INTRODUCTION:

Breast engorgement occurs in the mammary glands due to expansion and pressure exerted by the
synthesis and storage of breast milk. It is also a main factor in altering the ability of the infant to
latch-on. Engorgement changes the shape and curvature of the nipple region by making the breast
inflexible, flat, hard, and swollen. The nipples on an engorged breast are flat or inverted. Sometimes
it may lead to striate on nipples, mainly a preceding symptom of septation mastitis.[1]
Engorgement usually happens when the breasts switch from colostrum to mature milk (often referred
to as when the milk "comes in"). However, engorgement can also happen later if lactating women
miss several nursing and not enough milk is expressed from the breasts. It can be exacerbated by
insufficient breastfeeding and/or blocked milk ducts. When engorged the breasts may swell, throb,
and cause mild to extreme pain.
Engorgement may lead to mastitis (inflammation of the breast) and untreated engorgement puts
pressure on the milk ducts, often causing a plugged duct. The woman will often feel a lump in one
part of the breast, and the skin in that area may be red and/or warm. If it continues unchecked, the
plugged duct can become a breast infection, at which point she may have a fever or flu-like
symptoms.

Mature female breast engorged during nursing phase

.
ANATOMY OF NORMAL BREAST
 BREAST ENGORGEMENT DEFINITION
It is the swelling of the breast due an increase in blood and lymp supply as a precursor to
lactation
OR
Breast engorgement occurs in the mammary glands due to expansion and pressure exerted
by the synthesis and storage of breast milk
CAUSES:
MATERNAL CAUSE:
• a) Due to exaggerated normal venous & lymphatic engorgement of the breast.
• b) May occur if feeds are delayed or restrict as a ed.
• c) When the baby is unable to feed efficiently:-
• Due to incorrect attachment.
• Due to congenital abnormality e.g. cleft lip or palate, esophageal atresia, etc.
 Onset :-
• It occur most commonly on 3rd or 4th day postpartum.
• Symptoms of breast engorgement:-
• Edematous & flushed breast
• Considerable pain & feeling of tenseness or heaviness in both the breasts.
• Painful breast feeding.
• Generalized malaise.
• Transient rise in temperature.
PREVENTION
• Avoid prelacteal feeds.
• Initiate breast feeding as early & unrestricted.
• Exclusive breast feeding on demand.
• Feeding in correct position.
• If any feedings are missed, express (pump) the milk from the breast, and when weaning
is started to the baby, do so gradually.
• Avoid bottles, pacifiers and nipple shields. These may cause nipple confusion/preference.
STEPS OF PROPER LATCHMENT:

1 Steps to a Good Latch:

 1. Make the mother Comfortable

Mother can breastfeed sitting up or lying down. Mother may find it easier to breastfeed if she is
sitting in a chair with a foot stool, to lift the feet. Lying on side is helpful if she had a cesarean
birth.
The baby needs to be very close to mother, so remove any clothes, hats, mittens or blankets
between mother and her baby.
If she have pain from the birth, analgesics may be given to mother. It is important to be comfortable
while breastfeeding.
2. Hold Your Baby Close for Feeding
The pictures show different ways to hold baby for feeding. In all positions, baby's tummy should
be against mother.

Wrap baby’s body and legs around you. This is called

'tummy to tummy'.

In this position, the baby will be at mother side, with his

head higher than the rest of his body. His tummy touches
the side of mother’s chest.
 In this position, the baby is tucked in close to you, tummy
to tummy. Lying on side may allow you to get more rest.

2. Support the Breast

it may be helpful
to shape your breast to fit the oval of your
baby’s mouth.
1. Make sure that bottom fingers of mother are
away from the areola (the darker circle
around your nipple) and out of the way of the
baby’s chin. Once your baby is latched on and
feeding well, you may not need to continue
holding your breast.
2. Cup breast with mother’s free hand. Gently
squeeze the breast from top to bottom, or side to
side, to shape it. This will depend on how
you are holding your baby. Do not pinch the breast.

