Dear Chayn,

I got a "how to get more from Lactnet" post this a.m., and stopped to lurk.
After reading your post, I have decided to permit myself to "come outside
and play with my friends again", and rejoin Lactnet, because "Business
before pleasure" issues (old taxes) have now been resolved;-)  I will go
straight to your question.


<Mother had an ideal birth and postpartum experience (as close to baby
friendly as we have here)>


Did the mother have 1) close to 1000 cc. of crystalloid IV fluid or more at
some point before or after birth? 2) some hours of IV pitocin induction or
augmentation (before birth) or many hours of IV pitocin during the
postpartum period?? 3) Does she have pendulous breasts?


IME, overhydration is frequently implicated when problems arise with normal
physiologic breastfeeding initiation. Depending on whether or how much
overhydration accumulates in the intrapartum period, I have noticed that
some degree of what I now call "Pre-L2 edema" often precedes normal
physiological engorgement and L-2 in both breasts. Whether or not "Pre-L-2
edema" occurred in this situation, an overlap of "Post L-2 edema" has now
been caused by milk stasis in the undrained breast. The stasis itself  has
potential to lead to eventual involution, as you fear. The subject of
interstitial fluid (ISF) has come to fascinate me. I am firmly convinced
that we must better understand more about the fluids in the interstitial
spaces, and use gravity to better advantage, not only in "laid back"
nursing, but in the relief of breast swelling.

Though we are not qualified to be lymphatic therapists, we can learn a great
deal from their insights in trying to assess the dynamic going's-on beneath
the skin of the swollen breast.  The collection and the resolution of
swelling is at least partly based on the law of gravity: Fluids move
"downhill" more easily than "uphill". Plus, as you suspect, this
mother's past history may have somehow compromised the lymphatic drainage
slightly on the right side, leading to the cascade of further breastfeeding
problems that have resisted familiar management principles.


All fluids enter the breast through the arterial system, but fluids*
leave*the breast in
*two opposing directions*. Milk moves *anteriorly and centrally*
through a *single
exit area,* the nipple-areolar complex. In contrast, interstitial fluid
needs to move *posteriorly and upward to *enter *many vessels*, venous and
lymphatic that travel toward the armpit and subclavian areas, to join blood
vessels that return to the heart. Upward massage (as welll as flat-finger
palpation/massage sometimes still advised for personal monthly breast exam)
helps resolution of edema, while forward massage facilitates milk transfer.


< I can not see any problems with the baby.  Milk came in on day 2.  Baby
nursed well on left side immediately after birth and through the hospital
stay but did not manage to relieve the right side. Mother tried pumping and
got out a few drops.  On the afternoon of day 3 she called me and began
using cold compresses and trying to manually move the milk.   I saw her on
the morning of day 4.  Breast was engorged but not a total rock.  I could
not see anything unusual, shape, size, scars, etc... Mom denies any injury
or surgery on that breast.  Using reverse pressure softening got a drop of
milk out.>


<We tried massage before and during breastfeeding.  We used a variety of
positions, including mother on all fours over the baby.  Nothing worked. Mom
tried to manually pump and didn't succeed.  She said that her experiences
with manual expression while leaning over hot water in the sink or any other
way of combining heat and massage has always made the situation worse.>


Novice moms usually catch on to my phone directions for RPS quite easily.
But to those already familiar with massage, hand expression and pumping,
RPS seems somehow counterintuitive, "just one more egg that automatically
gets put in the same basket",  which can blind them to certain important
concepts,


 For tough cases, here is RPS in a nutshell:


1)  Don't waste time or energy on hot or cold treatments.


2)  Promptly utilize gravity. Have the mother lie flat, breast on top of
chest wall.


3)  Apply comfortable steady inward pressure (best done with fingers, or
with fingers through a nipple shield or bottle nipple etc.) on the areola
all around the nipple base, for as long as it takes to really soften the
areola-if really needed, up to 20-30 minutes.


4) Do this just on one breast before each attempt at latch or milk removal.


5) Don't expect milk to come out during RPS. The primary purpose is move
milk and ISF backward into the breast temporarily to soften the areola to
make it pliable for 5-10 minutes. Pliability of the areola then facilitates
milk removal by fingertips or baby.


