Just getting around to reading last week's posts.

Brenda was discussing a client who went to ER with nipple blebs, and was also new enough (apparently after much peripartum IV fluid) to have edema, and had been using RPS as one way to deal with painful latch issues:

< When she told the LC at this hospital about doing RPS she was told "that doesn't work!" to which she replied "Oh yeah? Then why was I getting relief then huh?" >

Once again I want to emphasize something which I have always mentioned in what I have written. But I now realize that I have never emphasized it strongly enough nor explained fully enough its crucial importance to the effectiveness of RPS in certain specific types of situations. So for so many on LN who seem to be supportive of RPS use, and to others who have not found it consistently helpful, I wanted to add some further explanation that might help. Maybe lots of you figured it out much sooner than I have;-)


I had heard of people finding that RPS "didn't seem to do much" for this client or that, and I myself, convinced as I was of its value, admit that I did notice a few patients where I couldn't figure out why swelling would come back and make the areola too firm again before the baby could have a chance to latch. I can remember a home visit on one swollen mom with at least a "C" or "D" bra cup, who was the daughter of a LLLL. I distinctly remember that her mother was keen on having her use the breast pump as part of managing the swelling. Shortly after I would do RPS, while the young mom was sitting up, the LLLL would encourage and assist her again with the pump, also while sitting up! Duh! Are there any clues there why the baby then still couldn't latch??


In retrospect I can see very clearly that at that time I had not yet studied in enough depth the physiologic factors involved in movement of excess interstitial fluid to realize what was happening. The closest familiar analogy I can make is to a sponge. In simple explanations to moms, I first ask them if they remember about how many bags of IV fluid they had, before and/or after birth, IV pi and when given, and have started using the term "spongy protective tissue" to explain the probability of temporary storage of some extra IV fluid they received as part of early breast swelling.


The last sentence of this quote is especially revealing:


<Importance of the Proteoglycan Filaments as a “Spacer” for the Cells and in Prevention Rapid Flow of Fluid in the Tissues. 
    The proteolycan filaments, along with the much larger collagen fibrils in the interstitial spaces, act as a “spacer” between the cells. Nutrients and ions do not diffuse readily through cell membranes; therefore, without adequate spacing between the cells, these nutrients, electrolytes, and cell waste products could not be rapidly exchanged between the blood capillaries and cells located at a distance from one another.
    The proteoglycan filaments also prevent fluid from flowing too easily through the tissue spaces. If it were not for the proteoglycan filaments, the simple act of a person standing up would cause large amounts of interstitial fluid to flow from the upper body to the lower body. When too much fluid accumulates in the interstitium, as occurs in edema, this extra fluid creates large channels that allow the fluid to flow readily through the interstitium.>  Hall JH, Guyton and Hall Textbook of Medical Physiology, 12th edition, 2011, Saunders Elsevier. p. 299

  
My contact with new moms now is mostly by phone. I myself have only in the past year begun nonchalantly ask their bra cup size as part of my counseling. I do this because I realize much more fully the reason(s) why someone with a pendulous breast would be more likely to experience quicker return of excess fluid back to the nipple-areolar complex, perhaps even before latching could occur, in response to gravity. Only definitely anti-gravity positions can prevent most of that. The closer to flat the mother is positioned during RPS, the more time it will keep the pressure of excess tissue fluid in the breast from moving back to the NAC.


Nor did I fully realize that the same thing occurs in an edematous, pendulous breast in response to vacuum, because in that situation, both gravity and vacuum are likely to be factors in the prompt movement of excess interstitial fluid toward the NAC. 


1.) The force of gravity would act on the weight of the fluid. 


2.) The internal pressure of the excess tissue fluid would push its way toward the area of low pressure in the flange tunnel area to try to equalize pressures, because "Nature abhors a vacuum." 


The more pendulous the breast, the more inventive the NICU or postpartum or home care nurse or LC or WIC peer or LLLL might need to be, depending on response to the pump. I confess I am not at all directly experienced in this situation with pumps, so I am using mostly imagination here. In the case of a mother with a very pendulous breast, it might be feasible for her to lie on her side and pump one side at a time (after thorough RPS). I seem to remember a letter to the editor of JHL in 2011(?) that described just such a suggestion in use at one hospital.  Or perhaps it might be possible to elevate both breasts upward from the abdomen with a pillow as close to 90 degrees from the chest wall as possible while pumping. If neither of these is feasible, then the alternative would be to do RPS more often in the mom with a pendulous, edematous breast, perhaps at 5 minute intervals, or according to how much resistance is developing to the exit of the milk flow when pumping. Perhaps there would be fewer reports of "getting a little colostrum the first day, and then getting less or nothing to come out the second day."


I realize that I'm probably "preaching to the choir", but it seemed like such an "aha" moment when I read that quote that I wanted to share it. I thank all of you who are fans of RPS for your support in spreading the word to moms, to hospital staff, pediatric and OB office staff and WIC staff members, and home visit nurses and LLL folk too. Excess peripartum IV fluid seems here to stay for the vast majority of new moms in our area, sometimes dramatically lifesaving, but more often, "not so much." I personally think that edema and its distortion of the NAC is one of the huge "flies in the ointment" of why so many mothers (and babies) get off to such a poor overall start at breastfeeding that families start "leaning on" AIM, resulting in less frequent milk removal, and the cascade to early weaning is "off to the races."  


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

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

Archives: http://community.lsoft.com/archives/LACTNET.html
To reach list owners: [log in to unmask]
Mail all list management commands to: [log in to unmask]
COMMANDS:
1. To temporarily stop your subscription write in the body of an email: set lactnet nomail
2. To start it again: set lactnet mail
3. To unsubscribe: unsubscribe lactnet
4. To get a comprehensive list of rules and directions: get lactnet welcome