RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE,KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

1. NAME OF THE MISS.LINDA RAJU

CANDIDATE AND 1st YEAR MSC. NURSING
ADDRESS ST.JOHNS COLLEGE OF
NURSING
KORAMANGALA,
BANGALORE.
560 034.

2. NAME OF THE ST.JOHNS COLLEGE OF

INSTITUTION NURSING BANGALORE.

3. COURSE OF STUDY MASTER OF SCIENCE

AND SUBJECT (NURSING) OBSTETRIC AND
GYNAECOLOGICAL NURSING

4. DATE OF 2-05-2013
ADMISSION TO THE
COURSE
 5. TITLE OF THE EFFECTIVENESS OF BREAST
STUDY MASSAGE ON LACTATION
AMONG IMMEDIATE
POSTNATAL MOTHERS.

6 .BRIEF RESUME OF INTENDED WORK

6.1 NEED FOR THE STUDY.

Mothers milk, time tested for millions of years, is the best nutrient for babies because it is

natures perfect food. -Robert. Mendelssohn-

Early breast milk is liquid gold (colostrum) which is very rich in nutrients and

antibodies to protect the baby1. The ideal food for the young infant is human milk, which has the

specific characteristics that match the growing infants nutritional requirements during first year of

life. It has diverse and compelling advantages to infants, mothers, families and society. These

include health, nutritional, immunological, developmental, psychological, social, economic and

environmental benefits.2

During breastfeeding, approximately 0.25-0.5 grams per day of secretory IgA

antibodies pass to the baby via the milk. This is one of the most important features of colostrums,

the breast milk created for newborns. The main targets for these antibodies are probably

microorganisms in the baby's intestine. There is some uptake of IgA to the rest of the body, but this

amount is relatively small. Also, breast milk contains several anti-infective factors such as bile salt

stimulated lipase (protecting against amoebic infections) and lactoferrin (which binds to iron and

inhibits the growth of intestinal bacteria).3

 Breastfeeding is a cost effective way of feeding an infant, providing nourishment for a

child at a small cost to the mother. Frequent and exclusive breastfeeding usually delays the return of

fertility through lactational amenorrhea, though breastfeeding is an imperfect means of birth control.

During breastfeeding beneficial hormones are released into the mother's body and the maternal bond

can be strengthened. 3

Malnutrition kills one out of three infants in India. 4 Children who are not breastfed are

almost six times more likely to die by the age of one month than children who receive at least some

breastmilk.3 66% of these death occur during the first year of life and is often caused by

inappropriate feeding practices..4

About one-fourth to one half of all infant deaths in developing countries occurs in the

first week of life. Immediate breast feeding within the first hour, followed by early exclusive

breastfeeding, improves the health & survival status of newborns. 5Proper breastfeeding exercise

could prevent millions of death every year. Promotion of early initiation of breastfeeding has the

potential to make a major contribution to the achievement of the child survival millennium

development goal; 16% of neonatal deaths could be saved if all infants were breastfed from day1 and

22% if breastfeeding started within the first hour. Breastfeeding promotion programs should

emphasize early initiation as well as exclusive breastfeeding.6

Exclusive breastfeeding during early months of life reduces infant morbidity and

mortality. World Health Organization (WHO) defines exclusive breastfeeding as, feeding an infant

only with breast milk, excluding solids or any other fluids (including infant formulas) except
medicines, vitamins, and minerals. WHO recommended infants to be exclusively breastfed during

first 6 months of life.7

UNICEF says that despite compelling evidence that exclusive breastfeeding prevents

diarrhea and pneumonia, global rates of breastfeeding have remained relatively stagnant in the

developing world, growing from32% in 1995 to 39% in 2010. If breastfeeding were promoted more

effectively, we would see more children survive, with lower rates of disease and lower rates of

malnutrition and stunting said UNICEF executive director Anthony Lake.4

In India, practices like discarding the colostrums, giving pre-lacteal feeds, early/late

weaning and use of formula feeds are still widely prevalent. The issue becomes an area of concern

since large numbers of babies born in India are low birth weight. Breastfeeding is the first

fundamental right of a child. The initiation of breastfeeding and the timely introduction of adequate,

safe and appropriate complementary foods in conjunction with continued breastfeeding are of prime

importance for the growth, development, health and nutrition of infants and children

everywhere. The prevalence of breastfeeding in India is still high (99% in rural areas and 96% in

urban areas). However, there are many cultural practices associated with infant feeding of which

