breast complications in puerperium

1. Breast complications in
puerperium
Neethu SS
Second year MSc Nursing

2. Puerperium
It is the period following child birth during which all
the body tissue especially pelvic organs revert back
to their pre pregnant stage both anatomically and
physiologically.
• It has 3 types:
• Immediate- within 24 hours
• Recent- within 7 days
• Remote- up to the end of 6 weeks

3. The common breast complications in puerperium are:
(1) Breast engorgement
(2) Cracked and retracted nipple leading to difficulty in
breast feeding
(3) Mastitis and breast abscess
(4) Lactation failure.
Breast engorgement and infection are responsible for
puerperal pyrexia.

4. Breast
Engorgement

5. It is a condition which occurs in mammary glands by expanding
veins and the pressure of new breast milk contained with in
them.

6. Cause
Breast engorgement is due to exaggerated normal venous
and lymphatic engorgement of the breasts which precedes
lactation. This in turn prevents escape of milk from the lacteal
system. The primiparous patient and the patient with inelastic
breasts are likely to be involved. Engorgement is an
indication that the baby is not in step with the stage of
lactation.

7. Onset
It usually manifests after the milk secretion starts (3rd
or 4th day postpartum).
Symptoms
• Considerable pain and feeling of tenseness or
heaviness in both the breasts
• Generalized malaise or even transient rise of
temperature and
• Painful breast feeding.

8. Prevention
• To avoid pre-lacteal feeds
• To initiate breast feeding
early and unrestricted
• exclusive breast feeding
on demand
• Feeding in correct
position

9. Treatment
(1)To support the breasts with a binder or brassiere
(2)Manual expression of any remaining milk after each feed
(3) To administer analgesics for pain
(4) The baby should be put to the breast regularly at
frequent intervals
(5)In a severe case gentle use of a breast pump may be
helpful. This will reduce the tension in the breast without
causing excess milk production.

10. CRACKED AND
RETRACTED NIPPLE

11. Cracked nipple
The nipple may become painful due to
• Loss of surface epithelium with the formation of a raw
area on the nipple
• Due to a fissure situated either at the tip or the base of
the nipple. These two conditions frequently co-exist and
are referred to as cracked nipple.

12. It is caused by
(a) unclean hygiene resulting in formation of a crust over the
nipple
(b) retracted nipple
(c) trauma from baby’s mouth due to incorrect attachment to the
breast.
The condition may remain asymptomatic but becomes painful
when the infant sucks. When infected, the infection may spread to
the deeper tissue producing mastitis.

13. Prophylaxis
local cleanliness during pregnancy and in
the puerperium before and after each
breast feeding to prevent crust formation
over the nipple.

14. Treatment
• Correct attachment will provide immediate relief from pain and rapid
healing.
• Fresh human milk and saliva have got healing properties.
• Purified lanonin with the mother’s milk is applied 3 or 4 times a day to
hasten healing. When it is severe, mother should use a breast pump and
the infant is fed with the expressed milk. Inflamed nipple and areola may
be due to thrush also.
• Miconazole lotion is applied over the nipple as well as in the baby’s
mouth if there is oral thrush. If it fails to heal up, rest is given to the
affected nipple using a breast pump while the nipples heal.
• Nipple shields can be used. The persistence of a nipple ulcer in spite of
therapy mentioned, needs biopsy to exclude malignancy.

15. Retracted and flat nipple
It is commonly met in primigravidae. It is usually
acquired.
Babies are unable to attach to the breast correctly
and are unable to suck adequately.
In difficult cases, manual expression of milk can
initiate lactation.
Gradually breast tissue becomes soft and more
protractile, so that feeding is possible

16. PLUGGED DUCT
A Plugged duct is where an occlusion or plug has
occurred in the milk passageways. This plug prevents
milk from passing through or the milk passage may be
slower than usual.

