BREAST CARE
INTRODUCTION
Breasts are very vulnerable and fragile part of women’s body. During pregnancy because of various hormonal changes in the body, breasts too undergo a number of changes. Therefore, it’s important to take special care of them during this period. The breasts also show prominent signs of pregnancy. They evolve and prepare themselves for the arrival of the newcomer.
DEFINITION
Breast care means care given to the breast by the mother during her prenatal period, intranatal period and postnatal period.
WHY IS BREAST CARE IMPORTANT?
Breast care means care given to the breast by the mother during her prenatal period, intranatal period and postnatal period.
WHY IS BREAST CARE IMPORTANT?
It is important to take care of your breasts if you plan to breastfeed or are breastfeeding. With good breast care, the mother can improve her breastfeeding experience for herself and for her baby. Taking care of breasts will also help to prevent problems that can happen while breastfeeding.
CARE OF THE BREAST DURING PREGNANCY PERIOD
During pregnancy due to increased blood flow, the breasts become tender and swollen. So, special care and attention should be given to the breasts so that after childbirth, the mother is fully prepared to breastfeed her baby without any problem.
It is important to begin preparing the breast for breastfeeding during the prenatal period.
(1) A well-fitting support bra should be worn at all times. This will provide good support for the enlarging breasts. As the breasts enlarge, an increase in bra and cup size should be worn. Avoid underwear bras, as under wires can put pressure on milk glands and interfere with milk production.
(3) During the last weeks of pregnancy, the breasts start preparing themselves for lactation Pads may be worn inside the bra cups to absorb possible colostrum leakage from the nipples. The pads should be changed if they become wet from leakage. Prolonged moisture against the nipples may lead to tenderness and cracking once the newborn infant begins nursing. Select from reusable and disposable varieties available at stores. Change them several times a day and allow the nipples to air dry each change.
(4) The breasts should be washed daily (without soap) to remove dried colostrum and to prevent irritation to the nipples. Lanolin may be applied to the nipples to prevent evaporation of perspiration, thereby softening the skin. Wet tea bags may be placed on the nipples, as the tea will release tannic acid, which will toughen the skin. The nipples should be air dried or blow dried after washing to help toughen them, especially if the patient plans to breastfeed.
(5) The major change during this period is the change in the breast size due to increase in fat and milk glands. This means, breast grows in size and weight. Wear a comfortable and correct size of bra. They must wear a good brand bra which provides support and holds the breast in place without squeezing them.
(6) The bra size should be changed according to the change in breast size during this phase. Choosing the right bra, prevents the breasts from sagging.
(7) Under wire bras should be avoided as they put pressure on the milk glands and thus interferes with lactation.
(8) As the size of the breast increases there are chances that this may lead to stretch marks. So expecting mothers should apply and massage stretch mark creams on their breast gently.
The nipples change in color and size as well. They sore, enlarge and stick out more. Too much dryness, too much friction and too much wetness, makes the nipples sore. So, inorder to avoid the dryness, expecting mother should avoid:
* Using soaps on their breasts and instead should apply good moisturising creams on them.* Rubbing the breast and nipples with towel
* Wearing tight and incorrect size bras
Breasts need regular and special attention during pregnancy. One should not overlook any tumours and must visit breast physician for their advice and treatment. Because even the smallest tumour can start growing during this period and interfere with the ducts and prove to be a hindrance during lactation.
WHY CARE OF THE BREAST SHOULD BE TAKEN DURING PREGNANCY?
Proper education of mother and relatives is possible and mandatory during pregnancy. Flat or inverted nipple can lead to difficulties in breastfeeding for the child. Hence, during pregnancy women can become aware of it & take necessary steps.
CARE OF FLAT AND INVERTED NIPPLES:
Nipples can be flat, normal, long or inverted. Flat nipples cannot be gripped easily. Inverted nipples cannot be held by fingers. Both can cause feeding difficulties and get injured while giving breastfeeding.
Steps of care:
Once breastfeeding is begun usually nipple starts protracting out.
Following tips can also help:
1. Try gentle pulling of nipples for flat nipples by fingers.
2. As shown in diagram cut a 10 ml syringe at the front end, remove the plunger from hind end and insert it from the cut front end. Then press open hind end of the syringe lightly over the areola covering the nipple and withdraw the plunger (which is now at the front cut end) so that the nipple is pulled into the syringe. Maintain pull for 20 to 30 seconds and then release. Gently remove the syringe. Nipple will remain protruded. Then put the child for breastfeeding.
3. Use “Nipple Shell” (hard plastic shell with holes worn over nipples) for flat and inverted nipples. If not available in the market, make it at home from wood, plastic or cap of feeding bottle. Remember, to make it with smooth margins So file all sharp margins, as there can be injurious.
BREAST DISCHARGE DURING PREGNANCY:
From fourth to sixth month of pregnancy, thick, yellow fluid begins to form inside the breast. This may or may not be, expressed out. There is no definite advantage or disadvantage of expressing this milk. Take care, while expressing this milk, to avoid injury to the nipples.
