To answer Patricia's and Phyllis' posts

Patricia, yes, most mothers in Zim hand express.  Pumps are hard to get and
expensive.  I see *very* few electric pumps, and never a double one here,
although I do use simple manual cylinder pumps sometimes.  It's quite cute
to go to the Neonatal units in the hospitals and see all the mothers sitting
together expressing into cups - they teach each other, mostly.  I think I
posted to Lactnet once about one large jolly mom who was getting about 2" of
froth on her milk from the force of the jets - amazing technique.

Phyllis, I think your described technique for manual expression is pretty
good!  I usually dispense with the massage, stroking, shaking and slapping
(sounds painful!) also the warm flannels and warm baths because I sometimes
find that mothers take so long going through these rituals that they then
have little time left for actually getting the milk out ... The only
fine-tuning of your technique I would suggest is that mother cups the whole
breast in her hand (only one hand) and uses the pad of the thumb and the pad
of the index finger on the edge of the areola (or even in a little bit
closer towards the nipple) in towards the chest wall, and then squeeze IN,
like a half-pinch.  Mother can experiment with placing finger and thumb 2
inches apart, 1.5, even less etc. and see what works best.  It is important
not to "spread" the thumb and forefinger apart when going in towards the
chest, just go backwards.  Yes, you use the ribs to push towards - back,
squeeze, release;  back, squeeze, release.  I find that some moms find it
almost impossible not to pull the nipple forward at the end, eg back,
squeeze, pull.  No!  It is back, squeeze, let go .... etc.  I also find it
can be quite helpful to use the other fingers (cupping the breast) to
squeeze IN at the same time as the fore-finger - this may be a form of
massage, but it does seem to increase the "flow".

I find that it works better if you get a little place going to make a jet
(or several jets), to stay with that position until it seems to be
completely used up - *then* change finger and thumb around on the areola to
find different ducts - ie don't move around too much if it's working well!

I agree with you that "meaty" breasts are more difficult.  I suspect that
this is more likely in the first few days postpartum when there is some
edema.  You may only get dribbles and not jets.  Once the edema has
completely resolved, then manual expression becomes much more quick and
efficient. I think the "easiest" breasts are about 4-months-into-lactation,
when they're really soft.

If a mom is having a hard time finding the right "place", or obviously
having difficulty with the initial technique I will often ask if I can show
her by doing it for her (hands are washed before-hand of course).  Sometimes
I have to feel where the right place is for her, and then get the jets and
then she can see that it works.  I encourage her to do it again - and again
- and again - until she masters the technique for herself.  Sometimes I find
that moms develop their own slightly different variations of the basic
technique which work much *better* than what I've shown, and this is *fine*!
Yes, it should not be painful.  And the fingers should not slide along the
skin, especially the thumb - I've seen open abrasions above the areola where
mothers of premies have expressed many times a day and rubbed the skin raw.

Phyllis, the massage can be used to stimulate another let-down, or work on
any lumpy areas in the breast *between* short bursts of hand-expressing.  I
usually suggest light finger-tip circles or gentle kneading with the
knuckles, working from the chest wall towards the areola, then
hand-expressing again.

Oh yes, it's possible to hand-express both breasts at the same time.  Mom
sits with a pillow on her lap and expresses with both hands into two bowls -
*very* undignified, but possible!

One last caution for the LC:  when you're teaching a mom to hand-express
always stand or sit to the side.  I've been squirted in the eyes twice.  My
doctor was *very* interested in this when I caught a nasty mystery virus a
couple of years back, and I count this as an occupational hazard now.  And
of course wash your hands carefully afterwards too.

Pamela Morrison IBCLC, Zimbabwe (who could *never* hand-express when I had
my babies, either, but then no-one taught me - it's all in the technique,
and just takes practice to become efficient).

--------------------------
Phyllis wrote, "I have read various instructions. They begin with massage,
both in circles and stroking toward the nipple, then leaning over and
shaking them,
essentially slapping them together and apart with your hands. All this in
preparation for expressing. Then to express, placing the thumb and one/two
fingers about mid-breast on opposite sides of the areola, press them towards
the rib cage.
Second, press the thumb and fingers towards each other, putting pressure
into the breast, but not so much that it hurts. Third, roll the thumb toward
the areola, and voila! milk!. Well, sometimes yes, sometimes no.

Much later, I learned that once this technique is learned, mom would begin
to do it quickly and rhythmically, constantly changing position on the
breast to access all the glands possible.

Sometimes it works beautifully. Sometimes it doesn't work at all. I find
this especially difficult on "meaty" and very large breasts. I feel I'm
missing the boat somewhere. When I tried it on myself years ago, mostly it
hurt. I couldn't find a way to hand express without feeling bruised in the
process.

Can some of you offer better techniques?

--- Phyllis Adamson, IBCLC

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