Which intervention would be helpful to a bottle feeding client whos experiencing hard engorged breasts?

Your Care Instructions

Breast engorgement is the painful overfilling of the breasts that can occur during breastfeeding. It usually occurs when your breasts make more milk than your baby can drink, when you are unable to breastfeed or pump, and when you stop breastfeeding your baby.

Breast engorgement can make it hard for your baby to latch on to your nipple. Your baby may then be unable to breastfeed. This makes engorgement worse.

If you breastfeed or pump, engorgement should get better in a few days. If you've stopped breastfeeding, it can take longer. Over time, your body will stop making milk. This can take up to several weeks.

Follow-up care is a key part of your treatment and safety. Be sure to make and go to all appointments, and call your doctor or nurse advice line (811 in most provinces and territories) if you are having problems. It's also a good idea to know your test results and keep a list of the medicines you take.

How can you care for yourself at home?

• If your doctor or midwife gave you medicine, take it exactly as prescribed. Call your doctor, midwife, or nurse call line if you think you are having a problem with your medicine.
• Take an over-the-counter pain medicine, such as acetaminophen (Tylenol), ibuprofen (Advil, Motrin), or naproxen (Aleve). Read and follow all instructions on the label.
• Do not take two or more pain medicines at the same time unless the doctor told you to. Many pain medicines have acetaminophen, which is Tylenol. Too much acetaminophen (Tylenol) can be harmful.
• If your baby is having a hard time latching on, let out (express) a small amount of milk with your hands or a pump. This will help soften your nipple and make it easier for your baby to latch on.
• If your breasts are uncomfortably full, pump or express breast milk by hand just until they are comfortable. Do not empty your breasts all the way. Releasing a lot of milk will cause your body to produce larger amounts of milk. This can make breast engorgement worse.
• Gently massage your breasts to help milk flow during breastfeeding or pumping.
• Apply a frozen wet towel, cold gel or ice packs, or bags of frozen vegetables to your breasts for 15 minutes at a time every hour as needed. (Put a thin cloth between the ice pack and your skin.)
• Avoid tight bras that press on your breasts. A tight bra can cause blocked milk ducts.

To prevent breast engorgement

• Put a warm, wet face cloth on your breasts before breastfeeding. This may help your breasts "let down," increasing the flow of milk. Or you can take a warm shower or use a heating pad set on low. (Never use a heating pad in bed, because you may fall asleep and burn yourself.)
• Change your baby's position occasionally to make sure that all parts of your breasts are emptied.
• Make sure your baby is latched on properly.
• Talk to your doctor, midwife, or a lactation consultant about any problems you have with breastfeeding.

When should you call for help?

Call your doctor now or seek immediate medical care if:

• You have symptoms of a breast infection, such as:
  • Increased pain, swelling, redness, or warmth around a breast.
  • Red streaks extending from the breast.
  • Pus draining from a breast.
  • A fever.

Watch closely for changes in your health, and be sure to contact your doctor, midwife, or nurse call line if:

• You do not get better as expected.

Where can you learn more?

Go to //www.healthwise.net/patientEd

Enter Z048 in the search box to learn more about "Breast Engorgement: Care Instructions".

Activity and Rest

Feeling tired after having a baby is normal. Get as much rest as possible and try napping when your baby sleeps. Gradually increase your activities as you feel up to it. If you have had a cesarean birth, you have also had major surgery. Limit your activity to caring for your baby and giving your body time to recover.

• Do not pick up anything that causes strain or discomfort in your stomach.
• Limit your daily activities to caring for the baby and light housework.
• You may go up stairs.
• Do not strain your stomach. Your skin will heal quickly, but the muscle underneath takes longer.
• Avoid swimming pools until vaginal bleeding has stopped.
• You can resume driving about a week after a vaginal birth or three weeks after a cesarean birth.

If you have received stitches as part of an episiotomy, that area may be uncomfortable. For comfort and healing:

• Apply ice packs in the first 24 hours.
• Sit in a sitz bath for 20 minutes, three times a day.
• Take pain medication as recommended by your physician or midwife.Each time you urinate, make a bowel movement, or change your sanitary pad, use a peribottle to squirt warm water from front to back and pat dry.

Birth Control

You can get pregnant after delivery even if you are not having regular periods and if you are breastfeeding. You should think about a birth control plan before you go home from the hospital.

