







































Education, Society and Human Studies 
ISSN 2690-3679 (Print) ISSN 2690-3687 (Online) 

Vol. 1, No. 2, 2020 
www.scholink.org/ojs/index.php/eshs 

22 

Original Paper 

Breast Engorgement among Women with Caesarean Section: 

Impact of Nursing Intervention 
Hanan Elzeblawy Hassan1*, Galal Ahmed EL-Kholy2, Aziza Ahmed Ateya3 & Amal Ahmed Hassan4 

1 Maternal and Newborn Health Nursing department, Faculty of Nursing, Beni-Suef University, Egypt 
2 Professor of obstetrics & gynecology, Faculty of Medicine, Benha University, Egypt 

3 Professor of Maternal and Newborn Health Nursing, Faculty of Nursing, Ain Shams University, Egypt 
4 Professor of Obstetrics and Women’s’ Health Nursing department, Benha University, Egypt 
* Hanan Elzeblawy Hassan, Maternal and Newborn Health Nursing department, Faculty of Nursing, 

Beni-Suef University, Egypt 

 

Received: May 29, 2020          Accepted: June 14, 2020         Online Published: June 23, 2020 

doi:10.22158/eshs.v1n2p22                       URL: http://dx.doi.org/10.22158/eshs.v1n2p22 

 

Abstract 

Background: Breast engorgement is defined as enlarged & filling of breast with milk. It is one of the 

most significant problems confronting nursing women, especially primiparous, in the first week of 

motherhood. The aim of the study was to investigate the impact of nursing intervention on relieve of 

breast engorgement among women with caesarean section. Design and setting an interventional study 

was conducted in postnatal unit of Beni-Suef University hospital. Sample was simple random sample 

comprised a total of 90 Primiparae’s cesarean section mothers; 45 in the interventional group & 45 in 

the control group. Tools of Data Collection were interview questionnaire sheet, knowledge assessment 

sheet and observational & Engorgement assessment scale. The study revealed that, the nursing 

intervention was more effective and contributed rapid recovery from breast engorgement especially 

among the older, educated, housewives, high social class's women and those who were rural dwellers. 

The study recommended that Prevention is a key element in reducing breast engorgement potentially 

among nursing mothers. So, primiparous mothers should learn about preventive measures for breast 

engorgement. Teaching mother how to express both breasts simultaneously to yield the most volume 

and to decrease time spend pumping each consecutively is the responsibility of health care providers. 

Keywords 

breast engorgement, primiparous, caesarian section, nursing intervention 

 

 



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1. Introduction 

The postpartum period “Puerperium”, as states by Susan A. and Wong H., is the interval between the 

birth of the newborn and the return of the reproductive organs to their normal no pregnant state. This 

period sometimes referred to 4th trimester of pregnancy. Although the Puerperium has traditionally been 

considered to last 6weeks, this time frame varies among women (WHO, 2001; WHO & UNECIF, 

1991). It is divided into immediate (the 1st 24 hours), early (up to 7 days) and remote (up to 6 weeks). 

The birth of infant signals the beginning of a new chapter in the life of the mother & her significant 

others (Bashir, 2008; WHO, 2002). 

Puerperium is a normal process that result in a series of unwelcome both physiological & psychological 

changes in women (especially for primiparae) as their bodies recover from pregnancy & labor (WHO, 

1995; WHO, 2001). The major physiological event of the puerperium is lactation. When the milk 

comes in, the breasts suddenly become larger, firmer and tenderer. New mothers experience a varying 

degree of discomfort at this time. Breast engorgement is considered among the most significant 

problems encountered in the 1st week of motherhood. The medical dictionary defines engorgement as 

local congestion, excessive fullness of any organ, vessel, or tissue due to an accumulation of fluid (Blck 

et al., 2007). Breast engorgement is stated by Litteton L. and Engerbeston J. in 2005 as enlarged and 

filling of the breasts with milk. Lactation literature refers to engorgement as the physiologic condition 

characterized by the painful swelling of the breasts associated with sudden increase in milk volume, 

lymphatic and vascular congestion, and interstitial edema during the first two weeks following birth. 

Engorgement is a normal physiologic process with a progression of events, not a result of trauma or 

injury to tissues (Walker, 2010; Hassan, 2011). 

A distinction exists between breast fullness and engorgement. Engorgement is a common response of 

the breast to the sudden change in hormones and the presence of an increased volume of milk. It 

usually occurs in 3rd to 5th day postpartum when the milk comes in and lasts about 24 hours (Wilson & 

Lowdermilk, 2006; Hassan et al., 2020a). When milk production increases rapidly, the volume of milk 

in the breast can exceed the capacity of the alveoli to store it. If the milk is not removed, over distention 

of the alveoli can cause the milk-secreting cells to become flattened & drawn out, even to rupture. The 

distinction can partly or completely occlude the capillary blood circulation surround the alveolar cells, 

further decreasing cellular activity. Congested blood vessels leak fluid into the surround tissue space 

contributing to edema. Pressure and congestion obstruct lymphatic drainage of the breasts, stagnate the 

system that rid the breast of toxins, bacteria, and cast-off cell parts, thereby predisposing the breast to 

mastitis (both inflammation & infection) (Walker, 2010; Buckley & Kulb, 2003). 

Breast engorgement is one of the most common minor discomforts confronting nursing women after 

delivery, especially primiparous. As a result of increased blood supply to the breast, it causes swelling 

of the tissue surrounding the milk ducts. The duct may be pinched shut so that the milk does not flow 

(Wilson & Lowdermilk, 2006; Riordan & Hoover, 2005). The breasts are firm, tinder, swollen and hot 



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and they are throbbing. The skin is taut, shiny, or transparent and low-grade fever. The tenderness and 

swelling may extend into the axilla. The areola is firm and the nipple may flatten, and the areola is too 

hard to grasp, making it difficult for a newborn to latch on (Wilson & Lowdermilk, 2006; Mohrbacher, 

IBCLC, & Stock, 1997; Hassan, 2011). 

Engorgement can be classified as involving only the areola, only the body of the breast, or both. It may 

occur in one or both breasts. Areolar engorgement involves clinical observations of a swollen areola 

with tight, shiny skin, probably involving over-full lactiferous sinuses. A puffy areola is thought to be 

tissue edema caused by large amounts of intravenous fluids received by some mothers during labor 

(Walker, 2010; Riordan, 2009). 

Some degree of breast engorgement is normal. Minimal or no engorgement in the first week postpartum 

has been associated with insufficient milk, early supplementation, and a higher percentage of 

breastfeeding decline in the early weeks. Women with mild to moderate hypoplastic breasts with a wide 

intramammary space (>1 inch) and a tubular shape are at particular risk for producing less than 50 % of 

the milk necessary for the first week (Newton & Newton, 1951, Neifert et al., 1990; Huggins et al., 

2000).  

Moderate to severe engorgement is of more concern. Rates of engorgement between 20% and 85% 

have been reported in the literature based on numerous definitions and are usually limited to the first 

few days postpartum. Such reports described engorgement as peaking between day 3 and day 6 and 

declining thereafter. However, data from two unpublished masters theses suggest that mothers 

experience more than one peak of engorgement and that engorgement may continue for as long as ten 

days or more (Riedel, 1991; Csar, 1991). 

Four patterns of engorgement have been described: a single experience of the firm, tender breasts 

followed by a resolution of symptoms; multiple peaks of engorgement followed by resolution; intense 

and painful engorgement lasting up to fourteen days; and minimal breast changes. These patterns 

demonstrate that the experience of engorgement is not the same for all mothers (Riedel, 1991; Csar, 

1991).  

