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Post Partum Period

Post Partum
Begins immediately after child birth
through the 6th post partum week
Reproductive track returns to
nonpregnant state
Adaptation to the maternal role and
modification to the family system

Safety for Mother and Infant


Prevent infant abductions
Check ID bands
Educate mother about safety
measures

Clinical Assessment
Review Antepartum and Intrapartum
history
Receive report
Determine educational needs
Consider religious and cultural factors
Assess for language barriers

Post Partum Assessment


BUBBLE-HE

Breast
Uterus
Bladder
Bowel

Lochia
Episiotomy
Legs
Emotion

Early Assessment
Vital signs
Temperature
Pulse
Blood pressure
Respirations

Breast Assessment
Inspect for size, contour, asymmetry
and engorgement
Nipples check for cracks, redness,
fissures
Note if nipples are flat, inverted or
erect
Evaluate for mastitis

Nursing Care
Lactating Mother

Supportive bra
Correct position
Correct latch-on technique
Warm showers
Expose to air

Nursing Care
Non-Lactating Mother

Avoid stimulation
Wear support bra 24hrs
Ice packs or cabbage leaves
Mild analgesic for discomfort

Assessment of Uterus

Location immediately after birth


Descends 1 cm/day
Consistency- firm/boggy
Location Height- measured in
fingerbreadths

Nursing care
Boggy fundus- massage until firm
Medications- Pitocin, Methergine,
Hemabate
Teach new mom to massage her
fundus

Afterpains
Intermittent uterine contractions due
to involution
Primiparous-mild
Multipara- more pronounced

Nursing Interventions
Patient in a prone position and place a
small pillow under her abdomen
Ambulation
Medicate with a mild analgesic

Bladder
Spontaneous void 6-8 hrs
Monitor output
Postpartum Diuresis

Nursing care
Encourage frequent voiding every 4-6
hours
Monitor intake and output for 24 hrs
Early ambulation
Void within 4 hrs after birth
Catheterize if unable to void

Bowel

Anatomy returns to normal location


Relaxin depresses bowel motility
Diminished intraabdominal pressure
Incontinence if sphincter lacerated
Spontaneous BM 2nd 3rd post
partum day

Nursing Care

Increase fiber in diet


6-8 glasses of water or juice
Stool softener
Laxative
Sitz bath for discomfort
Medications for hemorrhoids

Lochia
Mixture of erythrocytes, epithelial
cells, blood, fragments of decidua,
mucus and bacteria
As involution proceeds it is the
necrotic sloughed off decidua
240-270 ml
Cesarean less
Present for 3-6 weeks

Lochia

Rubra
Serosa
Alba
Documentation

Nursing Care
Educate mother on the stages of lochia
Caution mother that an increase, foul odor
or return to rubra lochia is not normal
Instruct patient to change peri pad
frequently
Peri care after each void

Pain Assessment
Determine source
Document location, type and duration
Interventions

Assess for DVT


Homans sign
Clinical assessment

Episiotomy
1-2 inch incision in the muscular area
between the vagina and the anus
Assess REEDA
Episiotomy care

Nursing Care

Peri care
Ice packs
Sitz baths
Dry heat
Topical medications

Episiotomy, Lacerations, C/S


Incisions

Inspect the perineum for episiotomy/lacerations


with REEDA assessment
Inspect C/S abdominal incisions for REEDA

R = redness (erythema)
E = edema
E = ecchymosis
D = drainage, discharge
A = approximation

Episiotomy

Postpartum Nursing
Interventions
Relief of Perineal Discomfort
Ice packs for 24 hours, then warm sitz bath
Topical agents - Epifoam
Perineal care warm water, gently wipe dry front to
back

A sitz bath promotes healing and provides relief


from perineal discomfort during the initial
weeks following birth.

