Peripartum Breastfeeding Management

All pregnant women should receive education about the benefits and management of breastfeeding to provide an opportunity to make an informed decision. The obstetrician with prenatal consultation should make an assessment of the potential for successful breastfeeding if a problem is identified. Labor and delivery with the presence of a doula has been shown to enhance breastfeeding. Mode of delivery and use of anesthesia and medications also impact breastfeeding. Provision for breastfeeding within the first hour of life and the availability of rooming-in are also essential. The Academy of Breastfeeding Medicine (ABM) provides a helpful protocol for successful peripartum management.

A model of breastfeeding policy is also provided by the ABM, which is designed so that hospitals can incorporate it into their own policies. It meets requirements for the Baby Friendly Hospital Initiative.

The Science of Suckling

The ability to lactate is characteristic of all mammals, from the most primitive to the most advanced. The divergence of suckling patterns, however, makes it urgent that human patterns be studied specifically. Some aquatic mammals, such as whales, nurse under water; others, such as the seal and sea lion, nurse on land. A variety of erect or recumbent postures are assumed by different terrestrial mammals. Nursing may be continuous, as in the joey attached to a marsupial teat, or at widely different intervals characteristic of the species and parallel to the nutrient concentrations of the milk. The intervals may be a half hour for dolphins, an hour for pigs, a day for rabbits, 2 days for tree shrews, or a week for northern fur seals.

New anatomy research gathered for the first time in 160 years since the brilliant work of Sir Ashley Cooper has been generated in the laboratory of Peter Hartmann in Australia and his eclectic team of scientists. They have had access to the latest digital technology. They have shown that the milk ducts of the breast are small ( Figure 8-1 ), compressible, superficial, and closely intertwined. There are no “dilated sinuses” that store large amounts of milk. The amount of adipose tissue in the breast is very variable and not a measure of the amount of glandular tissue; there is twice as much glandular tissue as fat. Magnetic resonance imaging has identified some central ducts in the breasts of lactating women. The anatomy of the lactating breast was redefined with ultrasound imaging in Hartmann’s laboratory. Ducts were found to number four to eight, and branches drain glandular tissue directly beneath the nipple and merge into a collecting duct very close to the nipple. They do increase in diameter during milk ejection. Milk production is not dependent on neural stimulation but is hormonal. Milk ejection is critical to successful lactation. Failure to remove milk results in decreased milk production. Multiple milk ejections occur during breastfeeding, even though a women usually only senses the first milk ejection.

Ultrasound image of a main milk duct (Toshiba, Aplio). The nipple is the round hypoechoic (dark) structure in the left of the image (N). The main duct (M) branches into two ducts (B) approximately 5 mm from the nipple. Note the small diameter of the ducts (approximately 3 mm).

(From Geddes DT: Inside the lactating breast: the latest anatomy research. J Midwifery Women’s Health 52(6), November/December 2007, Figure 3.)

Although many anatomic distinctions exist as well, the principal mechanism of milk removal common to all mammals is the contractile response of the mammary myoepithelium under the hormonal influence of oxytocin released from the neurohypophysis.

The key function in all species is effective control of milk delivery to the young in the right amount and at the appropriate intervals, which requires a production system, exit channels, a prehensile appendage, an expulsion mechanism, and a retention mechanism. The primary, secondary, and tertiary ducts form an uninterrupted channel for the passage of milk from the milk-producing alveoli to the prehensile appendage. A process of erection of the areolar region facilitates prehension by the young during suckling. The principal object of the suction produced by the facial musculature of the young is to draw the nipple into the mouth and retain it there. Positive pressure is used to expel milk from the gland by the contractile changes in the mammary gland provided by the myoepithelial cells (see Figure 3-15 ). The sympathetic nervous stimuli can oppose milk ejection by increasing vasoconstrictor tone, thereby reducing access of circulating oxytocin to the mammary myoepithelium. Sympathetic activity also can occur during conditions of apprehension or muscular exertion. The milk-ejection reflex can be blocked by emotional disturbance or reflex excitation of the neurohypophysis. The central nervous system control of milk ejection indeed suggests that restraining mechanisms exist to ensure that milk ejection can only occur under circumstances wholly conducive to the effective removal of milk by the suckling young.

In all species that have been studied, a rise in intramammary pressure and flow of milk occurs as a reflex event in suckling. The excitation of the neurohypophysis results in the release of oxytocin, which is conveyed via the bloodstream to mammary capillaries, where it evokes contraction of the myoepithelium. The successive ejection pressure peaks, demonstrated in lactating women, can be duplicated more accurately by a series of separate oxytocin injections than by the same total dose as a single injection or by a continuous infusion of the hormone. This strongly suggests that oxytocin is released from the neurohypophysis in spurts. The study of suckling patterns in all species shows a high degree of ritualization, which in turn suggests a close neural connection between cognitive or behavioral and hormonal responses.

Attention has focused on the mechanisms that control suckling behavior, on its incidence, on events that precipitate and terminate it, on the effects of stress, and on how development modifies it. Suckling is characteristic of each species and is vital for survival. Suckling means to take nourishment at the breast and specifically refers to “breastfeeding” in all species. Sucking , however, means to draw into the mouth by means of a partial vacuum, which is the process employed when bottle feeding. Sucking also means to consume by licking.

Although suckling has been studied in young and mothers in other species, a large portion of human data have been collected using a rubber nipple and bottle. Other mammals suckle only in the nutritive mode, whether receiving milk from the nipple or not. Human infants were noted to have two distinct patterns with rubber nipples: a nutritive mode and a nonnutritive mode. ^, When this work was repeated using the breastfeeding model, no difference between nutritive and nonnutritive suckling rates, but rather a continuous variation of suckling rate in response to milk-flow rate, has been seen. Suckling rates in other species correlate with milk composition and species-specific feeding schedules (one suck per second in great apes and four to five sucks per second in sheep and goats).

In further experiments, an inverse linear relationship was found between milk flow and suckling rate. Thus the higher the milk flow, the lower the suckling rate. In human infants younger than 12 weeks of age, suckling will terminate with sleep and be reinstated on awakening, a pattern that is well described in other species. In infants older than 12 weeks, suckling is not always terminated by sleep. At 12 to 24 weeks, infants will play with the nipple, explore the mother, and not always elicit nipple attachment. Continuous measurement of milk intake during a given feeding from one breast showed a progressive reduction in intake volume per suck and an increase in the proportion of time spent pausing between bursts of sucking.

Using the miniature Doppler ultrasound flow transducer, Woolridge and Baum studied 32 normal mother-baby pairs from 5 to 9 days postpartum. Intakes during trials averaged 34.2 g (± 3.7 g) on the first breast and 26.2 g (± 3.5 g) on the second breast. At the start of feeds, the average suck volume was about 0.14 mL/suck, which decreased to about 0.10 mL/suck or less. The mean latency for release of milk was 2.2 minutes after the infant began to suckle. The researchers also noted that on the first breast the flow increased and stabilized after 2 minutes, with concomitant slowing and stabilizing of sucking pattern during the remainder of the feed. On the second breast the suck volume fell off dramatically toward the end of the feed (50% reduction from peak to end of feed) ( Figure 8-2 ).