certain undesirable like delayed initiation, need to be discouraged. 8

Lactation is affected by large number of maternal factors like mode of delivery, body

mass index, surgery, illness, breast and nipple abnormality and labor experiences. Psychological

stress resulting from pain and fatigue after labor, lack of support to mother and difficulties

encountered on initiation of breastfeeding causes neuroendocrine dysregulation leading to

irregularities in hypothalamus-pituitary-adrenal axis function, leading to delayed onset of milk

production and insufficient milk.9

Breast massage is defined as the technique entails specific kneading, rubbing, and or

squeezing strokes applied to the soft tissue of the breast to increase lymph and blood flow. Before

nursing, gentle massage toward the nipple allow some milk to flow out and help to soften the nipple

for easier latch. During nursing, gentle compress and massaging will stimulate the letdown of milk.

It is the easiest and cheapest method.10

Considering the ease of implementation and obvious lack of adverse effects, non

pharmacologic measures are attractive option over pharmacologic measures for improving

lactation.Motivation for breastfeeding, social support; nursing frequency and good breast feeding

experience are other factors have positive impact on lactation. Research has demonstrated that

mothers require active support for establishing and sustaining appropriate breastfeeding practices.11

The researcher during her clinical experience recognized that most of the post natal

mother in the initial period find difficulties in the feeding because of insufficient breast milk. The

common complain of the post natal mother was not enough milk. The researcher opted the study as it

is a simple and inexpensive method to improve lactation. The effect of breast massage on lactation

may help the post natal other to feed their babies satisfactorily and with confidence.

6.2 REVIEW OF LITERATURE:

The organizer will organize the review under the following headings:
-Factors affecting lactation.

-Alternative therapies for improving lactation

-Effect of breast massage on lactation.

FACTORS AFFECTING LACTATION

Breast milk is considered the optimal food source for newborns through 1 year of age.

Many factors influence overall maternal production, including maternal pain, illness, balance of time

when returning to work, anxiety, or emotional stress. Several common problems that may arise

during the breastfeeding period, such as breast engorgement, plugged milk duct, breast infection and

insufficient milk supply, originate from conditions that lead the mother to inadequate empty the

breasts. Incorrect techniques, not frequent breastfeeding and breastfeeding on scheduled times,

pacifiers and food suppliers are important risk factors that can predispose to lactation problems. The

adequate management of those conditions is fundamental, as if not treated they frequently lead to

early weaning. There are specific measures that should be taken to empty the breasts effectively.12

As milk production increases, over-distention of the alveoli causes the milk-secreting

cells to become flattened & occlude the capillary blood circulation surrounding the alveolar cells.

Congestion contributes to edema & obstructs lymphatic drainage of the breasts, stagnating the

system that rid the breasts of toxins & bacteria, & leading to mastitis. In very severe cases can cause

numbness or tingling of the hands from pressure on the nerves.In addition, a protein called the

feedback inhibitor of lactation (FIL) accumulates in the mammary gland during milk stasis. It acts as

a major trigger of apoptosis, that causes involution of the milk-secreting gland, collapse of the

alveolar structures and the cessation of milk production. 13

 A study has been done to determine factors that may affect the onset time of lactation

in vaginal & LSCS deliveries among 300 parturient mothers. There was a meaningful difference

between average time of milk-ejection in groups with different types of delivery. The study suggest

that any kind of stress including LSCS may postpone milk ejection by hormonal inhibition for few

days after delivery and this will result in newborn weight loss and failure of nursing by mothers. 14

A cross-sectional study was conducted among 240 mothers to study the socio-cultural

factors affecting breastfeeding practices and decision among rural women. It was found that 56.6%

of mothers initiated breastfeeding within first 24 hours of delivery. Shorter duration of breastfeeding

was observed among mothers with higher socio economic status. Literacy status had little effect on

continuation of breastfeeding for more than six months.81.19% mothers had no knowledge regarding

exclusive breastfeeding.15

ALTERNATIVE THERAPIES FOR IMPROVING LACTATION:

Complementary and alternative therapies have been proposed to assist with lactation in

mothers. These methods for increasing breast milk supply include herbal galactagogues, kangaroo

mothering, and relaxation therapies. Metoclopramide, oxytocin, fenugreek, and milk thistle have

shown mixed results in improving milk production.16

Fenugreek seed has been used to support healthy milk production since biblical times.