17. Management
• Learn how to position baby so that the
baby can latch on properly
• Try using warm compresses
• Take a mild pain reliever, such as
ibuprofen

18. SORE NIPPLES
Sore nipples are any persistent pain in the nipples that
lasts throughout the entire breastfeeding or hurts
between feedings

19. PREVENTION
• use a proper breastfeeding technique
• keep the nipples dry by exposing them to air or
sunlight
• avoid products that remove the natural protection of
nipples, such as soaps, alcohol.
• breastfeed on demand
• avoid the use of nipple shields

20. MANAGENENT
• Offer the least affected breast first
• Express enough milk before breastfeeding to stimulate
the let-down reflex, thus preventing the infant from
sucking too vigorously on the breast
• Alternate between different positions, reducing the
pressure on sore areas or on damaged tissues
• Use "breast shells“
• Use oral or systemic analgesics

21. ACUTE MASTITIS
Mastitis is
inflammation of the
breast tissue,
usually unilateral
after the milk flow
is established.

22. The incidence of mastitis is 2–5 percent in lactating
and less than 1 percent in nonlactating women.
The common organisms involved are Staphylococcus
aureus, S. epidermidis and Streptococci viridians.
Risk factors
• mastitis are poor nursing
• maternal fatigue
• cracked nipple.

23. Mode of infection
There are two different types of mastitis depending upon the site of
infection.
(1) Infection that involves the breast parenchymal tissues leading to
cellulitis. The lacteal system remains unaffected.
(2) Infection gains access through the lactiferous duct leading to
development of primary mammary adenitis. The source of
organisms is the infant’s nose and throat.
Noninfective mastitis may be due to milk stasis. Feeding from the
affected breast solves the problem

24. Onset
In superficial cellulitis, the onset is acute during first 2–4 weeks
postpartum. However, acute mastitis may occur even several weeks after
the delivery. Clinical features
Symptoms
• Generalized malaise and headache
• Fever (102°F or more) with chills, and
• Severe pain and tender swelling in one quadrant of the breast.
Signs
• Presence of toxic features
• Presence of a swelling on the breast.
• The overlying skin is red, hot and flushed and feels tense and tender.

25. Complications
Due to variable destruction of breast tissues, it leads to the
formation of a breast abscess.
PROPHYLAXIS
• Thorough hand washing before each feed
• cleaning the nipples before and after each feed and
keeping them dry
• reduce the nosocomial infection rates

26. Management
 Breast support
 Plenty of oral fluids
 Breast feeding is continued with good attachment. Nursing
is initiated on the uninfected side first to establish let down
 The infected side is emptied manually with each feed

27.  Dicloxacillin (penicillinase resistant penicillin) is the drug of
choice.
A dose of 500 mg every 6 hours orally is started till the
sensitivity report available.
Erythromycin is an alternative to patients who are allergic to
penicillin.
Antibiotic therapy is continued for at least 7 days
• Analgesics (Ibuprofen) are given for pain
• Milk flow is maintained by breast feeding the infant.
• This prevents proliferation of staphylococcus in the stagnant
milk. The ingested staphylococcus will be digested without
any harm.

28. BREAST ABSCESS
Breast abscess is
caused by
infection of the
engorged
glandular system
of the breasts.

29. Signs and Symptoms of Breast Abscess
• Fever:
• Abscess on the breast
• Severe Pain occurs on movement
of the entire breast.
• The axillary (armpit) lymph nodes
may also get inflamed, red and
tender

30. Features
• Flushed breasts not responding to antibiotics
promptly
• Brawny edema of the overlying skin
• Marked tenderness with fluctuation
• Swinging temperature

31. • If an abscess is formed, it is to be drained under general anesthesia by a deep radial
incision extending from near the areolar margin to prevent injury of the lactiferous
ducts.
• Incision perpendicular to the lactiferous ducts increases the risk of fistula formation and
ductal occlusion.
• Finger exploration is done to break up the walls of the loculi. The cavity is loosely
packed with gauze which should be replaced after 24 hours by a smaller pack.
• The procedure is continued till it heals up. The abscess can also be drained by serial
percutaneous needle aspiration under ultrasound guidance.
• Surgical drainage is commonly done.