Mother-infant pattern of milk flow.

(From Lucas A, Lucas PJ, Baum JD: Pattern of milk flow in breast-fed infants, Lancet 2:57, 1979.)

These observations support the theory that infants become satiated at the breast, and milk remains unconsumed in the breast. During the first month of life, infants consume a given amount of fluid with decreasing investment of time. The amount of fluid per suck increases over time. The control of intake appears to come under intrinsic control of the infant during the first month of life.

A cineradiographic study of breastfeeding was done by Ardran et al. in 1957 and compared with a similar study of bottle feeding. The nipples and areolae of 41 breastfeeding mothers were coated with a paste of barium sulfate in lanolin, and cineradiographic films were taken with the infant at breast. These were then reviewed meticulously. Box 8-1 lists the authors’ conclusions in their original description. These observations are of historic interest, but newer techniques in imagery have more accurately described the understanding of human suckling.

The development of real-time ultrasound improved the definition of images. Several studies have been published using this noninvasive technique to observe the action of the infant’s tongue and buccal mucosa and the maternal nipple areola. Using a video recorder in the 1980s that allowed frame-by-frame analysis and recorded simultaneous respiration, the pattern of suck, swallow, and breathing was documented during a period of active suckling at the breast. A suck was defined by Weber et al. as the beginning of one indentation of the nipple by the tongue to the beginning of the next. Weber et al. had examined six breastfed and six bottle-fed infants between 1 and 6 days of life. Not all sucks were associated with a swallow. Box 8-2 summarizes the process.

Observations of suckling using improved techniques from 2 to 26 weeks showed that suckling starts with a series of fast sucking movements and then stabilizes. In a 2-week-old breastfeeding infant, sucking and breathing pattern proportions alternated smoothly at about two sucks to one breath, with swallowing occurring with every suck. Bottle feeding patterns were variable and sometimes asynchronous with sucking and breathing.

The process of suckling has been described as a pulsating process similar to peristalsis along the rest of the gastrointestinal (GI) tract. This undulating motion, as described by cineradiography, did not involve stroking or friction, as was clearly pointed out by Woolridge. The nipple should not move in and out of the infant’s mouth if the breast is positioned correctly. The tip of the tongue does not move along the nipple. The positive pressure of the tongue against the teat (areola and nipple), coupled with ejection of the milk from increased intraductal pressure, evacuates the milk, not suction. The negative pressure created in the mouth holds the nipple and breast in place and reduces the “work” to refill the ducts. Visual observations and videotapes made in our laboratory to study suckling show the undulating motion of the external buccal surfaces even in newborns. Ultrasound confirms the molding of buccal mucosa and tongue around the teat, leaving no space.

In breastfeeding the tongue action is a “rolling,” or peristaltic, action from the tip of the tongue to the base, not side to side. In bottle feeding the tongue action is more piston like or squeezing. When the infant rests between sucks, the human nipple is indented by the tongue, and the latex teat is expanded in bottle feeding ( Figures 8-3 and 8-4 ).

Ultrasound of infant at breast. Still picture of ultrasound scan frame from video recording. Scanner head is at bottom, with a sector view of 90 degrees. Below is an artist’s impression of image showing key features. Image is seen best when tilted through 45 degrees so that the infant’s head is vertical. Picture corresponds to point in sucking cycle when maximum point of compression of nipple by tongue has almost reached tip of nipple. Once nipple has become fully expanded, fresh cycle of compression will be initiated at base of nipple and will then move back.

(From Weber F, Woolridge MW, Baum JD: An ultrasonographic study of the organization of sucking and swallowing by newborn infants, Dev Med Child Neurol 28:19, 1986.)

Infant sucking on rubber nipple, which fills mouth and thus prevents tongue action and provides flow without tongue movement. Flow occurs even if lips are not tight around rubber hub.

The change in nipple dimensions during suckling is detailed by Smith et al., who also used ultrasound and examined 16 term infants ages 60 to 120 days and their mothers. They demonstrated that human nipples are highly elastic and elongate during active feeding, including approximately 2 cm of areola, to form a teat approximately twice its resting length. They also showed that infants’ cheeks (buccal membranes), with their thick layer of fatty tissue, known as sucking fat pads, act to make a passive seal to create a vacuum (as opposed to the concept that the cheeks are sucked in by the negative pressure). Milk ejection was noted to occur after maximal compression of the nipple.

Suckling Patterns as Indicators of Problems or Pathology

The behavior of an infant at birth is the first opportunity to observe the infant’s adeptness at suckling. In a careful analysis of videotapes of newborns in the first 90 minutes of life, Widström and Thingström-Paulsson observed a consistent pattern. Licking movements preceded and followed the rooting reflex in alert infants. The tongue was placed in the bottom of the mouth cavity during distinct rooting. The authors suggest that forcing the infant to the breast might disturb reflex action and tongue position. They further observed that a healthy infant should be given the opportunity to show hunger and optimal reflexes and attach to the mother’s nipple by itself.

Righard and Alade observed that an infant placed on the mother’s abdomen will self-attach to the breast and suckle correctly in less than 50 minutes. They further reported that when the infants were separated from their mothers for delivery room procedures, the initial suckling attempts were disturbed, and many infants were too drowsy to suckle at all.

Righard and Alade also investigated the prognostic value of suckling technique (faulty vs. correct) during the first week after birth in relation to the long-term success of breastfeeding. For assessment of breastfeeding technique, 82 healthy mother-infant pairs were observed before discharge. The authors defined correct sucking as the infant’s mouth being wide open, the tongue under the areola, and the milk expressed in slow, deep sucks. Incorrect sucking was defined as the infant positioned as if bottle feeding, using the nipple as a teat. The oral searching reflex was defined as the infant opening the mouth wide in response to proximity of the nipple to the lips and thrusting the tongue forward in preparation to taking the breast. This reflex is a part of the normal response to circumoral stimulus, resulting in rooting by the infant, who comes forward, opens the mouth wide, and extends the tongue when stimulated centrally on the lower lip and even the upper lip. Stimulus on the side of the mouth or cheeks elicits turning to that side.

It was first noted by Barnes et al. that mothers with difficult labors and deliveries had more problems breastfeeding. The influence of mode of delivery on the initiation of breastfeeding has been reported. For infants delivered by vacuum extraction or cesarean delivery, suckling was delayed and they received more supplements, C-section patients also received postdelivery narcotics, which changed suckling patterns. Parity increases chances of success in lactation, according to Dewey et al. They confirmed the influence of mode of delivery, duration of labor, labor medications, and the use of artificial feedings and pacifiers as well. When these factors are present, extra care should be made to support the mother’s efforts to breastfeed ( Figure 8-5 ), particularly monitoring at day 3 and the day of discharge.

