I have been musing on the many recent posts that link with something I've
been wondering about for over 30 years, since the increase in IV's in
labor, especially with synthetic oxytocin (pitocin), and the introduction
of more electric breast pumps into hospitals.

<. . systemic maternal edema and observed delayed onset lactogenesis II.
For years I have noted that there is a tendancy for moms with those
swollen ankles, etc. to have no early experience of engorgement. Their
milk trickles in, and doesn't typically build to a good supply for
several weeks.> < . . .but it is most common in women with pitocin
inductions who have had lots of IV fluids.  I definately think this needs
study.>

<I agree with Barbara Wilson Clay's observations of systemic edema and
delay in lactogenesis. I have seen a series of women who have received
pitocin, lots of IV fluids in labor. They typically have extreme edema
of the legs and sometimes the areolar tissue. Milk comes in very late,
past the 5th day and it comes in in drips. . . I agree that a study is
needed.>

<Attempted
pumpiing with a hospital grade pump - only drops obtained.> <At that time
she rated engorgement a 5 out of 5 -
very firm, no s&s of mastitis.>

<I am amazed at the
number of nipples which, on examination, look
well-everted, but then retract toward the chest wall
with compression (the "pinch test").>

<very little to no expressible colostrum,
engorgement which is not relieved with nursing or pumping and then no
milk. I
have a hunch that this unrelieved engorgement, coupled with the picture
of
very tight breast tissue, leads to involution. Or maybe it is the very
tight
breast tissue which leads to severe engorgement which is difficult to
impossible to relieve before the milk dries up.  I agree with Barbara
Wilson
Clay that there is something in the mechanics of breastfeeding that we
are
missing here.>

I cannot give the exact reference, but there were 2 articles in the same
edition of JHL about 1995 that reported on an extensive scholarly
research study of engorgement. (Barbara, can you help out here?)

I remember that I did not give them too much personal credence because
the independent variables did not include, nor exclude, either IV's or
Pitocin (which even before common IV use for induction, I remember we
used to give 1 cc. of pitocin after delivery of the placenta, by IM
injection to vaginally delivered mothers, and by intrauterine injection
to C. Section mothers, more if the uterus was boggy.)

I agree that some newer, in-depth studies need to be done taking these
additional factors into account, and comparing mothers with various
interventions in hospital labor and delivery, with home or birth center
births without IV's or any form of synthetic oxytocin.

I doubt these studies would convince any physicians to modify their
protocols. But they could provide solid evidence on which to base
pro-active childbirth and breastfeeding education for informed consent,
as well as breastfeeding interventions.

My reading has led me to some understanding that oxytocin shares chemical
similarities with ADH (antidiuretic hormone), and probable competition
for binding sites.

Overhydration also affects ADH action. I have noted that many women with
such interventions take close to two weeks to attain significant
diuresis.

Different formulations and amounts of IV fluids might effect the sodium
levels in the body. Serum proteins (possibly effected by fasting?) also
play a role in tissue fluid exchange. Gravity itself plays a role in the
distribution of edema (i.e. pendulous breasts, or perhaps more in ankles
when breasts are not pendulous?).

Given that we are confronted with the existence of L&D interventions with
no control over the probability of some edema, I feel the next best thing
for our clients is for us to understand how to avoid complicating its
effect on the initiation of lactation.

Normal amounts of tissue fluid can be increased by 30% before edema can
be assessed visually. Excess fluid occupies space and effects tautness of
the breast and elasticity of the nipple-areolar complex.

Therefore, I think it is important to realize that even without visible
edema, the presence of excess tissue fluid can enter into the mechanics
of milk transfer.

Technology has value, but "hands on" care, and actual palpation will
always have a valuable place in health care. And there will always be
HCP's who have not become knowledgeable or comfortable with it. But I
think "First, do no harm." might apply here.

From 2 of my posts June 14: < vacuum does not "pull", even though it
feels like it. In the case of a breast pump, it greatly reduces the air
pressure on a few square inches of skin, causing the normal air pressure
(at whatever altitude) to exert force on the rest of the surface of the
breast to seem to "push" the front of the breast into the flange because
"nature abhors a vacuum"! . . . . .Pumps act on flesh first, including
all the blood, tissue fluid, connective tissue, etc, as well as any milk
present . . .>

<Vacuum does not act directly on milk till it exits the nipple. It acts
first on flesh. If overhydration is present, vacuum can cause
accumulation of edema
in the area circumscribed by the bell of the pump, causing the areola
itself to "suddenly and mysteriously" become swollen, perhaps moreso than
the rest of the breast eventually appears to be.

This concentrated layer of edema often prevents effective compression of
the milk sinuses by infant, pump or fingertips, thereby theoretically
reducing the amount of colostrum . . . . >

Once again, we are back at "thorough removal of milk is the main stimulus
for milk production." Even at this hormonal stage of lactogenesis, I
wonder if this plays some part in its speed.

With binding site interference, who knows how this effects triggering and
vitality of the MER? This, according to veterinary literature, is THE
most important factor in efficiency of milk removal. Even if interference
exists, "Breast compression can simulate . . . . . .MER." as Dr. Jack
says.

If we were to avoid the vacuum effect on the breast tissue in the early
postpartum period, a baby's good latch and/or use of effective massage
and fingertip extraction (via a method like the Marmet method) would
theoretically move forward larger amounts of colostrum sooner (and
oftener), which might lead to faster production. (This method can yield
colostrum easily in most mothers, even in late pregnancy.)

If despite the avoidance of early pumping, or even because of it, there
is already enough edema to interfere with compression of the sinuses,
then Reverse Pressure Softening before latching or fingertip extraction
helps. From my post of 3/28/01:

<Simply place your thumbs or the flats of the mother's two fore fingers
(perhaps placing your thumbs on top of them) just opposite each other,
near the base of the nipple. Press the areola gently but firmly straight
inward toward the chest wall for a full 60 seconds by the clock, then
repeat in the opposite quadrants.

Or if the mother has short nails, I tell her to curve the 3 middle
fingertips of each hand and "plant them" at the base of the nipple with
the flat surface of the fingernails actually touching the sides of the
nipple, then press straight inward on the areola.

I suggest that she sing a full lullaby, which occupies close to 60
seconds and sounds less worrisome than watching the clock. And as Diane
has so cleverly put it in one of her new papers, the object is simply to
make a ring of dimples at the base of the nipple.>

<This maneuver accomplishes three things:

1) It temporarily moves excess interstitial fluid toward the inner lymph
channels and temporarily removes it from the areolar and subareolar area,
to give the baby a fighting chance of a better latch.

2) It presses on the anterior openings of the milk sinuses, relieving any
overfullness by temporarily pushing milk back up into the contributing
ducts. (When sinuses are overly full, direct compression of them causes
distinct pain. When they are less full, fingertip expression is painless
and much easier, and provides further softening of the areola)

3) Stimulation of the nerves deep beneath the nipple never seems to fail
to elicit MER.>

(Well, maybe not, if binding site interference exists.)

<I hope many of you find this helpful. Edema does not have to be severe
for this to help. In fact, in cases with severe edema, it may be
necessary to do it more than once before the feeding to accomplish enough
softening to help milk transfer.>

Jean (striving on Independence Day toward independence from so many
breastfeeding problems)
**********************
K. Jean Cotterman RNC, IBCLC
Dayton, Ohio USA

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