THE PREVENTION OF : THE NURSING PROBLEM *

By EDITH C. THOMAS, R.G.N., S.C.M. Sister Midwife, Simpson Memorial Maternity Pavilion, Royal Infirmary, Edinburgh

ADMINISTRATIVE ARRANGEMENTS FOR THE CARE OF THE LACTATING MOTHER AT THE SIMPSON MEMORIAL MATERNlT* PAVILION. Ante-Natal Instruction

This was originally given by the Senior and Junior Medical Officers in Charge of the Clinic. As these Clinics have grown considerably that in numbers and the Medical Officers are very busy, it was found they tended to overlook the importance of the and were primarily interested in the detection of obstetric abnormalities. Since January 1947 there has been a sister at each ante-natal clinic whose sole duty it is to examine the breasts and to give instruction in preparation for lactation. The routine is as follows :? (1) All patients are seen at their first visit, the breasts examined ^ and the history of any previous trouble taken. note is made on the ante-natal card when to report again- the (2) Patients with tending to retract report back at twenty-eighth week, or earlier if retraction is very pr0' nounced. Thereafter they are seen at fortnightly intervals- (3) All other patients are seen at the thirty-second week. this way all patients have their breasts seen at least twice during pregnancy by the sister, and more often as need arises. (4) The sister is present at the Infant Welfare Clinics to help with breast-feeding difficulties after discharge from hospital- are The Lying-in Wards.?Apart from the ante-natal ward, there three normal wards, an isolation ward and one where women lying-in a with venereal disease are delivered and nursed. These each have 111 nucleus of permanent nursing staff, with personal variations technique, combined with frequently changing pupil midwives. There is a resident paediatric registrar and a staff of daily visiting paediatricians- the The actual conduct of breast feeding and the routine care of link breasts is very largely in the hands of the ward sister who is the the between the obstetrician (in charge of the mother's breasts) and paediatrician (in charge of the baby). The Infant Welfare Clinic.?Mothers living within easy reach

* Read at a meeting of the Edinburgh Obstetrical Society, 8th January 1947- 436 THE PREVENTION OF MASTITIS: THE NURSING PROBLEM 437

hospital bring their babies at regular intervals during the first ^ear life. Test feeding is arranged where necessary and a check is ePt on the baby's and the mother's health. A sister dietitian gives advice both here and in the ante-natal lnic and makes sure the mothers are obtaining all their priority l0ns. A lady almoner is also present to deal with social difficulties, arid arrange holidays at a convalescent home where needed. Importance of Breast Feeding.?Without entering into the old ?ntroversy of breast versus bottle-feeding, it may be taken that -ssful breast-feeding is the ideal at which to aim, largely because greater immunity to infection thereby conferred on the baby, great majority of hospital mothers will continue to breast-feed elr babies if they realise this, and above all, if we can initiate and mtain fetation and But we have no to painlessly adequately. right unless we take to rria adY0cate breast-feeding precautions prevent

^aUSes ?f Mastitis.?Mastitis is most often due to some lesion in thee surface of the , and the nipple with poor protraction is the f0rte. reac% damaged. This lesion commonly occurs in the first night, during or just after the first coming in of the milk (the

? r^ement when the is most to le stage) nipple prone damage. The afte?n .may ^eal an^ yet mastitis supervene some days later, often ha^" ^^charge from hospital. It has been suggested that the infection at the time damage took place and lain latent. ^nteredreast should be If there is there is d fading virtually painless. pain, either real or so that as in is ma?e potential, pain, always medicine, Warning. It is also no encouragement to a mother to continue east-feeding. careful ante-natal m Nipples.?However preparation, many ^amaSed6rS suffer from tender at some time the pue nipples during Even a lens it is not to see an PfriUm- through always possible but if is allowed to the lens Will abn?rmal, suckling continue, ater show (a) inflammation, (6) scattered petechise (often in a a or a raw area on the a 00 small blister, (d) nipple surface, ?r ^or in of the da entry every passing staphylococcus. If, spite the^6' SUc^in? is continued, a genuine will develop, Crack ?ften at one of the normal furrows in the situated the bottom of niPP^e> and recognisable by inflammation or bleeding. This may to beal. The crack at the base of the nipple is rel^,SeVera*lVely uncommon?it is the one which be attributed to thet-u only might baby's bite. of Cracked Nipple.?Nearly all damage to the ce nipple ls caused by suction. Generally speaking, the well-shaped elastic areola is sucked well back into the so t^6 baby's mouth, sens^ive has suction it. The po tip hardly any falling upon ^~^eve^?Ped nipple, with an inelastic areola, will remain in the front of the baby's mouth. In the same way, during the early days, v?l. liv. no. 8 2 E 2 438 EDITH C. THOMAS