CARE OF THE BREAST DURING BREASTFEEDING
Need of breast care for all lactating mothers is most necessary as this directly links health of mother and her baby. So it becomes important to take care of your breasts if you are breastfeeding. Good breast care improves health of your breast and in turn breast feeding for you and your baby.
v Avoid pressure on the breasts:
Do not wear underwear bras, and avoid wearing bras that are too tight and clothes that are tight over the breasts. Avoid wearing or carrying items that can squeeze or press on the breasts. These include big purses, baby carriers and slings, and diaper bags. After rinsing the breasts, you might want to apply a few drops of breast milk or colostrum to the areolas. These substances will soothe and protect your nipple. In addition, some women find it beneficial to rub a few drops of corn oil or olive oil on their nipples.
v Sleeping Position:
Sleeping in a face down position may squeeze your breasts and block milk ducts.
v Breast support:
Wear a supportive bra. This can be a regular bra that the mother takes off when she breastfeed or a nursing bra with breast flaps. Cotton bras are best as they will not trap moisture that can irritate the nipples. Make sure the bra fits correctly and does not squeeze the breasts.
v Do not use underwire Bra:
Avoid wearing underwire bras. The milk ducts extend up towards the armpits. Underwire bras can squeeze the breasts and pinch on milk ducts, and cause plugged ducts or mastitis (breast infection).
v Cleaning the breasts:
Always keep the breasts clean. Wash breasts with warm water once or twice every day. Strictly do not use soap or other cleansing agents. These can wash up the natural lubrication and may cause cracking of nipples and may irritate nipples. Always keep the hands clean while touching your breasts to prevent infections. Always wash the hands thoroughly for 15 seconds before breastfeeding, expressing, or pumping. Then dry them completely and always use a clean paper towel after every washing.
v Keep the nipples dry:
Do not wear plastic nipple shells or plastic-lined nursing pads. These can trap moisture and do not allow air flow to the nipple. Placing cotton fabric breast pads inside your bra will let air inside. Change breast pads often to prevent irritation. If nipples are damaged, nursing pads may stick to the nipple. Soak the pads in warm water to help remove them.
v Nipple conditioning:
Let the nipples air dry after breastfeeding. Use breast milk or pure lanolin ointment or some pure milk fat on the nipples if needed to keep them from getting chapped and dried out. Avoid creams and lotions that can cause an allergic reaction with irritation of the skin.
v Breast Creams for Dry or Cracked Nipples:
Often, women who are breastfeeding will develop dry and/or cracked nipples. This can make breastfeeding quite painful. In order to soothe and heal nipples, some mothers use a breast cream, such as Pure Lan® or Lansinoh®, after they nurse. If the mother chose to use one of these creams, she shouldn't wash it off after application.
v Using Nursing Pads to Prevent Leaks:
At some point or another, many breastfeeding moms will experience leakage. In fact, many pregnant women will leak milk or colostrum during their second or third trimesters. Leaking milk can not only stain your clothes but can also lead to embarrassing situations. In order to keep your clothes dry, you might consider wearing nursing pads.Many breastfeeding moms opt to use washable or disposable nursing pads. If selecting this type of nursing pad, you should look for one that is made of 100 percent cotton. This will allow air to circulate around the breasts and the nipples. Avoid pads with plastic linings, which may not allow sufficient airflow and may contribute to nipple infections.If the mother does not want to buy nursing pads, she can create one by cutting a disposable diaper into the desired shape and removing the plastic lining. Also, some women use cloth diapers or handkerchiefs as nursing pads. She should not use a sanitary pad as a nursing pad, as it will prevent air from circulating.If the mother uses a nursing pad, she should change it or dispose of it as soon as it becomes damp. Wearing a moist pad can lead to irritation and infection.
WHAT PROBLEMS MAY OCCUR WHEN BREASTFEEDING?
· Decreased nipple blood supply: This can cause the mother to have pain and blanching (becoming pale) of her nipples while breastfeeding. Decrease the amount of caffeine the mother drink, such as in coffee, tea, and soda, to help prevent nipple blanching. Do not smoke and avoid being in cold areas. Certain medicines may make the blood vessels get narrow and decrease blood flow to the nipples. Always ask the caregiver before using any medicine. Let him know when the mother has nipple blanching.
· Engorgement: Although it is normal for the breasts to fill with milk, they can become too full. Breast engorgement is a condition where the breasts are painful and very swollen from too much milk inside. Breastfeeding the baby often will help empty the milk and prevent engorgement. If the baby cannot empty the breast milk, the mother can express milk from her breasts by hand or with a breast pump. Ask the caregiver for more information about breast fullness verses breast engorgement. Tell the caregiver if the mother want more information on expressing breast milk.
· Leaking breasts: The breasts may leak when they are full of milk and not emptied often. The mother may see milk dripping from her nipples. This is normal. To stop this, cross the arms over the chest and press them lightly over the nipples. The mother can also wear nursing pads inside her bra to soak up the milk. Wear several layers of clothing, and avoid wearing solid colored shirts. Doing these things may make the leaking milk harder to see on her clothes.