Maternal Physiological
Adaptations

Hematological System
Decrease in blood volume
Elevated WBC
Increased Fibrinogen

Hormonal Levels
Estrogen and Progesterone decrease
Anterior pituitary-prolactin for lactation
Expulsion of the placenta- placental
lactogen, cortisol, growth hormone,
and insulinase levels decrease
Honeymoon phase- insulin needs
decrease

Neurological System

Maternal fatigue
Transient neurological changes
Headaches
Carpel tunnel improvement

Renal
GFR, Creatinine, and BUN return to
prepregnant levels within 2-3 months
Urinary glucose levels return to
nonpregnant levels by 2nd PP wk
Protienuria resolves by the 6th PP wk
Natriuresis / Diuresis

Integumentary System
Darken pigmentation gradually fades
Hair regrowth returns to normal in 612 months
Striae( stretch marks) fade to silvery
lines

Cardiovascular System
Heart returns to normal position
Cardiac output elevated above
prelabor levels up to 48 hrs. PP

Immune System
Rubella
Administer to nonimmune mothers
Safe for nursing mothers
Avoid pregnancy for 1 month
Flu-type symptoms may occur

Immune System
Rho (D) immune globulin
Mother Rh negative, infant Rh
positive
Negative coombs test
300 mcg of RhoGam within 72 hrs
after delivery
Card issued to mother

Reproductive System
Involution of uterus
Healing of placental site
Vaginal changes

Menstruation and Ovulation


Nonlactactating mother
Menstruation returns in 6-8 wks
First cycle may be anovulatory
Lactating mother
Delayed ovulation and menstruation

Musculoskeletal System
Relaxation of pelvic joints, ligaments,
and soft tissue
Muscle fatigue and general body
aches from labor and delivery of
newborn
Rectus abdominis diastasis

Multicultural Nursing Care


Enhance Cultural Sensitivity
Understand cultural influences on the
post partum period
Provide culturally appropriate care

HIV/AIDS
Gloves safety glasses
Discourage breast feeding
Avoid contact personal body fluid with
infants mucous membranes

Postpartal Surgical Patient


Tubal ligation
Cesarean birth

Breastfeeding
Colostrum is produced during pregnancy and
immediately after birth, contains antibodies
Replaced in 2-4 days with milk
Teach: clean breast first in shower, proper
positioning, release suction with finger, avoid
soap on nipples, disposable bra pads, S&S
of complications redness, swelling, fever,
tenderness, cracked nipples (usually
mastitis unilateral)

Breast Feeding
Optimal method of feeding infant
Breast milk- Bacteriologically safe,
fresh, readily available

Breastfeeding
Lactogenesis- secretion of milk
Milk ejection reflex- let down reflex

Breastfeeding
Cue signs
Latch-on
Assess for milk let down

LATCHwascreatedtoprovideasystematicmethodfor
breastfeedingassessmentandcharting.

Breastfeeding
Positions
Cradle hold
Foot ball
Side lying

Ineffective Breastfeeding
Incorrect latch-on
Inverted nipples
Breast engorgement

Collection and Storage


Breast Milk
Room temperature- 4 hrs
Refrigerator- 5-7 days
Deep freezer- 6-7 months

Formula Feeding
Formula preparation
Periodically check nipple integrity
Bottle preparation

Breastfeeding Pathophysiology
Before delivery, increased estrogen
stimulates duct formation, progesterone
promotes development of lobules and alveoli
After delivery, estrogen and progesterone
decrease, prolactin increases to promote
milk production by stimulating alveoli
Newborn suck releases oxytocin to stimulate
let-down reflex

Composition of Breast Milk


Breast milk is 90% water; 10% solids consisting
of carbohydrates, proteins, fats, minerals and
vitamins
Composition can vary according to gestational
age and stage of lactation
Helps meet changing needs of baby
Foremilk high water content, vitamins, protein
Hindmilk - higher fat content

Immunologic and Nutritional


Properties
Secretory IgA, immunoglobulin found in colostrum
and breast milk, has antiviral, antibacterial,
antigenic-inhibiting properties
Contains enzymes and leukocytes that protect against
pathogens
Composed of lactose, lipids, polyunsaturated fatty
acids, amino acids, especially taurine
Cholesterol, long-chain polyunsaturated fatty acids, and
balance of amino acids in breast milk help with
myelination and neurologic development

Advantages of Breastfeeding
Provides immunologic protection
Infants digest and absorb component of breast milk
easier
Provides more vitamins to infant if mother's diet is
adequate
Strengthens mother-infant attachment
No additional cost
Breast milk requires no preparation
AAP= Only food for 6 months, w/ foods for 12
months

Disadvantages of Breastfeeding
Many medications pass through to breast
milk
Father unable to equally participate in
actual feeding of infant
Mother may have difficulty being separated
from infant

