INTRODUCTION

The first milk your breasts produce is called colostrum. It’s a highly nutritious first milk
that your body begins making in pregnancy. Colostrum transitions to breast milk after
three to five days. Engorgement tends to occur during this time because your milk
production is ramping up. Your breasts will be fuller, firmer, swollen and tender to the
touch. After several days, the pain and discomfort should gradually subside.

The increase in blood supply helps your body make breast milk for your baby, but it can
cause severe engorgement. Engorged breasts are a temporary problem but can happen as
long as you produce milk.

The most common reasons for breast engorgement are:

 You’ve given birth and your milk is “coming in.”

 You’re breastfeeding (chestfeeding) and skip nursing sessions.

 Your baby changes their feeding schedule. For example, they start sleeping
through the night.

 You skip pumping sessions or forget to pump when you’re away from your baby.

 You have an oversupply or make more milk than your baby needs.

 You’re weaning your child from breastmilk to another form of milk.

It can be tricky to balance managing your milk supply and preventing engorgement.
However, there are ways you can relieve the discomfort and minimize complications
from engorged breasts.

DEFINITION

Breast engorgement is when your breasts are painful, swollen and tender because they’re
overly full of milk. It occurs most often in the days and weeks after giving birth due to
milk production and increased blood supply to your breasts (chest).

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Breast Engorgement after Birth

Some degree of breast engorgement is normal during the first week or two after your
baby's birth. An increase in blood flow to your breasts along with a surge in your milk
supply often results in your breasts getting overly full.

If you're breastfeeding, this stage of breast engorgement typically starts to get better
within a few days as your feeding habits take hold and your milk production adjusts to
meet your baby's needs. Those who aren't planning to breastfeed also experience breast
engorgement.

Because your body doesn't know your feeding plans, it will make breast milk. You'll
begin to feel the telltale fullness when your milk comes in between the third and fifth day
postpartum.

If you don't remove the breast milk, your body will gradually stop making more. The
uncomfortable part of engorgement should only last a few days, but you'll continue to
make milk for a few weeks until production fully tapers off.

CAUSES OF BREAST ENGORGEMENT

Certain conditions or events may make you more likely to experience

the swollen fullness that’s commonly associated with breast engorgement. These causes
include:

 missing a feeding

 skipping a pumping session

 creating an overabundance of milk for the baby’s appetite

 supplementing with formula between nursing sessions, which may reduce nursing
later

 weaning too quickly

 nursing a baby that’s ill

 difficulty with latching and sucking

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  not expressing breast milk when it first comes in because you don’t plan to
breastfeed

Other Causes of Breast Engorgement

Whenever breast milk builds up in your breasts and it's not removed regularly or fully,
swelling and firmness can develop. The following situations can lead to breast
engorgement.

 Schedule Changes

Whether you nurse, pump, supplement with formula, or do any combination of the three,
schedule changes can have a big impact on your milk supply. When milk that is normally
expressed at a certain time isn't, it sits in the breasts and causes them to fill, which can
quickly lead to breast engorgement if not managed.

For instance, you might notice engorgement when your baby's nap schedule changes and
they are now sleeping during what would normally be a feeding time. Going back to
work also can lead to engorgement.

Even when you can nurse or pump, there may be a change that leads to engorgement. For
example, your child may have trouble nursing if they are sick and have a stuffy nose,
which can lead to not eat as much.

If engorgement does happen, the key is to go easy on yourself. Nursing parents are tired
and busy, so it's easy for breast engorgement to sneak up on you.

 Overabundant Milk Supply

Generally, the amount of breast milk your body makes is based on demand. The more
your baby nurses, the more milk is produced, optimally at just the right level to keep your
baby full but not engorge your breasts.

However, this process can occasionally get out of whack, particularly when your supply
is just getting established. And producing too much milk, or hyperlactation, can cause
engorgement.

o Causes of Overabundant Milk Supply

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 Some possible causes of hyperlactation, or an overabundant milk supply, include:

 Genetics: You may simply have a biological predisposition to make a lot of breast
milk.

 How you breastfeed: Excess milk production is often the result of not adequately
draining both breasts, which can happen if you tend to breastfeed more on one side
or the other.

 Overpumping: If you pump too frequently, this prompts more milk at that session
as well as future sessions.

 Hormone level: You may have an overabundance of the hormone prolactin, which

is responsible for stimulating milk production.

