Resmy V. et al. / Journal of Science / Vol 4 / Issue 10 / 2014 / 620-624.

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Journal of Science Nursing

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EFFECT OF LUKEWARM WATER COMPRESS ON PREVENTION

OF NIPPLE PAIN AND BREAST ENGORGEMENT AMONG
PRIMIPAROUS AT A SELECTED HOSPITAL IN CHENNAI
Resmy V1*, S.J. Nalini2, G. Sumathi2
1
M.Sc.(N) Student, 2 Reader, Sri Ramachandra College of Nursing, Porur, Chennai 600116, Tamil Nadu, India.

ABSTRACT
Globally the exclusive breastfeeding rate is 37%. In India, breastfeeding rate is 96%. The common problems affecting
breastfeeding is breast engorgement and nipple pain. An equivalent control group posttest only design study was conducted
among 60 primiparous who underwent caesarean section using convenient sampling technique. The nature of the study was
briefed to participants and consent was taken. For the study group along with routine care, lukewarm water (43 46 Celsius)
was applied with a sponge cloth over the breast which was replaced every five minutes for a total duration of 20 minutes(10
minutes before and 10 minutes after breastfeeding) for two sittings on second, third and fourth postnatal day. The control
group received routine care. Posttest for breast engorgement was assessed with six point breast engorgement scale and nipple
pain with numerical pain scale for the study and control group on the third, fourth and fifth postnatal day. The data was
analysed. Mean age for participants was 24 years and for the control group was 24.17years. Homogeneity was maintained for
the background variables in both groups. Comparison between the observations of the study and control group showed a
significant reduction in nipple pain and breast engorgement at p<0.001 in all the three sittings. This study suggests that
lukewarm water compress consistently prevents nipple pain and breast engorgement among primiparous.

Keywords: Nipple pain, Breast engorgement, Breastfeeding, Primiparous.

INTRODUCTION
The postnatal period begins soon after the birth
of a baby and extends up to six weeks. Breastfeeding is a
universal practice. Global rate of exclusive breastfeeding
according to WHO (2013) is 37%. Indian statistics
suggests 96% of the children are breastfed, of that only
29% of the urban population and 21% of the rural
population are breastfed within an hour immediately after
birth [1]. Breastfeeding problems such as breast
engorgement, flat or inverted nipple or mastitis were
detected in 4.9% of the women in India [2]. Though
breastfeeding is a common practice, because of many
factors it will not be successful for all the mothers. The
most common problems affecting breastfeeding is breast
engorgement and nipple pain due to excessive milk
production, outflow obstruction or poor removal of milk
by the baby. It usually manifests after the milk secretion
starts. Joanna Briggs Institute information (2005) states
that the incidence of nipple pain varies from 34% to 96%
with maximum at day three and starts decreasing by day
seven in primi mothers. Breast engorgement rate varies
from 72% to 85% in postnatal mothers and occurs most
commonly between day three and five in two third of
women with tenderness on fifth day [3]. Due to the
influence of parity, type of anaesthesia, delayed initiation
of breastfeeding, and increased use of formula feeds, the
incidence of insufficient milk supply is higher in
caesarean section mothers than those mothers who
undergo vaginal delivery [4].
Breast engorgement assessment in first 14 days
puerperium showed that regardless of delivery method,
primi mothers experience breast engorgement sooner and
more severe than second time breast feeding mothers [5].
Breastfeeding is more difficult after a caesarean section
because of maternal pain, fatigue, delayed access to baby,

