Susan wrote:
<I'm hoping Jean Cotterman is checking Lactnet, because I had an unexpected
case today in terms of edema in the areola.  The baby was one week old,
gaining well until
Friday.  The baby was persistently feeding at night so mom wanted to find
out what to do.
The baby had lost weight since Friday, but in the range of possible
variation in scales.
The baby completely tired out at the breast and took barely 1.0 oz after an
hour of
poking and prodding.  (And yes, even without a scale I could tell this baby
wasn't
doing it).  At first mom didn't release well to the pump until she applied
far greater pressure.
Then it dawned on me as she took the pump shields off that she had edema in
the areola.  It
was not at all apparant untli she pumped.  Jamming the pump parts in deeper
seemed to push
back the edema and help her release milk.  She hadn't had a prolonged labor
or lots
of IV fluids, nor edema in her legs or feet.  I only found it out by
accident.

What do you think of this?>


Here are some thoughts that spring to mind.


Perhaps it may have been more "back-up edema" rather than so much
"flood-related edema of IV's etc". I am presuming she didn't have any
pre-eclampsia/edema, etc. if she managed to get by without "lots of IV
fluids." It often doesn't take a whole lot, depending on her hydration
status when she went into labor. Breast edema can be insidious and sometimes
hard to differentiate from normal circulatory changes of Lactogenesis II.


Are her breasts pendulous??? Gravity is one factor that plays into edema of
the front of the breasts. Many women with pendulous breasts have some degree
of breast edema even in the prenatal period.


With the possible variation in scales, it's possible to speculate that even
though the baby seemed to be gaining weight, perhaps he was draining the
breast less effectively while the breast was producing milk very
effectively, and with inefficient drainage of the lobules and ducts, the
resultant pressure on venous and lymphatic capillaries could have produced a
subtle kind of "back-up" edema. (like happened to my plumbing when a tree
grew its roots slowly into a drainage tile.)


Those of you born in the 40's, 50's and even the 60's, give your moms an
extra hug. "Back-up" edema is the kind we always saw 40-50 years ago when
there were many long labors, few C. Sections, very few inductions, (most
with castor oil, artificial rupture of membranes, or nasal swab saturated
with pitocin, being refined in its manufacture at the time), no IV's, NPO
during labor, and probably many dehydrated mothers. Babies were NPO the
first 12 hours, then fed glucose water q.4h x3. In the meantime, with return
to oral fluids after the nausea of general anesthesia cleared, the mother's
hydration status normalized and allowed circulatory shift from involuting
uterus to breast producing evolution of lactogensis II pretty much "on
schedule" by the third day at least. She could see and hold her tightly
swaddled baby at least by 24 hours, earlier if she had birthed in the
daytime the previous day, and woe be unto her if she tried to unwrap the
baby! "Germs" you know!.

At 24 hours, the babies were permitted to start breastfeeding for 3 minutes,
on one breast and back to the nursery in 30 minutes, probably supplemented
if they acted hungry. Four hours later moms were instructed to feed them 3
minutes on the other breast. They were encouraged to have the baby fed
formula at 2 a.m. and 6 a.m., whereupon the second nursing day (the third
postpartum day!) moms were instructed to nurse 5 minutes on one breast, and
4 hours later, 5 minutes on the other breast, etc, perhaps another night of
formula in the nursery if their milk wasn't obviously "in". If they were
close to the 5th postpartum day, they were discharged home "without sore
nipples" to the satisfaction of the maternity staff, and instructed to
increase the nursing time to 7-10 minutes on one side per feeding that day,
etc. etc. There were nothing but "bicycle horn" breast pumps, and they were
seldom used. We never heard the word "jaundice" used in the nursery back
then.



As a mother using these instructions in the '50's, I stopped at 5-10 days
with my first 3 children with nipples too painful and damaged to go on
alone, without support from anyone who knew "the score". In 1959, with La
Leche enlightenment, I finally succeeded in overcoming these problems with
my fourth child for a very rewarding 9 month experience. In the early 60's,
I worked as a night nurse on the "normal" postpartum floor. I began to
observe mothers more closely, and I was able to follow mothers sometimes 4-5
nights in a row. I definitely observed frank edema of the breasts in many by
the 3rd night, along with a copious milk supply, in many of them. From a
Ross instruction manual, I learned to hand express to help them, and found
that it was easier to express in the quadrants where the front of the
baby's jaws had been compressing in those moms who might always have been
using the same position. (They had pitted the edema.) I was keeping these
observations of naturally occurring edema due to "backed-up" milk pressure
in my mind, pondering but not understanding.


In the early '70's, full blown perinatal medicine was developing and labor
interventions became more common. Staff instruction was needed, and to
supply that, I was eventually promoted. This position also allowed me to
help change protocols for earlier nursing, demand feeding and nursing on
both sides. I left the hospital in the mid '70's for public health, and
returned part time one weekend a month in the '80's. And I was slowly
recognizing that the edema I often saw in the '80's seemed totally
different from the edema I had become so familiar with in the 60's.
Gradually, 2+2 began to add up to 4, and I began to use "modified Hoffman
technique" for moms with latch problems. Eventually, somewhere along the
line, RPS was conceived. But it had a very long gestation period while I
tried to figure out just what the differences were between "standard OB
care" in each of those two time periods. Lactnet exchanges in the late '90's
finally helped "put the icing on the cake"!


OTOH, there are more  questions that come to mind right off:


Had she been using the pump at all prior to the time you were observing
her??


Edema does not become visible, nor does it "pit" until the tissues have 30%
more interstitial fluid than they normally hold. It is possible to have less
than 30% extra interstitial fluid from gravity's effect on very pendulous
breasts, from "back-up" causes without IV"s, or with a smaller volume of IV
fluid that wouldn't necessarily produce ankle edema. However, if some
smaller % of excess interstitial fluid is there, it can interfere with
latching and the extrusion force of the baby's tongue on the subareolar
ducts, and also possibly "bury" the areolar nerves that can elicit the MER
without fail. Even this small amount of excess interstitial fluid can be
attracted into the flange area by vacuum; the stronger the vacuum, the more
of it may be attracted. So, if she had been using the pump at all during the
preceding 7 days, some extra intersitial fluid from "back-up" conditions may
have been attracted into the flange area. It's my experience that 10-14 days
is a more common time for total resolution of even small amounts of edema,
or for that matter, plain normal engorgement. Many have just barely
"crested" any swelling period by 7 days, and latching problems are still
common.


You were fortunate that "jamming the flange" into the breast displaced some
edema backwards, because the angulation of most pump flanges, including the
Avent, for that purpose is not near as efficient as if it were flat right at
the base. Was it by chance a Dr. Brown pump? I am currently looking that
flange over as perhaps one that may be closer to flat against the areola.
That's why fingers do it more efficiently. As a further development of the
"soft ring" method illustrated in the JHL article, I have discovered that
using a standard bottle, with the nipple removed and re-inserted from the
outside, down into the bottle, makes an excellent "gizmo" for applying RPS,
with the bottle providing a comfortable "handle".

If anyone would like my further thoughts on Pitting Edema and RPS, please
email me privately.

Jean
************
K. Jean Cotterman RNC, IBCLC
Dayton, OH USA

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