PHYSIOLOGY AND MANAGEMENT OF LACTATION

GOAL At the end of the topic UCM students should understand the structure of the breast and the processes in milk production and management of lactation

SPECIFIC OBJECTIVES
Define the breast Describe the specific structures of the breast Discuss all the processes occurring in the breast for milk production Discuss the role of the midwife to ensure successful breast feeding

Definition
It is an accessory of reproductive system that secretes milk after child birth to nourish the infant Compound secreting glands composed of glandular and connective tissue arranged in lobes Each lobe is divided into lobules that consist of alveoli and ducts

THE BREAST:
Richly supplied with blood Lactiferous ducts carry milk from the alveoli of each lobe and unite to form larger ducts Ducts widens to form lactiferous sinuses where milk is stored beneath the areola The nipple is composed of erectile tissue and contain plain muscle fibres that controls the flow of milk

THE BREAST:
Areola an area surrounding the nipple where glands of montogomery are located that produce an oily fluid that keeps the nipple soft

ANATOMY OF THE BREAST:

THE BREAST

ANATOMY OF THE BREAST:

The mature female breast is composed of essentially four structures: lobules or glands; milk ducts; fat and connective tissue . The lobules group together into larger units called lobes. On average there are 15-20 lobes in each breast arranged roughly in a wheel spoke pattern emanating from the nipple/areolar area.

Cont;
Nipple: composed of sensitive erectile tissue that respond to sexual stimulation Areola: surrounds nipple darker in colour than surrounding skin Montgomery tubercles: Sebaceous glands found in areola that produces oily substance to lubricates and protect the nipple

Cont;
Lobes : 15 20 lobes arranged around and behind the nipple, areola containing alveoli Alveoli: Small sacs containing acin cells that secretes milk. It is highly supplied with blood through mammary arteries Myo epithelial cells: contract and helps in propelling milk in lactiferous ducts. Lactiferous sinuses: temporary storage sites for milk

Cont;
Blood supply: internal and external mammary arteries and intercoastal arteries Nerve supply: supplied by 4th ,5th , 6th inter thoracic nerves Function Provide nourishments and provide antibodies to the infant through lactation Source of pleasurable sexual sensation.

MAMMARY GROWTH:
In Pregnancy High levels of oestrogen and progesterone stimulate growth of the alveoli and duct system to prepare for lactation. Prolactin stimulates milk production but it is inhibited during pregnancy by oestrogen and progesterone levels. The inhibition ceases when the placenta is delivered and active milk production occurs in response to infant suckling.

Physiology of lactation
Three phases Production of milk Flow of milk Withdraw of milk by baby

MILK ESTABLISHMENT AND MAINTAINCE AFTER DELIVERY

After delivery of the placenta estrogen and progestrone drops and production of prolactin is no longer prohibited Prolactin promote milk production and initiate lactation Prolactin changes dormant alveolar cells to produce breastmilk Suckling of the baby maintains lactation

MILK PRODUCTION:
Milk is formed as tiny fatty globules within the alveoli As new globules are produced, the droplets are pushed towards the surface of the cell to the lactiferous tubule Droplets from other cells join other cells then the alveoli become filled with milk Abundant blood supply to the breast helps milk production

THE FLOW OF BREAST MILK:

More milk is produced along lactiferous tubules that pushes milk formed behind the nipple Milk stored in the lactiferous sinuses beneath aleola is called FOREMILK and that being produced is HINDMILK Mechanically milk is drawn off by the infant suckling Cells surrounding the alveoli and tiny ducts contract to force milk towards the nipple

THE NUERO-HORMONAL REFLEX:

Suckling transmits impulses to the pituitary gland then the Anterior pituitary gland release Prolactin that produce lactation Then the posterior pituitary gland release oxytocin that stimulate the myo epithelial cells to contract forcing milk to the nipple Contraction of smooth muscle causes the milk to flow Nipple becomes erect Uterine muscles contract

THE NUERO-HORMONAL REFLEX:

The reflex causes the HIND MILK to be available for the baby and cause milk to drip from both nipples from ducts and tubules The reflex will allow milk to flow later after hearing baby cry, thinking of feeding the baby and leaking of milk may occur Pricking of the breast,warmth, feeling fullness are sensations of Let down of the milk

INHIBITION OF THE LET- DOWN REFLEX

Inhibition of contraction of M-E cells and vasoconstriction of the mammary blood vessels will reduce the amount of oxytocin This can be brought about by stress,pain,fear,anxiety embarrassment and worry

WITHDRAW OF MILK BY SUCKLING:

Nipple and areola are drawn into the babys mouth The jaws express the milk from the sinuses which is foremilk A vaccum is created in the babys mouth which draws the hindmilk down the alveoli The more milk is drawn off the lactiferous sinuses and lower ducts more milk flow from upper lactiferous ducts, tubules and alveoli This continues till the breast is empty

