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1. Breast problems after
delivery and its management
Sunil Kumar Daha

2.  Breast complications in puerperium
1. Breast engorgement
2. Cracked and retracted nipple
3. Mastitis
4. Breast abscess
5. Lactation failure

3. Breast Engorgement
Common in primiparous and patient with inelastic breasts
Onset: 3 to 5 days after delivery (if do not breast feed)
exaggerated normal venous and lymphatic engorgement of breast which precede
lactation
Prevents the escape of milk from lacteal system

4. Symptoms
Considerable pain and feeling of heaviness in both the breasts
Generalized malaise or even transient rise of temperature and
Painful breast feeding.

5. Prevention
 Avoid prelacteal feeds
 Initiate breast feeding early and unrestricted
Exclusive breast feeding on demand,
 Feeding in correct position

6. Treatment
 Support the breasts with a binder or brassiere
Manual expression of any remaining milk after each feed
 To administer analgesics for pain
The baby should be put to the breast regularly at frequent intervals
In a severe case gentle use of a breast pump may be helpful.

7. Cracked nipple
The nipple may be painful due to:
Loss of surface epithelium
Due to a fissure situated at tip or base of nipple or at both area
 Causes:
Poor hygiene  formation of crust over the nipple
Retracted nipple
Trauma from baby’s mouth due to incorrect attachment to mother’s breast
Infection with candida albicans and S. aureus
*Condition may be asymptomatic but becomes painful when the infant sucks the breast

8. Prophylaxis
Local cleanliness during pregnancy and puerperium, before and after each
breastfeeding to prevent crust formation in the nipple
Treatment
Latch on will provide immediate relief from pain and rapid healing
Purified lanonin with mother’s milk applied 3-4 times a day to hasten healing
*Fresh human milk and saliva have got healing properties

9. Treatment cotd…
Miconazole lotion applied over nipple as well as in the baby’s mouth (if there
is oral thrush).
If fails to heal, rest is given to affected nipple using breast pump while the
nipple heals.
*Biopsy is needed to exclude malignancy, if nipple ulcer persists in spite of above therapy

10. Retracted and flat nipple
Common in primigravidae
Babies can attach and are able to suck adequately
If unable to suck, manual expression of milk and fed

11. Acute Mastitis
incidence:
2-5% in Lactating mothers
<1% in non-lactating mothers
Organisms involved:
Staphylococcus aureus
Staphylococcus epidermidis
Viridans streptococci

12. Risk factors
Poor nursing
Maternal fatigue and cracked nipple
Types of mastitis (based upon site of infection)
Infection in breast parenchymal tissue cellulitis
Infection in lactiferous ducts primary mammilary adenitis
Non-infective mastitis due to milk stasis

13. Clinical features
Symptoms:
Generalized malaise and headache, nausea, vomiting
 Fever (102°F or more) with chills
Severe pain and tender swelling in one quadrant of the breast
Signs include
toxic features
swelling on the breast
 The overlying skin- red, hot and flushed and feels tense and tender.

14. Management
Breast support
Plenty of oral fluids
Continued breastfeeding in the unaffected side
Infected side manually emptied
Dicloxacillin is drug of choice 500 mg 6 hourly for 7 days
Erythromycin is alternative to the people allergic to penicillin
Analgesics for pain *Breast feeding maintains flow- prevents proliferation of staphylococcus
in the stagnant milk

15. Prophylaxis
Hand wash before each feed
Clean nipple before and after each feed with mild soap
Keep nipple dry
Complications
breast abscess due to variable destruction of breast tissues

16. Breast Abscess
Clinical features
Flushed breast not responding to antibiotics promptly
Edema of overlying skin
Marked tenderness with fluctuation
Swinging temperature
Breast pain : due to engorgement, infection (Candida albicans)
nipple trauma, mastitis or occasionally with let down reflex

17. Management:
Surgical draining of abscess (Incision and drainage under general anesthesia)
Breast feeding is continued from uninvolved side
Infected breast is mechanically pumped every 2 hours and with every let
down

18. Lactation failure
Inadequate milk production
Causes:
Infrequent suckling
Depression or anxiety state in puerperium
Reluctant or apprehension to nursing
Ill development of nipples
Painful breast lesions
Endogenous suppression of prolactin(retained placental bits)
Prolactin inhibition(pyridoxine, ergot preparation, diuretics)

19. Treatment guidelines
Antenatal
Counsel mother
Take care of breast abnormalities (retracted nipples)
Puerperium
Encourage adequate fluid intake
Nurse baby regularly
Treat painful local lesions
Selective dopamine antagonist (Metoclopramide 10mg TDS Po)

20. References
• Konar.H, DC Dutta’s Textbook of obstetrics 8th edition, Jaypee
publication
• Cunningham ,Bloom, Spong,Dashe,Hoffan,Casey,Sheffield,
Williams obstetrics,24th edition ,Mc Graw Hill education

21. Thank You