Thank you Rachel, Virginia and Maria. Hear! Hear! Once again, I am emphasizing that I think we need to spread the 500 year old evidence based scientific message, among lactation professionals, at least, that VACUUM DOES NOT PULL; OTHER FORCES PUSH.

I would like to add to that list of profitable "gimmicks": the electronic rigamarole(s) built into expensive pumps to trigger the MER! Without ever explaining to the mom the empowering concept that nature supplies her with her own veritable "inner breastpump"! And that the MER is the most powerful force in milk transfer! And that it is the mother's very own MER at work that allows this magical electronic gizmo to perform this fascinating and rewarding result! 


I have recently been preparing my own latest project (another post for another time), and while gaining ideas, sat in on an infant feeding class of each of our WIC peers throughout the county, and even one done by an RD, IBCLC. Each class was a little different, some had to be "taught on the fly" for participants with other time commitments, some non-English speaking mothers, etc. etc. All in all, I was impressed with the way everyone handled the challenges. I was disappointed though to find that absolutely NO ONE explained the let-down reflex. I think that a simple explanation of MER really empowers mothers and their significant others to know about one more "natural" wonder that is already within their bodies, to know the common things that interfere with it, and how to use their own fingers and hands to facilitate it when helpful.


It took me a while to figure this phenomenon out while the concepts of RPS formed themselves in my mind over the years. But eventually, notice it, I did, namely that RPS, held steadily for at least 30 seconds (or more if needed to displace edema), has never, IME, failed to elicit an MER, usually within the SECOND 60 SECONDS after it was first applied.
 

I once responded to a midwife/lactnetter who was staying for many hours a day in the hospital with her 8year old, stressed out by his illness, and having a hard time with MER when pumping for her 2 y.o. baby at home. I explained RPS carefully, and suggested she try it as instructed and then wait 60 seconds before she began to pump, and repeat a little later during the pumping if necessary. She was ecstatic. I think it would be a great help for mothers with babies in NICU aswell as for those who plan to pump at work to know this. Pictures, and aromas, backrubs and built-in recordings of cries can of course, eventually do the job much of the time, but I have never seen appropriately-done RPS fail to elicit MER promptly. This is predictable, quick and under the mother's volition even if she is under stress.


My inquisitive reviewing of the anatomy eventually revealed the clue as to why it works as it does. There is no fatty tissue in the nipple-areolar complex according to the surgeons. Nerves arriving from all around the breast must pass closely beneath the skin of the nipple areolar junction as they are on their route to enter the nipple through it's underside, into the center of the nipple, destined to wind and curl loosely around each one of the galactophores located in the central area of the nipple (not the outsides) all the way to the tip of the nipple. 


RPS presses on and stimulates these nerves when fingertip pressure is steadily held for at least 20-30 seconds on the areola near the thin skinned area where it joins the base of the nipple. Of course, if the mother has a lot of edema in that area, it's going to take RPS a little longer to relieve the edema, and perhaps even reach the nerves themselves. I have a caution though, for those helping moms with very pendulous or very full breasts: RPS requires gravitational help (and explanation of it as a TOOL the mom can continue to utilize) to continue holding edema at bay, so it stays out of the way for long enough for latching, or effective pumping. 


The neurological arc of the MER will be signaled during the process of RPS. The extra 60 seconds is simply to allow the oxytocin time to travel through the blood stream to the myoepithelial cells and start stimulating them to contract and move milk forward within the ducts. Among the many other time-honored ways to try to facilitate the MER, fingertip expression also does a marvelous job using the same anatomcal paths explained above. 


Edema is defined as 30% or more interstitial fluid than is normal for that tissue, and while fluid is collecting in tissues, quite a lot may be present but not yet visible to the unsuspecting eye. Some degree of edema is often present in the sub-areolar tissues in the early days, whether from: 
           1) pre-L-2 edema from multiple peripartum IV's, more with pitocin induction, augmentation or many hours of 3rd 
                stage  management, or 
           2) the "old-fashioned" post-L-2 edema from undrained ducts causing circulatory crowding during and after L-2, or
           3) one or both, superimposed on L-2 itself!


It is often difficult or impossible to do fingertip expression when all this is in progress. But CAREFUL RPS FACILITATES EASY FINGERTIP EXPRESSION. I consider this another benefit of teaching RPS either prenatally or early within the first 48 hours, while presenting another opportunity to praise her body's ability to "send messages to the back of the breast to push milk forward now and then toward the baby." 


I have found that it really needs to be emphasized to moms that these are two distinctly separate processes being taught: RPS needs to be done well first, then as a second skill, fingertip expression itself will work much better. This way, as tissues are affected by swelling, moms are more likely to remember and understand how to successfully perform productive fingertip expression despite any edema, as a quick and easy option while lactogenesis 2 is "barrelling down upon the her" within the 24-48 hours after she is discharged! 


One newby IBCLC wrote me this week that in demonstrating, she uses one of mom's breasts to demo while having mom use the other! New insights arrive every day!!If the privacy is available and the mom is open to it, I think the mother's own breast makes a superlative teaching aid because she is benefitting from two separate routes of kinesthetic learning - sensations from her fingertips, and sensations from her breasts, while simultaneously seeing and hearing it explained! This process has really shown me a lot of lightbulbs turning on over mom's heads over the years!!


