Kristen writes:
<I advised her to treat the swelling and if the milk volumes pumped don't
increase over the next few hours but she remains uncomfortable to call
me. she is coming in again tomorrow for a weight check. So my question
is, what would you have done, RPS? When would you have initiated it? When
do you say we have done enough for now, go home and rest and lets see
what happens? thank you for you help. Nothing like trial by fire- Kristen
Panzer, MS IBCLC >

In January, Rosellina Cosentino wrote me privately and has given me
permission to post:
<I need your help and advice!  Recently I had 2 mothers with such a bad
edema, that I could only get few drops of milk out. After trying the cold
for 20 min, many times, or warm compresses with RPS, I still had nill
milk come out.  Mom #1 went home and continued cold therapy  and after 7
hours the baby was able to suckle and receive milk.  I sent Mom #2 home
with continued cold therapy. The next day she was still congested and
baby was not able to receive milk.
Is it normal to wait so long before the edema and congestion stops?>



The very best way I have found to <treat the swelling > is by using RPS
as the very first intervention to facilitate milk removal, adding breast
compression, followed by continued frequent milk removal, always using
RPS before latch or pumping. Below are points about the effective use of
RPS which I have apparently not yet emphasized clearly and strongly
enough, though many people seem to be figuring it out themselves. I
sometimes wonder why it took me so many years of seeing it to figure it
out for my own self, since pitting edema is a principle that's been
around for eons. I had to go back and review a lot of physiology to "get
it" well enough to start explaining it at a professional level.



1) the more pendulous and/or the more swollen the breast and/or firm the
areola, the more important it is to utilize gravity while doing RPS. 



This is primarily to prevent prompt re-entry of excess tissue fluid into
the areolar tissues. (Some degree of dependent edema in the
nipple-areolar complex can even occur during pregnancy, or
premenstrually, if the breast is pendulous enough.) The goal is to
provide a few extra minutes of "improved latchability". Unless the the
areola softens easily without the mother lying on her back, it's much
more effective to use the mother-supine position when doing RPS for the
first few times. (If, in addition, comfort allows the baby-prone nursing
position, the weight of the baby then helps achieve and maintain the
latch, as well as further  encouraging venous and lymphatic drainage
during the feeding. This also dovetails nicely with skin to skin contact
and is relaxing for the mother, with potential to help minimize sleep
deprivation effects. The MER will continue to work sufficiently well
against gravity if effective latch and suckling occur.)  



2) the firmer the areola, the more minutes of RPS may be needed, at least
the first time or two. Riordan has phrased it very succinctly in the 3rd
edition of BF & HL: "The length of time will depend on the severity of
the edema." (p. 207)



(In my own experience, 1-3 minutes works fine for many moms early on.
Martha Johnson in Eugene, Oregon has taught her staff to proactively
teach all moms to use RPS from the first day, and hopefully one day will
do formal research on it. I am awaiting results of Rachel Myr's research
as well. But if severe swelling and/or areolar firmness has been allowed
to develop, a total of 10-15 minutes or more may be needed for the first
application to produce areolar pliability. I myself have never
experienced it taking as long as 30 minutes to achieve positive results.)




If it hurts, the pressure is too firm. Judge the time as you go by how
the tissue responds. Pressure needs to be steady and firm, but gentle,
judging by her body language. Or better yet, encourage the mom to do RPS
on her own areola, and slowly add the strength of your fingers on top of
her fingers to help. Be patient and invest that time in instructing the
mother. The skill will save her much discomfort and frustration during
successful initiation of breastfeeding, especially after hospital
discharge. 



We can't see inside the breast the way we can see inside a bottle.
Despite the most experienced eyes and fingertips, we can only guess
roughly what percentages of which fluids are causing breast swelling on
any given day (or hour)during establishment of lactogenesis II. It's
helpful to think in terms of these spaces and fluids:

1) Inside of vessels: blood, lymph (physiologic increase in arterial
circulation to bring in raw materials and corresponding increase in
venous and lymphatic circulation to remove what's not needed)
2) Outside of vessels, between the cells: tissue fluid, (to transfer raw
materials from  circulation to milk-making cells, and transfer metabolic
waste back to the circulation.) 
3) Expanding the alveoli and ducts: both the milk in the process of
synthesis, as well as the completely secreted milk .