 Baby strike: An overabundant supply can also happen temporarily if your baby
is refusing the breast.

 Baby growth spurt: Your baby may suddenly start nursing much more, which
can stimulate an overproduction of milk that results in engorgement.

 Medications: Galactagogues, drugs that may be taken to treat other conditions or

specifically to boost milk production, may lead to an oversupply.

 Breast implants: Breast implants may block the flow of breast milk from your
breasts. In this case, your baby's suckling keeps stimulating more milk, but it sits
in your breast instead of being expressed.

 Weaning or Supplementing

Breast engorgement also can happen when you make adjustments to your baby's diet,
such as adding first foods, supplementing with formula, or switching to formula or milk.
(Note: The American Academy of Pediatrics does not recommend cow's milk for babies
until age 1.).

If you're supplementing your child with formula between feedings, they may not drink as
much while nursing, which can result in a temporary oversupply. Also, if weaning takes

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place too rapidly, the same situation occurs. For this reason, gradually reducing the length
and frequency of feedings is recommended.

SIGNS AND SYMPTOMS OF BREAST ENGORGEMENT

The symptoms of breast engorgement will be different for each person. However, breasts
that are engorged may feel:

 hard or tight

 tender or warm to touch

 heavy or full

 lumpy

 swollen

The swelling may be contained to one breast, or it may occur in both. Swelling can also
extend up the breast and into the nearby armpit.

The veins running under the breast’s skin may become more noticeable. This is a result of
the increased blood flow, as well as the tightness of the skin over the veins.

Some with breast engorgement may experience a low-grade fever and fatigue in the first
days of milk production. This is sometimes called a “milk fever.” You can continue to
nurse if you have this fever.

However, it’s a good idea to alert your doctor to your increased temperature. That’s
because some infections in the breast can cause fever, too, and these infections need to be
treated before they become bigger issues.

Mastitis, for example, is an infection that causes inflammation of the breast tissue. It’s
most commonly caused by milk trapped in the breast. Untreated mastitis can lead to
complications such as a collection of pus in the clogged milk ducts.

TREATMENT FOR BREAST ENGORGEMENT

The treatments for breast engorgement will depend on whether you’re breastfeeding or
not.

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For those who are breastfeeding, treatments for breast engorgement include:

 using a warm compress, or taking a warm shower to encourage milk let down

 feeding more regularly, or at least every one to three hours

 nursing for as long as the baby is hungry

 massaging your breasts while nursing

 applying a cold compress or ice pack to relieve pain and swelling

 alternating feeding positions to drain milk from all areas of the breast

 alternating breasts at feedings so your baby empties your supply

 hand expressing or using a pump when you can’t nurse

 taking doctor-approved pain medication

For those who don’t breastfeed, painful engorgement typically lasts about one day. After
that period, your breasts may still feel full and heavy, but the discomfort and pain should
subside. You can wait out this period, or you can use one of the following treatments:

 using a cold compress or ice packs to ease swelling and inflammation

 taking pain medication approved by your doctor

 wearing a supportive bra that prevents your breasts from moving significantly

PREVENTION OF BREAST ENGORGEMENT

You can’t prevent breast engorgement in the first days after giving birth. Until your body
knows how to regulate your milk production, you may overproduce.

However, you can prevent later episodes of breast engorgement with these tips and
techniques:

 Feed or pump regularly. Your body makes milk regularly, regardless of nursing

schedule. Nurse your baby at least every one to three hours. Pump if your baby
isn’t hungry or you’re away.

 Use ice packs to decrease supply. In addition to cooling and calming inflamed
breast tissue, ice packs and cold compresses may help decrease milk supply.

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 That’s because the cool packs turn off the “let down” signal in your breasts that
tells your body to make more milk.

 Remove small amounts of breast milk. If you need to relieve the pressure, you
can hand express some breast milk or pump a bit. Don’t pump or express too
much, however. It could backfire on you, and your body may end up trying to
produce more milk to make up for what you just removed.

 Wean slowly. If you’re too quick to stop nursing, your weaning plan may
backfire. You could end up with too much milk. Slowly wean your child so your
body can adjust to the decreased need.

If you don’t breastfeed, you can wait out breast milk production. In a matter of days, your
body will understand it doesn’t need to produce milk and the supply will dry up. This will
stop the engorgement.

Don’t be tempted to express or pump milk. You’ll signal to your body that it needs to
produce milk, and you may prolong discomfort.

