I'm behind on LN, having recently gotten back from my midwinter Arizona
vacation. (Sigh!)
At this late date, 10+ days after her post, I am prompted to write my
reactions, not as criticism of Jeanne's plan, but to share ideas that might
be considered for any future such cases.
My goal is to try to explain enough of what I have learned by reading more
extensively, in hopes that hospital LC's and nurses can feel comfortable in
discussing this with colleagues, particularly obstetricians,
anesthesiologists and nurses from all areas of OB. In this way, perhaps at
least, lactation and feeding assessments and interventions can be improved
in light of these observations. (You can e-mail me privately at my above new
e-mail address if you want my small article on Pitting Edema and RPS,)
On 2/21, Jeanne wrote:
<Mother states her bra size was 34B before pregnancy, but grew to 34 LL by
the end of pregnancy. >
I am not certain that that technically constitutes actual gigantomastia.
Leaven had a thorough article on this within the past 2 years, by a
leader-"survivor" of actual gigantomastia. The more pendulous the breast
becomes, the more gravity may impede the natural return of the normally
increased tissue fluid of pregnancy back into the circulation.
<She said the outer area of her breasts were =
thickening by the time of delivery.>
Actual breast tissue does not grow this rapidly, nor is this likely to be
lactogenesis II during this time frame, especially with no early, frequent
effective latching. Without seeing this mother, this timing suggests to me
the early onset of overhydration. This is evidenced as breast tissue rapidly
developing edema, defined as exess interstitial fluid (ISF). This timing
alone leads me to wonder:
1. Whether she had crystalloid (non-protein) IV fluid;-) (Just because
this is now so common, we, as LC's, must not accept obvious swelling as
"normal", and fail to consider the potential problems multiple IV's can
cause. This is a very important part of the history.
2. If so, how many total hours before the birth of the placenta did
this IV administration go on (tocolysis, i.e. trying to stop labor?,
induction? High BP?) How many hours did it continue after the birth of the
placenta?
3. How much total fluid was administered before the birth of the
placenta? (which is nature's trigger to begin the cascade leading to
Lactogenesis II.) Overhydration greatly impacts the speed with which excess
interstitial fluid forms. It can overwhelm the lymphatic capacity to
drain different areas: breasts, ankles, even lungs, (which can sometimes
result in pulmonary edema, a dangerous complication!).
4. How many units of pitocin in all did she receive; and when, in
relation to time of placental birth, or after, and how long total? Depending
on the total amount received, pitocin has the potential to act like ADH
(anti-diuretic hormone). However, the excess ISF must first leave the
intersitial spaces and re-enter the blood vessels to be delivered to the
kidneys, where anti-diuretic (or, for that matter, diuretic) effects occur.
<Today, 18 hours postpartum, her breasts were so thick and full, we could
not "pit" the areolae using Reverse Pressure Softening.>
1. But at least it still has the best potential to trigger MER, which
is the strongest force in milk transfer.
2. Was gravity used as the first line of therapy? (e.g., positioning
the mother flat on her back, for as long and often as comfortable?) This
both helps the fluid to move toward natural venous and lymphatic drainage
pathways, and when it is moved by a sufficiently long period of RPS, to
stay out of pitted areas long enough for latching, or very short periods of
pumping on medium.
3. How many minutes at a time was the finger pressure sustained? The
more severe the edema, the longer the pressure must be applied, but not so
forcefully as to be uncomfortable. This may require a full 15-30 minutes of
constant pressure at the first several applications, in severest cases. (by
the mother, with assistance of significant other if HCP too busy to stay and
observe? However, the time interval while applying the first round of RPS
personally is an excellent time to encourage the mom to tell about her birth
experience, explore her feelings about her baby and breastfeeding goals,
demonstrate RPS and its importance, and do specific teaching about the
importance of a soft areola in latching, etc. etc. Can you teach your
nursing assistants to help support moms fingers as she presses???)
4. Was RPS applied simultaneously at all parts of the central areola,
(6 fingers with, or without soft ring methods?) or was pressure only applied
to 2 quadrants (thumbs or straight fingers.) Without alternating quadrants
every 2-3 minutes when using either of these last two methods, the excess
interstitial fluid simply moves back and forth to the area of no pressure
instead of inward.
5. At what point did pumping enter the sequence? At what vacuum
strength and for how long at any one time? The greater the amount of
excess ISF, and the stronger the vacuum, the more likely and easily that
vacuum will attract ISF into the flange area to defeat your purposes by
"burying" the subareolar ducts beneath yet thicker layers of edema..
