Breast Exam and Assessment
Breast Changes in Pregnancy
- Mammary growth and development are essential elements of pregnancy in order for the newborn to be provided with nourishment in the postpartum period. Throughout pregnancy the mammary exocrine glands, composed of ductal, epithelial and myoepithelial components, all undergo hyperplasia or enlargement in order to prepare for lactation.
- Most women have the ability to produce a sufficient milk supply for their babies. Neifert estimates that “5% of women may have primary insufficient lactation because of anatomic breast variations or medical illness that make them unable to produce a full milk supply despite heroic efforts.”9
Mammary changes during pregnancy
- The increases in ovarian and placental estrogens and progestins are responsible for the mammary changes during pregnancy. Breast changes throughout the first half of pregnancy are a result of proliferation of the alveolar epithelial cells, the formation of new ducts, and the development of lobular architecture. During this time, as the ductal and lobar epithelium proliferates, the breast will enlarge. Along with breast enlargement in the early stages of pregnancy, the areolar skin will darken, and Montgomery’s glands will become prominent.
- Towards the end of pregnancy, proliferation of the alveolar epithelial cells will decline, and the epithelium will begin to differentiate for secretory activity. Fat droplets will accumulate in the alveolar epithelium and colostrum will fill the alveolar and ductal space in the 3rd trimester. In late pregnancy, prolactin stimulates the synthesis of milk fats and protein.
- At the end of pregnancy, each breast will gain up to 400 grams due to retention of water, electrolytes and proteins along with the proliferation of ductal and lobar epithelium. The deposition of fat and hypertrophy of connective tissue add to the weight gain. Furthermore, blood vessels hypertrophy and increase the blood supply twofold during pregnancy.
The Academy of Breastfeeding Medicine Protocol Committee, along with the U.S. Department of Health and Human services, recommend the following when conducting a physical examination during pregnancy19:
- Observe for appropriate breast development, surgical scars, and nipple contour.
- Perform areolar compression if nipples are flat or inverted.
- Review the physiologic changes of pregnancy such as volume growth and leakage of colostrum.
- Consider repeating the breast examination in the third trimester as breast anatomy will change throughout pregnancy.
- Assure the expectant mother that her anatomy is sufficient for successful breastfeeding or discuss the availability of support and assistance if suggested by physical exam.
The following anatomical concerns should be discussed with the patient and other members of the healthcare team as they indicate a potential concern for milk production16:
- Absence of breast changes in pregnancy or early days postpartum.
- No postpartum breast fullness or signs of milk changing from colostrum to mature milk.
- Unilateral underdeveloped breast or marked that asymmetry may indicate inadequate glandular tissue in one or both breasts.
- History of previous breast surgery (see sidebar)
Breast shells should not be used in the third trimester to promote correction of inverted nipples because their use has actually been shown to reduce the success of breastfeeding. In the same study, exercises to evert the nipples were shown to have no effect on breast-feeding success.16 Postpartum eversion techniques such as shells, everters, shields and pumps have not been studied in prospective experimental controlled studies. Women with inverted nipples should be counseled that breastfeeding will be assessed in the immediate postpartum period and that referral to a lactation specialist may be necessary to establish an appropriate plan of care for her and the newborn.
Each breast is composed of 15 to 25 lobes arranged radially and separated by varying amounts of fat and connective tissue mixed throughout the breast. Each lobe is composed of lobules which are made up of large numbers of alveoli. An alveolus is made up of secretory epithelium, also known as myoepithelial cells, which synthesize the various milk constituents. The last layer surrounding the alveolus is the capillary network. The arterial blood supply to the alveolus is identified by the upper right arrow and venous drainage by the arrow beneath. Each alveolus has a duct that will join other ducts to form a single duct for each lobe. This ductal system will eventually empty the milk components through the nipple.21 (Williams Obstetrics, 23e, Chapter 30. The Puerperium)
Impact of breast surgery on breast feeding
Any breast surgery or injury may adversely impact breastfeeding. Breast surgery and injury may affect the anatomy needed for milk production, namely affecting the amount of sufficient glandular tissue and intact nerve pathways and milk ducts. In order to properly counsel the mother, a detailed history regarding surgery or injury, and a proper assessment of innervation and sensation must be accomplished.
