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Multiple choice questions 1-1 for Breast engorgement in the setting of delayed onset of lactogenesis II

Learning Objectives

  1. Describe the physiology of lactogenesis II
  2. Recognize maternal risk factors for delayed onset of lactogenesis II
  3. Describe normal growth and development of the newborn in the first week postpartum
  4. Recognize the association between lactogenesis II and breast engorgement
  5. Describe strategies for alleviating breast engorgement

Question 1

A 33 year old G2P2 presents with new onset, bilateral breast pain on postpartum day 6. The pain began early this morning and is described by the patient as dull, achy, and a 7/10 on the pain scale. She does not have any nipple pain until she attempts to breastfeed, when she experiences a pain of 9/10 and has to stop breastfeeding. She breastfed her son successfully within the first hour of life. Until yesterday she was breastfeeding him on demand for about 15-45 minutes at a time. Starting last night he became increasingly fussy and since this morning he is refusing to breastfeed. She has been bottle-feeding him frozen breast milk left over from her first child who just turned 2. She does not recall experiencing this level of pain with her first baby.

The patient gained 45 lbs (20.4 kg) during this pregnancy. Her pregnancy was further complicated by poorly controlled gestational diabetes for which she took metformin. She was induced at 37 weeks and gave birth to a baby boy weighing 9 pounds, 10 ounces (4.36 kg). Labor lasted 20 h total with over 2 hours of pushing.  Patient received an epidural and was discharged from the hospital on day 2.

This patient’s milk ‘came in’ on day 6 postpartum, suggesting a delay in the onset of lactogenesis II. Which of the following is not an independent risk factor for delayed onset lactogenesis II?

 

Question 2

A 33 year old G2P2 presents with new onset, bilateral breast pain on postpartum day 6. The pain began early this morning and is described by the patient as dull, achy, and a 7/10 on the pain scale. She does not have any nipple pain until she attempts to breastfeed, when she experiences a pain of 9/10 and has to stop breastfeeding. She breastfed her son successfully within the first hour of life. Until yesterday she was breastfeeding him on demand for about 15-45 minutes at a time. Starting last night he became increasingly fussy and since this morning he is refusing to breastfeed. She has been bottle-feeding him frozen breast milk left over from her first child who just turned 2. She does not recall experiencing this level of pain with her first baby.

The patient gained 45 lbs (20.4 kg) during this pregnancy. Her pregnancy was further complicated by poorly controlled gestational diabetes for which she took metformin. She was induced at 37 weeks and gave birth to a baby boy weighing 9 pounds, 10 ounces (4.36 kg). Labor lasted 20 h total with over 2 hours of pushing.  Patient received an epidural and was discharged from the hospital on day 2.

The physical assessment reveals firm breasts that are both tender to light palpation. Both nipples are slightly fissured, but no pus or blood are visible. The areolae surrounding the nipples are edematous, causing the nipples to appear flattened. She has 1+ pitting edema to mid-tibia, bilaterally. What is the best course of action to alleviate this patient’s symptoms?

 

Question 3

A 33 year old G2P2 presents with new onset, bilateral breast pain on postpartum day 6. The pain began early this morning and is described by the patient as dull, achy, and a 7/10 on the pain scale. She does not have any nipple pain until she attempts to breastfeed, when she experiences a pain of 9/10 and has to stop breastfeeding. She breastfed her son successfully within the first hour of life. Until yesterday she was breastfeeding him on demand for about 15-45 minutes at a time. Starting last night he became increasingly fussy and since this morning he is refusing to breastfeed. She has been bottle-feeding him frozen breast milk left over from her first child who just turned 2. She does not recall experiencing this level of pain with her first baby.

The patient gained 45 lbs (20.4 kg) during this pregnancy. Her pregnancy was further complicated by poorly controlled gestational diabetes for which she took metformin. She was induced at 37 weeks and gave birth to a baby boy weighing 9 pounds, 10 ounces (4.36 kg). Labor lasted 20 h total with over 2 hours of pushing.  Patient received an epidural and was discharged from the hospital on day 2.

How would you teach this patient to alleviate the breast engorgement? 

 
 
 
 

Question 4

A 33 year old G2P2 presents with new onset, bilateral breast pain on postpartum day 6. The pain began early this morning and is described by the patient as dull, achy, and a 7/10 on the pain scale. She does not have any nipple pain until she attempts to breastfeed, when she experiences a pain of 9/10 and has to stop breastfeeding. She breastfed her son successfully within the first hour of life. Until yesterday she was breastfeeding him on demand for about 15-45 minutes at a time. Starting last night he became increasingly fussy and since this morning he is refusing to breastfeed. She has been bottle-feeding him frozen breast milk left over from her first child who just turned 2. She does not recall experiencing this level of pain with her first baby.

The patient gained 45 lbs (20.4 kg) during this pregnancy. Her pregnancy was further complicated by poorly controlled gestational diabetes for which she took metformin. She was induced at 37 weeks and gave birth to a baby boy weighing 9 pounds, 10 ounces (4.36 kg). Labor lasted 20 h total with over 2 hours of pushing.  Patient received an epidural and was discharged from the hospital on day 2.