An individual mother’s risk for and course of engorgement are; (1) Failure to prevent or resolve milk 

stasis is resulting from infrequent or inadequate drainage of the breasts. The higher the cumulative 

number of minutes of sucking during the early days postpartum, the less pain from engorgement 

mothers describes (Moon & Humenick, 1989), (2) Small breast size (other than hypoplastic and 

tubular). Mothers with small breasts may need to experience a greater number of breastfeedings over 

24 hours than women with a larger milk storage capacity (Day & Hartmann, 1995), (3) Previous 

breastfeeding experience, but not parity, influences engorgement. Second-time breastfeeding mothers 

experience greater levels of engorgement sooner with faster resolution than first-time breastfeeding 

mothers. Breast engorgement for multiparous mothers’ breastfeeding for the first time was similar to 

primiparous breastfeeding mothers. Robson (1990) found that mothers in a non-engorged group were 



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more likely to have never experienced engorgement following previous births than mothers in the 

engorged group (Mc Lachlan et al., 1993; Robson, 1990). (4) Mothers with high rates of milk synthesis 

(hyper lactation) or large amounts of milk such as mothers of multiples may see milk stasis magnified 

if infants consume less milk, if less milk is pumped, or whenever milk volume significantly exceeds 

milk removal (Livingstone, 1996), (5) Limited mother/infant contact in the early days; Shiau (1997) 

demonstrated significantly less engorgement on day three in mothers who participated in skin-to-skin 

care of their full-term babies rather than standard nursery care.  

If breast engorgement is not promptly treated, it may lead to some complications such as; (1) feeding 

problems or slow weight gain if the baby is unable to latch on the engorged breast (Davidson et al., 

2008), (2) Sore and cracked nipple due to the baby fumbling on/off as he tries to grasp hold of a too 

firm breast. (Morland Schultz & Hill, 2005), (3) Deep breast (Fraser et al., 2004), (4) Thrush: is a 

fungal infection can be formed on the nipple or within the breast (especially cracked nipple or 

congested breast), as they live on milk (Agamy, 2011), (5) Plugged ducts results from accumulation of 

milk or dead cells that have not been expelled from the breast. (Orshan, 2008), (6) Mastitis; Also, 

neglected engorgement may be a forerunner and predisposes to more serious breast problems such as 

Mastitis (acute intramammary) (Riordan, 2005a; WHO, 2000). 

Prevention is still the best medicine for engorged breast and other breast-feeding’s problems. Numerous 

preventive strategies have been seen over the years including restricting fluids, prenatal expression of 

colostrum, prenatal breast massage, and postnatal breast massage, binding the breasts, or wearing a 

tight bra. Mothers experience less severe forms of engorgement with early frequent feedings, 

self-demand feedings, unlimited sucking times, and with babies who demonstrate correct suckling 

techniques (Cable & Davis, 1997; Nikodem, 2006; Salhan, 2007; Davidson et al., 2008; Wilson & 

Lowdermilk, 2006). 

When breast engorgement is evident, it could be relieved by several pharmacological and nursing 

measures. The main pharmacological measures are regular analgesia for 24 to 48 hours to reduce pain. 

The mother can take acetaminophen (Tylenol) for breast discomfort (Fraser et al., 2004). Use of an 

anti-inflammatory agent (Danzen) significantly improved symptoms Ibuprofen may help reduce pain 

and swelling associated with engorgement (Litteleton & Engebretson, 2005). The use of an oxytocin 

nasal spray prescribed just before infant feeding to relieve breast engorgement or to promote to flow of 

milk at the beginning of the period of nursing (Snowden et al., 2001).  

For nursing measures; a plethora of treatment modalities for engorgement have been put forward, both 

anecdotally and in the literature, such as hot compresses, hot showers, soaking the breasts in a bowl of 

hot water, cold compresses after feedings, cold packs before feedings, ice packs, frozen bags of 

vegetables, both hot and cold therapy, binding the breasts, manual expression, mechanical expression, 

lymphatic breast massage, frequent feedings, alternate massage, chilled cabbage leaves, room 

temperature cabbage leaves, and cabbage leaf extract (Zagloul et al., 2020; Jacob, 2005; Benson & 



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Pernall, 2002). 

1.1 Significant of the Study 

Breast engorgement is considered among the most significant problems encountered in the first week of 

motherhood. Moderate to severe engorgement is of more concern. Rates of engorgement between 20% 

and 85% have been reported in the literature based on numerous definitions. It is one of the most 

common minor discomforts confronting nursing women 2-4 days after delivery, especially primiparae. 

Women may report red, swollen, warm, firm, tender, uncomfortable, overall heaviness, and full and 

throbbing pain in the breasts that may extend to the axilla, on examination; there may be pyrexia and 

tachycardia. The main importance lies in the fact that the engorged breast can prevent nursing, leading 

to decrease in the milk production. In addition, engorgement may be forerunner of acute-non infective 

mastitis (acute intra mammary) and breast abscess. Mastitis is an actual inflammation of breast tissue; 

if mastitis is not treated properly and promptly it may lead to breast abscess (Hanretty et al., 2003). 

One of the most important aspects of midwifery care is providing accurate and consistent advice on 

how to prevent breast engorgement and, if problem occurs, how to overcome it, in order to reduce early 

cessation of breast feeding. Therefore, this study was undertaken to: Assess women knowledge and 

practiced regarding breast feeding. Assess the prevalence and severity of breast engorgement among a 

group of breastfeeding women delivered caesarian section. Apply and find out the effect of some 

nursing measures that may relief breast engorgement among a group of breastfeeding women with 

caesarean section. 

1.2 Aim of the Study 

Investigate the impact of nursing intervention on relieve of breast engorgement among women with 

caesarean section. The aims of this study achieved through: 

• Apply deferent measures of nursing intervention for women to relieve the engorgement of the 

breast; these measures are: 

1) Appling of warm compresses for affected breast for 20 minutes before each feeding. 

2) Administered cold cabbage leaves which were refrigerated in the freezer for approximately 

20-30 minutes. 

3) Massaging the breast and emptying the breast by manual (or pump) expression of milk. 

• Evaluate the effect of nursing measures on the relief of breast engorgement comparing with 

routine hospital care. 

1.3 Research Hypothesis 

Breast engorgement among puerperal women delivered caesarian section will be relieved after 

application of nursing intervention. 

 

 

 



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2. Method 

2.1 Technical Design: 

2.1.1 Study design: This study is an interventional study. 

2.1.2 Setting: The study was conducted in postnatal unit of Beni-Suef University hospital. 

2.1.3 Subjects: 

2.1.3.1 Samples size: 

Total study subjects of 90 women who suffer from breast engorgement for a period of 6 months were 

included in the study from the previous mentioned setting with the following criteria: 

• Primiparous women. 

• Women with caesarean section delivery. 

• Free from medical disease which interfere with breastfeeding (infectious disease as active 

pulmonary tuberculosis). 

• Initiate breast feeding. 

• Her baby is normal. 

2.1.3.2 Sample type: 

Primiparous women who delivered by caesarean section randomly selected. They were equally 

allocated into two groups an intervention and a control group: 

A- study (intervention) group: 

This group comprised half of the mothers (45 women) who suffer from breast engorgement. They were 

trained to apply three nursing measures to relief engorgement.  

B- Control group:  

This group were comprised the other half the mothers (45 women) who suffer from breast engorgement 

and they were left for the routine postnatal hospital care. 

2.1.4 Tools of Data Collection: 

Two tools were used to collect the necessary data about the study subjects as the following: 

Tool (1): A specialized designed structured interview schedule was developed based on the review of 

currently related literature and used by the researcher to collect the necessary data about the study 

subjects. It included the general characteristics of the study subjects such as: name, age, residence, 

address, phone number, educational level, type of family, family income, occupation. 