And of course, it's a great time to add in teaching the usefulness of alternate breast compression if the baby snoozes too often at breast. For even though we probably won't tell moms this, we are providing her a skill to supply some of those "other forces to push milk forward", (because at least, we ourselves fully realize, that neither baby's vacuum nor pump vacuum is actually PULLING!) My grandson recently enjoyed being asked to gently assist with alternate breast compression for the well-being of both his wife and baby daughter!;-)


Though I don't work directly with pumps, nor in a hospital NICU, I, like most of you, have heard frequent tales of "I got a few cc's of milk the first pumping or two, but was unable to get much, or any, to come out during the next few pumpings (or days!). This courtesy of the "friendly vacuum forces" setting up the scenario that leads excess interstitial fluid to push its way forward to try to neutralize/balance the pressures within the flange tunnel (distinctly "downhill" in the pendulous breast. I read somewhere last year (letter to the editor in JHL????) that one LC has early postpartum mothers with pendulous or overly full breasts lie down on their side and pump one breast at a time, "outsmarting" gravity quite a bit.) 


In response to vacuum and/or gravity any excess interstitial fluid "jumps at the chance" to flood into the flange tunnel area like a river overflows its banks after too much rain. Excess interstitial fluid soon collects in the interstitial tissue spaces between the ducts in the subareolar areas. It can crowd/flatten the actual subareolar ducts (whatever we call them), so that no further milk can pass through nature's conduits from the from milk-making tissue to the surface of the nipple. This goes on until either someone gets a light bulb over their head to teach the mom RPS, or simply waits several days till some of the swelling resolves. Too often I have heard moms say they were advised, by professionals or family,  to simply "turn up the vacuum". This often results in skin-shearing forces at the nipple base and/or formation of blisters (filled with some of the excess interstitial fluid) at the tip of the nipple! 


On the brighterside, I heard from one colleague in Oregon recently that she while helping a NICU mom with pumping, she palpated a small "knot" deep inside the mom's nipple itself. Being thoroughly familiar with the concept of RPS, she applied RPS directly and steadily inward on the tip of the nipple itself, for at least 60 seconds or more. Then the mom got a a prompt flow with the pump, and if needed, she did it again during the pumping session. 


My guess is that this mom had a pea-sized or small raspberry-sized "knot" made up of her 4-9 or so-dare I say it- very full, as yet unelasticized lactiferous sinuses-crowded together deep within the basal area of an edematous nipple. I figure that in her case they were a little more anteriorly placed than in many moms I have examined. 


RPS simply "uncrowded" the inter-ductal and subnipple-areolar interstitial area from both milk and edema, and then the "let-down" used the newly freed up, now uncrowded conduits to drain the precious cargo to the outside surface unrestrained for several moments by any constriction from edema. In other words, the milk, aided by the MER, won the race to move forward to neutralize the vacuum before the edema could crowd its way back into the flange tunnel!!
 

Rachel, I referenced you and this same clinician in the 2003 Leaven RPS article. It has just dawned on me that when each of you, independently said you had successfully done RPS on the nipple itself, I was presuming you meant gently squeezing the nipple tissue from opposite sides. Maybe you yourself were referring to pushing inward on the tip of the nipple itself??? or gently squeezing from both sides while simultaneously pushing inward on the nipple button?? Understanding all this may also enter into making the appropriate choice of flange tunnel sizes and provides insights that may avoid frequently having to change to larger tunnels during this early period.


I'd sure be glad for anyone who sees any value in this additional explanation to use the info in practice and get back to us on Lactnet, me in particular, and see if we can spread the word like a "flashmob" to HCP's helping mothers with these situations. Other clinicians have told me that if they teach NICU moms to do RPS before pumping, and when needed, take short breaks to do breast compression and repeat RPS about every 5-7 minutes during early pumping, the result is a larger, faster yield even t that point in time. Perhaps it's simply an alternate way to combine the use of nature's built in breast pump, and fingertip expression with mechnical pumping that has been so successful for Dr. Jane Morton's practice at Stanford. When she spoke at ILCA last year, I asked my question about areolar edema, but in the mothers she sees she did not consider it a problem. I don't know how their OB's manage labors there.


IME, IF and HOW labor is "managed", sometimes admittedly in genuine, dire emergencies, then makes a terrific difference regarding the function of the 3 dimensional nipple-areolar complex during these crucial first 7-10 days.  The timing and amount of the resulting breast edema, especially when further effected by pumping, needs much more formal research by those who are capable of strict evidence-based academic research. I hope someone soon accomplishes this, to prove or disprove these observations.  One midwife in Iran had been corresponding privately with me, but alas, I have not been able to contact her since early 2011. I and the many others around the globe who have corresponded privately with me have been basing certain phases of our practice on these empirical observations ever since I began articulating the RPS principle starting on Lactnet in the late 1990's.


That's my two cents worth for today.

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

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