Laurie wrote:

> do you think moms putting bras on after the first 24 hrs or so has
> any
> contribution to it?>

By this, I presume she meant "Could a bra make edema an even worse
problem?"

I'm with Winnie. I think it's a matter of the individual breast, the
individual bra, and the individual preference, with no hard and fast
rule.

I remember there *used to be* a ritual fetish, a hard and fast rule in
our OB department 3+ decades ago. The postpartum nurse felt she had
fulfilled her responsibilities (or that another one had not fulfilled
hers) when the leakage pads, the mammol cream, and the sterile 2x2's had
been issued, charged for and charted, and the requisite bra (or firm
binder) were in place, 24 hours a day!

I was of course considered a renegade because I advised moms to try
removing their bras at feeding time in order to handle the breast (as in
fingertip expression and massage and breast compression) and learn to use
it as a feeding tool.

Of course, there is less skin to skin contact with the bra on at feeding
times too. I have noticed the opening is particularly small for learning
and latching purposes on an A cup bra, the very mothers who probably have
absolutely no physical need for a bra! I think it may tend to make
feeding more "technical", less personal, as in mimicking a bottle in a
bottle holder for some moms to feed through the flap opening.

However, some mothers with very large heavy breasts, leaving the bra on
at feeding times is a great assistance to them.

With a heavy breast, gravity itself often slows down the return of tissue
fluid from the most dependent parts of the breast. However, I find the
problem of even broad straps compressing the shoulder muscles (and
sometimes arm nerves) begins to bother me if I "cinch up" the uplift too
tightly, even 35 years postpartum!

Sitting up to feed versus lying down, either sidelying or Australian
position, distributes the gravitational forces differently as well.
Compression is actually one of the means to help edema return to the
lymphatic tree (e.g. elastic stockings) Yet, it needs to be balanced out
with consideration of the effect of compression of milk against the
alveolar membranes too.

There is much research still to be done about engorgement. I throw this
out for discussion.

How many of you "eyeball" a postpartum breast to guesstimate whether
swelling is mostly edema or mostly milk, or six of one and half a dozen
of the other on that particular day? Palpating the upper outer quadrant
to see if you can recognize separate lobular swellings lets you know that
a significant amount of milk is filling and/or backed up in the glandular
tree. If you begin to see shiny skin puffy enough to show the bra seams,
etc.,  this give clues that much edema is also trapped in the inner
connective tissues.

While milk leaves the breast in a central and downward/forward direction,
edema leaves in the opposite direction, and the current general
instructions (as in massaging under the shower)seem only to reflect the
milk removal aspect.

Tissue fluid leaves via the lymphatic pathways, in an upward and backward
direction, mostly through the axilla, but a significant amount through
the pectoral muscles and the clavicular area. I remember the old
"heartburn/lactation exercise" taught in the early days of Grantley Dick
Read childbirth classes. I don't think it would hurt for someone to
resurrect it and do some research on it.

Maybe we should be considering having moms lie in a prone position for
short time periods, with the appropriate arm outstretched to free up the
axilla,  and do or have her or a significant other do some gentle
circular and upward massage (similar to flats of fingers at monthly BSE)
starting in the upper, outer regions of the breast when we see that a
significant amount of edema is present. This need not conflict in anyway
with forward downward massage of lumpy areas at another time to aid milk
removal.

< i discourage bra wearing in hospital. the nurses
> have gotten over their compulsion to advise bra-wearing, but as soon as
any breast fullness is detected, they advise pts to put on the bra. this
of
> course coincides to the milk 'coming in' so does the bra wearing help
or hinder?>

Depends. And the ritualism of the instruction may also depend on the
individual nurse's psychological outlook and comfort or discomfort with
helping mothers with their breasts, if I remember correctly. Out of
sight, out of mind perhaps?? None of those nurses of yore ever seemed to
have a problem with massaging a fundus vigorously, but massage a breast??
Heaven forbid!

Jean
**********
K. Jean Cotterman RNC, RLC, IBCLC\
Dayton, OH

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