Vascular Engorgement. The word "vascular" describes a part of the body that has a rich blood supply with lots of blood vessels. Once the placenta has been delivered, the hormone prolactin starts to work. Under its influence, the breasts are prepared for milk production, which takes the shape of a huge increase of blood to the area.

This may happen at about 2-4 days after birth and is a normal event. ( RCM, 1991). There is no particular treatment for this type of engorgement, which should disappear after a few days. Take Paracetamol if your breasts are very painful. Also, wear a well-fitted bra so that your breasts are well supported. When buying a bra try to go to a shop or a department store that will measure you properly and take into account the increase in the size of your breasts once you start to feed. It may cost a little more but it’s worth it.

Try cold compresses using a flannel or a terry nappy. You could try cabbage leaves. (Inch and Fisher, 2000). White or Savoy cabbages are best as they offer a good fit. Put a cup shaped leaf inside your bra (the colder the better so keep refrigerated), it is really soothing. You may smell like coleslaw for a while but who cares if it works!

Feed baby on demand as usual. Allow baby to feed whenever and for as long as she wants to. You may find that your nipples are swollen making it more difficult to get the baby latched on –so be careful. You don’t want sore nipples on top of sore breasts! Try to smooth away the swelling from the areola up towards the breast before you feed.

Milk engorgement, however, occurs later when the milk has come in. It happens when the supply of milk stored in the breast isn’t removed sufficiently well to empty the breast properly. It may happen if baby hasn’t been able to feed at the breast freely or (and dare it be mentioned again) if the baby isn’t latched on properly (sorry!) Your forgiven for yawning but when baby is positioned correctly at the breast it stimulates the release of oxytocin which pushes the milk forward from where it is stored in the deeper part of the breast. The breast empties as the baby feeds. If the let down reflex is poor or absent then the milk remains in the breast and eventually the volume of milk becomes too much for the breast to store comfortably. (Inch and fisher, 2000).

Unfortunately, if the engorgement is prolonged this condition will begin to affect your milk supply and may cause mastitis (an inflammation or infection of the breast). It is vital that you seek help from your midwife or someone who is trained to help women with breast feeding problems (see info section). You may find that occasionally your breasts feel very full and tender especially if baby has slept for longer than usual or is having a "content" day. This is perfectly normal and illustrates the changes in baby’s appetite day to day. What isn’t normal is an unsettled baby and you with very full breasts-that’s when you need help, unless you are able to sought the problem out yourself. So here goes:

First of all check baby’s position on the breast. Are the lips curled outwards?

Is most or all of the areola (the pigmented surrounds of the nipple) in baby’s mouth? When baby sucks can you see the jaw’s movement leading up towards the temple? Is baby settled when feeding? Make sure that baby’s grip on the nipple is firm but comfortable. Is baby able to feed freely both day and night? If baby were unable to do so, that would cause a backlog of milk in the breasts. If you are supplementing the baby with formular milk that again would "confuse" the breast. The problem may be very easy to remedy on your own but if you are stumped get a trained supporter or midwife to help.

If you are certain that the baby is latched on properly then there are a few things you can do to ease the discomfort. However, the problem will return if the cause of it is still present, and the main causes tend to be a poorly positioned baby (managed to sneak that one in unnoticed!) or the restriction of feeds. So, here are a few useful hints to help ease milk engorgement:

• If you are finding it difficult to attach the baby to the breast because the nipple is swollen, smooth away the swelling towards the breast to soften it slightly and this should make it easier for baby to get on. (Inch and fisher, 2000).

• You may need to express some milk off to soften the breast either by hand expression or a pump especially if the breasts are becoming inflamed. Gentle expression is what is called for and generally once will suffice but it is possible that it may need repeating. (Thomson et al, 1984). To hand express gently but firmly massage the breast from the top towards the nipple moving over the whole breast (not forgetting the area underneath). Use small circular movements. Apply hot flannels before you start to help the milk to flow. Then carefully place the fingers of one hand below the nipple on the margin where the areola meets the skin of the breast. Your thumb is placed above the nipple in the same way. You should be able to feel the lactiferous sinuses (temporary storage spaces for the milk-it’s these that baby squeezes when feeding) like soft beads.  With your fingers in the correct position push backwards into your ribs. The action then is a rolling and squeezing of your fingers and thumb together. You have to be gentle so as not to bruise the delicate breast tissue inside and avoid rubbing the skin, as the friction will make the area sore. It may take a little while to get the milk to flow but keep squeezing as described and eventually milk will appear. Work one breast then the other. Keep working each breast in turn until the milk stops flowing. If you want to save the milk, use a sterile container to catch the drips and squirts. If not, soak it up on towels or try expressing in the bath. The heat of the water will help in the same way as the hot flannels. Just a quick word – there is a knack to this. Be patient and relaxed and work methodically. Rotate the finger position around the nipple (to get all the stores of milk from the ducts), push into the ribs and roll the fingers. You may also have to repeat the massage to encourage the milk to flow again.
  
