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      <h1 id="top">3.3 Physical preparation</h1>
      <div class="section" id="Nipple_preparation"><h2>Nipple preparation</h2>
    <div>
      <p> The old texts abound with advice on nipple preparation techniques. Studies from the 1970s all found that any physical preparation of the nipples is entirely unnecessary and should <strong>NOT</strong> be recommended.</p>
      <p> In several large international trials treatment of inverted or non-protractile nipples during pregnancy, the use of Hoffman's nipple stretching exercises and/or breast shells revealed NO difference to the nipples compared to a group who had no intervention. Women in the intervention groups were more likely to not initiate breastfeeding or wean early. Therefore this practice is also not to be recommended.<sup><a href="#note1">1</a></sup> </p>
      <p> Routine expression of colostrum is likewise not necessary and could cause anxiety in women who are not comfortable handling their breasts in this manner, or in those who are unable to express colostrum - a fact which is not related to ability to breastfeed. <br />However, antenatal expression and collection of colostrum may be recommended for certain maternal or newborn medical reasons.<sup><a href="#note2">2</a></sup> This ready supply of colostrum will negate the need for artificial infant milk if a supplement is necessary. It also provides an ideal opportunity to teach mothers how to hand express, a skill they will need to learn anyway. </p>
      <p> </p>
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      <div class="section" id="Prenatal_breast_examination"><h2>Prenatal breast examination</h2>
    <div>
      <p> While there is no physical preparation necessary for breastfeeding, examination of the breasts during a routine prenatal check-up can reveal information that could assist with the care of the mother and baby postnatally, and it provides an ideal opportunity to discuss breastfeeding and any concerns the mother may have. Have the mother in a sitting position. </p>
      <p><span style="font-weight: bold;">The breast</span> is composed of glandular tissue (functional tissue), fibrous tissue and fatty tissue. Breast size is variable between women, and even in the same woman, being mostly dependent on the amount of fatty tissue present. Glandular tissue influences size to a lesser degree.</p>
      <p>The glandular tissue begins to function as a milk producing gland during pregnancy. The duct system and terminal milk-producing buds, called alveoli, proliferate during the first half of the pregnancy. Breast size increases for most women during this time. <br /></p>
      <p>Under the influence of the hormone prolactin, small amounts of colostrum are produced. Pregnancy progesterone inhibits full milk production. Breastmilk is synthesised and stored in the alveoli and travels through the duct system towards the nipple openings.</p>
      <p><span style="font-weight: bold;">The nipple</span> is in the centre of the areola and the least important structure of the breast during breastfeeding, being merely the structure through which the ends of the ductal system pass. Unfortunately, it is often the most commented on by the mother's advisors, forecasting success or failure of breastfeeding on the size and erectile nature of the nipple, which of course is incorrect. </p>
      <p> The areola may darken during pregnancy. Montgomery's follicles are tiny glands that have a pimple-like appearance on the areola and become more prominent during pregnancy. These follicles may secrete an oily substance, and some secrete tiny droplets of milk. Maternal areola odor is produced which enhances the newborn's sucking activity.<sup><a href="#note3">3</a></sup> Washing the breasts before feeding is not recommended as it washes away these protective secretions, and the important prefeeding stimulus provided by the unique smell.<br /></p>
    </div>
    <div class="section" id="Inspection"><h3>Inspection</h3>
      <div>
        <ul>
          <li><strong>Size and shape:</strong> Breasts and nipples come in an infinite variety of sizes and shapes. Breast size is not related to milk production. Remember, it's <em>breast</em>feeding, not nipple feeding. A 'different' nipple shape could provide mother and baby with a challenge - the key is to achieve good latch to the breast. </li>
          <li><strong>Asymmetry:</strong> Most women have asymmetrical breasts. Marked asymmetry should be noted, but no further action is necessary. If the smaller breast is felt to be hypoplastic, it is helpful to note that one breast can produce sufficient breastmilk for the baby. </li>
          <li><strong>Large breasts:</strong> Some women with very large breasts may like to discuss their feelings about their breasts and what breastfeeding is going to mean to them. Knowing how to help this mother to feed easily and discreetly could be the significant factor in her infant feeding decision. <br /></li>
          <li><strong>Skin appearance:</strong> The skin should appear smooth without thickening or dimpling, which, while rare in women of child-bearing age, could indicate an underlying tumour. Skin conditions such as psoriasis, dermatitis or bacterial or herpetic lesions should also be noted. </li>
          <li><strong>Scarring:</strong> Record the position and reason for surgical or injury scars noting their potential to impact on breastfeeding (eg. breast reduction surgery, areola incision, burns etc). <br /></li>
        </ul>
      </div>
      <div class="captionBox"><img width="307" height="242" src="images/montgom_foll_sc.jpg" alt="Nipple, areola and prominent Montgomery's follicles." /><p>Nipple, areola and prominent Montgomery's follicles. <br />&copy; S.Cox, IBCLC</p></div>
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    <div class="section" id="Palpation"><h3>Palpation</h3>
      <div>
        <p>
			This is an ideal health education opportunity to discuss and demonstrate breast self-examination as a routine breast screening technique for breast cancer, but which can also be useful to detect blocked ducts during lactation.
