Reverse Pressure Softening
by K. Jean Cotterman, RNC, IBCLC

More health care providers are observing that mothers receiving multiple intrapartum IV's experience delay in expected postpartum fluid shift. Increased edema during the puerperium complicates engorgement, increases sub-areolar tissue resistance, distorts the nipple and interferes with comfortable, efficient latching. Edema may appear early, or later, within 48-96 hours, often lasting 10-14 days. (This may depend on both the quantity of IV fluid given and the time of infusion in relation to placental delivery, the stimulus for lactogenesis II.)

Reverse pressure softening (RPS) is a simple intervention that has proven very helpful in the first 14 days postpartum. RPS uses gentle positive pressure to soften a 1-2 inch area of the areola surrounding the base of the nipple, temporarily moving some swelling slightly backward and upward into the breast. RPS may be applied by the health care provider, and/or taught to the mother/significant others, if necessary, over the telephone.

Interstitial fluid volume increases 30% above normal before edema becomes visible. (Guyton, 1977) To contain edema, areolar tissues must expand, limiting their ability to extend the nipple well into the baby's mouth. Early proactive use of RPS causes no harm and may facilitate increased milk transfer, reduce risk of nipple trauma, and help resolve engorgement.

Conversely, pumping may attract edema into the flange area, especially at maximum vacuum settings. Areolar tissue may then appear "thickened", seeming to "bury" the subareolar ducts. Then, 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:


Two handed, one-step method.
Fingernails short, fingertips curved; each one touching the side of nipple.

Two handed, two-step method.
Using 2 or 3 straight fingers on each side, first knuckles touching nipple. Move ¼ turn. Repeat above & below nipple.

Two thumbs, two-step method (Step 1).
Using straight thumbs, base of thumbnail even with side of nipple.
Drawn by Kyle Cotterman

Two thumbs, two-step method (Step 2)
Move ¼ turn. Repeat above & below nipple.
Drawn by Kyle Cotterman

One handed “flower hold”
Fingernails short, fingertips curved, placed where baby’s tongue will go.
To see your areola better, try using a hand mirror.

Soft ring method
Cut off bottom half of an artificial nipple to place on areola to press with fingers.

 
  • After RPS, additional fingertip expression to further soften the areola is much easier, more comfortable and more productive. Creating a special niche for the chin often permits deeper latching.
  • Benefits of RPS include:


    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 and credit for diagrams by Kyle Cotterman are retained. You may contact me at: [email protected]

    Written May, 2002
    Updated June, 2003
    Updated April 2005

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