Breastfeeding Mother
Breastfeeding mother needs to know
How breast milk is produced
How to correctly position infant for feeding
Procedures for feeding infant
Number of times per day breastfed infant should be put
to the breast
How to express and store breast milk
How and when to supplement with formula
How to care for breasts
Medications that pass through breast milk
Support groups for breastfeeding

Review signs and symptoms of engorgement, plugged


milk ducts, mastitis

Figure 292
Four common
breastfeeding positions. A, Football hold. B,

Formula Preparations
Three categories of formulas based on cow
milk proteins, soy protein-based formulas,
specialized or therapeutic formulas - all are
enriched with vitamins, particularly vitamin
D
Most common cow milk protein-based
formulas attempt to duplicate same
concentration of carbohydrates, proteins,
fats as 20kcal/oz same as breast milk

Bottle-Feeding Advantages
Provides good nutrition to infant
Father can participate in infant feeding
patterns

Bottle-Feeding Disadvantages
May need to try different formulas before
finding one that is well-tolerated by infant
Proper preparation necessary for nutrition
adequacy

Bottle-Feeding Mother
Bottle-feeding mother needs to know
Types of formula available and how to prepare each type
Procedure for feeding infant
How to correctly position infant for bottle-feeding
How to safely store formula
How to safely care for bottles and nipples
Amount of formula to feed infant at each feeding
How often to feed infant
Expected weight gain

Bottle Feeding Mother


Teach to wear a binder or tight-fitting sports
bra day and night for two weeks.
Do not allow hot water from shower to run
over breasts
Avoid manual stimulation
Apply cabbage leaves (dries up breast)
Use acetaminophen for discomfort

Family and Infant Bonding

Transitioning to parenthood
Assuming the mothering role
Parental bonding
Factors that interrupt bonding

Transitioning to parenthood

Difficult and challenging


Provide emotional support
Accurate information
Nursing goal create a supportive teaching
environment

Assuming the mothering role


Rubins three phases
Taking in
Taking hold
Letting-go

Psychosocial Needs
Promoting bonding
Rubins Phases
Taking in wants to be
taken care of
Taking hold takes charge
Letting go more realistic

Bonding
Bonding process helps to lay the
foundation for nurturing care
Touch- skin to skin
Eye contact
Breastfeeding

Postpartum Blues
Transient periods of depression
during the first 1 to 2 weeks
postpartum
Tearfulness
Sad feeling
Confusion
Insomnia

Post Partum Blues


Is normal, mild, transient condition affects
50-70% of women
Begins 3-4 days after childbirth, peaks on
the 4-5 day and resolves within 2 wks
Symptoms: insomnia, fatigue, tearfulness,
mood instability, anxiety
Nursing care: encouraged to rest, take care
of self, discuss feelings, it is self-limiting

Nursing Care

Remind mom that the Blues are normal


Encourage rest
Utilize relaxation techniques
Share her feelings with her partner
If symptoms do not resolve and progress
to depression medical treatment needs to
be sought

Father-Infant Interaction
Engrossment
Sense of absorption
Preoccupation Interest in infant

Discharge
Preparation for discharge should begin when
expectant mother enters birthing unit
Mother needs to be aware of signs of postpartum
complications and should be aware of her selfcare needs
Nurses should begin first by assessing knowledge
and expectations of new mother and family
Nurse should be available to answer questions
and provide support to parents

Discharge
Printed Information

Nurse should review with new mother any


information she has received regarding
postpartum exercises, prevent of fatigue, sitz
bath and perineal care, etc. - nurse should
spend time with parent to determine if they
have any last-minute questions before
discharge
Printed information about local agencies and
support groups should be given to new family

Discharge Planning and


Teaching
Self Care

Discharge Teaching

Fundus and Lochia


Episiotomy care
Incision care
Signs of infection- box 15-5 pg 505
Elimination

Discharge Teaching

Nutrition
Exercise
Pain management
Sexual activity
Contraception

Discharge Instructions

S/S complications
PP Exercises
Rest
Avoid overexertion
Sexual activity
Hygiene
Sitz baths
Incision care

Referral numbers
Nutrition
PP appointment
Birth certificate info
Infant care
Infant complications
Infant follow-up
Family bonding