engorgement of the breast prevents this elasticity of the areola, and if suckling is permitted, a damaged nipple is the invariable result. Both mothers and babies too, are often far from skilful and the baby not infrequently fails to open his mouth wide enough to obtain a g?? or the hold, the mother draws back, not realising that a firm grip on baby's part is the painless way. of A free flow colostrum in the first few days will act as a lubricant of in the process suckling and is the precursor of freely flowing milk- there will Consequently be less danger of engorgement, as the surpluS milk will tend to leak out.

Preventive Measures Ante-Natal. Waller holds that the ideal breast for feeding a baby a thin has (a) elastic skin, (3) a reasonable nipple with good protraction) an increase in (c) size in pregnancy equivalent to 2-4 inches in chest measurement, and (d) a supply of colostrum easily expressed fro111 several ducts. In this type of breast the milk will flow out easily and there is little risk of engorgement or cracked The " nipples. expelling mechanism or the draught reflex will come into action as early as tenth to fourteenth day. Ante-natal care can (a) improve the nipple protraction, (b) increase the ease of outflow of colostrum, and (c) render the unyielding breast somewhat more supple. (a) Depending upon the degree of retraction, glass nipple sheHs (Fig. 1) should be worn for the last three to four months of pregnancy- These shells were originally worn to protect the mother's clothing during lactation, but are extensively used by Waller for the correction of retracted nipples. They consist of circular glass cups with a centra1 over the hole fitting nipple (Figs. 2 and 3). Worn under a well-fitti^ brassiere, they apply steady pressure on the breast and areola. The woman is instructed to wear and them for a few hours daily at first, or then steadily all day. Most women wear them without discomfort protest, and after a few weeks the improvement is often astonishing- (b) and (c). As for increasing suppleness and ease of outfl0^ ante-natally, the woman is taught to massage the breasts nightly a little oil or liquid paraffin in the last couple of months. She encircles the breast far back with both hands, thumbs on top* fingers underneath, and slides them firmly from to areola periphery * about a dozen times. Then, supporting the breast with one hand) an little colostrum is expressed by pressure on the areola with finger ^ve thumb of the other hand. The whole procedure takes less than minutes daily and is easily taught. There is the added advantage that the woman can apply manual expression in hospital or after discharge as need arises. The fear that it might lead to premature labour appears groundless- If the nipple area seems dry-skinned, lanoline ointment is of use- m

Fig. i

Fig. 2 -

Fig. 3

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. ?^ap ?3lg

Fig. 4 THE PREVENTION OF MASTITIS: THE NURSING PROBLEM 439 In the Lying-in Wards.?On the day after delivery a supporting reast binder should be applied. The baby is put to the breast four- to six-hourly, and is allowed y a few minutes at each breast at first till the milk comes in. About same the second day the mother should begin to use the ?ast and This will ^ massage expression just before feeding-time. P to keep the breast tension low and the milk flowing freely.