The benefits of fenugreek in breastfeeding are believed to stem from diosgenin, a compound that is

similar to the female hormone estrogen. More specifically, diosgenin has been shown experimentally

to increase milk flow. As such, the use of fenugreek to encourage lactation could offer help to

women with insufficient supply. However, there needs to be more scientific evidence of the herb's

effectiveness in increasing milk production. Breast compression is a technique that is used to help
drain the milk from breast, improve let-down response, and encourage a sleepy baby to keep

sucking at the breast. These actions will help foster an increase in milk supply.17

The Marmet Technique of manual expression recommends assisting the milk- ejection

reflex by massaging the milk producing cells and ducts in a circular motion similar to that used in a

breast examination. This massage technique is used in conjunction with light stroking motions from

the base of the breast to the nipple and shaking the breast while leaning forward so gravity will help

the milk eject.10

A randomized control study on primipara mothers of china to observe the difference

between acupoint Tuina and simple instruction and education to improve the lactation of the

parturient after delivery. Fifty-six cases of primipara were divided into an acupoint Tuina group (28

cases) and a control group (28 cases) according to the order of entering group, the acupoint Tuina

group was treated with Tuina intervention at local acupoint of the breast and distant acupoint on the

basis of the instruction and education of breast feeding; the control group was treated with simple

instruction and education of breast feeding. The study concluded that parturient had sufficient milk

in acupoint Tuina group after treatment, and the time start to lactate was earlier than that of control

group. The acupoint Tuina is good for parturient to lactate early and lactate more.18

A quasi experimental study was conducted for a period of 16 months, to assess the

effectiveness of back massage on lactation among immediate postnatal mothers.220 mothers were

enrolled and lactation was assessed on the based on various parameters. The result was significantly

higher post feed weight gain, higher mean number of urinations and stools passed per day and better

satisfaction in the study group compared to the control group.9

EFFECT OF BREAST MASSAGE ON LACTATION

One of the most powerful stimulants to the secretion of milk is massage of the breast.

To study the effectiveness of Alternate Breast Massage, the researcher took two

groups of 30 mothers each: one group was taught the massage, and the other group was not taught

the technique. The babies of mothers in both groups were weighed before and after feeding to

determine the amount of milk ingested. Babies in the massage group consumed an average of 22.3

gm more per feeding than the babies in the non-massage group. When the daily totals were

compared, the babies in the experimental group received an average of 4.5 ounces of milk more than

the babies in the control group.10

In a study was done in lactating women pump their breasts simultaneously using an

electric breast pump, while massaging only one breast and utilizing the other breast as a control. The

procedure was repeated the following day with the women massaging the opposite breast. This

resulted in 36 pairs of samples for comparison. Mean volume of milk pumped from the massaged

breast was 4.8 ml greater than that from the non- massaged breast. Mean creamatocrit from the

massaged breast was 1.92% higher than from the non-massaged breast. These results indicate that

breast massage can increase volume and fat content of breast milk. Increasing fat content

coincidently increases caloric value.19

A cross-sectional study milk samples took immediately before and after breast

massage from healthy, exclusively breastfeeding mothers. Breast massage significantly increased

total solids, lipids, casein concentration, and gross energy. Other studied the effect of breast massage

on breast-milk protein. Analyzing milk samples from 39 healthy breastfeeding mothers, they

demonstrated a significantly increased whey protein concentration following breast massage.10

 A descriptive study on compared sequential and simultaneous breast pumping on

volume and fat content of expressed milk, as well as the effect of breast massage on milk volume

and fat content. Their results showed that simultaneous pumping is more effective in producing milk

than sequential pumping, and that breast massage has an additive effect, improving milk expression

by both methods. 10

A study done on hands-on pumping technique in which the mother used bilateral

pumping with an electric breast pump while simultaneously compressing the breasts and massaging

firmer areas. They demonstrated that pump-dependent mothers of preterm infants and mothers

otherwise at risk for insufficient milk production can attain and sustain good milk volumes using

hands-on pumping and breast massage. They concluded that increased milk production results from

more effective breast emptying rather than increasing the frequency or duration of the pumping

sessions. They recommended that studies of pumping effectiveness should factor in the use of breast

massage. Mortons video, Hand Expression of Breast milk, demonstrates the use of gentle breast

massage before hand expression to stimulate the flow of milk. The video, how to Use Your Hands

When you pump, demonstrates the use of breast massage and compression during pumping to

improve emptying of the breast to increase milk production. This technique emphasizes the

importance of massaging the entire breast including the periphery.10

6.3 STATEMENT OF THE PROBLEM:

A study to assess the effectiveness of breast massage on lactation among immediate postnatal

mothers in a selected hospital, Bangalore.