Tool (2): Engorgement assessment scale: This tool was especially designed to provide the baseline 

data of the subjects regarding their signs and symptoms of engorged breast. It was implemented by 

using an observational check list which illustrated the breast current condition (redness, swollen or 

edema of the skin and pain) as well as pyrexia. In addition, follow up-checklist to assess the 

effectiveness of the nursing interventions compared to routine hospital practices used to relieve the 

breast engorgement among the two groups to identify degree of improvement after applying the three 

suggested methods of treatment for breast engorgement (warm compresses, frozen cabbage leaves 



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compress and breast milk expression). This tool comprised four main parts: 

Part (A): Modified Reeda Scale (RS) (Note 1)  

The modified Reeda Scale (RS, 1989) was used to provide the most objective means for evaluating the 

condition of the engorged breast after delivery in relation to redness (R). Mild redness was 

characterized by presence less than 0.25 cm of redness in the bilateral breasts or less than 0.5 cm of 

redness in the unilateral breast. Moderate redness was characterized by an increase of redness to 0.5 cm 

in the bilateral breasts or 1 cm in only one breast. Severe redness was characterized by an increase of 

redness to more than 0.5 cm in each breast or more than 1 cm in only one breast. 

Redness was determined through four levels: 

a- 0 = no redness. 

b- 1 = < 0.25 cm bilateral or < 0.5 cm unilateral        (mild redness). 

c- 2 = 0.5 cm bilateral or = 1 cm unilateral        (moderate redness).  

d- 3 = > 0.5cm bilateral or > 1 cm unilateral          (severe redness). 

Part (B): Visual Analog Scale (VAS)  

It is a subjective self-reported scale for description mother self-rating of pain. The scale was used to 

identify the three pain levels according to La Foy and Geden (1989) as the following: 

Mild pain was characterized by pinking and/or aching, Moderate pain was characterized by pressing, 

sharp cramping, and burning, while sever pain was characterized by no tolerance to pain.  

Pain was determined through four levels: 

a- 0 = no pain. 

b- 1 = mild pain. 

c- 2 = moderate pain.  

d- 3 = severe pain. 

Part (C): Newton’s Scale (1951)  

This scale entails measuring the chest circumference just above the nipple in the semi-recumbent 

position during the first 12 hours after delivery (Jacob, 2005; Snowden et al., 2005). This measurement 

is considered to baseline measurement to assess breast edema as the following: 

No edema was characterized by an increase of chest circumference of less than 1.5 cm. Mild edema 

was characterized by an increase of chest circumference of 1.5 cm to less than 2.5 cm. Moderate edema 

was characterized by an increase of chest circumference of 2.5 cm to less than 4 cm. Sever edema was 

characterized by an increase of chest circumference of more than 4 cm. 

Breast edema was determined through four levels: 

a- 0 = no edema. 

b- 1 = mild edema. 

c- 2 = moderate edema.  

d- 3 = severe edema. 



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Part (D): Pyrexia Chart 

Thermometer is used to measure body temperature (to determine pyrexia). 

Pyrexia was assessed through four levels: 

a- 0 = 37-    0c                                            (no pyrexia). 

b- 1 = 37.5- 0c                                            (mild pyrexia). 

c- 2 = 38-    0c                                           (moderate 

pyrexia). 

d- 3 = 38.5- 0c                                            (severe pyrexia). 

Breast Engorgement Total Scale 

The occurrence of breast engorgement was determined according to collection of the total scores in 

Tool (3): 

Total (T) = redness + pain + edema + pyrexia. 

The degree of breast engorgement was estimated according to the following: 

 T < 4                          considered as no breast engorgement. 

 T ≥ 4 & < 8                     considered as mild breast engorgement.     

 T ≥ 8 & < 12                    considered as moderate breast engorgement.     

 T ≥ 12                         considered as sever breast engorgement. 

a. 0 = no engorgement. 

b. 1 = mild engorgement. 

c. 2 = moderate engorgement.  

d. 3 = severe engorgement. 

2.2 Operational Design 

The study to be completed was passed through different phases as follows: Preparatory phase then the 

pilot study and the field work.  

2.2.1 Preparatory Phase  

Tools development:-The tools of data collection were developed by the researcher after extensive 

review of recent and related literature.  

2.2.2 Ethical Considerations: 

• The researcher took consent from women included to participate in the study. 

• The researcher tools didn’t embarrass of modesty and didn't cause any harm or pain for the 

participant women. 

• The researcher tools didn’t cause any physical, psychological and social risk. 

• The participant has right to withdraw at any time. 

2.2.3 Pilot Study 

A pilot study was carried out on 10% of women (9 cases) who were excluded from the sample to 

ascertain their clarity, estimated time, efficiency and applicability and the necessary changes were 



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undertaken. 

2.2.4 Field Work (Procedure): 

The researcher selects lactating caesarean women who fulfilled the criteria. The researcher explained 

the purpose of the study to every woman, and then her consent to participate in the study was obtained. 

Each interview was conducted individually and in total privacy to assure that information to be 

obtained will be confidential and will be used only for research purpose.  

Six days per week specified for data collection until the study sample completed over a period of 6 

months starting from the beginning of January till June 2010. Women attended to the postnatal ward 

were interview. The average number of interviewee was 1-3 per day and the time taken for each sheet 

to complete was 60-75 minutes, depending upon the response of interviewee.  

The study proceeds as the following: 

A. The whole primiparous caesarean women were interviewed by the researcher during the first 12 

hours after delivery to find out general characteristics of the sample and assess their knowledge about 

breastfeeding and breast engorgement. In addition, the condition of their breasts was assessed during 

the initial interview according to the pre-designed check list which is used on the Newton's Scale. This 

assessment was considered as the base-line measurement of chest circumference. 

B. The percent of sample who had breast engorgement among all primiparous women delivered by 

caesarian section were 55.9% all over the period of the study (6 months).  

C. The whole sample (90 lactating women) that was actually suffered from breast engorgement. They 

were interviewed by the researcher in the 3rd postnatal day to identify their current signs, symptoms 

and complain (base-line data of the participants).  

Group (1): Study group  

This group were comprised half of the women who suffered from breast engorgement and different 

nursing measures were instituted & instructions, booklet was given for them. The methods of 

intervention were: 

1) Appling of warm compresses for affected breast for 20 minutes before each feeding. Heat 

application is used in form of hot compresses, hot shower, or hot soaks. The temperature of hot 

compresses ranged between 43oc & 46oc. 

2) Administered cold cabbage leaves which were refrigerated in the freezer for approximately 20-30 

minutes prior to the procedure. Cold leaves were placed inside the women's brassier for 30 minutes. 

3) Massaging the breast and emptying the breast by manual (or pump) expression of milk after each 

feeding was demonstrated at first by the researcher on one breast and re-demonstrated by the mother on 

the other breast.  

Group (2): Control group 

This group were comprised the other half of the women who suffered from breast engorgement and 

were left to the routine postnatal hospital care. 



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2.2.5 Follow up: 

Reassessment of women's breast condition; using the same tools which were used in the 1st visit; was 

done for two groups at 3rd, 4th,and 5th day post-partum , and they instructed to come to outpatient clinic 

for follow-up visits at 7th, and 9th day post-partum. The breast was observed for (redness, edema, and 

pain) and the mother observed for pyrexia. A comparison was then done between the 1st and successive 

measurements which were done in the 3rd day and in the  4th, 5th, 7th, and 9th day after delivery.  

2.3 Administrative Design 

Official permission to conduct the study was obtained from responsible authorities after explanation of 

the purpose of the study. 

2.4 Statistical Design 

The data collected were computerized, revised, categorized, tabulated, analyzed, and presented in 

descriptive and associated statistical form using the statistical software SPSS. The necessary tables 

were then prepared and statistical formulas were used. The following statistical measures were used: 

A. Descriptive measures included percentages, arithmetic mean (x -), and Standard Deviation (SD). 

B. Statistical tests included: 

1) Chi square (X2) test for analysis of qualitative variables. 

2) T test for analysis of quantitative variables. 

3) r test for analysis of correlation association. 

