Lactation

Physiological changes after childbirth

The postpartum period is accompanied by active recovery of the woman's body. The ligamentous apparatus of the uterus returns to normal mostly by the end of the 3rd week. The perineal muscles, if there was no trauma during childbirth, begin to restore their function in the very first days and regain normal tone by days 10–12. The anterior abdominal wall remains relaxed for a long time due to overdistension, and in multiparous women, diastasis recti in the umbilical region may persist for life. Against the background of these changes, the process of breast milk production is triggered.

Preparation and mechanisms of lactogenesis

During pregnancy, the mammary glands prepare for secretion under the influence of estrogens, progesterone, prolactin, and human chorionic gonadotropin (hCG). During this period, hyperplasia of the glandular lobules occurs, ducts and terminal alveoli develop, and blood flow increases significantly.

True lactogenesis (breast milk secretion) starts within the first 2–3 days postpartum. Milk excretion is ensured by two main mechanisms:

1. Hormonal: oxytocin, released by the posterior pituitary gland, causes contraction of the myoepithelial cells surrounding the ducts. Prolactin is responsible for the actual production of secretion by alveolar cells.
2. Reflexive: the excretion process is triggered and maintained by the stimulus of infant suckling.

Evolution of secretion: from colostrum to mature milk

In the first 2–3 days, the glands produce colostrum (colostrum) — a thick, yellowish fluid with an extremely high caloric value.

• Cellular composition: leukocytes (lymphocytes and segmented neutrophils), milk fat globules, and specific colostrum bodies (large, irregular cells with a pale nucleus).
• Nutritional value: contains a high amount of proteins, fats, essential fatty acids, phospholipids, cholesterol, vitamins, hormones, and minerals.
• Immunity: lymphocytes and maternal immunoglobulins (IgA, IgM, IgG) play a huge role in the formation of the infant's passive immunity.

Later, breast milk begins to be produced—the optimal food for an infant in the first year of life. It is characterized by high digestibility in the gastrointestinal tract and provides reliable protection against respiratory and intestinal infections.

Features of breast milk composition:

• Proteins: protein fractions are completely identical to the maternal blood serum fractions and do not depend on dietary proteins. In the first days of lactation, the concentration of protein and salts is significantly higher than in subsequent periods.
• Carbohydrates: compared to colostrum, breast milk contains a large amount of lactose.

Feeding guidelines and breast care

The intensity of milk production directly depends on the quality of breast emptying. On days 2–3, the breasts become uniformly dense and remain painless.

• Regimen: regular feeding on demand (the infant's desire) is necessary. The infant is applied to each breast alternately, or to both during one feeding if milk supply is insufficient.
• Hygiene: the glands are washed with warm water and soap before and after each feeding. The direction of movement must be strict: from the nipple to the axilla.
• Prevention of problems: to prevent nipple fissures, careful visual inspection is important, and suckling time before full milk ejection should not exceed 5 minutes. Starting from the 3rd day, it is necessary to wear a bra.
• Expression: indicated only at the beginning of feeding in case of hypersecretion, if the baby cannot cope with the volume. Excess milk should be expressed into sterile freezing bags. In case of pronounced engorgement (often occurs on days 3–4), fluid intake is restricted and physiotherapy is prescribed.

Organization of postpartum management

Normally, a postpartum woman stays in the postpartum ward for 3 to 5 days. The most appropriate placement is in single rooms with a bathroom, where rooming-in for mother and child is organized.

Medical staff adheres to an active management strategy: early mobilization implies that women get up within a few hours after both physiological and operative deliveries.

To monitor the condition in the postpartum period, the following must be assessed:

• General well-being and body temperature.
• Hemodynamic parameters (pulse, blood pressure).
• State of the mammary glands and the nature of lactation.
• Uterine contraction (involution) and lochia.
• Physiological excretions (urination and defecation).

Special attention is paid to infection prevention. This includes cyclical ward occupation, strict adherence to asepsis and antisepsis rules, thorough sanitary processing of premises, and the use of disposable instruments. Patients with any signs of infection are subject to immediate isolation in the septic/observation ward.

Class and exam questions

What else to study on this topic

• Uterine involution and characteristics of lochia
• Restoration of the musculo-ligamentous apparatus after childbirth
• Infection prevention and operation of the observation ward
• Principles of active postpartum management
• Cellular composition and immunological value of colostrum

Other topics in the "Obstetrics" section

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.