4. Support Your Baby's Neck

With other hand, support the base of the baby's head. The palm of this hand should be supporting
baby’s shoulders.
The baby’s head should be tilted back slightly. Be careful not to push baby’s head into your breast.
The nipple should point towards your baby's nose.
5. Wait for a Wide Open Mouth and Pull Your Baby Close

3. Tilt the baby’s head back slightly so his chin touches

the underside of breast. The nipple should be sitting
slightly above the baby's upper lip.
4. Wait for the baby to open his mouth wide with his
tongue forward and down. Baby’s mouth should look like
he/she is yawning.

o As soon as baby's mouth is open wide, aim nipple to

the roof of his mouth and quickly pull him towards you.
Move baby's head and body together in a straight line. Your nipple and areola should be in
his mouth. His chin should be touching the mother’s breast.

If baby does not open wide, it may help to express a few

drops of milk down to the end of nipple.

Be patient. Keep the baby’s body, including his hips,

close to mother. Baby will be able to breathe easily while
breastfeeding.

PREVENTION
Aim:-
• The management is aimed at enabling the baby to feed well.
Measures and Nursing Responsibility:-
Manual expression any remaining milk after each feed.
  Use gentle massage, deep breathing, soft music or other relaxation techniques before and
during nursing.
 The baby should be put to breast regularly at frequent interval.
 Hot fermentation or hot water bottles can be put on the breast to reduce congestion along
with hand-expression of milk which will soften the areola, making it easier for the baby to
latch-on to your breast.
STEPS OF MANUAL EXPRESSION OF BREAST MILK