C. Graphical presentation included Column-chart diagrams.  

D. The level of significance selected for this study was P equal to or less than 0.05. 

 

3. Result 

Table 1 illustrates the distribution of the study subjects according to their general characteristics. It was 

found that, the mean age was 23.9 ± 6.6 and the mean age of marriage was 22.2 ± 6.4 for the study 

group and 22.6 ± 4.9 and 21.04 ± 6.1, respectively, for the control group. Concerning their level of 

education, it was clear that those who had secondary or equivalent secondary education constituted 

48.9% of the study group and 31.1% of the control group. The majority of both the study & control 

groups (71.1% & 80%) were housewives. The same table shows that (51.1% & 53.4%) of both study & 

control group, respectively, were from rural areas. Considering the type of family, it was observed that 

similar proportion (51.1%) of both study & control subjects had extended family. In relation to family 

income, it was observed from the same table that (64.4%) of the study group and (51.1%) of the control 

group didn’t have enough family income. While a minority of both groups (8.9%) were had more than 

enough for their need. No significant differences found between two groups which indicated 

homogeneity of the two groups. 

Figure 1 presents distribution of the samples according to severity degree of breast engorgement before 

application of nursing measures. It was observed that moderate engorgement scored the highest 



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percentage (48.9% & 42.3%) for the study and control group, respectively. 

Figure 2 portrays distribution of the samples according to severity degree of signs & symptoms breast 

engorgement before application of nursing measures. 

Table 2 shows that, in the 3rd day (before intervention), 51.1% of the study compared to 6.7% of the 

control group had severe redness. After intervention, it was found that, the percentage of severe redness 

declined to 4.4% in the 4th day and completely absents by the 5th day in the study group. While 

increased to 26.7% in the 4th day and 31.1% by the 5th day in the control group. Concerning the 

complete recovery from redness, the table shows that, it was achieved among the whole study group 

(100%) by the 7th day, while in control group; only 24.4% of the sample was completely recovered by 

the 9th day.  

Regarding to severe pain, the table shows that, in the postpartum 3rd day (before intervention), there is 

46.6% of the study sample compared to 4.4% of the control group suffer from severe pain, while, in the 

4th day this percentage declined to 0.0% in the study group. While increased to 31.1% in the 5th day and 

completely absents by the 9th day in the control group. When the complete recovery from pain was 

considered, the entire study group (100%) was recovered by the 7th day postpartum, while only 20% in 

the control group were recovered completely until the 9th day postpartum.  

It is observed that, in the 3rd day (before intervention), 40% of the study sample compared to 6.7% of 

the control group had severe edema. After intervention, it was found that, the percentage of severe 

edema declined to 2.2% in the 4th day and completely absents by the 5th day in the study group. While 

increased to 28.9% in the 5th day and completely absents by the 9th day in the control group. concerning 

the complete recovery from edema , the table shows that , it was achieved among the whole study 

group (100%) by the 7th day ,while in control group, (55.6%) of the sample were completely recovered 

by the 9th day postpartum. 

Regarding to severe pyrexia, the table shows that, in the postpartum 3rd day (before intervention), 

51.1% of the study sample compared to 4.4% of the control group suffer from severe pyrexia, while, In 

the 4th day it was found that, complete absence of severe pyrexia in the study group, while remaining 

the same percentage until the 5th day in the control group. When the complete recovery from pyrexia 

was considered, the entire study group (100%) was recovered by the 5th day postpartum, while 93.3% 

of the control group was recovered completely by the 9th day postpartum.  

Figure 3 shows comparison between study and control group regarding their complete recovery from 

breast engorgement throughout follow up visits. It was observed that all of study group completely 

recovered (100%) in the fifth day compared to only 40% of the control group. 

Table 3 reveals that the complete recovery from (redness, pain & edema) for the study group 

throughout follow up visits was at the postpartum seventh day, while for the control group it extended 

after the ninth day postpartum. However, the complete recovery from pyrexia for the study group was 

at the postpartum fifth day compared to later than ninth day postpartum for the control group.  



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Table 4 illustrates a strong significant negative correlation association was found between the degree of 

breast engorgement and the age & age of marriage for both the study and control sample. The percent 

of illiterate women in both groups (3.0 ± 0.0 & 1.8 ± 0.8) had got high level of engorgement as 

compared to university educated women (1.4 ± 0.5 & 1.7± 0.5) in both groups. The same table 

illustrates that, level of breast engorgement increased in urban areas (2.3 ± 0.6 & 2.28 ± 0.8) compared 

to rural ones (1.8 ± 0.6 & 1.83 ± 0.7). It was observed a strong significant negative correlation 

association between the degree of breast engorgement and family income for both the study and control 

sample, respectively, r = - 0.86, - 0.88. 

It was observed in Table 5 that, in the control group, 90.6% of women who aged less than 25 years 

were relieved from breast engorgement on the ninth day. While all of, participated women in, the study 

group were relived from breast engorgement on the fifth day. The same table illustrates that the 

majority of the illiterate, read & writing women in the control group (85.7%) relieved from breast 

engorgement on the ninth day. The table shows that only 8.3% from housewives among the control 

group were recovered from breast engorgement on the fourth day and 91.7% of them were relieved on 

ninth day as compared with (90.6%) from housewives of the study group who were recovered on the 

fourth day and all of them were relieved on fifth day. The table also shows that (88.9%) of the study 

group who married ≥20 years old was relieved on the fourth day. In comparison, none of the women in 

the control group recovered on the same day. The table shows that only 12.5% of the rural women 

among the control group were relieved from breast engorgement on the fourth day and 50% from them 

were relieved on the fifth day as compared with (87%) of the same dwellers of the study group who 

were relieved on the fourth day and all of them relieved on the fifth day. 

 

Table 1. Distribution of the Samples according to their General Characteristics 

Variables  

Sample groups  

T & X2 

Test 
Study Group (n = 45) Control Group (n = 45) 

N % N % 

Age( in years)     

 

T= 1. 08 

 

 

<20  14 31.1 12 26.7 

20- 14 31.1 20 44.4 

25- 8 17.8 10 22.2 

30-40 9 20 3 6.7 

Mean     X- ± SD 23.9 ± 6.6 22.6. ± 4.9 

Education:     
 

X2 =3.3 
Illiteracy 4 8.9 7 15.6 

Read  & write + Basic education  10 22.2 14 31.1 



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*Significant, P < 0.05 

 

Secondary equivalent education 22 48.9 14 31.1 

University education 9 20 10 22.2 

Occupation:     
 

X2 =1.0 
Working  13 28.9 9 20 

Housewife  32 71.1 36 80 

Age of Marriage:     

T = 0.89 
< 20years 27 60 31 68.9 

≥ 20 years  18 40 14 31.1 

Mean     X- ± SD 22.2 ± 6.4 21.04 ± 6.1 

Duration of Marriage:     

X2 =0.8 
≤5 years 18 40 14 31.1 

>5 years 27 60 31 68.9 

Mean     X- ± SD 5.8 ± 2.8 2.3 ± 3.3 

Residence:      

0.04 

 

Urban  22 48.9 21 46.6 

Rural  23 51.1 24 53.4 

Types of Family:      

identical 

 

Extended Family 23 51.1 23 51.1 

Nuclear Family 22 48.9 22 48.9 

Family Size:     

0.18 

 

3- 5 21 46.7 23 51.1 

 > 5 24 53.3 22 48.9 

Mean     X- ± SD 6.1 ± 2.01 5.95 ± 2.02 

Family Income:     

 

2.0  

Unsatisfied (not enough) 29 64.4 23 51.1 

Just enough(enough for living only) 12 26.7 18 40 

Satisfy (enough & can save from it ) 4 8.9 4 8.9 



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Figure 1. Distribution of Subjects according to Degree of Breast Engorgement and Its Signs & 

Symptoms throughout Follow up Visits 

 

 

Figure 2. Distributions of the Samples according to Severity Degree of Signs & Symptoms Breast 

Engorgement before Application of Nursing Measures 

 



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Table 2. Distribution of the Sample according to Scoring of Signs & Symptoms (Redness, Pain, 

Pyrexia, and Edema) in the Breast Engorgement throughout Follow up Visits (By Using Reeda 

Scale) 

