Reverse Pressure Softening

by Jean Cotterman RNC, IBCLC

More health care providers are observing that mothers who receive multiple intrapartum IV's experience delay in expected postpartum fluid shift. Increased edema during the early postpartum period intensifies engorgement, increases sub-areolar tissue resistance, distorts the nipple and interferes with comfortable, efficient latching.

I want to share an intervention that has proven very helpful in the first 7-14 days postpartum. I call it Reverse Pressure Softening. This measure uses gentle positive pressure, and can be performed by the health care provider, and/or taught to the mother herself, if necessary, over the telephone.

Interstitial fluid volume can increase 30% above normal before it appears as edema to the naked eye. (Guyton) Consequently, early proactive use of RPS can facilitate increased milk transfer, prevent nipple discomfort and damage, and speed resolution of engorgement.

Conversely, vacuum applied during this period has the potential to cause further accumulation of edema in the tissue within the pump flange area, especially when maximum settings are selected. Such an "extra layer of edema" can effectively bury the sinuses beneath the thickening areolar tissue. When this happens, neither infant tongue action, fingertip expression nor the pump itself removes milk very successfully.

RPS is best performed immediately before each attempt to latch, for as many feedings as needed. Steady, gentle pressure inward toward the chest wall is exerted for a full 60 seconds or longer, focusing on the areola where it joins the base of the nipple. (A mother can be encouraged to sing a lullaby rather than watch the clock.)

If her fingernails are quite short, she can press with the curved fingertips of both hands simultaneously, with the nails nearly touching the sides of the nipple. The goal is to create a ring of 6-8 small "dimples" or pits on the areola at the base of the nipple. If performed by the health care provider, the flats of two thumbs or two fingers can also be used sideways, creating an inch long depression just above and below the nipple. But this will require another 60 seconds of pressure in opposite quadrants, partially overlapping the first set of pits, to soften the same general area at the base of the nipple.

If swelling is extremely firm, and the multiple fingertip method is being used, one or more three minute periods of constant reverse pressure may yield better results. (Watching sand flowing through a 3-minute egg-timer is one example of a relaxing way for a mother to avoid impatience and clock-watching.)

However, if the flats of two thumbs or fingers are being used, a more even distribution of interstitial fluid is obtained by alternating quadrants repeatedly for three or more 60 second applications each.

The effect is threefold.

1. Any excess interstitial fluid is temporarily moved inward in the direction of natural lymphatic drainage.
2. Longitudinal compression of the sinuses displaces some milk slightly backward into the ducts. Relieving over-distention of the walls of the milk sinuses reduces latch discomfort. Elasticity is freed for drawing the nipple-areolar complex more deeply into the mouth and responding to the stripping action of the tongue. .
3. The milk ejection reflex is automatically triggered by the steady stimulation of nerves supplying the nipple-areolar complex, propelling milk toward the front of the breast, nearly always within 5 minutes or less.

After application of RPS, any additional fingertip expression necessary to further soften the areola is much easier, more comfortable and more productive. If engorgement is severe, additional fingertip expression to create a special niche for the chin often permits deeper latching.
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Guyton, AC, Basic Human Physiology: Normal Function and Mechanisms of Disease, 2nd Ed., W. B. Saunders Co. Philadelphia, 1977, p. 321.

Permission is hereby given to reproduce and distribute this article as long as the original wording and my authorship are retained. You may contact me at mellomom@juno.com.