THE FEMALE BREAST

KAIRA C.
BSc NRS/RM/RN
GENERAL OBJECTIVE
• At the end of the lecture students should demonstrate an
understanding of the female breasts
SPECIFIC OBJECTIVES
• At the end of the lecture students should be able to:
1. Define the term breasts
2. Describe the microscopic structure of the breast
3. Discuss the developmental stages of the breast
4. Explain physiology of lactation
5. Outline the factors which can affect the content and supply
of milk
6. Outline the composition of breast milk
7. State the benefits of breastfeeding
INTRODUCTION
• The female breasts or mammary glands, are the accessory
organs of reproduction and secret milk for nourishment of the
young.
• Breasts exist in both sexes and are present as rudimentary
glands at birth.
• In the male, they normally remain rudimentary throughout.
• In females they continue to develop, their development starts
at about the 4th week of intrauterine life and remain under
developed before puberty, but undergo further development
during and after puberty..
• The greatest amount of development of the breast takes
place during pregnancy and after delivery.
• During pregnancy hormones prepare the breasts for active
use after delivery.
• It is important for nurses to have knowledge on the structure
of the female breast, physiology of lactation and care of the
breast for them to render help to women who present with
reproductive health related conditions.
Gross structure of the female breast

GROSS STRUCTURE OF THE BREAST

The illustration below shows the gross structure of the female breast;
• Definition
• The breasts or mammary glands are specialized glands of the
skin of the female mammals, which secret milk for
nourishment of the young(Dorland 2009).
• Situation
One breast is situated on each side of the sternum and
extends between the levels of the second and sixth ribs.
• The breasts lie on the superficial fascia of the chest wall over
the pectoralis major muscle, and are stabilised by the
suspensory ligaments.
• Shape
• Each breast is a hemispherical swelling and has a tail of tissue
extending towards the axilla (the axillary tail of Spence).
Size
• The size of the breasts varies with each individual and with
the stage of development as well as with age.
• It is not uncommon for one breast to be a little larger than the
other.
GROSS STRUCTURE
• The axillary tail – is the breast extending towards the axilla.
• The areola – is a circular area of loose, pigmented skin about
2.5cm in diameter at the center of each breast.
• It is pale pink in colour in the light skinned but darker in the
dark skinned, the colour deepening in pregnancy.
• The colour varies in different races and deepens with
pregnancy.
• Sebaceous glands
• Within the area of areola lie approximately 20 sebaceous
glands which in pregnancy enlarge and are known as
Montgomery tubercles.
• The nipple
• Lies in the center of the areola at the level of the fourth rib.
• It is a protuberance about 6mm in length composed of
pigmented erectile tissue.
• It is a highly sensitive structure.
• The surface of the nipple is perforated by small orifices, the
opening of the lactiferous ducts.
• It is covered with epithelium
MICROSCOPIC STRUCTURE OF THE BREAST
• The breast is composed mainly of glandular tissue, some fatty
tissue, and is covered with skin.
• The glandular tissue is divided into 18 lobes which are completely
separated by bands of fibrous tissue, internal structure resemble
the segments of a halved grape fruit or orange.
• Each lobe is a self contained working unit and is composed of the
following structures:
1. Alveoli – this contains the milk secreting cells, the acini cells
which extract from the mammary blood supply the factors
essential for milk formation.
• Around each alveolus lie myoepithelial cells also known as ‘basket
or spider cells’
• When these cells are stimulated by oxytocin, they contract
releasing milk into the lactiferous duct.
2. Lactiferous tubules
• These are small ducts which connect the alveoli.
3. Lactiferous duct – a central duct into which the tubules run
The continuation of each lactiferous duct forms the ampulla,
4. Ampulla The widened-out portion of the duct where milk is
stored.
It lies under the areola.
The ampulla extends and open on to the nipple.
Diagram showing the cross section of the female breast
Diagram showing the cross section of the female breast
Diagram showing the cross section of the female breast
• Blood supply – by the internal mammary artery, the external
mammary artery and the upper intercostal arteries. Venous
drainage is through corresponding vessels into the internal
mammary and axillary veins.
• Lymphatic drainage
• Largely into the axillary glands with some drainage into the portal
fissure of the liver and mediastinal glands. The lymphatic vessels of
each breast communicate with one another.
Nerve supply
• The function of the breast is largely controlled by hormone activity
but the skin is supplied by branches of the thoracic nerves, also
some sympathetic nerve supply especially on the areola and nipple.
DEVELOPMENTAL STAGES OF THE BREAST