<but the weight is cumbersome. Her skin is so tight, the pores are easily
visible.>
The skin has it's own lymphatic drainage vessels, that eventually feed into
deeper ones. What you describe is evidence of both deep (weight) and
superficial (shiny tight skin with pores almost like "orange peel") edema.
Superficial signs showed that excess interstitial fluid was not being
absorbed quickly enough by the dermal lymphatic vessels in the subareolar
anatomic formation known as "Sappey's plexus". There is a slight
natural negative pressure inside these lymphatic vessels, and even slight
vacuum may therefore interfere with nature's method of attracting
interstitial fluid, especially large protein molecules, into the dermal
lymphatic vessels. Positive pressure at least has the potential to help
fluid entry into dermal lymphatics.
<Baby is acting even younger than 37 weeks and makes very little sucking
effort and no
rooting behavior at all. Dear mother wanted so much to breastfeed.>
At this point, which seems somewhere between 10 and 14 days, I hope you can
give (or have given) an update now that the swelling from edema should be
clearing noticeably. Such subareolar tissue resistance often frustrates even
robust babies, which then adds the factor of nipple trauma.
<I set up a pump and had her massage her breasts>
In which direction? Edema leaves the breast (to return to the heart via
the subclavian veins and superior vena cava), in the opposite direction of
the flow of the milk, i.e., it must travel upward, and posteriorly, about
75% through the axillary area and about 25% through the intercostal and
subclavicular areas. I think all of us in the lactation community need to
know a great deal more about what PT's, or those who have taken the
lymphatic drainage course, do for clearing distal lymphatic channels to
promote better lymphatic drainage of the breast itself. Won't some of you
LC's and/or PT's please write about this? Linda Pohl? Are you still with us?
Can you squeeze in the time to write a little, at least on LN?
< then do reverse pressure softening>
Again, how long, etc. as explained above.
<then started the pump>
At what strength and for how long? The action of a breast pump on a breast
is not like a straw immersed in a soft drink. It corresponds more to the
action of a vacuum cleaner, honestly! It will pick up whatever is the
"loosest", and maybe more of what you don't want than what you do want!.
< I used largest flanges as the areola diameter is about 4 inches. I
suspect the nipple itself would fit into a 16mm nipple shield, however.>
I have observed that neither the diameter of the nipple nor that of the
areola is as sure a guide in choosing a flange tunnel for efficient milk
transfer as the diameter at the area of the locatiion of most of the
lactiferous sinuses, found about 1-3 cm from the base of the nipple in a
particular breast. The placement in one breast may be different than the
placement in the other breast in the same woman. They can usually be
palpated in late pregnancy/early postpartum. The flange tunnel needs to hit
just at the middle or better yet, slightly behind them. With the mother's
permission, let your own fingertips and kinesthetic sense be your guide, no
matter what the latest literature tries to convince us.
< We were only able to pump drops of =
colostrum.>
Probably because that's all that was there, having collected in the sinuses
during mid/late pregnancy, and not yet starting to increase in volume at
clse to 18 hours.
<Doctor's orders were to either bottle or gavage feed (based on poor feeding
behavior), so I helped her bottle feed and must say the baby was a most
reluctant feeding. She only took 15ml ABM/colostrum and then began to gag.>
Rule # 1: Feed the baby. Stomach is only marble sized at that time-have
"belly balls" yet come to your staff's attention??
<After reading the Lactnet archives, I called mother's night nurse and
encouraged her to give the mother ice packs to use ad lib throughout the
night.>
Not too ad lib, please though. Ice packs should not be used more than 20
minutes at a time, nor oftener than about every 2 hours, according to the
physical therapy literatire I have been reading, in order not to cause
tissue damage (potential for frostbite, even if covered as recommended.)
< Also continue RPS before pumping.>
Using gravity, and the suggestions above.
<I hadn't thought of using bromocriptine because mother's supply seems
blocked by the tremendous swelling.>
Has there been any change in the information that bromcryptin is
contraindicated (at least here in the US) because of potential
life-threatening complications (blood clots, strokes??)
Besides, as you say, the tremendous amount of excess interstitial fluid is
diluting the raw materials and hormones and slowing their transfer to the
walls of the alveoli. It seems too early to consider prolactin levels the
problem here, except for the fact that the prolactin is diluted in the blood
stream and having a hard time reaching the alveoli to get in there and do
its job.
BTW, I welcome any LN or private discussion on points where others differ
with my observations. RPS is still a work in progress. Feedback has
helped to develop and improve the effectiveness that so many of you have
reported so far.
Jean
***********************
K. Jean Cotterman RNC, IBCLC
Dayton, Ohio USA
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