- Reduction Mammoplasty
Many women elect to have breast reduction surgeries to reduce the volume of the breast due to a range of symptoms patients with large breasts may experience. Reduction mammoplasty patients are likely to have some difficulty producing enough milk, especially with periareolar incisions. There are many different types of breast reduction surgical techniques; the inferior pedicle technique may have a lesser impact on milk supply and is the most common technique in North America. This technique involves moving the intact areola and nipple to a higher position on the breast while maintaining the attachment to underlying tissues through a pedicle which contains intact ducts, nerves, and blood supply.20
Stanford University reports that women with reduction mammoplasty surgery can still feel their milk “come in” and can easily express small volumes. Due to the disruption of the collecting system, it is the exceptional mother who can exclusively breastfeed. This may be a risk for any mother with periareolar incisions. Mothers should be encouraged and taught proactive measures to maximize production, and yet be provided with realistic expectations, close follow-up, and clear indications of inadequate milk intake.
Stanford University recommends that, “for mothers with breast reduction, the ultimate potential for exclusive breastfeeding can be increased by practicing both breastfeeding 8-12 times per day as well as hand and pump expression for the first 3-5 days. The frequency of milk expression during the first five days is more important than the duration of nursing or pumping in determining ultimate milk production capacity.”
Stanford University also has a suggested script to use with mothers who have undergone a reduction mammoplasty:
"Some of the newer techniques for breast surgery enable some mothers to exclusively breastfeed, but this is not the rule. How we handle these first three days can make all the difference in how much milk your breast can ultimately produce. The best strategy is to increase the number of times we express small volumes of milk from the breast in the first 3 to 5 days, beginning on the first day. For example, every waking hour, hand express small volumes of milk from each breast for about 5 minutes. In addition to this, breastfeed frequently, 10-12 times per day, instead of the usual 8 times. You need to see your baby’s doctor if your baby is not having several liquidy, bright yellow bowel movements a day by the 4th to 5th day. In fact, it might be best to have your baby checked out when he’s about 3 days old. Have your doctor keep a close eye on your baby’s weight for the first two weeks."
- Augmentation Mammoplasty
Breast implantation or augmentation mammoplasty techniques have improved tremendously and are often compatible with successful breastfeeding. Many women who choose to have this procedure can still successfully lactate and exclusively breastfeed. As long as the surgery incision is not periareolar, there should not be any loss of integrity to the breast tissue or interruption of ducts, nerve supply, or blood supply to the gland or nipple. When implants are placed with a periareolar approach, concern centers on storage capacity reduction, damage to nerves and damage to ducts. The reason for augmentations should be explored. Sometimes women have underlying reasons such as minimal breast changes in adolescence or discrepant breast sizes that could cause poor milk production.
Complications for mothers with breast implants include possible engorgement and impairment of milk removal, compromising milk production. Stanford University recommends preventative measures mainly focusing on breast emptying. For mothers with breast augmentation, they suggest to teach hand expression and to stress the importance of frequent, effective nursing and emptying, especially between the 3rd to 5th days. Due to a risk of impairment of milk removal, these breastfed infants necessitate a close follow-up and mothers need to know clear indicators of suboptimal milk intake.22
Stanford University has a suggested script to use with mothers who have undergone an augmentation mammoplasty:
"When your milk comes in, in larger volumes, around the 3rd or 4th day, you may experience more pressure. During this time, the implants can make it a little more difficult for the milk to flow freely. We need to practice hand expression now, so that when you start feeling full, you’ll be an expert at getting the milk to flow. The plan is to keep milk moving through the breast every few hours – day and night. Any time you start to feel fullness, hand express a bit of milk, waken the baby to feed and then hand express again. This will make it much easier for your baby to nurse and more comfortable for you."
- Other Breast-Related Interventions
- Lumpectomy or Biopsy may affect breastfeeding if significant nerves or ducts have been removed.
- In terms of previous treatment for breast cancer, radiation after lumpectomy may interfere with lactation. The mother can usually breastfeed on an unaffected breast.
- The circumstances vary in terms of burns, trauma, and chest tubes, however, many people with severe trauma and burns to the breast have been able to breastfeed with success.
- Pierced nipples are not associated with breastfeeding difficulties. Nipple piercings should be removed before feeding.23