It is recommended that you use condoms with foam. You can buy both at a pharmacy. If your doctor has ordered birth control pills for you, you should use another form of birth control (such as foam and condoms) for the first month until your menstrual periods become regular.

After your six-week checkup, you may return to your choice of birth control. Keep in mind that some forms of birth control affect breastfeeding. Discuss the options for ongoing birth control with your doctor or nurse midwife.

Mothers of Preemies

Family planning is also important for moms of preemies. Many women feel overwhelmed after preterm birth. While it can be hard to think about yourself, it is important to take control of your reproductive life. This includes using appropriate birth control methods and getting pregnant again only when you are ready to get pregnant.

Breast Care

Whether you are feeding your baby at the breast or with a bottle, your body will naturally produce milk. As your milk supply increases, your breasts may become very tender and/or swollen. This is called engorgement and begins on the second or third day after your baby's birth. It will last about 24 to 48 hours.

If Your Breasts Become Engorged When Breastfeeding

• Wear a bra with good support 24 hours a day.
• Take a warm shower or apply a warm face cloth to your breasts. The heat may help milk flow.
• Pump or hand express milk before nursing to soften the breast if your baby is having trouble latching on because your breasts are engorged.
• Apply a cold compress after feeding. It may help relieve swelling.
• Take Tylenol or Motrin for discomfort.
• Nurse your baby frequently to help your milk supply and reduce engorgement.

If Your Breasts Become Engorged When Bottle Feeding

• Wear a bra with good support 24 hours a day.
• Avoid handling your breasts.
• Do not pump or hand express milk. This will only increase the engorgement.
• Take Tylenol or Motrin for discomfort.

Call the Warm Line at 1-800-711-7011 if you have any questions or concerns.

A Well Balanced Diet is Vital

After your six-week checkup is a good time to start exercising again, but talk with your doctor before you start a formal exercise program. Your body will return to its pre-pregnant state naturally, except for muscle tone. Exercise will help you regain this tone.

You can try Kegel exercises to help tighten the muscles around the vagina. You can begin these shortly after delivery. Tighten the muscles that surround the opening of the vagina and rectum as if you are trying not to urinate. Hold for several seconds and then slowly relax. Repeat five to 10 times, several times a day.

In addition, you can help your body return to normal by using good body mechanics. Sit, stand, and walk with proper postural alignment. Bend at your knees to pick things up. Avoid bending from the waist, which strains and pulls the back muscles.

Eating Well After Your Baby is Born

Your body needs time and a balanced diet to recover from pregnancy and adjust to meeting the needs of your new baby.

Things to Keep in Mind

• While you are breastfeeding continue to eat a well-balanced intake of food from the basic food groups and drink adequate fluids. The basic food groups include:
• • Dairy.
  • Protein (animal and plant-based sources).
  • Colorful fruits and vegetables.
  • Starches and whole grains.
  • Other foods including good fats.
• Stay hydrated with appropriate fluids. Special diets may be needed only for nutrition-related medical conditions, otherwise, eat regularly. Your body uses energy stored during your pregnancy weight gain for milk production for your baby. If you are not breastfeeding, lower calorie intake will help you lose any desired weight.
• You should drink eight to 10 glasses of fluids (water, juice, milk) every day. Limit caffeine, including soda, tea, coffee and chocolate, and highly sweetened beverages.
• A well-balanced intake includes:
  • Protein from meat.
  • Eggs and cheese.
  • Plant-based proteins such as peanut butter and soy.
  • Ancient grains like quinoa.
• Including high fiber foods and adequate water intake may help with regular bowel movements. High fiber foods include:
• • Fresh fruits.
  • Vegetables.
  • Bran and bran products.
  • Other whole grain products.
  • Fresh fruits.
• Dairy which includes low- fat milk products, such as cheeses and yogurt or lactose free products, should be included in your daily diet. Keeping your intake of high fat and sugary foods and snacks low and smaller portions will help reduce your calorie intake for weight reduction.
• Finish taking your prenatal vitamins and iron pills as prescribed. If you are breastfeeding, take them the entire time you are nursing. Your doctor can renew your prenatal vitamin prescription if you run out.

For any significant problems such as severe constipation, please contact your health care provider for a laxative or stool softener or other medical advice. If you would like a nutrition consult, have your health care provider make a referral to the Women & Infants Outpatient Nutrition Services Department at (401) 274-1122, ext. 42749.