Discharge Teaching
New mother should gradually increase
activities and ambulation after birth
Avoid heavy lifting, excessive stair climbing,
strenuous activity, vacuuming
Resume light housekeeping by second
week at home
Delay returning to work until after 6-week
postpartum examination

Discharge Teaching
Recommend exercise to provide health
benefits to new mother
Nurse should encourage client to begin
simple exercises while on nursing unit
Inform her that increased lochia and pain
may necessitate a change in her activity

Sexual Activity and


Contraception

Sleep deprivation, vaginal dryness, and lack


of time together may impact resumption of
sexual activity
Usually sexual intercourse is resumed once
episiotomy has healed and lochia has
stopped (about 3 6 weeks)
Breastfeeding mother may have leakage of
milk from nipples with sexual arousal due to
oxytocin release

Contraception
Information on contraception should be part
of discharge planning
Nursing staff need to identify advantages,
disadvantages, risk factors, any
contraindications
Breastfeeding mothers concerned that
contraceptive method will interfere with
ability to breastfeed - they should be given
available options progesterone only

Parent-Infant Attachment
Tell parents it is normal to have both
positive and negative feelings about
parenthood
Stress uniqueness of each infant
Provide time and privacy for the new family
Include parents in nursing intervention

Reaction of Siblings
Sibling visits reassure children their mother
is well
Father may need to hold new baby, so
mother can hug older children
Suggest to parent that bringing doll home
allows young child to "care for" and identify
with parents

Infant Care
New mother and family should know basic
infant care
Information about tub baths
Cord treatment, When to anticipate cord will fall
off
Family should be comfortable in feeding and
handling infant, as well as safety concerns
Immunizations
When to call the doctor

Discharge Teaching
Nurse should review with new mother any information she
has received regarding postpartum exercises, prevent of
fatigue, sitz bath and perineal care, etc. - nurse should
spend time with parent to determine if they have any lastminute questions before discharge
Printed information about local agencies and support
groups should be given to new family

Types of Follow-Up Care


Telephone calls - nurses must listen carefully and ask
open-ended questions
Return visits - Within one week after first visit
Telephone follow-up - Within 3 days of discharge
Baby care/postpartum classes
New mother support groups
Need to have a caring attitude in these activities

Main Purpose of the Home


Visit

Assessment

Status of mother and infant


Adaptation and adjustment of family to new baby

Determine current informational needs


Teaching
Self-care
Infant Care

Opportunity to answer additional questions related to


infant care and feeding
Counseling
Provide emotional support to mother and family
Referrals

Maternal Assessments at Home


Vital signs: Should be at prepregnancy level
Weight: Expect weight to be near prepregnancy level at 6
weeks postpartum
Condition of breasts
Condition of abdomen, including healing cesarean incision
if applicable
Elimination pattern: should return to normal by 4 to 6
weeks postpartum

Maternal Assessment
Lochia
Should progress from lochia rubra to lochia alba
If not breastfeeding, menstrual pattern should return
about 6 weeks postpartum

Fundus
Uterus should return to normal size by 6 weeks
postpartum

Perineum: Episiotomy and lacerations should


show signs of healing

Breastfeeding Assessment
Nipple soreness - Peaks on days 3 and 6, then
recedes
Cracked nipples
Allow nipples to air dry after breastfeeding
Nurse frequently
Alternate breasts
Change infant's position regularly
Breast engorgement, plugged ducts
Effect of alcohol and medications
Return to work
Weaning

Family Assessment
Bonding: Appropriate demonstration of bonding
should be apparent
Level of comfort: parents should display appropriate
levels of comfort with the infant
Siblings should be adjusting to new baby
Parental role adjustment
Parents should be working on division of labor
Changes in financial status
Communication changes
Readjustment of sexual relations
Adjustment to new daily tasks

Contraception: Parents understand need to choose


and use a method of contraception

Relinquishing a Baby
Many reasons why a woman decides she cannot
parent her baby
Emotional crisis may arise as woman attempts to
resolve her concerns
As she faces these concerns, social pressures against
giving up baby

Mother may need to complete grieving process to


work through her decision - she may have made
considerable adjustments to her lifestyle to give
birth

Relinquishing a Baby (contd)


Nursing staff need to honor any special
requests after birth and encourage mother
to express her feelings
Seeing newborn may assist mother in
grieving process
Some mothers may request early discharge
or transfer to another unit