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      <div class="section" id="Record-keeping"><h2>Record-keeping</h2>
    <div>
      <p> It is important to record the signs and symptoms you noted at this examination. Later in the pregnancy the mother could be referred to a Lactation Consultant to discuss any issues which may impact on breastfeeding, such as breast reduction, augmentation, or if the mother has a concern about her capability to breastfeed. A medical review is indicated for other abnormalities noted. </p>
      <p> Markedly small or asymmetrical breasts may, or may not, make breastfeeding difficult. Postnatally, routine procedures should readily identify babies who are receiving insufficient breastmilk. However, a note in the mother's chart will alert staff to remain vigilant. </p>
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            <td class="body"><img src="design/thinker.gif" class="icon" alt="" /><h3>The power of words.</h3>
    <div>
      <p>
			It's often been commented that the most important organ for successful breastfeeding is the brain. There are essential hormones released here, but of <strong>MORE</strong> importance is the belief by the mother that she can breastfeed. A positive attitude by all her health care providers is essential to prevent self-doubt limiting the mother's potential.
		</p>
      <p>
			Be aware of the words you use and the impact they have on a mother's self-confidence.
		</p>
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      <div class="section" id="What_should_I_remember_"><h2>What should I remember?</h2>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/remember.png" class="icon" alt="" /><h3></h3>
      <div>
        <ul>
          <li>Prenatal preparation of the breasts and nipples is not necessary</li>
          <li>Breasts and nipples are all different and usually have no impact on breastfeeding ability or milk production</li>
          <li>The normal physiologic changes to the breasts during pregnancy</li>
          <li>How to note and record anomalies of a breast examination</li>
        </ul>
        <br />
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      <div class="section" id="Self-test_Quiz"><h2>Self-test Quiz</h2>
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      <div></div><div class="activity" id="activity_e">
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	new MCQ('All of the following are reasons during her pregnancy that you may show a woman how to hand express some colostrum, EXCEPT:', [{text:'to see if she will have colostrum in her breasts when her baby is born.',feedback:'You are correct. Not being able to express anything during pregnancy is not indicative of her ability to provide colostrum after the baby is born.',score:1},{text:'the mother has Type 1 diabetes mellitus.',feedback:'That\'s a very good reason to express antenatally. Her baby is at greater risk of hypoglycaemia, and being given formula supplements in some units. Having her own milk ready for the baby is a good idea.',score:0},{text:'the mother is expecting twins.',feedback:'That\'s a good reason to have some extra colostrum available from the time they are born in case it\'s needed.',score:0},{text:'to teach the mother how to hand express.',feedback:'Should the opportunity arise this is a good time to teach this skill that she will require after the birth of the baby.',score:0}]),
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    </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
    <div class="section" id="Assessment_Quiz"><h3>Assessment Quiz</h3>
      <div>
        <p>
		When you are happy that you've understood all the information in this topic you will be ready to complete the Module 3 Assessment. To do this, go to the course opening page, scroll down to the Assessment section and choose Module 3.