Percentage of mothers with delayed onset of milk production, by parity and infant birth weight, adjusted for mode of delivery, duration of stage II labor, maternal body mass index, and flat or inverted nipples (bars with different letters are significantly different, p < 0.05). Vertical bars, birth weight ≤ 3600 g; horizontal bars, birth weight > 3600 g. N = 69 primiparas with infants ≤ 3600 g, 61 primiparas with infants > 3600 g, 40 multiparas with infants ≤ 3600 g, and 71 multiparas with infants > 3600 g.

(From Dewey KG, Nommsen-Rivers LA, Heinig MJ, Cohen RJ: Risk factors for suboptimal infant breastfeeding behavior, delayed onset lactation, and excess neonatal weight loss, Pediatrics 112:607, 2003.)

C-section rates have risen and fewer women who deliver by C-section breastfeed. Initiation rates require more support and monitoring for C-section patients. At 6 months the long-term success, however, is the same for both vaginal and operative patients who breastfeed.

Medications During Labor and Epidural Anesthesia

Because of repeated concerns about the possible effect of intrapartum epidural anesthesia on a newborn infant’s ability to suckle and the rising incidence of epidurals in some hospitals (more than 50% of vaginal deliveries), Rosen and Lawrence investigated 83 mother-infant dyads who either exclusively breastfed or bottle-fed. An infant’s ability to nurse at the breast or take a bottle was scored from multiple observations. Weight loss in the first few days was also evaluated. Epidural anesthesia had no apparent effect (although analgesics showed a relationship) on ability to feed or initial weight loss. However, prolonged epidural use (beyond 4 hours or repeated dosing) may well have an effect because the drug has time to be absorbed into the systemic circulation.

The question of duration of epidural anesthesia was investigated by Bader et al., who found that maternal venous and umbilical venous levels of fentanyl and bupivacaine were relatively constant whether the epidural lasted 1 hour or up to 15 hours. Total doses varied between 27 and 200 mg for bupivacaine and 22 to 300 mg for fentanyl. Significantly, however, bupivacaine was measurable in the umbilical venous sample of the infants (0.15 ± 0.06 mg/mL). The significance of fetal tissue uptake is unclear. Umbilical artery blood gases and neurobehavioral scores were normal. Neonatal urine in another study had small, but measurable, bupivacaine metabolites 36 hours after delivery when spinal anesthesia was used for cesarean delivery. It is noteworthy that usually the infant is delivered within 15 minutes of medication administration for cesarean delivery, so fetal exposure is minimal when used for C-sections.

The effect on infants of different doses of meperidine given to mothers in labor has been clearly demonstrated. Most hospitals no longer use meperidine.

The sucking rhythms of infants with a normal perinatal course were compared with those of infants with perinatal distress. The analysis showed that rhythms of nonnutritive sucking were significantly different from rhythms of normal control subjects even when no gross neurologic signs were present. Subtle difficulties with feeding are sometimes the only perinatal evidence of the impact of hypoxia, as noted by low Apgar scores.

Infants whose mothers received bupivacaine epidural anesthesia were described to be less alert and have less ability to orient over the first month of life. Bupivacaine and its metabolites are found in the circulation of infants for the first 3 days of life whose mothers had epidural anesthesia. More recent studies report use of lower doses of bupivacaine and either fentanyl or sufentanyl. Less sufentanyl appeared in the cord blood. Only the Rosen and Lawrence study reported the effects of epidural anesthesia on feeding ability of the neonates.

Cesarean Delivery

The effect of cesarean delivery on breastfeeding has long been thought to be significant. With the rise in rates of cesarean delivery, the question becomes imperative. A study of 97 women who had infants by cesarean delivery and 88 who delivered vaginally was designed to determine milk production rates at each feed in the first week of life. The volume of milk transferred to the infants born by cesarean delivery was significantly less than that received by the infants born vaginally from days 2 to 5, but volumes were comparable by day 6. Birth weight was regained on day 6 by 40% of the vaginally delivered infants but only 20% of the infants born by cesarean delivery.

A comparison of early sucking dynamics during breastfeeding after C-section showed minor differences in suckling itself; duration and milk intake were similar in both section and vaginally delivered women. Successful initiation, however, required additional lactation support and monitoring in women who were delivered by C-section.

Sucking Stimulus and Prolactin

When lactating postpartum women nurse their infants, the prolactin level increases from a high baseline level to levels several times over the mean baseline. When nursing women played with but did not feed their infants, prolactin did not rise, despite the initiation of milk dripping. Substitution of a breast pump at regular intervals caused prolactin elevations similar in timing and magnitude to those induced by sucking. When normal, menstruating, nonlactating adult women were stimulated with a breast pump for 30 minutes, significant prolactin increases occurred in 7 of the 18 women. No response was obtained in normal men.

When the prolactin response was used as a measure of “success” in establishing lactation in the first week postpartum, no difference in prolactin levels was seen between women who had been considered good producers and those who were considered poor producers. Mothers whose infants were in the special care unit, and who were using a breast pump to establish lactation, had minimal prolactin response to pumping but produced a mean of 86 g of milk per pumping. When prolactin levels were measured after use of the breast pump at uniform settings, all three groups were similar. This and the work of others demonstrates that infant suckling plays a significant role in adequate milk production.

Knowledge about infant suckling has been accumulating rapidly, but only recently has it involved study of suckling at the breast. It has been established that the patterns are different mechanically. At the breast, nutritive and nonnutritive suckling varies only in rate, not in pattern. Infants can suckle immediately at birth and tolerate mother’s milk (colostrum) best as the pattern of respirations remains physiologic. Inadequate suckling can influence maternal production, but inadequate suckling can be improved.

Management of breastfeeding is best discussed in terms of the three stages: (1) prenatal period, (2) immediate postpartum, or hospital, period, and (3) postnatal, or posthospital, period.

Prenatal Period

It is most effective to prepare for breastfeeding well in advance of delivery. Prospective parents should consider feeding plans for an infant during the prenatal period, after the pregnancy is well established. Once quickening (awareness of fetal movement) has occurred, an infant becomes more of a reality for the mother and she can relate to planning. Except in sophisticated cultures, the parents generally will not initiate this decision-making discussion, and it is appropriately introduced by the obstetrician, family physician, or midwife in the second trimester. Use of ultrasound and the presentation of an ultrasound picture of the fetus to the parents confirms the reality of a baby. Particularly with first children, it is appropriate to suggest to the parents that they select a pediatrician early. They should request a prenatal conference with the pediatrician to discuss not only feeding but also points of management and child rearing about which they might have questions. If the mother is receiving prenatal care from a family practice physician, then this step is automatic.

Many mothers decide long before the pregnancy about feeding the infant, but those who choose bottle feeding admit they could have been persuaded, if only someone had cared enough to tell them how important breastfeeding is to the infant. All women know mother’s milk is best. Clearly, health care providers have made breastfeeding too complicated and burdened mothers with so many rules and regulations that they cannot cope and default to bottle feeding. When health care workers try to persuade a woman to breastfeed, they perpetuate the image of a difficult chore by saying, “Why not give it a try? It’s not that bad,” or “You’ll be surprised. It isn’t that hard,” instead of conveying opportunity and good experience with, “It is a marvelous opportunity for you and your baby,” or “It will be a special joy.” Employment is often cited as the cause of early weaning, but it is actually unemployed women who are at home bottle feeding (see Chapter 18 ). Any time spent breastfeeding is worthwhile for a working mother and her infant.

