Lisa writes:

<Hello wise ones!! Permission to post. I have a new c-section with large breast and VERY small nipples. Baby is very interested and sucks on anything close to him but I just don't feel like positioning is working. Mom attempted football hold and they are getting a few good sucks but the nipple is pinched when baby comes off. Is there another position that would better aid mom and latching. Thank you for all of your input!!>

Lisa,


One factor to consider is that for the next 7-10 days, the areola may well be a very important part of the nipple-areolar complex to concentrate on.  There is no milk in the nipple. It is essentially a conduit between the baby and the milk ducts deeper in the subareolar tissue that lead to the nipple. Making the areolar tissue soft and pliable before each attempt to latch can help the the baby change the shape of the areola during the latching process to extend any size/shape nipple back further toward the soft palate. Less chance of nipple damage and better chance of milk transfer, including triggering the MER. In addition, laid back positioning is even more helpful with a pendulous breast because it engages gravity in the total latching process.

 
What I am trying to say is, things may get worse before they get better if tissue resistance of the areola is part of the difficulty in getting a deep latch, regardless of any other factors such as TT. Reverse Pressure Softening used for 60 or more seconds before each latch attempt, especially using a "laid-back" position when doing it, in consideration of her large breast size, can do no harm. It may help even if other factors are entering in. To be most helpful, it must be repeated immediately before each latching attempt for several days till the areola stays pliable between nursings.


You can access it on www.kellymom.com/bf/concerns/.../rev_pressure_soft_cotterman.html



Overhydration can lead to various amounts of generalized edema, and the breast is often one of the main areas of the body to participate in edema storage. This is especially true if the mother's breasts are pendulous, because gravity will allow the edema to collect "downhill" in the breast, which means, near the nipple-areolar complex! This may even have been present during late pregnancy because of the dependency of the breast.


If the mom had a scheduled C.S. with no labor or induction or augmentation, and just the regional anesthetic and the IV's used for management, she will have had relatively less IV fluid, closer to the time of the birth, and probably less chance for overhyration. 


However, if an IV with pitocin was run for 12-24+hours after birth, this will make any edema of the breast take more time to collect, and will "peak" a little later, around 4-7 days postpartum, IME. If she had hours of IV fluid before the C.S., especially if there was IV pitocin for induction or augmentation, this raises the likelihood of edema in the postpartum breasts due to the antidiuretic properties of pitocin. 


The chances that distortion/lack of pliability of the areola and nipple-areolar complex by breast edema may both precede and even be  superimposed upon L-2, are even more, may even help delay L-2, and may last longer, up to 10+ days. Many don't realize that using a pump at this stage will simply encourage interstitial fluid to push forward toward the flange to neutralize the vacuum, unless RPS is used before and every 5-7 minutes during pumping to avoid "burial" of the ducts by edema. Fingertip expression is often facilitated by RPS beforehand.


Few that I know of have chosen to research this formally as yet, and no one that I know of has yet succeeded. So this is based solely on my clinical observations and the feedback of many, many clinicians and mothers around the world.


I will also send you some updated versions privately.


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

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