http://doi.org/ 10.33698/NRF00182  –  Maria, Davinder  Kaur, Surinder  Jaspal

Abstract: Breast engorgement is a physiological condition characterized by painful swelling of the breasts. It results from sudden increase in milk volume, lymphatic and vascular congestion, and interstitial edema during the first two weeks following childbirth. It may also result from insufficient breastfeeding or any kind of obstruction in milk ducts. So, there is a need to disseminate information regarding efficacy of non-pharmacological intervention in breast engorgement. The current study was carried out to know the effect of chilled cabbage leaves vs. hot compression on breast engorgement among post natal mothers admitted in post natal wards of Nehru Hospital, PGIMER, Chandigarh. A total of 64 mothers with breast engorgement were enrolled in the study. Interventions were randomized by simple lottery method. Same kind of intervention was given to all the available subjects for one week and after that other intervention was given for next week. In the first week all the available subjects were given hot compression and at second week chilled cabbage leave were applied. Standardized tools i.e. numerical rating pain scale (N.R.S.) and 6 point breast engorgement scale were used to assess the severity of pain and engorgement level. The protocol for application of chilled cabbage leaves and hot compression was prepared and validated by experts. Pain score and engorgement score was compared between the groups and within groups. The analysis of data was done by using descriptive and inferential statistics. At the end of intervention severity of pain and breast engorgement was decreased in both groups. Hence both the interventions were effective in relieving pain and reducing breast engorgement.

Keywords:Breast engorgement, hot compression, chilled cabbage leaves.

Correspondence at Avinash Rana LecturerNational Institute of Nursing Education (NINE), PGIMER, Chandigarh

Introduction:Breast engorgement is a postnatal physiological unpleasant condition in which painful swelling, redness and hardness of the breasts is there due to sudden increase in milk volume, lymphatic and vascular congestion, and interstitial edema during a time when mothers are coping with the demands of a new baby.1,2 Engorgement is a swelling and distension of the breasts,usually in the early days of initiation of lactation due to vascular dilatation as well as Application of green cabbage leaves is also noticed to reduce swelling in moderate to the arrival milk.3 Previous research studies severe engorgement. The common green suggest that breast engorgement occurs most commonly from 3 to 5 post-partum day4, with some women presenting as late as cabbage (Brassica capitata) is used for engorgement therapy. It has been suggested that it contains a chemical sinigrin 9 to 10 day or even 14th day.4,5  Breast (allylisothiocyanate) that is absorbed Engorgement is associated with severe pain, nipple tenderness and fissures of the nipple and infection which can result in cessation of breast feeding. The engorgement is characterized by the appearance of shining breast, firmness, hardness of breast, mild to through the mother skin, which reduces oedema and increases milk flow.15 Cabbage has both antibiotic and anti-irritant properties. It improves the blood flow in and out of the area, allowing the body to reabsorb the fluid trapped in the breasts. Cabbage severe fever and discomfort.6,7 Managing compresses should not be used if the skin is breast engorgement has always been a challenge for nurses working with post natal broken i.e. cracked, bleeding or blistered nipples etc. If the skin is broken, place the mothers.Many pharmacological and non-cabbage leaves around the breast, without pharmaceutical methods for the treatment of breast engorgement have been explored. Pharmaceutical methods include administration of diuretics 8 , anti-covering irritated skin as it contains sulpha that causes irritation. Also, cabbage is not recommended for individuals who are allergic to sulpha. It was important for nurses inflammatory drugs9 like serrapeptase and to compare the impact of different non antipyretics. Non pharmacological methods include  hot    compresses and   hot pharmacological therapies for managing breast engorgement. Hence the present showers,cold cabbage compresses,10 cold study was undertaken. gel pads,11GuaSha (massage) therapy,12 breast binding,13 breast massage.4 Many non-pharmacological interventions are used to relieve breast engorgement. Use of chilled cabbage leaves and hot compression is one of them. Both are natural ways of treating and reduce maternal morbidity and help to improve lactation. There is great need of studying effect of chilled cabbage leaves and hot compression and comparing their effect on breast engorgement.15,16 Application of warm compression (a hand towel or sponge cloth dampened with warm water) on the breasts just before the mother feed is the common method to get the milk flowing due to vasodilatation.17

Objective:To assess and compare the effect of chilled cabbage leaves and hot compression on breast engorgement among post natal mothers admitted in PGIMER, Chandigarh.

