Martha wrote:
<When we checked her breast, we could feel the same 
> firm circle of tissue that had been pulled into the pump flange.  
> The hot towel went back on again.
> 
> I believe the pump is pulling edema down from surrounding tissue 
> into the pump flange, which then occludes the milk ducts.  The 
> tissue softens with application of heat, and then the milk can flow 
> again, but only until the pump pulls that edema back down.   
> 
> The take-home message here is that pumping can exacerbate edema, to 
> the extent that milk flow is impeded or even occluded.  We should all 
> watch what is flowing when an engorged mother is pumping, and take 
> action when needed to keep the breast flowing. 
 
Just as I have tried to warn in my RPS articles, except that I think a
lot of people have rolled right over the top of that fact because their
mind was so boggled with new information directly opposite from what they
have been doing because they completely misunderstand the vacuum
principles involved! 


"Inappropriate vacuum use might account for many reports of “swollen
areolas”. Unless vacuum is used with discrimination, it may encourage
migration of more fluid into the NAC due to elevated interstitial fluid
pressure within surrounding mammary tissue plus atmospheric pressure upon
nearby surfaces. This may attract an extra layer of edema within the pump
flange area that increases the thickness of the superficial areolar
tissue over the sinuses and sometimes the nipple. This “cushion” impedes
access to the sinuses, making it difficult for infant tongue action,
fingertip expression or the pump itself to remove milk very successfully.
"

I learned some fascinating facts about the history of vacuum by Googling:

http://galileo.imss.firenze.it/vuoto/ 
An interesting quote from another site:
"Moreover, atmospheric pressure does not squash our bodies, because they
are counter-balanced by an equal internal pressure. A human being would
explode in a vacuum, because his internal pressure would not be balanced
by atmospheric pressure."


I have noticed that many continue to start with pumping, cold packs, warm
compresses, cabbage, etc. before resorting to RPS. Rushing straight to
the pump in pursuit of milk removal is often based on a faulty
understanding of vacuum application. (Breast pumps do not operate on the
same principle as a straw immersed directly in a liquid, nor by any
principle of “siphoning” but more like a vacuum cleaner on a surface.
Vacuum affects all tissues, including circulatory vessels, duct walls and
types of fluids within the flange area.) Pumping may severely complicate
matters, especially when the intrapartum history reveals the potential
for developing severe edema. When intervention is needed to facilitate
latching, I recommend early, regular use of RPS to reposition excess
tissue fluid inward, rather than pumping (often with maximum vacuum!!)
"to draw nipples out". 

The very best way I have found to treat the swelling is by using RPS as
the very first intervention, to facilitate milk removal, adding alternate
breast compression during the feeding (if the baby stops drinking).
Follow this by continued very frequent milk removal, always using RPS
before either latch or pumping, for at least the first 7-14 days. Help
the mother understand that MER is the primary factor in effective milk
transfer. Encourage her to use RPS on the areola, (and on the nipple if
need be) each time before pumping, as well as to use breast
compression/massage to keep pumping sessions short, using medium or less
vacuum. Another clinician recently shared with me that their staff finds
that engorged and/or edematous mothers who must pump exclusively for
small or ill babies often get "tons" more milk by doing thorough RPS,
pumping a few minutes, and alternating repeat periods of RPS with short
pumping bouts, than by pumping alone. ((It occurs to me that you probably
could have skipped the repeat hot packs to the areola, and instead, done
short periods of repeating RPS alternating with the short periods of
pumping and still gotten excellent results.)
 
This reduces the risk of attracting a thick layer of tissue fluid into
the nipple-areolar tissues that might interfere with the compression of
the subareolar ducts by the infant’s tongue, the fingers or the flange
tunnel. Avoiding frank attraction of tissue fluid into the flange area
also minimizes effect on nipple size, reducing the subsequent need to
change flange size. 



I want to emphasize several important principles:
1) the more pendulous and/or more swollen the breast and/or firm the
areola, the more important it becomes to utilize gravity while doing RPS,
(e.g., the mother lying flat.) 
This is primarily to prevent prompt re-entry of excess tissue fluid back
into the areolar area. (Dependent edema in the nipple-areolar complex may
even occur during pregnancy if the breast is pendulous.) The goal is to
provide a few extra minutes of "improved latchability". Unless the areola
softens easily and stays soft for a while without the mother lying on her
back, it's much more effective to use the mother-supine position when
doing RPS for the first few times. 
(If, in addition, comfort allows the baby-prone nursing position, the
weight of the baby then helps achieve and maintain the latch, as well as
further encouraging venous and lymphatic drainage during the feeding.
This also dovetails nicely with skin to skin contact and is relaxing for
the mother, with potential to help minimize sleep deprivation effects.
The MER will continue to work sufficiently well against gravity if
effective latch and suckling occur.) 


2) the firmer the areola, the more minutes of RPS may be needed, at least
the first time or two. Riordan has phrased it very succinctly in the 3rd
edition of Breastfeeding  & Human Lactation: "The length of time will
depend on the severity of the edema." (p. 207)
(In my own experience, 1-3 minutes works fine for many moms early on.)
One clinician has her staff proactively teach all moms to use RPS from
the first day, and reports that empirically, this seems to reduce the
development of problems. RPS may be started at any time. No harm will
result. Even if no edema is currently visible, filling of the ducts under
the areola also contributes to subareolar tissue resistance. It is
amazing how much improvement in areolar pliability results even when no
one has yet recognized any edema, subareolar tissue resistance, or nipple
retraction. But if severe swelling and/or areolar firmness have been
allowed to develop, a full 10-15 minutes or more of RPS may be needed for
each of the first several applications in order to achieve sufficient
areolar pliability for effective latching. (“The physiologic unit of the
nipple-areolar complex appears to function as a closely connected system.
Forces acting on any one part of the NAC may cause other parts to
compensate.“ (JHL RPS article).
Remember that the technical definition of edema is simply ‘more
interstitial fluid than normal for that tissue’. However, excess fluid
does not become visible (by pitting) until the tissues are holding at
least 30% more fluid than normal. Nevertheless, 29% (25%, 15%, etc.)
still contributes subareolar resistance and nipple-areolar distortion.
When nipple-areolar tissue expands to hold extra fluid, it is forced to
compensate by a directly proportionate reduction in the freedom of the
areola to extend the nipple inward into the baby's mouth. The more
tightly expanded the NAC with retained fluid and/or distended subareolar
ducts, the more it impacts the latching process for baby and mother.
If RPS hurts, the pressure is too firm. Judge the time as you go by how
the tissue responds. Pressure needs to be steady and firm, but gentle,
judging by the mother's body language. Or better yet, encourage the
mother to do RPS on her own areola, and slowly add the strength of your
fingers on top of her fingers to help. Be patient and invest that time in
instructing the mother. The skill taught well and early will save her
much discomfort and frustration during successful initiation of
breastfeeding, especially after hospital discharge. 

The above paragraphs were excerpted from some "further, advanced thoughts
on RPS and pitting edema" I have been writing. I would be glad to send a
copy privately to anyone who asks.


K. Jean Cotterman RNC, IBCLC
Dayton, Ohio USA 
A quote from Pascal, medieval pioneer in understanding laws of
hydraulics:
"We are usually convinced more easily by reasons we have found ourselves
than by those which have occurred to others." 

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