Complications After Delivery

Bleeding from the vagina is normal in both vaginal and cesarean births. It usually lasts 10 days to three weeks. The color of the bleeding will change from bright red to brownish to tan, and will become less in amount and then disappear. You can take showers and baths at any time, but do not douche before your six-week checkup.

Warning Signs

Some new mothers develop complications following their delivery whether it was a vaginal or cesarean birth. Call your doctor if you have any of the following signs or symptoms:

• Fever of 100.4 degrees or higher.
• Increased bleeding without an increase in activity. If you have increased your activity, try resting for an hour. If your flow does not decrease, call your doctor.
• Passing large clots (the size of a quarter or larger).
• Severe pain in your abdomen, chest or legs.
• Tender, painful or reddened breasts.
• Painful or frequent urination.
• Severe headache or vision problems.
• Shortness of breath.
• Swelling of hands or face.
• Severe pain, tenderness, redness or yellow drainage from the incision if you had had a cesarean birth (a small amount of clear, sticky fluid may ooze from the incision, and this is normal).

Postpartum Depression

Your emotional health is just as important as your physical health. As the number one medical complication of pregnancy and childbirth, one in five women suffers from a mood disorder during their pregnancy and postpartum period. Know that you are not alone. Seeking help is the best thing you can do for yourself and your family. 

Taking Control of Your Health After Delivery

Diabetes in Pregnancy

I was told I had diabetes during pregnancy. What does this mean?

 There are several types of diabetes that can be diagnosed before or during pregnancy, including:

Gestational Diabetes: Gestational diabetes is a type of high blood sugar that is brought on by pregnancy. Normally your body makes a hormone called insulin which keeps your blood sugar under control. During pregnancy the placenta makes hormones that cause your body to respond less to insulin, so your sugars are higher (we call this “insulin resistance” – meaning your body is more “resistant” to the insulin it is making). If your blood sugars were too high in pregnancy, then your doctor may have started you on insulin. This doesn’t mean your body isn’t making insulin. Instead it means that your body needs MORE insulin to do the same work keeping your blood sugars at a good level.  

Type 2 Diabetes: Type 2 diabetes is a type of high blood sugar that is NOT brought on by pregnancy. Even though pregnancy does not cause Type 2 diabetes, sometimes it is first diagnosed during pregnancy. Like gestational diabetes, it is caused by your body being resistant to the insulin it makes.

Type 1 Diabetes: Type 1 diabetes is a type of high blood sugar that is NOT brought on by pregnancy and is often diagnosed early in life (as a child or teen). It is different from type 2 diabetes because people with type 1 diabetes have problems making insulin. They make little or no insulin.

I was diagnosed with diabetes in pregnancy but told it was likely type 2 diabetes. What does this mean?

Gestational diabetes is diagnosed in the second or third trimester, a time where the placenta is growing quickly and making more hormones that raise your blood sugars. But, if your blood sugars were high early in pregnancy (when the placenta is small and its hormones are not affecting your sugars much), this means you probably had high blood sugars even before pregnancy (rather than high sugars caused by pregnancy). If the blood sugars were high before pregnancy, this may mean you have pre-diabetes or Type 2 diabetes. Another way your doctor can tell if you had high blood sugars before pregnancy is by sending a blood test called a “hemoglobin A1c” which indicates your average blood sugars over the past 3 months. If this test is high, it may mean that you had high blood sugars before pregnancy.

If I had gestational diabetes, does this mean I will have diabetes after I deliver?

Not necessarily. For most patients, gestational diabetes goes away after pregnancy. Sometimes patients will continue to have high blood sugars after pregnancy. In these circumstances they may be diagnosed with pre-diabetes or type 2 diabetes. The only way to know if your diabetes goes away after delivery is to have a glucose tolerance test (see below for more information). But, even if your blood sugars go back to normal after pregnancy, you are at higher risk of having diabetes later in life.

What is a Glucose tolerance test?

A glucose tolerance test is a blood test that is done after you are given a certain amount of sugar (glucose) to drink to see how your body handles the sugar. We recommend that you have this test done again after you deliver to see if your diabetes has gone away now that the pregnancy is over. The test should be done by 12 weeks (3 months) after delivery. For some patients, the diabetes does not go away. If that happens, it is likely that you have Type 2 diabetes.

If my postpartum glucose tolerance test is negative, am I still at risk?

