Ann writes in response to Arly's question:
"film . . . showed moms gently rolling and tugging their nipples prior to
feedings. What this does is start the hormonal stimulation and there are
many women who bring up colostrum just doing this.>

I imagine through folk wisdom that women in close-knit social and
multi-generational cultural surroundings, especially in agricultural
societies, have for aeons passed along an intuited knowledge about the
MER, and self-stimulation of the nipple to achieve it. Is this what you
are referring to as "bringing colostrum up"?

In giving anticipatory guidance one on one prenatally, I have palpated
many nipple-areolar complexes and examined for nipple protracitlity and
taught many mothers hand expression in late pregnancy. I have found that
some colostrum is already far forward in the breast, and at least a drop
or two of colostrum is expressible in most mothers in the late third
trimester. Fingertip expression itself almost always stimulates MER, but
some colostrum was already "up" forward in the subareolar ducts (sinuses)
to begin with. Some mothers even leak copiously prenatally due to short
galactophores (collecting ducts) and shallow sinuses.

<I have been doing this with every mother, especially in the first 2 days
so that they get comfortable with touching, bring out the colostrum, and
I can see how responsive their nipples are. I do not like to be the ones
to touch their nipples because it may not be comfortable for them and I
could potentially pinch too hard.>

Some people are uncomfortable being "hands on" practitioners, especially
if they are trained in a non hands-on profession or are the baby's HCP.
Obstetrical practitioners are by definition "hands on" of the pelvic
area, but not necessarily the breast. I respect your feelings and your
sensitivity to the mothers' sensations and feelings. From comments we
hear in our WIC office from new mothers, they sometimes perceive some
hospital nurses and LC's as rough and insensitive. (I don't doubt that
some in the past have said the same about me. I hope I have become more
sensitive with experience.)

But for those interested, so much more can be learned about function of
the particular nipple by palpation (slow gentle compression, never
pinching!) than by visualization alone. Heredity and embryological
development have a great deal to do with the amount and distribution of
connective tissue (which includes muscular tissue) in the nipple areolar
complex. A nipple can appear to be flat, or nearly flat and still have
excellent protractility.

Deep protractility is what matters to the baby's efforts, so that the
areola can elongate to position the muscular part of the nipple deeply
toward the soft palate and the sinuses accessible to the tongue. A nipple
can also appear to be very well everted but function with a remarkable
degree of retraction, exposing the muscular part (mammilla) to a great
deal of trauma between the tongue and the hard palate, and preventing the
milking of the subareolar ducts (sinuses) by the tongue..

One must of course ask the mother's permission. If you go slowly, elicit
feedback from the mother and watch her body language closely, you can be
sensitive and still learn much, one mother at a time, about her
particular nipple anatomy and function. .

< Regarding your next comment you said: >What I wonder is, in a nipple
that in late pregnancy has shown little to no protractility, and has not
improved in the hours since delivery and the baby for whatever reason
can't take the whole nipple-areolar complex into his mouth and breastfeed
successfully, what are others doing to correct the situation?>

After being an L&D nurse for years, this is how I began, first as a
postpartum/nursery nurse, and later, as a childbirth educator and
prenatal nurse, to get interested in the subject of nipple protractility,
and the inner anatomy of the nipple-areolar complex, by doing prenatal
nipple function assessments. We offered private assessments at the end of
a prenatal breastfeeding class, and every mother came to the class
expecting to receive this assessment. This means they were self-selected,
of course, but so many were very appreciative, because the opportunity
seems to be ignored in obstetrical practice.

I have seen nipple protractility improved prenatally by judicious use of
vacuum after 37 weeks g.a. I have close-up pictures from several cases. I
disagree with the conclusions of the small amount of formal research on
the subject but I have refused to ignore what I saw when I recognized
marked potential for problems and pretend that nothing could be done
prenatally anyway. I realize some mothers are turned off by the idea of
preparation. But I think the mother deserves to be informed of
conflicting opinions on the subject and make her own decision as to
whether she wants to prepare by working on protractility prenatally.