· Nipple pain: The mother can get sore nipples when she first start breastfeeding. This should get better as her body gets used to breastfeeding. She can get sore, cracked, or bleeding nipples if her baby is not latched-on in a good position. To prevent this, she needs to be careful when positioning your baby to feed. Make sure her baby has a mouthful of her breast when he feeds. To latch-on well, his lips and gums should be on her areola and not just on her nipple. Help the baby to latch-on and come off the breast without sucking to prevent injuring the nipple. Ask the caregiver for more information about nipple soreness.
· Plugged milk ducts: Milk ducts are pathways where milk flows from milk producing areas in the breast down to the nipple. Things that can block the milk ducts include milk that gets thicker, scar tissue, or something pressing on them. The blockage can decrease or stop the flow of the breast milk in one part of the breast. It can make the milk build up inside and cause the breast to swell. Plugged ducts can lead to getting a breast abscess (area of infection in the breast) or mastitis. Always empty the breasts completely and do not let long periods of time pass between breast feedings. Breastfeeding often will help to prevent from getting plugged ducts again or getting a breast infection. Ask the caregiver for more information about breastfeeding and plugged ducts.
HOW CAN THE MOTHER PREVENT PROBLEMS WITH HER BREASTS BEFORE HER BABY IS BORN?
· Prenatal nipple conditioning: This uses exercises to help decrease nipple discomfort when the mother starts to breastfeed her baby. These exercises may also cause her uterus to have contractions. This can cause her baby to be born too early. Ask the caregiver first before trying any nipple conditioning exercise. The mother can also dress so that her nipples rub against the clothes she wears. Do these exercises two times each day starting six weeks before the baby is due to be born:
o Massage the breasts gently.
o Roll the nipples between the fingers for 1 to 2 minutes. The mother can also use a special cream while rolling her nipples.
o Rub the nipples gently with a soft towel for 15 seconds.
HOW CAN THE MOTHER PREVENT PROBLEMS WITH HER BREASTS WHILE BREASTFEEDING?
· Break the suction from the baby's suckling before taking him off the breast. Make sure the baby is not suckling anymore before taking him off the breast. To stop the baby from suckling, gently insert the finger into his mouth. This will loosen his attachment to the breast and the mother can lift him off easily without pulling on her nipple.
· Breastfeed or pump at least eight times a day, and breastfeed as often as the baby wants. The baby can feed 8 to 12 times a day, or even more. Make sure the baby has a mouthful of the mother’s breast so he could suckle easily. The baby will get the right milk flow when he has a mouthful of her breast. Offer both breasts when breastfeeding. Be sure the first breast is completely emptied before offering the second breast. Use a breast pump to remove and store leftover milk after the baby has finished feeding. The mother may also use it to remove excess milk if she misses a breastfeeding session, or any time her breasts feel very full. Ask the caregiver for more information on how to use a breast pump.
· Find a comfortable position during breastfeeding. Hold the baby in a position where he can suckle at your breasts easily and comfortably. Learn the feeding positions that are comfortable and line the breast up well with the baby's mouth. Use one of these positions every time you breastfeed your baby. If the baby is not in the right position he may have trouble latching-on and suckling easily. He may not get enough milk and may suck harder. This can cause pain or change the shape of the nipple for a few minutes. Make sure the baby is well latched-on so he can suckle easily. Ask the caregiver for more information about how to hold and breastfeed the baby.
· Learn how to get the baby to latch-on well. To latch-on means that the baby has taken all of the nipple and part of the areola (dark circle around your nipple) far into his mouth. Latch-on is important for the baby to get enough breast milk. The mother will know the baby is latched-on well if:
o The breast or nipple does not hurt while feeding.
o The baby is able to suckle milk right away after he latches-on. Suckling should change from quick short sucks to slow deep sucks. The mother should be able to hear him swallowing and see his jaw move downward with each suck.
o The nipple is the same shape as it was before the feed started when the baby comes off her breast.
· Make sure you are relaxed during breastfeeding. The mother should be relaxed and calm during breastfeeding. This helps increase the flow of her breast milk. Put a warm wet cloth on her breast or take a warm shower to increase her milk flow.
· Make sure the baby is relaxed during breastfeeding. Making sure the baby is relaxed during breastfeeding will help him to completely empty the breasts. Massage the breasts so he does not have to work at getting your milk to start flowing. If the baby is suckling too hard and breastfeeding becomes painful, the mother needs to relax his mouth. To do this she needs to massage his jaw below his ears. Stroke in a circular motion to relax and widen his mouth. She can gently pull her baby's chin down using a finger. This lets his tongue stick out and rest between his gums and her nipple. Hold the baby's head so that his jaw is behind the nipple. In this way, milk can be squeezed out and there will be enough milk flowing out.
· Use devices for breastfeeding correctly. Read the instructions that come with the breast pump. Use the device as instructed and always keep it clean. If it causes any injury to the breast, stop using it. The mother may need help to learn how to use it. She can get this from a caregiver or other professional, such as a lactation consultant. Do not use breast pads that irritate the breasts or trap too much moisture. These breast pads increase the risk for nipple damage and infection. Use nipple shields or shells only as directed by the caregiver or lactation consultant.
CONCLUSION
Breastfeeding moms know that breast care changes after giving birth. The breasts undergo a number of changes during pregnancy and continue to change as a woman's milk supply comes in and her baby begins feeding. Knowing how to care for the breasts during this time will benefit both the mother and her new baby.
