Dear Jean,
Do you find it interesting that this postpartum edema is seen as 'normal'
to mothers?  I think that ob's have gotten so used to seeing it, that they
don't realize that their procedures are the cause, NOT the physiological
process of delivery.  I've observed a few postpartum teachings by obs, and
was intrigued about how little is understood about this.

Just wondering,
Melissa Senf, RNC, IBCLC


On Sun, May 19, 2013 at 2:28 AM, K. Jean Cotterman <[log in to unmask]>wrote:

> This is my suggestion: absolute prevention of nipple trauma so no
> treatment is necessary:
>
>
> 1) Teach mother about Reverse Pressure Softening during pregnancy, using
> pictures and verbally and with demo breast. Any degree of breast
> pendulousness combined with the tendency to retain extra fluid during
> pregnancy can cause some edema to gather in the areolar/subareolar tissues,
> (and nipple) even during pregnancy. (Any prenatal practice of RPS is
> contraindicated if her OB has given warning about no sexual activity in
> pregnancy.)
>
>
> 2) For those mothers who are open to anticipatory guidance about complete
> avoidance of nipple trauma, review in very early labor, offering to teach
> or review RPS. Help her understand the need for the areola to be as soft as
> her own lips are, right before each latching right from the start, and
> before each feeding for the first 7-14 days, so that the areola can change
> shape easily to extend the nipple itself deep into the mouth toward the
> soft palate area,  in response to baby's latching attempts right from the
> beginning.
>
>
> 3) When teaching RPS just prior to or in early labor, in addition to her
> sight and hearing, offer to use her kinesthetic sense, with her fingers (or
> yours, with permission) directly on the areola, or on top of her fingers.
> Have her lying back at least far enough that the nipple is above heart
> level, especially if breasts are C Cup or beyond. This is to use gravity to
> keep any tissue fluids (and/or colostrum from full ducts) "at bay", e.g.
> moved back upward an inch or so in breast for at least 5 minutes. Then, if
> done right before offering breast, baby is empowered to get a deeper latch.
> In addition, any necessary hand expression is much easier and more
> productive (due to MER, plus edema having been moved out of subareolar
> tissues.)
>
>
> 3) I suggest (my empirical observation) that this is especially important
> if mom is going to get (oral +) IV fluids in excess of 2000-2500  cc. in
> any one 24 hour period, and especially if IV pitocin (anti-diuretic effect)
> is used for induction, augmentation or for hours after birth if at risk for
> postpartum hemorrhage. IME, this total amount of (oral +) IV fluid/and/or
> pitocin drip, is enough to place her at risk for starting to develop what I
> call Pre-L2 edema-other places but especially edema of the dependent part
> of the breast, well before hormonal changes have increased breast
> circulation that brings on L-2 to eventually cause the ducts to begin to
> really fill.
>
>
> 4) It ought to go without saying, but I'll say it anyway. Any vacuum
> allows excess interstitial fluid (edema) to push its way forward into
> flange and nipple-areolar complex area. If HCP or mother believes fingertip
> expression (after preliminary RPS) is not removing enough colostrum and
> that a pump is really necessary, have mom do RPS before pumping, and
> several times during pumping, on medium or lower vacuum. Remember to factor
> in gravity into the equation too.
>
>
> 5) I would really like feedback, especially negative feedback. This is a
> strong hypothesis of mine, and I'd be happy to be persuaded that I am not
> on target in any way, if indeed I am not.
>
>
> I would like to know both the "interpersonal" reactions of staff and moms,
> and I would like to get hospital personnel making private notes on 24 hour
> fluid intakes, IV pitocin dosage/duration, and observations of the time of
> appearance of any edema within 24-48 hours after the 2000-2500 cc.
> volume/24 hours.
>
>
> Remember that "invisible" edema can be present when interstitial tissue
> has up to 30% more than is normal for that tissue. Even "invisible edema"
> can offer resistance to the normal functioning of the subareolar tissues.
>
>
> Pitting edema, by definition, becomes visible when interstitial tissue has
> 30% or more than normal for that tissue, and can offer even greater
> resistance to natural function of the subareolar tissues.
>
>
> Someone (many someones) on the intrapartum scenes all over the world, in
> many differing obstetrical management "cultures", needs to be connecting
> volume of IV's/pitocin "dots" with the timing/appearance of any edema of
> the areola and subareolar tissues and consequent limitation of function.
>
>
> If enough empirical agreement is evident to enough people, perhaps we can
> persuade someone someday to measure colloid osmotic pressures, or at least
> serial albumin levels to get enough scientific evidence to prove a
> connection on which to base practice for those mothers who become at risk
> for breastfeeding complications caused by areolar edema when "standard
> management" or dire emergency requires >2000-2500 cc. oral/IV intake/24
> hours, especially when hours of IV pitocin are part of the mix.
>
>
> K. Jean Cotterman RNC-E, IBCLC
> WIC Volunteer LC     Dayton OH
>
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