OSCE hand expression Flashcards
- Using the model breast identify the structures and their functions: 4
We will talk about the external and internal structures of the breast. Firstly, externally at the centre of the breast we have the nipple which is made of erectile tissue. Surrounding this area is the areola which is a more dark and pigmented area and on the areola are small, raised dots which are called Montgomery’s tubules. The Montgomery’s tubule’s function is to emit sebum which helps the nipple and areola to remain soft during the postnatal period.
The shape of the breast is caused by the adipose tissue and the other fatty structures within the breast. so to debunk a common myth that some people may have, the volume of milk that you will have will not equal to the size of your breasts, so do not worry about this.
In terms of internal structures of the breast, we will look at this on a cellular level. Inside the breast there are clusters of alveoli which are lined on the inside with milk producing cells called lactocytes. There are also myoepithelial cells that surround the alveoli, and their function is to contract and expel the milk from the alveoli which was made internally. From there we have lactiferous ducts and the milk is expelled down towards the lactiferous ducts and they propel the milk out through the entrance of the nipple here.
- Name the hormone that stimulates milk production and identify its source and target cell. Explain the physiological process which stimulates the initiation of milk production. Give three examples of how effective milk production can be achieved /stimulated. 3
Prolactin is produced in the anterior pituitary gland in the brain and it acts on the lactocytes to stimulate milk production.
Milk stimulation is also initiated by the delivery of the placenta as there will be a significant drop in oestrogen and progesterone in the body.
Early feeding, good positioning and attachment, also making sure to effectively empty the breast. Skin to skin contact. This will also help to establish and initiate milk production.
- Identify the hormone responsible for the ‘let down reflex.’
Where is it released from?
Name the cells this hormone acts on and the effect it has on them.
Explain the factors which will help or hinder the release of this hormone. 7
Oxytocin, otherwise known as the love hormone, is produced in the posterior pituitary gland and is responsible for the let down reflex. Prolactin is involved in production of milk, but oxytocin is involved in causing myoepithelial cells around the alveoli to contract and propel the milk along the lactiferous ducts and out to the entrance of the nipple.
Anything that makes you feel good and safe will help the production of oxytocin, such as hugging and smelling your baby, knowing that your baby is near you, thinking of them and smelling them. Factors that may inhibit oxytocin production is if you are feeling stressed or anxious, lack of sleep which can be very common in the postnatal period, being in pain, or being separated from your baby such as if they have to go to the neonatal unit.
- Name the whey protein involved in the autocrine production and maintenance of breastmilk. Explain how this works. 2
Feedback inhibitor of lactation is local within the breast, and it increases in production as your breast milk accumulates in the breast. If this milk isn’t removed, this creates a negative feedback mechanism which signals to your body to stop producing milk. This is why ensuring to empty the breast can be an effective way to stimulate milk production. This can be removed through effective feeding or hand expressing. If not removed, there will be a build-up of the feedback inhibitor of lactation, and this will cease milk production.
- How soon should a woman be taught hand expression?
Identify FOUR reasons why she will need to be able to hand express? 3
Antenatally and within 6-24 hours within giving birth.
- To remove breastmilk if for any reason she is not breastfeeding to ensure milk production is continuing to be stimulated.
- To store milk for a later time if she is going to be separate from baby eg neonatal unit, becoming busy with work
- To store milk for situations where unable to breastfeed due to pain and struggling to attach
- Helps to improve milk content and keep stimulating milk production.
- How can Abeje be helped to prepare for hand expression? 4
She can be prepared similar to how she would if about to feed her baby; should be comfortable, relaxed and has a private and dignified environment, whatever this means for her. She should also be equipped with the correct knowledge as this will empower her to express confidently and safely on her own, know how often and what time to express.
She should also gather all the equipment required such as a syringe or cup to express into.
- How many times a day would you advise Abeje to hand express if Tahir was unable to feed at the breast and why? 2
Encouraged to express roughly 8-10 times a day and ideally once at night. This is because of her prolactin levels will be higher at night. Expressing frequently itself will also increase her prolactin production and ensure milk production is maintained. This will also prevent the build-up of feedback inhibitor of lactation that we previously spoke about.
