Re: Doreen's reply to Jaye:

Dear all: 
re: Jaye’s case:

My first thought was that mom’s milk did come in...

”She experienced her milk coming in on day 3 –
4 with extreme fullness but never pumped more than drops at that time – even
with pumping q. 2 hrs.”  

...but that the IV fluids in labour...


”Mom on IV Fluids for approximately 15 hours, given Pitocin at lowest levels for
approx. 10 hours, then an (light – Anesths words) Epidural for approximately
6 hours – 1 bolus and then a 2nd dose just before delivery when they
increased the Pit and then 30 min later, after 10 min. of pushing baby was
born”.

.....resulted in overall fluid overload/edema, including breast tissue and areola. The areolar edema would be exacerbated by pumping, effectively blocking off the flow of milk.  A perfect situation for RPS.(reverse pressure softening)
Inability to move milk could then result in involution.  
What do others think?
Doreen Vanderstoep, RN, IBCLC>

My eye caught: <”Mom on IV Fluids for approximately 15 hours, given Pitocin at lowest levels for
approx. 10 hours, then an (light – Anesths words) Epidural for approximately
6 hours – 1 bolus and then a 2nd dose just before delivery when they
increased the Pit and then 30 min later, after 10 min. of pushing baby was
born”.>

To my knowledge no one has researched this in relation to lactation issues yet, and such research is sorely needed. All the civic, personal and political work in the world is not really going to succeed in the best increase in the breastfeeding rate unless someone tries to research the effect of perinatal medicine, especially intrapartum care in R/T the course of early lactation, so moms can make a good start rather than getting discouraged or not being able to get over certain hurdles.


That "number of hours on IV fluids" is a very generalized description. It is the amount of total oral and IV fluids within any one 24 hour period, and how many such 24 hour periods (including their relation to the mothers BMI, I bet, that would be a much more accurate way to approach this research. This record of fluid intake must also include any fluids given (with pitocin) for 12-48 hours or so of third-stage management. I have seen moms with that plan experiencing an extra surge in edema around day 6 or so, after they have left the hospital. 


And pray tell, what was the precise number of units of pitocin the mother received over-all in the "Pitocin at lowest levels for approx. 10 hours" then "when they increased the Pit" etc. is just too general a statement from which to derive much meaning. I am not knocking Pitocin per se. From the first mother in OB I ever helped care for in 1948 all through my career as an OB nurse, I have never known of a mother who did not get at least 1 cc. (10 units) (pituitin, back then, till pitocin's invention in 1953, and it's subsequent Nobel prize in Chemistry in 1955) at least IM after birth of the placenta. 


Death from postpartum hemorrhage is still highest in those underdeveloped countries where it is not available for care of mothers. But it seems to me that there is so much nonchalance in its common usage today that its antidiuretic effect on the kidneys as a factor in the amount and the length of continuance of breast edema has been almost totally ignored.


In the mid-1980's, this type of research on IV fluids was done by obstetricians and anesthesiologists, at least on the effect of the total amounts of IV fluids on colloid osmotic pressure and anesthetic safety and induction safety were concerned. But unfortunately, I don't think the research was carried out for a long enough time postpartum to investigate the effect on lactation sequellae. 


Gonik B, Cotton DB, Peripartum colloid osmotic pressure changes: effects of controlled fluid management, Am J Obstet Gynecol Mar 1985; 151 (6): 812-815.
Cotton DB, Gonik B, Spillman T, Dorman KF, Intrapartum to postpartum changes in colloid osmotic pressure, Am J Obstetr Gynecol, 1984;149(2):174-177.
Gonik G, Cotton DB, Peripartum colloid osmotic pressure changes: influence of intravenous hydration, Am J Obstet Gynecol, Sept. 1984;150 (1):99-100.
Park GE, Hauch MA, Curlin F, Datta S, Bader AM, The effects of varying volumes of crystalloid administration before Cesarean delivery on maternal hemodynamics and colloid osmotic pressure, Anesth Analg 1996; 83:299-303.


If anyone were to be able to replicate this research but extend the time frame of follow-up and the effect on the mothers' breasts in the first 2 weeks, I believe a great deal of insight on breast edema and its effect on early initiation of breastfeeding might be gained. So many clinicians do not even seem to recognize it, or that it's due to appear within 2-3 days after birth, so often after a mother is discharged from the hospital. I believe it is a subject ripe for anticipatory guidance prenatally and in the hospital and could add helpful insights during pediatric newborn visits.


And as far as ".....resulted in overall fluid overload/edema, including breast tissue and areola. The areolar edema would be exacerbated by pumping, effectively blocking off the flow of milk.> <extreme fullness but never pumped more than drops at that time> (This maternal report is a dead giveaway to what is going on, and we at WIC hear if often from moms with babies in the NICU.)


Yes, the pump manufacturers have got so many of us in the palm of their hand with our "common sense knowledge" about vacuum "hopefully pulling milk out" like a straw sucking a soft drink! NOT! Actually, without the boundaries that blood vessels and milk ducts impose on other fluids in the breast, the higher pressure of loosely contained excess interstitial fluids collected in the edematous breast tissues push themselves forward toward the NAK, like a flood or a swamp, assisted by gravity in dependent breasts (C cup or beyond) trying to equalize the difference between the vacuum.  500 years of scientific evidence base exist for the fact that vacuum does not pull; other forces push. Maybe such quotations could be posted on attractive wall placques in NICU's???? 


There are ways around this dilemma. In particular, I recommend the commentary of Dr. Jane Morton "The Importance of Hands" in the current issue of JHL p. 276 (August 2012, Vol. 28, Number 3.) 


Repeated use of RPS (and including gravity in the equation) is but one other small technique to help early postpartum milk removal by temporarily freeing the areolar tissues from such edema for latching, for pumping and it even makes hand expression itself more productive.


And yes, we certainly know that <Inability to move milk could then result in involution.>


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

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