. does as it does 0r engorgement occur, quite frequently overnight ln ^e space of an hour or two, suckling should not be allowed for fe r ?f till the tension can a nipple damage* subsides and the baby^ get good grip. either the mother herself or the nurse should gently j^a^eanwhile,a^G little milk can be for a fe breasts, though probably expressed UndW ^eec*s" ^he binder is firmly re-applied with rolls of cotton-wool cha^ kreasts if all pendulous. If permitted by the doctor in r^G' s^bcestrol 20 if there is severe en 5-10 mgm. (even mgm. very r^ement) given every four hours till ease is felt, is of very great Vaj^ The if curtailing of the engorgement time is of great importance t^e' m?ther is to her milk The tyjjj going preserve supply. stilbcestrol ai~np down milk secretion at 0r considerably first, but if expression, S??n as be the milk will rise a?a" possible, suckling continued, yield n?rma^ *n f?ur t? five days. e Th^0 COntrol of tension will lessen the possibility of nipple damage, be a no to rigid rule for nursing staff that baby is allowed there is by ,e pain with suckling. The breasts should be expressed that should never cause the mother Pain 4)?a procedure thin ^reast pump, working as it does by suction, does the very antif should be avoided. A sterile dressing, preferably with an ointment, should be kept over the nipples, and the baby giVer^P?lce breast milk by spoon or bottle till the nipple is-healed. Su of ?f Ante-Natal Instruction.?The above-mentioned methods instruction have been taught at one of the ante-natal clinicse-natala number of months, taking patients largely at random and -tyatch'0Verthe in The i^ ^ ln.^ sequel the several lying-in wards. management the ^SPlta* varied from ward to ward, and the figures refer purely to spent in 6 hospital. Controls were taken two wards?a normal and the t from lying-in ^?n Ward A certain ntimb (67 and 33 patients respectively). tra^ /r ^ pupil mothers developed puerperal pyrexia and were Thered t0 the IsoIation Ward- ti]j m?thers had to attend the sister on two or more occasions she ^Vas %h0 satisfied they were doing the treatment correctly. Those ^?r ?ne on^ (IO) an(^ ^id not reP0I"t back have not been ' Eluded16 ^erefore the mothers were anxious to f pupil presumably breast ' To by Jl offset this advantage, a certain number were referred edical Wii-k Officers on account of retracted nipples or difficulties Previous lactations. 440 EDITH C. THOMAS

Nature of Complications Observed.?(a) Damaged nipples, where suckling was temporarily suspended on this account ; (b) severe engorgement, i.e. breasts tense, hard and painful?baby unable i-e' suckle or obtaining negligible quantities of milk ; (c) mastitis, flushed area on breast and pyrexia ; (d) weaning of baby, because of breast difficulty or deficient lactation.

TABLE i Pupils. Controls. Symptom-free lactation 56 32 Complicated lactation 44 68

TABLE 2 Nature of Complications * Pupils. Controls. Damaged nipples ... 29 36 Severe engorgement ... 3 9 Mastitis ...... 6 Weaning of baby ... 4 9

* Numerous patients recorded under more than one heading.

TABLE 3 Adequacy of Lactation Pupils. Controls. Mothers discharged with adequate lactation 83 64 Mothers discharged with inadequate lacta- 13 27 tion?i.e. babies requiring a comple- mentary feed

Mothers lactating on discharge . . 96 91

TABLE 4 Treatment of Retracted Nipples Pupils. Successfully treated with nipple shells . . 6 Not successful ...... 1

? Comments on Tables.?To base results on such a small number cases as 200 is not ideal. in Especially is the incidence of mastitis _ Control group high ; 4 out of the 6 cases occurred in the Isola^011 Ward, and two of the patients were definitely debilitated. Even with careful ante-natal instruction, 44 per cent, of the mothe had difficulty with lactation, so that it is not an easy, natural functi01^a*1 Thus instruction must be combined with the most unremitting care vigilance in the early days after the baby is born.

Suggestions for Improvement in the Prevention of Mastitis

More in . (1) attention the ante-natal period. j (2) Very much greater care in the puerperium, possibly supervise by the paediatrician. PROBLEM 441 The PREVENTION OF MASTITIS: THE NURSING cessation of suckling, I (3) Prompt treatment of painful nipple by at each ee mg lme. sterile dressing, and manual expression of breast much enco ? Ferlie, Matron, S.M.M.P., for Acknowledgements.?'Miss is for to wor' in rnent; Emeritus Professor permission - Johnstone, o *atal McNeil for his unfailing support clinic; Emeritus Professor ^ their wards > Ceding; The Ward Sisters for permission to visit patients in Mothers and Ba , Jove all, Dr Waller and Sister Grose of the British Hospital for Woolwich.

REFERENCES Edinburgh.) ^o-Natal Deaths due to Infection (1947). (H.M. Stationery Office, Waller, Harold. Clinical Studies in Lactation. Heinemann, 1938. " Breast Arch. WALLer, Harold (March 1946). The Early Failure of Feeding, Ch., (I946), 21, 1.