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From:
"K. Jean Cotterman" <[log in to unmask]>
Reply To:
Lactation Information and Discussion <[log in to unmask]>
Date:
Sat, 29 Dec 2012 16:40:40 -0500
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Betsy writes:

<Mom of a 5 day old baby has severely eroded nipple tip and serious crack at the base of her right nipple.  . . . .Engorgement is very bad. . . . . . .We resolved the engorgement. . . .

At 5 days???????

Sorry. For me, the use of the word "engorgement" in this day and age is practically like the use of the word "bellyache" in my youth: the early and mid 20th century. It has become essentially a "wastebasket term" to me when problem-solving in the 21st century. It depends on how the mother's labor was "managed" (or not), either in "developed" countries, (or not). We will always have mothers with true emergency situations that require life saving measures of IV fluid and pitocin, so we would do well to know how to help those mothers. But IME, many mothers receive "management" for far different reasons. 


Also, in the early to mid 20th century, the moms I cared for in my locality were seldom induced with medications (pituitrin and pitocin were only first made and used in the 1940's-1950's) NPO during even long labors, given "twilight sleep" to dry the mouth, no IV fluids except in dire emergencies, general anesthetics with attendant N&V afterward, and babies were not put to the breast for 24 hours, and for scheduled and short periods during waking hours and supplemented and complemented ad lib. These are the conditions under which much of the early writing about engorgement may have been written. The word has continued in use despite the introduction and common use of "management of labor" as part of perinatal medicine.


IME, in my locale today, postpartum breast swelling can consist of any combination of: 1) normal evolution of breast circulation following involution of the uterus, 2)storage of excess IV fluids in the spongy protective tissues of the breast (especially if pitocin's anti-diuretic effects are involved) and/or 3)actual milk in the process of formation or storage.


These questions occur to me:does she have a C-cup bra or larger, in other words, any amount of pendulousness??? If so, gravity may be complicating the equation. Vacuum, too, often complicates the equation (because 5 centuries of evidence base exists to prove that vacuum does not pull; other forces push. But few folks in the lactation world seem to be conscious of that.) Even more pertinent, did she have IV fluids? >2000 cc in any one 24 hour period? Any number of hours of IV pitocin, either for induction, augmentation or especially for many hours of third stage management???? 


If so, before  eventual return to the circulation for elimination by the kidneys, storage of excess hydration moves first to the interstitial tissue through which the hormones and raw materials for L-2 must be able to pass to reach the membranes of the milk making cells so that L-2 may begin. Thus, excess interstitial fluid may push forward to distort the nipple-areolar complex, delay the onset of L-2, sometimes overlay the swelling of L-2, and sometimes, if IV pitocin was given for hours postpartum, increase on day 4-6 to further complicate matters by responding to gravity (in C-cup or beyond) and/or vacuum. 


Whatever is decided about the damage, to avoid further damage, since she is taking a "nipple vacation", if C cup or larger, I would encourage:

1) Have the mom assume a well "laid back position", 

2) have her elevate one breast above the rib cage/heart, and 

3) Then, possibly use a minute or two of upward massage of the breast (as if soothing lotion) upward toward the axilla and central chest, to help the lymphatic drainage 

4) Then do a slow, 3-5+ minutes of gentle RPS all around the areola at the base of the nipple so as to help get the interstitial fluid back away from the pump flange area. 

5) before pumping (with an appropriate size flange), have her lie flat on her side to pump one side for 5-7 minutes (to keep gravity at bay on the interstitial fluid that pushes its way forward like floodwaters in response to gravity as well as vacuum.) When 

6) when the flow slows, take a short break to massage the upper breast to push milk forward manually, 

7) resume the anti-gravity position, repeat the RPS for 1-3+ minutes, turn again flat on one side to pump 5-7 minutes more. Better to use short frequent pumping sessions more often using the above anti-gravity suggestions till even 10-14 days in some situations with hours and hours of IV fluids/IV pitocin.

8) When she when she goes back to direct breast feeding, it may be helpful to use some version of the above hints to remove gravity from the equation much of the time, and use RPS gently for as many minutes as it takes to fully soften the areola before latching.

This series of considerations would of course not be needed if the mother's breast is not pendulous, and in a situation with few hours, if any, of IV fluids. 


But this illustrates why the word "engorgement" in the 21st century has begun to give me a "bellyache";-)


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


  
 
 

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