I sent Mardrey a copy of my Feb. 4 post headed "Terrific edema after IV's
and pitocin", a small part of which is below:

<Diuretics can't effect the fluids unless, or until, the excess fluid
actually re-enters the circulatory system, because until it does, it
cannot, of course, be carried to the kidneys for excretion. Also, the
pitocin molecule is very similar to the anti-diuretic hormone (ADH)
molecule, so the total amount of pitocin received would seem to have some
bearing on whether and how quickly and easily the kidneys could respond
to diuretics, be they pharmaceutical or from foods.

In the meantime, it is also helpful to remember that pressure adds to the
forces causing tissue fluid to re-enter the venous and lymphatic
capillaries. Gravity is one such force. (It's important to remember that
although fluids enter the breast through the arterial system, they leave
the breast in two opposite directions: milk forward and centrally, tissue
fluid upward and posteriorly.)

The breasts, especially the front of the breast, where the all important
nipple-areolar complex is situated, can be elevated by having the mother
spend a lot of time flat on her back with support to the breasts. Gravity
will then lead fluid away from the front of the breast to the natural
channels of lymphatic and venous drainage in the upper posterior parts of
the breast, the inner chest, etc. to the subclavian and jugular
confluence near where the fluid re-enters the large veins on their way
back to the heart. Gentle massage of the breast (somewhat like that used
in the monthly breast self-exam) in an upward direction, starting near
the clavicle, can assist this clearing of the tissue fluid swelling from
the breast. So can movement of the pectoral muscles.
(Does anyone remember the old "heartburn-lactation" exercise taught in
CBE classes in the 50's?)

For the ankles, while massage has traditionally been discouraged for fear
of causing emboli, active motion of leg muscles, and perhaps elastic hose
and elevation of the legs for parts of the day might also provide helpful
pressure.>

Given what she describes about the effect of the pump:
<she has so much fluid (from before the birth as well) that when she
tries to pump her nipple and areola fill up with fluid and take on the
shape of the pump flange tunnel.  I watched this happen yesterday when we
changed to the extra-large flange, and before five minutes had passed her
nipple had expanded to be touching the sides of the tunnel all the way to
the nipple tip.>

I would suggest first of all, using RPS on the nipple itself, and on the
areola close to the nipple, as far outward as the pump has attracted
extra tissue fluid, for as many minutes as it takes. No real limit, as
long as you look at the skin color. It might be helpful to cut off the
top of a standard rubber nipple and place just the base around the
mother's nipple to use the fingers to exert pressure on the areola
through it. This can even then be done with the one-handed method (a-la
Rachel Myr's great suggestion). The goal is to displace the edema so that
nursing or pumping can more easily compress the milk sinuses (or
subareolar ducts, if you prefer to refer to them that way.)

This will also trigger the MER strongly within 3-4 minutes at most. After
that, short stints at pumping (perhaps less than the 5 minutes after
which she said she began to notice the forward attraction of the edema),
using minimal vacuum, or moderate at the most, to begin removing milk.
After 5 minutes or so, stop and massage especially the upper, outer
quadrant of the breast forward gently, or use breast compression during
the pumping if someone else (or a cut-out old bra), (or one-sided
pumping), can hold the flanges on. If the edema once again begins to show
inside the flanges, stop and do RPS all over again and repeat the short
stints of pumping.

You can find my illustrated article on RPS in the April/May 2003 Leaven,
and I am happy to report that a more detailed article is now in press for
JHL.

Due to the immediacy of the situation, I also sent Mardrey some
attachments with directions and diagrams re: Reverse Pressure Softening
to intervene with the effects on the nipple-areolar complex to "level the
playing field" so the babies have a better chance of latching. This
prepares the areola marvelously for the effective use of a nipple shield,
if their size makes that a better option right now.  I believe the Leaven
article is available on-line through the LLL site, but if you cannot get
the Leaven article, I am prepared to do the same for anyone else who
wants to learn more about this.

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

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