Lisa writes:

<I was reading the archived messages on edema and delayed milk supply and have yet to find any links to research on preventing fluid from entering the breast following induction or csection and therefore preventing delayed milk supply through early breastfeeding (within the first 6 hours pospartum).>


Fluid enters the interstitial spaces for storage when mom receives (oral +) more IV fluid in 24 hours than a normal intake for a healthy person i.e. 2000-2500 cc. total. If she has received a significant amount of pitocin through hours of prenatal induction or augmentation or third stage management for 12-48 hours postpartum, even more fluid is retained . The normal number of molecules of raw matierals, hormones etc. being released from the arterial capillaries are diluted by the excess interstitial fluid, thereby slowing their arrival at the basement membrane of the milk making cells, which have to receive enough of them before they can initiate the onset of Lactogenesis 2. 


This delay also happens partly because the pitocin molecule can attach to the ADH (anti-diuretic hormone) binding sites in the kidney to somewhat delay prompt exit of fluid. (Natural oxytocin has this feature, logically to help body have MER and release milk from the breast and then tell the kidney to slow down urine formation so there is enough interstitial fluid left near the milk making cells for nature to make milk faster the first hour after a feeding removes FIL.)


The baby's nursing early on also spikes already high prolactin levels also, but if the progesterone in the fatty tissue can't promptly leave via the interstitial fluid through the venous capillaries and lymphatic capillaries, the binding sites are not available promptly for the prolactin. 


 < IE- How the baby at the breast early on signals to the body or prevents the IV fluid given from collecting in the breast> 


IV fluid which is given in quantities beyond 2000-2500 cc. or so in any one 24 hour period ends up with the excess gradually physiologically shunted to the interstitial tissue for temporary storagewithin 24-48 hours. This is caused by normal mechanisms in the blood stream trying to maintain homeostasis of the colloid osmotic pressure of the bloodstream in a healthy young woman.  (Hall JE, Guyton and Hall Textbook of Medical Physiology, 12th edition, 2011, Saunders-Elsevier.) 


The fact that an excess was given is an iatrogenic condition, but obstetricians and anesthesiologists are wary of liability issues if emergencies occur, and I doubt if our issues with breast edema will ever convince them to reduce the quantities per 24 hours. There will always be dire emergencies where mom and/or baby can only be saved by massive IV infusions and pitocin, and other drugs effecting the blood vessels, so we need to learn to deal with the resultant breast edema anyway. Other than adding the pressure of his weight to lymphatic drainage, I don't believe there is anything even the healthiest baby can do to keep (excess) IV fluid from collecting temporarily in the interstitial fluid in mom'sbreast. 


< and holding up the milk in the ducts.>

Collection of excess interstitial fluid will in fact, crowd the tissues behind the nipple with enough pressure aound the ducts eventually to exceed the pressure of the MER and "hold up milk in the ducts." Edema, which begins to pit after the tissue is holding more than 30% more fluid than its normally designed to store physiologically, will begin to migrate toward the nipple-areolar area: 


1) by gravity and/or 


2) by tissue pressure of excess interstitial fluids moving toward low pressure (vacuum) area in the pump flange trying to equalize the pressures. Nature abhors a vacuum. Vacuum does not pull; other forces push. Even the meteorolgists tell us "high pressure areas move toward low pressure areas.


If we pattern our interventions in line with gravity and positive pressure by 


1.) elevating the heavy (C cup and beyond) breast above the heart before pitting the areolar edema (RPS) and stimulating MER before and during pauses every 5-7 minutes if needed, during attempts to remove milk, then 


2.) use mostly the positive pressure of fingertip expression to remove milk in the first week or so, rather than so routinely using vacuum (often unwisely by then mistakenly turning it up stronger and stronger as milk removal slows) , and 


3) learn a lot more about elementary principles of assisting lymphatic removal of interstitial fluid (principles that are routinely taught to lay persons afflicted with lymphedema), 


we can avoid this invasion of excess interstitial fluid into the nipple-areolar complex area to interfere with exit of milk from the ducts, till the mom's body has gradually excreted most of the edema by day 7-14 (in extreme cases). 


<Does anyone have any links to the research or know of this research? I remember learning about it but can't pinpoint the studies..  Maybe it was done by a breast researcher vs an IBCLC?>


There are some researchers (IBCLC's and others) who are beginning to do more and more research on breast edema. I know of one such study on breast edema now starting in Canada that will take several yeas to complete. We need many, many more.


The opinions above are my anecdotal conclusions from my observation of the changing patterns in postpartum breast swelling from the waning days of the WW 2 baby boom, continuing over the past 63 years. My first student nurse clinical night duty for one month was in 1948, alone on postpartum. Mothers with vaginal deliveries stayed 4-5 days. The few inductions, beyond term, were done by artificial rupture of membranes, or very rarely, nasal pitocin (a q-tip dipped in an ampoule of pitocin was kept in one nostril till labor became sufficiently active to suit the doctor!!!).


They had been NPO often for 24+ hour labors, received just 1 cc. of pitocin IM, + ergotrate or methergine after the placenta, no IV fluids except in the direst of emergencies, received twilight sleep in labor (making their mouth dry), general anesthetics (making them nauseated for hours postpartum and likely to faint easily if gotten up before 8-12 hours). Babies were NPO for 12 hours, received 5% glucose water per rubber nipple every 4 hours x 3,  and at 24 hours, started time-limited, rigidly scheduled breast feeding on one breast per feeding  There was liberal complementary and supplementary formula feeding in the newborn nurseries 24/7. There was plenty of breast swelling by the 2nd or 3rd night!!! There were no pumps except bicycle horn hand pumps, which required a doctor's specific order to use. 


I palpated many swollen  breasts and applied dozens and dozens of breast binders that month, partly because nursing bras had not yet appeared on the market! The binders were welcomed by the moms because they felt so good. Only if applied tightly and kept on 24/7 for mothers who lost their babies or preferred to go beyond suppression of lactation with stilbesterol 3 times a day, did they cause milk to eventually dry up. (Compression is one of the main mechanisms that today's lymphedema treatment utilizes.) 


I worked in the hospital OB department for 23 years extending through the implementation of the new management practices of perinatal care with plenty of IVs, etc. etc. and have followed the radical shift in the nature of postpartum breast swelling despite early initiation of breastfeeding on demand. I heard of this continuing while I worked on public health prenatal care for 20 years and have continued to observe this pattern during my volunteer practice with WIC to the present. 


I am noting a few studies of IV fluids/edema/etc. especially in connection with excess weight loss in newborns whose moms got IV's in the hours before birth. I am certain there are many that I don't know of, and whichever ones you or anyone else finds, I would love to know about them. 


If you have not read this article, I think you might find it of interest, including some of the references dealing with colloid osmotic pressure changes with differing amounts of IV fluid in the intrapartum period.


Cotterman KJ, Reverse Pressure Softening: A Simple Tool to Prepare Areola for Easier Latching During Engorgement, Journal of Human Lactation, May 2004, vol. 20, iss. 2, pp. 227-237. 


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

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