Prenatal Breastfeeding Assessment:

How to Tell Whether Your Client Will Be At-Risk for Breastfeeding Problems

By Erin McCarter, RN, IBCLC

ErinMcCarterBeing knowledgable about how the female body provides optimal health for her offspring is a fundamental part of being a Midwife.  A thorough evaluation of a woman’s breasts, her breastfeeding history, and surgery or trauma to her breasts is a critical part of her prenatal care.  Very few women don’t have the anatomy to exclusively breastfeed, but by preparing an at-risk woman prenatally, we can ensure that we are protecting and bolstering her breastfeeding relationship while maintaining good health for the newborn.

Complete development of mammary function only occurs during pregnancy.  This is related to the hormonal changes of pregnancy.  Womens’ breasts vary in size, shape, color, and placement.  Some asymmetry is normal.  Women with small breasts can still make as much milk as a larger-breasted woman, as it is the amount of glandular tissue under the skin that is more important than the amount of adipose tissue.  Supernumeray breasts and/or accessory nipples may occur along the milk line which runs from the groin to the axilla.  This can vary from a small mole, to an extra nipple under the breast, to breast tissue in the armpit.  It is rare, but still considered normal.  Development of skin tags on the breast is also a normal part of pregnancy.

Taking a History

First discuss her breast changes that she’s experienced since the pregnancy began. Did she have breast changes during the pregnancy?  These include increased vasculature over the breast tissue, widening and/or darkening of the areola, increase in nipple size, increase in breast size, an increase in Montgomery glands over the areola, and possible leaking of colostrum.  Colostrum, the first milk, is available as early as 16 weeks gestation.  Breast tenderness and increased nipple sensitivity are also reassuring signs that adequately functioning breast tissue is responding to hormonal changes.

Has she ever experience any trauma to her breasts?  This may be a point that she divulges sexual abuse or feelings of self-loathing, a wonderful time to further connect with your client and provide her with an opportunity for personal growth.  Women usually feel better when someone shares in their pain and Midwives can help by active listening, connecting the client to a therapist if necessary, or by assuring the woman that you are here to help and you’re going to work together to make a plan.  Of course, there is also blunt trauma that may have occurred in a car accident or bad fall.  If there has been nerve damage to the 4th, 5th, and 6th, intercostal nerves, then there may be a decrease in the signaling to and from the brain.

Has she had breast augmentation? Why?  Sometimes a woman seeks cosmetic surgery to ‘correct’ very asymmetrical breasts or hypoplasia.  Be sure to understand why she sought out cosmetic surgery and ask her if the surgeon discussed her breastfeeding ability with her.  Augmentation tends to have less of an impact on breastfeeding than a reduction, as we have not taken out any breast tissue.  But because the amount of glandular tissue in each woman’s breasts is not truly known, it is hard to know whether a breast reduction will cut her normal supply by 1/5 or by 1/2.  A wonderful internet resource is the website called Breastfeeding After Breast and Nipple Surgeries (bfar.org).  Keep in mind that a surgery that involved completely removing the nipple and then putting it back on has likely severely damaged the nerve responses, and is very problematic for breastfeeding.

What is her breastfeeding history?  Relevant questions to ask are, how long did you breastfeed your previous child(ren)?  Did you have any concerns?  Did you have an obvious day when your milk set in?  Did you ever have any concerns with your milk supply?  The good news is that if a woman has a history of low milk supply, she will likely make a bit more with subsequent children.  This is because each time a woman has a baby, a new layer of Prolactin receptor sites is laid down in her breast tissue.  And the more receptor sites she has, the more milk she’ll make.  However, keep in mind that any evidence of hormone imbalances, such as diabetes, thyroid problems, Polycystic Ovarian Syndrome, androgenism, or male-patterned facial and body hair could be a potential threat to a good milk supply.