Community Resources

Support groups
Home visits
Telephone follow-up
Outpatient Clinics

Postpartum Complications

Postpartum Hemorrhage
Blood loss of more than 500 ml of
blood after a vaginal birth
1000 ml of blood after cesarean
section
Any amount of bleeding that places
mother in hemodynamic jeopardy

Postpartum Hemorrhage
LARRY- common causes of early
PPH
Laceration
Atony
Retained placental tissue
Ruptured uterus
You pulled to hard on the cord

Postpartum Hemorrhage

4 Ts- factors associated with PPH


Tone
Trauma
Tissue
Thrombin

Postpartum Hemorrhage
Tone/Atony
Altered muscle tone due to
overdistention
Prolonged or rapid labor
Infection
Anesthesia

Postpartum Hemorrhage
Trauma
Cervical lacerations
Vaginal lacerations
Hematomas of vulva, vagina or
peritoneal areas.

Postpartum Hemorrhage
Tissue
Retained placental fragments
Uterine inversion
Subinvolution

Postpartum Hemorrhage
Thrombin
Disorders of the clotting mechanism
This should be suspected when
bleeding persists without an
identifiable cause

Management of PPH

Frequent VS
Fundal massage
Administer medications- Box 16-1
Monitor blood loss for amount
Maintain IV
Type & cross match
Empty bladder

Hematoma
Localized collection of blood in
connective or soft tissue under the
skin
Risk factors
Signs and symptoms
Management

Postpartum Infections
A fever of 100.4 or higher after the
first 24 hrs for 2 successive days of
the first 10 PP days
Fever of 102.2 or greater within first
24 hrs- sever pelvic sepsis Group A or
B streptococcus

Postpartum Infections

Endometritis
Wound infection
UTI
Mastitis
Septic Pelvic Thrombophlebitis

Endometritis
Involves the endometrium, decidua
and adjacent myometrium of the
uterus
Lower abdominal tenderness or pain
Temperature
Foul-smelling lochia

Nursing Care
Administer broad spectrum antibiotic
Provide analgesia
Provide emotional support

Wound Infection
Sites- Cesarean incision, episiotomy
and genital tract laceration
Drainage
Edema
Tenderness
Separation of wound edges

Nursing Care

Aseptic wound management


Frequent perineal pad changes
Good hand washing
Administer antibiotics
Analgesics

Urinary Tract Infection

Burning and pain on urination


Lower abdominal pain
Low grade fever
Flank pain
Protienuria, hematuria, bacteriuria,
nitrates and WBC

Nursing Care

Frequent emptying of bladder


Increase fluid intake
Antibiotics
Analgesics

Mastitis

Infection of the breast (one sided)


Seen 2-3 weeks after delivery
Caused by staphylococcus aureus
Infected nipple fissure - to ductal
system involvement- edema obstructs
milk flow in a lobe- mastitis

Mastitis Symptoms
Flu like symptoms
Tender, hot, red area on one breast
Breast distention with milk

Nursing Management
Empty the breast by increasing the
frequency of nursing or pumping
Antibiodics
Analgesics

Postpartum Infection
Education
Continue antibiotics
Monitor temperature and notify
provider if temp greater then 100.4
Watch for signs and symptoms of a
recurrence
Practice good hand washing

Thrombophlebitis and
Thrombosis
Thrombosis (blood Clot) can cause
inflammation of the blood vessel
(thrombophlebitis) which can cause
thromboembolism (obstruction of
blood vessel)

Assessment Superfical
Tenderness and pain in extremity
Warm and pinkish red color over
thrombus area
Palpable- feels bumpy and hard
Increased pain when ambulating

Nursing Care

NSAIDs for pain


Bed rest elevate affected leg
Warm compresses
Elastic stockings

Assessment Deep Vein


Located from foot to pelvis- can
dislodge and cause PE
Calf swelling
Warmth
Tenderness
Pedal edema
Diminished peripheral pulses

Pulmonary Embolism
Abrupt onset: chest pain, dyspnea,
diaphoresis, syncope, anxiety
ABC response

Nursing Care

Bed rest
Elevate effected leg
Continuous moist heat
TED hose both legs
Analgesics PRN
Anticoagulation therapy

Rh Incompatibility
Antibodies cross placenta and
attach to fetal red blood cells
destroying them

Rh Incompatibility
Mother Rh- negative and fetus Rh positive
If Rh positive blood enters system of Rh
negative mother reacts by developing
antibodies to destroy RBCs with Rh
positive antigens
Blood may mix during third stage of labor
First child not effected

Rhisoimmunizationsequence.Rhpositivefatherand
Rhnegativemother.

