engorgement Flashcards
Situation
Sophia is 4 days postnatal following a universal midwifery care and vaginal birth in the local centre. She has been successfully breastfeeding her baby Joshua once he was born. You are the community midwife who is routinely visiting her at home today
Initial introductions and assessment
Introduce myself- Hi my name is Carly i am the student Midwife to do a postnatal visit
Explain i will be conducting a postnatal check
Get consent for check
Apply PPE
At her how she is feeling and how breastfeeding is going
Sophia describes she is tried, feels Joshua is cluster feeding and is awake overnight a lot. She is worried he isn’t getting enough milk and her breast are feeling really heavy and swollen. Today she is feels they are really uncomfortable, it seems to have happened over night.
What may be the problem?
I think you may have engorgement
Explain to sophia what engorgement is and what the signs and symptoms can include;
Engorgement is a build up of milk in the breast and if not manage properly can develop into Mastitis
Sign and Symptoms are
-warm to touch
-tight and shiny skin
- flattened nippples
-low grade fever
-pain
-swollen
Explain the causes of engorgement
Abrupt weaning- This is when there there is a sudden stop in breastfeeding and the body doesn’t have time to regulate how much milk is needing to be produced. The hormone FIL takes time to be activated and until it is milk will continue to be processed as the body is anticipating a feed and causes an oversupply in the breast
Oversupply- This often happen between day 3-5 as the body needs time to adjust to how much baby is feeding and how much is required. Often will resolve quickly after a routine is established with feeding
Missed or delayed feeds- if a feed is missed the body will anticipate it being emptied however isn’t and then will continue to produce milk to accommodate the next feed however results in a build up and engorgement to happen
Ineffective attachment- This can cause pain when feeding resulting is shorter feeds and the milk not being emptied fully. Resulting is baby feeding more regularly but not effectively cause milk to remain in the ducts and build up
Sophia feels you she missed her ante-natalappointments so didn’t know about this.
Explain the anatomy and physiology of breastfeeding to her.
External structure of the breast
- Fatty adipose tissue- creates the size and shape of the breast
- areola- darker central area of the breast that helps guild baby to correct part of the breast
- montgomery tubercles- raised part on the areola that release sebum to keep nipple moisturised and creates a small for baby to look for
-nipple- the centre of the breast that the milk is expelled from
Internal structures of the breast
- ribs- creates the structure of the body
-Alveolar clusters- contain multiple alveoli
-Alveoli- lined with lactoytes
-Lactoctes- milk producing cells
-Myoepithelial cells- Contractile cells
-Lactiferous ducts- transport milk to exit the nipple
Hormones
Oxytocin- Feel good hormone and stimulated the let down reflex, allowing the milk to flow to the baby
When baby is suckling it send a signal and release oxytocin from the posterior pituitary gland. It allows the myopithial cells to contract and push the milk to the exit. Oxytocin creates an emotional bond with baby and can be stimulated by touch, sight, smell, sound and taste from baby
Prolactin- is the milk producing hormone. After the delivery of the placenta progesterone levels fall. This stimulates proclamation receptors. When baby suckles prolactin is released from anterior pituitary gland. The hormones acts on lactoyes promoting production of milk. Prolactin is at its highest during baby suckling and during the night when sleeping.
FIL- Helps regulate and control milk production. It is a whey protein. As the breast fills FIL signals the lactoytes to slow down. This is an example of negative feedback mechanism. When milk is emptied FIL decreases and allows more production of milk and prevent overproduction
Management strategies to support sophia
Routine postnatal checks
Inspect the breast with consent
Observe a breastfeeding and take a breastfeeding history to ensure effective attachment
Give methods of support to ease symptoms and stop reoccurring
Consider treatment options
Support methods
Advice to continue breastfeeding or pumping- use breastfeeding assessment tool to ensure effective feeding
Revisit feeding cues and positioning and attachment
Revisit hand expression
Encourage gentile breast massage
Breast compression
Warm therapy before and between feeds
Cool therapy post feeds
Advice loose and suitable clothing
Arrange follow up visit and give worsening advice
Sophia tells you she is feeling overwhelmed and worried. She feels she should stop breastfeeding however wants to continue.
Explain methods of attachment and different feeding positions
The cradle and cross cradle hold- Baby lies across the woman body being support by opposite hand.
Rugby Ball hold- baby is tucked under mother’s arm with the same arm support back and head. This can be effective is blocked milk duct is round to the outer side of the breast
Upright- when abby is upright on mother lap. Helps baby with reflux as they are sitting more upright
Side lying- Mum and baby are lying side ways looking at each other. Allows mum to be more comfortable and can relive some pressure
Koala
Biological nurturing
Attachment
Used to describe how baby latches onto breast. There needs to be a large amount of breast in babies mouth to have an effective feed.
Wide mouth, chin leading, asymmetrical attachment
C- close in to mother
H- head free to allow baby to find its way to breast and latch effectively
I- The body should be in line to allow baby to swallow
N- nose to nipple allows baby to make a wide mouth and fit the breast into the mouth
S- sustainable for mother and baby to be in a position to stay for a while
Ways to know effective attachment;
More are also above than below
Mouth wide open
Cheeks are full
Rhythmic sucking
Shouldn’t be painful
What treatment options are available to help with her discomfort and what safety productions need to be followed
Before administrating drugs;
Check name band and compare to case notes
Check DOB and kardex
Any allergies
Up to date weight
The correct dose
The correct route
The correct drug has been prescribed and signed
The patient is consenting to taking it
Observe taking medication at correct time
Paracetamol
For pain and is taking orally
<50kg 500mg every 4hours up to 6 times in 24hrs (MAX 3g in 24hrs)
or
1g 3 times in 24 hours (MAX 3g in 24hrs)
>50kg 1g every 4 hours up to 4 times in 24hrs (MAX 4g in 24hrs)
Not to give is any allergy to paracetamol
Ibuprofen
For pain and inflammation
Taken orally
400mg 3 times at least 6hrs apart (MAX 1.2g in 24hrs)
Don’t give if allergic or asthmatic
Sophias partner martin is also there and asks how he can support Sophia
How would you manage this situation
i would encourage him to actively listen to Sophia explaining how she is feeling, look how for verbal and non verbal cues and encourage them to communicate with each other. I would educate martin in how he may assist Sophia
I would be empathetic and give patient centered care
Educate family members
Encourage to ask questions
How would you conclude visit with Sophia
Ask if she had any other questions
Give her time to express her feeling
Give worsening advice
Plan a follow up visit that suits the family
Ensure she has the correct telephone numbers if symptoms get worse or she has any other questions
Document all my finding
Date time and sign my documentation
