OBG PPT Moment

1. PHYSIOLOGY OF
LACTATION, BREAST
FEEDING, BABY FRIENDLY
HOSPITALS
ADITIJ DHAMIJA 180101220
ANKITA DHANUKA 180101222
SHASHANK TOMER 180101238

2. PHYSIOLOGY OF
LACTATION
FREQUENCY LIST
PHYSIOLOGY OF LACTATION [4 MARKS] (FEBRUARY
2020)
PHYSIOLOGY OF LACTATION [4 MARKS] (JULY 2016)
SUPPRESSION OF LACTATION [4 MARKS] (JANUARY
2015)

3. CLINICAL CASE
REF - HTTPS://WWW.NCBI.NLM.NIH.GOV/PMC/ARTICLES/PMC3066722/
A 40 year old patient, G3P3, with no significant medical or surgical history, was admitted to
the intensive care unit with hemorrhagic shock due to postpartum hemorrhage following a
normal delivery at home.
Clinical examination revealed an undetectable blood pressure, a tachycardia of 120
beats/min, cold peripheries, pale conjunctivae and polypnea.
Following emergency care, the patient developed lactational failure. Long term consequences
were prolonged amenorrhea, fatigue and apathy.

4. DEVELOPMENT OF MAMMARY GLANDS
• 6th week of gestation- Mammary glands begin to develop as solid growths of epidermis
called mammary ridges.
• Under the influence of estrogen from placenta, mammary ridges canalize to form
ducts.
• At birth, mammary glands of males and females are identical, composed of 15-20
rudimentary lactiferous ducts.
• Female breasts develop further after puberty under the influence of estrogen from
developing follicle and corpus luteum each month
• Enlargement occurs due to deposition of fat and connective tissue. Nipple becomes
enlarged and pigmented. There is further growth and branching of lactiferous ducts.

6. IS SMOKING A RISK FACTOR FOR BREAST CANCER
IN MEN(MBC)?
SOURCE -
HTTPS://WWW.NCBI.NLM.NIH.GOV/PMC/ARTICLES/PMC4116310/

7. Nicotine reduces circulating estrogen levels
There is indeed reduced risk of MBC.

8. PHYSIOLOGY OF LACTATION
Divided into 4 phases:-
(a) Preparation of breasts (Mammogenesis).
(b) Synthesis and secretion from the breast alveoli (Lactogenesis).
(c) Ejection of milk (Galactokinesis).
(d) Maintenance of lactation (Galactopoiesis)

9. MAMMOGENESIS
Mammogenesis is remarkable growth of both ductal and lobuloalveolar systems
throughout a woman’s life.
Stage-I mammogenesis - During puberty, lobule type 1 is formed. Changes in the level
of estrogen and progesterone during each menstrual cycle stimulate lobule 1 to produce
new alveolar buds and eventually evolve to more mature structures, known as type-2 and
type-3 lobules. Once puberty is complete, no further changes occur to the female breast until
pregnancy.

10. During pregnancy, stage-II mammogenesis (alveolar development and maturation of the
epithelium) occurs largely in response to higher levels of progesterone. The increased
volume of breast tissue during pregnancy is a result of the proliferation of secretory tissue.
In early pregnancy, lobule type 3 is formed due to the influence of chorionic gonadotropin.
These newly formed lobules have larger size and number of epithelial cells composing each
acinus. In late pregnancy, the proliferation of new acini are reduced, and the lumen becomes
distended with secretory material or colostrum.

11. During labor and lactation, further growth and differentiation can be seen in the lobule along
with milk secretion. The glandular component of the breast has now increased to the point where
it is mainly formed of epithelial elements and very little stroma. This will persist throughout
lactation.
Finally, the involution of mammary glands occurs with the cessation of lactation and requires a
combination of lactogenic hormone deprivation and local autocrine signals that signal apoptotic
cell death and tissue remodeling. Full regression does not occur, and pregnancy causes a
permanent increase in the size and number of lobules. Following lactation, there is always the
potential of the glands to produce milk in response to regular stimulation.

12. LACTOGENESIS
2 stages: secretory initiation and secretory activation
Stage I lactogenesis (secretory initiation) takes place during the second half of pregnancy.
The placenta supplies high levels of progesterone which inhibit further differentiation. In this
stage, small amounts of milk can be secreted by week 16 gestation. By late pregnancy, some
women can express colostrum.

