Jennifer,
You seem to be working with multiple challenges with this mother. I can
only address the ones I have read about or had direct experience with.
< Dad described mom's breasts
pre-surgery as cone-shaped, like little pyramids. I suspect this mom has
tubular breasts, but it is really hard to tell due to the implants.>
From his description, I doubt this mother had tubular breasts to begin
with. A pyramid, by definition, has a broad base and narrows evenly. The
pyramid description bodes well, because much of the glandular tissue
forms in the general area corresponding to the base of that pyramid.
Plus, a very large percentage of the glandular tissue is normally in the
upper, outer quadrant along the chest wall, extending into the axilla.
Tubular breasts, even if only the areola is tubular (trunk breast), seem
to be bulbous with a base almost the same diameter as the breast itself.
Even then, it is difficult to tell whether there is glandular tissue
deeper, nearer the chest wall and how much. When in doubt, keep
stimulating!
<breast implants, which were placed near the chest wall and there was no
cutting at all near the nipples.>
I believe such surgical placement puts the implant behind the pectoral
muscles, which would mean that a layer of muscles lies between the
implant and the breast, so that just the general contour and measurement
of the bust line would be increased.
From what little I have read in LC and surgical literature, plus the one
mother with tubular breasts that I've seen, my impression is that such a
placement couldn't possibly do much to change the general shape of a
tubular breast, even if it were of the type where there is a wide space
between the breasts. In other words, if they were initially tubular, to
your practiced eye, they'd still be obviously tubular.
<Her
areolas are somewhat swollen, but on day 3, I thought this might be from
the
epidural.>
I have read this comment several times recently, and I can't help but
believe some misunderstanding has now created a snowballing effect of
misinformation in the LC community.
I personally cannot envision how an epidural could have some special type
of effect just specifically upon the areola itself. I would certainly
like to hear feedback and references on this point.
Whatever epidurals do, I do not believe there has been enough research
yet to separate the effects on the mother's breasts by variables of
different drugs used, different dosages, from the mere fact of IV fluids,
often to the point of overhydration, etc.
In my experience (and it is admittedly a long time since I was directly
in a hospital and able to correlate charting of IV's with degree of
swelling),
my suspicion is that breast and generalized swelling have more to do with
multiple IV's. How many sacks did she have?
As for the areolar edema, this area could be at special risk for edema
when a pump is used on a mother who has had multiple IV's. In high school
physics we learned that "Nature abhors a vacuum." IMHO, it stands to
reason that the vacuum will be filled with whatever combination of skin,
connective tissue, fluid, blood, milk, etc. that will move most easily in
that direction to try to equalize pressure.
One of my "mantras" is "Suction does not pull on milk. It pulls on
flesh." It is not uncommon for intracellular fluid to move within the
flesh subjected to suction, toward the space exposed to the vacuum.
Sometimes this is so pronounced that a thick enough layer of edema
develops in the outer layer to prevent effective compression of the
underlying milk sinuses by hand, by the baby, or by the pump.
That is one of the main reasons I prefer, for early milk harvesting and
stimulation:
* intermittent gentle massage to trigger MER (which is the strongest
force in moving the milk forward in the breast, and moving milk out of
the alveoli themselves is important in stimulating production)
* along with fingertip expression, as in the Marmet method.
By definition, there can be up to 30% excess tissue fluid present before
it becomes visible enough to be called edema. From references describing
another technique for another purpose, I developed what I call Reverse
Pressure Softening. (See archives.)
I have observed:
* that this moves excess interstitial fluid inward toward the lymph
channels and temporarily, away from the milk sinuses.
* often triggers an MER
* and it makes fingertip expression easier and more comfortable during
the early postpartum period.
In this way I know I am not compounding the problem of edema in the
areola.
She is just 1 week postpartum. It would be a good idea to have her keep
tabs on the color and the nature of her lochia in the next week or two to
be sure it gradually turns tannish, without clots or bright red bleeding
that might suggest retained placenta.
Good luck, and keep us informed of the progress. If you could get her to
agree to some medical photography, it might help develop a broader
reference base for others in the future.
Jean
***************
K. Jean Cotterman RNC, IBCLC
Dayton, Ohio USA
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