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Monday, 20 August 2012

A breast abscess: the physical manifestation of postnatal depression

A small, silver scar at the top of my left breast, just down from my armpit, is all that remains of a story that could curl the toes of many.

If you're squeamish, read on with caution. There's no overly graphic photographs: but I'll spare no detail in the prose. So perhaps don't read this and eat.

I've never shared much of this story because it always seems so secondary to the bigger problems I was suffering at the time: the debilitating mindset of postnatal depression. (You can read more about that here and here.) I'm sharing this story now because I think it is an important illustration that even the most severe of breastfeeding complications needn't always equate to weaning; and that often, breastfeeding complications are intricately tied with what's going on in our mind.

When my first baby was about a week old, I awoke feeling a bit achey and feverish, with some pain in my left breast. My milk was flooding in, so both breasts were a bit tender anyway. My mum took one look at me and said I had mastitis. Instantly, I was terrified. The idea of going to the doctor, of getting dressed and getting out of the house with this baby was more fearful than I could contemplate. I was annoyed; I didn't need this. I was struggling enough with this new baby – I didn't have time to think about what was wrong with me, too.

Only a few days out of hospital, I called the midwives on the maternity ward, unsure what else to do. The midwife pithily told me to use cold packs between feeds for the pain, to use warm packs before and during feeds to aid milk flow, and to aim the baby's chin toward the blockage during feeds. She said to go to the doctor for antibiotics if my temperature rose above 38.1 degrees.

So now I had a basic set of things to do; but I still didn't know what mastitis actually was, what caused it, what I should expect, or how quickly I should recover. But, conversely, I also didn't know that I needed to know these other things.

This went on and off for a few weeks. Some days I would feel feverish and achey, others not so much. If I was feeling feverish I'd start with the hot/cold packs; but that was about it. It began to just become another annoyance of mothering; another straw on the camel's back that was my overwhelming burden.

The day before my 6-week postnatal checkup with my GP, I suddenly felt annoyed with this persistent lump in my left breast. My entire life had been flipped upside down and I felt like nothing was going right. So, in the shower, I dug my fingertips into it; pressing and pushing and feeling intensely angry that it wasn't going away. I remember crying.

Bad move.

The next day, at my GP's appointment, he asked me if I was happy, and I shrugged and responded that I didn't know. We talked briefly about postnatal depression, and I pretty much brushed it off. He then asked me how breastfeeding was going, and I mentioned the mastitis. Once he took a look at the affected area, now a blue-purple lump that was exquisitely painful to touch, he calmly said it had abscessed, and he recommended draining it with a needle – much like a big pimple. Was I okay with that?

Was I okay with that? With, you know, sticking a needle into the painful, festering bruise on my breast?

So whilst my husband held our 6-week old baby, I removed my shirt and lay on the clinic table. A nurse instructed me to put my left arm back behind my head, and she placed a surgical sheet with a hole in it over the raised purple lesion on my breast. She carefully covered my skin with antiseptic, whilst I winced with pain at her touch.

I wondered how my life had come to this.

My doctor came in, he was friendly and reassuring but I was still petrified. The nurse murmured to him, "Are you going to use a local anaesthetic?"
"No, the local would hurt more than the aspiration," he answered.
Oh, shit. "Just give me a stick to bite on," I joked weakly.
They all tittered. (Pun intended).

As I took some deep breaths, the sting of the needle bit into tender flesh. But I must admit, after the initial twinge, the pain was bearable – almost a relief. He spent a minute or so drawing up fluid, and he commented that more pus had come out that he had anticipated.

"You'll feel much better with all that out," the nurse said.

I hoped so, but I knew there were more problems filling me at that moment than just pus.

Over the following weeks, as the fog around me thickened, the abscess never seemed to truly heal. Some days it was itchy, some days it was tender, but it never seemed to get better or worse. The area stayed a red or purple, and sometimes was scabbed over.

This isn't my breast, but is quite similar to how my abscess looked
Image source
My baby was often fussy feeding from that breast, particularly on the days when I was feeling achey or sore. But we managed, the other breast seemed to compensate beautifully.

And then suddenly, one day when my baby was about three months old and I was staying at my parents house, my breast began to swell again. The area around the wound became hot, pink and inflamed, and it the pain increased tenfold. But I ignored it. I didn't have the headspace for a physical problem, and besides, it would hopefully just go away again.

