On 4/29/06, Jeanette Panchula <[log in to unmask] > wrote:

>  <I want to publicly thank Jean for her Reverse Pressure Softening>
>

 Thank you Jeanette. But this reminds me about a quote from "Case Studies in
Breastfeeding" by Kadwell and Turner-Maffei, one of several very interesting
books I bought this week at the OLCA Breastfest:

"Discovery consists of seeing what everybody has seen and thinking what
nobody has thought." Albert von Szent-Gyorgi, Biochemist (1893-1986.)

The moment I read that, I thought "Bingo! That's how RPS has come into
being!"


So far, RPS has at least been mentioned in several textbooks, some in more
detail than others. But I do not have the expertise nor the situation to do
what is considered formal academic research. I have just received a query
from a midwife in Iran who wishes to research RPS, and I know of one other
proposed research project overseas. Until such research happens and gets
published, it will never get into the "evidence-based" classification, and
therefore won't get real academic attention, nor will it be considered in
the Cochrane studies or the other studies that only consider certain kinds
of formal research articles, etc. etc. Clinical observations come first, to
form the hypotheses on which to base formal research. But formal research is
essential in bringing new practices to the attention of other disciplines,
especially in today's climate of "evidence based" health care.

But I recognize Jeanette's frustration because many of the same questions
entered my mind over the years, and my JHL article was my attempt to draw
attention to what I consider "one of the main elephants in the perinatal
living room."


< I just made a home visit (unfortunately, didn't get a referral until day
6) to a lovely African American mom who was determined (as had her sisters)
to breastfeed - but the breasts became two enormous torpedoes - hard and
totally inflexible.  Nipple totally flattened so that you would think there
were none - hard as a knee!  So heavy she was using ace bandages to provide
support, as no bra she had could support them.>

 There has yet not been established a definition of engorgement that would
help us describe it in quantifiable terms. And, as Jeanette notes, neither
is there much realization that there is a difference between symptoms of
overhydration compared to normal physiological engorgement to move into the
breast the raw materials needed to make milk. In that light, as soon as I
can find it in my files, I want to re-read the 1994 JHL article by Humenick
and Hill, as well as the new one they wrote for this year for another
journal (can't remember which, right now.).

>  <With RPS and a very willing baby, (skin to skin, mom on her back and
> baby on top we were able to move fluids back and breastmilk out)>
>
Jeanette made greater use of gravity in three different ways:


1)Having the mother lie on her back to do RPS and to feed uses gravity
 to encourage venous and lymphatic flow to move naturally upward and
posteriorly through the axillary and subclavian pathways toward the heart.



2) Having the baby lie prone on top of the breasts further encourages this
by providing extra physical compression of the excess intersitial fluid in
mother's breast to encourage re-entry into the circulation. This results
from the weight of the baby's head on one breast, and the baby's body over
the other breast, if mom is comfortable enough to have the weight of the
hips placed across the other breast.


3) The weight of the baby's head also serves to keep the baby's mouth much
more deeply latched, for more effective milk transfer, since even the robust
baby would tire out quickly unless s/he just relaxed the neck to cooperate
with gravity. (I like teaching this position for many reasons, and even
wonder if it might help in situations of tongue-tie.)


Effective milk transfer happens even if the MER is going against gravity.
And as mentioned in Robert's research, feeding the baby had a greater effect
on the swelling than the effect of either method of cabbage treatment she
used in her research.


< How this will have affected her breastmilk production, I won't know for a
while.>

 Well, from this case, I would like to emphasize that it's never too soon to
start RPS. I have never seen it cause harm, and I think it has great
potential to prevent complications such as this, especially when large
quantities of crystalloid IV fluid have been given. As sad for the mom as
the pain became, from the accumulation of swelling and the failure to
properly diagnose it earlier, it was better to get the pressure relieved at
6 days than any later. With continued regular milk removal, I think Jeanette
probably rescued the situation in time to prevent any major damage or
involution to the glandular tissue.

I have a suspicion that it will not impact this particular mother's supply.
In fact, she may be one who ends up with problems of oversupply,( which
incidentally is the subject of Barbara Wilson-Clay's article in Consultant's
Corner in the latest JHL.) But that's another idea, and another post for
another day.