13. Stage II lactogenesis (secretory activation) starts with copious milk production after delivery.
With the removal of the placenta at delivery, the rapid drop in progesterone, as well as the
presence of elevated levels of prolactin, cortisol, and insulin, are what stimulate this stage.
Usually, at days 2 or 3 postpartum, most women experience swelling of the breast along with
copious milk production.

14. In primiparous women, the secretory activation stage is slightly delayed, and early milk
volume is lower. Lower milk volume is also observed in women who had cesarean births
compared with those who delivered vaginally. Late onset of milk production has also been
seen in women who have had retained placental fragments, diabetes, and stressful vaginal
deliveries. With retained placental fragments, lactogenesis stage II could be inhibited by the
continued secretion of progesterone and would continue to be inhibited until removal of the
remaining placental fragments.

15. LACTOGENESIS
• Principal sites for production of milk - Alveolar cells
• Some secretory activity is evident (colostrum) during pregnancy and accelerated following
delivery, milk secretion actually starts on 3rd or 4th postpartum day.
• Around this time, the breasts become engorged, tense, tender and feel warm.
• Inspite of a high prolactin level during pregnancy, milk secretion is suppressed because
estrogen and progesterone circulating during pregnancy make the breast tissues
unresponsive to prolactin. When the estrogen and progesterone decrease following
delivery, prolactin begins its milk secretory activity in previously fully developed mammary
glands.
• Prolactin, PTH, insulin, growth hormone and glucocorticoids are the important hormones in
this stage.

16. GALACTOKINESIS
• Oxytocin is the major galactokinetic hormone.
• Discharge of milk from the mammary glands depends not only on the suction
exerted by the baby during suckling but also on the contractile mechanism which
expresses the milk from the alveoli into the ducts.

17. Q. OXYTOCIN RELEASED DURING GALACTOKINESIS
IS PROTECTIVE AGAINST WHICH DREADED POST-
PARTUM COMPLICATION IN MOTHER?

18. POST-PARTUM HEMMORHAGE
Oxytocin causes involution of uterus.

19. Lactation is maintained by regular removal of milk and stimulation of the nipple, which
triggers prolactin release from the anterior pituitary gland and oxytocin from the posterior
pituitary gland. For the ongoing synthesis and secretion of milk, the mammary gland must
receive hormonal signals; and although prolactin and oxytocin act independently on different
cellular receptors, their combined action is essential for successful lactation.

20. MILK EJECTION REFLEX
• During suckling, impulses from the nipple and areola pass via thoracic sensory (4, 5 and 6)
afferent neural arc to the paraventricular and supraoptic nuclei of the hypothalamus to
synthesize and transport oxytocin to the posterior pituitary.
• Oxytocin is liberated from the posterior pituitary, produces contraction of the myoepithelial
cells of the alveoli and the ducts containing the milk.
• The milk is forced down into the ampulla of the lactiferous ducts, where from it can be
expressed by the mother or sucked out by the baby.
• A sensation of rise of pressure in the breasts by milk experienced by the mother at the
beginning of sucking is called “draught”.
• The milk ejection reflex is inhibited by factors such as pain, anxiety, depression.

22. GALACTOPOIESIS
• Prolactin is the single most important galactopoietic hormone.
• Prolactin levels return to normal within a few weeks.
• Each time an infant feeds, neurohumoral reflex leads to a burst of PRL secretion.
• For maintenance of effective and continuous lactation, frequency of suckling
(>8/24 hours) is essential. Distension of the alveoli by retained milk is due to
failure of suckling. Hence periodic breastfeeding is necessary.

23. LACTATIONAL AMENNORHEA
Breastfeeding delays the resumption of normal ovarian cycles by disrupting the
pattern of pulsatile release of GnRH from the hypothalamus and hence LH from
the pituitary. The plasma concentrations of FSH during lactation are sufficient to induce
follicle growth, but the inadequate pulsatile LH signal results in a reduced estradiol
production by these follicles. When follicle growth and estradiol secretion does increase
to normal, the suckling stimulus prevents the generation of a normal preovulatory LH
surge and follicles either fail to rupture, or become atretic or cystic. Only when the
suckling stimulus declines sufficiently to allow generation of a normal preovulatory LH
surge to occur will ovulation take place with the formation of a corpus luteum of variable
normality. Thus suckling delays the resumption of normal ovarian cyclicity by disrupting
but not totally inhibiting, the normal pattern of release of GnRH by the hypothalamus.
The mechanism of suckling-induced disruption of GnRH release remains unknown.

