Rachel Cruz wrote:

<I'm new to Lactnet in that I've never posted before. I work as the IBCLC
in a level 3 NICU in NJ. I've had twin moms who are very successful with
developing a full milk supply for both babies pumping 8x/day. The most
important pieces of the equation are the early initiation of pumping
coupled with hand expression and the use of a hospital grade pump. >


Welcome to Lactnet! Warning! It has potential to become somewhat addictive! For me, at least;-)


If I remember correctly, Paula Meier's research recommends 10x/24 hours, and no necessity to wait equal times between pumping, as regular effective milk removal as well as the 24 hour total removed is what counts. I seem to remember the conclusion that for some mothers at least, it's better to build somewhat of an oversupply in the early weeks. This is because it's often easier to tamp down an oversupply than build a bigger one at a future time period beyond the mother's hormonal state in the first 4+ weeks. Obviously the MOT you cited didn't need this, but there are certainly other mothers who might.


I have often "borrowed" her hint to help a mom under such stressful conditions avoid clockwatching and timing by having her prepare each day a small cup or snackbag with 10 M&M's, Cheerios, or whatever is her choice for a tiny snack. She rewards herself each time she double pumps, and when the snacks are gone, she is done till her breasts wake her up to start the next 24 hour day.


I would like to add to the other excellent suggestions in your post two other observations I have found it helpful to factor in. They are: 


1) Gravity and the pendulousness of mom's breasts and its effect on movement of interstitial fluid toward the nipple-areolar complex. For moms with pendulous breasts, even though supported as well as possible, gravity may cause some edema to collect near the nipple areolar complex even in late pregnancy. This needs to be factored in because of the possibility of edema crowding ducts, making hand expression difficult or impossible, and even more edema pushing forward toward vacuum, often reducing the yield of pumping despite obvious palpation of full glandular tissue. This effect may be made even more problematic by #2:


2)The mother's peripartum IV fluid history e.g. "Did she have >2000 cc. in any one 24 hour period? And if so, which period (in relation to the time of birth of the placenta(e)? Also, did any of those IV's contain pitocin?" MOT and others with greatly distended uteri now often receive 24-36+ hours of IV pitocin after birth to prevent hemorrhage. Pitocin has a side effect of antidiuresis.


I have seen moms who received this type of third stage management be able to initiate direct breastfeeding in the hospital, yet gradually start to experience the onset of edema even a day or so following their hospital discharge. It often only then begins to show up in ankles, etc., including in the breasts, sometimes with delayed lactogenesis, and in other cases, superimposed on it, starting at that late point to interfere with direct BF and/or pumping. 


In addition, at the general point at which the mother has received from 2000-2500 cc. of fluid in any one 24 hour period before the birth of the placenta, breast edema may even have become noticeable before or by the time of birth. This can even show up as blisters on the surface of the nipple formed during the initial breastfeeding at birth! If a mother receives pitocin for induction or augmentation for hours before birth, this often results in the onset of edema within the next 24 hours, often making fingertip expression difficult or impossible. Vacuum may compound the problem, since vacuum does not pull; other forces push. (As our friend Diane Wiessinger has taught us well, we must watch our language!) 


Depending on the amount of excess interstitial fluid in the breast, it may easily and quickly push its way forward to neutralize the vacuum in time to crowd the subareolar tissues. Then, once the ducts become compressed by edematous subareolar tissues, even MER, and breast compression may not be able to force much milk to the surface where milk itself could then push forward into the vacuum to neutralize it.

 
Many colleagues around the world have reported that they have found Reverse Pressure Softening very helpful. Many have further discovered that the use of neutral gravity positioning (including when pumping) and/or antigravity positioning in pendulous breasts is an important thing to consider to improve the successful use of RPS. 


By positioning to counteract the effects of gravity, the temporary effect of RPS is extended for a longer time, to facilitate latching and/or to spare the subareolar ducts from re-entry and compression effects of edema during pumping. It is also useful to repeat RPS several times during pumping if edema pushes its way forward again into the flange tunnel. An added benefit of RPS is its ability to trigger (and re-trigger) the MER several times to shorten the pumping period. 


K.Jean Cotterman RNC-E, IBCLC
WIC Volunteer LC        Dayton OH


Cotterman, KJ, Too swollen to latch on?: try Reverse Pressure Softening first, Leaven Apr. May 2003, pp. 38-40.

Cotterman KJ, Reverse Pressure Softening: A Simple Tool to Prepare Areola for Easier Latching During Engorgement, Journal of Human Lactation, May 2004, vol. 20, iss. 2, pp. 227-237. 

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