Va
ria

bl
e Breast Engorgement 

throughout Follow up 

Visits  

Scoring 

X- ± SD T Test Non 

% 

Mild 

% 

Moderate 

% 

Sever 

% 

Sc
or

in
g 

of
 R

ed
ne

ss
 

3rd day      

5.7* Study Group 0.0 15.6 33.3 51.1 2.4 ± 0.7 

Control Group 0.0 48.9 44.4 6.7 1.6 ± 0.6 

4th day       

7.1* Study Group 35.5 48.9 11.2 4.4 0.8 ± 0.8 

Control Group 2.2 20 51.1 26.7 2.0 ± 0.8 

5th day       

12.9* Study Group 95.6 4.4 0.0 0.0 0.04 ± 0.2 

Control Group 13.3 35.6 20 31.1 1.8 ± 0.9 

7th day       

5.0 * Study Group 100 0.0 0.0 0.0 0.0 

Control Group 33.3 28.9 22.2 15.6 1.2 ± 1.1 

9th day       

13.3* Study Group 100 0.0 0.0 0.0 0.0 

Control Group 24.4 75.6 0.0 0.0 0.8 ± 0.4 

Sc
or

in
g 

of
 P

ai
n 

3rd day      

5.5* Study Group 2.2 15.6 35.6 46.6 2.3 ± 0.7 

Control Group 0.0 40.0 55.6 4.4 1.6 ± 0.6 

4th day       

6.9* Study Group 53.3 40.0 6.7 0.0 0.7 ± 0.8 

Control Group 2.2 24.4 49.0 24.4 2.0 ± 0.8 

5th day       

2.4* Study Group 97.8 2.2 0.0 0.0 1.6 ± 0.8 

Control Group 13.3 40.0 15.6 31.1 2.0 ± 0.8 

7th day       
20.0* 

Study Group 100 0.0 0.0 0.0 0.0 ± 0.0 



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Control Group 31.1 33.3 17.8 17.8 1.2 ± 1.1 

9th day       

13.3* Study Group 100 0.0 0.0 0.0 0.0 ± 0.0 

Control Group 20.0 80.0 0.0 0.0 0.8 ± 0.4 

Sc
or

in
g 

of
 P

yr
ex

ia
 

3rd day      

1.02 Study Group 0.0 22.2 26.7 51.1 2.3 ± 0.8 

Control Group 24.4 44.4 26.7 4.4 1.1 ± 0.8 

4th day       

2.2* Study Group 80.0 15.6 4.4 0.0 1.3 ± 0.5 

Control Group 0.0 51.1 44.5 4.4 1.5 ± 0.6 

5th day       

9.2* Study Group 100 0.0 0.0 0.0 0.0 ± 0.0 

Control Group 26.7 28.9 40 4.4 1.2 ± 0.9 

7th day       

9.0* Study Group 100 0.0 0.0 0.0 0.0 ± 0.0 

Control Group 33.3 15.6 51.1 0.0 1.17 ± 0.9 

9th day       

1.8 Study Group 100 0.0 0.0 0.0 0.0 ± 0.0 

Control Group 93.3 6.7 0.0 0.0 0.07 ± 0.3 

Sc
or

in
g 

of
 E

de
m

a 

3rd day       5.7* 

Study Group 0.0 15.6 44.4 40.0 2.2 ± 0.7  

Control Group 0.0 62.2 31.1 6.7 1.4 ± 0.6  

4th day       

0.9 Study Group 62.2 28.9 6.7 2.2 0.5 ± 0.7 

Control Group 4.4 31.1 51.1 13.3 1.7 ± 0.7 

5th day       

6.3* Study Group 71.1 28.9 0.0 0.0 0.3 ± 0.5 

Control Group 20.0 33.3 17.8 28.9 1.5 ± 1.1 

7th day       

7.5* Study Group 100 0.0 0.0 0.0 0.0 ± 0.0 

Control Group 28.9 57.8 8.9 4.4 0.9 ± 0.8 



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*Significant, P < 0.05  

 

Figure 3. Complete Recovery from Breast Engorgement and Its Signs & Symptoms throughout 

Follow up Visits 

 

 

 

 

 

 

 

 

 

 

 

 

 

9th day       

5.6* Study Group 100 0.0 0.0 0.0 0.0 ± 0.0 

Control Group 55.6 42.2 2.2 0.0 0.5 ± 0.6 

Study Group

Control Group

0

20

40

60

80

100

4th day 5th day 7th day 9th day after 9th day
Study Group 77.8 100 100 100 100 0
Control Group 6.7 40 66.7 93.3 100 0

Comparison  between Study and control groups regarding complete 
recovery from breast engorgement  through follow up . 



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Table 3. Comparison between Study Group and Control Group Regarding Complete Recovery 

from Signs & Symptoms of Breast Engorgement throughout Follow up Visits 

*Significant, P < 0.05  

 

Table 4. Relationship between Degree of Breast Engorgement of the Studied Women in the Two 

Groups and Their General Characteristics 

S 
&

 S
 

Sample Group 

Complete Recovery From Signs & Symptoms Of Breast Engorgement 

Throughout Follow Up Visits. 
X2 Test 

3rd day 4th day 5th day 7th day 9th day 

N % N % N % N % N % 

Redness 
Study Group 0 0 16 35.5 43 95.6 45 100 45 100 

64.2* 
Control Group 0 0 1 2.2 6 13.3 15 33.3 11 24.4 

Pain 
Study Group 1 2.2 24 53.3 44 97.8 45 100 45 100 

60.8* 
Control Group 0 0 1 2.2 6 13.3 14 31.1 9 20 

Edema 
Study Group 0 0 28 62.2 32 71.1 45 100 45 100 

57.2* 
Control Group 0 0 2 4.4 9 20 13 28.9 25 55.6 

Pyrexia 
Study Group 0 0 36 80 45 100 45 100 45 100 

29.8* 
Control Group 11 24.4 0 0 12 26.7 15 33.3 42 93.3 

Variables 
Study Group  Control Group 

Mean     X- ± SD Mean     X- ± SD 

Age / Year   

<20 2.4  ±   0.6 2.3  ±   0.8 

20- 2.3  ±   0.6 2.2  ±   0.7 

25- 1.9  ±   0.6 1.7  ±   0.7 

30-40 1.2  ±   0.3 0.5 ±   0.0 

r  Test - 0.8* - 0.7*  

Education   

Illiteracy 3.0 ±  0.0 1.8  ±   0.8 

Read  & write + Basic education 2.6  ±   0.5 2.4  ±   0.8 

Secondary equivalent education 1.8  ±   0 .6 1.9  ±   0.7 

  University  education 1.4  ±   0.5 1.7  ±   0.5 

r   Test       - 0.95* - 0.6* 



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* Significant Association           + Positive Association          - Negative Association 

 

Table 5. Relationship between Recovery Level of Breast Engorgement of the Studied Women in 

the Two Groups throughout Follow up Visits and Their General Characteristics 

Variable  

General Characteristics 

 