The medical profession has been hesitant to take anything but a neutral position in discussions of breastfeeding for fear of pressuring mothers. The evidence is stronger than ever that breastfeeding has distinct advantages for infants and mothers. Parents have the right to hear the data. They can make their own choices. Fear of instilling guilt is a poor reason to deprive a mother of an informed choice, especially because women generally do not feel guilty about their own informed decision. After interviews with hundreds of mothers, half of whom chose to bottle feed, not one felt guilty, but some were disappointed that their physician did not discuss infant feeding.

The prenatal discussion should also include any questions the parents may have about the lactation process and a mother’s ability to provide adequately for the infant. An examination of the breasts is part of good prenatal care and an excellent opportunity to discuss breastfeeding. If any anatomic abnormalities exist, then they should be discussed. The breast tissue should be checked for lumps and cysts that might need treatment. The amount of mammary tissue is not correlated with the ability to produce milk. The more generous gland usually results from a more generous fat pad. During pregnancy the fat is replaced by proliferating acini. A woman with small breasts should not be discouraged from nursing.

Breast texture should be assessed by palpation. An inelastic breast gives the impression it is firmly knit together, and the overlying skin is taut and firm so it cannot be picked up. The elastic breast is looser, the overlying skin is free, and the tissue is more easily picked up. Inelastic breasts are more prone to engorgement and seem improved by prepartum massaging and close attention to prevention of engorgement ( Figure 8-6 ).

Texture of breast tissue can be assessed by picking up skin of breast. A, Inelastic breast tissue. B, Elastic breast tissue.

Examination of the areola and nipple is equally important to identify any anatomic problems that may need attention before delivery. Gross malformations and inversion of the nipple can be easily detected, but lesser problems may go unnoticed. One must test for freedom of protrusion. When the areola is compressed and the nipple retracts instead of protrudes, it indicates a “tied nipple,” or inverted nipple, caused by the persistence of fibers from the original embryologic invagination of the mammary dimple ( Figure 8-7 ).

A, Normal nipple averts with gentle pressure. B, Inverted or tied nipple inverts with gentle pressure.

Although a physician may provide literature on breastfeeding or suggest reading sources for the patient, one should avoid dismissing the parents’ questions by merely suggesting appropriate readings, because their decision making will be enhanced by open discussion with a knowledgeable professional. Although parents may have access to childbirth preparation programs in the community, they should not be dismissed to get all their information from such sources. When parents have no opportunity to discuss with their care provider issues such as early infant contact, nursing the infant in the delivery room, and family-centered maternity care, they often experience tremendous disappointment and misunderstanding.

The concerns most frequently expressed by mothers considering breastfeeding are related to themselves, not the infant. Mothers who are more concerned about their own well-being have more trouble adjusting to motherhood and should be provided with more support in adapting to the role. They may be helped by selecting a doula to support them, because our modern culture tends to isolate young couples. Raphael describes a doula as one of “those individuals who surround, interact with, and aid the mother at any time within the perinatal period, which includes pregnancy, birth and lactation.” Doulas have been further studied by Klaus and Kennell, who found a clear relationship between the presence of a doula in labor and the outcome of delivery, the mother’s personal experience, and her recovery period (including breastfeeding).

Concerns most frequently expressed prenatally by mothers include the following:

• 1.
  

  What is the effect on the mother’s figure? Data indicate that breasts are affected by heredity, age, and pregnancy in that order and only minimally by lactation. Women who have never borne children may “lose their figures” long before a multipara who nurses her infants. Pregnancy enlarges breasts temporarily, as does early lactation, but the effect is temporary. Poor diet and lack of exercise will destroy a figure in both men and women long before any other influence.

  
  
• 2.
  

  What is the effect on the mother’s freedom? Obviously, only a mother can breastfeed an infant; however, ample data support that it is possible to maintain a career, keep a job, or just get away from the house and still nurse in today’s world. Mothers in primitive cultures have returned to the fields, or some form of productivity outside the home, out of sheer necessity for generations. Mothers concerned about this often are best reassured by their peers—that is, mothers who are nursing. In communities with nursing mother groups, it is a simple referral. Employment statistics have revealed that women do successfully return to the work force and continue breastfeeding. Employment is rarely a reason for not breastfeeding, but it may influence duration ( Chapter 18 ).

  
  
• 3.
  

  Many women are concerned about exposing their breasts. Despite the constant barrage of publicity about breasts in the modern press, many women are embarrassed to consider baring their breasts. As pointed out in Chapter 6 , shame and embarrassment are important considerations when helping a mother accept breastfeeding. Shame and anxieties arise from the influence of one’s life history and previous events; thus intervention is necessary at many levels. Clothes that make discreet breastfeeding possible are readily available and fashionable. Considerable body exposure is not necessary for breastfeeding. In a public survey performed in the Midwest, few people, male or female, in any age group considered breastfeeding embarrassing, and 82% would want their child breastfed. Universal publicity about breastfeeding in public places has created a more accepting attitude in most people, so that a nursing mother no longer needs to hide to feed her infant.

Preparation of the Breasts

The prenatal period is a time for a couple to prepare for their new role as parents and to learn as much as possible about breastfeeding. Most mothers do no special preparation and are successful. Carefully controlled studies do not support the contention that fair-skinned women, especially redheads, are more prone to developing cracked, sore nipples than are others. Mothers who have had trouble with tender, cracked nipples when nursing a previous infant will need extra assistance in putting the infant to breast properly in the first few days, but elaborate rituals prenatally may actually cause problems. Nipple preparation has a negative effect on some women who are not ready to handle their breasts for these preparations during pregnancy and has not proved to make a difference. Proper positioning is highly important.

Bathing should be as usual, with minimal or no soap directly on the nipples and thorough rinsing. Some recommend patting the nipple dry with a soft towel, but this should not be done except after a shower or bath. Persistent removal of natural oils of the nipple and areola actually predisposes the skin to irritation. Montgomery glands in the areola secrete a sebaceous material for the cleansing and lubrication of the areola and nipple. This should not be removed by soaps or chemicals. Tincture of benzoin, alcohol, and other drying agents are contraindicated because they predispose the nipples to cracking during early lactation. Wearing protective brassieres, modern women do not experience the friction to the nipples that looser clothing causes, which may be why cracked nipples are a common problem in modern society but almost unheard of in developing countries and among other mammals. In Scandinavia, it is suggested that pregnant women get as much air and sunshine as possible directly on the breasts before delivery. Wearing a nursing brassiere with the flaps down to expose the nipples under loose clothing serves the same purpose. However, aggressive and abrasive treatment of the nipples does not prevent nipple pain postpartum and may aggravate it. Gentle love making involving the breasts is usually safe and is the most effective preparation.