BIBLIOGRAPHY
Books
· Adele Pillitteri , “TEXTBOOK OF MATERNAL AND CHILD HEALTH NURSING”, 5th edition, published by Lippincott Williams and Wilkins, Page no: 229-236
· Annamma Jacob, “A COMPREHENSIVE TEXTBOOK OF MIDWIFERY”,
2nd edition, Jaypee Brothers Medical Publishers, 2008, Page No. 151-153.
· Diane M. Fraser, “MYLES TEXTBOOK FOR MIDWIVES”, 14th edition, Library of Congress Cataloging in Publication,2003,Page No. 762.
· Novak, Broom, “TEXTBOOK OF MATERNAL AND CHILD HEALTH NURSING”, 9th edition Mosby Publication, Page no: 337-341.
Website
http://www.drketan.com/breastfeed/chapter_2.pdf
BREAST SELF EXAMINATION
INTRODUCTION
Women may perform breast self exams to help detect changes in their breasts to call to their physicians' attention. Performing regular breast self exams can help women become familiar with the individual characteristics of their breasts and notice any changes.
DEFINITION
Breast self – examination (BSE) is a screening method used in an attempt to detect early breast cancer. The method involves the woman herself looking at and feeling each breast for possible lumps, distortions or swelling. Women older than 20 years should perform monthly breast examinations (BSE).
TECHNIQUES TO PERFORM BREAST EXAMINATION
An pictorial example of breast self-examination in six steps. Steps 1-3 involve inspection of the breast with the arms hanging next to the body, behind the head and in the side. Step 4 is palpation of the breast. Step 5 is palpation of the nipple. Step 6 is palpation of the breast while lying down.
A variety of methods and patterns are used in breast self-exams. Most methods suggest that the woman stand in front of a mirror with the torso exposed to view. She looks in the mirror for visual signs of dimpling, swelling, or redness on or near the breasts. This is usually repeated in several positions, such as while having hands on the hips, and then again with arms held overhead.
The woman then palpates her breasts with the pads of her fingers to feel for lumps (either superficial or deeper in tissue) or soreness. There are several common patterns, which are designed to ensure complete coverage. The vertical strip pattern involves moving the fingers up and down over the breast. The pie-wedge pattern starts at the nipple and moves outward. The circular pattern involves moving the fingers in concentric circles from the nipple outward. Some guidelines suggest mentally dividing the breast into four quadrants and checking each quadrant separately. The palpation process covers the entire breast, including the "axillary tail" of each breast that extends toward the axilla (armpit). This is usually done once while standing in front of the mirror and again while lying down.
In the shower
A BSE can easily be performed while you're in the bath or shower. Some women discover breast masses when their skin is moist.
o Raise your right arm.
o With soapy hands and fingers flat, check your right breast.
o Use the same small circles and up-and-down pattern described earlier.
o Repeat on the left breast.
Various mnemonic devices are used as teaching devices. One is called the seven P's of BSE, after seven steps that are named to have the same first initial: Positions, Perimeter, Palpation, Pressure, Pattern, Practice, and Planning what to do if a change is found in the breast tissue.
For pre-menopausal women, most methods suggest that the self-exam be performed at the same stage of the woman's menstrual cycle, because the normal hormone fluctuations can cause changes in the breasts. The most commonly recommended time is just after the end of the period, because the breasts are least likely to be swollen and tender at this time. Women who are postmenopausal or have irregular cycles might do a self-exam once a month regardless of their menstrual cycle.
DESCRIPTION
To complete a monthly BSE:- When lying down, place a pillow under the right shoulder and position the right arm behind the head. Using the finger pads of the three middle fingers on the left hand, check the entire breast area. Use small circles and follow an up-and-down pattern while pressing firmly enough to know how the breast feels from month to month. This exam should then be repeated on the left breast using the finger pads of the right hand with the pillow under the left shoulder.
- When standing before a mirror, any changes in the shape or look of the breasts should be checked. In order to look for any skin or nipple changes such as dimpling or nipple discharge, the arms should first be placed at the sides and then overhead. Hands are then placed firmly on hips to flex chest muscles, and then the body should be bent forward.
- When taking a shower, the right arm should be raised. By using soapy hands and fingers flat the right breast and outer part of the breast can be examined. The same small circles and up-and-down pattern used when lying down should be used in an upright position. Repeat on the left breast.
PREPARATION
Before beginning a monthly BSE, a woman's breasts should be completely exposed.
THE FIVE STEPS OF BREAST EAXMINATION
Step 1: Begin by looking at your breasts in the mirror with your shoulders straight and your arms on your hips.
Here's what you should look for:
· Breasts that are their usual size, shape, and color
· Breasts that are evenly shaped without visible distortion or swelling
If you see any of the following changes, bring them to your doctor's attention:
· Dimpling, puckering, or bulging of the skin
· A nipple that has changed position or an inverted nipple (pushed inward instead of sticking out)
· Redness, soreness, rash, or swelling
Breast Self-Exam - Step 1
Step 2: Now, raise your arms and look for the same changes.
Breast Self-Exam - Steps 2 and 3
Step 3: While you're at the mirror, look for any signs of fluid coming out of one or both nipples (this could be a watery, milky, or yellow fluid or blood).
