BREAST ENGORGEMENT

Definition: Breast engorgement means the breasts are full of milk and are painful. This usually occurs when a mother makes more milk than her baby uses or when there is no breastfeeding (by choice or if the mother lost the baby). The mother’s breasts may become firm, painful and swollen which makes it hard for the baby to breastfeed.

TREATMENT

• For breastfeeding mothers:
  
  • Advise to empty the breast (manually by expressing the milk or with breast pump)
  • Warm compress and encourage breastfeeding
• If mother is not breastfeeding (e.g., in case of stillbirth, neonatal death, or by choice):
  
  • Advise her to avoid expressing the milk
  • Apply cold compress, or cabbage leaves as required
  • Wear a firm supporting bra
  • Give:
    
    • Tablet Ibuprofen 400 mg 8 hourly for 3 days
    • Bromocriptine* 2.5 mg 12 hourly for 14 days (Problem of rebound engorgement) OR
    • Cabergoline 0.5 mg 2 tablets as a stat dose immediately after delivery to stop the production of breast milk

NOTE:

• Do not breastfeed/give baby any expressed breast milk once pharmacological treatment is initiated
• Bromocriptine has been associated with an increased risk of maternal stroke, seizures, cardiovascular disorders, death and possibly psychosis

FOLLOW-UP

• Return after 1 week and 6 weeks to postnatal clinic

MASTITIS

DEFINITION: Mastitis is inflammation of the breast tissue that results in breast pain, swelling, warmth and redness. The patient may also have fever and chills.

PREDISPOSING FACTORS

• Cracked nipples
• Breast engorgement
• Oral infection in the baby

DIFFERENTIAL DIAGNOSIS

• Breast abscess
• Breast engorgement

INVESTIGATIONS (In severe cases only)

• Culture of breast milk
• Complete blood count (CBC) for White blood count

MANAGEMENT

• Counsel and reassure the mother
• Encourage breastfeeding on the unaffected breast
• Demonstrate proper position and breast attachment
• Place warm compress over the breast before breastfeeding to allow free flow of milk
• Apply cold compress to affected breast after breastfeeding
• Give antibiotics:
  
  • Oral flucloxacillin 500 mg 8 hourly for 5 days OR
  • Ampiclox 500 mg 6 hourly for 5 days
• Oral analgesia:
  
  • Ibuprofen 400 mg 8 hourly for 3 days OR
  • Paracetamol 1 g 8 hourly for 3 days

SUBSEQUENT TREATMENT

• If condition does not subside within 48 hours, review and treat according to culture and sensitivity
• Treat infection in baby’s mouth if present

PRECAUTIONS TO TAKE IN ORDER TO AVOID COMPLICATIONS

• Continue breastfeeding to keep breasts empty
• Treat baby’s infection (e.g., oral thrush)
• Educate patient on causes, treatment and best breastfeeding practices
• Ensure compliance with antibiotic therapy to avoid abscess formation

FOLLOW-UP

• Return after 1 week and 6 weeks to postnatal clinic
• Attend appropriate clinic

CRACKED/SORE NIPPLES

DEFINITION: Loss of epithelium covering considerable area of the nipple or a small, deep fissure situated at either the tip or base of the nipple, resulting in sore or painful nipples.

CAUSES

• Improper positioning and attachment of the baby on the breast
• Baby with oral thrush
• Severe dry skin
• Breast eczema

DIAGNOSIS

• Take history
• Perform breast (nipple) examination

MANAGEMENT

• Counsel and demonstrate to the mother proper positioning and attachment of the baby on the breast
• Advise to continue breastfeeding
• Express some breast milk and apply it around the affected nipple and leave it exposed
• Keep nipple clean and moist
• If crack is deep and painful, rest affected breast but express the breast milk from it frequently; baby may be fed on this milk with cup and spoon
• Provide health education and counselling
• Give analgesics
• If severe pain or swelling occurs, manage as mastitis

PRECAUTIONS TO TAKE IN ORDER TO AVOID COMPLICATIONS

• Start counselling for breastfeeding in antenatal period
• Initiate early if she chooses breastfeeding
• Avoid infection of breasts by keeping them clean
• Avoid engorgement by feeding baby on demand
• Properly position and fix baby to breast (part of areola should be inside baby’s mouth)
• Treat infection from baby’s mouth (e.g., thrush)
• Ensure complete emptying of the breast after feeding

FOLLOW-UP

• At each appointment of postnatal clinic and YCC
• Look for healing of the nipples
• Check for proper attachment technique

PUERPERAL SEPSIS

DEFINITION: Puerperal sepsis is infection of the genital tract at any time between the birth of the baby to the forty-second day following delivery or post-abortion. It is characterized by fever after delivery and offensive vaginal discharge.