Group 

Follow up visits 

4h day 5th day 7th day 9th day >9th day 

A
ge

 / 
Ye

ar
 

< 25 - 
Study  Group (n = 45) 78.6 100.0 - - - 

Control Group (n = 45) 0.0 25.0 53.1 90.6 100.0 

25 - 
Study  Group (n=45) 75.0 100.0 - - - 

Study  Group (n = 45) 30.0 80.0 100.0 - - 

30-40 
Control Group (n = 45) 77.8 100.0 - - - 

Study  Group (n = 45) 0.0 66.7 100.0 - - 

r   Test 
Study  Group  + 0.93 * 

Control Group + 0.81 * 

Ed
uc

at
io

n Illiteracy, Read  & write   
Study  Group (n = 45) 42.9 100.0 - - - 

Control Group (n = 45) 0.0 9.5 28.6     85.7     100.0  

 Occupation   

Working  2.4  ±   0.7 2.2  ±   0.8 

Housewife  1.9  ±   0.7 2.0  ±   0.8 

r   Test + 0.81* + 0.74* 

Age of Marriage   

<20years 2.4  ±   0.7 2.0  ±   0.7 

≥ 20 years  1.8  ±   0.6 1.9  ±   0.8 

r   Test - 0.8* - 0.7* 

Residence   

Urban  2.3  ±   0.6 2.28  ±   0.8 

Rural  1.8  ±   0 .6 1.83  ±   0.7 

r   Test Identical   

Family Income   

Unsatisfied (not enough)  2.5 ± 0.6 2.7 ± 0.6 

Just enough (enough for living only) 1.7 ± 0.8 1.9 ± 0.8 

Satisfy (enough & can save from it ) 1.2 ± 0.5 1.0 ± 0.5 

r   Test  - 0.86*  - 0.88* 



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Secondary equivalent  

education 

Study  Group (n = 45) 90.9 100.0 - - - 

Control Group (n = 45) 14.3     64.3 100.0    - - 

University  education 
Study  Group (n = 45) 100.0 - - - - 

Control Group (n = 45) 11.1     77.8 100.0    - - 

r   Test 
Study  Group  + 0.87 *   

Control Group + 0.75 * 

O
cc

up
at

io
n 

Working 
Study  Group (n = 45) 38.5 100.0 - - - 

Control Group (n = 45) 0.0 33.3 66.7 100.0 - 

Housewives 
Study  Group (n = 45) 90.6 100.0 - - - 

Control Group (n = 45) 8.3 41.7 66.7 91.7 100.0 

r   Test 
Study  Group  + 0.93 * 

Control Group + 0.69 * 

A
ge

 o
f m

ar
ria

ge
 

< 20 years 
Study  Group (n = 45) 70.4 100.0 - - - 

Control Group (n = 45) 9.7 41.9 64.5 90.3 100.0 

≥ 20 years 
Study  Group (n = 45) 88.9 100.0 - - - 

Control Group (n = 45) 0.0 35.7 71.4 100.0 - 

r   Test 

Study  Group  + 0.97 * 

Control Group + 0.76 * 

 

R
es

id
en

ce
 

Urban 
Study  Group (n = 45) 77.2 100.0 - - - 

Control Group (n = 45) 0.0 28.6 52.4 85.7 100.0 

Rural 
Study  Group (n = 45) 87.0 100.0 - - - 

Control Group (n = 45) 12.5 50.0 79.2 100.0 - 

r   Test 

 

Study  Group + 0.99 * 

Control Group + 0.74 * 

* Significant Association            + Positive Association              -Negative Association 

 

4. Discussion 

Breast engorgement during the early puerperium is one of the most common causes of morbidity 

affecting functions and experience of early motherhood (Hassan et al., 2020b; Jelovesk, 2006). Breast 

engorgement is a physiological condition that is characterized by painful swelling of the breasts as a 

result of a sudden increase in milk volume, lymphatic and vascular congestion, and interstitial edema 



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during the first two weeks following childbirth. This condition is caused by insufficient breastfeeding 

and/or obstruction in the milk ducts. Breast pain during breastfeeding is a common problem. The 

occurrence of such condition faced by the mother adds to her apprehension and anxiety may lead to 

other severe breastfeeding problems for mother with consequent discontinuation of breastfeeding or 

addition of supplements of animal milk/commercial infant formula. Also, negligence of breast 

engorgement may lead to certain serious complication such as mastitis and breast abscess (Fraser et al., 

2004; Hanretty et al., 2003). 

Intervention toward the goal of alleviating or relieving patient pain and other discomforts related to 

engorgement and its causes are primarily nursing functions. Concerning postpartum pain, some women 

choose not to use medications at all or to use it infrequently for various reasons, therefore, alternative 

methods to relieve these discomforts need to be available to such women (pediatric advisor, 2009, 

Hendrson et al., 2004; Benson & Pernall, 2002). 

The best treatment for engorged breast is prevention; prevention is still the best medicine for any 

breastfeeding problem. Over the years, numerous strategies for the treatment of this problem have been 

employed such as kangaroo care, fluid limitation, binding the breasts or wearing a tight brassiere, hot 

and cold compresses, and application of cabbage leaves (Cable & Davis, 1997). 

The present study was conducted to investigate the effect of nursing intervention on relief of breast 

engorgement among women with cesarean section. The study highlights the need for strengthening 

mother training as well as pointing out to what extent their knowledge and practices toward 

breastfeeding. This leads to safe breastfeeding and prevents engorgement.  

The results of the study reveal that the socio-demographic and general characteristics of the subjects 

correlate, as expected, with the middle class of the Egyptian society. Where the mean age of the study 

and control participants was 23.3 years, and the mean age of marriage was 21.6 years old, the majority 

were, housewives and more than one half of them were rural dwellers and nearly similar proportion 

live within extended families as usual for rural communities. Considering the relatively high mean age 

of marriage of the subjects (in Upper Egypt) may reflect that the age of marriage has been raised in 

response to our national policy to limit family size. However, the prevalence of housewives, rural and 

unsatisfied family income among a sizable proportion of the study subjects may explain their 

reluctance to seek health services within their communities. In other words, working, urban women 

who have enough income are usually more likely to have better access to community health services 

which provide proper preparation, education, and care during antenatal and postnatal periods. 

The present study clearly illustrates that all women suffer signs and symptoms (redness, pain, edema, 

and pyrexia) of breast engorgement. The results of the present study illustrate the degrees of breast 

engorgement. Studies have shown that 20-85% of breastfeeding women experienced moderate and 

severe breast engorgement. The degree of engorgement usually lessens with each child. First-time 

mothers often suffer more from engorgement than women who are nursing their second or third child, 



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because the time it takes for the mature milk to "come in" seems to shorten with each child (Aniansson, 

2009). 

When the relationship between certain characteristics of puerperal women and the degree of breast 

engorgement was investigated, it was revealed that older women were less likely to develop high 

degree breast engorgement than younger ones. Furthermore, a strongly negative correlation was 

observed between women's degree of breast engorgement and their age. This may be because older 

primiparae are more likely to be concerned about their babies, thus they followed instructions more 

accurately and breastfed their babies appropriately. Lactational failure, however, leads to the absence of 

suckling and failure of ejection which may lead to engorgement and stasis of milk (Moon & Humenick, 

1989). 

It was also evident from the results that better-educated women had less breast engorgement degree, 

while women with limited educational background had more breast engorgement degree. A strongly 

negative correlation was observed between women's degree of breast engorgement and their education. 

This was expected since educated women are more likely to have better access to the community health 

care services and source of information that help in early detection and proper management of minor 

discomforts during puerperium. These results were in line with Hassan (2000). It was also mentioned 

that women who had been educated were open-minded to new ideas (Biennial report, 1996). Also, this 

finding went hand with El-Sherbeni (1988), Sheha et al., (2018), and Hassanine et al., (2017); all of 

them emphasized on the importance of education in the prevention and control of maternity health 

problems. Moreover, education should be a mean that enables women to gain access to knowledge. The 

more educated women received a better contribution to their empowerment. Education of women could 

also improve the health of the entire family. Women with more education should also be able to control 

many events in their lives. Thereby, access to education had to be a fundamental human right and a 

prerequisite to social, cultural and economic well-being (Rowley, 1992; Hassan et al., 2019; Sheha et 

al., 2020). 

The results of the present study also revealed a strong positive correlation women's degree of breast 

engorgement and their occupation. It was no wonder to find housewives and rural women are less 

likely to develop a higher degree of breast engorgement. This was expected since housewives and rural 

citizens accept their role as lactating mothers and practice it accurately as they are guided. This is 

opposite to urban working ones who prepare themselves in the wrong way for employment. Salhan S. 

et al. (2007), reported that, to help the mothers to maintain breastfeeding while working, the nurse 

should emphasized to the mother that she must establish a good milk supply, plan how and where she 

will pump the breast at work as well as planning baby feeding during the mother's working time.  

