Definition
A.Breast engorgement is swollen, tender breasts caused by overfilling of milk, increased blood flow, and fluids in the breasts.
Incidence
A.Breast engorgement may affect 40% of postpartum mothers.
Pathogenesis
A.Primary engorgement is the result of distension and stasis of the vascular and lymphatic circulations occurring 2 to 4 days following delivery. It is prompted by the decrease in progesterone levels after the placenta is delivered.
B.Secondary engorgement is caused by distension of the lobules and alveoli with milk as lactation is established. It may occur from excessive stimulation of milk production via pumping, taking medications to increase milk supply, or decreased milk extraction from not feeding the baby as often. Without stimulation by suckling and removal of milk, secretion of prolactin decreases and milk production decreases and finally ceases.
Predisposing Factors
A.Engorgement often develops if early feedings are not frequent enough, suckling is inadequate, or breastfeeding is not conducted in a relaxed atmosphere.
Common Complaints
A.Swollen, tender breasts.
B.Discomfort when breastfeeding.
C.A low-grade fever lasting between 4 and 16 hours.
Other Signs and Symptoms
A.Pain, tenderness, and redness in one area of the breast is associated with mastitis.
B.Physical examination should not be focused just on breast symptoms but should include a general ruling out of other potential problems, such as coexistent urinary tract infection (UTI).
Subjective Data
A.Elicit onset, duration, and course of symptoms. Review the frequency of breastfeeding and/or use of breast pump. Is the patient still breastfeeding, or has she stopped because of the discomfort?
B.Exclude other causes of fever, such as UTI, wound infection, and red streaks on one or both breasts, to rule out mastitis.
C.Quantify pain symptoms and relief measures, including heat packs, ice packs, breast binder, and analgesics such as Tylenol.
Physical Examination
A.Check temperature, blood pressure (BP), and pulse.
B.Inspect: Examine the breasts for erythemic streaks on breasts. Check episiotomy or abdominal incision, if indicated.
C.Palpate:
1.Examine the breasts for tenderness, hardness, warmth, and lumps.
2.Palpate axilla for lymphadenopathy.
3.Check back for costovertebral angle (CVA) tenderness.
Diagnostic Tests
A.Tests generally are not indicated for breast engorgement.
B.Urine culture or wound culture, if applicable.
Differential Diagnoses
A.Breast engorgement.
B.Mastitis.
Plan
A.General interventions:
1.Encourage the patient to take analgesics prior to breastfeeding and continue breastfeeding.
2.Encourage ice packs for discomfort and frequent breastfeeding. There should be no stimulation to the breasts other than that provided by the baby when nursing, and the patient should take analgesics for discomfort. Reassure her that engorgement is temporary and usually resolves within 24 to 48 hours.
B. 
See Section III: Patient Teaching Guide Postpartum Breast Engorgement
:
1.Educate the patient regarding milk production.
2.Advise the patient to breastfeed frequently to reduce chances of engorgement.
3.Provide reassurance and support for the patient to continue breastfeeding through this temporary period of discomfort. Engorgement may last 2 to 3 days before milk supply meets demand; continuation of breastfeeding will resolve discomfort and problem.
C.Pharmaceutical therapy: Acetaminophen (Tylenol) two tablets 500 to 1,000 mg every 4 to 6 hours, or ibuprofen 400 to 600 mg orally 30 to 45 minutes prior to breastfeeding and as needed.
Follow-Up
A.Follow-up may not be required for engorgement.
B.Lactation consultation if indicated.
Individual Considerations
A.Pregnancy loss: It is imperative to discuss breast care and engorgement with women who have a second-trimester termination of pregnancy, have a stillbirth, or experience a neonatal loss.