6.4 OBJECTIVES OF THE STUDY

1. To assess the effectiveness of breast massage on lactation among the immediate postnatal mothers.

2. To determine the association between lactation and selected baseline variables.

6.5 OPERATIONAL DEFINITIONS:

EFFECTIVENESS:

The extent to which something succeeds.20

In this study effectiveness refers to the extent in which breast massage enhance the

lactation as evidenced by post feed weight gain of neonates, number of urinations and number of

stools.

BREAST MASSAGE:

A method of stroking, rubbing, kneading and manipulating the breast to stimulate milk production.20

In this study it refers to the art of massaging the milk producing cells and ducts before

feeding. Massage start at the top of the breast and press firmly in a circular motion on the skin of

chest wall then spiral around the breast toward the areola (2min). Stroking the breast from the chest

wall to the nipple with a light tickle-like stroke ( 2min) and shaking the breast gently while leaning

forward so that gravity will help the milk ejection (1 min). (Marmet C.Lactation Institute) It will be

done for three times per day (morning, afternoon and evening).

LACTATION:

The period during which the infant is nourished from the breast.20

In this study it refers to the process of production of milk from the mammary gland

following and continued removal of accumulating milk from the breast as and when necessary.

IMMEDIATE POSTNATAL MOTHERS:

The period after childbirth.21

 In this study postnatal mother refers to the mother who had given birth to the child after

37 completed gestational age and mothers include first postnatal day up to three days.

BASELINE VARIABLES:

Age, Education, Body mass index, Parity, Nature of delivery, Source of information.

6.6 ASSUMPTIONS:

-Postnatal mothers may experience inadequate lactation during the 1st week after delivery.

-Breast massage may improve lactation in postnatal mothers.

6.7 DELIMINATION:

The study is limited to immediate postnatal mothers in SJMCH with a live term baby in the

postnatal wards.

6.8 PROJECTED OUTCOME:

The study will help to enhance lactation thereby facilitate weight gain of neonates and also early

initiation will help to promote exclusive breastfeeding.

6.9 HYPOTHESIS

H1: There will be significant effect between the breast massage and lactation at 0.05 level of

significance.

H2: There will be a significant association between lactation and selected baseline variables at 0.05

level of significance.

7 MATERIALS AND METHODS

7.1. SOURCE OF DATA:

The data will be collected from mothers within third postnatal day and their live baby in SJMCH.

7.1.1 RESEARCH DESIGN:

The research design used in this study will be quasi experimental.

7.1.2 SETTING:

The study will be conducted in the postnatal ward of St. Johns medical college hospital, Bangalore.

It is a tertiary care teaching institute and 1200 bedded multispecialty hospital with obstetrics and

gynecological department. Obstetrical ward is 75 bedded, in which the postnatal ward consists of 26

beds. On an average, 200 deliveries are conducted per month.

7.1.3 POPULATION:

The population in this study includes all the postnatal mothers with a live baby admitted in St. Johns

Medical College Hospital, Bangalore.

7.2 METHODS OF DATA COLLECTION

7.2.1 SAMPLING TECHINQUE:

The sample will be selected by purposive sampling technique and the subjects will be assigned to the

experimental and control group. Computer-assisted random sequences is using for the random

assignment of the subjects.

7.2.2 SAMPLING SIZE:

Sample size includes 44 immediate postnatal mothers: comprises of 22 postnatal mothers in

experimental group and 22 postnatal mothers in control group, which is calculated from the previous

study with 80% power of study and 0.05% level of significance.

7.2.3 INCLUSION CRITERIA:

-Term postnatal mother with a live baby with weight of more than 2.5kg.

-Postnatal mothers after the first initiation of breast feeding (normal delivery1 hr, L S C S 2 hr).

7.2.4 EXCLUSION CRITERIA:

-Mothers whose baby is separated after birth and admitted in NICU with any complication.
-Healthy newborn with cleft palate and abnormalities in oral cavity.

-Postnatal mothers and neonates who are participating in other research studies.

7.2.5 TOOL FOR THE STUDY:

SECTION A: A structured interview for collecting the baseline variables of postnatal mother.

SECTION B: Infant Weighing machine.

SECTION C: Semi structured checklist consist of:

Pre feed weight (three times a day)

Post feed weight (three times a day).
Number of urinations per day.
Number of stools per day.