Regarding age at marriage of the studied subjects, the results of the present study presented that 

three-fifths of the study group and more than two-thirds of the control group married at age less than 20 

years. Furthermore, a strongly negative correlation was noticed between women’s age at marriage and 



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women’s degree of breast engorgement. It was not surprising to find that younger women tend to have 

a higher degree of breast engorgement than older ones. This might be because day by day life enhances 

women’s experience and improves their knowledge. This result was considered by Ghulam (1979) who 

stated that early marriage could harm the mother’s education, and also her understanding of how to 

relieve the minor discomforts during pregnancy. This result was supported by the other researches 

which indicated the fact that early marriage and pregnancy had hindered women to finish their 

education and to get a good job and had become financially dependent on their family. Therefore, teen 

mothers were more likely to live in poverty than women who were in delayed childbearing age 

(PBWRC, 2000; Smith & Maurer, 2000). Moreover delaying age at marriage was a key to improving 

women’s status and maybe a way of increasing their leverages in the decision-making the process 

(Ibrahim, Mensch, & El Gibaly, 1998). 

The results of the present study had also revealed a strongly negative correlation between women’s 

degree of breast engorgement and their family income. Degree of breast engorgement was more 

prevalent among poor women as most women were likely lived in large and extended families. This 

increased family size might reduce the per capita income and amount of care the mother gained 

especially during her puerperium. This would affect badly on the mother's health and her health 

practices. This was in accordance with Abrams and Gordon (1961) and William (1967). Moreover, 

poverty, type, and size of the family might increase the burden on women caring for many persons and 

striving hard for a living (WHO, 1995). These results were supported by the fourth world conference 

(1995) which denoted that statistics about women and poverty were all too familiar, where women were 

the majority of 1.3 billion people living in extreme poverty. Those poor women were more likely to live 

in crowded houses. 

It was observed from the results of the present study that, the degree of breast engorgement was higher 

among women who did not know than those who had correct but incomplete knowledge. A strongly 

positive correlation was found between the degree of breast engorgement and women’s knowledge 

regarding breast engorgement. This may be since most women’s knowledge was about the definition, 

causes and rarely about complications, prevention, and treatment of breast engorgement. This agrees 

with the fact that women need complete knowledge to perform correctively breast care and 

breastfeeding which consequently would prevent breast engorgement (Auvenshine & Enriquez, 1990). 

Breast engorgement is a very frequent problem among postpartum mothers. If the mother gets breast 

engorgement, she should believe that it will soon heal. The mother should continue breastfeeding. 

Podgurski (1995) indicated that most breastfeeding problems can be solved if it is continued and 

without the use of expensive medical advice. If the mother stops feeding, the problem may get worse. 

However, several similar problems common to breastfeeding can be prevented or eased through simple 

techniques or addressed with common, simple treatment options. The use of comfort measures to 

relieve breastfeeding discomfort is seen as an area of nursing responsibility. In general, many local 



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comfort measures are being applied to relieve discomforts during breastfeeding (Guest, 2005). 

Robson (1990) reported that heat application in the form of hot compresses, hot showers, or hot soaks 

is poorly researched and has usually been more of a comfort measure to activate the milk ejection 

reflex, rather than a treatment for edema. Some mothers complain that heat exacerbates the 

engorgement, causes throbbing and an increased feeling of fullness (Wilson & Lowdermilk, 2006). The 

application of heat is an effective way to increase circulation to breast, provide comfort and reduce 

edema (Mattson & Smith, 2000; Montle, Haslon, & Barton, 2004). A warm shower just before feeding 

may help to relieve engorgement. Mother can also cover her breasts with a warm washcloth and plastic 

dipper to keep the heat in (pediatric advisor, 2009). 

Moreover, a cold compress may apply to the breast to prevent edema and numbness. The cool promotes 

pain relief by decreasing the excitability of the nerve ending, decreasing nerve conduction local 

vasoconstriction with reduces edema, decrease muscle irritability and spasm. In her book, 

“Breastfeeding-A Guide for the Medical Profession”, Dr. Ruth Lawrence (1999) recommends applying 

cold packs to the breasts after feeding to help reducing swelling, warmth, and pain. Robson discusses 

that application of cold for 20 minute would have a minimal vasoconstriction effect in the deeper breast 

tissue and that venous and lymphatic drainage would be enhanced in the deeper tissue due to the 

accelerated circulation to and from the superficial tissues.  

Along with frequent nursing or pumping, many breastfeeding advocates suggest using cabbage leaves 

to reduce swelling when a mother experiences moderate to severe engorgement. Actual research data is 

spared, but the published studies and anecdotal reports from mothers, who have used it, seem to 

support its value in reducing breast engorgement (SU, 2010). 

In addition, some breastfeeding experts recommended using cool cabbage leaves to treat uncomfortable 

breast engorgement. Many women who have tried cabbage leaves claim the treatment beings relief 

from discomfort and improve milk flow. (Cabbage has been used for centuries as a folk remedy for a 

wide variety of ailments) (Pediatric advisor, 2009; Wilson & Lowdermilk, 2006). It’s not entirely clear 

why cabbage leaves would reduce breast engorgement, but the green cabbage plant contains a high 

concentration of sulfur, which is known to reduce swelling and inflammation in all tissues (Andrews, 

2010). Cabbage is known to contain sinigrin (allylisothiocyanate) rapine, mustard oil, magnesium, 

oxalates, and sulfur heterosides. Herbalists believe that cabbage has both antibiotic and anti-irritant 

properties (Lawrence, 2010). It is theorized, that this natural mixture of ingredients from Mother 

Nature’s Kitchen, helps decrease tissue congestion by dilating (opening) local capillaries (small blood 

vessels), which improves the blood flow in and out of the area, allowing the body to reabsorb the fluid 

which is trapped in the breasts. Cabbage may also have a type of drawing or wicking action that helps 

to move trapping fluid. In many cases, science is finding cures from Mother Nature’s Kitchen can’t be 

duplicated in the laboratory. This may be the reason why a gel made from cabbage leaf extract was not 

effective in treating engorgement as mentioned by Ayers (2000), Caplan (1999), Shifer (1995), and 



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Roberts (1995). 

Rosier (1998) and Fraser D and Cooper M. (2009) anecdotally describes the use of chilled cabbage 

leaves applied to engorged breasts and changed every two hours in a small sample of women as having 

a rapid effect on reducing edema and increasing flow. Nikodem et al. (1993) showed a non-significant 

trend in reduced engorgement in mothers using cabbage leaves. Roberts (1995) compared chilled 

cabbage leaves and gel packs and found a similar significant reduction in pain with both methods. With 

two-thirds of the mothers preferred the cabbage due to a stronger, more immediate effect. Roberts et al. 

(1998). Studied the use of cabbage extract cream applied to the breasts which had no more effect than 

the placebo cream. 

This study is supported by the finding of Snowden HM et al. (2001) who reviewed research studies to 

determine the effect of several interventions to relieve symptoms of breast engorgement among 

breastfeeding women and found that cabbage leaves were effective in the treatment of this painful 

condition. Cabbage leaves were preferred by mothers. The advantage of using cabbage leaves is its low 

cost and convenience as compared to other medical regimens. The present study also supported by the 

finding of Arora, Vatsa, and Dadhwal V. (2008) who reported that cold cabbage leaves as well as 

alternate hot and cold compresses both can be used in the treatment of breast engorgement. 

When breasts are severely engorged, the baby often cannot latch on property. Pumping or manually 

expressing some breast milk can help to reduce engorgement, allowing the baby to suckle, which will 

help to alleviate the swelling and prevent future episodes. Massaging the breasts as the babies' nurses 

can help to get out as much milk as possible. Many women are afraid to pump or express milk while 

they are engorged because they think it will cause them to make even more milk. However, 

engorgement is a problem of poor milk flow, rather too much milk. If the breasts are so full that it’s 

hard for the baby to latch on correctly, it may want to pump or hand express some milk before the 

feeding. Express enough to soften the nipple and areola so the baby can better grasp the breast. If the 

breast is still uncomfortably full after feeding the baby, pump for a few minutes until the breasts are 

softer and the milk flowing better, reduce the firmness enough to relieve discomfort and reduce obvious 

softening (pediatric advisor, 2009). 