Step 4: Next, feel your breasts while lying down, using your right hand to feel your left breast and then your left hand to feel your right breast. Use a firm, smooth touch with the first few finger pads of your hand, keeping the fingers flat and together. Use a circular motion, about the size of a quarter.
Cover the entire breast from top to bottom, side to side — from your collarbone to the top of your abdomen, and from your armpit to your cleavage.
Follow a pattern to be sure that you cover the whole breast. You can begin at the nipple, moving in larger and larger circles until you reach the outer edge of the breast. You can also move your fingers up and down vertically, in rows, as if you were mowing a lawn. This up-and-down approach seems to work best for most women. Be sure to feel all the tissue from the front to the back of your breasts: for the skin and tissue just beneath, use light pressure; use medium pressure for tissue in the middle of your breasts; use firm pressure for the deep tissue in the back. When you've reached the deep tissue, you should be able to feel down to your ribcage.
Breast Self-Exam - Step 4
Step 5: Finally, feel your breasts while you are standing or sitting. Many women find that the easiest way to feel their breasts is when their skin is wet and slippery, so they like to do this step in the shower. Cover your entire breast, using the same hand movements described in Step 4.
Breast Self-Exam - Step 5
NORMAL RESULTS
Each woman's breasts has their own normal look and feel. By completing a BSE each month, a woman can determine what is normal for her and check for changes that may arise. A regular pattern of lumpiness in the breasts is normal.
ABNORMAL RESULTS
If any changes are noticed during a monthly BSE, such as a new, hard lump in the breast or underarms, a doctor should examine the area immediately. Other trouble signs that should not be ignored include:- change in breast size or shape
- dimpling or puckering of the skin
- redness, swelling, or warmth that does not go away
- pain in one area that does not vary with a woman's monthly cycle
- a nipple that pulls in
- discharge from the nipple that begins suddenly and appears only in one breast
- one nipple that has an itchy, sore, or scaling area
LIMITATIONS
According to a meta-analysis in the Cochrane Collaboration, two large trials in Russia and Shanghai found no beneficial effects of screening by breast self-examination "but do suggest increased harm in terms of increased numbers of benign lesions identified and an increased number of biopsies performed." They concluded, "At present, screening by breast self-examination or physical examination cannot be recommended."
Although breast self-examination increases the number of biopsies performed on women, it does not reduce mortality from breast cancer. In a large clinical trial involving more than 260,000 female Chinese factory workers, half were carefully taught by nurses at their factories to perform monthly breast self-exam, and the other half were not. The women taught self-exam detected more benign (normal or harmless lumps) or early-stage breast disease, but equal numbers of women died from breast cancer in each group.
Because breast self-exam is not proven to save lives, it is no longer routinely recommended by health authorities for general use. It may be appropriate in women who have a particularly high risk of developing breast cancer. Some charitable organizations, whose donations depend on promoting fear of breast cancer, still promote this technique as a one-size-fits-all, universal screening approach, even in the low-risk women who are most likely to be harmed by unnecessary invasive follow-up procedures. Among groups promoting evidence-based medicine, awareness of breast health and familiarity with one's own body is typically promoted instead of self-exams.
CONCLUSION
Breast self examination has been universally accepted by the experts as a very simple, significant and effective method of early detection of Breast cancer. As with all other types of cancer early detection and a high index of suspicion are the keys to combating the menace of cancer.
BIBLIOGRAPHY
Books
1. Altman, Roberta and Michael J. Sarg, "BREAST SELF-EXAMINATION", The Cancer Dictionary, Checkmark Books, 2000, Page No: 547- 556.
2. Bruce. R, Richard E. Blackwell, “ESSENTIAL REPRODUCTIVE MEDICINE”, 3rd edition, Library Of Congress Cataloging-In-Publication, 2005, Page No: 351 - 356.
3. Pillitiri A, “MATERNAL AND CHILD HEALTH”,5th edition, Mosby, St.Louis, Philadelphia, 2007, Page No: 245-253.
4. Norman F. Gant, “WILLIAMS OBSTETRICS”, 21st edition, Library of Congress Cataloging in Publication, 2001, Page No. 400-405.
Website
CLINICAL BREAST EXAMINATION
INTRODUCTION:
The premise underlying CBE is that visually inspecting and palpating of the breast and surrounding tissue can detect breast abnormalities. CBE was considered by the committee to include a continuum of integrally related components, from the examination itself, to interpretation and reporting of findings, to patient follow up. The recommendations for performance in this report represent general standards that can be immediately disseminated and adopted based on current evidence.
Neither CBE nor mammography is a substitute for the other as an independent examination for detecting breast abnormalities. When a suspicious mass is found on CBE, it must be evaluated and explained even if mammography examination does not show an abnormality.
However, the practitioner needs to be alert to the possibility of carcinoma at all times. Early detection of potential malignancies has been and continuous to be the single most important factor in the successful treatment of this disease. Since professional assessment is done only periodically , each woman is advised to do a breast self-examination on a monthly basis at the time when the breast is least affected by menstrual changes, 4 to 10 days after the last menstrual period.