• Breast development starts in utero and remains under

developed before puberty, but undergo further
development during and after puberty.
Intra uterine life
• Primary breast development of both sexes appear about
the 4th week of development in utero.
• In the 6th week about 20 mammary buds develop and
towards the end of intra uterine life these canalize
forming primitive milk secreting cells i.e. lactiferous ducts
and myoepithelial cells.
• Later the mammary pit forms where lactiferous ducts open as
well as the nipple.
• Most of the 20 mammary buds degenerate leaving 2, one on
either side.
• But if degeneration of mammary ridge fails, there will be extra
breasts or nipples.
• At birth
• The breast tissue is inactive and only the nipple is prominent,
however due to maternal hormones circulating in the blood
stream, the breast tissue may enlarge in the 1st few weeks of life.
• And milk may be secreted from the breast.
• The condition resolves without treatment as the maternal
hormone is withdrawn from the infant and the infant
develops its own hormones.
• Mothers should be reassured and advised not to squeeze as
that may cause infection
At puberty
• In the females there is a rise of hormonal levels which leads
to further development of the breast.
• Preceding periods of menstruation for about 2 years, the
tissue buds, glandular tissue, lactiferous tubules and ducts
proliferate
• Fatty and fibrous tissue also increase and the nipple and areola
become pronounced.
• There is a high increase of progesterone levels which stimulate the
proliferation of the alveoli, increase in fatty and fibrous tissue
leading to increase in the size of the breast.
During child bearing
• During non- pregnant state, breast change depends on the stage of
the menstrual cycle.
• Before menses, there is increase in progesterone produced by the
corpus luteum making the breasts to enlarge.
• With the commencement of menses and decrease in levels of
progesterone, the breast size tends to reduce.
• Changes during pregnancy
• The changes start even before a woman misses her period.
• Oestrogen stimulates further development of lactiferous
ducts and tubules, areola and nipple.
• Progesterone proliferates the alveoli in readiness for milk
production which leads to enlargement and multiplication
of alveoli
• In the early stages of pregnancy, oestrogen and
progesterone are released by the corpus luteum in the
ovary and once the placenta develops by 12 weeks,
• It takes over the secretion of these hormones to prepare the
breasts for production and secretion of milk.
3rd – 4th weeks
• there is pricking and tingling sensation around the nipples
due to increased blood supply.
6th -8th weeks
• The soft tissue of the breast becomes nodular to touch.
• The developing ducts and gland tissue enlarge and become
tense and painful due to further increase in blood supply.
• The subcutaneous veins become more clearly visible
• About 12 weeks
• the areola becomes darker and is referred toas primary
areola.
• The sebaceous gland around the nipple enlarges
(Montgomery tubercles) and secretes sebum which keeps the
nipple soft and supple.
• Colostrum may start to leak especially in multigravida who
has successfully breastfed.
• This colostrum is clear in color and helps in preparing the
secreting structure for free flow of milk during postnatal
period.
• About 16 weeks
• The mottled zone of pigmentation extends beyond the
primary areola and is referred to as secondary areola.
• The secondary areola is more in dark skinned women and
disappears after birth.
• Colostrum appears after 16 weeks of pregnancy and is more
yellow in color with creamy consistency and can be
expressed from the breast.
• During late pregnancy- colostrum may leak from the breast.
• Progesterone causes the nipple to be more prominent and
mobile.
• Despite all these changes, lactation is only established and
maintained after birth of the baby.
NB- Refer to notes on physiology of pregnancy for breast
changes
• After menopause With absence of ovarian hormones, breast
glands atrophy and secretory cells of the alveoli degenerate.
• Connective tissue also shows degenerative changes with a
decrease in stromal cells and collagen
PHYSIOLOGY OF LACTATION
There are two factors governed by hormones which are involved in
the physiology of lactation, these are ;
• Production of milk
• Passage of milk
• (i) PRODUCTION OF MILK
• Prolactin, a hormone secreted by the anterior pituitary gland, is
essential for the production of breast milk.
• Its levels in the maternal circulation rise during pregnancy, but its
action is blocked by the placental hormones.
• With separation and expulsion of the placenta at the end of labour,
the oestrogen and progesterone levels are gradually reduced to the
point where Prolactin can be released and activated
• An increased blood supply circulates through the breast and
essential substances for milk formation are extracted.
• Fatty globules and protein molecules from within the base of
the secretory cells distend the acini and push their way into
the lactiferous tubules.
• Raised levels of Prolactin inhibit ovulation and therefore have
a contraceptive function as well, but the mother needs to
breast feed 2 to 3 hourly for this to be effective.
• Prolactin levels are at their highest during the night and if
night feeds are the first to be discontinued then more reliable
methods of contraception must be used if pregnancy is to be
avoid
• (ii) PASSAGE OF MILK
• Two factors are involved in the transit of milk from the
secretory cells to the nipple, these are:
a. Back pressure
• The force of new globules forming in the cells pushes the
foremost ones into the lactiferous tubules and by suckling the
infant stimulates secretion of more milk.
• Some of the milk is stored in the lactiferous sinuses or ampulla
until the next feed, this is known as fore milk.
• b. Neuro-hormonal reflex
(let-down reflex)
When the baby is put to the breast, the rhythmical sucking
movement produces nervous stimuli which cause
unconditioned reflex in the posterior pituitary gland.
• The direct result of this is the liberation of Oxytocin from the
posterior pituitary.
• Oxytocin causes the myoepithelial cells (‘basket’ or
‘spider’cells) around the alveoli to contract and push milk into
the lactiferous vessels and so more milk flows to the ampullae
• This ‘let down’ reflex can be inhibited by pain, e.g. perineal
sutures.
• It is therefore important to ensure that the mother is in a
comfortable position, relaxed and pain free, especially during
feeding times.
• This same oxytocin secretion also causes the uterine muscles
to contract and so aids involution of that organ during the
peuperium
MAINTENANCE OF MILK PRODUCTION / LACTATION

