Natascha,
It was my practice for years as a prenatal nurse to offer nipple
assessments in the 3rd trimester to moms planning to nurse. I found that
a large percentage of moms retain SOME extra fluid normally, all over
their body, during late pregnancy. If this "condition" is actually
hypertrophy of breast tissue, that of course is a whole different
situation.
Some mothers seem to notice more fluid retention in the breasts than
others do, but I found it very common to see enough edema to show visible
imprints of bra seams and some functional retraction of the nipple,
especially if the mother's breasts were pendulous to start with. This
swelling in pregnancy seemed to be more noticeable in moms who reported
they were more prone to premenstrual breast swelling and water
retention.
It seems that for eons, nature in her wisdom, has been preparing mothers
in this manner during pregnancy. In case of hemorrhage during labor,
fluid could be drawn out of the tissues quickly to maintain blood
pressure for a short time in an minor emergency until the baby could be
put to breast immediately after birth to expel the placenta and contract
the uterus.
There was a time 3-5 decades ago when physicians in this country at
least, routinely placed nearly all mothers on diuretics, thinking they
were reducing the possibilities of "toxemia", or PIH as we call it today.
This practice fell out of favor about 30 years ago, and many physicians
trained in the meantime don't remember. Few of them, unless they can spot
edema with the naked eye, even press a thumb on the ankle or shin any
more to test it to see if it will "pit". That used to be a familiar
gesture at every prenatal appointment.
This is one of the reasons mothers in the 3rd trimester are encouraged to
lie down on their side at least once mid-day, to shift the weight of the
uterus and allow better circulation to the extremities and kidneys, to
get rid of any swelling making the mother uncomfortable (tight shoes
etc.)
Unfortunately, IV fluids in labor, IV pitocin induction and/or
augmentation, and especially those fluids given to "overhydrate" for the
sake of blood pressure control during epidural, seem to delay the body's
postpartum clearing of this fluid.
It may be due to competition with binding sites for anti-diuretic
hormone. I don't pretend to understand it thoroughly, and am trying to
find references to help me do so. It is not unusual to see mothers with
pitting edema all the way up in their thighs even at 10 days postpartum.
The breast tissue seems to participate in the retention of this excess
fluid.
When this situation must be managed postpartum in order to allow the baby
to latch effectively, IMHO the use of a breast pump to "pull the nipple
out" is counterproductive. In fact, it can make matters worse, because
the vacuum often simply draws more tissue fluid forward in the areola,
"burying" the milk sinuses deep in a thick layer of edema.
If breast shells are used, the larger opening seems to produce the same
type of effect as the pump, but if shells with the smaller opening are
used inside the bra for 20 minutes before nursing, this may displace
excess tissue fluid from the areola near the nipple.
If a mother is assessed as having little protractility to her nipple, the
tissues are quite often crowded with fluid even if it is not apparent to
the naked eye. I have found it effective to use what I call "Reverse
Pressure Softening" before attempting to latch. This is essentially
"pitting" the edema out of the area temporarily, and consists of two
phases. The purpose is to free up as much of the mother's elastic
potential as possible for the baby to use in latching.
1) First, pressure is placed on the areola, close to the nipple:
* Right next to the base of the nipple, mom (with short
fingernails, using both hands) places the tips of her
index, middle and ring fingers (bent) on the areola and
pushes straight in toward the ribs for long enough to
sing a lullabye (45-60 seconds if actual timing is
desired.)
* This moves any excess interstitial tissue fluid back toward
the lymph capillaries. It may also push milk back up from
the overfull sinuses into the ducts temporarily, or may
cause some to come out the nipple.
* (A HCP can also do this for the mother to start out, by using
both thumbs placed at the base of the nipple and exerting
pressure as described above. It will be necessary to move
the thumbs 90 degrees around and press a second time to
"pit" what the mother can "pit" with 6 fingertips.)
2) Finish with deep digital extraction:
*Start an inch or 1 1/4 inch from the base of the nipple, using
bent fingers. Press firmly back toward the ribs while
rhythmically closing the fingertips over the milk
sinuses to remove enough to make the deep areolar area
very soft.
*All this may also elicit MER so the baby gets more in a
shorter time. This pitting will last long enough to give
the
baby a fighting chance to attempt a decent latch. If the
second side is used, it is better to soften it just prior
to latch.
Palpation of the softened side in comparison with the unprepared side can
demonstrate to the mother just how much tissue resistance has been moved
out of the way to help the baby. I keep reassuring moms that this
swelling is temporary, and they can skip this step when the baby can
latch without problems or nipple trauma.
I would really be interested in feedback from anyone who tries this and
finds it helpful, or disagrees strongly, etc., etc. I feel strongly that
it is a previously unrecognized missing piece of the puzzle for achieving
a good latch in the lactation initiation process.
Jean
-------------------------------------
K. Jean Cotterman RNC, IBCLC
Dayton, Ohio
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