COMPLICATIONS OF ENGORGED BREASTS

While breast engorgement usually goes away on its own with proper management, it can
create problems for both the breastfeeding parent and baby. Here is what you need to
know about the risks of prolonged engorgement.

 Problems for the Baby

Engorgement can sometimes lead to an overactive let-down reflex. This fast flow can
cause your baby to briefly gag, choke, and swallow excessive amounts of air as they're
trying to latch on and feed. If this is a recurrent problem, pump a bit of milk before each
nursing session.

Low milk supply may not seem like a likely outcome of engorgement, but it is possible if
the issue is persistent. Engorgement makes your breasts full and hard, which can cause
your nipples to become flat. This can cause a poor latch and result in your baby drinking

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less. When this milk stays inside the breast, it signals that milk is not needed and slows
milk production.1

Some babies may also go on a nursing strike during engorgement due to frustration from
trying to latch on or coping with a strong letdown. Low milk supply aside, this alone can
cause poor weight gain and erode breastfeeding confidence.

 Problems for the Breastfeeding Parent

Many people leave the hospital within a few days of childbirth, so breast engorgement
often begins at home. Because this condition can be painful and cause difficulty with
latching on, it's a common cause of early weaning.

Many nursing parents expect breastfeeding to be easy but find that getting the hang of it
can actually be challenging. Know that it's not your fault and these are common issues.

In addition to the discomfort, engorgement also can lead to a host of issues. These
include painful blebs (blisters covering a nipple opening), plugged milk ducts, sore
nipples, or mastitis. Always consult a healthcare provider or lactation consultant to ensure
you have the correct diagnosis.

SUBINVOLUTION

Sub involution of placental site also known as placental site vascular sub involution or
sub involution of uteroplacental arteries, is an important contributor to secondary
postpartum bleeding. Sub involution of the placental site refers to delayed or inadequate
physiologic closure and sloughing of the superficial modified spiral arteries at the
placental attachment site. Sub involution can be identified and documented by the typical
clinical features and the histologic findings in postpartum endometrial curettings and
hysterectomy specimens. Although detailed studies have been performed by several
authors to determine the normal and abnormal anatomy and histology of the uterine
placental site, there is a relative lack of practice-oriented literature on the topic of sub
involution. Sub involution of the placental site is commonly associated with delayed

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post-partum or post abortal hemorrhage. It tends to occur in the older group of obstetrical
patients and in multiparae.

DEFINITION

Uterus involution refers to the process where your pregnant uterus (womb) returns to the

way it was before pregnancy. Your uterus goes through major changes when you’re
pregnant. The lining of your uterus thickens, your blood vessels widen and your uterus
grows several times its normal size. These changes transform your uterus into a space of
nourishment and protection for a growing fetus.

Diagram showing subinvolution

Description

 Subinvolution is delayed return of the enlarged uterus to normal size and function.

Etiology

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  Subinvolution results from retained placental fragments and membranes,
endometritis, or uterine fibroid tumor; treatment depends on the cause .

Pathophysiology

 Uterine atony or placental fragments prevent the uterus from contracting

effectively.

Assessment Findings

Clinical manifestations include:

1. Prolonged lochial discharge

2. Irregular or excessive bleeding

3. Larger than normal uterus

4. Boggy uterus (occasionally)

Normal involution of the uteroplacental arteries

After delivery, a physiologic mechanism of uteroplacental arterial involution is required

to eliminate these altered vessels. In the third trimester, this process begins modestly as
the endovascular extravillous cytotrophoblasts are replaced by maternal-derived
endothelial cells. The exact temporal relationships are not fully elucidated, but several
involution events occur within the uteroplacental vascular bed in the few days after
delivery. These changes include occlusive fibrointimal thickening, endarteritis,
thrombosis, regeneration of the internal elastic lamina, and disappearance of both
endovascular and interstitial extravillous cytotrophoblasts. Although the histomorphology
of involutional events is well described, the exact molecular basis that triggers these
changes remains poorly understood. Necrosis and sloughing of the decidua and
superficial endomyometrium occur in tandem with the involutional vascular changes.
Contraction of the uterine smooth muscle also contributes to mechanical shrinkage and
involution of the placental site as a whole. Taken together, one very important
consequence of these changes is to limit the loss of blood at the placental site after
delivery.