Materials and Methods:This was a quasi-experimental study conducted from July to September,2013. Study was conducted in Clean Labor Room and Maternity Ward of PGIMER, Chandigarh. Permission from Head of the Department Of Gynaecology and Obstetrics was taken before conducting research study. The institute ethics committee of Post Graduate Institute of Medical Education and Research, Chandigarh approved the study.The protocol for application of chilled cabbage leaves and hot compression was developed by literature review and was validated by experts. Two standardize tools i.e ‘Numerical Pain Rating Scale’ and ‘6 Point Engorgement Scale’ was used. A pilot study was conducted to check the feasibility of tool. It was found that it was feasible to implement the tool. After that data was collected from subjects in the month of July and August in the selected post natal wards. All post natal mother admitted in selected wards of PGIMER, Chandigarh having breast engorgement were included. No individual randomization was attempted instead randomization of the interventions was done by slip method. The purpose and method of study were explained and informed written consent was obtained from the participants. Hot compression was considered as intervention 1 in which all the subjects in group 1 were given intervention and chilled cabbage leaves were considered as intervention 2. This intervention was given to all the available subjects of group 2 for one week in one type of intervention was given for a week to all the subjects available to avoid contamination. In the first week all the subjects were given hot compression for breast engorgement twice a day and in the next week chilled cabbage leaves were applied twice a day. A patch test was done by applying a small piece of cabbage leaf on the skin to test sensitivity before starting treatment. None of the women was found sensitive to cabbage leaf. The inclusion criterion was women getting same type of anti-inflammatory drugs/analgesics, Day 1 to day 7 of post-partum period. Total 64 mothers with 32 in each group met the inclusion criteria for study. Mothers having sensitivity to ‘sulfa’, broken skin of breast, taking lactation suppressants were excluded. To assess the effect of intervention pain and engorgement score of all the subjects was assessed before and after each treatment. The subjects of group – 1 were treated with hot compress and subjects of group – 2 were treated with chilled cabbage leaves as per protocol. Intervention was given twice a day and total 5 treatments were given to the each subject as per protocol. The analysis of data was done by using descriptive and inferential statistics. Chi square, Paired t-test, unpaired t-test was applied to analyze the data.

Results:Table 1 shows most of the subjects experiencing breast engorgement were in the age group of 25-28 years and least were in the age group of 33-36 years of age in both the groups (hot compression and chilled cabbage leaves). Two third subjects were graduate i.e. 62.4% in group 1 (hot compression) and 68.8% in group 2 (chilled cabbage leaves). And only a few were illiterate mothers i.e. 3.1% in both the groups. Out of all subjects maximum mothers belonged to Hindu religion. Most of the subjects were from joint families i.e. 81.2% from the group 1 (hot compression) and 71.9% from the group 2(chilled cabbage leaves) were living in joint families.One third of subjects had income up to Rs 20,000/- per month i.e. 31.2% mothers from group 1 and 34.4% mothers from group 2. Both groups were comparable as indicated by chi square test (p>0.05).