The use of lanolin, which is miscible with water and thus allows normal evaporation from the skin, does no apparent harm but in controlled studies also made no difference prenatally. Women allergic to wool will also be allergic to lanolin. The use of vitamin A and D ointment prophylactically also makes no difference, having an effect only in the treatment of fissures later. In climates with average to high humidity, ointments are not routinely recommended for breasts and may interfere with Montgomery gland secretion. In extremely dry climates, using ointments sparingly is often necessary.

Some believe gentle traction to the point of discomfort, but not pain, reduces perception of pain in the first week of lactation. A study, carefully controlled to eliminate subjective discrepancies of interpretation, revealed no significant difference in nipple sensitivity or trauma in those who practiced prenatal nipple rolling, application of breast cream, or expression of colostrum compared with those who had untreated breasts. No increased pain or trauma was reported among fair-skinned participants in the study, treated or untreated. Because many women are not inclined to manipulate their breasts before delivery and might be discouraged from breastfeeding if it is implied that this must be done, physicians should prescribe treatment only when an indication exists.

Preparation of the Nipples

Flat nipples or inverted nipples do not preclude breastfeeding. Flat nipples respond to the same passive treatment with a breast shell that works for inverted nipples. The shells can be worn during the last trimester by women who choose to do so ( Figure 8-8 ). They should be recommended only after careful examination and discussion about advantages and disadvantages by the physician. Follow-up at subsequent prenatal visits is also appropriate.

Breast shells: vented domes worn over ring that allows nipple to evert. Shell is slipped into cup of well-fitting brassiere. Available in several styles and designs.

Alexander et al. estimated that 10% of pregnant women have inverted or nonprotractile nipples, which are thought to contribute to breastfeeding problems. Breast shells (plastic disks with holes in the center and a domed cover) (see Figure 8-8 ) and Hoffman exercises (stretching and pulling of the nipple and areola, vertically and horizontally) are the most common treatments suggested. Alexander et al. compared use of shells with no treatment and found more sustained improvement in the untreated group. The difference in use of shells/no shells was 52% and 60%, which is not significant. A large multicenter trial of shells, Hoffman exercises, and no prenatal treatment showed “no treatment” to be most effective. Nipple stretching has had no significant impact and is contraindicated because of its tendency to initiate uterine contractions. The most significant finding was that more women who were instructed to wear shells or do nipple exercises than control subjects who had no prenatal preparation failed to initiate breastfeeding at delivery. More study women also discontinued breastfeeding by 6 weeks compared with control subjects. The women complained that shells caused discomfort, embarrassment, sweating, rash, or milk leakage or were conspicuous.

Such studies illustrate some of the risks of using untried methods to solve problems, although some women probably benefit by using shells. The question deserves further study. The process of assessing anatomic problems and initiating management should not be a deterrent to breastfeeding.

Inverted nipples (see Figure 8-7 ) can be diagnosed by pressing the areola between the thumb and the forefinger. A flat or normal nipple will protrude; a truly inverted nipple will retract. True inverted nipples are actually rare. Mildly retracting nipples can be improved with gentle stretching to evert them, preferably done before delivery.

One or both nipples may be pierced and may have jewelry inserted. The jewelry should be removed during pregnancy, or as soon as observed, to allow the nipple to recover and avoid any infection. Usually nursing proceeds without a problem. Sometimes milk will leak from the piercings. It can be absorbed by keeping a washcloth handy. The jewelry should not be worn while breastfeeding. The major risk to the mother is infection, which can be avoided by good hygiene and not wearing the jewelry. The risk of the infant swallowing the jewelry if left in place is monumental.

Nipple Stimulation to Induce Labor

The obstetric literature abounds with articles about the use of nipple stimulation in place of the traditional oxytocin challenge test to induce uterine contraction; only a few are cited here. ^{, ,} Using a breast pump or manual expression to produce colostrum is reported to induce labor or increase the strength of contractions in desultory labor.

Taylor and Green reported a case of severe abruptio placentae after nipple stimulation. A series of patients induced labor with self-manipulation of the breasts with a 45% success rate. All patients in the series showed some ripening of the cervix with dilatation and effacement in 3 days of breast stimulation. Lipitz et al., Amatayakul et al., and Taylor and Green reported a relatively high incidence (45.5%) of exaggerated uterine activity in response to a breast-stimulation stress test, usually within 7 minutes of initiation of stimulation. Although all the cases and series cannot be reported here, it is clear that nipple stimulation in the third trimester can initiate uterine contractions and, in some, labor. Under the direction of an obstetrician, breast stimulation can be effective therapeutically, but it should not be attempted without obstetric evaluation and guidance.

Suggesting stretching (Hoffman) exercises is not advised, especially in women with a tendency to early labor. No study since Hoffman’s initial report of two cases has shown the process to be effective in the nipples. Stretching the areola forcefully can damage the delicate Montgomery glands. Prepartum mastitis has also occurred with prenatal expression of colostrum. Whether manipulating the breast prenatally provides the mother with greater comfort in breastfeeding has not been demonstrated. Mothers who choose to bottle feed have told us that having to “exercise” their breasts is one of the “rules” that kept them from breastfeeding.

Pumping with a pulsatile electric pump with a soft Silastic flange has been shown to facilitate latch-on with flat or inverted nipples after delivery. The breast is gently pumped on low settings until the teat is drawn out, and then the infant is offered the breast. Similar pumping is done on the second breast, when that nipple is also inverted, before placing the infant on that breast. Usually the pumping can be discontinued after a few days, or a hand pump is adequate if preferred. Pumping needs to be continued at home to evert the nipples.

These approaches avoid the risk for never initiating breastfeeding. They also provide one-on-one support from the nursing staff, which is very different from sending the mother home to use a strange plastic device.

An infant breastfeeds. An infant does not nipple-feed. If the nipples are flat or inverted, extra care is needed to provide enough areolar tissue in the infant’s mouth to allow latch-on. Experienced postpartum nurses can facilitate the breastfeeding experience by assisting with the initial latch to the breast.

Surgical Correction

Inverted nipples have been known to medicine for centuries. Treatment has included various exercises, use of older vigorous infants to suckle, and the use of adults who are hired for this purpose in difficult cases. The first surgical procedure was described in 1873. Other techniques have since been advanced. ^, A primary indication for surgical repair of the inverted nipple is the chronic occurrence of central pockets of inflammation of the nipple, leading to the spread of infection and infectious mastitis. A simple method for correction without division of the lactiferous ducts involves using a purse-string suture and traction of holding sutures. The procedure can be done in the office under local anesthesia, according to Hauben and Mahler. A truly inverted nipple may have fewer ducts. The microscopic pathologic examination of severely inverted nipples indicates the ducts are abnormal.