A coordinated increase in all three factors is physiologically normal
during lactogenesis II, but the proportions of each factor change from
day to day, even feeding to feeding. However, many people fail to
recognize that this process is sometimes greatly altered by iatrogenic
causes such as labor interventions,  injudicious vacuum use and factors
interfering with feeding efficiency. A rough guide would be to ask the
mother how many sacks of fluid she remembers receiving. The more sacks,
the greater the potential for edema and the more days it may last. Many
get swollen ankles, which is a perfect opening to uncritically suggest
the probability of "fluid retention" (without risk of expressing your
personal opinion of routine labor interventions. By that time, it's
history, and flaming the physicians doesn't help relieve the swelling or
the mom's emotional state.)



Retention of excess tissue fluid delays removal of metabolic waste
primarily through venous capillaries, and to a lesser extent, the
lymphatic capillaries. It seems counterproductive to me to constrict
those capillaries for any other reason than short periods of pain relief.
Therefore, I would avoid the use of either ice (or warmth) as a direct
attempt to manipulate the circulation per se before RPS. On very rare
occasions, five minutes of a covered ice pack on the areola to numb it
somewhat may be needed before RPS can be comfortably done. (In my view, a
swollen breast is not really analogous to athletic injury, which causes
damaged, oozing blood vessels  requiring cold to cause vasoconstriction
and clotting.) I do sometimes suggest using short (< 20 minutes) of cold
or heat between feedings for comfort, leaving it to the mom to decide
what works best for her. Often, just using RPS to facilitate latch and
increasing milk transfer with frequent feeding works the best of all to
achieve comfort.



Intuition, experience and common logic tell us that milk removal will
help reduce swelling. But I believe rushing straight to the pump in
pursuit of milk removal is often based on a faulty understanding of
vacuum application (not the same as a straw immersed in a drink), and may
complicate matters just as often as not. When intervention is needed to
facilitate latching, I recommend the early and regular use of RPS, rather
than pumping "to draw out nipples". RPS may be started at any time,
especially if the mom received hours or days of IV's before birth. No
harm will result. Even if no edema is currently visible, filling of the
ducts under the areola also contributes to subareolar tissue resistance.
It is amazing how much improvement in areolar pliability results even
when no one has yet recognized any subareolar tissue resistance. 



Remember that the technical definition of edema (at which time it becomes
visible) is when the tissues are holding at least 30% more fluid than
normal. 29% (25%, 15%, etc.) still contributes subareolar resistance and
nipple-areolar distortion. When nipple-areolar tissue is forced to
compensate by expanding to hold the extra fluid, a directly proportionate
reduction occurs in the ability of the areola to extend the nipple inward
into the baby's mouth, impacting the latching process for baby and
mother. 



If milk removal is the goal, help the mother understand that MER is the
primary factor in effective milk transfer. During the first 10-14 days,
encourage her to use RPS on the areola, (and on the nipple if need be)
each time before pumping, as well as to use breast compression/massage to
keep pumping sessions short, using medium or less vacuum. 



This will reduce the risk of attracting an extra layer of tissue fluid
into the nipple-areolar tissues that might interfere with the compression
of the subareolar ducts by the flange tunnel. Avoiding frank attraction
of tissue fluid into the flange area also minimizes effect on nipple size
with the subsequent need to change flange size.



If my observations above not been your experience, I would like to know
about it, on or off the list, so I can think it over even further.
Without the experience and comments of my many, many lactnet friends,
this "baby" would never have been birthed!


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

             ***********************************************

To temporarily stop your subscription: set lactnet nomail
To start it again: set lactnet mail (or digest)
To unsubscribe: unsubscribe lactnet
All commands go to [log in to unmask]

The LACTNET mailing list is powered by L-Soft's renowned
LISTSERV(R) list management software together with L-Soft's LSMTP(R)
mailer for lightning fast mail delivery. For more information, go to:
http://www.lsoft.com/LISTSERV-powered.html