Table 1: Socio demographic profile of subjects

Variable Group 1

(hot compression) N=32 n (%)

Group 2

(chilled cabbage leaves) N=32 n(%)

2

z , df,p

Age (years)

20-24

25-28

29-32

33-36

 

6(18.8)

15(46.9)

8(25.0)

3(9.4)

 

11(34.4)

14(43.8)

6(18.8)

1(3.1)

 

2.79

3

0.42

Education Illiterate up to 10th Graduate

Post graduate

 

1(3.1)

7(21.9)

20(62.4)

4(12.5)

 

1(3.1)

7(13.9)

22(68.8)

2(6.2)

 

 

4.51

3

0.42

Religion Hindu Sikh Muslim  

21(65.6)

8(25.0)

3(9.4)

 

22(68.8)

6(18.8)

4(12.5)

 

0.89

2

0.64

Family type Nuclear Joint  

6(18.8)

26(81.2)

 

9(28.1)

23(71.9)

 

0.78

1, 0.37

Type of delivery

NVD L.S.C.S

 

19(59.4)

13(40.6)

 

23(71.9)

9(28.1)

1.11

1

0.29

Post natal day

1-3

4-6

 

23(71.9)

9(28.1)

 

23(71.9)

9(28.1)

 

0.0,

1, 1

 Table 2 shows comparison of intensity of pain in the breast experienced by the subjects during pre-intervention and post intervention phase in both the groups (application of chilled cabbage leaves and application of hot compress). Before intervention the mean pain scores of both groups were comparable i.e. both the groups experienced similar intensity of pain.The intensity of pain was decreased in both the groups. The difference in pre and post intervention intensity of pain in the breast as indicated by pain score in both the intervention groups was statistically significant as indicated by paired t test (p<0.05). This indicated that both the interventions (application of chilled cabbage leaves and application of hot compress) were effective in reducing the pain in the engorged breast. The effectiveness of chilled cabbage leaves was little more as the mean pain score after the application of chilled cabbage leaves was low i.e. 0.06 ± 0.25 as compared to the application of hot compression i.e. 0.19± 1.02. Though this difference was statistically not significant as per unpaired t test P>0.05. This indicates that both interventions were equally effective in reducing intensity of pain in engorged breast as mean pain score reduced after both the interventions significantly.

Table 2: Comparison of change in mean pain score level before and after intervention in group 1 and 2

 

Group Pre Intervention mean Pain Score± SD Post Intervention Mean Pain Score ± SD t, df, p (paired-t test)
Group 1(hot compression) N=32 7.66 ± 1.34 0.19± 1.02 32.63, 31

<0.001

Group 2(chilled cabbage leaves) N=32 7.97 ± 1.18 0.06 ± 0.25 39.02, 31

<0.001

Unpaired t test t, df, p 0.99, 62, 0.324 1.331, 62, 0.188

 Table 3 shows the impact of two interventions i.e. application of chilled cabbage leaves and application of hot compression on the engorged breast in managing breast engorgement. The level of engorgement in the breast as indicated by mean engorgement score in both groups was not comparable before starting the intervention. The level of breast engorgement during pre intervention phase was significantly higher in group 2 (chilled cabbage leave) as compared to group 1 (hot compression) as indicated by mean engorgement score was 5.88±0.33 & 5.62±0.48 respectively. (P<0.05 as per unpaired t test). The result showed that post intervention mean engorgement score decreased significantly in both the interventions groups as compared to pre intervention engorgement score as per paired t test (p<0.05). This indicated that both the interventions were effective in relieving breast engorgement. The effectiveness of application chilled cabbage leaves on engorged breast was little more as the mean engorgement score after the application of chilled cabbage leaves was comparatively little low i.e. 1.06 ± 0.24 as compared to the application of hot compression i.e. 1.16± 0.36. Though this difference was statistically not significant as per unpaired t test (p>0.05). This indicated that both the intervention were equally effective in managing breast engorgement.

