Anne,

I refer you to my post on Nov. 27, 2010 titled Re: 24 hour pitocin drip after delivery


After reading it, I think you will find many similarities between the your client's situation and the one described in the above cited post. My theorizing is much the same in this case.


At 8 days, depending on the amount of IV fluid and pitocin she received before the birth of the placenta, and how much of each she received after that time, it is entirely possible that for several days she has been near "the crest" of the flood of interstitial fluid that may have exceeded 30% above the normal amount for that tissue to hold. It is thereby occupying interstitial spaces as edema, as explained in the previous post. 



The more edema there is in the subareolar tissues, the less likely the force of the MER is to be able to force milk out past the squamo-columnar cell junction and all the way through to the nipple pores where it can finally be seen.This is  especially likely if she has a fairly long-shanked nipple (1 cm. or so). Not all mothers can feel any sensation when the MER occurs. It is my guess that she has in fact been having MER's without sensations, and there are no visual clues due to the resistance of the edema crowding the nipple-areolar ducts. It is a wonder to me that she is getting as much milk out as she is.



< Nipples are damaged from pumping, both at tip and at friction zones, >



This suggests to me 
1) that vacuum has been advanced too far toward maximum in hopes of removing more milk, and 
2) that the flange tunnel size may not actually be appropriately admitting enough areolar tissue to create hydraulic pressure helpful in pushing the milk forward toward the vacuum. 
3) Perhaps that size will work well without the trauma if you can teach her to displace edema by using the following cycle for pumping during the rest of this first 14 days:
4) RPS 1(+) minutes to soften areola/trigger MER, pump on minimum or medium 5-7 minutes, take a short break for gentle forward massage of full areas, and repeat the entire cycle 2-4 times.) 


Vacuum does not pull. Other forces push. Her skin cells, her blood vessels and blood pressure in the skin in the tips of her nipples, and all the tissues exposed to the tunnel are trying to push forward, moving from a period of greater pressure to an area of lesser pressure, trying to "normalize" the two pressures, because "Nature abhors a vacuum." 



Too much vacuum, or exposure for too long a time, sometimes risks actual "blood blisters" and skin shear. The skin layers are delicate and the normal circulation to nipple skin and inner nipple tissue may be impeded by this strong push toward the vacuum area to "normalize" the two pressures.



From your description, I am going to go out on a limb by describing the perceptions in my "mind's eye" here. I would be interested in what happens if you would do this:



1) Ask this mother to take the supine position, lying down flat with one pillow so that both the breasts are above the chest wall (to utilize gravity in attracting and keeping edema away from the nipple-areolar complex temporarily).



2) With her permission, you, yourself, perform reverse pressure softening on one breast, using your thumbs (for best leverage). With right thumb pointing left (and left thumb pointing right), place the entire first joint of the thumbs lengthwise on the areola, touching the nipple above and below.  The base of both thumbnails should be lined up with the center of the nipple. (This will eventually need to be repeated, [with both thumbs pointing the same direction toward the mom's head],  touching the nipple at the side quadrants of the areola to soften the entire 1-2 cm. circumference of the areola at the base of the nipple.) 



3) Ask her to alert you to any slightest pain as you slowly, gently but steadily begin to press inward toward the chest wall. 



4) If she senses any pain, "lighten up" the amount of inward pressure till she is comfortable, and continue steady pressure for a longer time. (Conversation dilutes the stress of clock-watchng for this time period. You can judge best how long to press by the "feel" of the progressive softening under your thumbs.)  I emphasize the word "steady". There is a video on the net (practically viral by now) that demonstrates RPS performed ineffectively with frequent pressure releases.)



5) At this point, depending on how much interstitial fluid there is in the nipple areolar complex, as a result of overhydration, antidiuretic effect of pitocin, gravity and possible injudicious use of vacuum, for the first time or two, it may even take a full 5-10 minutes to displace excess interstitial fluid from the areola at the base of the nipple. 



6) IME, an MER will promptly occur within 30-60 seconds, possibly because of the "TAP" reflex (as it is called in veterinary medicine) from pressure directly on the myoepithelial cells in the lower ducts. There is also a good probability of the signal from the nerves comcentrated in the subareolar area, going the usual route to the brain in the neural  arc of the reflex, competing with stress hormones, to trigger release of oxytocin. 



7) It is another matter entirely how quickly the oxytocin can travel through the circulation to the capillaries of the breast and through the excess interstitial fluid to finally reach the myoepithelial cells around the alveoli and the upper ducts. 



As yet, in hundreds of mothers, I have never failed to see an MER occur within approximately 30-60 seconds after RPS done with continous, steady pressure. 



If you and the mother choose to participate in this "empirical research", please let me know if my perceptions are wrong. Fair is fair. (It would be even nicer, for her and for me, if you found at least part of them right;-)



K. Jean Cotterman RNC-E, IBCLC
WIC Volunteer LC 
Dayton OH

Mepham TB, Physiology of Lactation, Open University Press, Philadelphia,
1987, p. 52.

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