1. Wash your hands. Your hands should be washed before you attempt to hand express breast
milk. If you washed your hands with cold water, let them warm up before touching your
breasts. Cold hands can cause the process to take longer than warm hands. If it's your first time
and you're feeling uncertain, you can also ask for help from a nurse, or even get some help
from your partner.
2. Put a cloth moistened with warm water over your breast for 2 minutes. This can help
with the expression of milk. Though it's not necessary, it certainly won't hurt the process.
3. Give your breasts a massage. If you want to prime your breasts for hand expression
further, you can give your breasts a gentle massage using your hands or a soft towel. Just
gently knead and massage the skin around both nipples to help your breasts relax and get
ready to produce milk.
4. Sit up and lean forward. This position will make it easier for you to express your milk
and to stay comfortable during the process. You won't express as much milk if you're
standing or lying down
5. Position your fingers over the milk reservoirs on your breast. You should position your
hands in a "C" above or below your nipple. Here's what you should do:
 Put your thumb above your nipple. It should rest approximately 1 inch (2.54 cm) above your
nipple.
 Place the first 2 fingers of your hand 1 inch (2.54 cm) below your nipple directly in line with your
thumb.
 Adjust your finger placement for comfort and your breast size.
 Refrain from cupping your breast in this position.
6. Apply pressure inward toward your chest wall. The pressure should be gentle and firm,
but should not feel like you are squeezing the breast at all. Avoid tightening or stretching
your skin over the areola, because this will make it more difficult to express the milk. Press
your thumb and index finger directly back into the breast tissue, into the wall of the chest.
Here are some other things to keep in mind:
*Remember to press back, not out, and to roll your fingers, not slide them.
*Roll your thumb and fingers forward so that you squeeze the milk out of the milk sinuses, which
are found under the areola, under the nipple.
*Keep fingers together. Spreading your fingers out reduces the effectiveness of the process.
*Lift larger breasts before applying pressure.
7. Express breast milk. Use a rolling motion away from your body with your thumb and fingers.
Compress your breast with this rolling motion. As the saying goes, you should press, compress,
and then relax. Once you get used to it, you should be able to fall into a rhythm, as if the baby were
nursing, which will help you express your breast milk more easily.
 Every woman's breasts are different. It's up to you to find the best position that helps you express
the most milk.
 You can also experiment with expressing your breast milk, massaging, expressing your milk, and
massaging again.
8. Collect the expressed breast milk in a container. If you're expressing just to make your breasts
feel more comfortable, you can express the milk into a towel or just express it over a sink. Here are some
things that you can do if you do want to save the milk for later use:
 Utilize milk bags to collect the expressed milk.
 Express the milk directly into bottles for later use.
 Use a funnel to direct the breast milk into your chosen container, if necessary.
 Use a container with a wider mouth, such as a coffee cup or a small jar. Once the cup is filled,
transfer the milk into a storage container.
9. Repeat the process on the other breast. Change positions slightly on each breast to completely
express all milk. Moving back and forth between the breasts will stimulate even more expression of milk.
In severe case gentle use of breast pump may be helpful. Excessive expression of milk will
stimulate the production of oxytocin & prolactin thus increasing the engorgement & delaying the
suppression of breast milk.
 If the nipples remain flat, wear multiple-holed breast shells for half an hour before
breastfeeding. This will help draw out the nipple, making it easier for the baby to latch-on.
 Icy cold compresses applied to the breasts can relieve discomfort and swelling after
breastfeeding.
 Administer analgesic for pain as per the physician order.
 Recently cabbage therapy is becoming popular for the relief of engorgement.
How to use of cabbage leaf compresses
 Purchase a head of common green cabbage at the grocery store.
 Remove the core and gently peel individual leaves away from the center of the head pulling
outward.
 Thoroughly wash the leaves.
 ..
 Leaves can be chilled in the refrigerator for extra benefits. Cool compresses tend to relieve
swelling more effectively than warm compresses. Some women find that crushed ice
placed over the cabbage leaves also helps.
 Just before use, crush the veins in the leaf with a rolling pin (or similar object), or slice off
the tops of the "veins" with a sharp knife.
 Drape several leaves over each breast. Use enough to cover ALL the engorged tissue,
including any swollen tissue under your arms.
 Leave the compress on until the leaves become wilted, about 20 to 30 minutes.
 Repeat application of cabbage leaves three or four times (about every 4 to 6 hours) per 24
hours, until engorgement subsides.
 For the mother who is not breastfeeding, continuous cabbage compresses can also be used
to help reduce the swelling in her breasts.
 Discontinue direct use immediately if skin breaks out, blisters, or becomes irritated.
 Place the leaves so they do not touch any already irritated areas, or broken skin.
 Note:-The mother’s fluid intake should not be restricted, as this has no direct effect on the
production.
RESEARCH ARTICLE
CONCLUSION
 Breast engorgement is a common problem after birth and during breast-feeding. It can be
prevent and treat at home. Mother do not need to visit the doctor. Breast feeding is currently
the most reliable, economical and safe medicine available for "drying up" the breasts and
preventing breast engorgement.