Table 3: Comparison of change in mean engorgement scores before and after intervention in Group 1 and 2

 

Group Pre Intervention mean Pain Score± SD Post Intervention Mean Pain Score ± SD t, df, p (paired-t test)
Group 1(hot compression) N=32 5.62 ± 0.49 1.16± 0.36 44.58

31

< 0.001

Group 2(chilled cabbage leaves) N=32 5.88 ± 0.33 1.06 ± 0.24 44.58

31

<0.001

Unpaired t test

t df p

 

2.30

61

0.025

 

1.152

61

0.254

 

 Table 4 shows the comparison of intensity of pain between different treatments by applying repeated ANOVA test. When the mean difference of pain score of pre-treatment was compared with mean score of all the post treatments 1,2,3,4,5 of group 1(hot compression) It was observed that there was subsequent increase in the mean pain score difference, showing that the pain intensity was deceased as the treatment was continued. Similarly, when the mean difference of pain score of pre-treatment was compared with mean score of all the 5 post treatments of group 2 (chilled cabbage leaves) there was subsequent increase in the mean pain score difference, showing that the pain intensity was deceased as the treatment was continued and the differences in most of the cases was statistically significant. So, the results show that both the interventions reduced the intensity of pain after each treatment indicated that each treatment was effective in reducing the intensity of pain in both groups by both treatment modalities. Table 5 shows the comparison of change in the mean engorgement score in between the treatments in both groups by applying repeated ANOVA test. When the mean difference of engorgement of pre- treatment was compared with all the 5 post treatments of group 1 (hot compression) there was subsequent increase in the mean engorgement difference, showing that the engorgement level was deceased after implementing hot compress at each treatment. This difference was found satistically significant indicated that each treatment provided relief to the subjects. The same was found in the group 2(chilled cabbage leaves). So, both the groups showed the decrease in the engorgement score after each treatment. This showed that both the interventions are equally effective and subjects got relief from the engorged breast after each treatment.

Table 4: Comparison of pain intensity in between different treatments in Group 1 and 2

 

Pain Group 1 Group 2
Mean Difference Std Error P Mean Difference Std Error P
Pre Treatment Post Treatment 1

Post Treatment 2

Post Treatment 3

Post Treatment 4

Post Treatment 5

1.83

3.50

5.33

6.66

8.66

0.30

0.56

0.42

0.61

0.42

0.02

0.02

0.00

0.00

0.00

1.66

3.00

5.00

6.33

8.66

0.33

0.00

0.00

0.66

0.33

0.56

<0.01

0.00

0.16

0.02

Post Treatment 1 Post Treatment 2

Post Treatment 3

Post Treatment 4

Post Treatment 5

1.66

3.50

4.83

6.80

0.33

0.23

0.47

0.30

0.06

0.00

0.00

0.00

1.33

3.33

4.66

7.00

0.33

0.33

0.33

0.00

0.56

0.02

0.07

<0.01

Post Treatment 2 Post Treatment 3

Post Treatment 4

Post Treatment 5

1.83

3.10

5.16

0.16

0.60

0.47

0.00

0.04

0.00

2.00

3.33

5.66

0.00

0.66

0.33

<0.01

0.56

0.05

Post Treatment 3 Post Treatment 4

Post Treatment 5

1.33

3.33

0.49

0.25

0.04

0.00

1.33

3.36

0.66

0.33

1.00

0.02

Post Treatment 4 Post Treatment 5 2.0 0.25 0.00 2.33 0.33 0.29

Table 5: Comparison of level of breast engorgement in between the treatments in group 1 and 2

Engorgement Group 1 Group 2
Mean Difference Std Error P Mean Difference Std Error P
Pre Treatment 1 Post Treatment 1

