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From:
"K. Jean Cotterman" <[log in to unmask]>
Reply To:
Lactation Information and Discussion <[log in to unmask]>
Date:
Tue, 8 May 2012 19:21:13 -0400
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I have had a special interest in inverted nipples for many years. I have not read whatever literature is defining Type 1,2 & 3 nipples and would be interested in a new reference to read. 

I agree that not all inverted nipples are of the same type, due to anatomical developmental differences in the subareolar area. When this single term is used, it can confuse things just as if we were to use the single term "fruit salad" when some of us are speaking apples and oranges versus pineapple and bananas! I have found the terms "invaginated" and "umbilicated" especially descriptive. 


There was one article about a Canadian doctor who placed nipple jewelry well underneath the nipple button, and the tissue expansion response of the subareolar ducts (now often used in plastic surgery, based on the example of abdominal skin growth during pregnancy) caused them to lengthen so that at term the nipples were no longer inverted. 


I have used prenatal vacuum preparation starting at 37 weeks (with physician's permission) and photographed perhaps 5-6 mothers with inverted nipples at various prenatal and postnatal stages. I have had at least two mothers whose nipples looked exactly like each others nipples during pregnancy. The nipples themselves were unable to be seen at all prenatally despite close inspection/palpation. 


One mother's nipples turned out to be "umbilicated", responding to the prenatal preparation by eventually coming out easily for a few minutes after pumping. By the time of birth, using a few minutes of pumping before feeding, they came out very easily for easy latching. 


The other mother had just one such totally inverted nipple (like her mother an aunt, so probably genetic), that did not respond whatsoever, so I considered this nipple invaginated. Her other nipple, just slightly retracting, did respond enough that one sided nursing worked very well for this mother. Milk issued from the invaginated side in response to MER, and with massage, pumping kept the breast relieved. I suggested to the mother as one option the possibility of continuing pumping this side for EBM supplement "just in case", but she became confident enough later to continue with one sided breastfeeding while letting the invaginated inverted side dry up. 


Renee's answer contained this sentence:
< most of the babies have figured out what to do and the pump has likely made the nipple / areola more stretchy.>


Would that it would work that way often. It has been my experience that areolae, rather than becoming stretchy,  often become more puffy from early pumping, due to the edema factor. Once again, before each pumping, I highly recommend manually moving any edema back upward out of the subareolar tissues temporarily, by using reverse pressure softening in a laid back position as part of the management strategy where pumps are used, especially if nipple inversion is part of the mix.


A MOT is probably more likely to receive "obstetrical management" in the peripartum period, also depending on the anesthetic. She may also receive 3rd stage management with IV pitocin for 1-2 days because of her higher risk for pospartum hemorrhage due to the extra enlargement/stretching of her uterus from twins. It is my observation that 
pre-L-2 edema (my phrase) may come relatively early if >2000 cc. of IV fluids in a 24 hour period are received before the birth of the placenta (the trigger for the hormonal cascade leading to L-2). 


This pre-L-2 edema seems to arrive correspondingly later (Day 4-6) if hours of postpartum IV fluids with the added antidiuretic effect of extra pitocin is added to the mother's own oral fluid intake, and may therefore arrive after the mother goes home. Thus, this edema may be superimposed on the swelling of L-2 itself, and both may lead to post-L2 edema (the old fashioned defined kind, before IV's or pitocin induction were common.) Definitions crafted at that time attributed edema as being caused by "back-up" of tissue fluid, unable to be processed efficiently because of already swollen circulatory vessels and overly full ducts.  "Engorgement" still remains poorly defined, partly because not all labors are "managed" alike.

Again, vacuum does not pull - other forces push, and edema pushes forward easily because it is not 'contained' within vessels or ducts, and therefore has much less resistance and can "push forward" more easily to equalize the pressure gradients. This often soon "crowds" the areolar tissues within the first several pumpings, preventing much milk removal or eversion of nipples, since areolar "stretch" is being used up containing edema, and crowding the ducts.


Depending on whether the mother's breasts are pendulous, gravity alone may concentrate this edema toward the nipple-areolar end of the breast.


So while I haven't answered the original question (about what might work for this particular mother) I do hope I have stimulated thinking about differentiating between kinds of nipple inversion, and between mothers who receive different types of "obstetric/anesthetic management" during labor. Pumps have turned out to be valuable tools, but I have seen them cause almost as many problems as they solve during the first week or two postpartum in cases where neither professionals nor lay people fully understand either vacuum principles and/or the microanatomy of the nipple-areolar end of the breast.


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

Scholten E, A novel correction of inverted nipples during pregnancy Am J Obstet Gynecol, Vol. 181, No. I, July 1999 p. 228-229.

Schwager RG, Smith JW, Fray GF, Goulian D Jr., Inversion of the Human Female Nipple, With a Simple Method of Treatment, Plastic & Reconstructive Surgery, Nov. 1974, Vol. 54, No. 5 pp. 564-569.

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