• Make sure that baby feeds from one breast each feed. (NCT, 1987). This way baby will receive the complete "meal" and empty your breast. When the baby gets bigger the other breast may be offered but remember to offer that breast next feed so that it too has a chance to be empty.
  
• Take something for the pain. Paracetamol is safe to take when breastfeeding. If you want to take anything else, check first with your midwife, GP or pharmacist.

• Try the cabbage leaves and /or the cold flannels to help soothe the discomfort.

• Wear a bra that fits properly. If the bra is too tight not only is it uncomfortable but it may also pinch the breast and trap pockets of milk adding to your engorgement if not creating it. Perhaps causing mastitis too (inflammation or infection of the breast).

• The breast is in sections or lobes on the inside so it is possible to have the majority of your breast soft but one section or area lumpy. Whilst baby is feeding, gently massage the area and release the "knot" of milk so that baby can remove it. Small, gentle circular movements over any lumpy areas should suffice. It is a good idea to check your breasts after each feed. The one that you have just fed from should feel evenly soft. The breast that is to be used for the next feed will probably feel heavier as you would expect.

MASTITIS

There are 2 kinds of mastitis. Non-infective mastitis is inflammation of the breast. That means that there is no bacterial infection in the breast but in infective mastitis, there is. Unfortunately, to distinguish between the two you would need to send a sample of milk to the lab so that any bacteria could be grown or white blood cells counted. This could take days and in the mean time you could become quite ill. Your GP will prescribe antibiotics that are safe to take whilst breast-feeding. KEEP FEEDING ON DEMAND AS USUAL. If you don’t your breasts may develop a more serious problem (Marshall et al, 1975) and, frankly, it is unnecessary to stop, the milk hasn’t become poisonous!

Signs and Symptoms

You will have a temperature and your pulse may be fast. A red, painful patch on one or both of your breasts should be visible although it is not always easy to see on yourself. You may not feel well either, similar to the flu: aches and shakes.

The Causes

For non-infective mastitis the cause is usually due to milk engorgement and can be prevented in the same way i.e. making sure that the breast is properly emptied.

Infective mastitis means that bacteria have managed to travel into the working part of the breast, generally through a break in the skin of the nipple. Other reasons include:

• A deficiency of iron, which may affect the way your body fights off infection. (Minchin, 1985), and poor nutrition. (Miranda et al, 1983).

• The use of creams and sprays on the nipples as these may affect the friendly bacteria, altering the balance allowing the harmful bacteria a chance to multiply and, given an opportunity, cause problems. (Inch, 1987).

• Non-infective mastitis that has not been adequately treated may develop into infective mastitis. (Thomsen et al. 1984).

Try to work out why you have developed a problem with your feeding. It may help you to resolve this hiccough and prevent future episodes.

You’ll have probably read the above and thought "hell’s teeth" or words to that effect! But knowing what could happen and how to deal with it or to contact people to help if you are unable to, is what this web site is all about. Don’t panic if you become engorged or even if you develop mastitis. Contact your midwife or GP and be reassured by knowing the solution to the problem too.

References.

Royal College of Midwives, 1991. Successful Breastfeeding. Second edition. Chapter 6. Pages 60-61.

Inch S and Fisher C, 2000. Breastfeeding: early problems. The Practising Midwife. 3(1): 12-15.

The National Childbirth Trust, 1987. Breastfeeding- Too much milk? Page 6.

Marshall BR et al, 1975. Sporadic Puerperal Mastitis. Journal of the Medical Association.

233(13): 1377-1379.

Minchin M, 1985. Breastfeeding Matters. Allen and Unwin, Australia. Page 163.

Miranda et al, 1983. Effects of Maternal Nutritional Status on Immunological Substances in Human Colostrum and Milk. American Journal of Clinical Nutrition. 37:632-640.

Inch s, 1987. Difficulties in Breastfeeding-Midwives in disarray? Journal of the Royal Society of Medicine. 80:53-57.

Thomson AC et al, 1984. Course and Treatment of Milk Stasis, Non-infectious Inflammation of the Breast and Infectious Mastitis in Nursing Women. American Journal of Obstetrics and Gynaecology. 149(5): 492-495.