7.2.6 DATA COLLECTION METHODS:

After obtaining permission from the authorities

Sample will be selected based on inclusion and exclusion criteria

Through consecutive sampling and then will be assigned to experimental and control group.
Purpose and need for the study will be explained to the postnatal mothers.
Informed consent from postnatal mothers will be obtained assuring the anonymity and

confidentiality.
In control group, pre feed weight and post feed weight of the baby will be assessed without giving

breast massage for three times a day, for consecutive three days.
Frequency of urination and stools will be recorded for the respective three days.
In experimental group, Intervention in the form of breast massage will be administered for 5min,

thrice a day for three consecutive days before feeding the baby.
Pre feed weight and post feed weight of the baby will be assessed after each breast feeding for

three times a day.

Frequency of urination and stools will be assessed for the respective three days.

7.2.7 DATA ANALYSIS PLAN:

The data will be analyzed using both descriptive (mean, median and SD) and inferential statistics (t

value, chi square) on the basis of objectives and hypothesis of the result. The result will be presented

in the form of tables and diagrams.

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION TO BE CONDUCTED ON

PATIENTS OR OTHER HUMANS OR ANIMALS? IF SO PLEASE DESCRIBE BRIEFLY.

Yes, The researcher needs to evaluate the effect of breast massage on lactation among postnatal

mothers after obtaining informed consent.

7.4 HAS ETHICAL CONSIDERATION BEEN OBTAINED FROM YOUR INSTITUTION

INCASE OF 7.3?

Ethical clearance will be obtained from Ethical Research committee.

REFERENCES

1. Your guide to breastfeeding retrieved from www.womens health gov.

2. Williams, Rodwell sue. Nutritional and diet therapy. St.Louis: Mosby; 1993: 360-9.

3. Breastfeeding. Retrived from en.wikipedia.org/wiki/breastfeeding.

4. World breastfeeding week (2012) The importance of breastfeeding india.com health aug

1,2012.

5. Baker EJ, Sanei LC, Franklin N. Early initiation of and exclusive breastfeeding in large

scale community based programme in Bolivia and magagara, Journal of health

population 2006 dec;24:530-9.

6. Breastfeeding initiation increase risk of neonatal mortality Karen m.edmond. Available

at www.pediatrics.org/cgl/dol/10.1542/peds-2005-1996delayed.
7. World health organization. World breast feeding week.aug 2008.
8. India lags behind in breastfeeding practices:report. 2012 dec6;25:157,newdelhi/agency

IANS.
9. Patel U, Gedam S. Back massage on lactation among postnatal mothers. International

journal of medical research and review . 2013 january;1(1):5-10.

10. Bowels C B . Breast massage a handy multipurpose tool to promote breastfeeding

success. clinical lactation,2011;2:21-24.available at www.clinical Lactation.org.

11. Benakappa DG, Raju M, Shivananda, Benakappa AD. Breast feeding practices in rural

Karnataka, acta paediatr jpn.1989 aug;31(4):391-8.

12. Giugliami ER. Common problems during lactation and their management.

Jpediatric(Rio J).2004/Nov:80(5):147-54:Available from URL:http://www.pubmed.com

13. Mary KS, New perspectives on engorgement. 1999 dec- 2000 jan;35(6):134-36.

14. Sakha k, Behbahan AGG. The onset of time of lactation after delivery. Medical journal of the

Islamic Republic of Iran.2005aug;19(2):135-139.

15. Yadavannavar M C, Patil S S. Socio-cultural factors affecting breast feeding practices and

decision in rural women. 2011 june; 1(2). Available from: www.ijpaes.com.

16. Complementary and alternative therapies for increasing breast milk supply for lactating

mothers of infants in NICU. Neonatal netw 2010 July August; 29(4): 222- 30.

17. Jensen R. Fenugreek-overlooked but not forgotten. UCLA alumnae Association Newsletter

1992;1:2-3.Ody P. The complete medicinal herbal Newyork: Dorling Kindersley:1993.

18. Lu P, Qui J, Yao F ,Zheng J J. Effect of acupoint tuina on lactation among for parturient.

Zhongguo Zhen Jic.2010;30(9):731-33.

19. Foda M.I, Kawashima T, Nakamura S, Kobayashi M, Oku T. Composition of milk obtained

from unmassaged versus massaged breasts of lactating mothers. J pediatr Gastroenterol Nutr,

2004 may;38(5):484-7.

20. Baillieres nurses dictionary. 24th ed. Barbara F. Eeller;2002. Elsevier; p. 127,244,226.

21. Oxford English dictionary.9th ed. Sara Hawker;2006. Oxford university press; p. 534.