Astheplacentaseparates,themotherisfurtherexposed
totheRhpositiveblood.

AntiRhpositiveantibodies(triangles)areformed.

InsubsequentpregnancieswithanRhpositivefetus,Rh
positiveredbloodcellsareattackedbytheantiRh
positivematernalantibodies,causinghemolysisofthe
redbloodcellsinthefetus.

RhoGAM
Rho (D) immune globulin suppresses the
stimulation of active immunity by Rhpositive foreign RBC
Given IM at 28 weeks antepartum and
within 72 hours of delivery 1 vial
Before 13 weeks give dose after
amniocentesis, miscarriage, ectopic
pregnancy

Before Administration
Never administer intravenously
Never administer to a neonate
Never administer to an Rh negative
patient who has been previously
sensitized to the Rh antigen
Confirm that the mother is Rh negative
Confirm infant is Rh positive and assess
direct coombs test

Coombs Test
Indirect coombs test on mother to determine the
presence of antibodies against fetal blood.
If the test is positive, amniocenteses may be
performed to determine the fetal Rh factor and
degrees of hyperbilirubinemia.
Direct coombs test is performed on the cord
blood. Positive coombs test indicates that
antibodies from the mother have attached to the
infants RBC. Bilirubin levels are followed closely
for changes that indicate that treatment should
be initiated or changed.

Postpartum
Depression/Psychosis

Postpartum depression- 15-25% - all ethnic


groups affected.
Cause unknown, may be r/t hormonal,
exhaustion, anger, chronic stress
S&S: starts first 4 wks and last several months,
fatigue, loss of self, suicide thoughts crying
TX: combination of psychotherapy, social, meds
Postpartum psychosis- rare, bipolar disorder
or major depression, frightening thoughts,
delusions of dead baby and hallucinations, need
psychiatric Tx, will not resolve itself

Infant Care

Cord care
Diapering
feeding
Stools
Urine
Baths
How to take temp

What are measures to


teach the mom in caring
for the perineum?

Comfort Measures
Relief of Perineal Discomfort

Ice packs
Topical agents
Perineal care
Sitz bath

Relief of hemorrhoidal discomfort may include


Sitz baths
Topical anesthetic ointments
Witch hazel pads

Ovulation and Menstruation


When does Menstruation generally return?
Return is prolonged for the breastfeeding
mom because of alterations in the
gonadotropin-releasing hormone
production.

Ovulation and Menstruation


Nurses need to teach moms that
breastfeeding is NOT a reliable
means of contraception.

Breasts
Allow the mother to assess her own
breasts -- similar to doing a self-breast
exam
ask if feels any nodules, lumps
ask if nipples are sore, reddened, blisters, cracks
Assess nipples for everted, flat, inverted.

Teach to care for breasts according to


whether they are breastfeeding or bottle
feeding.

Process of Lactation
Sucking of infant stimulates the nerves beneath skin
of the areola to transmit messages to the
hypothalamus
Hypothalamus sends messages to the pituitary gland

Anterior pituitary -- stimulates Prolactin


to be released which is the ultimate
stimulation for milk production
Posterior pituitary -- releases Oxytocin
which stimulates the contraction of the
cells around the alveoli in the
mammary glands. This causes milk to
be propelled through the duct system
to the infant. This is the LET-DOWN
reflex. Felt as a tingling sensation

Breastfeeding Care
No soap on the nipples, wash in water
wear supportive bra
Breastfeeding tips:
Most important is the latch-on Teach measures to
assist with the infant getting the nipple and areola in the
mouth
Teach different positions to hold the baby
No timing
Relax to allow for let-down
express colostrum on the nipples after feeding
remember drops of colostrum are the same as ounces of
milk -- if wetting 6 - 10 diapers / day, then must be
getting enough to eat

Suppression of Lactation
Key is to teach the mother measures to
decrease stimulation of the breasts
Wear a tight-fitting bra or binder
Do not express milk from the breasts
Take shower with back to the warm water
Ice packs

THE END