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Subject:
From:
"K. Jean Cotterman" <[log in to unmask]>
Reply To:
Lactation Information and Discussion <[log in to unmask]>
Date:
Tue, 8 Apr 2014 04:20:47 -0400
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< And told no more pumping as it will prevent the wounds(2: one
bottom, one side) - - - - - ->  I’m not sure I agree with this.  If the setting
is on low, why would it prevent healing ?>

Because vacuum does not pull, other forces push, including the blood pressure inside the damaged 
blood vessels in the wound. 

<THE PROBLEM:  BFeeding med.Dr. said no more pumping (it will keep
the fissures from healing); hand expression only.  Mom is unable to 
bfeed from that side due to pain.  Mom is unable to hand express
successfully and is greatly adding to her frustration.  She’s has
tried massaging, warm showers and compresses.>

Depending on the depth of the wounds, multiple layers of skin, and maybe blood vessel healing 
need to take place, and that takes time. If you regularly observe the wounds, 
(or guide her by phone) you can then follow the (wise) physician's initial cautious guidance, and 
teach the mother to manage the edema by gravity and by hand, till you and she can test when it is 
safe to gradually re-introduce short (5 minute) bouts of pumping on low vacuum as described below.


You state that the mom is about 10 days postpartum. Depending on whether she had a lot of IV fluid 
(especially if she had long hours of IV pitocin), especially if she had it for long hours after the placental birth, 
she may still have some breast edema. This is especially true if her breasts are C cup or larger. 


<Mom keeps at hand expression without success; frustration is growing, as is her
engorgement.>


Edema makes hand expression difficult, and application of vacuum creates a better 
chance for edema to push itself forward toward the flange, making hand expression 
that much more difficult. 


Warmth expands blood vessels, making the breasts even larger, so I would encourage her to
discontinue it and trigger the MER as below. If she wants to use cold compresses for comfort, 
fine, but using gravity will help her lymphatic drainage reduce edema, (and it's less trouble;-).

This may help:
 
If breasts are C cup or larger, have her lie back far enough to get nipples higher than heart. Teach her to do 
    reverse pressure softening for slow count of 50 till she gets an MER and any edema is moved 1-2 inches 
    upward temporarily in the breast to soften areola. (This may even allow the baby to get a
    deep enough latch that results in little or no pain.)

kellymom.com/bf/concerns/mother/rev_pressure_soft_cotterman/‎


After RPS, fingertip expression at the right "sweet spot" should be much easier. (If you are teaching her 
over the phone, this may be difficult, as some moms "catch on" more easily through their sense of touch, 
rather than by words. Some have no idea of their internal nipple/areolar anatomy. It helps to suggest 
that her thumb and 2 fingers be placed about 3/4 to 1 inch back from the base of the nipple, 'and that 
there is "no forward pull" involved. Instead, steady pressure inward toward the chest wall while the 
thumb (at the 12 o'clock position) "rolls" in place to meet the opposite pressure of the two fingers 
that should be at exactly the 6 o'clock position (or 9 & 3). 


If you are present with her, with her permission, you can stand behind her so that your hand is in 
the same orientation as hers, and demonstrate on her breast. Or place her fingers in the appropriate 
place and put your fingers on top of hers to perform hand expression till she gets the hang of it.)


When the damaged area appears to be healed enough that no rawness is visible, it may be safe to 
resume gentle pumping in the following way, which many brand new mothers find gives more 
milk in fewer total minutes, with short sessions repeated more often:

1) Start with laid back position for RPS for slow count of 50 with nipple higher than heart if C cup 
     or more, to trigger MER and displace edema temporarily.

2) Pump on low for no more than 5 minutes by the clock. If she is very pendulous and/or swollen, 
    keep gravity from pushing edema forward again by having her lie on her side to pump one side at a time.

3) Inspect the damaged area to be certain the wound has not reopened due to the 
    vacuum and that none of the delicate healing area has been disturbed. 

4) Gently massage from the axilla and upper breast for 1-2 minutes to move some milk forward

5) If wound tissue is holding up, without visibly disturbing the healing, repeat steps 2,3 &4 for no more 
    than twice, for a total of just 3 vacuum periods of 5 minutes each.

6) Short, more frequent bouts of milk removal about every 1 1/2 to 2 hours when awake will keep
    supply up but still allow continued healing of the skin damage. 


I hope some of these suggestions may help.


K. Jean Cotterman RNC-E, IBCLC
Dayton OH

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