<Jean, I'm still thinking about your post -- wondering how soon the extra  
fluid in the tissue is manifested as we don't *see* edema, as you've pointed  
out, until there is a real 30% overload of fluid.  So I'm wondering if  
pumping within that first hour after birth is still an issue. >

Well, Jan, I'm going way out of my "league" here, but a recent article I read by an anesthesiologist points out that intravenous fluid IS, in fact, a medication, in and of itself! Jacob M, Chapel D, Rehm M, The ‘third space’ -fact or fiction?, Best Practice & Research Clinical Anesthesiology 23 (2009) 145-157. The complete PDF is available on line for anyone who is interested in learning more from the viewpoint of research done by anesthesiologists on escape of certain components of plasma out into the interstitial spaces, which we then term 'edema' when the amount of fluid becomes more than the tissue normally holds. 


This interest I have in this subject is an extension of the references I used for my RPS article. The ones I used were written in the mid '80's, and there seemed to be quite a few, written by obstetricians and anesthesiologists. They measured changes in what is known as the colloid osmotic pressure (COP) of the mothers' blood at certain time intervals, and with several different basic amounts of intravenous fluid to compare the results on the mothers' COP. 


They were, of course, trying to find ways to avoid complications like pleural edema and various cardiac effects of too much fluid. I cannot remember if they took the mother's BMI into consideration, but I do know that several of them had groups of mothers who received no IV fluids or meds, and used their results as normal ranges for various times before labor, and I believe 6 hours and/or 12 hours later. If anyone knows of articles quoting postpartum COP at further time spans, I would like to read them.

<wondering how soon the extra fluid in the tissue is manifested>  The answer is simply: "THAT DEPENDS" ! First of all, many mothers have some visible edema during late pregnancy. (If she has pendulous breasts, gravity may have shunted some edema toward the nipple/areolar complex in the last month or so of the pregnancy, so she may have some breast edema when admitted.)


Beyond that, it is the question that no one has yet researched in regard to the first 10-14 days. If mothers get >2000-2500 cc of fluid in less than a 24 hour time period before the birth of the placenta, especially if that fluid had pitocin as part of it (antidiuretic qualities cause kidneys to reabsorb some of the water back into the blood stream rather than excrete it), that mother may also ALREADY HAVE SOME DEGREE OF BREAST EDEMA BEFORE DELIVERY (sorry, only way to emphasize). 


If she had less fluid before birth of the placenta, but received hours of fluid after the birth, she may be discharged home before the edema becomes visible in the breasts. I would imagine that pediatricians and pediatric nurse practitioners, visiting nurses and WIC folks would be the ones to see moms in this stage. Whenever it appears, use of vacuum will encourage movement of interstitial fluid toward the flange possibly crowding the ducts, preventing removal of much colostrum. I wonder if that might be why you are not getting as much after the first time you pump. I wonder what would happen if RPS were to be used to displace any even "invisible" edema prior to and repeated 1-2 times during the subsequent times the pump is used in the early days???

I realize that institutional permission must be obtained for certain kinds of research. However, those LN colleagues who work in hospitals, L&D especially, could shed some light on whether my theories "hold water";-) by 1) knowing, from the mother's chart, which mothers received how much IV fluid and/or IV pit for how many hours before birth, 2) sharing this information when turning over the mother's care to the postpartum/nursery nursery nurses who will be observing the mothers continued breastfeeding sessions and 3)specifically looking for the timing of the appearance of visible edema and relate it to the known facts about time and amounts of IV fluids. The ankles too, may offer good clues correlated to breast edema. Maybe we could spark some eventual interest in formal research. 


Prior to Marcia Walker's 2000 article on engorgement in which I believe she made mention of the LN discussions of swelling r/t IV fluids that we had been commenting on for several years, absolutely NONE of the articles on engorgement that have continued to be cited all these years . . NONE of them make any mention of whether, when or HOW MUCH IV fluid was received by the mothers with various degrees of swelling. The closest any of them came was to say the mothers received "routine obstetrical care". Which adds up to all different volumes of IV fluids at many different times in relation to the appearance of swelling.

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

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