Betsy,
I presume this mom with what you term nipple adhesions is in the early
postpartum period.
If she (baby) can draw the nipple into a nipple shield with no difficulty
and (mom) is using the pump before each feeding to draw the nipples out,
then it seems to me that part of the difficulty is an excess of
interstitial fluid deep in the nipple-areolar complex, "using up" much of
the small amount of available stretch.
It is seen so commonly that most HCP's don't even recognize it as edema.
Even if it does not look obviously edematous to the naked eye, there is
almost always more interstitial fluid in this area during late pregnancy
and early postpartum than one might suppose. This is very common in
engorgement, especially if the mother had IV's in labor (and/or pitocin
induction). This increases any subareolar tissue resistance to the baby's
latch.
Technically speaking, I don't think a pump "draws" a nipple out as much
as it "pushes" edema back toward deeper lymphatics. This temporarily
displaces the interstitial fluid under the nipple and the areola so that
the tissue surrounding the nipple can respond to the baby's vacuum and
carry the nipple inward into the baby's mouth.
Same principle applies with shells put in place for 20+ minutes before a
feeding.
I have found the Hoffman technique to be misunderstood (and maligned),
and so I steer clear of the term now. Instead, I teach the mom what I now
call "Reverse Pressure Softening".
This is essentially "pitting" the edema out of the area temporarily, and
consists of two phases. The purpose is to free up as much of the mother's
elastic potential as possible for the baby to use in latching.
1) First, pressure is placed on the areola, close to the nipple:
* Right next to the base of the nipple, mom (with short
fingernails, using both hands) places the tips of her index,
middle and ring fingers (bent) on the areola and pushes
straight in toward the ribs for long enough to sing a
lullabye (45-60 seconds if actual timing is desired.)
* This moves any excess interstitial tissue fluid back toward
the lymph capillaries. It may also temporarily push milk back
up from the overfull sinuses into the ducts further above ,
or may cause some to come out the nipple.
* (A HCP can also do this for the mother to start out, by using
both thumbs placed at the base of the nipple and exerting
pressure as described above. It will be necessary to move
the thumbs 90 degrees around and press a second time to
"pit" what the mother can "pit" with 6 fingertips.)
2) Finish with deep digital extraction:
*Start an inch or 1 1/4 inch from the base of the nipple, using
bent fingers. Press firmly back toward the ribs while
rhythmically closing the fingertips over the milk sinuses to
remove enough to make the deep areolar area very soft.
*All this may also elicit MER so the baby gets more in a
shorter time. This pitting will last long enough to give the
baby a fighting chance to attempt a decent latch. If the
second side is used, it is better to soften it just prior to
latch.
* It may often be helpful to locate the area where baby's
chin will nestle and create a depression by massaging
milk
out of the area.
Palpation of the softened side in comparison with the unprepared side can
demonstrate to the mother just how much tissue resistance has been moved
out of the way to help the baby. I keep reassuring moms that this
swelling is temporary, and they can skip this step when the baby can
latch without problems or nipple trauma.
Jean
***********************************
K. Jean Cotterman RNC, IBCLC
Dayton, Ohio USA
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