When I teach someone OVER THE PHONE to hand-express, I tell them to use reverse pressure softening first, if the breast is firm, then GENTLY "pinch" the nipples (just barely squeeze) 15 or 20 times, then move the finger/thumb just beyond the nipple tip and repeat very rapidly, then move back a 1/16th of an inch every 20-30 seconds until they feel firmer tissue (we used to think it was lactiferous sinuses! But know it's actually alveoli close to the nipple).  Once they find this area, I have them capture the "lump" between thumb and finger slightly farther out than the middle and compress like making thumb prints in cookie dough and roll over the area as if moving a pea through a straw without sliding the skin or squeezing straight towards the opposite digit.  The roll ends up in front of the "lump" and holds a second, then back to the edge of the digits that is farthest from the nipple. This technique seems to mimic what babies do with their gums and tongue and initiates let-down.  I've always had good luck with this description.  Since we get about 1000 phone calls a month, we have worked hard on oral descriptions of visual processes!  Some of my analogies are a little gross - so we won't go into that here!  But people get them!

-----Original Message-----
From: Lactation Information and Discussion [mailto:[log in to unmask]] On Behalf Of Rachel Myr
Sent: Thursday, May 21, 2009 6:48 AM
Subject: Guidance for hand expression

I am looking at the free, downloadable materials on breastfeeding from Wellstart, as referred to by Julianna Lim (thanks for the link!).  While most of it looks good, as usual I'm unhappy with the instructions for hand expression of milk.  The spots for the mother to compress are described in terms of distance from the edge of the areola.  The thumb is to be placed above the nipple, 3 to 4 centimeters back from the EDGE of the areola, and index finger at the same distance back, on the underside of the breast.  It makes my breasts hurt just to think what it would feel like to apply compression between these points. (Sorry if that was Too Much Information!) Of course it is more complicated to explain to women how they can tell when they are in the right place to compress on their own breast, but the description in this manual is fraught with risk.  Areolas vary a LOT in diameter.  Some women will have their fingers 10 or 12 cm back from the nipple tip if they use this method - hardly the spot likely to be compressed by the baby's gums during breastfeeding, unless they have given birth to a calf or perhaps an alligator.
I don't know how I can tell where on a breast the best place to compress is, but I can usually tell, and I show it to the woman when we talk about hand expression.  She puts her hand on her breast and I place mine over hers if need be, to help her find that spot.  
Using the areolar edge as a landmark to follow is problematic, as we all know from working with mothers who are unable to make sure that the ENTIRE areola is in the baby's mouth.  Hand expression is not a difficult skill and most mothers pick it up easily in one or two quick sessions with someone who knows how to do it, but it is not a skill that is easily transmissible by the schematic written descriptions I so often find.  Since it IS an essential skill, I am constantly on the lookout for good educational materials about how to do it, and I am generally disappointed.
Rachel Myr
Kristiansand, Norway

             ***********************************************

Archives: http://community.lsoft.com/archives/LACTNET.html
To reach list owners: [log in to unmask]
Mail all list management commands to: [log in to unmask]
COMMANDS:
1. To temporarily stop your subscription write in the body of an email: set lactnet nomail 2. To start it again: set lactnet mail 3. To unsubscribe: unsubscribe lactnet 4. To get a comprehensive list of rules and directions: get lactnet welcome

             ***********************************************

Archives: http://community.lsoft.com/archives/LACTNET.html
To reach list owners: [log in to unmask]
Mail all list management commands to: [log in to unmask]
COMMANDS:
1. To temporarily stop your subscription write in the body of an email: set lactnet nomail
2. To start it again: set lactnet mail
3. To unsubscribe: unsubscribe lactnet
4. To get a comprehensive list of rules and directions: get lactnet welcome