Christine writes:

<She is experiencing a lot of milk leaking and breast discomfort which
 sounds
like Lactogenesis II.  When she called her OB he told her to pump  and store
the milk.  She called the hospital and spoke to the IBCLC there  who told
her
to absolutely NOT pump. >

If she is quoting her OB correctly, I find this UNBELIEVABLE! Imagine what
dire medico-legal things might happen to one of US if we were to have given
this kind of advice to someone who has a placenta just waiting to hemorrhage
if the uterus starts to contract causing the cervix to begin to thin and
tear itself away from the placenta!


<First, a lot of this is outside the scope of what I can really talk to as
 an
IBCLC and some of it is really over my head in terms of what I know re:
lactation.  I suggested a second opinion from a high-risk OB that has
 already
consulted on her case while she was in-patient.>


Good thinking. It might eventually also be good to check if the meds she has
received might have any such side effects. While some of the meds to prevent
pre-term labor are to stop any natural oxytocic action, drug chemistry is
such a complicated thing that perhaps calling Dr. Hale and checking each med
out might be worth a try to see if there might be any side effect on the
breast. But before you do any of that, I am hazarding a guess that there may
be a much simpler explanation.


Here is one thing I can suggest for you to do. Have you inspected her
breast? What is the length of her nipple shaft?? It has been my experience
that mothers with a short nipple shaft also have short galactophores (the
tubings extending from the surface of the nipple down through its center to
the distal ends of the lactiferous sinuses) so that their lactiferous
sinuses are much closer to the surface of the nipple than those of a mother
who has a longer nipple shaft and therefore longer galactophores. Since she
is an experienced nursing mother, it is also theoretically possible that her
lactiferous sinuses, while certainly not as large as past diagrams may have
led us to believe, may be somewhat larger and more elastic now than when she
was a primilacta. Even a tiny bit larger would be enough to hold more
droplets of colostrum than when she was a primilacta.


I have cared for numerous mothers prenatally who leaked at night in the
third trimester, and found that when a mom with short nipple
shaft/galactophores is loosely dressed, the mere touch of the bedclothes is
often enough to stimulate a very minor MER. Between this and capillary
attraction, with such short galactophores, they leak much more easily.
Especially since this mom is confined to bedrest and perhaps not wearing a
bra, or just a thin sleep bra, this might very well provide an explanation.
The more she leaks, of course, the more colostrum nature will try to
replace. That may have given you the impression of Lactogenesis II starting.



This is a hormonally determined process, and if any serious thing like
placental abruption were to have happened and started the cascade toward
Lactogenesis II, I believe she would have much more observable uterine and
fetal symptoms, quite possibly severe abdominal pain, hemorrhage, internal
or vaginal, shock and even fetal demise. My guess is that this is simply
Lactogenesis I trying to replace the leaked colostrum, and that stopping MER
stimulation to slow or stop the leakage will stop the extra production of
the colostrum, cutting down on any breast swelling and discomfort within a
few days.


My suggestion is to closely cover the nipples and the areola directly with
breast pads or something thick enough inside a comfortable bra to prevent
any tactile stimulation to the entire nipple-areolar complex, therefore
stopping the MER's, and I think the leakage and subsequent replacement
production will stop within a day or two.


<She is worried about causing her milk to dry up or decrease now b/c of the
unknown milk supply at birth.>

If my guess is correct, then stopping the process by stopping the
stimulation and the leakage will be very reassuring to her. Complete bedrest
is psychologically very stressful on moms. It has shrunk her world and
reduces the things she has to focus her attention on. It is entirely
possible that the whole situation bothers her thoughts much more than if she
were up and around preoccupied with concentrating on her household and
family duties.


<We discussed ice packs, heat, Tylenol, as well as areolar compression to
attempt to express milk.>

I think this will prove entirely unnecessary if my guess is correct. If ice
packs are used, please limit the time to no more than 20 minutes and no
oftener than 90 minutes apart so as not to damage the tissue with danger of
frostbite. Tylenol should cause no problem, and if it makes her feel better,
go for it. I would definitely protect the areola from any stimulation,
because the nerves are so close to the skin near the nipple that compression
there is sure to stimulate MER. I think you want to avoid that as much as
possible.


< She said she feels a let down frequently but  doesn't feel any
contractions with that let down.>


Thank heavens. Contractions are the last thing she needs at this point.


< She asked about just  allowing nipples to rub the inside of her shirt
(without bra) and see if that  helped increase leaking (to move milk for
comfort) without actually causing more
contractions.>


That might bring her more comfort in the short run, but in the long run,
reversing the process with the suggestions above makes more sense to me. I
am presuming that even colostrum has some degree of feedback inhibitor, so
keeping it in the breast should theoretically start to reverse this process
back down to normal breast conditions for the late third trimester.


If my guess about the depth of her nipple shaft is wrong, no harm will come
from trying the plan anyway, to see if a few days of this might reverse the
process back to normal. Please keep us posted as to whether you can persuade
her to try this, and if so, what happens. Maybe we can all learn something
new from this. (This type of "trial" constitutes the extent of my research
capabilities, folks!)


Jean
**************
K. Jean Cotterman RNC, IBCLC
Dayton, OH USA

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