• breastfeeding;
  • nursing care;
  • initiation and duration of breastfeeding


  1. Top of page
  3. Conclusions

In 1972, breast care during pregnancy by nurses primarily concentrated on preparation of the nipples for breastfeeding. There is now a vast amount of research evidence that demonstrates the positive impact breastfeeding has on maternal and infant health. In this article, we compare the principles of 1972 with contemporary research-based information. Nurses continue to have an important role on the outcomes of breastfeeding initiation, duration, and exclusivity.

Breastfeeding is one of the most important ways women can care for their infants, as breast milk provides protection from many illnesses during infancy and optimizes growth and development. In addition breastfeeding provides protection for women from premenopausal breast cancer, ovarian cancer, and type II diabetes (Association of Women's Health, Obstetric, and Neonatal Nursing [AWHONN], 2007). Although the importance of breastfeeding for women and infants has not changed over the past 40 years, the information available to health care professionals about the importance to individual and public health has. Nurses have conducted or have been involved in many of the studies that have informed changes in practice. The purpose of this article is to compare past nursing recommendations for breast care during pregnancy (Countryman, 1972) with nurses' current role in educating and supporting women and families in breastfeeding

The focus of Countryman's article was preparing nurses to teach women how to care for their breasts during pregnancy so that they could successfully breastfeed after birth (1972). In Table 1, key assessments and interventions nurses provided for patients during pregnancy are presented. The most important distinction between 1972 and 2011 is that formerly a woman's breast and nipples had to be prepared and conditioned during pregnancy for breastfeeding to be successful. Interventions to toughen the nipples and treat any inverted nipples were part of regular patient education during pregnancy. Another important part of the nurse's role was fitting of brassieres during pregnancy. One of the most important recommendations from 1972 highlighted the nurse's role to teach and reinforce the information and interventions from the first prenatal visit through the entire pregnancy.

Table 1. Comparison of Breast Care Recommendations From 1972 to 2010
Breast Care
Recommendation 1972Recommendation 2010Rationale/research
Regular care beginning 1st trimesterAssess for any medical or physical condition that could affect the mother's ability to breastfeed. If any of these are identified, prenatal providers may refer to lactation professionalAcademy of Breastfeeding Medicine (ABM) Protocol Committee #5 (2008)
Breast historyMaternal injury to breast or surgeryThese conditions may negatively affect a mother's milk supply (Bodley & Powers, 1999; Dewey, Nommsen-Rivers, Heinig, & Cohen, 2003; Hill et al., 2004; Marasco et al., 2000). Women who have had problems with previous breastfeeding experience should be assessed for risk during subsequent pregnancies as this may affect their ability to breastfeed (Lawrence & Lawrence, 2005).
Breast reduction or augmentation chest surgery 
History of infertility 
Previous history of breastfeeding problems or concerns 
Instruction/supervision in breast & nipple care at 1st prenatal visitInform all pregnant women about the importance of breastfeeding for the health of all mothers and infants to allow women to make an informed decision about infant feedingAll women have the right to receive accurate information about breastfeeding (ABM Protocol Committee #19, 2009; American Academy of Pediatrics, 2005; American College of Obstetricians & Gynecologists, Committees on Health Care for Underserved Women and Obstetric Practice, 2000; AWHONN, 2007).
Nurse to continue discussion and guidance throughout pregnancyEncourage reading, in-office discussions and attendance at a local breastfeeding classes or La Leche League meetingsAvoid educational materials provided by formula manufacturers (Howard et al., 2000)
Refer to peer counseling resourcesHealth care providers and peers can have an important influence on the initiation and duration of breastfeeding (DiGirolamo, Thompson, Martorell, Fein, & Grummer-Strawn, 2005; Noble et al., 2003; Riordan, 2005; Rossman, 2007; Sikorski, Renfrew, Pindoria, & Wade, 2003)
Thorough breast examAssess breasts, identify changes during pregnancyA number of breast changes are commonly experienced during pregnancy, including breast enlargement, increased tenderness, darkening and/or enlargement of the areola, small amounts of colostrum leakage, increased visibility of veining on the chest, prominence of the glands of Montgomery, protrusion of the nipple, and appearance of stretch marks on the breasts (Lawrence & Lawrence, 2005). Absence of such changes may cause concern in mothers and health care providers and may signal a need for closer follow-up postbirth (Walker, 2006)
Assess for nipple tattoos or piercings 
Recommendations for brassieres, detailed instructions about brassiere fittingExpect breast and areolar growth during pregnancyWomen should wear a supportive comfortable bra (LeLeache League, 2000)
Hygiene—avoid soap on nipplesClear water with daily shower, no soap, creams, or lotionsPersistent removal of natural oils of the nipple and areola predisposes the skin to irritation. Montgomery glands in the areola secrete a sebaceous material for the cleansing and lubrication of the areola and nipple (Lawrence & Lawrence, 2005)
To condition skin of the nipple, dry breasts, areola, and nipples after bath/shower with terry cloth towelPat dry after bathing, no rubbing, tugging, or stimulation 
Regimen for toughening and erecting nipples (finger grasp and roll) During pregnancy, stimulation of the nipple, expression, or pumping may stimulate release of oxytocin and cause the uterus to contract and could be associated with an increased risk of preterm labor after 20 weeks in at-risk women (Guinn et al., 1994)
Inverted nipples—use breast shield during pregnancyRefer to International Board Certified Lactation Consultant (IBCLC) for thorough assessment or for questions or concernsResearch has not demonstrated that nipple preparation such as wearing breast shells, or pulling on or manipulating the nipple improves nipple protractility (Alexander, Grant, & Campbell, 1992; MAIN Trial Collaborative Group, 1994; Riordan 2005)

