Melissa,

There will always be mothers who have major complications where saving the lives of the babies and the mothers will require large amounts of intravenous fluid, and often, hours of IV pitocin, as part of the management. 


<She was in the ICU for a little over 48 hours, but began pumping about 24 hours after the birth.  We are now about 84 hours pp (3.5 days).> 


It's great that you have been able to seek further input at this point in the time frame. I think you are on a positive track. 


I think it's important to review her IV history. You make no mention of the total amount of IV fluid, nor over how many hours it was administered before the birth of the placenta, whether or not there may also have been long hours of IV pitocin for third stage management, or possible blood transfusion(s) as well. But I'm going to assume there was <2000-2500 cc. of IV fluid given in at least one 24 hour time period, and quite possibly, more. 


Edema often results from temporary storage of the extra IV fluid.  Different degrees of edema can complicate the intiation of breastfeeding, sometimes effecting the latching process as well as delaying the onset of lactogenesis 2. A deeper understanding of interstitial fluid dynamics and lymphatic drainage, as well as the physics of vacuum and the effect of gravity can help manage edema more effectively. Reverse PressureSoftening (RPS) can be a valuable tool for managing edema temporarily both before feedings, and before milk removal by fingertip expression or pumping



http://kellymom.com/bf/concerns/mother/rev_pressure_soft_cotterman/



These are factors to consider in anticipating and compensating for edema:


1.  The amount of fluid >2000-2500 cc. received in any 24 hour time period is one factor. 


2.  A separate factor is the timing of its administration in relation to the time of the placental delivery (the trigger for the cascade leading to Lactogenesis-2). If this much IV fluid and/or hours of IV pitocin are given in the 24 hours before birth, what I refer to as "pre-L-2 edema" often arrives well within 24-48 hours, before L-2 itself, and I have noted it even seems to have the potential to delay L-2.


3. The amount and duration and the timing of IV pitocin drip seems to be yet another factor, as the pitocin molecule has some similarities with the anti-diuretic hormone (ADH) molecule, and can attach to the ADH binding sites in the kidney and thereby slow down the elimination of fluid. When any of these things happen, it is very common to notice within the next 24-48 hours some generalized edema as the body stores much of the extra fluid in the interstitial tissue, both in the breasts and in the ankles and elsewhere.  


Nature's normal mechanism for fluid storage is in the interstitial tissue in a "gel" form, through which raw materials and waste products can still travel quickly between the cells and the circulation. When interstitial fluid storage approaches about 30% above the normal storage capacity, any more of the excess fluid will then be very "loosely" contained and can begin to form "tiny pools and rivulets" within the interstitial fluid gel, and be easily pushed around by pressure (pitting). It can also "push" its way forward more easily (sort of like swamp water, a flood or a waterfall!) in the direction of gravity, and/or in the direction of vacuum. It's not that the vacuum is pulling.  It's that the weight and pressure of the loose fluid pushes its way forward toward the low pressure area of the vacuum source, trying to equalize pressures, because "Nature abhors a vacuum". 



For this reason, the use of a breast pump on a mother who has had a lot of IV fluid, etc. as above, often results in larger amounts of "looser" edema fluid crowding into the flange area, burying and compressing the subareolar ducts, causing any previous rate of milk removal to slow down or stop for a while. This concentration of edema makes the areolar tissue too firm for the baby, the fingertips or the pump to apply compression to the subareolar ducts to achieve milk removal, unless RPS is utilized effectively before every attempt at milk removal.



The amount and timing of pitocin administration sometimes seems to be yet an additional factor contributing to breast edema. In years past, 6+ decades ago when I first worked L&D, all mothers received at least 1 cc. of pitocin IM after delivery of the placenta. So I don't believe that I have ever worked with a mother who didn't receive at least 1 cc. of pitocin. In the last decade or so, mothers in our area who are at increased risk for postpartum hemorrhage have often received third stage management using IV pitocin drip for many hours after placental delivery (12-48+ hours). Approximately 24-48 hours after that much postpartum IV fluid/pit is given, the edema that results will start to appear in the body tissues, including those in the breast.  For many mothers this added load of edema "hits" well after they have been discharged from the hospital, perhaps leading to further tissue swelling showing up, on or about postpartum day 5-6, often also superimposed on Lactogenesis 2, maybe showing up as prolongation or additional peaks of swelling, depending on the efficiency of milk removal or lack thereof. This is an important reason to give anticipatory guidance and teach mom to do RPS so she'll be able to cope better with swelling throughout the first week at home.