Yes. If you had gestational diabetes, you are at a higher risk of having Type 2 diabetes in the future. It is very important to see your primary care doctor at least every year to be screened for diabetes, high blood pressure, and other medical problems.

If you had gestational diabetes in one pregnancy, you are also more likely to have gestational diabetes in future pregnancies. It is important to talk to your obstetric provider before planning your next pregnancy. Having high blood sugars early in pregnancy (in the first 12 weeks) increases your risk for miscarriage and your baby’s risk of birth defects. By working with your medical providers to get your blood sugars into a normal range before pregnancy, you will be setting yourself and your baby up for success.

Why am I still at risk for Type 2 diabetes if my gestational diabetes went away?

Pregnancy can be like a “stress test” for your body. It may reveal some weaknesses with how your body handles sugar. Your risk may also be higher because a lot of the conditions that make you more likely to have gestational diabetes also make you more likely to have Type 2 diabetes. These may include:

• Overweight and obesity  
• Family history
• Race and ethnicity
• Tobacco use
• Limited exercise and activity

Why is diabetes so bad?

Having high blood sugar levels can cause damage to important organs (like your heart, kidneys, brain, and eyes) as well as your blood vessels and nerves over time. Patients who keep their blood sugars in a safe range are less likely to have medical problems from diabetes (like heart attacks, strokes, blindness, numbness in toes and fingers, etc). That’s why earlier diagnosis and blood sugar control is important.

What can I do to lower my risk?

• Breastfeed if you can. Breastfeeding gives your baby the right balance of nutrients and helps you burn calories.
• Try to return to your pre-pregnancy weight by 1 year after you deliver. You can prevent or delay diabetes by losing even 5% of your body weight. For example, if you weigh 200 pounds, losing 10 pounds can go a long way!
• Be more active! Going for a walk can help burn calories and relieve stress. Walking one mile takes an average of 20 minutes and burns about 100 calories!
• Healthy Eating:
  • Choose whole grains (oatmeal, whole grain bread, etc) instead of refined grains (white bread, pasta, white rice) and processed foods (cakes, muffins, cookies)
  • Select healthy fats (liquid fats like olive oil are healthier than solid fats like butter) but be careful because they have a similar amount of calories
  • Have fresh fruits instead of snacks with added sugars
  • Aim to fill half your plate vegetables and fruits when you eat meals. The more colors the better!
  • Drink water instead of sweetened beverages. (Did you know: One can of soda a day can lead to ~15 pound weight gain in a year? To burn off the calories from one can of soda requires 30 minutes of running.)
• If you use tobacco, consider quitting. Smoking or vaping tobacco increases damage to blood vessels of the brain and the heart.

These healthy habits can also decrease your family’s risk of diabetes. Children of mothers with gestational diabetes are more likely to have diabetes in their life too. So get the whole family involved!

I’m interested. Is there help? Are there programs to help me?

Yes! You are NOT ALONE. You can always talk to your obstetrical or primary care provider.

Learn more about diabetes and prevention methods:

• Care New England Diabetes Resources
• Rhode Island Department of Health Diabetes Prevention Classes
• ACOG Gestational Diabetes 
• CDC Pregnancy and Gestational Diabetes
• American Diabetes Association 
• UpToDate

High Blood Pressure During and After Pregnancy

I was told I had high blood pressure during or after pregnancy, but what does this mean?

You may have been diagnosed with high blood pressure during or after pregnancy. There are a few different types of high blood pressure that can be diagnosed during or after pregnancy, including:

Gestational hypertension: Gestational hypertension is high blood pressure that only starts during pregnancy and goes away after pregnancy. It does not usually cause problems during pregnancy, but can affect your health over the long term.

Preeclampsia: Preeclampsia is a more dangerous condition with high blood pressure that can start any time in the second half of pregnancy or even after the baby is born and comes along with other problems like too much protein in the urine or problems with organs like the liver, kidneys, brain, eyes, or placenta. It may go away after pregnancy, but can also affect your long term health.

Chronic hypertension: Chronic hypertension is longstanding high blood pressure that is diagnosed before pregnancy or very early in pregnancy, but is not caused by pregnancy. This does not go away after pregnancy and affects your long term health.

What does this mean for my long term health?

It is important to know if you had high blood pressure during or after your pregnancy because this can affect your long term health. If you are not sure which type of high blood pressure you had, ask your obstetric medical provider.

