Melissa wrote:

<Dear Jean,
Do you find it interesting that this postpartum edema is seen as 'normal'
to mothers?  I think that ob's have gotten so used to seeing it, that they
don't realize that their procedures are the cause, NOT the physiological
process of delivery.  I've observed a few postpartum teachings by obs, and
was intrigued about how little is understood about this.>

A little history. One of my first rotations in nurses training had me working
solo night duty (with one "drop-in visit" by the night supervisor) in 1948 
(soon to be 65 whole years ago). This was in the earlier days of the WW2 baby
boom, with moms with SVD's staying 4-5 days, and C.S. moms staying 7-10 days.

The monthly excitement in L&D was whether the handwritten "log"
of deliveries would go past 300 births a month (3600 births per year in a 
community hospital with much of night duty coverage by student nurses, and
the only "obstetricians" were general practice doctors who were especially
interested in OB. They had to refer to surgeons for C. Sections in surgery in 
another building about 2 blocks away, accessed through a winding tunnel passing
the hospital laundry and central supply areas, then up 3 flights in the elevator.)

As an RN, I worked part time and full time staff and charge nurse duty on every
shift and every department of OB between children. Family practice doctors cared
for both mothers and babies, and frenulum inspection and appropriate clipping 
was almost universal, so I never got much experience with tongue tie itself as a 
cause of damaged nipples. 

I was offered a newly created position as Maternity Inservice Clinician from 1970-1976. 
In preparation, I was sent to the first 3-week doctor-nurse team Perinatal Education 
Workshop, at the University of Colorado (where they were doing the initial work on
SGA, AGA and LGA babies.) 

The position was established at the request of obstetricians to bring the nursing
staff out of the "old obstetric mentality" (with its own set of iatrogenic practices) 
into the developing concept of perinatal medicine, (with an entirely new set of 
potentially iatrogenic practices) both for mothers and babies.

There was a gradual turnover in medical care providers as fewer and fewer 
general practitioners continued to deliver babies, partly due to the increase 
in liability insurance for delivering babies. This also resulted in more of the 
well-baby infant care by pediatricians. More and more trained obstetricians
came on staff with a resultant increase in "managed care", e.g. more and better 
management of prenatal complications such as pre-eclampsia, IV pitocin drip for 
augmentation, then more inductions, etc. 

At the same time, general anesthesia, mostly by nurse anesthetists (without IV's 
except in dire emergencies) gave way at first to locals, pudendal blocks and caudals,
and then quickly, to regional anesthesia by anesthesiologists, accompanied with its 
attendant IV's. 

Over those decades, it was interesting to watch the nursing staff, as well as the 
family practice residents become accepting of the gradual appearance of more and 
more edematous mothers postpartum, and to hear mothers themselves exclaim in
unbelief as they stepped on the scales of how "little" weight they had lost from 
their last prenatal weight. 

Then came the experiment into literal "drive-by" deliveries when mothers were
often discharged at 8 hours (some, if NCB, by choice, to escape hospital breastfeeding
routines of delay and timing, etc.), 24, 36 hours etc. till the process
was arrested with general agreement and possible insurance company help(?) 
that 48 hours after birth was more reasonable for SVB moms. The C. Section
discharge times gradually came down to where it amazes me now to see some 
C.S. mothers discharged on the 3rd post-op day. Gradually, everyone came to see
postpartum edema so frequently that it began to be taken (and acceopted) as 
"normal". 

So, the 3rd-4th night breast swelling I saw as "normal" in 1948 is almost entirely 
different from what I have been seeing on the 3rd-6th day in volunteering at WIC 
in the 21st century. I am desperately hoping I can persuade someone with the
appropriate research skills to take my observations seriously enough to continue
serial observation of colloid osmotic pressures on through and beyond the 
establishment of Lactogenesis 2.

K. Jean Cotterman RNC-E, IBCLC
WIC Volunteer LC     Dayton OH

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