The maintenance of lactation depends on:

[Link] by the baby and nipple stimulation
• without suckling and emptying of the breasts, there will be no
stimulus for breasts to produce more milk.
• The more the infant is put to the breast, the better will be the
supply.
• Breast fed infants need to feed frequently especially in the
early neonatal days.
• The infant needs to be correctly ‘fixed’ at the breast to
promote right amount of stimulus.
• The stimulus of the infant’s gums should be on the skin of the
areola so that pressure is exerted on the underlying ampulla
where the milk is stored.
• Therefore the baby feeds from the breast and not from the
nipple.
• If the mother complains of pain then the infant is not fixed.
• In response to sucking, prolactin is released from the anterior
pituitary gland which stimulates the production of milk.
• [Link]’s emotional state
• The mother must WANT to breastfeed for breastfeeding to be
successful.
• She should not be too anxious about breastfeeding as this
may have an effect on the release of oxytocin and the let-
down reflex
• Complete emptying of the breast
• The infant should empty one breast before being offered the
second one.
• If he does not empty the second breast then he should be
offered that first in the next feed.
• If the baby is to be really satisfied, he needs both fore-milk
and hind milk at the same feed.
• This can be achieved by complete emptying of the breast.
• It is important that the baby is fed on demand and as long as
he wants so that supply is neither inadequate nor too great.
• If milk is not removed as it is produced, lactation maybe
suppressed because milk engorgement of the alveoli occurs
and the basket cells cannot contract.
Baby attachment to breast
FACTORS WHICH CAN AFFECT THE CONTENT AND SUPPLY OF MILK

[Link] of alveolar cells

• These are responsible for converting amino-acids into
caseinogens and glucose into lactose.
• The amino-acids are present in the blood supply to the breast.
• [Link] nutrition in the mother
• Normally, the mother’s diet does not affect the composition
of milk to any degree, but an excess of fat in her diet may lead
to decreased milk production.
• Also malnutrition may lead to a considerable reduction in
production of milk and a significant reduction in the protein
content.
• In addition, in malnourished mothers, the milk excreted has less
calcium, magnesium, potassium, vitamin C and riboflavin.
3. An adequate maternal intake of fluids
• up to 2 litres of fluid per day, is necessary for a good milk supply.
4. Adequate sleep
the Prolactin buildup is greatest during sleep and therefore lack
of sleep, tiredness, worry and anxiety adversely affect the
production of milk.
[Link] and regular emptying of the breasts
• either by suckling or by mechanical expression of milk.
[Link]’s emotional state
• the mother should be relaxed, not stressed, worried or
anxious.
• These factors may inhibit the let-down reflex.
COMPOSITION OF BREAST MILK
• There is a gradual change from Colostrum to ‘mature’ milk
during the first 14 days of life.
• Sometimes this transitional phase takes even longer as much
depends whether the glandular breast tissue is being
reactivated or activated for the first time.
• It also depends upon how soon and how effectively the infant
learns to suckle.
• There is a considerable variation in the composition and
calorific value of breast milk according to each individual
mother, the time of day and even during one feed.
• There is a higher fat content at midday in the hind-milk, while
the fore-milk always contains more water and protein.
• The later breast milk is an alkaline fluid, bluish-white in colour
with a specific gravity of 1031.
The properties & components of breast milk

