 66-82. Mead, L. J., Chuffo, R., Lawlor-Klean, P., & Meier, P. (1991). Breastfeeding success with preterm quadruplets. Journal of Obstetric, Gynecologic, andNeonata1 Nursing, 21, 221226. Ramp, J. B., Baylor, J. R., Casamento, V. K., Gerald, A. L., Golczynski, D. C., & McComiskey, C. A. (1989). Conjoined twins: A multidisciplinary approach. Neonatal Network, 8(1), 29-39. Saint, L., Maggiore, P., & Hartman, P. E. (1986). Yield and nutrient content of milk in eight women breast-feeding twins and one woman breast-feeding triplets. British Journal of Nutrition, 56,49-58. Sollid, D. T., Evans, B. T., McClowry, S. G., & Garrett, A. (1989). Breast feeding multiples.Journal ofPerinata1 a n d NeonatalNursing, 3(1), 46-65.
Address for correspondence: Elizabeth A . LaFleur, RN, Mayo Foundatton Hospttals, Department of Nursing, Neonatal Intensive Care Unlt, Rochester, MN 55905.
Elizabeth A . LaFleur Is a neonatal intenslve care staff nurse at Mayo Foundation Hospitals, Rochester, MN.
References Bell, A. N. (1982). Separating conjoined twins: A care plan. Association of Operating Room Nurses Journal, 35 (I), 4757.
Kathryn M . Niesen Is a perlnatal clhtcal nurse specialist at Mayo Foundation Hospitals, Rochester, MN, and an assistant professor of nursing at Mayo Medtcal School, Rochester, MN.
244 J O C N N
Volume 25, Number 3