From my observations I began to develop my concepts about reverse
pressure softening in the immediate postpartum period. In  Eugene,
Oregon, Martha Johnson tells me that she and her staff are teaching all
new mothers pro-active use of RPS from the earliest feedings, due to the
increased number of labor interventions that are causing increased edema
in the postpartum breast. This way, the mother benefits from the
increased pliability of the areola and the advance triggering of MER from
the very first feeding, and is also equipped with this skill to improve
latchability during any increase in edema that often arrives after she
leaves the hospital.

< I've seen these situations correct themselves, and I believe most of
them can>

Yes, but too often, not in the crucial first two weeks of breastfeeding
when mother and baby are trying to learn.

<but there seem to be only two tools for change other = than the baby:
the pump and the reverse syringe. It would be a shame not to correct a
correctable situation.> . .<Also if she has any areola edema the nipple
cannot reach deep enough into the shield, even with reverse pressure.>

By definition, edema is excess interstitial fluid. It is not visible to
the naked eye until there is 30% more fluid than the tissues normally
contain, and pitting does not begin to occur till there is 30-50% more
fluid than normal. What then if a mother has 29% more? 15% more? Even
5-10% more? Many mothers have this much or perhaps more already in late
pregnancy, especially if the breast is pendulous. IME, some degree of
excess tissue fluid in the nipple areolar complex is almost always one
factor (besides genetics, surgery or breast disease) in poor
protractility of the nipple.

The more interstitial fluid and colostrum/milk, intraductally there is
present beneath and deep inside the areola, the more minutes it takes for
RPS to comfortably move either/both fluids far enough away from the
surface to temporarily improve protractility for long enough for the baby
to latch effectively. The more marked the swelling, the more slowly and
gently it should be started, watching the mother's body language before
any increase in pressure.

For some mothers, 1-2 full minutes is very helpful. For others with
severe edema and/or poor protractility, perhaps 5-10 full minutes (or
more if desired) when the baby begins giving hunger cues, may be
necessary to fully soften the deeper areas behind the areola during the
height of swelling. If fingernails are short, curved fingers seem to give
better leverage than straight fingers. Thumbs also give the HCP better
leverage.

< I have found in the first couple of days the nipple more sensitive so
pulling on it with a pump or syringe can be uncomfortable.>

Especially if anyone involved has the mechanistic, 'wet-vac, sump-pump'
mindset that "more vacuum is better and quicker, and the more severe the
problem appears to be, the higher the vacuum should logically be". This
has the potential to make matters worse! Interstital fluid can be
attracted to the nipple-areolar complex by too much vacuum.

<I strongly believe women should wait until they are at least 24 hours
postpartum before introducing a nipple shield. I find it more difficult
for the baby to obtain the droplets of colostrum through the shield.>

To use a shield, or not to use a shield-that is the question. It is a
highly individual assessment, but certainly, increasing nipple
protractility by softening the areola, and stimulating the MER before
latch are important and helpful whether or not a shield seems indicated.
If the areola is softened it can extend the location of the subareolar
ducts (sinuses) forward much more easily to compress themselves against
the tunnel of either a shield or a pump flange.

<Having the mother hand express, dropping her colostrum onto the baby's
lips and mouth has the benefit of knowing the baby actually got the
colostrum.>

I heartily agree. And even hand expressing a few drops into a baby spoon
to feed the baby is sometimes easier to manage. I believe knowing the
ancient womanly skill of how to hand express empowers mothers. So few
mothers coming home from hospitals in our city ever seem to have a foggy
idea of how to do it efficiently. Becoming too reliant on technology can
result in "throwing the baby out with the bathwater."
Jean
************
K. Jean Cotterman RNC, IBCLC
Dayton, Ohio USA

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