The contemporary antepartal approach to nursing care is history, assessment, and referrals versus interventions to prepare the nipples. Another key difference in contemporary nursing practice is the nurses' role in educating women and the public about the health benefits of breastfeeding for the women and her infant; most often the decision to breastfeed is made before pregnancy (AWHONN, 2007). Thus, all women should have accurate information during the preconception and prenatal periods about the important health benefits of breastfeeding for the mother and infant to assist women to make informed choices about infant feeding. Researchers have found that women in some communities have not been provided with accurate information to inform their decisions about infant feeding because health care providers have made assumptions about whether a specific mother will breast or formula feed her infant based on a woman's demographic characteristics (McCarter-Spaulding, 2004). Women of all ethnicities have the right to be provided with accurate information as they make their feeding decisions. Education should never be withheld because of health care providers' thoughts about whether a mother might breast feed her infant.

It is crucial for nurses to emphasize the importance of breastfeeding for mother and infant.

All women should have a thorough history and assessment that includes the breast and any other illnesses or conditions that might affect a woman's ability to produce an adequate milk supply for her infant. For example, women who have had polycystic ovarian disease and a history of infertility may have difficulty producing an adequate milk supply to sustain infant growth (Marasco, Marmet, & Shell, 2000). Prior surgical procedures such as breast augmentation or reduction may also interfere with an adequate milk supply (Hill, Wilhelm, Aldag, & Chatterton, 2004). Nurses must verify the woman's history and conduct appropriate assessments during pregnancy, birth, and postpartum to monitor the woman's milk production and her infant' nutritional intake. Referrals to appropriate personnel, agencies, and organizations should be made to educate and support women to make informed decisions about infant feeding through lactation consultants, classes, and peer counselor programs (AWHONN, 2007).

Another principle that was not emphasized 40 years ago is the need for careful assessment of the mother and infant during hospitalization and the early postpartum period. Many of the potential risk factors for a women's inability to provide adequate amounts of breastmilk include her inability to breastfeed a previous infant, maternal obesity, preterm labor, or separation from her infant. Excessive infant weight loss, supplements of artificial milk, or inadequate stools and voids help nurses and other health care providers carefully monitor for inadequate transfer of milk. These kinds of assessments are necessary for health care providers to help women and infants be successful in their initiation, exclusivity, and duration of breastfeeding (AWHONN, 2007)

In 1972, breastfeeding support focused on the preparation of the nipples and breasts.

An important theme in Countryman's (1972) article was the notion of registered nurses (RNs) providing care for women in outpatient settings. The importance of care provided by the RN was clearly acknowledged, although subsequent research has demonstrated that the preparation of the nipples during pregnancy is not necessary (AWHONN, 2007). Additionally, researchers and experts have demonstrated that nipple preparation during pregnancy may be harmful by reducing important oils and lubricants and that in some women nipple stimulation may cause contractions that could be related to increased risk of preterm labor (Guinn et al., 1994). Thus the scope of nursing influence has expanded considerably in the last 40 years. As we have learned, nurses and other health care providers can have a great deal of influence on a woman's choice of feeding and the duration of breastfeeding (AWHONN).


  1. Top of page
  3. Conclusions

Although nurses have closely examined research results and worked to change practice, it is important to remember the different type of care provided at a particular time in history. Often, the primary challenge is to get current knowledge systematically and quickly translated into clinical practice. It is important to celebrate the practice changes nurses have made and respect those who have gone before with the understanding that they were providing the best care at the time.

The RN continues to have an important role in helping women initiate and continue breastfeeding. One important role is to communicate information about conditions that can negatively affect a woman's milk supply during pregnancy, birth, and postpartum care in settings that can vary from brief hospitalization to outpatient settings in the community. In the hospital and beyond, nurses must maximize breastfeeding outcomes by identifying risk factors for problems, fostering breastfeeding behaviors, and building maternal confidence, knowledge and skills. The important message from Countryman's 40-year-old article is that although many of the practice recommendations have changed, the importance of care provided by the RN to support the initiation and continuation of breastfeeding continues.