We know that women with high blood pressure during pregnancy are more likely to have long-term high blood pressure, stroke (blood clot or bleeding in the brain), diabetes (high blood sugars), and heart disease in the future.

Even if your blood pressure goes back to normal a few months after you deliver, you should still have your blood pressure checked with your primary medical provider at 6 months and 1 year after you deliver, and then every year after to make sure you are not developing high blood pressure.

If your blood pressure does not go back to normal after you deliver, it is important to see your primary medical provider – they can help you keep your blood pressure in a healthy range and check for any problems that may happen from high blood pressure over the long term.

Are there things I can do to lower my chances of having high blood pressure over the long term?

Yes, even small changes can make a big difference!

If you are above a healthy weight, lowering your weight by 5% (10 lbs if you weigh 200 lbs) can lower your chances of high blood pressure, heart disease, and diabetes.

Eating healthy foods (like whole fruits, vegetables, and whole grains) and avoiding processed foods high in sugars, fats, and salt can help keep you at a healthy weight and blood pressure. Ask to see a nutritionist if you have questions about healthy eating.

Keeping active by doing at least 30 minutes, 5 times per week, of dedicated exercise that gets your heart rate up can help to lower your blood pressure. If you are not sure where to start, try walking and increase your pace over time!

If you smoke, consider quitting. Smoking can raise your blood pressure and affect your heart over time.

What about if I want another pregnancy in the future?

All of the above recommendations can help get you ready for a future pregnancy, but it is important to also talk with your obstetric provider so that you can make a safe plan for pregnancy together. There are certain medications that can be used to decrease your risks during pregnancy.

What is the proper way to check my blood pressure at home?

//www.preeclampsia.org/blood-pressure

Where can I get more information?

Preeclampsia Foundation: //www.preeclampsia.org/women-and-families

ACOG: //www.acog.org/patient-resources/faqs/womens-health/managing-high-blood-pressure

UpToDate: //www.uptodate.com/contents/preeclampsia-the-basics?topicRef=16893&source=see_link

Reaching a Healthy Weight After Pregnancy

How quickly should I lose weight after having a baby?

After pregnancy, the goal is to return to your pre-pregnancy weight by the time your baby is 1 year old. If you have a body mass index (BMI) over 30 or do not return to your pre-pregnancy weight, you have higher chances of having high blood pressure (hypertension), high blood sugar (diabetes or pre-diabetes), high cholesterol, and infertility.

How much weight should I lose?

Even small changes can make a big difference! While we recommend aiming to return to your pre-pregnancy weight by 1 year after delivery, lowering your weight by even 5% (for example, losing 10 lbs if you weigh 200 lbs) can lower your future risk of high blood pressure (hypertension), heart disease (like a heart attack or heart failure), high blood sugar (diabetes or pre-diabetes), and certain types of cancer. We know that healthy food choices and portions help the most with weight loss; if you want help with this, ask for a referral to a nutritionist. Breastfeeding and exercising may also help you with this weight loss so aim to exercise for 150 minutes each week and breastfeed if you are able.

What about if I want another pregnancy in the future?

If you are thinking of having another child, it is important to know that having obesity puts you at higher risk of having medical problems during pregnancy, like preeclampsia and diabetes. Losing weight before your next pregnancy can lower your risk and can even increase your chances of getting pregnant.

How can I decrease my risk of having medical problems in future pregnancies?

• Get active
• Eat a heart-healthy diet
• Stay at a healthy weight
• If you smoke, consider quitting
• See your doctor at least once per year to be screened for high blood pressure (hypertension), high blood sugar (diabetes or pre-diabetes), high cholesterol, and obesity
• If you want some help with weight loss, ask your healthcare provider for a referral to see a nutritionist to help you attain your goal
• If you want to get pregnant, talk with your Ob/Gyn or a Maternal-Fetal Medicine Specialist about planning another pregnancy

Where can I get more information?

ACOG: //www.acog.org/patient-resources/faqs/pregnancy/obesity-and-pregnancy 

ACOG: //www.acog.org/patient-resources/faqs/pregnancy/good-health-before-pregnancy-prepregnancy-care

March of Dimes: //www.marchofdimes.org/pregnancy/being-overweight-during-pregnancy.aspx

CDC: //www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-weight-gain.htm

ACOG Healthy Eating: //www.acog.org/patient-resources/faqs/womens-health/healthy-eating

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