• An average sample of breast milk, collected over 24 hours, is

said to contain:
• Protein 1.5%
• Mineral salts 0.25%
• Fat 3.5%
• Water 87.8%
• Carbohydrates 7.0%
• Vitamins as in Colostrum
• Calorific value = 80 kilojoules per 30 ml
• Protein -in breast milk is much easier for the infant to digest
than the protein in cow’s milk.
• The curd protein is casein.
• Levels of proteins, lactalbumin and lactoglobulin, are
proportionately higher in breast milk than in cow’s milk.
• Fat- breast milk has equal proportions of saturated and
unsaturated fats which the infant absorbs more easily than
the coarse fat globule of cow’s milk.
Carbohydrate
• contains the bifidus factor which is absent in cow’s milk.
Mineral salts-
• Sodium is at an ideal level for the human infant
• Calcium, phosphorus magnesium are more suitable for the
infant than the higher levels in cow’s milk.
• Iron, the low levels of iron do not reduce the anti-infective
properties of lactoferrin.
• Vitamins, levels of vitamins A, B, C, D and E are higher than in
cow’s milk but there is less vitamin K.
Protective factors
Are present in breast milk as well as in Colostrum.
• Protective immunoglobulins
• Lactoferrin
• Lysosome
• Antitrypsin factor
• Bifidus factor
• Copstrum
Why is breast milk best for the baby?

• Breast milk is the best for the baby because of it properties, it

has all that is needed for the baby and also has protective
factors in the first milk called Colostrum.
BENEFITS OF BREASTFEEDING
To the baby
• It provides the ideal nutrition for infants.
• It has a nearly perfect mix of vitamins, protein, and fat, everything
the baby needs to grow.
• It's all provided in a form more easily digested than infant formula.
• Breast milk contains antibodies that help the baby fight off viruses
and bacteria. Breastfeeding lowers the baby's risk of having asthma
or allergies.
• Babies who are breastfed exclusively for the first 6 months, without
any formula, have fewer ear infections, respiratory illnesses, and
bouts of diarrhoea.
• They also have fewer hospitalizations.
• Breastfeeding has been linked to higher IQ scores in later
childhood in some studies.
• It builds the bond between the mother and baby which makes
the baby feel secure.
• Breastfed infants are more likely to gain the right amount of
weight as they grow rather than become overweight children.
• Breastfeeding also plays a role in the prevention of Sudden
Infant Death Syndrome (SIDS).
• It's been thought to lower the risk of diabetes, obesity and
certain cancers as well.
To the mother
• Breastfeeding burns extra calories, so it can help the woman
lose pregnancy weight faster.
• It releases the hormone oxytocin, which helps the uterus
return to its pre-pregnancy size and may reduce uterine
bleeding after birth.
• Breastfeeding also lowers the risk of breast and ovarian cancer.
• Breastfeeding the baby exclusively will delay ovulation, which
means delayed menstruation.
• It can be used as a method of family planning.
• It may also lower the risk of osteoporosis.
• It saves the mother time and money since she doesn't have
to buy and measure formula, sterilize nipples, or warm
bottles.
• It gives the mother regular time to relax quietly with her
newborn as they bond.
• Breastfeeding is cheap and affordable.
• Breast milk is readily available
SUMMARY
• The breasts or mammary glands are specialized glands of the skin
of the female mammals, which secret milk for nourishment of the
young
• They are accessory organs of the female reproduction.
• They are situated on the anterior chest wall over the 2nd to 6th ribs
separated from the chest wall by a layer of loose connective tissue
• Their gross structure is composed of the axillary tails, nipple,
sebaceous glands and the areola, while their microscopic
structures include the alvoeli, lactiferous tubules and ducts,
ampullae the continuation of the lactiferous ducts.
• Nerve supply is by the branches of the Thoracic nerve.
• They undergo development from
• 4th week of intra uterine life until menopause when they start
to degenerate.
• Production and passage of milk is governed by the hormones
Prolactin and Oxytocin.
• Maintenance of milk production depends on Suckling by the
baby and nipple stimulation and Mother’s emotional state,
factors such as frequent and regular empting of the breast,
maternal nutrition and fluid in-take, rest, sleep and mental
state can affect the production of milk.
• Breast milk contains all that is needed for the baby and also
ASSIGNMENT
1. Read and make notes on advantages and disadvantages of
breastfeeding.
2. Read on fertilization and fetal development that will be the
next topic
REFERENCES
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Midwives. 14th Edition. Churchill Livingstone. Edinburgh. ISBN
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• Sellers P. M. (2008), Midwifery A Textbook and Reference for
Midwives inSouthern Africa. Volume 1, Juta and company Ltd.
• Ross and Wilson (2011),Anatomy and physiology,11th Edition,
Elsevier ltd, Churchil Livingstone.
• Sellers M., P., (2008), Midwifery, A Text book and Reference
Book For Midwives in Southern Africa, Volume II, Juta and
Company LTD, Lansdowne 7779.
• Tiran, D. (2012). Bailliere’s Midwives Dictionary. 12 th Edition.
Elsevier. Edinburgh. ISBN 978-0-7020—4484-7
• Verralls. S (1993), Anatomy and Physiology Applied to
Obstetrics, 3rd Edition, Longman Singapore Publishers ltd,
New York.
• WHO (2003), integrated Management of Pregnancy and
Childbirth: managing newborn problems. Dept of
reproductive health and research, WHO, Geneva.