Corresponding Author:- Resmy V Email:- resmyshibu@gmail.com

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early use of supplementary feedings, separation of baby
from mother, and effect of medications [6]. Moist heat
application to engorged breasts, especially before feeding
helps to increase circulation and brings the hormone
oxytocin to trigger milk let-down. Wrapping the breasts in
warm, wet towels for ten to twenty minutes initiates milk
dripping and decreases breast congestion [7]. The options
for preventing breast engorgement includes frequent
breastfeeding, breast massage, hot compress and showers,
cold compress before and after feedings, frozen bag of
vegetables, manual and mechanical expression, chilled
cabbage leaves, application of neem leaves or jasmine
flower and use of oxytocin nasal sprays. The lukewarm
water compress is simple, easily available home remedy
convenient to apply without pain and side effects,
promotes the well-being and comfort of mother and baby
and prevents breast engorgement.
The objectives of the study are to:
1. Assess the effect of lukewarm water compress on
prevention of nipple pain among primiparous.
2. Evaluate the effect of lukewarm water compress on
prevention of breast engorgement among primiparous.
3. Associate the selected background variables with
nipple pain and breast engorgement among primiparous.
MATERIALS AND METHODS
Equivalent control group posttest only design
was adopted for the study. The study population consisted
of primiparous who delivered through caesarean section
and are available from the second to the fifth day of
postnatal period at SRH. 60 primiparous were selected for
the study by a non probability convenient sampling
method, 30 in study group and 30 in control group.
Primiparous who underwent cesarean section, willing to
participate in the study, able to understand Tamil or
English and babies roomed in with their mothers were
included in the study group. Primiparous who underwent
cesarean section and receiving lactation
suppressants/stimulants, had any breast/nipple problem or
with any antenatal or postnatal complications were
excluded. The instrument used for this study had three
sections:
Section A: Part 1: Demographic variables
Part 2: Maternal and neonatal variables
Section B: Numerical pain scale
Section C: Breast Engorgement Assessment Scale
Procedure
The participants were explained about the nature
of the study and consent was taken. For the study group
along with routine care, lukewarm water was applied
(temperature between 43 46 Celsius) with a sponge
cloth over the breast which is replaced every five minutes,
for a total duration of 20 minutes(10 minutes before and
10 minutes after breastfeeding) for two sittings, morning
and evening on second, third and fourth postnatal day.
The control group received routine care. After
intervention session for the study group, breast
engorgement was assessed with six point breast
engorgement scale and pain with numerical pain scale for
the study and control group primiparous on the third,
fourth and fifth postnatal day.
Statistical Methods
The Descriptive statistics (frequency, mean
standard deviation) were used to assess the demographic
variables of both groups. Inferential statistics(chi-square,
independent t test RMANNOVA, one-way ANNOVA)
were used to compare the nipple pain and breast
engorgement between the groups after the intervention, to
assess the effect of intervention within the group and
between the groups at the time of intervals and to
associate the nipple pain and breast engorgement with the
background variables using SPSS version 16.
RESULTS
Table 1 depicts that with respect to the
demographic variables, 83.33% of mothers in the study
group and 73.3% in the control group were in the age
group of 21-30 years. The mean age for the study group
was 24 years and for the control group was 24.17years.
66.7% in the study group and 73.3% in the control group
were from joint family. 73.3% in the study group and
70% in the control group had higher secondary education.
60% in the study group and 66.6% in the control group
were from semi urban area. 56.7% in the study group and
53.3% in the control group had monthly income of more
than Rs. 8001/-.Table 2 illustrates that regarding the
maternal and neonatal variables, 100% of mothers in the
study group and 86.5% in the control group were primi
gravidae. All participants received spinal anaesthesia.
50% of the mothers in the study group and 53.7% in the
control group had male babies. 70% of the babies in the
study group and 73.3% in the control group were between
2and 3 kgs. 40% in the study group and 46.7% in the
control group preferred assistance from others while
feeding. 50% in the study group and 70% in the control
group fed on demand. In table 3 the comparison of nipple
pain between the three posttest observation within the
study and control group indicated a statistical significance
at p<0.001. The comparison of nipple pain between the
observations of the study and control groups also showed
statistical significance at p<0.001.
In table 4 the comparison of breast engorgement
scores between the three posttest observation within the
study and control group indicated a statistical significance
at p<0.001. The comparison of nipple pain between the
observations of the study and control groups also showed
statistical significance at p<0.001.
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Table 1. Frequency, percentage distribution and chi square of demographic variables of primiparous in the study and
the control group (N=60)
Demographic Study group (n=30) Control group (n=30)
2 p value
Variables No. % No. %
1. Age (in years)
a. < 20 04 13.34 03 10.0
3.00
b. 20 30 25 83.33 22 73.3
0.22(NS)
c. > 30 01 3.33 05 16.7
2. Type of Family
a. Nuclear 10 33.3 08 26.7 0.32
b. Joint 20 66.7 22 73.3 0.75(NS)
3. Educational Status
a. Higher Secondary 22 73.3 21 70.0 0.82
b. Graduate & above 08 26.7 09 30.0 0.77(NS)
4.Type of living
a. Rural 04 13.3 02 06.7
0.77
b. Urban 08 26.7 08 26.7
0.68(NS)
c. Semi urban 18 60 20 66.6
5. Monthly Income (in Rs.)
a. 5001 8000 13 43.3 14 46.7 0.067
b. Above 8001 17 56.7 16 53.3 0.80(NS)
NS Non Significant

