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Breast Assessment

Usually little attention is given to prenatal assessment of the breast and nipples because of Western cultural inhibitions about the breast and lack of recognition of its importance. As a consequence, after giving birth, mothers may experience feeding difficulties that could have been prevented. Nurses and lactation consultants practicing as primary caregivers are the ideal people to perform a prenatal breast assessment, particularly because physicians (especially males) are often reluctant to do so.

Ideal for teaching as well as for data gathering, physical assessment of the breast and nipples includes both inspection and palpation. While one is assessing the breasts, the following observations and questions are relevant.

Inspection. Size, symmetry, and shape of the breasts proper have minimal effect on lactation. The assessment provides the opportunity to reassure the woman with small breasts that she will be able to breastfeed and have a sufficient supply of milk. Asymmetry of breast size is usually normal, but marked asymmetry may be an indication of inadequate glandular tissue in a small minority of women (see Color Plate 27). Hypoplasia (lack of breast tissue) accompanied by a wide space between breasts (intramammary space) is another anatomical "red flag" associated with insufficient lactation (Huggins, Petok, & Mireles, 2000). When mothers with possible hypoplasia (underdeveloped breasts) are identified, their newborn baby should be monitored closely for adequate milk intake. Inadequate glandular tissue might prevent the mother from exclusively breastfeeding her baby; however, she can continue to enjoy the breastfeeding relationship if she provides the baby with additional nutrition while feeding from the breast.

For the woman with large breasts, discussing the importance of a support bra and where such a bra may be obtained is helpful. Holding and feeding her infant will not be the same for the large-breasted woman as for mothers with average-sized breasts. Instead of simply holding the breast, the mother with large breasts may need to lift her breast and to hold or push part of the breast back to permit her infant to grasp the nipple and maintain an adequate airway. During prenatal discussions, the mother may talk about some of her deeper feelings about having large breasts and her decision to breastfeed.

The skin of the breast should be inspected for any deviations. Skin turgor and elasticity can be assessed by gently pinching the skin, although the effect of elasticity on lactation is questionable: women who have been pregnant before have more elastic skin because it has been stretched from a previous pregnancy; women pregnant for the first time have firmer tissue.

A lateral incision in the vicinity of the cutaneous branch of the fourth intercostal nerve (left breast, 5 o'clock position; right breast, 7 o'clock position) made during breast augmentation or reduction surgery may mean severed innervation of the nipple and areola (Farina, Newby, & Alani, 1980). Surgery on the breast, especially if it involves an incision at the areolar margin, is likely to interfere to some degree with milk production. However, even having undergone such surgery, most mothers still can breastfeed. Breast-reduction surgery, because of the greater likelihood of the movement and replacement of nipple tissue, is more likely than augmentation surgery (Hurst, 1996) to negatively influence later lactation performance (Neifert et al., 1990). Scar tissue from injury should be evaluated for its effect on skin elasticity and the degree to which nerve reactivity may have been affected.

Note should also be taken of any skin thickening and dimpling of the breast or nipple tissue. Although rare in a woman of childbearing age, such a change could be an early sign of a tumor a nd should be promptly referred to a physician for evaluation.

Now is the time to ask questions: "Have your breasts grown during pregnancy?" "Have you had any tenderness and soreness?" An increase in breast size, swelling, and tenderness usually indicates adequately functioning breast tissue responsive to hormonal changes.

Next, the nipple should be carefully inspected. (For the purpose of this discussion, nipple will refer to the areola as well as the nipple shaft and pores.) If the nipples appear small, explain that the size of a woman's nipples is of secondary importance to their functional ability. Likewise, any nipple structural abnormality such as inversion should be assessed only in terms of its function.

The look of the breast does not dictate its ability to function. A case in point may be women who have sustained significant scarring from burns (see Color Plate 25). Second- and third-degree burns rarely extend so deeply into the parenchyma that they destroy the glandular tissue of the breast, even when the burns have occurred in adulthood. Significant scarring of the dermis and epidermis, however, may result in (1) reduced maternal sensation when the infant suckles, (2) minimal tissue elasticity, thus requiring the mother to alter the baby's position at the breast, and (3) reduced milk ejection if a nipple has been surgically reconstructed. Nevertheless, scar tissue on the breast or nipple does not, by itself, preclude breastfeeding.

Palpation. After thorough hand washing, the nurse or lactation consultant should assess the nipple by compressing or palpating the areola between the forefinger and the thumb just behind the base of the nipple (the pinch test). This action simulates the compression that occurs when the infant is at the breast. Because of possible nipple adhesions within the underlying connective tissue, a nipple that initially appears everted may retract inwardly on stimulation. Conversely, a nipple that appears flattened

Breast Pinch

FIGURE 3-11. (A) Protracting normal nipple. (B) Moderate to severe retraction. (C) Inverted-appearing nipple, which when compressed using pinch test, will either invert farther inward or will protract forward. (D) True inversion; nipple inverts further.

or inverted may, on palpation, evert; therefore, differentiation must be made between structure and function in assessing the nipples.

The classification of nipple function in Table 3-3 is suggested as standard terminology. It must be emphasized that although many primigravidas have nipples that tend to retract during pregnancy, most evert easily by the end of pregnancy and do not interfere with breastfeeding. Thus nipple assessment should be performed periodically through the pregnancy to track changes and to inform the mother how her body is preparing to feed her baby.

Classification of Nipple Function

When the nipple is compressed using the pinch test, it responds in one of the ways identified in Figure 3-11. This response may reflect degree of function.

Flat or retracted nipples may be treatable during pregnancy. Dysfunction may be present in one nipple while the other is perfectly normal, or it may be present in both nipples. Retraction or inversion can prevent the infant from effectively milking milk ducts that lie beneath the areola. Retraction or simple inversion identified in early pregnancy, however, does not necessarily foretell later difficulty. The infant forms a teat not only from the nipple but from the surrounding breast tissue. When inversion is noted early in pregnancy, time is on the mother's side. As pregnancy progresses, hormonal changes increase the size and protractibility of the nipples. The mother also has time to use interventions that help prevent subsequent feeding problems.

Concepts to Practice

Encouraging early and frequent breastfeeding is a simple, low-cost recommendation for breastfeeding initiation. If the infant is able to suckle effectively at the breast soon after birth, there is a direct relationship between the frequency and strength of suckling and subsequent availability of breastmilk. There appears to be an early "window of opportunity" for the infant's suckling to stimulate prolactin receptors (discussed earlier in this chapter), which in turn enhances milk production. A basic knowledge of anatomy and physiology is put to valuable use when the lactation consultant or nurse translates basic concepts into easily understandable teaching materials. If a client realizes a stressful environment

FIGURE 3-11. (A) Protracting normal nipple. (B) Moderate to severe retraction. (C) Inverted-appearing nipple, which when compressed using pinch test, will either invert farther inward or will protract forward. (D) True inversion; nipple inverts further.

Table 3-3

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New Mothers Guide to Breast Feeding

New Mothers Guide to Breast Feeding

For many years, scientists have been playing out the ingredients that make breast milk the perfect food for babies. They've discovered to day over 200 close compounds to fight infection, help the immune system mature, aid in digestion, and support brain growth - nature made properties that science simply cannot copy. The important long term benefits of breast feeding include reduced risk of asthma, allergies, obesity, and some forms of childhood cancer. The more that scientists continue to learn, the better breast milk looks.

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Responses

  • mimosa
    How to tset protractibility of breast?
    4 years ago
  • Lidya Rezene
    Do breast with nipple eversion grow?
    2 years ago

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