1. A Study to assess the effectiveness of cabbage leaf application (treatment) on pain and
hardness in breast engorgement and its effect on the duration of breastfeeding.
Abstract
BACKGROUND:
Breast engorgement is a condition that affects breastfeeding mothers early in the postpartum. The
discomfort and tenderness as a result of the engorgement is a major contributing factor to the early
cessation of breastfeeding. Many treatments for breast engorgement have been attempted and
explored.
OBJECTIVE:
To examine the effectiveness of cabbage leaf treatment on pain and hardness of the engorged
breasts of post-partum women and its influence on the duration of breastfeeding in women with
breast engorgement.
INCLUSION CRITERIA:
Postpartum lactating mothers 13 to 50 years of age and of any parity in the first two weeks
postpartum with breast engorgement.Cabbage leaf treatment on breast engorgement in reducing
pain, hardness and increasing the duration of breastfeeding.Primary outcomes: engorgement,
severity of the distention, hardness to touch and pain associated with breast engorgement.
Secondary outcome: duration of breastfeeding.Quantitative studies including RCTs, quasi-
randomized trials and quasi-experimental studies.
SEARCH STRATEGY:
Studies in English language from inception of the relevant databases to 2010 were considered for
inclusion in this review.The databases searched included: CINAHL, MEDLINE, SCOPUS,
EMBASE, Web of Science, Science Direct. The search for unpublished studies included: Google
Scholar, Mednar, Proquest.
METHODOLOGICAL QUALITY:
Studies were assessed by two independent reviewers for methodological validity using
standardised critical appraisal tools from the Joanna Briggs Institute.
DATA EXTRACTION:
Data were extracted using the standardised data extraction tools from the Joanna Briggs Institute.
DATA SYNTHESIS:
The results were presented in narrative format as the meta-analysis was not appropriate because
study methods were heterogeneous.
RESULTS:
Four studies were included in this review: one RCT and two quasi-randomized studies and one
quasi-experimental study. In one RCT after the first cabbage leaf application, fewer mothers were
reporting breast engorgement through their second to fourth assessments as compared to the
control group. On the second assessment a smaller proportion in the intervention group thought
their breasts were engorged (51% vs 57%, p = 0.68). In one study the experimental group receiving
cabbage leaf treatment improved from a pre-treatment score of 5.17 (70%) to 3.02 (20%) (p
=<0.001). In addition, hot and cold compresses appear to reduce scores more effectively than cold
cabbage leaf (p<0.001). In one study both cabbage leaf and hot and cold compresses interventions
decreased numerical pain scores (p≤0.001) and thus pain in breast engorgement. In a study results
showed statistically significant reduction in pain scores for both room temperature 2.0 points
(37%) and chilled cabbage leaf 2.1 points (38%) (p=0.0001). There was no statistical difference in
mean pre and post treatment scores of room temperature and chilled cabbage leaf (p=0.84).In one
study pre and post treatment scores using the Bourbonnais scale showed a statistically significant
reduction in pain scores: 1.8 points (30%) with cabbage leaf and 2.2 points (39%) with gel packs
(p=0.0001). In one study it was found that 18% more mothers who received the cabbage leaf
intervention were exclusively breastfeeding at six weeks (p= 0.09). Less mothers had stopped
breastfeeding prior to eight days (8.88% vs 24% p= 0.09) and overall duration of breastfeeding
was longer in the intervention group (36 vs. 30 days, p=0.04).
CONCLUSION:
Overall results showed that cabbage leaf treatment used on women with breast engorgement did
reduce pain, the hardness of the engorged breasts and increased the duration of breast feeding. The
current available evidence suggests that cabbage leaf treatment helps reduce pain in breast
engorgement and lengthens breastfeeding duration, although some studies have also report that
cabbage leaf treatment is not effective. Cabbage leaf may be useful in the treatment of breast
engorgement. The chilled cabbage leaf may be used for breast engorgement in breastfeeding
women but there is insufficient evidence to suggest the generalized use of cabbage leaf in protocols
for the treatment of breast engorgement. Researchers should aim to achieve more homogeneity
across the studies by using similar tools and instruments (preferably validated) to compare the
effectiveness of cabbage leaf treatment; measuring similar outcomes (i.e pain scores, breast
engorgement scores, duration of breastfeeding).

2.A study to assess comparison of cabbage leaves versus hot and cold compresses in the
treatment of breast engorgement

Objective: To assess and compare the efficacy of cold cabbage leaves and hot and cold
compresses in the treatment of breast engorgement. Material and Methods: This was a quasi-
experimental study conducted in the postnatal ward of the All India Institute of Medical Sciences
(AIIMS), New Delhi. The study comprised a total of 60 mothers; 30 in the experimental group and
30 in the control group. The control group received alternate hot and cold compresses and the
experimental group received cold cabbage leaf treatment for relieving breast engorgement. The
pre- and post-treatment scores of breast engorgement and pain were recorded. The data were
analyzed using descriptive and inferential statistical methods using the statistical software
STRATA.