Table 2. Frequency, percentage distribution and chi square of maternal and neonatal variables of primiparous in the
study and the control group (N=60)
Maternal Study group (n=30) Control group (n=30) 2
Variables No. % No. % p value
1. Gravida
a. 1 30 100.0 26 86.7
4.29
b. 2 0 00.0 03 10.0
0.12(NS)
c. 3 0 00.0 01 3.3
2. Type of anaesthesia
a. Spinal 30 100.0 30 100.0
b. Epidural 00 00.0 00 00.0
-
c. General 00 00.0 00 00.0
3. Sex of the baby
a. Male 15 50.0 16 53.3 0.07
b. Female 15 50.0 14 46.7 0.80(NS)
4. Weight of the baby (in kgs)
a. 2 to 3 21 70.0 22 73.3 0.04
b. > 3 09 30.0 08 26.7 0.85(NS)
5. Preferred Maternal Position for
feeding
a. Sitting 08 26.7 03 10.0
b. Side lying 10 33.3 13 43.3 2.82
c. Assisting 12 40.0 14 46.7 0.24(NS)
6. Frequency of feeding (in hours)
a. 1 00 00.0 01 03.3
b. 2 06 20.0 01 03.3
5.82
c. 3 09 30.0 07 23.4
0.12(NS)
d. Demand feeding 15 50.0 21 70.0
NS Non Significant.

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Table 3. Comparison of nipple pain among primiparous between the observations within the groups and between the
observations. (N=60)
Nipple pain
Groups Posttest 1 Posttest 2 Posttest 3 F and p value between F and p value
Mean SD Mean SD Mean SD observation between groups
Study 80.97
2.53 1.17 1.20 1.03 0.67 0.66
group 0.000*** 81.88
Control 22.15 0.000***
5.17 1.46 6.17 1.23 6.53 1.43
group 0.000***
*** p<0.001

Table 4. Comparison of breast engorgement among primiparous between the observations within the groups and
between the groups. (N=60)
Breast engorgement
Groups Posttest 1 Posttest 2 Posttest 3 F and p value F andp value between
Mean SD Mean SD Mean SD between observations groups
Study 11.02
1.73 0.74 1.37 0.49 1.17 0.38
group 0.001** 112.38
Control 127.53 0.000***
2.03 0.77 3.40 0.56 4.17 0.79
group 0.000***
** p<0.01, *** p<0.001