Fraser and Cooper (2004) reported that the occurrence of problems (such as engorgement) would 

require artificial removal of milk. WHO/UNICEF (1993) stresses the importance of teaching all 

mothers how to express their milk in the first or second day after delivery. Breast pumping for a new 

mother should commence 6 to 24 hours after birth (Spicer, 2001). Milk removal commence by the third 

postpartum day to promote the likelihood of successful lactation (Labbok, 2001b). Expressing milk 

decreases the mechanical stress on the alveoli, preventing the cell death process, prevents blood 

circulation damages, alleviates the impedance to lymph and fluid drainage; decrease the risk of mastitis 

and compromised milk production, and gives relief to the mother (Walker, 2000). Hand expression and 

the electronic pump may be most helpful, as this drain the milk ducts better (Riordan, 2009; Johnson, 



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2010). 

In the present study, the nursing measures (study group) were used as a method of treatment for breast 

engorgement. Checking the findings of this study reveals that, symptoms and signs improved 

significantly by time until complete recovery occurred. Maximum recovery from pyrexia was achieved 

among women in the fourth postpartum day, while maximum recovery from pain, redness, and edema 

was achieved among the same group by the fifths postpartum day. In Egypt among the currently 

available agents for the treatment such measures as cold, warmth, breast expression or pumping and 

cool cabbage which are used to alleviate signs & symptoms of Breast engorgement (redness, pain, 

edema, and pyrexia). 

According to the results yielded by the present study, nursing measures seemed to be very useful in 

achieving a complete recovery of engorgement earlier and faster than routine hospital care. This 

coincides with Gamal El-deen (1993). Similar results reported by Ziemer and Pigeon (1995) who 

revealed a significant difference between women’s follow up visits and complete or maximum relief of 

signs and symptoms among the control group (routine hospital care). Maximum relief from edema and 

pyrexia were achieved by ninth postpartum day, while Maximum relief from redness and pain were 

accomplished among women of the same group later than ninth postpartum day. 

The relationship between women’s general characteristics and relief of their breast engorgement was 

also investigated. The results of the present study revealed that nursing intervention was effective in its 

relief in a shorter time than routine hospital care.  

As regards age, it was observed that complete recovery from breast engorgement was earlier among 

older women than younger ones. Furthermore, a positive correlation was observed between the 

recovery level of breast engorgement and their age. This may be explained by lack of experience of 

younger women, in addition, that those women are less likely to breastfeed than older ones; 

consequently, they were less liable to be relieved from breast engorgement. A similar finding was 

reported by Gamal EL-deen (1993). Other studies carried out in this field revealed that young mothers 

who were given a bucket of glucose water from the hospital were still giving water supplements after 

every feeding at the second postpartum week, despite full, dripping breasts. The mother and father 

stated that these feedings were against their better judgment but they had continued because they 

thought that it was what they were supposed to do. On the other hand, giving the infant a supplement 

can cause what is termed nipple confusion. The baby discovers that it is easier to suck on a rubber 

nipple and refuse the breasts. Consequently, breast engorgement may be developed and also difficult to 

be relieved (Hill, 1991). 

From the present study, it was not surprising to find that the recovery level of breast engorgement was 

better in highly educated women. A highly significant positive correlation was noticed between 

women’s education and their recovery level from breast engorgement. This result is in accordance with 

Gamal EL-deen (1993) who reported that the relief of breast engorgement is faster in highly educated 



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and middle social class women. This may be explained by the fact that educated and higher social class 

women were more likely to breastfeed their infant more frequently and longer than others. This is in 

line with the report of Applebaum (1975), Hill (1991) and Akin et al. (1981) who stated that the 

frequency of breastfeeding increased across all educational and income levels. Also, women of higher 

social status breastfeed longer than women of lower status. Also, many authors reported that in 

developing countries, the U.S.A. and Sweden, breastfeeding is now more common among highly 

educated women. All these are reflecting the relief of breast engorgement, but when the women receive 

both support and information, such support and this information had a positive effect on successful 

breastfeeding and consequently prevent breast complications (Applebaum, 1975). 

Dealing with occupation and residence, the results of the present study revealed that, recovery level of 

breast engorgement was better among rural dwellers and housewives. Furthermore, a significant strong 

positive correlation was observed between the recovery level of breast engorgement and occupation 

and residence. This is not amazing as rural dwellers and housewives accept their role as lactating 

mothers and practice it accurately as they are guided as mentioned before.  

Again, the relief of breast engorgement was faster in women whose age of marriage more than 20 years 

old. A significant strong positive correlation was observed between the recovery level of breast 

engorgement and mother's age of marriage. This may be explained by the fact that older women were 

more able to grasp and implement the instructions than younger ones. However, this might be due to 

the fact that day by day life enhances women’s experience and improves their knowledge. Also, early 

marriage could hurt the mother’s education as mentioned before (WHO, 1979). 

Finally, the results of the present study reveal that the three methods used for the treatment of breast 

engorgement namely (cabbage, hot compresses, and milk expression) have eventually leaded to their 

recovery and relief of their signs and symptoms. Furthermore, the study suggests that cabbage with its 

properties may be a superiorly effective agent in treating the engorged breast. Also, milk expression 

gives an important role in decreasing the occurrence of subsequent breastfeeding problems such as 

engorgement, mastitis, and abscess. This is due to the fact that women with low economic status tend to 

neglect themselves and deal with engorgement is a serious problem. This may consequently lead to 

other risk breastfeeding problems. Such mothers never ask for medical advice because they find it 

financially costly. One of the most important properties of all mentioned measures as a treatment of 

engorgement is being economically financial and easy to use. So, the nurse can play an important role 

in the prevention and resolve of breast problems through proper counseling and education.  

 

5. Conclusion 

Based on the findings revealed by the present study, it can be concluded:  

The degrees of severity of breast engorgement was higher with younger, less educated, working, urban, 

lower social classes women. The study also accepts the research hypotheses as, the nursing intervention 



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was more effective and contributed rapid recovery from breast engorgement especially among the older, 

educated, housewives, high social classes women and those who from rural areas than others.  

 

6. Recommendations 

In light of the results of the present study, the following recommendations are suggested:  

 Prevention is a key element in reducing breast engorgement potentially among nursing mothers. So, 

mothers should learn about preventive measures for breast engorgement.  

 Teaching mother how to express both breasts simultaneously to yield the most volume and to 

decrease time spend pumping each consecutively is the responsibility of health care providers. 

Additional, local WIC programs may provide a breast pump to engorged breast mothers and/or babies 

born preterm. 

Further studies should be done in this area as follows:  

 Further researches are needed to clarify the magnitude of the breast engorgement problem in Egypt 

as a whole and compare between rural and urban areas to find out the suitable solution for it.  

 Factors affecting the usage of traditional practices should be studied in depth by the health team for 

better management of these factors. This will affect positively the outcome of pregnancy & women 

health.  

 Research should be encouraged to find the relation between the use of traditional practices and 

various socio-demographic and obstetrical factors on a larger sample size.  

 

Acknowledgement 

Although it is usually easy to write down words to thank others for their help, my words do fail me to 

express my sincerest appreciation to my highly distinguished professor who helped me a lot to 

complete my study. My profound thanks gratefulness and appreciation to the soul of my professor Prof. 

Dr. Galal Ahmed El_Kholy, Professor of Obstetrics and Gynecology, Faculty of Medicine, Benha 

University, for his kind supervision, unlimited support, continuous guidance, and assistance. Words 

cannot express my deepest gratitude and appreciation to him; without his sincere advice, prompt 

assistance and over lasting helpful support my project and thesis would not have been completed. 

Thanks again and I hope that God will have mercy on him, reassures and relaxes his pure soul, and live 
him in Supreme paradise. 

 

 

 

 

 

 



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Note 

Note 1. The Reeda Scale is a tool used to provide the most effective means for evaluating the condition 

of the skin in relation to 5 factors (redness, edema, ecchymosis and healing). “To assess the effect of 

comfort measures on the healing process by Hill (1989)”. 

 