As the examiner proceeds through the examination , the woman is taught about BSE or if she already follows a routine for BSE , her knowledge and technique are refreshed.At the start of the examination, the breasts are abserved for symmetry , contour , color, size, and surface characterstics such as vascularity , moles, and nevi. The nipples are checked for areolar pigmentation and discharge and for response to stimulation (i.e., erection, flattening or inversion)
- The Examination:
a. Adopt standards for CBE that include a stepwise progression of elements consisting of clinical history, visual inspection, and palpation.
.
.
|
|
|
Clinicians are encouraged to adopt and implement the following standards for performance of the CBE examination. Efforts to encourage widespread dissemination of these standards must be implemented as a partnership between clinicians and health care organizations.
Clinical History :
A clinical history that identifies the patient’s personal and family health history is useful in assessing risk of breast cancer. Some women will not report symptoms until asked, and a clinical history provides an important opportunity to seek out this information. This health history can direct attention to potentially relevant symptoms and provides important context for interpreting findings. The clinical guidelines and policy statements of many organizations concerning the performance of screening CBE emphasize the importance of a woman’s individual risk for breast cancer.15 Furthermore, information on clinical history can help guide follow up. The clinical history also provides an opportunity for the provider to explain the benefits and limitations of the examination, its elements, the time involved, and the related events that occur after the examination (interpretation, reporting, and follow up).
A clinical history that identifies the patient’s personal and family health history is useful in assessing risk of breast cancer. Some women will not report symptoms until asked, and a clinical history provides an important opportunity to seek out this information. This health history can direct attention to potentially relevant symptoms and provides important context for interpreting findings. The clinical guidelines and policy statements of many organizations concerning the performance of screening CBE emphasize the importance of a woman’s individual risk for breast cancer.15 Furthermore, information on clinical history can help guide follow up. The clinical history also provides an opportunity for the provider to explain the benefits and limitations of the examination, its elements, the time involved, and the related events that occur after the examination (interpretation, reporting, and follow up).
The clinical history should:
- Identify screening practices for breast health,when they were performed, and results. These practices include breast self-examination (BSE), prior CBE, and prior screening and diagnostic mammograms.
- Ask about any breast changesand how they were identified. This includes changes in appearance of skin or nipples, presence of lumps, pain (focal versus general and constant versus cyclic), itching, or staining of garments or bed sheets that would indicate spontaneous nipple discharge.
- Assess riskby asking about age and personal history, including benign breast disease, biopsy, cancer, cosmetic or other breast surgery, history of hormonal therapy, and/or oral contraceptive use, obstetric history, family history, and health promotion habits (eg, exercise, nutrition).
Visual Inspection:
Once the clinical history has been completed, the patient’s breasts should be visually inspected. To minimize awkwardness and potential misunderstandings, providers should inform women in advance that a visual inspection will be performed and describe what is being assessed during this part of the examination. The patient should sit with her hands pushing tightly on her hips. This position contracts the pectoralis major muscles and enhances identification of asymmetries. Although adding multiple positions (eg, hands over head and hands at sides) may further assist identification of asymmetries, it does not add substantively to the single position recommended and may reduce time devoted to palpation. When conducting the visual inspection, the provider must view the breasts from all sides and should:
Once the clinical history has been completed, the patient’s breasts should be visually inspected. To minimize awkwardness and potential misunderstandings, providers should inform women in advance that a visual inspection will be performed and describe what is being assessed during this part of the examination. The patient should sit with her hands pushing tightly on her hips. This position contracts the pectoralis major muscles and enhances identification of asymmetries. Although adding multiple positions (eg, hands over head and hands at sides) may further assist identification of asymmetries, it does not add substantively to the single position recommended and may reduce time devoted to palpation. When conducting the visual inspection, the provider must view the breasts from all sides and should:
- Assess symmetry in breast shape or contour (subtle changes or differences) and
- Assess skin changes, particularly any skin erythema, retraction or dimpling, and nipple changes. Physical signs associated with advanced breast cancer have been summarized using the acronym BREAST, signifying Breast mass, Retraction, Edema, Axillary mass, Scaly nipple, and Tender breast.
If the clinician is seeing the patient on a regular basis, visual inspection allows the monitoring of changes in appearance over time when observations are compared with previously documented examination. Visual inspection takes only a short amount of time, with the remainder of the examination spent predominately on palpation.
Palpation:
Following the visual inspection, the examiner palpates each breast and nearby lymph nodes. To minimize awkwardness and the potential for misunderstanding, providers should inform women in advance that palpation will be performed and describe what is being assessed during this part of the examination. Palpation provides an opportunity for discussion of the normal variability of breast characteristics and the importance of women becoming familiar with the characteristics of their own breasts. Thoroughness is essential; palpation must examine all breast tissue as well as nearby lymph nodes. Appropriate palpation includes five key characteristics:
Following the visual inspection, the examiner palpates each breast and nearby lymph nodes. To minimize awkwardness and the potential for misunderstanding, providers should inform women in advance that palpation will be performed and describe what is being assessed during this part of the examination. Palpation provides an opportunity for discussion of the normal variability of breast characteristics and the importance of women becoming familiar with the characteristics of their own breasts. Thoroughness is essential; palpation must examine all breast tissue as well as nearby lymph nodes. Appropriate palpation includes five key characteristics:
- Position: Patients should be sitting for palpation of the axillary, supraclavicular, and infraclavicular lymph nodes. Patients should be lying down for breast palpation, with their ipsilateral hand overhead to flatten the breast tissue on the chest wall, thereby reducing the thickness of the breast tissue being palpated (Figure 1). If this maneuver does not result in a relatively even distribution of breast tissue, the breast should be further centralized by placing a small pillow under the shoulder/lower back on the side of the breast being examined. The tissue being examined needs to be as thin as possible over the chest wall. The examiner must be able to see the full palpation area.