Later that night, in bed I lay on my right side, rolled a little forward breastfeeding the baby from my left breast. I could hear her beginning to snuffle, and I thought nothing of it at first, thinking she must just have a runny nose. But over the space of a few minutes her snuffling became more pronounced, and she began to fuss.

I flicked on the bedside lamp, and to my horror, saw her face was covered in pus. Thick yellowish liquid was all over her eyelashes, and all over her mouth and chin and nose. Pus was streaming from the wound in my breast. I shrieked. My mum came into the room, she helped me clean up and we put a dressing over the wound on my breast. I'm sure I spent some more time crying and feeling like an enormous failure; but I just don't remember it.

A few days later, I awoke again in the middle of the night. My shirt felt slick and damp, and as I sat up, I could feel it was heavy and wet all the way around to my back. In the bathroom, I removed a t-shirt covered with pus and blood. As I cleaned the wound, more pus would ooze out. Bending over the sink, I gently applied pressure either side of the swelling, and like a big pimple, it ruptured. I managed to massage out as much fluid as I could, put on a clean shirt, dressed the wound and went back to bed, mortified.

More weeks passed, and sometimes the abscess would leak, but I paid very little attention to it. And then, at 16 weeks postpartum, I finally approached my GP for help with my mental state. As well as prescribing a mild anti-depressant, he referred me to a surgeon to have the abscess incised and drained. He apologised for letting it get this far. I knew he was just being nice; it was I, after all, who had kept it all hidden.

The ultrasound I had before meeting the surgeon revealed a fluid-filled cavity in my left breast the size of a cricket ball. I distinctly remember the sonographer's eyes widening when he enquired how long this had been there, and I apathetically replied, "about three months."

The day before I saw the surgeon for the first time, the abscess ruptured again. It was another huge drain, and left me feeling queasy and revolted. However, my depression was starting to lift, so I was finally able to see the abscess for what it was: a wound, a transient condition that I just needed to pay a little attention to and kick. Just as my depression was not who I was, I wasn't this abscess, and this abscess wasn't me.

Of course, the next day the surgeon saw me, cheerful and without a swollen breast, and decided he wanted another ultrasound. "I'm reluctant to slice you open if I don't need to," he said. I appreciated his sentiments immensely.

This time, the ultrasound was done in a bigger clinic, equipped for more than just imaging. A doctor did the ultrasound, carefully assessed the cavity, and inserted another needle under the guidance of the ultrasound image. I watched him draw almost 20mls of fluid from my breast.

But when the doctor saw the fluid filling the syringe, he seemed happy. Now, the fluid was clear, slightly pink, not at all like the thick, sickly yellow pus I'd become accustomed to. "This is good," he pronounced, "this isn't infected. I'll just drain all this out and you'll be fine."

And I was. I returned to the surgeon, who shook my hand with a smile and said he hoped never to see me again. The feeling was very mutual.

The abscess was gone. I had a handle on my PND. In my mind, it is absolutely no coincidence that the timing of the two recoveries was so well matched. The pressure and pain building in my breast, festering under the surface away from obvious awareness, was a physical manifestation of what was going on in my mind.

I have read many stories from women suffering severe or repeated bouts of mastitis, or abscess, who have felt no choice but to wean. Obviously, people did ask me if I was "still" breastfeeding during my treatments for the abscess. But truth be told, stopping breastfeeding never entered my mind. I knew that weaning would only exacerbate the problem: my milk could take months to dry up completely, and in the meantime, I'd have breasts swollen with unmoving milk, I'd have a baby whose health would be compromised by weaning from my breastmilk, but most of all, I would have nothing left to give my baby. Weaning wasn't an option – I simply had to breastfeed.

And besides, in my mind, I never really made a conscious connection between the abscess and the act of breastfeeding my baby: the abscess was more about my inner turmoil and pain, than the simple act of lactogenesis.

Stories of breast abscess are quite rare; stories of women continuing breastfeeding through treatment even rarer. So I hope my story may help other mothers, who may be going through something similar, and are perhaps hoping to keep breastfeeding: even when everyone around them wonders why.

Further information on mastitis and breast abscess:–mum/mastitis