Hand Expression Prenatally

Some breastfeeding instructions suggest hand expressing the breast to produce a few drops of colostrum every day for the last few weeks of pregnancy. Fortunately, the instructions usually suggest the patient consult her physician first. Manual or any kind of pumping of the breasts may stimulate the uterus to contract. Hand expression has no particular benefit and means that the early-sequestered cells are expressed away in the drops of colostrum before delivery and are lost to the infant. Occasionally, prepartum mastitis has developed from this treatment. The risks far outweigh any seeming benefit.

Summary

• 1.
  

  During the first trimester, make the initial breast examination. Initiate the discussion about how the infant is to be fed and the benefits of breastfeeding. If anatomic variations may interfere with lactation, mention them and discuss possible remedies.

  
  
• 2.
  

  At each prenatal visit, offer information about breastfeeding.

  
  
• 3.
  

  Investigate the mother’s knowledge of breastfeeding, and document her information base to fill in the gaps and correct misinformation. Also inquire about any treatments or routines she has initiated on her own, so that the total management is appropriate.

  
  
• 4.
  

  Once quickening has been experienced, the parents are ready to plan more concretely about the baby. Suggest a visit with the pediatrician.

  
  
• 5.
  

  As delivery approaches, initiate discussion about feeding the infant immediately after birth, feeding protocols, and the mother’s special needs or requests.

  
  
• 6.
  

  Be familiar with community resources so that patients can be wisely referred for peer support or assistance unavailable from one’s office staff.

  
  
• 7.
  

  As more women are electing to breastfeed, consider adding a board certified lactation consultant to your staff.

Immediate Postpartum Period

Immediately after the placenta has separated, the establishment of lactation begins. This is a critical period because many mothers who do not receive the proper support in the hospital are driven to failure at breastfeeding by inept management.

Nursing at Delivery

Every birthing center, certified as “Baby Friendly” or not, should provide the basic minimal management recommended by the ten steps of the Innocenti Declaration.

A mother should be assisted to nurse the infant promptly after delivery and certainly within 30 to 60 minutes. Even if she does not ask, the obstetrician and delivery room staff should suggest and facilitate it. ^, It is step 4 of the 10 steps. Data confirm the view that delivery room or birthing center protocols that intercept interaction and suckling between mother and infant also have a negative impact on long-term lactation success.

Oxytocin levels at 15, 30, and 45 minutes after delivery are significantly elevated, coinciding with the expulsion of the placenta. Oxytocin has been associated with positive maternal feelings and with maternal bonding; thus it is appropriate to optimize mother-infant interaction at this point of high oxytocin levels by facilitating suckling.

Disease-oriented physicians, who have been trained to give trials of water first, hours after delivery, are always concerned that the infant may aspirate. Clinical signs of potential for aspiration include low Apgar score, increased secretions, and polyhydramnios. Actually, most infants in the world go straight to the breast on delivery, which has a physiologic effect on the uterus, causing it to contract. Because sugar water and cow milk formulas are irritating to the lungs if aspirated, delay in feeding has been the rule in the United States, where most infants are bottle-fed. Colostrum is not irritating, however, and is readily absorbed by the respiratory tree if aspirated, providing sIgA as well in the pulmonary tree. Putting the infant to the breast within the first hour is optimal and compatible with Baby Friendly hospital guidelines.

A few possible obstacles exist to immediate nursing: (1) a heavily medicated mother, (2) an infant with a 5-minute Apgar score less than 6, and (3) a premature infant less than 35 weeks of gestation. The concern for an infant with a tracheoesophageal fistula is important, but a few precautions should suffice. If hydramnios or excess secretions are present at birth, a tube should be passed to the stomach to make sure the esophagus is patent. If all is well, the infant may nurse. If a tracheoesophageal fistula is found, it is a surgical emergency. Choanal atresia is another anomaly that would be of concern, but infants cannot suck on the breast, or on anything, if they cannot breathe through the nose. Usually an infant with choanal atresia has a low Apgar score or needs some assistance in establishing respirations. Infants are obligate nose breathers.

As noted earlier, healthy newborns placed on the mother’s abdomen will find their way to the breast and latch on if unimpeded. For this first breastfeeding, it may be best to have the mother on a bed wide enough to have the infant lie beside her. Newer delivery tables are wide enough. An infant should not be dangled in midair over the breast. If an infant has not been allowed to crawl up to the breast, then the mother should be assisted to turn onto her side. The infant should be presented to the breast, with the ventral surface of the infant to the ventral surface of the mother. The infant should not have to turn the head toward the breast. The mother may need assistance in holding her breast so as to present the nipple squarely into the infant’s mouth, which is stimulated to open by stroking the center of the lower lip with the nipple.

When the nipple touches the lower lip, the infant will open widely and extend the tongue under the nipple. The breast will be drawn into the mouth, the nipple and areola elongated into a teat, and the suckling reflex initiated.

Both mother and infant will do better if there is an atmosphere of tranquillity in the room. The other risk to the infant is thermal stress. If the room is air-conditioned, it may be necessary to provide a radiant warmer over the infant and mother, especially if the infant is naked for skin-to-skin contact. Some mothers have shaking chills following the strenuous event of labor and cannot provide adequate warmth for the infant without some external source of heat or a blanket.

Chilling an infant may set off a chain of events from hypothermia to hypoglycemia to tachypnea to mild acidosis to the extent of requiring a septic workup. Hypothermia is therefore more easily prevented than treated.

If possible, mother, father, and infant should remain together for the next hour or so. The first hour for the infant is usually one of quiet alertness, a state that will usually recur only briefly again in the next few days. It is important to delay the instillation of prophylactic eyedrops until after this time spent with the mother. If the drops are put into the eyes, blepharospasm will prevent the infant from opening the eyes and will mar eye-to-eye contact and further adaptation of the neonate. Only if there is a known risk for gonorrhea should the drops be put in immediately. If the mother has delivered in a birthing center, early contact and nursing should be part of the routine; however, it is equally important for all deliveries.

Protocols in delivery rooms for nursing procedures have included the prompt administration of eyedrops before leaving the delivery area, which is not based on medical necessity but rather hospital management and nursing control.

Two natural hand positions for the mother to introduce the breast are used most often. With attention to a few details, either position works (one is not right and the other wrong). The scissor grasp is the placement of the thumb and index finger above the areola and the other three fingers below the breast for support, thus allowing some compression of the areola. Care should be taken that the hand is not in the infant’s way of getting sufficient areola into the mouth ( Figure 8-9 ). This grip has been used for centuries and was shown in sketches and paintings even before the Christian era. It may work better than the palmar grasp if the hand is large or the breast small.

Scissor grasp, presenting breast while supporting infant.

The palmar grasp is the placement of all the fingers under the breast and only the thumb above ( Figure 8-10 ). This has been called the C-hold but is actually a V-hold, depending on the size of the breast and the size of the hand. This gives firm support to the breast. It permits directing the breast squarely into the infant’s mouth and avoids the need to press the breast away from the infant’s nose. The palmar grasp is similar to the prehensile grasp of apes when they nurse their young.

Palmar grasp for initiating breastfeeding.