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SYMPTOMS OF SUBINVOLUTION OF UTERUS

Subinvolution symptoms include:

 Postpartum hemorrhage

 Prolonged lochial discharge

 Larger than normal uterus

 Boggy uterus (occasionally)

COMMON CAUSES OF SUBINVOLUTION OF UTERUS

The following are the most common causes of Sub involution of uterus:

 uterine fibroids

 uterine prolapse

 caesarean section

 grand multiparity

 overdistension of uterus in twins

 uterine sepsis

RISK FACTORS FOR SUBINVOLUTION OF UTERUS

The following factors may increase the likelihood of Sub involution of uterus:

 long period of labor

 full bladder

 maternal infection

 anesthesia

 persistent lochia bleeding

 retained placenta

 difficulty in delivery

 abuse of ergot

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  retained products of conception

PREVENTION OF SUBINVOLUTION OF UTERUS

Yes, it may be possible to prevent Subinvolution of uterus. Prevention may be possible

by doing the following:

 daily monitoring of fundal height to prevent uterine subinvolution

COMPLICATIONS OF SUBINVOLUTION OF UTERUS IF UNTREATED

Yes, Sub involution of uterus causes complications if it is not treated. Below is the list of
complications and problems that may arise if Sub involution of uterus is left untreated:

 postpartum uterine bleeding

PROCEDURES FOR TREATMENT OF SUB INVOLUTION OF UTERUS

The following procedures are used to treat Sub involution of uterus:

 Hysterectomy: Partial or complete removal of uterus

NURSING MANAGEMENT

1. Prevent excessive blood loss, infection, and other complications.

a. Massage uterus, facilitate voiding, and report blood loss.

b. Monitor blood pressure and pulse rate.

c. Administer prescribed medications.

d. Be prepared for possible D&C.

2. Assist the client and family to deal with physical and emotional stresses of postpartum
complications.

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SUMMARY/CONCLUSION

Breast engorgement is when your breasts are painful, swollen and tender because
they’re overly full of milk. It occurs most often in the days and weeks after giving birth
due to milk production and increased blood supply to your breasts (chest).

The increase in blood supply helps your body make breast milk for your baby, but it can
cause severe engorgement. Engorged breasts are a temporary problem but can happen as
long as you produce milk.

Uterus involution refers to the process where your pregnant uterus (womb) returns to the
way it was before pregnancy. Your uterus goes through major changes when you’re
pregnant. The lining of your uterus thickens, your blood vessels widen and your uterus
grows several times its normal size. These changes transform your uterus into a space of
nourishment and protection for a growing fetus.

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REFERENCES

Alekseev NP, Vladimir II, Nadezhda TE. Pathological postpartum breast engorgement:

prediction, prevention, and
resolution. (https://pubmed.ncbi.nlm.nih.gov/25774443/) Breastfeed Med. 2015
May;10(4):203-8. Accessed 10/17/2022.

Jamie A. Weydert and Jo Ann Benda (2006) Subinvolution of the Placental Site as an
Anatomic Cause of Postpartum Uterine Bleeding: A Review. Archives of
Pathology & Laboratory Medicine: October 2006, Vol. 130, No. 10, pp. 1538-
1542.

Mangesi L, Dowswell T. Treatments for breast engorgement during lactation. Cochrane

Database Syst Rev. 2010;(9):CD006946. doi:10.1002/14651858.CD006946.pub2

National Health Service. Breast pain and

breastfeeding. (https://www.nhs.uk/conditions/baby/breastfeeding-and-bottle-
feeding/breastfeeding-problems/breast-pain/) Accessed 10/17/2022.

Paliulyte V, Drasutiene GS, Ramasauskaite D, Bartkeviciene D, Zakareviciene J,

Kurmanavicius J. Physiological uterine involution in primiparous and multiparous
women: ultrasound study. (https://pubmed.ncbi.nlm.nih.gov/28555159/) Obstet
Gynecol Int. 2017;2017:6739345. Accessed 4/4/2022.

Pregnancy Birth & Baby. Breast

engorgement. (https://www.pregnancybirthbaby.org.au/breast-engorgement) Acc
essed 10/17/2022.

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Pustotina O. (2015). Management of mastitis and breast engorgement in breastfeeding
women. DOI:
10.3109/14767058.2015.1114092

Üçyiğit A, Johns J. The postpartum ultrasound

scan. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5105363/) Ultrasound.
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