Hi Barbara,
I am also very interested in this. I have discussed how to do a study of breast edema with my doctor pals who are better acquainted with research methodology, but I have never done research, and have way too much on my plate right now to get started. There was an article published in an Australian journal, if you are real interested I can dig the citation up for you, about a device called the "Roberts Durometer", a custom made gizmo for testing the hardness of breasts. Wonder how much one of these costs? Other than having a mechanical tool for measuring breast firmness, you would have to devise some type of assessment scale, which would of course be subjective depending on the examiner and therefore not as reliable. But I can sure tell you that I check breasts every day, and many of the "flat nipples" I see are just grossly swollen breasts. Some of them change dramatically from one day to the next. I have become a huge fan of Jean Cotterman's Reverse Pressure Softening, and teach it to nearly every mom I work with.
As an old L&D nurse I can also tell you that when a mom gets a labor epidural, you put in the largest bore IV catheter her vein will accommodate (in case she later needs blood), and you run in up to 1.5 liters of fluid in the 20-30 minutes before the anesthesiologist comes in to place the epidural. Depending how long she labors, and whether she bleeds a lot after the delivery, she will get several more liters. Generally this is lactated Ringer's or some other type of "crystalloid" IV solution, which my retired surgeon buddy tells me goes straight into the interstitial space and stay there for a LONG time. Pitocin aggravates this, because it has an antidiuretic effect.
I would guess that 75-90% of women delivering in the US get labor epidurals. Many receive pitocin to counteract the slowing effect of the epidural on the forces of labor. When you add it up, it is a rare woman who delivers without an IV. Hence the OBs at the bedside telling moms that their elephantine feet and ankles are "normal," and that it will take a couple weeks for the swelling to recede!
Martha J.
-----Original Message-----
From: Barbara Wilson-Clay [mailto:[log in to unmask]]
Sent: Saturday, September 13, 2003 4:45 PM
To: Johnson, Martha (Lactation-SHMC)
Subject: Re: pushing equipment and mastitis
I am very interested in the issue of edematous nipples. I wish someone
would do a study on this.
B.
Barbara Wilson-Clay, BS, IBCLC
Austin Lactation Associates
LactNews Press
www.lactnews.com
----- Original Message -----
From: "Johnson, Martha (Lactation-SHMC)" <[log in to unmask]>
To: "Barbara Wilson-Clay" <[log in to unmask]>
Cc: <[log in to unmask]>
Sent: Saturday, September 13, 2003 2:24 PM
Subject: RE: pushing equipment and mastitis
Hi Barbara et al--
I am a hospital based LC, who has low-tech leanings. I agree that moms are
getting too much equipment pushed at them. I think there are a number of
causes for this. I would say that several main causes are:
1. Very short hospital stays. Nurses and LCs really want to see babies
successful at breast before they go out the door, so we get desperate and
try whatever works.
2. Changes in obstetric practice have radically altered the way newborns
feed during the first days of life. The induced 37-38 weeker; the baby
delivered by vacuum extraction to a mom whose epidural made her unable to
push effectively; the baby whose mom's nipples are grossly edematous after a
day of IV fluids-- all of these have become clinically commonplace in the
past 5 years. when I started practice as an L&D nurse in the late 80's, may
of these situations were not common. I would say without hesitation that
the babies I see now do not feed like the babies I used to see 10-15 years
ago. It is a "difference between common and normal" as someone on Lactnet
put it brilliantly not long ago. Just because we see something all the time
clinically does not mean that is what's normal.
3. The other factor is our gizmo-obsessed culture. Nurses, LCs, and
parents want a quick fix for every problem, and tools and gadgets look like
the fix. I used to have a UNICEF video that showed mothers of premature
babies at a hospital in Nairobi Kenya, hand-expressing milk at speeds that
no electric pump could match! A good lesson for our culture.
Martha Johnson RN IBCLC
Eugene Oregon
-----Original Message-----
From: Barbara Wilson-Clay [mailto:[log in to unmask]]
Sent: Friday, September 12, 2003 3:41 PM
Subject: pushing equipment and mastitis
While I know LCs who are extremely conscientious about not pushing equiment
at new mothers, one certainly hears stories from clients about LC contacts
that have resulted in the sale of many hundreds of dollars worth of products
and no resolution of the orginal problem. In my experience, bras, pillows,
stools, etc. are not the answer to breastfeeding problems. Since they are
typically available in commercial retail establishments, and can be
purchased on a non-emergency basis, the ethics of LCs selling these items
seem questionable to me. It is a very slippery slope and quite tempting to
provide a pump or whatever when you also suspect that the next person trying
to sell something to the mom may know far less than you do in terms of
teaching the mom how to use the equipment. However, it is still part of the
ethics of LC practice to avoid putting profit before the patient.
To put a slightly less sinister spin on it (as I think most LCs are very
ethical) I think that a lot of equipment is sort of thrown at problems
without there always being a good rationale for its use due to inexperience
and lack of a better idea of how to fix the problem.
The feeding tube device is a good example. They are expensive, finicky, and
most of the people who use them hate them. Occasionally you get an adoptive
mom who is thrilled about the feeding tube device and thinks its the
greatest thing in the world, but I am puzzled by all the moms with poorly
sucking babies who are sold these $50 devices for no good reason. Unless
the baby has a normal suck, the supply lines don't really work very well.
The supply line works best for a normal baby and a mom with a really low
milk supply. The same problem of irrational selection occurs with nipple
shields. I love nipple shields for certain problems; they work like a
charm. But I am always seeing moms who have been given one and I wonder
why? Their problem is not going to be solved by this particular tool. I
say again that there are serious deficits in LC training, and one area where
this is very visable is tool use.
Anyway, my real point in posting was to say that Pam has an interesting idea
that perhaps the early overuse of pumps is contributing to mastitis. That
would require a focused study, of course, to confirm. There could be other
possibilities. Many of these moms have nipples that crack in the germy
hospital environment and become bacterially contaminated. These moms are
more and more sent home with instructions to seal these wounds with
occulsives. I suspect this is done without any advice to flush or debride
the wounds prior to using things like hydrogels or lots of lanolin. Latch
is still poorly taught in hospitals, and I think the sore nipple advice is
generally inadequate because it doesn't emphasize first aid cleansing. The
real incidence of lactation mastitis is still under exploration, and
researchers such as Fetherston and Amir (in Australia) and Foxman (in the
US) have published excellent articles looking at risk factors. I'd have to
go back and review to see if there is a connection mentioned in these
articles with regard to incidence of pump use.
One final thought about frequent use of equipment in the early postpartum:
The population that consults LCs after discharge is by definition a high
risk population. Why would they need us otherwise? So are these moms
using pumps more than a mom would be with a more successfully feeding baby?
Causality, coincidence, iatrogenic affect... lots of possibilities.
Barbara Wilson-Clay, BS, IBCLC
Austin Lactation Associates
LactNews Press
www.lactnews.com
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