230 Obstetrics and Gynecology Board Review •••
❍ A 2-week-old infant cries and wants to nurse every 1 to 2 hours around the clock. When at the breast,
he nurses for about 5 minutes and falls asleep so the mother puts him down. She is now exhausted and
thinking of bottlefeeding. What can you do to save this breastfeeding experience? What is wrong?
This mother needs information, guidance, and reassurance. Her infant is not nursing long enough with each
episode. The infant is only receiving the “foremilk,” which is high in proteins, carbohydrates, and water. He falls
asleep before getting the “hindmilk,” which is high in fat and satiates the appetite and takes longer to digest. This
infant should be stimulated when he dozes off, changed to the opposite breast, and not put down immediately.
If this fails, the mother can pump or express the hindmilk at that time, and it can be given by another caregiver
later so the mother can rest. This process is only a temporary measure as decreased contact time at the breast will
ultimately lead to decreased milk production.
❍ What is breast engorgement?
Engorgement refers to swelling of the breast and can occur early or late in the postpartum period. Early
engorgement is secondary to edema, tissue swelling, and accumulated milk, while late engorgement is due solely to
accumulated milk.
❍ What are some effective treatments of engorgement?
Frequent breastfeeding with complete breast emptying at each feeding.
Warm compresses or shower prior to feedings.
Cold compresses after/between feedings to decrease swelling.
Acetaminophen or ibuprofen for pain control.
Pumping or expressing a small amount of milk prior to breastfeeding to improve latch-on.
Avoidance of pumping for longer than 10 minutes, as this can increase milk supply.
❍ How are plugged ducts distinguished from mastitis?
Plugged ducts are localized areas of milk stasis with distention of mammary tissue. Symptoms include a palpable
lump with tenderness. They are distinguished from mastitis by the absence of signs of systemic infection such as
fever, erythema, or myalgia. Their etiology is unknown.
❍ How are plugged ducts treated?
Plugged ducts are treated by frequent feedings that drain the affected breast entirely. Warm showers or compresses
can be used to facilitate drainage. The affected area of the breast can be manually massaged to drain the duct.
❍ What is mastitis and what causes it?
Mastitis is an infection of the breast. It typically presents as a hard, red, tender, swollen area of the breast associated
with fever, myalgia, chills, malaise, and flu-like symptoms. Common etiologic agents include Staphylococcus aureus,
streptococcus, and Escherichia coli.
❍ What is the proper management of a patient with postpartum mastitis?
Antibiotics (dicloxacillin is the drug of choice), hydration, rest, and analgesics. It is also essential that the breast
continue to be emptied regularly. If unable to nurse due to discomfort, she should pump or manually express milk.
Warm compresses will aid the letdown and soothe the breast.