Post Treatment 2

Post Treatment 3

Post Treatment 4

Post Treatment 5

0.66

1.33

1.83

3.00

4.60

0.21

0.21

0.16

0.25

0.33

1.0

0.56

0.56

0.52

0.34

0.66

1.00

2.00

3.00

5.00

0.33

0.00

0.00

0.00

0.00

0.33

<0.01

<0.01

<0.01

<0.01

Post Treatment 1 Post Treatment 2

Post Treatment 3

Post Treatment 4

Post Treatment 5

0.66

1.16

2.33

4.00

0.21

0.16

0.21

0.25

1.0

0.0

0.29

0.12

0.33

1.33

2.33

4.33

0.33

0.33

0.33

0.33

0.08

0.09

0.29

0.08

Post Treatment 2 Post Treatment 3

Post Treatment 4

Post Treatment 5

0.50

1.66

3.33

0.22

0.21

0.33

0.0

0.85

0.29

1.00

2.00

4.00

0.00

0.00

0.00

<0.01

<0.01

<0.01

Post Treatment 3 Post Treatment 4

Post Treatment 5

1.16

2.83

0.16

0.16

0.85

0.22

1.00

3.00

0.00

0.00

0.02

0.01

Post Treatment 4 Post Treatment 5 1.66 0.21 0.85 2.00 0.00 <0.01

Discussion:Breast engorgement is common problem among post natal mothers. Engorgement typically begins on the 3rd to 5th day after birth, and subsides within 12-48 hours if properly treated. If the engorgement is not relieved at proper time, the nipples become sore and cracked. This is caused as baby’s attempts to latch on to overfull breasts. Without treatment, severe engorgement lead to blocked milk ducts and breast infection, called mastitis.In the clinical setting numerous strategies for the treatment of this problem have been employed such as hot compression, cold compression, and application of cabbage leaves, fluid limitation, binding the breasts or wearing a tight brassiere. The present study was conducted to know the effectiveness of chilled cabbage leaves and hot compression on breast engorgement. The pain was assessed by numerical pain rating scale and engorgement was assessed by 6 point engorgement scale.Randomized controlled trials have been conducted to assess the effectiveness of cabbage leaves on breast engorgement. These types of remedies do not involve much cost and are readily available. Robert et `al also compared the efficacy of cabbage leaf extract with that of a placebo in the treatment of breast engorgement in lactating women and concluded that both the groups received equal relief from the discomfort and the hardness in breast tissue decreased substantially.17 Where as present study was conducted to know the effectiveness of chilled cabbage leaves and hot compression on breast engorgement. The results showed that both the interventions are effective in reducing the breast engorgement and intensity of pain.Many studies have been done to examine the effects of cabbage leaves in various ways, in an attempt to work out why exactly they are believed to relieve engorgement. One hypothesis is that they have a cooling effect. A study was done to compare chilled gel packs with chilled cabbage leaves, both were equally effective in relieving pain and engorgement. By contrast, another study found that chilling has no difference, even room temperature cabbage leaves were just as good as chilled in both cases. 11 One of the studies conducted in AIIMS, New Delhi on cold cabbage leaves vs. alternate hot and cold compresses, concluded that both can be used in the treatment of breast engorgement. Hot and cold compresses are more effective than cold cabbage leaves alone in relieving pain due to breast engorgement.16 Present study has also shown effectiveness for breast engorgement with both the treatments.Mean engorgement score after the application of chilled cabbage leaves was comparatively little low i.e. 1.06 ± 0.24 as compared to after the application of hot compression i.e. 1.16 ± 0.36 though difference was statistically not significant.Both the interventions used in present study i.e. chilled cabbage leaves and hot compression are easily available. These do not require many skills; do not require any special cost. These can be done at hospital and at home as well. These are basically home remedies that must be considered as the first line of treatment. This approach provides opportunity of cure without significant risk, burden or complications. In present study no side effect of cabbage leaves has been found on doing the patch test before its application. So its use is safe for the mothers. Along with the application of intervention, health education to the mothers is must regarding proper breast feeding, proper compliance with the treatment to increase the success rate of the intervention.It is concluded that application of chilled cabbage leaves and hot compression are effective for relieving breast engorgement. Both the protocols were successfully implemented in the clinical setting. As both the treatment modalities are low cost and easily available. It can be implemented by the nurses in day to day practice at hospital as well as at home to manage breast engorgement.

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