Martha Johnson writes: <I have recently run across another technique in
Sheila Humphrey's Nursing Mother's Herbal, which is a FANTASTIC treatment
adjunct to RPS for edema. I don't have her book with me right now, but I
think she calls it something like "lymphatic drainage breast massage."
Lots of us do breast massage and encourage moms to do it, especially
while breasts are engorged. In my hospital we always did massage from the
outer breast DOWN towards the nipple/areola. Sheila wisely points out
that the lymphatic drainage for the breast is in the armpit. This means
we need to massage the breast UPWARDS and outwards, towards the armpit,
to mobilize lymphatic fluid. I've had amazing success with this technique
on very congested breasts, in the following order: 1. Mom lies on her
back in bed. Apply moist heat for 5-10 minutes. 2. Have her lift her arm
above her head and let it rest on her pillow. Do lymphatic massage as
described above. 3. Now do RPS 4. Pump, or bring baby to breast. The
pumping moms get SO much more milk out after this treatment, it's
amazing. I've started calling it the "Breast Spa Treatment," and the
nurses are all asking me to show them how to do it. >

It is good to know there is an easily accessible book for those wishing
to know more about this.  It's important to be careful with the term
"lymphatic drainage breast massage" as this rightly seems to fall into
the professional domain of the licensed massage therapist, who has a more
in-depth knowledge of lymphatic physiology.. A French physician Dr. Bruno
Chikli gave a presentation on it at ILCA a few years back, and I have
read an article by him in a newsletter for massage therapists. He has a
whole course on it through the Upledger Institute (with which I have no
connection). I personally know of at least 2 IBCLC's who have taken the
course, and there are probably quite a few more.


I was careful to avoid using this specific terminology in writing my May
2004 JHL article "Reverse Pressure Softening: A Simple Tool to Prepare
Areola for Easier Latching during Engorgement". Lymphatic drainage
terminology would have been out my depth, but I attempted to strongly
suggest some of the principles Martha comments on when I wrote:


"Under normal conditions, 90% of interstitial fluid re-enters the venous
end of circulatory capillaries, while the remaining 10%, including
protein molecules, re-enters lymphatic capillaries. Glandular tissue is
most heavily concentrated in the upper outer quadrant of the breast, the
same general area where 75% of lymphatic drainage moves toward the
axilla. Other lymphatic vessels pass between the pectoral muscles, the
intercostal muscles, and under the clavicle, all ultimately emptying into
the large veins leading back to the heart.. While fluids enter the breast
through the arterial system, they must exit in two opposing directions.
(1) Milk advances through the glandular compartment in an anterior and
central direction, converging toward the nipple, the only exit. Thus,
ineffective milk flow through the nipple-areolar complex automatically
impedes milk flow from the rest of the breast. (2) Interstitial fluid
leaves the breast in the opposite direction, moving posteriorly and
superiorly, utilizing numerous venous and lymphatic capillaries to
re-enter the circulatory system.

Understanding these physiological principles and natural directional
patterns of fluids leaving the breast during engorgement may be helpful
in choosing interventions: (1) whether and how to use positive or
negative pressure, (2) the appropriate direction for any massage
depending on whether the immediate goal is to move milk or edema, (3) the
possible therapeutic value of gravity in helping resolve severe breast
edema, and (4) the possible therapeutic value of assisting lymphatic flow
by active/ passive motion of arm and chest muscles.. . . "A traffic jam
at rush hour" provides a simple analogy for teaching mothers about the
changing course of engorgement. "



Martha has been a wonderful support to me as I have been developing my
concepts, so I know she will not be insulted if chide her about "missing
some of  the fine print" on the first reading of my article. From some of
the other questions I sometimes receive, I know she is not the only one
(LOL).  



While writing it, I myself had to reread many of my references multiple
times before I could move beyond a surface understanding of the anatomy
and physiology of the breast. This was the only way I could explain my
observations in terms that other disciplines might respect. One of my
goals was to challenge researchers to consider intravenous fluids and
edema as variables in future engorgement research, and stimulate more
appropriate choices in nursing interventions. A secondary goal was to
prepare LC's and nurses to dialog with physicians about increased edema
of the breast as a side-effect of medical interventions. I realize that
made for a somewhat complicated article. So be it. It is a complicated
subject about which there is still much to learn, for the sake of the
mothers and babies in our care. Thank you to all who have been so
supportive.


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



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