Breast Assessment:  Inspection & Palpation

First notice the roundness of the breasts. A breast with adequate glandular tissue is usually round on all sides.  If a woman’s breasts are not very full underneath, or there is a wide space between the breasts, that can be a signal that she’s lacking glandular tissue.  Sometimes the most predominant feature of a hypoplastic breast is a puffy appearing areola.  The photos below are examples of women who will likely need to supplement their infant’s feedings.

Conversely, a woman with very large pendulous breasts can sometimes have a real problem latching her baby, as her tissue is hard to manage and her nipple may point down, making it difficult for her to see.  Helping her trouble-shoot positioning after the baby arrives will be helpful.  Very obese women can sometimes have difficulty with milk supply if they have hormonal imbalances.

Next palpate the woman’s breasts.  This is a great time to review the importance of self breast exams, as well as a time to prepare the woman for further anticipated breast changes once she has her baby.  Her colostrum will become transitional milk and the volume with drastically increase between days 2-5.  I have taken to using the phrase the “milk sets in” vs. the “milk comes in,” as coming in feels like it negates the colostrum.  With this process, called Lactogenesis II and newly renamed Secretory Activation by Peter Hartmann, 2007, the breasts will undergo dramatic changes.  The mother should anticipate a very obvious experience of breast swelling, heaviness, but most importantly, her breasts will become lumpy during engorgement, as the milk glands then swell with milk.  Lumps in her breasts are a normal and welcomed change, not a sign that she now has breast cancer.

Next, look at the nipples.  Truly, the length of the nipple does not have much to do with whether the baby will be able to latch well, as the baby should be latching onto the breast tissue and not the nipple.  Yet, when a woman’s nipple is inverted at rest or retracts when the breast is compressed, properly latching a newborn can be a bit of a challenge.  Most babies have an interest in latching and sucking.  However, if you’ve got a baby that has a diminished suck reflex and a mama that has inverted nipples, this can be a real hurdle.  This is one of the most appropriate times to introduce a nipple shield; however, it is always a good policy to wait 24 hours before ever introducing a nipple shield.  Good hand expression and spoon feeding is a better way to navigate this first postpartum day for any baby who is not latching well.

To further evaluate the nipples it is important to palpate the areola at the base of the nipple between the thumb and forefinger, to assess if there is any retraction of the nipple.  Sometimes an inverted looking nipple will protract, or evert, with compression; however, most of the time an inverted nipple will further retract with compression.  There is connective tissue behind the nipple that is tight with an inverted nipple.  Breastfeeding will cause the connective tissue to break up as the nipple tissue becomes more elastic.  If a woman is unhappy about how her nipple looks, it can be a pleasant reward that breastfeeding can remodel the inverted nipple.

To help a woman understand how inverted or retracting nipples will impact her breastfeeding experience, talk about the importance of “sandwiching” a “bite” of breast when latching.  By really making an obvious bite of breast, this will help the baby know where to latch.  Tell her you will be there to help her with her first feeding and that you will work through it together.  Having a woman practice handling her breasts will make her more familiar with her body and can be helpful with latching technique later on.

The very large nipple can also be a hurdle to breastfeeding.  In some cases a woman whose nipple is so predominant that the baby can only accommodate the nipple tissue in the mouth, the baby cannot adequately transfer milk, as they are not massaging the breast tissue to elicit milk.  The baby’s weight gain can be negatively affected and supplementation may be required.

Conclusion

Prenatal breast assessment and history of previous breastfeeding experiences is a fundamental part of Midwifery care.  When this is done prenatally, concerns can be identified and addressed before the baby arrives.  If you suspect that a woman might be at-risk for breastfeeding difficulties, she can be referred to a Lactation Consultant prenatally, for further support and planning.  In the next IMC Newsletter, Part 2 of this discussion:  Prenatal Breastfeeding Counseling for the Woman with Suspected Low Milk Supply.  What do you tell your client and what is the plan?  Stay tuned!

Erin McCarter is an International Board Certified Lactation Consultant & Registered Nurse.  She works for Mother’s Milk & More in Boise, ID.  www.MothersMilkandMore.com

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