My breasts feel extremely full and uncomfortable. What is happening and what can I do about it?

Your milk will become more plentiful or "come in" some time between the second and sixth day after you give birth. Before that time, your baby will receive "early milk" known as colostrum, which will provide him with all the nourishment he needs, plus important antibodies and other immune properties to protect him from illness. It takes about two weeks for your milk to gradually transition into mature milk.

When your milk becomes more plentiful, your breasts may seem filled to bursting. This fullness is due to additional blood and fluid traveling to the breasts, preparing them for producing milk, as well as the increased volume of the milk itself. Some women only notice a little fullness, while others experience quite a bit more. Usually, the fullness subsides in 12-48 hours. It is especially important to continue to breastfeed your baby frequently since removing the milk from the breasts relieves the engorgement by allowing room for the excess fluids to flow out of the region.

You can prevent or minimize the effects of engorgement by:

• Nursing early and often. Nurse as soon after the birth as possible, and at least ten times a day after that.
• Ensuring that your baby is positioned well and is latched on properly. (See How do I position my baby to breastfeed? for more information on proper positioning and latch.)
• Nursing "on cue". If your baby sleeps more than two to three hours during the day or four hours at night, wake him to nurse.
• Allowing baby to finish the first breast before switching sides. This means to wait until baby falls asleep or comes off the breast on his own. There is no need to limit baby's time on the breast.
• If your baby is not nursing at all, or is not nursing well, hand expressing or pumping your milk as frequently as baby would nurse.

For some mothers, the normal sense of fullness continues, their breasts becoming hard and painful. Most mothers find that frequent nursing helps to relieve any discomfort. Additional suggestions for dealing with the discomfort of engorgement include:

• Gentle Breast Massage

With the palm of your hand and starting from the top of your chest (just below your collar bone), gently stroke the breast downward in a circular motion, toward the nipple. This may be more effective when done while you are in the shower or while leaning over a basin of warm water and splashing water over your breasts.

• Warm Compresses, Massage, Cold Compresses

Some mothers find that applying a warm, moist compress and expressing some milk just before feedings helps to relieve engorgement. Using heat for too long will increase swelling and inflammation, so it is best to keep it brief. Cold compresses can be used between to reduce swelling and relieve pain.

• Cabbage Compresses

A popular home remedy for relieving the discomfort of engorgement is cabbage leaf compresses. Rinse the inner leaves of a head of cabbage, remove the hard vein, and crush with a rolling pin (or similar). They can be used refrigerated or at room temperature. Drape leaves directly over breasts, inside the bra. Change when the leaves become wilted, or every two hours. Discontinue use if rash or other signs of allergy occur. There have been anecdotal reports that overuse of cabbage compresses can reduce milk production, therefore some experts suggest mothers discontinue the compresses when the swelling goes down.

Contact your health care provider immediately if:

• Engorgement is not relieved by any of the above comfort measures.
• You begin experiencing symptoms of mastitis: fever of greater than 100.6°F (38.1°C), red/painful/swollen breast(s), chills, "flu-like" symptoms.
• Your baby is unable to latch on to your breast.
• Your baby is not having enough wet and dirty diapers. (See How can I tell if my baby is getting enough milk? for more information.)

Engorgement can cause the nipples to flatten, or the dark area around the nipple, the areola, to become hard and swollen. This can be a problem if the fullness makes it difficult for baby to latch on. A technique that can help is reverse pressure softening. Reverse pressure softening, or RPS, softens the areola to make latching and removing milk easier. It is not the same as hand expression (although it is okay if some milk does come out). The following article is a description of RPS, with illustrations.

Reverse Pressure Softening K. Jean Cotterman RNC, IBCLC (mellomom@gmail.com) What is it? Reverse pressure softening is a new way to soften the circle around your nipple (the a-re-o-la) to make latching and getting your milk out easy while your baby and you are learning. Latching shouldn't be painful. If your areola is soft enough to change shape while feeding, it helps your baby gently extend your nipple deep inside his mouth, so his tongue and jaws can press on milk ducts under the areola. (These motions differ from those that artificial nipples force a baby to use.) This new method is not the same as removing milk with your fingers. Don't expect milk to come from your nipple while you soften your areola this way. (But it's OK if some milk does come out.) When is it helpful? Try reverse pressure softening in the early days after birth if you begin to notice firmness of the areola, latch pain or breast fullness. (This full feeling is only partly due to milk. Delayed or skipped feedings may also cause the tissue around your milk ducts to hold extra fluid much like a sponge does. This fluid never goes to your baby.) Intravenous (IV) fluids, or drugs such as pitocin may cause even more retained tissue fluid, which often takes 7-14 days to go away. Avoid long pumping sessions and high vacuum settings on breast pumps to prevent extra swelling of the areola itself. Feel your areola and the tissue deeper inside it. Is it soft and easy to squeeze, like your earlobe or your lip? Or does it feel firmer and harder to compress, like your chin? if so, it's time to try reverse pressure softening just before each time you offer your baby your breast. (Some mothers soften their areola before feeding, for a week or longer, till swelling goes down, baby can be heard swallowing milk regularly, and latching is always painfree without softening first.) Why does it work? Reverse pressure softening briefly moves some swelling backward and upward into your breast to soften your areola so it can change shape and extend your nipple. It sends a special signal to the back of your breasts to start moving milk forward (let-down reflex) where your baby's tongue can reach it. It also makes it easy to remove milk with your fingertips or with short periods of slow gentle pumping, combined with gentle forward massage of the upper breast, if you need to remove milk for your baby. Where should I press? It is most important to soften the areola in the whole one-inch area all around where it joins your nipple. Soften even more of the areola if you wish. You may also want to soften a place where your baby's chin will be able to move easily against the breast. Reverse pressure softening should cause no discomfort. How do I do Reverse Pressure Softening? K. Jean Cotterman RNC, IBCLC (mellomom@gmail.com) Illustrations by Kyle Cotterman, Dayton, Ohio You (or your helper, from in front, or behind you) choose one of the patterns pictured. Place the fingers/thumbs on the circle touching the nipple. (If swelling is very firm, lie down on your back, and/or ask someone to help by pressing his or her fingers on top of your fingers.) Push gently but firmly straight inward toward your ribs. Hold the pressure steady for a period of 1 to 3 full minutes. Relax, breathe easy, sing a lullaby, listen to a favorite song or have someone else watch a clock or set a timer. To see your areola better, try using a hand mirror. It's OK to repeat the inward pressure again as often as you need. Deep "dimples" may form, lasting long enough for easy latching. Keep testing how soft your areola feels. You may also press with a soft ring made by cutting off half of an artificial nipple. Offer your baby your breast promptly while the circle is soft. One handed "flower hold." Fingernails short, fingertips curved, placed where baby's tongue will go Two handed, one-step method. Fingernails short, fingertips curved, each one touching the side of the nipple (You may ask someone to help press by placing fingers or thumbs on top of yours.) Two step method, two hands, using 2 or 3 straight fingers each side, first knuckles touching nipple. Move ¼ turn, repeat above & below nipple Two step method, two hands, using straight thumbs, base of thumbnail even with side of nipple. Move ¼ turn, repeat, thumbs above & below nipple Soft ring method. Cut off bottom half of an artificial nipple to place on areola to press with fingers © 2004 Lactation Education Consultants. May be reproduced for non-commercial purposes.

More information on the early weeks of breastfeeding can be found in our Web resource collection.