Apes, however, are unable to assume another hand posture neurologically or anatomically. If too much pressure is exerted by the human thumb, the nipple will be tipped upward ( Figure 8-11 ), causing abrasion of the underside of the nipple. It is preferable that the nipple be directed horizontally as it is placed in the mouth (see Figure 8-11 ) or tipped down slightly. The palmar grasp can be used when there is nipple pain, soreness, or trauma. It is also useful when the mother’s hand is too small for a large breast. The mother should be encouraged to use the hand position that is most natural and comfortable.

Palmar grasp (C-hold). A, When palm and fingers cup breast with support and thumb rests lightly above areola, nipple projects straight ahead or slightly downward (correct). B, When fingers come forward and thumb presses firmly above, nipple tips up and causes improper positioning. Improper positioning is a common cause of nipple abrasion (lower half) and pain with suckling.

(Modified from Higgins K: The nursing mother’s companion, ed 2, Boston, 1990, Harvard Common Press.)

Diagnosing Breastfeeding Problems

To solve the problem of unsuccessful nursing, someone should observe a mother feeding the infant. Often the problem is a simple one, such as a mother so uncomfortable and tense that the let-down reflex will not trigger or perhaps an infant with a poor suck or poor latch. In these cases and others the diagnosis can be made most easily by direct observation.

In addition to a mother’s hand position, the manner in which the infant is held or placed to breastfeed is important. There is no one right position. Shortly after birth, lying down may be preferable for the mother. She lies on her side and the infant is placed on his or her side facing the breast, which the mother supports with her upper hand. She can use her lower hand to cradle the infant and bring him or her close. Pillows help sustain the mother’s position with one against her back and one between her knees. The pillow between the knees is essential to keep her from rolling over should she drift asleep. She may also lie semiinclined. When a mother is sitting up, the cradle position, with the mother bringing the infant to the breast while cradling the infant in her bent elbow, is the most common and natural position, especially once a mother is home.

Head control can be a problem with the cradle position the first few days, as the infant requires more support to hold the head.

The cross-cradle or cross-over hold works best with mother sitting erect and one to two pillows in her lap so the baby is just at the level of the breast and not above the breast. Short women may only need one small pillow. The infant is held with the opposite arm so that the infant’s head and shoulders are held ( Figure 8-12 ). The thumb is below one ear and the fingers are below the other ear. With the head tipped back slightly and the infant brought to the breast, the nipple can stroke the infant’s lower lip. Visual demonstration of the latch is available online. “Fifteen-Minute Helper” is a physician-produced video for the physician audience created by Jane Morten, MD, from Stanford University. There is a link at www.nursingmotherscompanion.com/resources .

Cross-cradle position.

The football hold is a misnomer; the infant is not tucked under the arm like a football but rather forward so that mother supports the infant’s head with her hand and the infant is supported by the mother’s arm. The infant must be squarely facing the breast.

These traditional postures were called into question by Colson et al., who observed less effective breastfeeding and declining duration in spite of aggressive maternal training in their programs. They studied 40 mothers and infants in England and France doing feeding videotapes during the first month. They described and compared primitive neonatal reflexes, investigating whether certain feeding behaviors and positions, termed biological nurturing , are associated with the release of these reflexes that they thought were pivotal to establish successful breastfeeding. When mothers chose their own body positions, they selected semiinclined positions, making the infant an abdominal feeder displaying antigravity reflexes, which aid in latching. Gravity pulled the infant’s chin and tongue forward, triggering mouth opening to achieve attachment. At the very least, it suggests that alternatives to side lying and sitting upright are viable positions to initiate lactation.

Introducing all the possible positions is overwhelming at first and should be avoided. With a little practice, mothers will find what works best.

Understanding the mechanism of suckling in the neonate ( Figure 8-13 ), however, is essential to recognizing ineffective sucking. As the breast is offered to the infant, the mouth opens wide and the tongue is extended as the nipple is drawn into the mouth ( Figure 8-14 ). In a rhythmic motion, the tongue moves up against the hard palate, as it draws the nipple and areola into the mouth, creating an elongated teat. The cheeks fill the mouth because of the sucking fat pads and provide further negative pressure because they do not collapse. The tongue undulates along the teat, while remaining in place, compressing the collecting ductules in the areola and “milking” them toward the nipple.

A, As infant grasps breast, tongue moves forward to draw in nipple. B, Nipple and areola move toward palate as glottis still permits breathing. C, Tongue moves along nipple, pressing it against hard palate and creating pressure. Ductules under areola are milked, and flow begins as a result of peristaltic movement of tongue. Glottis closes. Swallow follows.

Latch-on response. In response to stimulating infant’s lower lip with nipple, mouth opens wide. This response has been called oral searching reflex. It is part of the circumoral rooting reflex.

(From Righard L, Alade MO: Sucking technique and its effect on success of breastfeeding, Birth 19:185, 1992.)

This undulation is peristalsis, which continues from tongue to pharynx and the entire gastro-intestinal track. Milk flows from the nipple and is swallowed as the swallowing reflex is triggered, and the peristaltic wave continues to the posterior tongue and pharynx and down the esophagus.

If an infant has a fluttering tongue that is discoordinate, it may not be as productive in stimulating ejection. If the infant cannot coordinate suck and swallow, choking occurs. Sometimes, if let-down is strong, the first rush of milk will cause choking. Stopping and starting again should solve the problem. If the mother’s milk flows abundantly with first let-down, she may need to express manually (and save) the first few milliliters to avoid choking the infant. Usually the flow moderates in the next few days. This problem is temporary or is limited to times when the infant has not been nursed for an unusually long interval. Positioning the infant over the breast with the mother on her back may diminish the flow due to gravity in these special cases.

If an infant’s jaw is slightly receding, the nipple may not stay in place. Gentle support from the mother’s index finger at the angle of the jaw, bringing it forward, will help. She may always have to support the breast with her hand (see Chapter 14 ).

An infant who is given a bottle or rubber nipple to suck can become confused because the milking action is different (see Figure 8-4 ). The relatively inflexible rubber nipple may keep the tongue from its usual rhythmic action. In addition, the flow from the bottle may be so rapid, even without sucking, that the infant learns to put the tongue against holes in the rubber nipple to slow down the flow. Some infants who have been breastfed gag when the relatively large rubber nipple is put in their mouths. When infants use the same tongue action needed for a rubber nipple while at the breast, they may even push the human nipple out of the mouth. When infants cannot grasp an engorged areola properly, they will clamp down on the nipple with the jaws, causing pain in the nipple and disrupting the ejection reflex. Manual expression of a little milk will soften the areola, permitting compression by the mother’s hand and an easier grasp by the infant.

A study of suck-swallow-breathe, oxygenation, and heart rate patterns had not been performed in breastfeeding infants. No measurements had been taken over the first 4 months of lactation in term infants. Fifteen infants were studied by Sakalidis et al.

Simultaneous recordings of vacuum, tongue movement respiration, swallowing, oxygen saturation, and heart rate were measured at about 1 month and at 2 to 4 months.