  1. Top of page
  3. Conclusions
  • Academy of Breastfeeding Medicine Protocol Committee. (2008). ABM clinical protocol #5: Peripartum breastfeeding management for the healthy mother and infant at term. Breastfeeding Medicine, 3 (2), 129-132. doi:DOI: 10.1089/bfm.2008.9998.
  • Academy of Breastfeeding Medicine Protocol Committee. (2009). ABM clinical protocol #19: Breastfeeding promotion in the prenatal setting. Breastfeeding Medicine, 4 (1), 43-45. doi:DOI: 10.1089/bfm.2008.9982.
  • Alexander, J., Grant, A., & Campbell, M. J. (1992). Randomized controlled trial of breast shells and Hoffman's exercises for inverted and non-protractile nipples. British Medical Journal, 304, 1030-1032.
  • American Academy of Pediatrics. (2005). Breastfeeding and the use of human milk. Pediatrics, 115, 496-506.
  • American College of Obstetricians and Gynecologists, Committees on Health Care for Underserved Women and Obstetric Practice. (2000). Breastfeeding: Maternal and infant aspects. In J. T.Queenan (Ed.), ACOG educational bulletin (pp. 1-15). Washington, DC: American College of Obstetricians and Gynecologists.
  • Association of Women's Health, Obstetric, & Neonatal Nursing. (2007). Breastfeeding support: Prenatal care through the first year (2nd ed (Evidence-Based Clinical Practice Guideline). Washington, DC: Author.
  • Bodley, V., & Powers, D. (1999). Patient with insufficient glandular tissue experiences milk supply increase attributed to progesterone treatment for luteal phase defect. Journal of Human Lactation, 15, 339-343.
  • Countryman, B. A. (1972). Breast care in pregnancy. Journal of Obstetric, Gynecological, & Neonatal Nursing, 1, 35-36. doi:DOI: 10.1111/j.1552-6909.1972.tb02703.x.
  • Dewey, K. D., Nommsen-Rivers, L. A., Heinig, M. J., & Cohen, R. J. (2003). Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation and excess neonatal weight loss. Pediatrics, 112, 607-619.
  • DiGirolamo, A., Thompson, N., Martorell, R., Fein, S., & Grummer-Strawn, L. (2005). Intention or experience? Predictors of continued breastfeeding. Health Education and Behavior, 32, 208-226.
  • Guinn, D. A., Wigton, T. R., James, J. A., Dunlop, D. D., Socol, M., & Frederiksen, M. C. (1994). Mammary stimulation test predicts preterm birth in nulliparous women. American Journal of Obstetrics and Gynecology, 170 (6), 1809-1812.
  • Hill, P. D., Wilhelm, P. A., Aldag, J. C., & Chatterton, R. T. (2004). Breast augmentation and lactation outcome: A case report. American Journal of Maternal Child Nursing, 29, 238-242.
  • Howard, C. R., Howard, F. M., Lawrence, R. A., Andresen, E., DeBlieck, E., & Weitzman, M. (2000). The effect on breastfeeding of physicians'office-based prenatal formula advertising. Obstetrics and Gynecology, 95 (2), 296-303.
  • Lawrence, R. A., & Lawrence, R. M. (2005). Breastfeeding: A guide for the medical profession. St. Louis, MO: Mosby.
  • LeLeache League. (2000). Womanly art of breastfeeding (6th ed.). Schaumberg, IL: La Leche League International.
  • MAIN Trial Collaborative Group. (1994). Preparing for breastfeeding: Treatment of inverted and non-protractile nipples in pregnancy. Midwifery, 10, 200-214.
  • Marasco, L., Marmet, C., & Shell, E. (2000). Polycystic ovary syndrome: A connection to insufficient milk supply? Journal of Human Lactation, 16, 143-148.
  • McCarter-Spaulding, D. (2004). The importance of breastfeeding in improving the health of African-Americans: A health policy perspective. Journal of Multicultural Nursing and Health, 19, 24-28.
  • Noble, L., Hand, I., Haynes, D., McVeigh, T., Kim, M., & Joon, J. J. (2003). Factors influencing initiation of breastfeeding among urban women. American Journal of Perinatology, 20, 477-483.
  • Riordan, J. (2005). Breastfeeding and human lactation (3rd ed.). London, U.K.: Jones & Bartlett.
  • Rossman, B. (2007). Breastfeeding peer counselors in the United States: Helping to build a culture and tradition of breastfeeding. Journal of Nurse Midwifery and Women's Health, 52 (6), 631-637.
  • Sikorski, J., Renfrew, M. J., Pindoria, S., & Wade, A. (2003). Support for Breastfeeding mothers: a systematic review. Paediatric and Perinatal Epidemiology, 17 (4), 407-417.
  • Walker, M. (2006). Breastfeeding management for the clinician using the evidence. London, U.K.: Jones & Bartlett.