- Explain to Abeje how to stimulate the oxytocin reflex. 1.5
Firstly, it is important to have your oxytocin flowing and eliminate as many negative factors as possible that can inhibit oxytocin production. Be relaxed and have your baby as near you as possible. If you’re not able to have your baby near you, have something of your baby so that you can smell their scent and be reminded of them, eg a piece of clothing. Having a nice environment of loved ones, comfort, safety can stimulate oxytocin production.
- Describe breast massage techniques. 3
There are different techniques for breast massaging. As all of these are very effective, it is up to you which ones you will use based on which is most comfortable for you. It is important to mention that before massaging and expressing, to wash your hands for hygiene reasons as you and your baby are especially vulnerable at this time. We can use the World health organisation 7 steps on how to do that effectively.
- ‘Fluttering motion’ – working your way around the breast with a feathered, light touch.
‘Rolling motion’ – with a fisted hand, moving downwards circularly rolling fist towards the areola. Working all the way around the breast.
‘fingertip massage’ – using a little more pressure than we did with the fluttering motion, massaging with fingertips and working around the breast down to however close to the nipple area that you feel comfortable with.
With each massage technique, it is important to work your way from the chest down to the areola area depending on how you choose to do this. Making sure to stimulate the entire breast, including the underneath.
Also you can do some nipple stimulation or nipple rolling, again this depends on what you feel comfortable with.
Now that you’ve got your oxytocin flowing and you’ve done some breast massaging, we can move on to actually trying to express milk.
- Using a visual aid explain and demonstrate how Abeje should hand express milk. 11
Put your thumb and finger for this in a c shape. Once you’ve created this c shape with your hand, you’re going to place your finger and thumb on the breast and work your way down towards the areola until you feel a change in texture. Once you find this change in texture, you want to stop because that indicates you’re in the right place to begin hand expressing. If this isn’t done correctly this can cause damage to the breast tissue. So with your finger and your thumb you’re going to compress and release, compress and release. This will be rhythmical to imitate what a baby would be doing if they were feeding from the breast. When you do notice that milk production has ceased whilst expressing, what you want to do is move the position of your finger and thumb the way that the hands of a clock move. This is because the alveoli and lactiferous ducts that we spoke about earlier are all around the breast, so it is important to stimulate each part and empty each part effectively. You would then repeat the same process on the other breast. This is so that you are effectively emptying both breasts.
When you’ve just had a baby, you might notice you have very minimal amounts of colostrum and may notice less and less as your milk continues to develop. Colostrum can take differing amounts of time to come to the surface, so this isn’t something to worry about if you don’t notice it coming through right away.
If expressing is painful or uncomfortable at any point it is important to not drag your fingers along the skin as this will cause you to be in pain or discomfort. Dragging your fingers to express rather than that compressing and releasing motion can cause damage and trauma to the skin, so it is important to be aware of this. So, if it painful at any point it is important to stop and reassess, and go through the steps again so that expressing is a comfortable, safe and effective experience for you.
What advice would you give Abeje regarding storage of breastmilk? 2
At room temperature:- can be kept for between 6-8 hours. In a fridge:- can be kept in fridge for up to 3 days and it is always advised to keep it towards the back of the fridge. This is because at the front or towards the door of the fridge, the temperature of the fridge will fluctuate as the door opens and closes.
If you’re somewhere where the temperature is more controlled so in the hospital/neonatal unit, breastmilk can be stored for up to 5 days.
Freezer:- for up to 3-6 months. This depends on the temperature of your freezer so it is worthwhile to check that.
- What advice should be given to Abeje regarding defrosting stored breastmilk? 2
- Can be taken out of freezer and put in the fridge for 12 hours which will bring it back up to the fridge temperature.
- If needed more immediately, it can be defrosted at room temperature or in a bowl of warm water.
- Never defrost it in a microwave because it can promote patches of heat.