Suck bursts became longer, pauses became shorter, vacuum levels decreased, oxygen saturation increased, and heart rate decreased as the infants matured. They consumed a similar amount of milk in a shorter time period ( Figures 8-15 and 8-16 ).

Significant relationships for vacuum between burst type and visit. Average vacuum levels for (A) peak, (B) baseline, and (C) pausing vacuums during early and later lactation. NNP, nonnutritive pausing; NNS, nonnutritive sucking; NP, nutritive pausing; NS, nutritive sucking. ^a P < 0.05 for interaction with burst type and visit.

(From Sakalidis VS, Kent JC, Garbin CP, et al.: Longitudinal changes in suck-swallow-breathe, oxygen saturation, and heart rate patterns in term breastfeeding infants, J Hum Lact 29(2):236–245, 2013.)

Significant relationships with burst type and visit (A) suck rate, (B) respiratory rate, (C) oxygen saturation, and (D) heart rate. NNP, nonnutritive pausing; NNS, nonnutritive sucking; NP, nutritive pausing; NS, nutritive sucking. ^a P < 0.05 for visit. ^b P < 0.05 for burst type. ^c P < 0.05 for interaction with burst type and visit.

(From Sakalidis VS, Kent JC, Garbin CP, et al.: Longitudinal changes in suck-swallow-breathe, oxygen saturation, and heart rate patterns in term breastfeeding infants, J Hum Lact 29(2):236–245, 2013.)

When observing an infant being breastfed, take note of the following:

• 1.
  

  Position of mother, body language, and tension. Pillows may provide support for the arms or the infant.

  
  
• 2.
  

  Position of infant. The infant’s ventral surface should be to the mother’s ventral surface, with the lower arm, if not swaddled, around the mother’s thorax. The infant cannot swallow if the head has to turn to the breast, and grasp of the areola will be poor. The infant’s head should be in the crook of the mother’s arm and moved toward the breast by the mother’s arm movement if cradle hold is used.

  
  
• 3.
  

  Position of mother’s hand on breast is not in the way of proper grasp by infant.

  
  
• 4.
  

  Position of infant’s lips on areola about 1 to 1½ inches (2.5 to 3.7 cm) from the base of nipple, thus facilitating the formation of the teat.

  
  
• 5.
  

  Lips should be flanged and lower lip not folded in so that the infant does not suck it.

  
  
• 6.
  

  Actual events around presenting breast and assisting the infant to latch on.

  
  
• 7.
  

  Response of the infant to lower lip stimulus by opening mouth wide (see Figure 8-14 ).

  
  
• 8.
  

  Motion of masseter muscle during suckling and sounds of swallowing.

  
  
• 9.
  

  Ratio of sucks to swallows should move to 1:1 as feeding progresses.

  
  
• 10.
  

  Mother is comfortable with no breast pain.

Engorgement

The best management of engorgement is prevention. The degree of engorgement lessens for a woman with each infant, because the time during which the milk “comes in” seems to shorten in multiparas. The primipara suffers most from engorgement.

Breast engorgement was carefully documented by Humenick et al. for 14 days postpartum in 114 breastfeeding women. Four distinct patterns emerged, varying from minimal engorgement to intense engorgement and including a bell-shaped and a multimodal pattern. Characteristics of mothers, infants, and feeding frequency were similar across all patterns. Engorgement in these women was increased in women breastfeeding for the second time, with women breastfeeding for the first time peaking at about 108 hours and second-time feeders at 100 hours. Engorgement cleared more quickly the second time. Clearly, mothers’ experiences differ under seemingly similar circumstances. With early discharge, mothers are already home when it occurs.

A number of often conflicting theories and explanations regarding engorgement have been proposed in the professional and lay literature. The dictionary defines engorgement as “swollen with blood,” and pathologists define it as “congestion.” Engorgement of the breast involves three elements: (1) congestion and increased vascularity, which is the physiologic response that follows removal of the placenta and does not depend on suckling; (2) accumulation of milk, also a physiologic response to placental removal; and (3) edema secondary to the swelling and obstruction of drainage of the lymphatic system by vascular increases and fullness of the alveoli. No parallel exists in nature because the underlying process is physiologic. Engorgement is not injury, hemorrhage, or trauma. When the physiologic process proceeds smoothly, no pain, discomfort, or excessive swelling occurs. When edema is identifiable, the surface of the breast pits with pressure. The process is then out of control, and intervention is necessary. It is important to distinguish engorgement from mastitis and gigantomastia, which are discussed in Chapter 16 .

Engorgement may involve only the areola, only the body of the breast (so-called peripheral engorgement), or both. A little bit of engorgement is normal. When the breast does not respond with engorgement and “fullness,” this is abnormal and requires attention.

Areolar Engorgement

When the areola is engorged, it obliterates the nipple and makes properly grasping the areola impossible for the infant. If the infant sucks only the nipple, it is exquisitely painful, because this is the only area of the breast with pain fibers. In addition, the collecting ductules are not “milked” and therefore do not empty, and the infant is frustrated by lack of milk.

The treatment is directed toward reducing the engorgement so that the infant can nurse effectively, which will further reduce the overdistended ducts. Gentle manual expression by the mother usually produces a small amount of flow and softens the areola. The presence of milk on the nipple will further encourage the infant’s sucking. Warm soaks just before a feeding may facilitate manual expression. Every mother should be taught how to express milk manually ( Figure 8-17 ). When an infant is put to the breast, the mother should compress the areola between two fingers to make it easier for the infant to grasp. Offering the breast this way makes it easier for any infant to grasp, especially when the infant needs encouragement to nurse ( Figure 8-18 ).

Position for manual expression of breast. Thumbs are brought toward areola, compressing areola between thumb and supporting fingers. With areola grasped, pressure is applied toward chest wall, and then pressure is released. This compression and pressure stimulate milking action.

When breast is offered to infant, areola is gently compressed between two fingers and breast is supported to ensure that infant is able to grasp areola adequately.

Peripheral Engorgement

Initially after delivery the breasts increase in vascularity and begin to swell. This usually starts in the second 24-hour period after delivery. Engorgement at this stage is vascular; thus pumping mechanically briefly to stimulate the breast, when the infant is not nursing adequately, is appropriate. Pumping “to relieve engorgement” will yield little milk and may traumatize the hypervascular breast.

The mother should be advised to wear a well-fitting but adjustable nursing brassiere that does not have thin straps or permanent plastic lining. She should wear it 24 h/day initially. With moderately severe engorgement, the breasts become full, hard, and tender. The swelling starts at the clavicle and goes to the lower rib cage and from the midaxillary line to the midsternum. The breasts may even become hard, tense, and warm. The mother typically complains of throbbing and aching pain and can find no comfortable position except to lie flat on her back and very still ( Figure 8-19 ).

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related

Related posts:

1. The Revolution in Infant Feeding
2. Physiology of Lactation
3. Protocol 3: Hospital Guidelines for the Use of Supplementary Feedings in the Healthy Term Breastfed Neonate
4. Protocol 16: Breastfeeding the Hypotonic Infant

Stay updated, free articles. Join our Telegram channel

Join