- Perimeter: All breast tissue falls within a pentagon shape (as opposed to the traditional perception of the breast as a conical structure). The examiner should use the following landmarks to cover all of this area: down the midaxillary line, across the inframammary ridge at the fifth/sixth rib, up the lateral edge of the sternum, across the clavicle, and back to the midaxilla.
- Pattern of search: The full extent of breast tissue should be searched using a "vertical strip" pattern (Figure 1). (A systematic analysis demonstrated the superiority of the vertical strip search pattern over concentric circle and radial spoke patterns in thoroughness of coverage, as performed by women trained in BSE to examine themselves.) The search should be initiated at the axilla. If a mastectomy has been performed, the chest wall, skin, and incision should be included.
- Palpation: The examiner should use the finger pads of the middle three fingers to palpate one breast at a time (Figure 2). Palpate with overlapping dime-sized circular motions. Tissue at and beneath the nipple should be palpated, not squeezed. Squeezing often results in discharge as well as discomfort. Only spontaneous discharge warrants further evaluation.Breast tissue in the upper outer quadrant and under the areola and nipple should be thoroughly searched, as these are the two most common sites for cancer to arise.
- Pressure: As each area of tissue is examined, three levels of pressure should be applied in sequence: light, medium, and deep, corresponding to subcutaneous, mid-level, and down to the chest wall (Figure 3). Adapt the palpation to the size, shape, and consistency of tissue, and accommodate pressure to other factors such as breast size and the presence of breast implants. Providers sometimes lack confidence performing CBE in women with breast implants; implants correctly placed are located behind the tissue of the breast. Therefore, the steps for CBE are exactly the same as in women without implants.
Duration for CBE:
· The duration of the examination is intentionally not specified, for several reasons. First, while thoroughness is related to time spent performing CBE, performance time can decrease with increased proficiency. Additionally, a variety of patient factors, such as breast size, tenderness, lumpiness, body weight, and risk factors, can influence the time required to perform a proficient CBE.
2. Interpretation and Reporting:
a. Reporting should consist of a summary of the relevant portions of a patient’s history and a description of whether the CBE is interpreted as normal/negative or abnormal. If abnormal, include a description of the visual and palpable findings, including changes in the appearance of skin or nipples, the presence of nipple discharge, the presence of breast masses or palpable asymmetries, and the presence of palpable lymph nodes.
The primary function of CBE is to identify abnormalities that warrant further evaluation; CBE alone is not capable of accurately distinguishing benign from malignant status. Interpreting the visual and tactile observations of CBE is complex. A variety of patient characteristics can influence interpretation, including age, parity, tissue density and nodularity, menopausal status, phase of the ovarian cycle, and health history.2
Ø For example: bloody nipple discharge during the last trimester of pregnancy or the first 3 months of lactation may be considered a normal physiologic change, but it would be interpreted quite differently in a woman who was not pregnant or lactating.
Ø Similarly, skin erythema or lymphedema would not necessarily be cause for further evaluation in a woman having recently undergone radiation therapy of the breast but would certainly require follow up in a woman without such a history.
Ø A more common and difficult challenge involves breast lumpiness or nodularity, which varies considerably among women and over time for the same woman. For example, increased nodularity might be normal during the luteal phase of the menstrual cycle, but at other times it might be cause for further examination.
In the most general form, the results of CBE can be interpreted in two ways:
- Normal/Negative: No abnormalities on visual inspection or palpation.
- Abnormal: Asymmetrical finding on either visual inspection or palpation that warrants further evaluation and possible referral. Findings will reflect a continuum of possible outcomes, from probably benign to highly suspicious of cancer. Determination of benign or malignant status, however, can be established only through further evaluation.
Reporting
Reporting should include a description of all findings in specific and precise language, regardless of interpretation. In the case of a negative interpretation, description of findings provides a baseline for interpreting future results from visual inspection and palpation. In the case of an abnormal interpretation, a description provides an important guide for follow-up examination.
Reporting should include a description of all findings in specific and precise language, regardless of interpretation. In the case of a negative interpretation, description of findings provides a baseline for interpreting future results from visual inspection and palpation. In the case of an abnormal interpretation, a description provides an important guide for follow-up examination.
Reporting should follow the same sequence as the examination itself. The following outline directs providers’ attention to those aspects of the exam that represent unique patient characteristics or abnormalities. To the extent possible, electronic reporting should be encouraged to provide compatibility with existing medical records systems and more efficient analysis of reporting trends.