6) Don't be tempted to use vacuum unless there is actually free flowing
leakage. Be cautious, because pumps can cause more edema in the areola in
the first 2 weeks, and sometimes in the nipple as well.


Dr. Gail Hertz gives the following directions to her mothers: "Count to 50
while steadily  pressing inward comfortably. If you are VERY
swollen, count VERY slowly." (At this stage, I would say have her lie flat
and count VERY, VERY slowly;-), perhaps even resorting to a clock, timing
the steady, firm but comfortable inward pressure toward the chest wall, for
10 minutes, even 20-30 minutes. (If her hand grows tired, she can have
someone help with pressure over her fingers, or use a standard feeding
bottle with the rubber nipple inserted upside down from outside the plastic
collar, placing it over her nipple, using the bottle as a handle.) This will
do at least 3 things.


1) RPS will certainly trigger the MER to move milk out of the alveoli, which
may modify stasis effects on the lactocytes.


2) RPS will move any milk within the subareolar ducts back inward an inch or
more, so the immediate subareolar ducts are not overdistended (I was
recently able to help an experienced mother with her 8th child, 9 weeks old,
still struggling with multiple latch problems including TT with this baby. I
could palpate overdistended subareolar ducts, which were a significant part
of the problem on the most difficult side, causing the baby to slip off and
the mother's nipple to be severely damaged. The subareolar ducts were not
distended on the baby's preferred side.).


3) Of equal or greater importance, RPS done while on the back moves the
ISF deeper into the breast's interstitial spaces where gravity will continue
to delay it from returning to the retroareolar spaces. This gives a long
enough time for latching in the baby-prone, or a really "laidback"
position. RPS using gravity, plus the weight of the baby's head continues to
encourage the excess interstitial fluid to move naturally toward the deeper
lymphatic channels as explained above


I would avoid the use of vacuum at this point. One of my favorite mantras to
moms is "Vacuum does not pull. Other forces push."


It may look and feel like vacuum pulls, but vacuum really just lowers the
pressure inside the flange below the external barometic pressure that the
weatherman talks about. Other forces (like MER, but also blood pressure,
interstitial fluid pressure, probably atmospheric pressure, breast
compression, etc.) combine to push the nipple-areolar complex into the
vacuum area to try to equalize the pressures, because "Nature abhors a
vacuum."


That is why a pump, especially with the mother's breast dependent, often
allows the opportunity for interstitial fluid (think "a river with
no banks") to surge slowly forward like a flood into the nipple-areolar,
subareolar and retroareolar interstitial tissues. The full ducts are either
buried too deep beneath the edema to compress themselves against the flange
tunnel, or the resistance of the flooded tissue is greater than
physiological MER pressure. MER therefore cannot propel milk
forward past the ISF pressure on the buried ducts.


This also effects hand (fingertip) expression and the normal physiological
actions of a baby's latch/suckling. Fingertip expression is often much
easier and more productive after a thorough application of RPS assisted by
gravity. Alternatively, thorough RPS as above, 5 minutes of pumping on low
or medium vacuum, pause for a minute of forward massage of "milk knots",
then repeating this same sequence 2-3 times, often yields more total milk,
and relief of discomfort than 15-20 minutes of straight pumping. After
another short period of RPS, you could then have her do some hand expression
afterward, as the Stanford films show, to increase the drainage of milk till
relief is obtained, and perhaps then try the latching.


<Baby was able to latch but did not transfer any milk. She slips down on
that side and the nipple is sore.>


I have also noticed what turned out to be hidden tongue ties several
times recently since listening to Cathy Watson Genna. On the off chance that
this may be one factor in the whole problem,  digital assessment of
the frenulum, rather than visual inspection alone, might help you decide
whether to refer for evaluation by a practitioner who can clip if necessary.


I hope these insights may be of some help.


I have reformulated my illustrated instruction sheet at the 6-7th grade
level, and am happy to share with anyone who asks.


K. Jean Cotterman RNC-E, IBCLC
Dayton, OH USA

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