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Subject:
From:
Kermaline Cotterman <[log in to unmask]>
Reply To:
Lactation Information and Discussion <[log in to unmask]>
Date:
Mon, 12 Dec 2005 15:33:45 -0500
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Mary writes:

<after she nurses her week old baby, her areola swells in a kind of half
moon pattern above 
her nipple and a little below it. It does not hurt or anything but we are
curious 
about what it could be. >

Despite the fact that this was a home birth, if edema is present, at one
week, it was probably very near its peak. You did not mention any
pumping, but my guess is that with the kind of history she has: 


< The other problems she is having are; breasts enlarged lots during all
three pregnancies, had too much milk with first two and has tons this
time, too. Has engorgement even with home birth, lots of nursing from
beginning.>


the temptation would be to use a pump to try to manage swelling,
mimicking some of the iatrogenic factors that often accompany hospital
birth: attracting edemas to the flanfe area, and overfull ducts crowding
the lumphatic drainage channels.  


Interstitial fluid is normally not "liquid" as the word 'fluid' suggests,
but is in a 'gel' form. The very definition of edema is that there is at
least 30% more interstitial fluid than normal. At 30-50% the gel cannot
absorb much more so that extra interstitial fluid is, in fact, more
"liquid" and can be pushed around more easily. Unfortunately, edema is
easily attracted into the vacuum, and that would make for extra edema in
the interstitial tissue of the areola, despite a <home birth, lots of
nursing from beginning.> 



(This is the reason that when RPS is being done with thumbs or straight
fingers in two quadrants at a time rather than simultaneous pressure all
around the central areola, it is important to alternate the quadrants
every 2-3 minutes so as to partially cover the previous pits, in order to
discourage the edema from going to the side of the fingers at the
surface, instead of into the deeper areas of the central areola, far
enough backward, out of the latch area.) 


If a baby is put to breast in either straight-across cradle, or
cross-cradle, or for that matter, straight-across football hold, if the
upper and lower jaws are compressing at 9:00 and 3:00 on the areola, that
means that the corners of the mouth (at 12:00 and 6:00, where there would
be little or no compression), would be the natural place for tissue fluid
to emigrate to, <in a kind of half moon pattern above her nipple and a
little below it.> 


Were she to lie down to nurse so that the jaws would be compressing at
12:00 and 6:00, the 'half-moons' would therefore end up at 9:00 and 3:00.
I suggest she stop using a pump, spend a fair amount of time lying nearly
flat on her back to let gravity help drain the interstitial fluid into
and pass upward through the venous and lymphatic channels, massage upward
toward the axilla and clavicle, (and this would be helped by the weight
of the baby if she were to nurse in 'Australian' or on-top-of-chest
position) and do a small amount of hand expression after RPS if she feels
she absolutely must remove some milk for relief.
 
<At first I thought it might be fluids as she had some pitting on RPS 
before nursing, but when I touched it it was very soft and then her
nipple 
became erect from the touching and the swelling disappeared. Swelling
came 
back when nipple relaxed.>

You are very observant. I think you were right the first time. Edema,
especially the more liquid >30-50% it becomes, doesn't have to be firm.
It all depends on how much 'room' there is in that particular tissue to
contain extra fluid. Remember that muscle, when it contracts, places
pressure on surrounding interstitial tissue and fluid. (In fact, the
pumping action of larger muscles is one of the main factors in moving
fluids upward from the lower parts of the body, and is one of the main
treatment modalities in treating lymphedema, and why use of the pectoral
muscles may even help some in resolving engorgement.) When her nipple
became erect, the radial and circular muscles may have placed some
pressure on the fluid, but my guess is that their firmness temporarily
altered the contour of the skin and 'terrain' a little so that the area
appeared evened out, making it appear to have moved the fluid. When the
nipple contraction ceased, it again became evident which quadrants had
fluid collection because the jaws had compressed the opposite quadrants. 


Another thought on <The other problems she is having are; breasts
enlarged lots during all three pregnancies, had too much milk with first
two and has tons this time, too. Has engorgement even with home birth,
lots of nursing from beginning.>

I see this mom as one who may have been gifted, when she was an embryo
within her own mom, with a full complement of secondary buds branching
off the primary bud, and every one of them canalized, so that she might
be one of those moms who truly might have 20 lobes to each breast,
whereas many others may have only 10, or fewer. I had a mom with such a
history (in-hospital, but completely natural water births and early
hospital discharge) several months ago. My prenatal plan suggested to her
was: 



1) to avoid heat from the beginning, other than an occasional warm shower
falling mainly on her back, 2) If needed for comfort, use cold packs for
20 minutes at a time, no oftener than every 2 hours. 3) use only one
breast for any and all feedings within a 3 hour period, switching to the
other during the next 3 hours, 4) very, very gradually begin extending
that time slightly, to take advantage of any possible 'feedback
inhibition' that might be operational at that stage. 5) completely avoid
pumping unless she absolutely felt she had to remove just a small amount
for comfort, preferably by hand expression.  6) use forward massage and
breast compression to keep milk moving forward during nursing, 7) then if
edema was obvious, spend time lying on her back, with upward massage
toward the axilla and clavicle to use gravity to help move interstitial
fluid backward through the lymph channels. She decided she didn't need
the cold packs, nor the time on her back with upward massage, but
otherwise followed this plan fairly closely. This, her 3rd nursing
experience was much more comfortable than the first two, and she had only
about 12 hours discomfort at the height of the swelling, and nursing
continues to be satisfactory.

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




 

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