CHARACTERSTICS OF NORMAL & ABNORMAL BREAST:
Normal Breast Characteristics:
- Clinical history – describe:
- Breast screening practices.
- Breast changes.
- Risk factors for breast cancer.
- Hormonal factors at time of examination (eg, time in menstrual cycle, pregnancy, breast feeding, hormonal contraceptives, hormone therapy).
- Visual inspection – describe:
- Scarring.
- Symmetry of breast shape and appearance of skin and nipple-areolar complex.
- Palpation of lymph node – describe results with respect to:
- Infra- and supraclavicular nodes.
- Axillary nodes.
- Breast palpation – describe results with respect to:
- Nodularity.
- Normal nodularity should not be described as a fibrocystic condition.
- Normal cyclic breast tenderness should not be described as a pathologic condition.
- Symmetry.
- Tenderness (focal versus generalized and constant versus intermittent).
- Recommended follow up.
Abnormal CBE: Abnormal Breast Characteristics:
- Clinical history – describe:
- Breast screening practices.
- Breast changes.
- Risk factors for breast cancer.
- Hormonal factors at time of examination (eg, time in menstrual cycle, pregnancy, breast feeding, hormonal contraceptives, hormone therapy).
- Visual inspection – describe:
- Contour (skin retraction, dimpling).
- Color (erythema).
- Texture (skin thickening or lymphedema).
- Skin retraction or dimpling.
- Nipple scaling or retraction.
- Nipple inversion (age of onset during adulthood).
- Location of abnormal findings or mass according to a clock face as the examiner faces the patient, clearly indicating whether the abnormality is in the right or left breast.
- Size/extent of abnormal finding or mass.
- Palpation – for each palpable abnormality (including breast tissue and infraclavicular,supraclavicular, and axillary lymph nodes), describe:
- Three-dimensional dominant mass or two-dimensional thickening.
- Location in three dimensions (subcutaneous, midlevel, next to chest wall, and according to a clock face as the examiner faces the patient).
- Size.
- Shape (round, oblong, irregular, lobular [having one to four rounded or curved extensions from a central mass]).
- Mobility (mobile, fixed to skin or chest wall).
- Consistency (soft, similar to surrounding breast tissue, hard).
- External texture (smooth, irregular [having bumps distributed over the external surface of the mass]).
- Nipple discharge.
- Spontaneous.
- Color.
- Number of involved ducts.
- Right or left breast, or both.
FOLLOW-UP:
The final but equally important component of the CBE is follow up; different types of findings will require different follow-up actions, but appropriate follow up is essential.
Follow Up for Normal/Negative CBE
In the case of a normal/negative CBE, a repeat CBE at the next screening interval or preventive health examination is the appropriate follow up. Descriptive findings from the normal/negative CBE should serve as the baseline for the next interval CBE.
In the case of a normal/negative CBE, a repeat CBE at the next screening interval or preventive health examination is the appropriate follow up. Descriptive findings from the normal/negative CBE should serve as the baseline for the next interval CBE.
Follow Up for Abnormal CBE
In the case of an abnormal CBE:
In the case of an abnormal CBE:
- The provider should not discount an abnormal CBE because of a negative mammogram or other imaging examination.
- Providers must follow up all conflicting or abnormal findings to satisfactory resolution using the actions outlined below.
- All referrals must ensure that a copy of the CBE report is provided to specialists performing follow-up imaging to assist in examination and interpretation.
One or more of the following follow-up options are available:
- Repeat CBE.
- Medical management of probably benign condition.
- Referral to a breast specialist.
- Imaging (ultrasound, mammography, magnetic resonance imaging).
- Aspiration.
- Biopsy (percutaneous or excisional).
Timing
The timing of follow-up actions must be appropriate to the findings and should be designed to minimize patient burden and psychological stress. For women aged 40 and older, a repeat CBE in the case of negative findings will likely occur as part of the woman’s regular preventive health care. Among women aged 40 and younger with a negative CBE, this interval may be longer. In the case of abnormal findings, follow up should take place at a shorter interval, at least within 6 months and usually within a shorter time frame.
The timing of follow-up actions must be appropriate to the findings and should be designed to minimize patient burden and psychological stress. For women aged 40 and older, a repeat CBE in the case of negative findings will likely occur as part of the woman’s regular preventive health care. Among women aged 40 and younger with a negative CBE, this interval may be longer. In the case of abnormal findings, follow up should take place at a shorter interval, at least within 6 months and usually within a shorter time frame.
CONCLUSION:
CBE can contribute to the ability of health care professionals and women to detect some breast cancers and should lead to appropriate follow-up care.
BIBLIOGRAPHY
Books
1. Laura R, Kathway A Mary, “TEXTBOOK OF COMPREHENSIVE MATERNITY NURSING”, 2nd edition, published by Mahlmeister, Page no: 868-872.
2. Norman F. Gant, “WILLIAMS OBSTETRICS”, 21st edition, Library of Congress Cataloging in Publication, 2001, Page No. 423-428.
Website
- http://www.healthline.com/galecontent/clinical-breast-examination
- http://www.fpnotebook.com/gyn/Exam/ClnclBrstExm.html
4. http://www.medicalhealthtests.com/breast...examination/clinical-breast-examination.html
