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. Just wondering, Melissa Senf, RNC, IBCLC On Sun, May 19, 2013 at 2:28 AM, K. Jean Cotterman <[log in to unmask]>wrote: > This is my suggestion: absolute prevention of nipple trauma so no > treatment is necessary: > > > 1) Teach mother about Reverse Pressure Softening during pregnancy, using > pictures and verbally and with demo breast. Any degree of breast > pendulousness combined with the tendency to retain extra fluid during > pregnancy can cause some edema to gather in the areolar/subareolar tissues, > (and nipple) even during pregnancy. (Any prenatal practice of RPS is > contraindicated if her OB has given warning about no sexual activity in > pregnancy.) > > > 2) For those mothers who are open to anticipatory guidance about complete > avoidance of nipple trauma, review in very early labor, offering to teach > or review RPS. Help her understand the need for the areola to be as soft as > her own lips are, right before each latching right from the start, and > before each feeding for the first 7-14 days, so that the areola can change > shape easily to extend the nipple itself deep into the mouth toward the > soft palate area, in response to baby's latching attempts right from the > beginning. > > > 3) When teaching RPS just prior to or in early labor, in addition to her > sight and hearing, offer to use her kinesthetic sense, with her fingers (or > yours, with permission) directly on the areola, or on top of her fingers. > Have her lying back at least far enough that the nipple is above heart > level, especially if breasts are C Cup or beyond. This is to use gravity to > keep any tissue fluids (and/or colostrum from full ducts) "at bay", e.g. > moved back upward an inch or so in breast for at least 5 minutes. Then, if > done right before offering breast, baby is empowered to get a deeper latch. > In addition, any necessary hand expression is much easier and more > productive (due to MER, plus edema having been moved out of subareolar > tissues.) > > > 3) I suggest (my empirical observation) that this is especially important > if mom is going to get (oral +) IV fluids in excess of 2000-2500 cc. in > any one 24 hour period, and especially if IV pitocin (anti-diuretic effect) > is used for induction, augmentation or for hours after birth if at risk for > postpartum hemorrhage. IME, this total amount of (oral +) IV fluid/and/or > pitocin drip, is enough to place her at risk for starting to develop what I > call Pre-L2 edema-other places but especially edema of the dependent part > of the breast, well before hormonal changes have increased breast > circulation that brings on L-2 to eventually cause the ducts to begin to > really fill. > > > 4) It ought to go without saying, but I'll say it anyway. Any vacuum > allows excess interstitial fluid (edema) to push its way forward into > flange and nipple-areolar complex area. If HCP or mother believes fingertip > expression (after preliminary RPS) is not removing enough colostrum and > that a pump is really necessary, have mom do RPS before pumping, and > several times during pumping, on medium or lower vacuum. Remember to factor > in gravity into the equation too. > > > 5) I would really like feedback, especially negative feedback. This is a > strong hypothesis of mine, and I'd be happy to be persuaded that I am not > on target in any way, if indeed I am not. > > > I would like to know both the "interpersonal" reactions of staff and moms, > and I would like to get hospital personnel making private notes on 24 hour > fluid intakes, IV pitocin dosage/duration, and observations of the time of > appearance of any edema within 24-48 hours after the 2000-2500 cc. > volume/24 hours. > > > Remember that "invisible" edema can be present when interstitial tissue > has up to 30% more than is normal for that tissue. Even "invisible edema" > can offer resistance to the normal functioning of the subareolar tissues. > > > Pitting edema, by definition, becomes visible when interstitial tissue has > 30% or more than normal for that tissue, and can offer even greater > resistance to natural function of the subareolar tissues. > > > Someone (many someones) on the intrapartum scenes all over the world, in > many differing obstetrical management "cultures", needs to be connecting > volume of IV's/pitocin "dots" with the timing/appearance of any edema of > the areola and subareolar tissues and consequent limitation of function. > > > If enough empirical agreement is evident to enough people, perhaps we can > persuade someone someday to measure colloid osmotic pressures, or at least > serial albumin levels to get enough scientific evidence to prove a > connection on which to base practice for those mothers who become at risk > for breastfeeding complications caused by areolar edema when "standard > management" or dire emergency requires >2000-2500 cc. oral/IV intake/24 > hours, especially when hours of IV pitocin are part of the mix. > > > K. Jean Cotterman RNC-E, IBCLC > WIC Volunteer LC Dayton OH > > *********************************************** > > Archives: http://community.lsoft.com/archives/LACTNET.html > To reach list owners: [log in to unmask] > Mail all list management commands to: [log in to unmask] > COMMANDS: > 1. To temporarily stop your subscription write in the body of an email: > set lactnet nomail > 2. To start it again: set lactnet mail > 3. To unsubscribe: unsubscribe lactnet > 4. To get a comprehensive list of rules and directions: get lactnet welcome > *********************************************** Archives: http://community.lsoft.com/archives/LACTNET.html To reach list owners: [log in to unmask] Mail all list management commands to: [log in to unmask] COMMANDS: 1. To temporarily stop your subscription write in the body of an email: set lactnet nomail 2. To start it again: set lactnet mail 3. To unsubscribe: unsubscribe lactnet 4. 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