24. LACTATION FAILURE
• Lactation failure refers to inadequate milk production.
• It may be due to infrequent suckling or due to endogenous suppression of
prolactin (ergot preparation, pyridoxine, diuretics or retained placental bits).
• Pain, anxiety and insecurity may be the hidden reasons. (What is the term
for psychological reasons causing physiological manifestations?)
• Unrestricted feeding at short interval (2–3 hours) is helpful.

25. GALACTOGOGUES
Drugs to improve milk production (galactogogues):
• Metoclopramide (10 mg thrice daily) increases milk volume by increasing prolactin
levels.
• Sulpiride (dopamine antagonist),
• Domperidone (by increasing prolactin levels).
• Intranasal oxytocin contracts myoepithelial cells and causes milk let down.

26. LACTATION SUPPRESSION
• Lactation is suppressed when the baby is born dead or dies in the neonatal period or if
breastfeeding is contraindicated.
• Methods commonly used are:
1. to stop breastfeeding,
2. to avoid pumping or milk expression,
3. to wear breast support,
4. ice packs to prevent engorgement,
5. analgesics (aspirin) to relieve pain and
6. a tight compression bandage is applied for 2–3 days.
7. In UK, Cabergoline (DA) is prescribed for stillbirth
• The natural inhibition of prolactin secretion will result in breast involution.

27. CASE ANSWER
Sheehan’s Syndrome
Hypopituitarism – Hypoprolactinemia and gonadotrophins are reduced
Lactational failure

28. QUESTION
Can transgender women lactate?

29. MAYBE.
SOURCE:
HTTPS://WWW.NCBI.NLM.NIH.GOV/PMC/ARTICLES/PMC5779241/

30. QUESTION
Is milk production affected in PCOS?

31. YES.
Androgens, which are typically high in PCOS, can interfere with and bind to
prolactin receptors, reducing the amount of milk produced. Insulin can also
disrupt a healthy milk supply.

32. QUESTION
A study published in Clinical Endocrinology (Oxford)
[doi: 10.1111/j.1365-2265.1982.tb01601.x.] reported
women who smoke have lower basal prolactin
concentration.
Based on this information, what is the expected
outcome of a study comparing breastfeeding duration
and perinatal smoking?

34. BREAST FEEDING

35. All the babies, regardless of
the type of delivery,
Exclusive breast feeding
should be given up to 6
months of age.

36. WHY IS
BREAST
FEEDING
IMPORTANT
?
• Breast milk is an ideal food with easy
digestion and low osmotic load.
• Protects against infection and
deficiency states as it contains
• 1. Vitamin D
• 2. Leukocytes, lactoperoxidase
• 3. Lysozyme, lactoferrin, interferon
• 4. Long-chain omega-3 fatty acids
• 5. Immunoglobulins IgA (secretory),
IgM, IgG
• 6. Supply of nutrients and vitamins

37. • Breast milk is a readily available food to the newborn
at body temperature and without any cost.
• Acts as a natural contraception to the mother
• It has laxative action
• No risk of allergy
• Psychological benefit of mother-child bonding
• Helps involution of the uterus
• Lessens the incidence of sore buttocks,
gastrointestinal infection and atopic eczema
• incidence of scurvy and rickets is significantly reduced

38. FIRST FEED
• Frequency of feeding:
• Time schedule-
First 24 hours, at an interval
of 2–3 hours.
Gradually, at 3–4 hours
pattern by the end of first
week.
• Baby should be fed more
on demand
•In healthy baby is put to
the breast immediately or
at most 1/2–1 hour
following normal delivery.
•Following cesarean
delivery a period of 4–6
hours may be sufficient
for the mother to feed her
baby.

