<I was asking because I might expect to get a few drops for many primips,
with
massage before and during expressing.>

I'd like to pose a question here to get a discussion going. Two points in
that sentence intrigue me.

For starters, the idea of massage before expressing has a 3-fold benefit
(it seems to me).

* A) It gives the mom practice (and permission) about handling her breast
as a feeding tool.
* B) It may help circulation of both blood and lymph, and physically move
some of the milk forward just by compression.
* C) It may trigger and condition the MER, and that is a wonderful
opportunity to educate every mother about this "neat system nature has
built into the breast that stimulates it to squirt the milk from the back
of the breast forward."

(How'm I doing, Geneva and Linda? And you thought I couldn't learn to
explain anything in simple terms!)

I can't tell you how many WIC mothers I call post-partum who, although
they may recognize that they leak on the opposite side when the baby
nurses, just simply don't seem to have a clue that there is any such
reflex as MER, let alone that it is THE most powerful force in milk
transfer, and can be triggered intentionally.

Without it, pumps (and babies) can transfer very little. I think we ought
to make a big deal out of being sure every mother knows that powerful
little secret as soon in the game as possible. I might even go so far as
to say it might make or break the experience for some to perceive this as
a helpful tool.

I have a hunch we might be able to head off some of that ubiquitous
iatrogenic engorgement we see in "managed labors" by teaching mothers to
massage the breast prior to and/or during every feeding in the early
(first 7-10) days. Early and frequent evacuation of the alveoli will also
enhance production.

The second point I'd like to find out about: What precisely are we
teaching the mother when we teach "expressing"?

Especially in this very early time period (before delivery if a NICU
situation is anticipated) and in the first 24-36 hours, I find that:

* emphasizing BACKWARD (that is, inward toward
  the chest wall) pressure as the first step, and
* maintaining that pressure during the second step,
  of actual compression of the fingers, as in the
  Marmet method or anything similar to it,

produces results so much more quickly and efficiently.

I also find that using the tips of the fingers and thumb in a direct line
with the nipple, 3/4" to 1 1/4" or so away from its base, somehow
produces more leverage than using the flats or the sides of the fingers.
I have so often seen a "lightbulb" go on over the mother's head when she
senses precisely where her particular milk sinuses are.

This of course is more comfortable for the mother to do if her
fingernails are short. But this seems to be such a sacrifice for so many,
that I try to tie it to the idea and that the loss of a few fingernails
is temporary, and not only will it be more comfortable as she learns to
use her breast as a feeding tool, but will also be more comfortable for
her baby as she learns to handle him.

I realize that as more milk arrives, many mothers will be able to remove
milk freely and easily by other methods. Some then begin to get results
by pump, or just plain massage with the flats of the hands, or just plain
compressing the flats of the finger directly against each other behind
the nipple without using any backward pressure to "hone in" on the
sinuses.

(These two [less effective] methods, BTW, are what are illustrated in the
Vida-AWHONN videos discussed on LN a few days ago.) So many mothers I
have helped seem to find those two motions slow and ineffective for milk
removal. They are thrilled to see the results when I teach them the
actual Marmet method or a slight variation thereof.

With the mother's permission, I believe she learns faster when I
personally, gently, locate her milk sinuses and demonstrate the motions
for her the first time. I think this is because this uses a third sense,
the kinesthetic, in addition to vision and hearing.

If at all possible, I stand slightly behind and to the side of her,
reaching over her shoulder, so that my thumb and fingers are in the same
plane as hers.
Often, I place her fingers appropriately, and my fingers over hers,
performing the motions by "shadowing her fingers"

By not facing her directly, this also seems to reduce any embarrassment
some mothers might feel. But I find it is also entirely possible to talk
most mothers through it over the phone, or with the help of a breast
model if the situation makes my own preferred approach unfeasible.

Anyone in a "non-hands-on" profession, or of a "hands-off" persuasion or
disposition or situation can teach it quite effectively with a little
practice, and a belief that it is a valuable skill to impart. I would
especially like for every maternity nurse, and other disciplines who
provide direct care, to become expert in teaching it.

I think it has potential to facilitate all that we go on to say and do
about latch, even if the baby is such a champ from the start that he's
way ahead of us. So much happens in those vulnerable days after mom goes
home. She can use all the insight we can give her.

I'd like to hear how much controversy or agreement lactnetters have about
this.

Jean
**********************
K. Jean Cotterman RNC, IBCLC
Dayton, Ohio USA

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