Karyn,

You did not say how many days postpartum this surrogate mother is. My guess is somewhere close to 4-6 at the time your consult happened. It would also enter into the swelling aspect how much crystalloid intravenous fluid and how much pitocin she had in the previous 7-14 days. 


Both the amount of nipple swelling you describe and the pain on hand expression make me think that the vacuum forces were too strong and/or used for too long a time. Vacuum does not pull. Other forces push.The enlargement of the nipple you describe is descriptive of excess intestitial fluid pushing its way into the flange area to try to balance the negative pressure of the vacuum and the postive pressures of everything else in the nipple-areolar tissues, including not only the excess interstitial fluid itself, but the blood pressure, the blood vessel walls, the skin cells, nerve cells, ductal walls, etc. Even a non engorged nipple swells somewhat during pumping, as evidenced in veterinary literature and also illustrated by Barbara Wilson-Clay in The Breastfeeding Atlas.
 

No matter what name anyone is now using for the ducts an inch or so deep behind the nipple, try to imagine a distended circular or even elongated balloon. The elastic walls at the largest circumference is stretched much thinner than the area at either end, either near where you blow it up, or where the "tip" once was. When the inside ducts 1/2 to 3/4 under the base of the nipple get very full, the walls at the most distended place get very thin. Another way to visualize it is if you have ever been riding in a car, develop a full bladder, and suddenly the driver slams on the brake and your seat belt suddenly compresses your bladder at it's center. It is very painful.
 
Given that there is already so much trauma apparently to many layers of the nipple-areolar complex, take a clean folded washcloth and saturate it with the warmest possible water that the mother can find comfortable on her wrist skin, and have her place the pack over the nipple and areola, covering it with her hand or a towel or diaper till it cools off to body temperature. Radlologists who do nipple duct procedures say this raises the pain threshhold in the nipple. 


Have the mother lie back at less than 30 degrees, or even prone. Some would teach the mother to do reverse pressure softening herself. But given her pain, at this point, it may be more effective if you explain briefly, ask her permission, and then you yourself apply RPS, all around the base of the nipple. Do RPS very,very slowly, steadily, gently (watch the mother's expression and back off if uncomfortable, and make the pressure more gentle for a longer time). Do this steadily for possibly even 5 or so minutes by the clock. This will focus compression at the distal (nearest the nipple) end of the duct to displace some of the milk slightly (1 inch or so) back upward into the connecting ducts. When the subareolar ducts are no longer overdistended whatsoever, then IME, the Marmet method of fingertip compression of the ducts will be comfortable.
 
 
 
<The glandular and connective tissue compartments occupying the NAC (nipple-areolar coplex) may be responsible for two separate compensatory effects, each temporarily modifiable by RPS.  (1) Temporary shortening of the depth of the nipple shaft may be due to traction on the galactophores due to tension from the walls of the distended lactiferous sinuses to which they are attached, and (2) expansion of the nipple circumference may be coincidental, due to edema in the connective tissue compartment of the NAC.> 

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. 

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

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