32. • Breast feeding is continued in the uninvolved side.
• The infected breast is mechanically pumped every two
hours and with every let down.
• Recurrence risk is about 10 percent.
• Once cellulitis has resolved breast feeding from the
involved side may be resumed
• Breast pain may be due to engorgement, infection
(Candida albicans), nipple trauma, mastitis or
occasionally with latching-on or let down reflex

33. Management
• Appropriate nursing technique, positioning and breast
care can reduce pain significantly when it is due to
nipple trauma, engorgement or mastitis
• Use of miconazole oral lotion or gel into both the nipples
and into infant’s mouth thrice daily for 2 weeks is helpful.

34. LACTATION FAILURE
(INADEQUATE MILK PRODUCTION)

35. The causes are:
• Infrequent suckling
• Depression or anxiety state in the puerperium Reluctance or
apprehension to nursing
• Ill development of the nipples
• Painful breast lesion
• Endogenous suppression of prolactin (retained placental bits)
• Prolactin inhibition (ergot preparations, diuretics, pyridoxin).

36. Treatment
For maintenance of effective lactation in an otherwise healthy
individual, the following guidelines are helpful.
• Antenatal:
• To counsel the mother regarding the advantages of nursing
her baby with breast milk
• To take care of any breast abnormality specially a retracted
nipple and to maintain adequate breast hygiene specially in
the last two months of pregnancy.

37. • Puerperium:
(1) To encourage adequate fluid intake
(2) To nurse the baby regularly
(3) Painful local lesion is to be treated to prevent development of
nursing phobia
(4) Metoclopramide, intranasal oxytocin and sulpiride (selective
dopamine antagonist) have been found to increase milk
production. They act by stimulating prolactin secretion.
Metoclopramide given in a dose of 10 mg thrice daily is found
helpful

38. Nursing management
Nursing assessment
• Daily observation of breast including consistency, color, surface temperature, and
nipple condition
• Observe breast feeding to ensure proper technique
• Note reporting of a tender area in breast that is warm, firm, and red.
• Check for malaise, chills, and elevated temperature
• Observe for local area of breast, with induration, tenderness, and erythema
• Red streaks may occur along lymphatic channels and tender enlarged axillary
nodes may be present
• Cultures or gram stains may be taken of breast milk to identify the causative
organism in case of mastitis

39. Nursing diagnosis
• Pain related to inflammation and infection
• Anxiety related to effect of infection on breast feeding
• Interrupted breast feeding related to infection and pain
• Knowledge deficit related to care of breasts, proper breast
feeding techniques and prevention of infection
• Altered parenting related to the client’s inability to continue
breast feeding
• Situational low self-esteem related to client’s inability to continue
breast feeding
• Risk for altered parent/ infant attachment related to possible
isolation from newborn

40. Nursing planning and interventions
• Client teaching about breast and nipple care
• Teaching on proper breast- feeding techniques
• Instruct the client in signs and symptoms of infection and the
need for proper treatment
• Inspect nipples every 8 hours for cracks, fissures, blisters
and excoriated areas.
• Advise to clean breast before and after breastfeeding
• Sore, tender nipples reported by the mother should be
inspected immediately.

41. • If areas of fluctuation or abscesses develop, these must be incised
and drained.
• Cold and heat therapy can be used
• Administer antibiotics
• Perform dressing changes following incision and drainage and
monitors the client’s wound for signs of healing
• Advise to temporarily stop breast feeding in case of high fever or
abscess develops requiring incision and drainage.
• To maintain lactation, the client is encouraged to express milk from
the affected breast every few hours once the pain has subsided
• Encourage the patient to wear a firm supportive brassiere for breast
support.

42. Nursing evaluation
• Anticipated outcomes of nursing care for the client with breast
complications:
• Demonstrate proper breast and nipple care and breast feeding
techniques
• Verbalizes signs and symptoms of complications
• Verbalizes a decrease in pain in affected area
• Verbalizes acceptance of condition
• Demonstrate positive coping behaviors

43. Thank you