DISCUSSION
The nipple pain between the observations in both
the study and the control groups showed a significant
difference at p<0.001. The control group had an increase
in pain score by 2.64 in posttest one, 4.87 in posttest two
and 5.86 in posttest three than the study group. The
comparison between the observations of the study and
control groups also denoted the statistical significance at
p<0.001.This results was supported by similar study
conducted by comparing the effectiveness of mother's
milk, tea compress and warm moist compress on the
prevention of nipple problems in 105 breastfeeding
primiparous who underwent normal as well as caesarean
section. 97.1% gave their first feeding with mother's milk
and of that 11.5% breastfed their infants within the first
half an hour. The result showed that nipple pain was less
in warm moist application to the nipple than in the
mother's milk and warm moist tea compress groups [8].
The breast engorgement between the
observations in both the study and the control group
showed a significant difference at p<0.01 and p<0.001
respectively. The control group had an increase in breast
engorgement score by 0.30 in posttest one, 2.03 in
posttest two and 3.00 in posttest three than the study
group. The comparison between the observations of the
study and control groups also denoted the statistical
significance at p<0.001. This study was supported by the
study conducted to identify the effect of warming up
breasts before pumping out breast milk among thirty-nine
mothers. A breast compress that was warmed up in a
microwave oven for one minute at 180 W was applied to
one of the breasts for 20 minutes, an electrical breast
pump was used for 15 minutes for sucking both breast.
The results showed that amount of breast milk
obtained from warmed breasts were significantly higher
than that obtained from nonwarmed breasts. The study
concluded that warming up breasts by a breast compress
is simple and affordable and helps to increases the amount
of breast milk. So the study indicates that the lukewarm
water compress before breastfeeding improves vascular
tone and prevents the stasis of milk and helps in milk let
down [9].
Association of nipple pain and breast
engorgement score with background variables revealed
that for study group, in posttest one nipple pain had a
significant association with type of family at p<0.01 and
breast engorgement was significantly associated with
maternal position for feeding at p<0.05. For control
group, in posttest one nipple pain had significant
association with educational status and weight of the baby
at p<0.05 and in posttest three nipple pain was
significantly associated with maternal position for feeding
and frequency of feeding hours at p<0.01 and p<0.001
respectively and breast engorgement has significant
association with frequency of feeding hours at
p<0.01.This was supported by a study conducted to
compare the breastfeeding patterns of mothers who
delivered their babies per vagina (82 mothers) and via
caesarean section (118 mothers). Results showed
statistically meaningful differences between the first,
second, and third breastfeeding sessions in both groups.
The study concluded that caesarean section mothers need
more guidance and support particularly in positioning
their babies for breastfeeding [10].

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Few limitations of the study are extraneous CONCLUSION

variables like environment, pain tolerance, attitude of the
subject was not taken in to consideration and the data
obtained regarding nipple pain was subjective. It is
recommended to conduct a comparative study to assess
the effect of lukewarm water compress with other
therapies, such as cabbage leaves, cold compress,
massage, gel packs as a preventive measure. This study
tested the utility of Ernestine Wiedenbachs Helping Art
of Clinical Nursing Theory based on the assumption that
breastfeeding mothers are open to three steps of nursing
practice which includes identification, ministration and
validation. Wiedenbachs Helping Art of Clinical Nursing
Theory has been justified as the hypothesis testing
denotes lukewarm water compress was effective in
preventing nipple pain and breast engorgement among
primiparous subjected to caesarean section.
Higher pain perception and poor pain tolerance
due to lack of experience is common among primiparous.
For successful breast feeding it is crucial to initiate
breastfeeding by all primiparous during immediate
postpartum period. This study suggests that lukewarm
water compress consistently prevents nipple pain and
breast engorgement among primiparous.
ACKNOWLEDGEMENT
With deep sense of gratitude I express my special
thanks to the Managing Trustee, SRU, Prof. P.V.
Ramachandran, M.Sc. (N)., chairman, Nursing Education,
Prof. Dr. Prasanna Baby, M.Sc. (N)., Ph.D., Principal, Dr.
S.J. Nalini, M.Sc. (N)., Ph.D., Mrs. G. Sumathi,
M.Sc.(N)., and faculty members for their support and
guidance. I am greatful to all postnatal mothers for their
participation and cooperation throughout the period of
study.

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