Puerperal pyrexia is febrile morbidity in the puerperium in which the body temperature rises to 38°C (100.4°F) or higher on any 2 of the first 10 days postpartum.

PUERPERAL SEPSIS IS CHARACTERISED BY:

• Temperature > 38°C
• Tachycardia
• Lower abdominal pain
• Sub-involuted uterus
• Foul-smelling lochia
• Pus discharge from the vagina
• Laboratory examination of discharge will reveal causative bacteria

DIFFERENTIAL DIAGNOSES

• Malaria
• UTI
• Upper and lower respiratory tract infection (URTI)
• Mastitis
• Breast abscess
• Thrombophlebitis/deep vein thrombosis (DVT)
• Wound infection (abdomen/episiotomy)

INVESTIGATIONS

• Swabs: From genital tract – high vaginal swab; and/or from the wound
• Urinalysis: Chemistry (Urine dipstick), Microscopy, culture and sensitivity
• Blood:
  
  • Malaria Rapid Diagnostic Test (RDT)
  • Blood slide for malaria parasites
  • Complete blood count (CBC)
  • Culture and sensitivity in severe cases
  • Blood grouping and cross-matching in case of severe anemia

EMERGENCY TREATMENT IF IN SHOCK OR DEHYDRATED:

• Assess general condition
• Record vital signs
• Give IV fluids (dextrose or normal saline)
• Start broad-spectrum antibiotics IV:
  
  • Ampicillin 500 mg 6 hourly
  • PLUS Gentamycin 80 mg 12 hourly
  • PLUS IV Metronidazole 500 mg 8 hourly for 3 days

NOTE:

• Give the above combination of antibiotics until the woman is fever-free for 48 hours
• The antibiotics are usually given for 3 days, however, if fever is still present on the third day continue with antibiotics until she is fever-free for 48 hours
• Oral antibiotics are not necessary after stopping IV antibiotics
• Give 100 mg hydrocortisone IV 12 hourly (two doses)
• Transfuse if severely anemic
• Refer or consult

SUBSEQUENT TREATMENT

• Identify the site of infection and treat accordingly:
  
  • Remove any retained placenta and membranes
  • For mastitis, breast abscess, UTI and URTI, refer to the respective sections
  • For septic thrombophlebitis/DVT: give anticoagulant therapy, antibiotics, etc.
  • For wound infection: irrigate wound, surgical debridement, give antibiotics and re-suture when wound is clean

PREVENTION OF PUERPERAL SEPSIS

• Strict observation of infection prevention procedures
• Swab and drape for delivery
• Use sterile or high-level disinfected instruments
• Avoid unnecessary pelvic examinations and prolonged labour
• Use prophylactic antibiotics only for emergency Caesarean sections
• Prevent hematoma formation in wounds by ensuring adequate hemostasis

PRECAUTIONS TO TAKE IN ORDER TO AVOID COMPLICATIONS

• Early detection and treatment of all infections during pregnancy/labour/puerperium to prevent systemic involvement
• Proper use of broad-spectrum antibiotics and change to appropriate antibiotics upon receipt of culture report
• Counselling of patient to complete the full course of drugs

FOLLOW-UP

• Review after 1 week and then again in 6 weeks or as needed
• Mother should be advised to abstain from sexual intercourse for at least 6 weeks
• Counsel on future pregnancies

OTHER DISORDERS OF THE PUERPERIUM: PSYCHIATRIC DISORDERS

POSTPARTUM BLUES

• It is a transient state of mental illness observed 4–5 days after delivery and it lasts for a few days
• Manifestations: Depression, anxiety, tearfulness, insomnia, helplessness and negative feelings toward the infant

POSTPARTUM DEPRESSION

• It is more gradual in onset over the first 4–6 months following delivery or abortion
• Manifested by: Loss of energy and appetite, insomnia, social withdrawal, irritability and even suicidal attitude

POSTPARTUM PSYCHOSIS (SCHIZOPHRENIA)

• Commonly seen in women with past history of psychosis or with a positive family history
• Onset is relatively sudden usually within 4 days of delivery
• Manifested by: Fear, restlessness, confusion followed by hallucinations, delusions and disorientation (usually manic or depressive)
• Psychotic women may have delusions
• Suicidal, infanticidal impulses may be present
• In that case temporary separation and nursing supervision are needed