	</p>
      </div>
    </div>
  </div>
      <div id="footnotes">
        <h3>Notes</h3>
        <ol>
          <li id="note1"><a href="references.html#main94" title="See full details">#</a> MAIN Collaborative Group Preparing for Breast Feeding (1994) Treatment of inverted and nonprotractile nipples in pregnancy</li>
          <li id="note2"><a href="references.html#coxs06" title="See full details">#</a> Cox S (2006) Breastfeeding with Confidence</li>
          <li id="note3"><a href="references.html#scha06" title="See full details">#</a> Schaal B et al. (2006) Human breast areolae as scent organs: morphological data and possible involvement in maternal-neonatal coadaptation</li>
        </ol>
      </div>
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      <h1>Breastfeeding Essentials</h1>
      <ol>
        <li>1.0 <a href="topic_1-0.html">Why Breastfeeding is Important</a><ol><li>1.1 <a href="topic_1-1.html">Biochemistry</a></li><li>1.2 <a href="topic_1-2.html">Immunology</a></li><li>1.3 <a href="topic_1-3.html">Relative risks</a></li></ol></li>
        <li>2.0 <a href="topic_2-0.html">Communication Skills</a><ol><li>2.1 <a href="topic_2-1.html">Non-verbal</a></li><li>2.2 <a href="topic_2-2.html">Listening skills</a></li><li>2.3 <a href="topic_2-3.html">Building confidence</a></li><li>2.4 <a href="topic_2-4.html">An example</a></li></ol></li>
        <li>3.0 <a href="topic_3-0.html">Pregnancy Care</a><ol><li>3.1 <a href="topic_3-1.html">The feeding decision</a></li><li>3.2 <a href="topic_3-2.html">The barriers</a></li><li class="current">3.3 <img src="design/bullet_arrow_right.png" alt="*" title="You are here" /><a href="topic_3-3.html">Physical preparation</a></li></ol></li>
        <li>4.0 <a href="topic_4-0.html">The Birth Experience</a><ol><li>4.1 <a href="topic_4-1.html">The first hours</a></li><li>4.2 <a href="topic_4-2.html">Labor interventions</a></li><li>4.3 <a href="topic_4-3.html">Postnatal interventions</a></li></ol></li>
        <li>5.0 <a href="topic_5-0.html">Breastfeeding the Baby</a><ol><li>5.1 <a href="topic_5-1.html">Positioning Principles</a></li><li>5.2 <a href="topic_5-2.html">Breastmilk transfer</a></li><li>5.3 <a href="topic_5-3.html">Assessing breastfeeding</a></li></ol></li>
        <li>6.0 <a href="topic_6-0.html">A time to learn</a><ol><li>6.1 <a href="topic_6-1.html">Practical skills</a></li><li>6.2 <a href="topic_6-2.html">Breastfeeding messages</a></li><li>6.3 <a href="topic_6-3.html">Normal growth</a></li><li>6.4 <a href="topic_6-4.html">Sleep</a></li><li>6.5 <a href="topic_6-5.html">Psychological support</a></li><li>6.6 <a href="topic_6-6.html">Discharge planning</a></li></ol></li>
        <li>7.0 <a href="topic_7-0.html">Infant Challenges</a><ol><li>7.1 <a href="topic_7-1.html">Late preterm infant; Non-latching</a></li><li>7.2 <a href="topic_7-2.html">Hypoglycemia; Jaundice</a></li><li>7.3 <a href="topic_7-3.html">Supplementation</a></li><li>7.4 <a href="topic_7-4.html">Crying baby</a></li><li>7.5 <a href="topic_7-5.html">Inadequate weight gain</a><ol><li>7.5.1 <a href="topic_7-5-1.html">Feeding-line device at the breast</a></li><li>7.5.2 <a href="topic_7-5-2.html">Cup feeding</a></li><li>7.5.3 <a href="topic_7-5-3.html">Finger Feeding</a></li><li>7.5.4 <a href="topic_7-5-4.html">Bottle feeding</a></li></ol></li></ol></li>
        <li>8.0 <a href="topic_8-0.html">Maternal Challenges</a><ol><li>8.1 <a href="topic_8-1.html">Engorgement</a></li><li>8.2 <a href="topic_8-2.html">Nipple Pain</a></li><li>8.3 <a href="topic_8-3.html">Breast Problems</a></li><li>8.4 <a href="topic_8-4.html">Insufficient breastmilk</a></li><li>8.5 <a href="topic_8-5.html">Medical, Surgical Issues</a></li></ol></li>
        <li>9.0 <a href="topic_9-0.html">Promotion, Protection and Support</a><ol><li>9.1 <a href="topic_9-1.html">The International Code of Marketing of Breastmilk Substitutes</a></li><li>9.2 <a href="topic_9-2.html">The Baby Friendly Initiative</a></li><li>9.3 <a href="topic_9-3.html">Young Child Feeding</a></li><li>9.4 <a href="topic_9-4.html">Local initiatives</a></li><li>9.5 <a href="topic_9-5.html">Infant feeding in emergencies</a></li></ol></li>
        <li>10.0 <a href="topic_10-0.html">Closing session</a><hr /></li>
        <li class="appendix"> <a href="references.html">List of references</a></li>
        <li class="appendix"> <a href="contents.html">Course contents</a></li>
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