Susan asks:

"Can someone summarize the differences between the Jane Morton/Stanford
video, the Chele Marmet/LLL method and the Norwegian/Rachel Myr versions of
hand expression? (not that those names are responsible, just trying to find
labels that will help identify which is which)
Rachel mentioned that if women were taught the Stanford version, they'd be
more likely to end up depending on pumps.  It's difficult for me to see on
the videos what specifics of technique you might feel work better-or worse.
Thanks for clarifying the aspects of hand expression that you feel make a
difference..."

Just my impression(s) here. First all, my disclaimer. I firmly believe that lactiferous sinuse do exist. I believe they exist to help the baby focus the hydraulic power of milk transfer using the principles of Pascal and Bernoulli (learned from google search;-). I believe lactiferous sinuses are DYNAMIC, (not shouting, just the only way I know to make the point stand out in Lactnet posts.) I believe they change shape, size and thickness during various stages of reproduction, just as does the uterus, etc. (and for that matter some reproductive organs of the opposite sex too.) Pictures of microscope views of sinuses in resting breast tissue abound. Contact me for references if you like.


When I saw the Stanford version, I was surprised. The video vividly gets the point across to moms that the pump is not the end-all, be-all way to remove milk, but I thought the placement of the fingers was much further back than I have demonstrated to moms, and sort of "blends into" that "farm-animal forward" trend that I often warn them against. 


Not having seen Rachel's method, from her description I can only surmise that it's somewhat the same as Chele's (which I use, usually minus the first steps of boob-drooping and massage, to trigger the MER). I once went to one of Chele's hand expression workshops at which she was helped by volunteer moms who were several months "into" breastfeeding, who served as our models/teaching aids. I was surprised at how pliable and large I found the sinuses at that time period in comparison to my main experience demonstrating HE. This had consisted of showing new mothers in the hospital, and then more years of teaching prenatally in the late third trimester.  I taught many of them in private sessions at prenatal BF classes for a CBE group, and also in 20 years of Public Health prenatal clinics, and now, in WIC, for moms with early problems (a.k.a. "trainwrecks" 2-3 days after hospital discharge;-) 


In the last half of the 3rd trimester, I have observed that the sinuses are usually small and more or less firm, sometimes even as small as "the lumps in tapioca, or like bee-bees" as I describe them to moms. My experience is that they have become slightly, but only slightly larger, but usually more pliable during the postpartum period, and I believe the elastic tissue in their walls becomes thinner and stretchier from the suckling and/or pumping during the first month. 


Therefore, by the 1 to 6 month period in which the "nonexistence" has been researched "they are unable to demonstrate the presence of lactiferous sinuses on ultrasound." (BTW that's a direct quote from someone closely involved in the research when I questioned him about it at the first conference in a city close enough to catch a Greyhound to after Diane Wiessinger reported the "news" to me when she first heard it at a Florida conference.)


I always call it "fingertip expression" because I have questioned so many moms to show me if they know how to "hand express". They so often place flat hands (U.S.) football-like around opposite sides of their upper breast and try to squeeze them together;-) Second most common misunderstanding I see is for them to "circle the circle" and squeeze, thumb at the 12 o'clock position on the areola and the fingertips of the first and second finger falling somewhere out beyond the areola at about the 4 o'clock or 8 o'clock position (depending on which hand on which breast), with any compression of the  thumb falling at about the middle knuckle of the first finger. Strongest mechanical force is from bent fingertips opposing tip of bent thumb


My personal script, now used most often over the phone to brand new moms, is to "imagine 6-8 tiny balloons full of milk shaped sort of like tiny toothpaste tubes, under the areola. Let's show you how to start pressing from the back of the tubes." (Everyone knows that starting from the back of a toothpaste tube gives you better results;-) 


(I have probably already heard her description of latch problems, maybe little or no pump results etc. and questioned how many bags of IV fluid she had, whether she had hours of pitocin before or after birth, whether her ankles are swollen and quite often teach her RPS, explaining the MER simply, and how this is going to trigger it in the process of softening the areola for easier fingertip expression and/or latching.) I have already cautioned her to do all this slowly and gently to keep it comfortable, because I have found that full sinuses can hurt if suddenly or forcefully compressed at their thinnest, greatest stretch place in the middle (just like when your driver slams on the brakes and the seat belt presses on your full bladder!) 



IME (24 years in a hospital back when GP's routinely clipped tight frenulums at the time of the first physical in the nursery), perhaps 75% of very early latch discomfort is from the baby's sudden strong compression of full lactiferous sinuses, explained in my opinion piece on Zones of nipple discomfort. You can request it from me privately if you like.


I have her imagine a clock superimposed on the areola. I have her start to judge the placement of thumb and fingers from 1 to 1 1/2 inches back from the base of the nipple, (usually always inside the outer boundary of the areola) with her thumb at the 12 o'clock position, and the tips of the 2nd and 3rd fingers precisely at the 6 o-clock position. I instruct her to press straight inward toward the ribs. 


I emphasize the need to maintain the inward pressure while the thumb rolls in place, as if to take an ID-type thumb print, while the 2 opposing fingertips squeeze inward from below to meet the thumb. Occasionally, there is a need to move forward to 1/2 inch behind the base, and slightly more often, to move the placement perhaps 2 inches back from the base of the nipple because I have found some women who seem to have sinuses either closer or slightly deeper behind the nipple. 



If she has come into WIC for a consult and it seems appropriate, I use the script and a demo breast, or with her permission, I position myself at her side so that my hand is in the same plane as hers. I either express directly, or often end up placing my thumb and fingers on top of hers so her kinesthetic learning sense is engaged both from the inside of her fingertips behind the sinuses, and from my pressure/direction sensed from the back side of her fingertips.


That's the experience of my fingertips and my observations, and sporadic reading research in medical texts, spanning well over a half century of hands-on clinical practice with prenatal, and recently delivered new moms.


K. Jean Cotterman RNC-E, IBCLC
WIC volunteer LC, Dayton OH, USA

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