39. DEMAND FEEDING
• The baby is put to the breast as soon as the baby
becomes hungry. there is no restriction of the number of
feeds and duration of suckling time.
• Baby is fed from one breast completely so that baby
gets both the foremilk and the hind milk. Then the baby
is put to the other breast if required. Hind milk is richer in
fat and supplies more calories and satiety to the infant.
• The next feed should start with the other breast

40. TECHNIQUE OF BREAST FEEDING
• The mother and the baby should be in a comfortable
position.
• Feeding in the sitting position, the mother holds the
baby in an inclined upright position on her lap;
• the baby’s head on her forearm on the same side
close to her breasts, the neck is slightly extended.
• Good attachment means
• 1.)the infant’s mouth is wide open
• 2.)chin touches the breast
• 3.)lower lip turned outwards
• 4.)majority of areola in baby’s mouth with only upper
areola visible above top lip and not the lower one

41. — Anxiety and Stress
Reassurance and practical support is helpful.
— Following operative delivery such as cesarean section or following
prolonged and exhaustive labor often there is a delay.
— Milk secretion is inadequate—unrestricted feeding.
Dopamine antagonist (metoclopramide) may be useful.
— Breast ailments such as engorgement of breast, cracked nipple,
depressed nipple and mastitis need treatment.
DIFFICULTIES IN BREASTFEEDING
AND THE MANAGEMENT
Due to mother:

42. DIFFICULTIES
IN
BREASTFEEDIN
G AND THE
MANAGEMENT
• Due to infant:
• — Low birth weight baby
• — Temporary illness such as respiratory
tract infection, nasal obstruction due to
congestion, lethargy due to jaundice and
oral thrush.
• — Overdistension of the stomach with
swallowed air—the problem can be
overcome by breaking the wind of the
baby several times during feeding.
• — Congenital malformation such as cleft
palate needs surgical correction

44. MATERNAL
NUTRITION
DURING
LACTATION
• A healthy mother while
breastfeeding will produce about
500–900 mL breast milk per day.
This will give her baby about 75
kcal/dL. This requires additional
750 kcal/day for the mother. This
amount is either to be
supplemented through her diet or
is made up from her body stores.
A store of 5 kg of fat throughout
pregnancy is adequate to make
up the nutritional deficit.

45. MATERNAL
NUTRITION
DURING
LACTATION
• There is additional need (increased by
50%) of folic acid, iron, calcium and
protein during pregnancy.
• Mother should drink at least 1 extra liter
of fluid per day to make up the fluid
loss through milk.
• Bone mineral density decreases in the
breastfed women and it returns to
normal after 12 months of stoppage of
breastfeeding

50. 2. ENSURE
THAT STAFF
HAVE
SUFFICIENT
KNOWLEDGE,
COMPETENCE
AND SKILLS TO
SUPPORT
BREASTFEEDIN
G.

51. 3. DISCUSS
THE
IMPORTANCE
AND
MANAGEMENT
OF
BREASTFEEDIN
G WITH
PREGNANT
WOMEN AND
THEIR
FAMILIES

52. •4. Facilitate
immediate and
uninterrupted
skin-to-skin
contact and
support mothers
to initiate
breastfeeding as
soon as possible
after birth.

53. 5. SUPPORT
MOTHERS TO
INITIATE AND
MAINTAIN
BREASTFEEDIN
G AND MANAGE
COMMON
DIFFICULTIES.

54. 6. DO NOT
PROVIDE
BREASTFED
NEWBORNS
ANY FOOD OR
FLUIDS
OTHER THAN
BREAST MILK,
UNLESS
MEDICALLY
INDICATED.

55. •7. ENABLE
MOTHERS
AND THEIR
INFANTS TO
REMAIN
TOGETHER
AND TO
PRACTISE
ROOMING-IN
24 HOURS A

56. 8. SUPPORT
MOTHERS TO
RECOGNIZE
AND
RESPOND TO
THEIR
INFANTS’
CUES FOR
FEEDING.

57. 9.
COUNSEL
MOTHERS
ON THE
USE AND
RISKS OF
FEEDING
BOTTLES,
TEATS AND
PACIFIERS.

58. 10.
COORDINATE
DISCHARGE SO
THAT PARENTS
AND THEIR
INFANTS HAVE
TIMELY ACCESS
TO ONGOING
SUPPORT AND
CARE.