Page 760 - ACCCN's Critical Care Nursing

Pregnancy and Postpartum Considerations 737

engorged; quite hard and lumpy in places, hot and tender
to touch. A reddened localised region in this setting may BOX 26.12 Principles of expressing
be indicative of mastitis and may require treatment with breast milk
antibiotics. The nipples should be examined for damage
if the woman is being expressed (or has had the infant How often should I express?
suckle). Hand expressing is usually not harmful to the Generally speaking, women are recommended to express 2–3
nipples and the nipples should not have any cracks. hrly. This may be difficult to achieve in the ICU environment.
Colostrum (or milk once it has come in) may leak from Clinicians should aim for at least 6 times per 24 hours including
the nipples; both colostrum and breast milk can be at least once overnight.
rubbed gently over the nipples to promote healthy tissue.
Machine expression may be harmful to the nipple if Hand express or machine express?
uneven and strong suction pressure is applied. It is recommended to use hand expression only in the first few
days with use of a machine reserved for when the milk has
Initiation and Establishment of Lactation come in. Always start and finish the expression by hand, as
hand expression provides a better stimulus for milk production
The establishment and maintenance of lactation is a than the machine does, and promotes release of the ‘let-down’
hormone-mediated process. The physiological trigger for reflex which will assist with milk flow and removal. Expressing
the establishment of lactation is a fall in progesterone by hand or machine should not be painful.
combined with maintained levels of prolactin and corti- Storage and transport of expressed milk
201
sol. In the initial postnatal period colostrum is pro-
duced. The normal timing for milk to ‘come in’ is between The most useful container for collection of expressed colostrum
202
3 and 4 days post-delivery, although establishment and is a 2 or 5 mL syringe and a specimen M&C container for small
‘coming in’ of breast milk may be delayed in critically ill volumes of milk. Always label the container with the woman’s
women. Additionally, the drug dopamine may hinder name, and the date and time of the expression. Use a new
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lactation, as it inhibits prolactin secretion. It is not collection container for each expression. Breast milk must be
likely that the severity of maternal illness plays much of stored in a refrigerator and may be frozen. A ‘cooler bag’ with
a role in the initial capacity to produce milk; anecdotally, ice packs should be used to transport the milk from ICU to
100 mL of breast milk has been expressed 4 hourly from where the baby is being cared for.
a postpartum woman on ECMO. The initial regularity of
hand expression and milk removal provide the stimulus
to produce milk.
For women who prefer to breastfeed the infant, reason-
able attempts to support this decision should be made.
Most women make a decision regarding infant feeding
either before becoming pregnant or during the first
trimester and in all pregnant women, the breasts have
developed and are capable of producing milk from 22
weeks onwards. 204,205
There is some debate regarding how crucial the first
24–48 hours are for the successful establishment of lacta-
tion. 206,207 In many cultures, colostrum is considered
poisonous and breastfeeding is withheld until after 48 FIGURE 26.5 How to hand express.
hours and so clearly the absence of breast stimulation in
the first 48 hours does not prohibit the establishment of
208
lactation. Hand expressing is recommended for the first Oxytocin is most commonly known for its role in the
few days until the milk ‘comes in’, and then to start and ‘let-down reflex’ of milk during breastfeeding, but also
finish each expressing episode along with the use of a has known effects on brain areas involved in emotion
209
breast pump (see Box 26.12 for principles and Figure and stress response, increased levels of oxytocin lower
26.5 for process). It is not uncommon for only a few blood pressure among mothers who breast feed their
drops of colostrum to be expressed each time in the first babies. This is known to improve a mother’s mood,
210
couple of days. It is believed that even a small total increases pain tolerance, and also has a possible positive
expressed volume of 5–10 mL per day of colostrum may association in wound healing. Prolactin may also be
be of value to stimulate the ‘coming in’ of full milk pro- responsible for intense ‘mothering’ feelings. 203
201
duction. The two key factors that support the establish-
ment of lactation are breast stimulation (infant suckling, If the mother’s intention was to formula feed, or if the
hand expression) and milk removal. The more often you baby has died, then the lactation process may be sup-
express and remove milk, the positive feedback mecha- pressed. In practice, this means providing no stimulation
nisms ensure that more milk is produced. Frequent, short to the breasts (i.e. no hand expression). Although used
expression of the breasts is more effective than prolonged in the past, medications are no longer used to influence
infrequent expressing. Overnight expression is also this process. With no breast expression, some women
important. may still experience milk ‘coming in’ at or after Day 4