Leslie writes:


<The mom who gave me permission to post her case has delivered. Baby girl came on her due date (yesterday). I was off yesterday, so just met her today.>


I just gave an inservice today which included a case of a mother with a different set of problems but "H" size breasts. This approach helped solve her problems:


I would like to know how much oral plus IV fluid she received in how many total hours during the whole intrapartum period. Also, did she receive prolonged pitocin drip for induction, augmentation or 3d stage management? 


Remember as well that fluids enter the breast in one way: through the arterial system, but leave the breast in two opposing directions 1)centrally and forward (distally), through the nipple and 2) Upward, (proximally) through many lymphatic and venous vessels. To be efficient, the direction of massage must be chosen according to which kind of fluid you presently wish to move.


<I found a very cute little girl with a small, tight mouth and a posterior tongue tie. Mom was already struggling to latch her. I also had a chance to do a more detailed exam on mom. Findings: very large (appx H cup),very soft and pillowy breasts.>
 

The breast is a lymphatic organ, and 75% of lymphatic drainage is upward through the axilla, so using gravity would certainly help normal lymphatic drainage. I recommend that 3-4 times daily, she lie flat (with her head on a pillow), elevate one breast at a time perpendicular to her ribcage, with 5 minutes or more of gentle massage in a proximal (inward toward the heart) direction to assist natural lymphatic drainage.
 

<Large areolas (>3"diameter)  and small, almost eroded looking nipples (about the size of an m&m candy). She says they were always like that. Mom's areola skin and overall breast skin are extremely elastic. I've been struggling for ways to describe this. No matter what we tried, the nipple and areola sunk away from the baby when she tried to latch.>


The embryonic development of the nipple proceeds inward within the areola, and even when completely developed, they remain closely connected, "all-of-a-piece" much as the palm and the fingers are. When nipple-areolar tissues expand to hold extra fluid, they are forced to compensate by a directly proportionate reduction in the freedom of the areola to extend the nipple inward into the baby's mouth. Just because the skin is extremely elastic is no sign that the rest of the deep subareolar tissues are elastic if excess interstitial fluid is being stored.  When the breast is pendulous, the most dependent part of the breast coincides with the "business end where the milk removal process must occur".


Such a pendulous breast, with the nipple-areolar complex well below the heart, by virtue of gravity alone often already has some edema at least during late pregnancy, even before any IV fluids might have been given. With this great amount of interstitial space it would permit a significant amount of interstitial fluid to be stored without necessarily showing obvious "pitting" yet. This would make the breast even more "weighty" and liable to drag out of baby's mouth unless the baby is lying in prone position directly on top of a supine mother so the weight of the baby's head is helping maintain the latch. (In this instance, I think this calls for more than "laid back", but requires the so-called Australian position for a while.)


<We tried a nipple shield to draw out her nipple and protect her skin from the effects of the baby's twisty latch. The nipple slightly everted into the shield, but when baby tried to acquire the shielded nipple the entire area sank away from baby.  Mom reports extreme sensitivity with her nipples, just the slight vacuum of drawing the nipple into the shield caused her to wince. Mom had a very stressful time of it with her previous infant and doesn't even want to consider pumping.>


Vacuum does not pull; other forces push. Hard to believe in this commercial era, but 500 years of evidence exist.  Nature still abhors a vacuum in this day and age. 


When the baby or a pump creates a vacuum, atmospheric pressure plus the hydrostatic force of many of the fluids within the skin and inner flesh of the nipple (blood pressure, interstitial fluid, but not necessarily the milk if the ducts are crowded by the interstitial fluid) will tend to push forward to neutralize the vacuum. This can cause pain to the mother if this "inward push" is strong enough to place shearing force on the nipple skin and other nipple tissues, especially at the base where it joins the visible external areola.  


It is certainly worth a try to raise the pain threshhold before any latching or manual intervention by using what a radiology text recommends be used before ductal lavage: Try folding a washcloth into a four layer compress and saturating it with the warmest water she can tolerate comfortably on her inner wrist, and apply it to the nipple-areolar area till it cools down naturally.  (There is an opposite alternative sometimes helpful for nipple pain: a small ice pack covered with a warm washcloth to numb the nipple-areolar area. However,  I would hesitate to recommend this on the off-chance that she may be at risk for Raynaud's syndrome.)


<I encouraged breast massage and tried to show her hand expression.
Mom felt able to massage breasts but did not do well with hand expression or RPS technique.>


Cotterman's rules for RPS are: There should be no pain, no pinching, no pulling, no stretching, and use gravity whenever necessary. 


Here is another very mother-friendly method that may be helpful. Select a formula bottle that has a standard silicone nipple whose opening is the exact diameter of a U.S. nickel. Unscrew the plastic collar, remove the nipple, screw the plastic collar on again and insert the nipple upside down from the outside, into the plastic ring. If the mother elevates the pendulous breast, places the silicone nipple over her own nipple, she can use the bottle as a handle, to exert gentle inward pressure at a 90 degree angle to the areola. This indirect method provides a very evenly distributed pressure without direct contact. She understandably has a lot of "psychological baggage" from her previous experience. I really feel her pain. BTDT with my first 3 children. (See WABF 2010 vignette before chapter 7.)


If she wishes, she can slowly attempt to increase the pressure. But if RPS hurts, the pressure is too firm. To get the desired result, simply reduce the pressure and extend the time. If any excess interstitial fluid and milk in the ducts is thoroughly moved back inward several inches within the breast, the deep subareolar tissue is then much freer to comfortably extend the nipple forward into the baby's mouth. Fingertip expression is then much easier to do with no discomfort once the subareolar ducts are relatively empty. 


If she does assent to the pump, I suggest she do RPS first in the supine position, roll over on her side and pump one side at a time in a side-lying position to remove gravity from the equation as much as possible. Pump on low, for only 5 minutes, pause and massage milk forward. Repeat the sequence of RPS, 5 minutes of pumping, and a minute of forward massage. She will be able to get more milk in 15 minutes than with continuous pumping. And of course, then try fingertip expression, a la the Jane Morton Stanford method after pumping.


< There were many more tears than milk today. I left them doing skin-to-skin care and having mom massage breasts regularly. I also left her literature on dividing frenulae (plural of frenulum?) as she was unsure about subjecting baby to a procedure. I am going to give them the MOBI site, TLC, and not sure what else... any ideas or critiques of what I am missing would be greatly appreciated (again)>


I would also recommend Dr. Lawrence Kotlow's site  http://kidsteeth.com/ Beautiful illustrations and very reassuring explanations.


Glad to oblige with my $.02 worth.


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

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