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1.5 Breast examination

Key Points - Case Study A

Joanne, aged 32, a regular patient, comes to see you when she is 12 weeks pregnant with her first baby. She has just returned from a trip around Australia and her pregnancy was confirmed by a doctor in the town they were in at the time. She has copies of her baseline blood tests with her and all are normal.

Would you discuss breastfeeding at this visit?

Topic 1.1: Discussing breastfeeding
It is important that doctors discuss infant feeding decisions and breastfeeding with women early in a pregnancy rather than waiting until the third trimester or after the baby is born.

What information would you give?

Topic 1.2: What information to give
When discussing infant feeding with mothers it is important to note that alternatives to breastfeeding have many undesirable outcomes.

Why do breastfeeding alternatives have different effects?

Topic 1.3: Effects of Breastfeeding alternatives
These effects are due in part to the presence in breast milk of substances and systems that act against infections and inflammation.

What are mothers' common and valid concerns about breastfeeding?

Topic 1.4: Common breastfeeding concerns
Exploring her concerns and providing information and reassurance is useful in allaying anxiety and prepares the parents for their changing role.

Would you examine her breasts at this visit?

Topic 1.5: Breast examination
Examine Joanne's breasts now and again in the third trimester. Examining a mother's breasts and nipples early in pregnancy emphasises the importance of breastfeeding, provides reassurance for most women that they are 'normal', allows the identification of any variations that may cause problems.

Would you examine her breasts at this visit?

Yes and again in the third trimester. Examining a mother's breasts and nipples early in pregnancy emphasises the importance of breastfeeding, provides reassurance for most women that they are 'normal' and allows the identification of any variations that may require planning of appropriate postpartum help.

Breasts are composed of both glandular and adipose tissue supported by a loose connective tissue network. Under hormonal influences during pregnancy (e.g. human placental lactogen, oestrogen, progesterone, prolactin, growth hormone) the glandular component of the breast increases with growth and branching of the ductal system, an increase in lobule formation and alveolar differentiation1,2.


© Health e-Learning

While there are great variations in breast size, breast tissue usually lies from the 2nd to the 6th rib and comprises between 15 and 20 lobes that differ in size and intertwine within the breast. Breast milk is stored in the alveoli of the lobes, ducts from the many alveoli joint to form a mean of 9 ducts (range 4 – 18) opening onto the nipple2,3.


© S.Cox IBCLC

Nipples also vary greatly in size (from less than 12 mm to more than 23 mm)4 and shape. Most protrude from the surface of the areola and become erect in response to tactile, thermal and sexual stimulation5. The nipple is surrounded by the areola that also varies in size and pigmentation with pigmentation increasing during pregnancy. Modified lactiferous ducts and sebaceous glands on the areola (known as Montgomery's follicles) become more prominent during pregnancy. These follicles produce a secretion containing anti-inflammatory factors that helps lubricate the nipple and prevent infection2,5.

Click on graphic for a larger image. .
© Ramsay DT, Hartmann RL, Hartmann PE

Major ducts in the lactating breast are small (mean diameter 2mm), easily compressible and lie superficially. Recent work indicates that milk is not stored in the ducts and the 'lactiferous sinuses' often depicted lying beneath the nipple/areola in schematic diagrams of lactating breasts do not exist1,2.
The breast is innervated by branches of the 2nd to 6th intercostal nerves that contain sympathetic and sensory fibres5 with the lateral cutaneous branches of the 3rd – 5th intercostal (usually the 4th) nerves being responsible for the sensory innervation of the nipple and areolar area2. Milk production, however, is independent of nerve stimulation1.

What anatomical variations would give rise to concerns?

Picture Description Advice
Asymmetrical Breasts

Image © S.Cox IBCLC

Abnormal appearance Breasts that are markedly asymmetric, are widely spaced with a narrow base, appear to have a large areola with little breast substance may be an indication of insufficient glandular tissue in the breast. Some women will also note no or minimal increase in breast size during pregnancy. While breast milk production will commence, these women often have difficulty producing sufficient breast milk for their infants to grow at an adequate rate. Careful follow-up postpartum (at least within 72 hours of hospital discharge and at least weekly thereafter until breastfeeding is well established) will enable an accurate assessment of the mother’s capacity to produce breast milk.
Scarred Breasts

Image © B.Ingle IBCLC

Scars indicating a history of breast surgery Identifying the reasons for breast surgery, the type of surgery performed and the position of any scars will enable an assessment of the impact the surgery may have on future breastfeeding. Breast reduction surgery often causes difficulties with breastfeeding due to a reduction in glandular tissue, interruption of the ductal system, and damage to the nerve supply to the nipple. While breast augmentation is less likely to cause problems, note needs to be taken of the reasons for the augmentation in the first place (eg hypoplastic breasts). Periareolar incisions may damage the sensory nerve supply to the nipple/areola complex and interrupt the afferent arm of the let down or milk-ejection reflex.
Inverted Nipple

Image © Goldfarb Breastfeeding Clinic

Flat or inverted nipples Occasionally nipples do not protrude but appear to be on the same plane, or below the plane of the areola (flat or inverted nipples). Gently compressing the areola will help distinguish between nipples that appear flat or inverted, but protrude with stimulation, and nipples that become more inverted with stimulation. Infants may have difficulty attaching to these nipples, breast drainage may be poor and the nipples may become painful and cracked. Although nipples often increase in size during pregnancy1 and become more protractile and elastic, by identifying flat and inverted nipples in the antenatal period strategies to increase the likelihood of successful breastfeeding can be instituted immediately postpartum. (See Case 4 for further information).

Notes

  1. # Geddes DT (2007) Gross anatomy of the lactating breast
  2. # Geddes DT (2007) Inside the lactating breast: The latest anatomy research
  3. # Going JJ et al. (2004) Escaping from Flatland: clinical and biological aspects of human mammary duct anatomy in three dimensions
  4. # Wilson-Clay B et al. (2002) The Breastfeeding Atlas
  5. # Brodribb W (2004) Breastfeeding Management