Diane,
The color change is cyanosis, from the tint that blood turns when the
oxygenated blood has released its molecules of oxygen and picked up
molecules of carbon dioxide.
This is readily seen when it happens in mothers with light skin
pigmentation on the nipple. I have even seen this happen when a mother is
using breast shells with a tight opening around her nipple for too long a
time. While I'm sure it can happen to a mother with darker skin
pigmentation, the color change is much more difficult to detect the
darker the pigment.
Is the vacuum being released frequently and long enough in cycles?
Applying the vacuum for too long at any one time is interfering with the
normal functioning of the capillary system in the nipple and the proper
exchange of oxygen and carbon dioxide.
This also creates a delay in the removal of other tissue wastes such as
lactic acid. (Lactic acid, for instance, is what creates pain in muscles
when they are overused.) It is also probably traumatically stretching
tissue that has hardly any more "stretch" available to respond to the
vacuum. There is probably also a component of the pain that is due to the
"rebound" surge of circulation into the deprived capillary system. (Like
when your foot has been asleep???)
Interstitial fluid is that fluid that normally surrounds capillaries and
cells. Dissolved in it are all the nutrients like glucose, protein,
sodium, oxygen etc. released from the capillaries and being "shipped in"
during the last leg of their journey to the cells. And similarly, the
waste products are "shipped out" in solution in the interstitial fluid,
to be reabsorbed into either the venous or lymphatic capillaries to make
its way back to the heart.
There is often excess interstitial fluid between the cells in a mom just
9 days post partum while she is undergoing the natural fluid shifts of
the postpartum period. This is especially evident if she has had
multiple IV's, pre-eclampsia, or lengthy pitocin induction.
The puffiness you mention happens because suction does not pull on milk.
It pulls on flesh, including its interstitial fluid. In my experience, if
swelling and areolar firmness are interfering with latching, it is
better to avoid the negative pressure of vacuum and all its above
mentioned effects.
I think it is better to exert gentle but firm, positive, reverse pressure
straight inward toward the ribs. To exert this pressure, the hcp's two
thumbs, (placed twice for successive 45-60 second periods), or the mom's
4-6 fingers on both hands are best placed on the areola just where it
meets the base of the nipple for 45-60 seconds or so.
This moves excess interstitial fluid out of the area temporarily. The
need is to free up more of the elastic potential of the areola and the
tissue overlying the milk reservoirs. It may also compress the milk
reservoirs slightly, redistributing overfullness back upward into the
ducts or outward from the nipple openings, and often triggers an MER.
If necessary, it is then easier to reposition the fingers further over
the milk sinuses to soften more of the areola by removing a few more
drops of milk, and thereafter, to attempt the latch. IMO, this firm but
gentle use of positive pressure to soften the areola is much gentler on
swollen tissues than the use of vacuum.
For the mother with the kind of nippleareolar complex you described,
there is certainly no need to "draw the nipple out", since <it is quite
long and about the size of a thumb.>
<Areola very small. Nipple tissue is almost bigger than areola>
Also, her milk sinuses are probably much closer behind the nipple than
most mothers. It is even possible that they are partially within the
nipple proper. I saw a Kenyan mother like this once.
If this is the case, any future milk removal is probably more effectively
and comfortably done by hand expression. If a pump is to be effective on
a breast after edema resolves, the "bend" in the flange of a pump must
fit so as to apply pressure directly over the milk reservoirs during the
vacuum phase. To do this, the inner diameter must not be too small so as
to pinch the nipple or too large as to "overshoot" the milk sinuses.
I hope my thoughts are helpful.
K. Jean Cotterman RNC, IBCLC
Dayton, Ohio
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