THE MAINTANANCE OF LACTATION:

Suckling and nipple stimulation The mothers emotional state Adequate rest of the mother( prolactin secretion takes place during rest and sleep) An adequate and balanced maternal diet An adequate maternal fluid intake

COMPONENTS OF BREAST MILK:

Fat and fatty acids for the development of the brain Carbohydrates for calorific requirements Protein Vitamins- A,D,E,K Iron for maitaining HB content of the infant Zinc, calcium

Components of breast milk

Leucocytes- During 10 days there are more white cells macrophages and neutrophils that destroy harmful bacteria Immunoglobulins protects mucosal surface against entry of pathogenic bacteria eg ecoli,salmonella,streptococci

COMPONENTS OF BREAST MILK:

Fat and protein higher in colostrum than in mature milk Good attachment allows the baby to have enough nutrients from a feed Exclusive breastfeeding is recommended for the first 6 months of life

MANAGEMENT OF LACTATION:
ANTENATALLY: Usually the nipples and aleolla develop during pregnancy, the mothers should be aware of nutritional and immunological advantages of breast feeding Good diet and preparation for lactation promotes successful breast feeding

MANAGEMENT OF LACTATION:
LABOUR AND DELIVERY: 1st feed should be initiated within 30 minutes after delivery to clear colostrum and stimulate milk secretion Midwife to initiate mother and child bonding within the 1st hour after birth Put the baby in skin to skin contact with the mothers abdomen or chest after birth

MANAGEMENT OF LACTATION:
POSITIONING OF THE MOTHER: Lying on her side Sitting up POSITING OF THE BABY: Babys body toward the mothers body Baby tummy to tummy ATTACHMENT: Baby to draw breast tissue and nipple into his mouth with his tongue

MANAGEMENT OF LACTATION:
If properly attached the breast is stretched into a teat in the babys mouth and there is minimal suction to hold the teat No pain is experience by the mother Midwives should assist women to attach the baby to the breast Foremilk is generous but lower in fat than hind milk that is higher in calories

MANAGEMENT OF LACTATION:
Midwives should have the skill to help the mothers to fix the baby to the breast Offer psychological support by giving encouragement, praise, understanding and be patient for successful lactation Massage the breast in order to stimulate more glandular tissue for production of breast milk Relieve the discomforts and make the mother more relaxed for successful lactation

MANAGEMENT OF LACTATION:
Provide time enough for rest and sleep that would promote milk production Nutrition and fluids: diet requiring 11,000kJ and 2 Lt of fluids in 24 hrs depending on the need of each individual Feed on demand and awake the baby to have enough milk Bringing up wind or burping the baby to remove air swallowed while breast feeding/ crying( baby to lie on one side ) avoid lieing on the back

MANAGEMENT OF LACTATION:
3- 4 Minutes on each breast in the first days to stimulate hindmilk secretion then 10 minutes depending on the infants needs and availability of milk No supplimentary or complimentary bottle feeds Offer both breast at each feed to stimulate the hind milk The more the baby feeds the greater will be the milk supply .

MANAGEMENT OF LACTATION:
Practice cluster feeding that is waking the baby frequently during the day to breast feed 1o 11 feeds in 24 hrs

Cleanliness: Wash hands before and after feeds clean the dirty nipples. Ensure nappy change after feeds

MANAGEMENT OF LACTATION:
The actual grasp of the nipple: Push down the chin and insert the nipple on the tongue The nipple and the areolar tissue should be pushed into the babys mouth The inside of both lips should be showing Mother should support the breast in a cup in her hand position not scissors /cigarette hold

THE EXPRESSION OF MILK FROM THE BREAST:

Expression increase the flow of milk in mothers with poor milk supply by applying heat and breast massage Full breast should be emptied to allow the baby to gain a good hold of the nipple Helps mothers with inverted ,retracted or very large nipples to feed the babies To store the milk for another feed to mothers with part time jobs

THE EXPRESSION OF MILK FROM THE BREAST:

To supply feed to babies that are unable to suckle sufficient breast milk like preterm babies and other neonatal conditions Expression can be done by applying heat, breast massage, the manual or hand expression . A breast pump can be used

BABY FRIENDLY INITIATIVES:

Have a written policy that is communicated to staff on breast feeding Train all staff Give information on the advantages of breast feeding to all mothers Help mothers to initiate breast feeding soon after birth Train mothers to maintain lactation even if they should be separated from their infant

BABY FRIENDLY INITIATIVES:

Do not give infants food or drink other than breast milk for the first 6 months Practice rooming in: Allow mothers and infants to remain together 24 hrs Encourage breast feeding on demand No artificial teats or dummies to breast feeding infants Have support groups for breast feeding and refer mothers to them