Ann Perry raises questions touching on a hot topic at my workplace these
days, namely how to start milk production, not to mention collection, when
baby is unable to come to breast.
I am pushing for our standard of care to be manual expression from the
start, collecting in medicine cups, moving on to a hospital-grade pump (more
specifically our 50 year old Egnells) as volume goes up and viscosity down,
around the second or third post partum day.
Currently we advise women to start pumping 10 minutes per side, 6-8 times in
24 hours.  For the first 36 hours it is extremely rare for milk yields to be
collectable, as they end up barely coating the flange or just getting caught
in the rubber valve between flange and bottle.  Hand expressing into a cup
allows the baby to get the first colostrum, it allows mother to see how much
there is and how easy it is to get out as she learns manual expression, and
it saves staff an enormous amount of work collecting, washing, sterilizing
and re-distributing collection sets.  We have enough pumps, but they are
large and noisy and clumsy.  A stack of medicine cups on mother's nightstand
takes no space at all, and she can express a few ml. every hour or so
without disturbing her neighbor or having to go find all the parts she
needs.  She can express lying on her side, so it is more conducive to rest,
and as many of our mothers of babies in the NICU have had cesareans, this is
yet another advantage.
My clinical impression (that unknown quantity by which so much bad practice
is justified, I know!) is that this is a more effective way of getting
things started.  Milk comes in in copious amounts around 48-60 hours if
mother is eager and willing to express frequently.
If baby is able to be held skin-to-skin there is usually a noticeable
increase in milk yield after a STS session.  Surprise surprise.

Putting this procedure into place will require all staff to learn manual
expression, but I find they learn it readily and there is virtually no
objection among mothers, to being shown how to do it.
Rachel Myr
Kristiansand, Norway

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