  <HOWEVER - I want to ask questions about these situations that we are
seeing all too often:

>
>             Why was so much fluid given to this mom that not only her
>       breasts, but her ankles and even her abdomen were swollen? (She reported
>       having been given 3 different medications to "augment" her labor.)>
>
>
 She is fortunate that she didn't also have pulmonary edema, a
life-threatening complication. Overhydration by infusion of excess
crystalloid
IV fluid has been thoroughly researched, documented and discussed in medical
literature for over 2-3 decades. Unfortunately, once labor interventions
start, (including epidurals) it seems that the amount of IV fluids begin to
add up quickly, and one reference states frankly that nurses often
administer them at a faster rate than was ordered by the physician. There is
a great lack of awareness on the part of physicians and nurses when startign
IV's of the "fallout" that will often ensue in the breast days a few later
during the initiation of lactation. Formal research is needed before they
will ever begin to be convinced.


>
>         <    Why did nurses in the hospital call this "engorgement" (it
>       started within hours after the birth) and tell mom just to "use warm
>       compresses">
>
>
 Because we LC's have much more to do in the way of education of the OB
staff about assessing the history for iatrogenic red flags, and the physical
signs and timing of initial edema versus edema superimposed on normal
engorgement. We must define terms more clearly, write more case studies
(that means you, too, Jeanette!;-), and above all, provide anticipatory
guidance to mothers. It's hugely unfair that they and their babies should
have to suffer because of this gaping hole in clinical awareness. I have
always felt it unfair that so many mothers are left feeling inadequate when
it's really our system that's inadequate.



>
>            < Why did MDs (both in the hospital and in the ER where she
>       had gone due to pain) insist that this, which was so obviously abnormal, was
>       "just engorgement" and tell her to just "wait a few days" (this was day 5
>       postpartum) and just bind them!  Grandma, who is a nurse, questioned the
>       doctor - and he got so mad he walked out on her!>
>
>
 Because they just don't know any better, and formal research is lacking.
And even then, changing what they learned, or didn't get taught in their
basic training would probably not be a priority, any more than updated
knowledge of tongue-tie and it's possible effect on breastfeeding is among a
large number of pediatricians. It's partly due to "cultural lag". Maybe I
need to write an article for an emergency room journal???? But breast
swelling probably doesn't rank very high in the priorities of 'emergencies'.




>
> <I also wonder - and please don't yell at me, just asking the question -
> if we are CAUSING this horrific swelling artificially, would not using
> diuretics help to remove it?>
>
 Edema, itself, is defined as >30% more fluid than normal "in the
interstitial spaces". Fluids must first re-enter into circulatory vessels to
be transported to the kidneys where the action of diuretics takes place.
Also, since the molecule of the hormone ADH and the molecule of oxytocin are
very similar, depending on the size of the doses of pitocin received, it can
have an antidiuretic effect by attaching to the ADH binding sites.


I would like to see the nutritional researchers among us think over the
possibility that a very high protein diet for 24-48 hours might help
to offset the effect that excess crystalloid IV fluids have on diluting the
protein concentration (colloid osmotic pressure) in the blood. This has a
profound effect on the retention inside or the movement of fluids out of and
re-entry back into the circulatory vessels. I would also like to see some
research on the use of some colloid solutions (albumen) when so much IV
fluid must be given during these interventions. Denise Fisher told me of a
presentation by a New Zealand midwife who noticed a correlation between the
level of albumen in the mother's blood and the timing of lactogenesis II, I
believe.


<  Why do these moms have to wait one to two weeks to be able to see their
ankles and feet?  If there are "protocols" to "augment labor" - what about
protocols to deal with the iatrogenic problems they have caused?>

 An excellent question Jeanette, and one that we have to keep raising to the
medical community whenever and however we can. The pediatricians actually
have a share in helping to get their colleagues to realize this, as these
complications prevent getting "the product" out of "the container" promptly,
which impacts the health and well-being of their tiny patients.

>  <I know, we should be convincing MDs to avoid all these interventions -
> but they ARE happening - what can be DONE once the problem has happened?>
>
 As a lactnet colleague initially pointed out to me, gravity is free, and
one thing that we LC's can make more use of, as Jeanette did so well. Also,
we need to understand more clearly the principle of vacuum and it's effect
on interstitial fluid during edema. If anyone wishes to contact me
privately, I will gladly send a short article to those who want more of my
thinking on pitting edema and the use of RPS. The original short illustrated
article on RPS, as well as the LLL Leaven article on it, are available on
several internet sites, in several languages. Just Google 'Reverse Pressure
Softening'.

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

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