Rosselina, on 8/22, replied to Cindy's original post "No let-down"
<you need oxytocin to transfer milk from the alveoli cells to the
newborn. If the breasts are too engorged the oxytocin might not be able
to reach the myothelial cells in the alveoli. I would suggest RPS, right
Jean?
Remember, in order to have the breastpump work to help with the
engorgement, you need the oxytocin to act on the alveoli. I would
suggest: 1. RPS 2. Latch the baby right after the RPS 3. if the breast
still fills full or engorged, hand express or use an electric breast
pump.
Yes, stress can inhibit the release of oxytocin, but I also heard that
during the war in Bosnia, mothers were able to breastfeed their newborn
successfully. >

By the time I had read Cincy's original post, on 8/20, she had written
back that the situation was resolving (isn't nature [and Cindy],
wonderful?) and Catherine Watson-Genna had also given a helpful reply in
which RPS was mentioned, so I decided not to post. But since Rosellina
brings it up, (thank you Rosellina;-), I have two points I want to
reinforce.

I think it is important that we realize that the term 'engorgement' has
become almost a 'wastebasket' term for postpartum breast swelling. It
does not adequately describe a great deal of the iatrogenic
swelling/edema seen in the breasts of mothers who may have received
larger doses of pitocin, and/or volumes of crystalloid IV fluids beyond
their hydration needs.

In my view, it is important that we pay closer attention about 1) when to
expect which part of the swelling, and 2) which part is due to which
factor, and recognize 3) which approximate proportion of the swelling is
which, and 4) when those proportions change. This effects decisions about
the most effective interventions. Swelling may be due to:

1) Rapid influx of new raw materials into the arterial system and
dilatation of  veins to remove unused blood components and wastes. 2)
Increased formation of varying amounts of interstitial fluid carrying
those raw materials to the alveoli and returning their metabolic waste
products to lymphatic vessels and venous capillaries, and 3) unknown
rates and amounts of increasing milk volume.

So the percentage of these 3 factors may be subtly changing on each and
every day that the mom perceives swelling. Discerning this will still be
just an educated guess, but  the swelling we are observing is not
necessarily the same on one day as it is the next, in one mother as it is
in another, nor the same as the various examples of 'physiological' or
'pathological' engorgement we have read about in breastfeeding literature
up to 2002.
The second point I want to reinforce is that there may be more than one
factor that triggers MER consistently within a few minutes after RPS.
It's also helpful to know that not only are myoepithelial cells arranged
in basket-like fashion around the alveoli, but they are also arranged in
a spiraling, longitudinal pattern all the way down the ducts as well.
It may be the stimulation of the concentration of nerves close under the
skin of the central areola that elicits oxytocin release in the usual
way. (And yes, Rosellina, I think that although the neural arc triggered
by RPS would probably reach the pituitary in the usual speedy way, the
greater the edema component of the swelling, the more the hormonal arc
might conceivably be delayed in reaching the myoepithelial cells . All
raw materials for milk, plus all the hormones necessary for secretion and
release must make their way out of the arterial capillaries, depending in
part on their concentration and osmotic forces in relation to the osmotic
pressures of plasma and interstitial fluid. They must then pass by virtue
of the strength of these forces through whatever amount of interstitial
fluid is present before they can reach their target cells. So,
conceivably, the larger and more dilute the collection of excess
interstitial fluid, the more delay there might be.)
But fortunately, myoepithelial cells can also respond reflexively to
direct pressure alone, presumably without the presence of oxytocin. I
have not found references yet as to the exact mechanism by which this
happens, but it is mentioned and referenced in my JHL article, for humans
as well as dairy animals. In agriculture it is known as the 'tap reflex'.
 So if the nerves are not buried too far under extra edema that has been
attracted to the areola by strong or long vacuum, the myoepitelial cells
in at least the subareolar ducts themselves, seem to contract promptly.
Perhaps that is also why massage of other areas of the breast often seems
to help trigger MER too.
This makes RPS valuable simply for triggering MER in any mother who needs
to do so, no matter what early or later stage of lactation she is in. I
hope that clinicians are consistently giving simple explanations of the
'miracle of MER' and educating mothers that their pumping will be more
productive if it is triggered 2-3 minutes before starting to pump,
especially mothers of babies in NICU. While baby pictures and pleasant
smells of baby clothing can of course be very helpful, the certainty of
RPS may be especially helpful under stressful conditions. (Hand
expression can of course achieve the same end, if edema or the mother's
lack of skill doesn't prevent it.)
Too many people, professionals as well as parents, are still thinking of
the 'straw-in-the-softdrink' or 'needle-in-the-medicine-vial' model of
using vacuum to extract milk. I think that is partly  responsible for the
unsatisfactory yield of  early pumping and pumps used at later times.
Even the newer components of many pump flanges/motor patterns.may not be
able to "signal" as effectively through a 'thick cushion of areolar
edema' as RPS can do.

I was faced with a new clinical situation recently that requires more
fine-tuning of the application of RPS. I'm still working on it. I always
appreciate any input from anyone who finds new ways to apply it, or a new
type of situation that benefits (or does not benefit) from its use.
Negative comments are welcome and helpful too. It is still a 'work in
progress'.
So much for housework today;-)

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

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