Deb writes:
<I'm so worried that, since she delivered eight days ago, this ongoing
edema
(if that is what's going on) could permanently impact her milk supply. >

IME, she has just crested the worst of it. It is not unusual to take a
full 10-14 days to approach a full resolution of the edema part itself,
depending on how overhydrated she became. Some moms are dehydrated to
begin with in labor, and need at least some of the fluid, and therefore
process it with few problems. Many others are not the least bit
dehydrated when the IV's are begun, and indeed are deliberately pumped
full of fluid to prevent a drop in blood pressure during the epidural. A
lot depends on when she had the IV fluids in relation to the time of the
delivery of the placenta (IV fluids starting 24-48 hours or so before the
birth of the placenta brings on edema much earlier than the time for
normal onset of lactogenesis, perhaps in L&D itself. That interferes with
early latching, and therefore delayed milk transfer is part of the
equation. Starting the IV fluids closer to birth and/or continuing them
on at a significant rate for up to 24 hours or longer makes the edema be
superimposed on the actual onset of lactogenesis II.) I think you need to
adjust your expectations of the time frame (and those of your client) and
try to keep the milk moving for at least another week or so. By that time
the excess tissue fluid should have a chance to make it out of the
tissues, into the blood vessels and thence to the kidneys and out.


<She also said she received at least 3 IV bags of fluids during L&D, >


That's at least 3 that she remembered. Some of the obstetric and
anesthesiology research articles reported that it was quite common for
mothers to receive IV fluid at a more rapid rate than ordered by the
attending physician, and therefore end up with more total fluid. There's
probably no way to have access to the figures on any Intake and output
records on her chart, but it would not be unusual for a mom's attention
to be focused elsewhere with the anesthesiologist standing at the head of
the table, so that she would not necessarily be aware of when they were
hanging new bags during birth/anesthetic itself. She could have gotten
more than the 3 bags she remembers. It would also be important to know if
she received a larger dose of pitocin than the standard 1-2 vials.
Pitocin is closely related chemically to the antidiuretic hormone and can
attach to binding sites for ADH.

BTW <try RPS for longer (3m), > if that means 3 minutes by the clock,
that is not a long time to use RPS in cases of severe swelling. Was she
lying on her back when this was done, and would she actually allow you
yourself to do it? It is incredibly taxing on one's patience to hold the
pressure constant for a full 10-15 minutes or more before
seeing/palpating significant areolar softening that allows easy latching
or short periods of gentle, productive pumping.  This long application
may have to be repeated before at least 2-3 more latch/short pumping
sessions before you can then shorten the time period of RPS before each
and every attempt to transfer milk. But the more swelling there is, the
longer the pressure may need to be to bring the desired initial clearing
of excess interstitial fluid from the nipple-areolar complex. The goal is
to free the crowding of the <breast tissue was very dense> that seems to
be impinging on the subareolar ducts, preventing them from adequate milk
transfer.



It's important to remember that while all fluids enter the breast through
the arterial system, they leave the breast in two opposing directions: 



1) Fluids that do make it into the glandular/ductal system as milk travel
anteriorly and centrally, converging solely on one exit area-the
nipple-areolar complex. (Of course, blockage there can back up causing
involution higher up, eventually, but I suspect that removing even small
amounts and keeping the milk moving is certainly not going to allow
significant involution by 8 days.) Forward massage helps when seeking to
move milk.



2) Fluids not needed for making milk must leave the breast in the
opposite direction, via numerous venous and lymphatic capillaries which
travel upward and posteriorly, 75% through the axillary area and most of
the rest in the direction of the clavicle. They ultimately enter the
major blood vessels behind the clavicle leading back to the heart.
Massage performed in a reclining position in the opposite direction,
(inward and upward), with flat fingers in circular motions like standard
breast exam helps lymphatic drainage. Massage is more effective if begun
at the clavicle and the outer areas of swelling, to clear them, then
gradually moving further down on the breast to move that swelling up and
back into the area just cleared of excess fluid. 

<I'm considering sending her to an endocrinologist just to check out the
mammary
tissue.  Can anyone else provide another suggestion?>

Do you know any physical therapists skilled in lymphatic drainage of the
breast? If you feel the need to refer without waiting 6-7 more days, I
suggest that would be the type of expert to refer to rather than an
endocrinologist.  

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

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