< Mom is attempting to pump regularly, but finds it painful due to several broken ribs.  She also finds the after-pains particularly uncomfortable - she believes due to a stapled incision.  She is not getting any colostrum through either hand expression or pumping.  As I'm writing this I also realize that she does look like she has some fairly significant edema so I think that having her discontinue pumping completely and go strictly to hand expression tomorrow would be wise - thoughts?>



While early milk removal is physiologically good, it is not necessarily effective to use vacuum on potentially edematous tissues to accomplish it. (Early pumping has been widely advised, and popularized, partly by the easy availability of expensiive, highly advertised pumps, plus a lack of understanding of the effect of vacuum on edematous tissues.) Vacuum use can make edematous swelling crowd around the subareolar ducts, resulting in actually blocking off further early removal of colostrum.  RPS used carefully before and several times during pumping may keep the edema at bay long enough to continue to obtain colostrum.



This mother's specific injuries and surgical discomforts all need to be taken into consideration while helping her avoid further future discomfort from her breasts. For this mother with broken ribs, she can use more gentle RPS pressure for a longer time depending on her level of rib discomfort. Help her find which is more comfortable: sitting up, or lying part way down on her back. Or if her breast is pendulous, have her try lying on her side if the rib pain permits. If so, then pumping one breast at a time while lying on her side might work. Each time after using RPS on the areola to make it pliable, fingertip expression will also be much easier for a while.


Softening the areola frequently before latch or milk removal by hand or pump will help the area function more efficiently. If a mother has a pendulous breast ("C" cup or beyond) gravity really attracts edema downward toward the nipple-areolar complex. When such a mom is trying to get her baby latched, even though RPS may be performed, swelling may return to the areola before the baby even has a chance to latch unless some marked degree of antigravity positioning is used.  When there is potential for serious edema in a mom with a smaller breast, encourage RPS with a slow count of 50 each time before latching, before hand expression, and before pumping and about every 5-7 minutes during short pumping sessions, until latching and pumping are easy without RPS (sometimes needed up to 7-10 days.) In some instances, depending on personal preferences of the mom and her family, with adequate explanation, the significant other(s) can be very helpful in massaging the breast and/or assisting in the application of RPS by adding the strength of their fingers to hers.


For mothers with factors favoring development of pre-L-2 edema, I recommend early (6-8 hours or earlier) and regular use of RPS (held for the very slow count of 50), to trigger the MER often. (Use regular, effective pain relief for any afterpains, because MER's are important to the breast function.) 



Continuing to think this subject through absolutely fascinates me. I am convinced there is so much more we can learn to think through to help mothers off to a good start if (or when) OB and anesthesia management interventions risk complicating early postpartum breast physiology. 


I have found it helpful to think this whole process through slowly while trying to visualize it: 


Fluids ENTER the lactating breast through the arterial system.  


But fluids must EXIT in TWO OPPOSING DIRECTIONS. (Just emphasizing;-)


1) as milk, moving anteriorly and centrally (and sometimes downward), through one single exit area, the nipple-areolar complex 


2) as tissue fluid moving laterally, posteriorly, and upward to enter numerous vessels both venous and lymphatic.


Under normal conditions, 10% of interstitial fluid return goes back into the circulation occurs through the lymphatic system. But the lymphatic system has the capacity to increase interstitial fluid return up to about 50%. (Hall JE, Guyton and Hall Textbook of Medical Physiology, Saunders-Elsevier, 12th edition, 2011, 177-189.) We need to ask the lymphatic therapists for suggestions on how to help that process. Lymphatic drainage professionals teach laypersons who are at risk for lymphedema the basic patterns of how to perform massage to increase lymphatic drainage. I am convinced that the lactation community could really learn much more from the lymphatic experts about lymphatic drainage in order to teach mothers the most effective paths of upward massage when they have marked breast edema. 


Thank you, lactnetters, for listening while I "think out loud", and thank you listmothers for providing us this forum to "pollinate" more ideas into our profession. I hope my musings stimulate other minds to contemplate this important and fascinating subject thoughtfully, so that more of us can teach moms to comfortably manage postpartum breast swelling in the most physiologic manner.


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





 

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