This is my suggestion: absolute prevention of nipple trauma so no treatment is necessary:


1) Teach mother about Reverse Pressure Softening during pregnancy, using pictures and verbally and with demo breast. Any degree of breast pendulousness combined with the tendency to retain extra fluid during pregnancy can cause some edema to gather in the areolar/subareolar tissues, (and nipple) even during pregnancy. (Any prenatal practice of RPS is contraindicated if her OB has given warning about no sexual activity in pregnancy.)
 

2) For those mothers who are open to anticipatory guidance about complete avoidance of nipple trauma, review in very early labor, offering to teach or review RPS. Help her understand the need for the areola to be as soft as her own lips are, right before each latching right from the start, and before each feeding for the first 7-14 days, so that the areola can change shape easily to extend the nipple itself deep into the mouth toward the soft palate area,  in response to baby's latching attempts right from the beginning. 


3) When teaching RPS just prior to or in early labor, in addition to her sight and hearing, offer to use her kinesthetic sense, with her fingers (or yours, with permission) directly on the areola, or on top of her fingers. Have her lying back at least far enough that the nipple is above heart level, especially if breasts are C Cup or beyond. This is to use gravity to keep any tissue fluids (and/or colostrum from full ducts) "at bay", e.g. moved back upward an inch or so in breast for at least 5 minutes. Then, if done right before offering breast, baby is empowered to get a deeper latch. In addition, any necessary hand expression is much easier and more productive (due to MER, plus edema having been moved out of subareolar tissues.)


3) I suggest (my empirical observation) that this is especially important if mom is going to get (oral +) IV fluids in excess of 2000-2500  cc. in any one 24 hour period, and especially if IV pitocin (anti-diuretic effect) is used for induction, augmentation or for hours after birth if at risk for postpartum hemorrhage. IME, this total amount of (oral +) IV fluid/and/or pitocin drip, is enough to place her at risk for starting to develop what I call Pre-L2 edema-other places but especially edema of the dependent part of the breast, well before hormonal changes have increased breast circulation that brings on L-2 to eventually cause the ducts to begin to really fill. 


4) It ought to go without saying, but I'll say it anyway. Any vacuum allows excess interstitial fluid (edema) to push its way forward into flange and nipple-areolar complex area. If HCP or mother believes fingertip expression (after preliminary RPS) is not removing enough colostrum and that a pump is really necessary, have mom do RPS before pumping, and several times during pumping, on medium or lower vacuum. Remember to factor in gravity into the equation too.


5) I would really like feedback, especially negative feedback. This is a strong hypothesis of mine, and I'd be happy to be persuaded that I am not on target in any way, if indeed I am not. 


I would like to know both the "interpersonal" reactions of staff and moms, and I would like to get hospital personnel making private notes on 24 hour fluid intakes, IV pitocin dosage/duration, and observations of the time of appearance of any edema within 24-48 hours after the 2000-2500 cc. volume/24 hours. 


Remember that "invisible" edema can be present when interstitial tissue has up to 30% more than is normal for that tissue. Even "invisible edema" can offer resistance to the normal functioning of the subareolar tissues. 


Pitting edema, by definition, becomes visible when interstitial tissue has 30% or more than normal for that tissue, and can offer even greater resistance to natural function of the subareolar tissues. 
 

Someone (many someones) on the intrapartum scenes all over the world, in many differing obstetrical management "cultures", needs to be connecting volume of IV's/pitocin "dots" with the timing/appearance of any edema of the areola and subareolar tissues and consequent limitation of function. 


If enough empirical agreement is evident to enough people, perhaps we can persuade someone someday to measure colloid osmotic pressures, or at least serial albumin levels to get enough scientific evidence to prove a connection on which to base practice for those mothers who become at risk for breastfeeding complications caused by areolar edema when "standard management" or dire emergency requires >2000-2500 cc. oral/IV intake/24 hours, especially when hours of IV pitocin are part of the mix.


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

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