I've been refining the way I teach asymmetrical latch to moms,
especially since talking to Diane Wiessinger and Tina Smillie a lot
about this issue...  I'm becoming more and more convinced that most
mothers should not support their breast at all, but bring the baby down
to the nipple.  Usually baby's belly will fit nicely along mom's
ribcage, and she can snuggle him there with a transitional hold
(cross-cradle, whatever you want to call it) with her arm running up his
back, and his neck in her hand.  This allows the head extension that is
essential for an asymmetrical latch.  The mom slides baby wherever she
needs to on her body to allow his philtrum (the area between upper lip
and nose) to touch the nipple.  The nipple should gently touch the
philtrum, and the baby's chin should ideally touch the breast, and his
chest should be touching mom as well (Diane noticed that almost all
successful latches eliminate the gap between baby's chest and mom's
chest).  This seems to turn on the baby's latching sequence of
behaviors, and he opens wide and grasps the breast.  This has worked
incredibly well for me, even with babies up to 3 months old who had
never taken the breast.  (With older babies I have the baby in a diaper
and mom shirtless, to maximize skin to skin contact.)
If mom's nipple points down or is inaccessible, I encourage her to wedge
the breast.  The breast can be wedged from above, with the thumb and
index finger, and this way the mom does not obstruct the areola.
Downward pointing or too-low-to-be-accessible nipples can also be lifted
with a rolled washcloth, or gentle pressure against the top of the breast.
If mom prefers the cradle hold, or has short arms and cannot support the
baby's entire trunk in a transitional hold, I show her how to use two
hands at first, the same side arm to support the baby's neck on her
wrist, and the hand on his back, the contralateral hand to hold baby's
tush and press his tummy against her abdomen.  Moms need to be reminded
to drop the arm that is supporting the baby's neck, so he can be at
nipple height.  Voila, no need to lift the breast, again, in most cases.
I think it saves us time to have a basic gameplan or strategy, but it's
important that we are able to modify it as neccessary to meet the needs
of each individual dyad.  The true skill of the LC is in knowing how and
when to modify for each unique combination of  traits and skills that we
see.
Catherine Watson Genna, BS, IBCLC   NYC

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