Body Changes after Pregnancy

Pregnancy is associated with a lot of body changes to prepare the mother for delivery and care of the newborn. Most of these changes are guided by hormones and they affect mood, weight, breasts, skin, blood, reproductive pathways and even position of organs in the abdomen. For instance, a mother gains an average of 12Kg over the period of pregnancy, the skin becomes smoother, the breasts become bigger and fuller and the tissues of the reproductive pathways become loose to allow them to stretch during delivery. The delivery process itself lasts less than a day and then suddenly you are un-pregnant again! The uterus shrinks back, the breasts start producing milk, there is sudden loss of weight and the skin now contains less volume than before, and the hormones come down to pre-pregnancy levels. Now question is, are some of these changes permanent?

Many times, my female patients ask me, "will my breasts get back to normal?", "does breast feeding make the breasts sag?" or "does precious ‘v' really stretch during vaginal delivery?" Bearing in mind that the wellness of the mother is crucial for the baby's health, these are crucial concerns that need to be addressed satisfactorily. Let's talk about the breasts for now.

The breast is made up of fatty and milk producing tissues and lies on the chest muscles (the pecs). The breast is held onto these underlying muscles by suspensory ligaments (coopers) which run from the muscles, through the breast tissue, to the skin. These ligaments hold the breast in position but become lax with age and menopause hence sagging.

Changes to the breast are one of the earliest signs of pregnancy and they happen to prepare for breastfeeding. These changes are guided by the hormones oestrogen, progesterone and prolactin and they are associated with increased breast mass, growth of milk glands and ducts, increased number and growth of blood vessels and darkening of the skin around the nipples. From as early as 16 weeks, the breasts are able to produce milk. The increase in mass and volume associated with pregnancy causes the ligaments and other tissues that hold the breast together and anchor it on the chest to stretch. Once you are through with breastfeeding, the breasts naturally shrink back in size because the glands, the ducts and other tissues are no longer needed for breastfeeding. However, when they shrink, they still leave the ligaments stretched and thus the breasts remain sagged.

Breast feeding does not cause the breast to sag!!

In studies comparing the levels of sagging between two groups of expectant mothers; those that breastfeed their children and those that do not, there have been no differences between the two groups on the level of sagging.
It is pregnancy that makes breasts to sag and it does not matter whether you decide to breastfeed or not! And research shows that the sagging increases with each pregnancy.

So what else increases your chances for breast sagging?

• Smoking - smoking impairs the mechanisms for building and repair of the ligaments that help to hold the breasts firm
• Initially big breast mass - this is thought to be because of the fact that the big mass tends to pull down and stretch the breast tissues
• Higher body mass index - Bigger women are more likely to have sagging, likely because they are more likely to have bigger breasts
• Weight loss - rapid weight loss means that your breasts become less fuller, more like a deflated balloon, and thus they are not held in place and position as before.
• Aging - as one ages, the ligaments stretch, destroy and as the hormonal levels go lower, they are more lax and unable to hold the breasts in position as before.

Breastfeeding does not worsen sagging and is in fact healthy for a mother and the baby. It is associated with a lower incidence of breast cancer for the mother, it promotes bonding between the mother and the baby, it allows for transfer of crucial nutrients and immunity strengthening substances (antibodies) from the mother to the baby, it is associated with lower incidence of allergies and asthma in the baby and some studies suggest that it may improve the baby's intelligence.

So how do you tell whether your breasts are sagging or not?

Well sagging is actually classified by surgeons using the Regnault criteria (see image below). This examines the level of the nipple relative to the infra-mammary crease (the point at which the lower level of the breast attached to the chest). The optimal level of the breast is usually about 5-7cm above this level. Sagging is significant when the nipples are at least 2 cm below this level. The lower the nipple below this level, the greater the extent of sagging.

Things to do to limit breast sagging include:
• Stop smoking
• Maintain your weight and avoid rapid changes
• Eat fruits and vegetables to promote healthier ligaments
• Exercise with the right inner garments to hold the breasts in place and limit the effect of gravity

Do bras cause breasts to sag?

This is controversial. When you fail to use a muscle or tissue in your body, it slowly shrinks in size and becomes weaker. A good example is in patients with polio or who have partial paralysis. The leg or arm that is affected shrinks and becomes smaller, weaker and basically less functional. It is thought that because of the support offered by the bras, the breast tissues and ligaments are put out of function and they become weaker and lax hence causing sagging. Because almost all women put on bras nowadays, it is difficult to tell whether there is some truth in this. On the other hand, failing to support your breasts during exercise means that they are yanked down by movement and gravity and the tissues and ligaments loosen. For now, these ideas are not backed by good research.

There is no medical treatment for breast sagging, only surgical options!

The aim of the surgical option is to restore the shape, volume and position of the nipples. The most surgical options are breast lifts (raising the breast position also known as mastopexy), breast implants (which is really adding volume to the breast using substances such as saline solution, silicon et.c), breast augmentation (altering the size and shape) or reconstruction (usually after removal of the breasts in breast cancer with the aim of restoring shape, position and size). Breast reduction is also considered for women with big breasts. Big breasts can be quite heavy (some women even experience breaking of breast straps) causing a strain and pain on the neck, back pains and headaches. In Kenya, these options in surgery are available in many hospitals; it is the costs (starting from Kshs. 8, 0000 and the expertise that ranges.
There are risks in breast surgery. These include the general risks associated with any surgery - bleeding, infection, anaesthetic problems. Other risks include failure to achieve the desired cosmesis, scarring, inability to breast feed, difficulty in recognising breast cancer and repeat sagging.

Well, next time we talk about changes in the precious 'V' after pregnancy.

Ps. this topic and other topics on changes in pregnancy were tackled comprehensively in a seminar in July. To request for these slides, register and send an e-mail to mtoto@mtotowangu.com. To also get information on areas where you can access surgical options, we are happy to guide you through the same channel of communication.

Breast sagging classification: Regnault Classification