I appreciate input and feedback from all, even if your experience is
negative. Without the consultative help, ardent support and spiritual
midwifery of many lactnetters, this "baby" would never have been birthed.
So now that the jet lag from ILCA and the vacation that followed is
resolving, I would certainly welcome help from all sources in further
defining the use of RPS.

I came up with my original caution on using RPS on mothers with breast
implants that I expressed in the May JHL, in response to the editorial
question about whether there were any situations where I would advise
against its use. I repeated that caution in my talk at ILCA. I admit that
liability issues were probably foremost in my mind. But breast pumps
themselves are not always exactly easy on engorged tissues, besides the
distinct possibility of their not working in many situations, or actually
making the areolar edema even worse. Engorgement itself in a breast that
is already spacially crowded places pressure on both the implant and the
alveoli. After reading the exchange in Lactnet, I wonder if my stand on
caution needs rethinking and further definition.

My first thought is to carefully inform the mother, demonstrating on a
breast model, and let her decide whether to devote a longer time to very
slowly, and as always, gently, perform RPS on herself. Or not. She has
her own kinesthetic sense, state of mind and strength of breastfeeding
goals to guide her. The HCP does not share that reality, and therein
still lies what I perceive as a liabiltiy issue. Someone did come up to
me in Scottsdale to report that that is how she handled it and the mother
was pleased with the opportunity to begin to gain relief through RPS.
Diane Wiessinger's counsel is right. It empowers the mother to be given
the chance to perform RPS on herself before determining if she would like
any assistance from us.

All of this reminds me that I don't consider RPS a "treatment" per se for
engorgement or for breast swelling brought on by fluid retention, and its
use does not pose the question of "either or" for any other method. I
only encourage that it be the first choice before other methods are
tried. It is more like a key to unlock barriers to milk removal by the
baby (or hand expression or a gently used pump) which is the definitive
relief measure to help begin resolving engorgement.

Rachel wrote: <Mellanie posts on a baby who is having trouble latching,
is jaundiced, and mother who is engorged, and who has implants under the
muscles of her chest wall. To me this case sounds like a pretty typical
case of engorgement. . . . . I would suggest trying Reverse Pressure
Softening before all attempts at milk removal, whether by pump or by
breastfeeding. >
Kathy Eng wrote: < -- Moms who have had pitocin or a c-section may have
the severe edema type of breast swelling that defies pumping. Indications
would be a mom with swollen ankles, hands, and breasts. I find that
nothing much "cures" it until their bodies can resolve the edema. Reverse
pressure softening works on the areola area for latch-on. >
Mellanie replied: < I forgot to mention it in my original post, but that
was what initially got the milk flowing enough so that we could begin
relieving the engorgement. That was one of the first gems I learned when
I joined Lactnet almost 2 years ago. :-)
Mary Kay Smith wrote: < I want to add the caveat about agressive
engorgement treatments for someone who has implants. RPS (reverse
pressure softening - look it up in the archives) may be a bit agressive
and risks bruising the breast tissue and even rupturing implants. >
I have gone to great lengths to discourage anyone from interpreting the
directions for RPS as "aggressive". It would only become aggressive if
one were unwilling to devote enough time and patience for the steadiness
of gentle pressure to do the job of redistributing the swelling slightly
away from the central areola. I added to that, in my ILCA talk, that I
don't consider any one way the "right" or "wrong" way to perform RPS, but
only suggest certain ways as more effective for specific situations. I
said that if I myself were to make rules, they would be: No pain. No
pinching. No pulling, No stretching." Administered with the guidelines I
have developed, I do not think RPS has any chance of "bruising" the
breast tissue, as the firmness one feels is not so much breast tissue as
it is fluids overcrowding natural space within those tissues. Firm but
gentle pressure, done slowly and patiently enough, with attention to the
mother's body language, moves the fluids comfortably and relieves the
local overcrowding. In fact, I have the strong impression that breast
pumps are too frequently being used by some professionals, as well as
poorly instructed parents, in a way that is, in fact, damaging to
distorted nipple-areolar tissue.

There was one example I want to share that I did not quite have time to
give in my talk's conclusion: I received an e-mail recently from a
Colorado LLL leader. She said: "I had a great experience last week with
RPS and a despairing c-section mom whose baby wasn't nursing at 4 days
pp. It took about 20-30 minutes of the technique to latch the baby on
(mom was still terribly edematous) -- and once that happened, it was just
like the sun came out from behind the clouds! Mom was ecstatic. That was
the corner that needed to be turned. Things have gone well ever since."
And yesterday, I received this from a well-known LC who gave me
permission to share: <I saw a mom on Wednesday who had called 5 lactation
specialists of varying credentials.  She had a screaming baby who
wouldn't nurse and she was engorged (similar situation).  Most people
were telling her over the phone to just pump for 5-10 minutes and then
try to latch the baby, but that advice wasn't working.  No one was
telling her how to feed the baby if the baby wouldn't latch.  So I talked
her through a bottle-feeding over the phone  . . . . .I was there for the
next feeding.   Wow.  THIS is why we see moms in person. You just can't
do this over the phone.  She was clinically engorged.  I have seen such a
severe case only one other time.  The cabbage had left deep indentations
in her breasts because they were absolutely rock hard.  So guess what.
I taught her RPS.  And you know what?  I didn't think it was possible,
but we were able to actually bring the baby to breast and he drained
three ounces from the breast in just a few minutes.  He was so happy!!!!
And, of course, so was the mom.  Then grandma held him and she continued
to pump that side and then the other (after RPS first).  It was
absolutely amazing, Jean. >

Other than the fact that phone directions can be, and have been very
helpful in many situations, I think these two examples illustrate why
perhaps a mother with implants might be better served by our dealing with
liability issues by giving her the opportunity to learn about
self-administered RPS so she can make an informed choice.

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

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