Results: Both the treatments, i.e., hot and cold compress and cabbage leaves were effective in
decreasing breast engorgement and pain in postnatal mothers (P ≤ 0.001). Cold cabbage leaves
and hot and cold compress were both equally effective in decreasing breast engorgement ( P =
0.07), whereas hot and cold compresses were found to be more effective than cold cabbage leaves
in relieving pain due to breast engorgement ( P ≤ 0.001) in postnatal mothers. Conclusion: Cold
cabbage leaves as well as alternate hot and cold compresses both can be used in the treatment of
breast engorgement. Hot and cold compresses are more effective in decreasing pain than cold
cabbage leaves in relieving pan due to breast engorgement.

Keywords: Breast engorgement, hot and cold compress, treatment

Introduction
Breast engorgement is a physiological condition that is characterized by painful swelling of
thebreasts as a result of a sudden increase in milk volume, lymphatic and vascular congestion, and
interstitial edema during the first two weeks following childbirth; this condition is caused by
insufficient breastfeeding and/or obstruction in milk ducts. Breast pain during breastfeeding is a
common problem that interferes with successful breastfeeding leading to exclusive abandonment
of breastfeeding. Over the years, numerous strategies for the treatment of this problem have been
employed such as kangaroo care, fluid limitation, binding the breasts or wearing a tight brassiere,
hot and cold compresses, and application of cabbage leaves. Very few researches have been
conducted to monitor the effect of cabbage leaves on breast engorgement with inconclusive and
conflicting results. A study on the efficacy of cabbage leaves can contribute to provide evidence
for introducing this intervention in clinical practice; thus, we conducted the present study.
Inclusion
1. Postnatal mothers with breast engorgement
2 .Willingness to participate in the study

Exclusion
1. Mothers with allergy to sulfa drugs and cabbage
2. Mothers with soft breasts; mothers receiving lactation suppressant
3. Mothers with infection in the breasts, breast abscess, mastitis, broken skin of breasts, bleeding
or cracked nipples
The subjects were enrolled based on the inclusion and exclusion criteria, and informed consent
was then obtained from them. The identification data and obstetric characteristics of each subject
were recorded in a validated subject data sheet. The study was conducted in two phases. In the first
phase, first 30 mothers in the control group were administered alternate hot and cold compresses.
Alternate warm moist sponge cloths and cold compresses were applied to the engorged breasts;
the cloths were replaced frequently after 1-2 min. This process was continued for 20 min. The
temperature of water for hot compress ranged between 43°C and 46°C, and that for cold compress
ranged between 10°C and 18°C as assessed by a lotion thermometer. After the completion of the
first phase, the next 30 mothers in the experimental group were administered cold cabbage leaf
treatment for relieving breast engorgement. Cabbage leaves were refrigerated in the freezer for
approximately 20-30 min prior to the procedure. Cold cabbage leaves were placed inside the
women's brassiere for 30 min. Both the treatments were performed three times a day for two
continuous days. This method was applied six times on each subject. The duration of each
intervention was 30 min. The pre- and post-treatment scores of breast engorgement and pain were
recorded after each treatment session. Breast engorgement was measured using a six-point breast
engorgement scale, and the pain score was assessed using a numerical rating pain scale. The data
obtained was processed in MS Excel sheet. The statistical analysis was performed using the
software STRATA.
RESULT
The two groups were homogeneous with regard to all demographic and obstetric variables as
analyzed by chi-square and Fisher's exact test except for breastfeeding for which adjusted analysis
using generalized estimating equations (GEE) was performed. By using the student's t test, no
difference was noted between the groups with regard to the pretreatment scores of breast
engorgement and pain. GEE was used to compare the correlated responses for the post treatment
scores for both the outcome variables between the two groups and to compare the pre- and post-
treatment scores within the groups. Both the treatments, i.e., hot and cold compress and cabbage
leaves, were effective in decreasing breast engorgement and pain in postnatal mothers Hot and
cold compresses were found to be more effective than cold cabbage leaves in relieving pain due
to breast engorgement ( P ≤ 0.001) in postnatal mothers.
CONCLUSION
Cold cabbage leaves as well as alternate hot and cold compresses both can be used in the treatment
of breast engorgement. Hot and cold compresses are more effective than cold cabbage leaves in
relieving pain due to breast engorgement.