Pam writes:
<I think in hospitals it is important to keep talking about "safety" and what is the evidence telling us?  We have strict protocol on hypoglycemia (low blood sugar) but the nurses (well the majority of them anyway) know that means breastfeed the baby, not necessarily formula.  Unless that baby isn't latching and then they (well, most of them) know to start mom on pumping.  I don't know but just a couple of nurses that will try to help the mom hand express colostrum.  Something I will bring up AGAIN in our annual review this year. >
 
 
Just as necessity is the mother of invention, I'd like to suggest that careful empirical observation has given birth to a lot of common sense hypotheses. This is largely how health care has thus far seemed to operate and integrate new ideas until someone accepts the challenge of doing the necessary research to disprove or prove the validity of such hypotheses. Until such evidence exists, is there no place for common sense?? Thus far, I am aware of only 2 researchers, one in Europe and one in the Middle East, who have yet thought about doing formal research on my empirical observations, but I hope more will try. 
 
 
A more indepth understanding of anatomy and physiology is helpful too. 
 
 
<These experiments give further support to the concept that the interstitial fluid pressure is normally negative but becomes positive as edema fluid accumulates.> 
Guyton AC, Interstitial Fluid Pressure: II. Pressure-Volume Curves of Interstitial Space, Circulation Research. 1965;16:452.) (Dr. Arthur C. Guyton was the preeminent cardiovascular physiologist of the 20th century, who researched interstitial fluid and edema extensively.)
 
 
Many mothers in the U. S., and around the world, now receive large volumes of IV fluid either for obstetric interventions and/or anesthesiology management. In addition, there is the anti-diuretic effect of any pitocin administered (be it for induction, augmentation, or the small dose nearly universally used in third stage management.) 
 
 
Depending on how early, how rapidly and how much IV fluid has been given, I have often observed what I call "pre-L-2" edema. For some few, it may be visible very early, perhaps already at birth. For many, it only becomes obvious soon after the mother is discharged around 48+ hours, with no HCP contact for several more days or longer. (It appears quite different to me from "post L-2 edema" which was what I observed in the mid-20th century, from different obstetrical and newborn care practices.) 
 
 
Specifically, my contention is that edema's early, gradual, predictable, unseen (insidious) formation needs to be understood and taken into account by postpartum health care providers. 
 
 
<Physicians have long been aware that signifcant reductions in COP values result in increased risk of pulmonary edema, a cardiopulmonary emergency, but thus far, no such association seems to have been recognized or apprecieated medically in regard to engorgement. Many lactation consultants and nurses have noticed increased edema in mothers who receive IV fluids>  
 
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. 
 
 
http://www.kellymom.com/bf/concerns/mom/rev_pressure_soft_cotterman.html
 
 
<Interstitial fluid volume increases 30% above normal before edema becomes visible. (Guyton) To contain edema, areolar tissues must expand, limiting their ability to extend the nipple well into the baby's mouth. Early proactive use of RPS causes no harm and may facilitate increased milk transfer, reduce risk of nipple trauma, and help resolve engorgement.
 
Conversely, pumping may attract  :-(  edema into the flange area, especially at maximum vacuum settings. Areolar tissue may then appear “thickened”, seeming to “bury” the subareolar ducts. Then, neither infant tongue action, fingertip expression nor the pump itself removes milk very successfully.>
 
 
What has been evidence based since at least the 15th century is the knowledge that vacuum (really) does not pull. Other forces push. Obviously, from the above paragraph, even though I fully recognized this, I had to learn to 'watch my language' when explainng it. Breast pump engineers, manufacturers and salespersons know this principle full well, but health care professionals seem to need a reminder of this fundamental law of nature. Let's not allow advertising to pull the wool over our eyes. 
 
 
When vacuum is applied to the nipple-areolar area, if edema is beginning to collect, its positive pressure differential will push the edema toward the tunnel of the flange because "nature abhors a vacuum." 
 
  
Demonstrating to a mother how to express colostrum into a spoon with her fingertips takes far less time (and expense) than providing and teaching her to use an expensive pump set that will be charged for, whether she uses it once or for days/weeks/months. 
 
 
OTOH, fingertip expression is free, and, while the subareolar ducts are being located and compressed, positive pressure is being exerted on the areola over Sappey's plexus and thus, may also assist physiologic lymphatic clearance of any excess tissue fluid present under the areola. If enough edema is already present to "bury" the ducts and prevent extrusion of colostrum by hand expression, I find RPS helpful. If a mother of a NICU baby must pump, then RPS before, and at 5-7 minute intervals several times during a pumping on medium or lower vacuum, has been reported privately to me to yield more milk sooner than continuous pumping for 10-20 minutes, on medium or high vacuum.
 
 
If and when anyone else seriously considers doing formal research on RPS, I would very much like to be notified. 
 
 
K. Jean Cotterman RNC-E, IBCLC
WIC Volunteer LC, Dayton, Ohio
 
 
 
 

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