What changes in the circulating hormone levels contributed to the development of the symptoms experienced by this patient?

 

Question 5

A 33 year old G2P2 presents with new onset, bilateral breast pain on postpartum day 6. The pain began early this morning and is described by the patient as dull, achy, and a 7/10 on the pain scale. She does not have any nipple pain until she attempts to breastfeed, when she experiences a pain of 9/10 and has to stop breastfeeding. She breastfed her son successfully within the first hour of life. Until yesterday she was breastfeeding him on demand for about 15-45 minutes at a time. Starting last night he became increasingly fussy and since this morning he is refusing to breastfeed. She has been bottle-feeding him frozen breast milk left over from her first child who just turned 2. She does not recall experiencing this level of pain with her first baby.

The patient gained 45 lbs (20.4 kg) during this pregnancy. Her pregnancy was further complicated by poorly controlled gestational diabetes for which she took metformin. She was induced at 37 weeks and gave birth to a baby boy weighing 9 pounds, 10 ounces (4.36 kg). Labor lasted 20 h total with over 2 hours of pushing.  Patient received an epidural and was discharged from the hospital on day 2.

What changes are occurring at the cellular level within the mammary gland to support lactogenesis II?

Multiple choice questions 1-2 for Breast engorgement in the setting of delayed onset of lactogenesis II

Learning Objectives

  1. Identify concerning clinical findings for a neonate whose mother has delayed lactogenesis II
  2. Describe abnormal growth and development of the newborn in the first week postpartum
  3. Identify inadequate breastfeeding practices in the first week postpartum
  4. Differentiate between causes of neonatal jaundice in the first week postpartum
  5. Review patient-centered communication strategies when interacting with the mother-infant dyad

Question 1

An anxious first time mother calls for your advice about her 7-day-old female infant. Which of the following statements from this mother would be a cause for concern? 

 

 

Question 2

An anxious first time mother calls for your advice about her 7-day-old female infant. She reports that yesterday her baby had 3 wet diapers.

When asked about her breastfeeding experience, the mom explains that she is worried that the newborn is not getting a good latch since the baby seems fussy while trying to breastfeed, after frequently falling asleep during feeds over the last few days. What additional question would be most helpful in assessing the feeding difficulties in this maternal-fetal dyad?

 

 

Question 3

An anxious first time mother calls for your advice about her 7-day-old female infant. She reports that yesterday her baby had 3 wet diapers. When asked about her breastfeeding experience, the mom explains that she is worried that the newborn is not getting a good latch since the baby seems fussy while trying to breastfeed, after frequently falling asleep during feeds over the last few days. She has been exclusively breastfeed and nurses every 4-6 hours.  

What is the appropriate response? 

 

 

Question 4

An anxious first time mother calls for your advice about her 7-day-old female infant. She reports that yesterday her baby had 3 wet diapers. When asked about her breastfeeding experience, the mom explains that she is worried that the newborn is not getting a good latch since the baby seems fussy while trying to breastfeed, after frequently falling asleep during feeds over the last few days. She has been exclusively breastfeed and nurses every 4-6 hours.

The mother explains that the newborn was born vaginally at 37 weeks gestation with a birth weight of 6 lb, 9 oz (2.97 kg). Labor was uncomplicated and mother and baby were released after 56 hours. When looking through the medical records, you see that total serum bilirubin at 56 h was 10.2 mg/dL. At the pediatrician appointment on day 4 pp, the infant was not distressed and no facial anomalies were noted. She was afebrile with HR 130 bpm, RR 42, weight 5 lb 14 oz (2.65 kg). Bilirubin was 14.8 mg/dL (normal < 2 mg/dL). The mother was advised to continue breastfeeding. Why is the bilirubin increasing? 

 

 

Question 5

An anxious first time mother calls for your advice about her 7-day-old female infant. She reports that yesterday her baby had 3 wet diapers. When asked about her breastfeeding experience, the mom explains that she is worried that the newborn is not getting a good latch since the baby seems fussy while trying to breastfeed, after frequently falling asleep during feeds over the last few days. She has been exclusively breastfeed and nurses every 4-6 hours.

The mother explains that the newborn was born vaginally at 37 weeks gestation with a birth weight of 6 lb, 9 oz (2.97 kg). Labor was uncomplicated and mother and baby were released after 56 hours. When looking through the medical records, you see that total serum bilirubin at 56 h was 10.2 mg/dL. At the pediatrician appointment on day 4 pp, the infant was not distressed and no facial anomalies were noted. She was afebrile with HR 130 bpm, RR 42, weight 5 lb 14 oz (2.65 kg, weight change ~ 10.7%). Bilirubin was 14.8 mg/dL (normal < 2 mg/dL). The mother was advised to continue breastfeeding.

The mother mentions that her breasts started feeling very full yesterday and the baby is refusing to latch. What is your recommendation?