Kathy D., you wrote: <The problem I have with any video for Third World women that suggests they not touch their breasts is that . . . . . . . . lots of women in Mali (my only real Third World experience) have 3-4 foot long breasts. Yes, you read that right. If they don't hold up the end of the breast and place the nipple in the baby's mouth, then they're going to have to have the baby out at the very end of their laps, or even on a chair, and do some pretty bizarre manipulating of the baby. I've seen toddlers standing *behind* their mothers, nursing, with the breast either thrown over the mother's shoulder, or pulled around the side underneath her arm. I've seen a child standing several feet away from the mother, holding the breast and nursing.> Kathy, I agree with the rest of your post about the hand washing. But please enlighten me on the above-fascinating piece of information like a missing piece of the puzzle always going on in my mind about anatomy and physiology of the breast. As a child, I had seen similar illustrations in National Geograpic. I've seen video(s) or photos of women of other cultures grasping behind the nipple, stretching their subareolar tissue upward/forward for an inch or two, with the heavy breast tugging below it. I don't know if this was in the immediate context of getting ready to feed, or express or what. But I have always wondered whether young women, having seen it done openly, might not attempt imitation and experimentation prenatally, amounting to a certain degree of prenatal preparation for breastfeeding. As a 5'6" woman with enough droop that I picked the center of my breast bone as a certain point of reference, 36" reached midway between my knee and my ankle, and 48" came to the joint of my big toe. I can't imagine what my life would be like with breasts that long! Is it just the difference in clothing (lack of bra/support) all of their reproductive life that results in this? Or is it some sort of inbred thing among the women, and what is the progression from menarche to menopause? Native women elsewhere stretched neck, ear lobes etc. Do they stretch their breasts in some special way? I am working with a mother now with what I term "functional retraction of the nipple" (also, their circumference was the size of a nickel) with DD cup breasts and a "pithy, doughy, edematous texture" of her subareolar tissue, and I was unable to palpate milk sinuses or express even a drop of colostrum when I first saw her at 34 weeks g.a. 25-30 years ago, I would have suggested she use aggressive (per old Egnell references) prenatal vacuum intervention from at least 37 weeks on till term, and then postpartum if necessary. I am convinced that it gave the mothers with severely non-protractile nipples the advantage of a more even playing (feeding) field, though I have not yet figured out a way to prove this. That was way back when we had general anesthetics, routine delayed and timed feedings and nothing but a bicycle horn pump and 2 kinds of shields- thick rubber, or plexiglass and rubber, and no real postpartum followup past 4-5 days in the hospital for most mothers. (Clandestine) medicine droppers were the only "assistive feeding tools" I had besides rubber nipples. Spoons and cups would have been unthinkable. Someone referred her for shells. But in light of the worldwide disagreement over the subject, along with the shells and my suggestions for reverse pressure tissue softening at bathtime (Hoffman, essentially), I gave her the BMJ article that concluded that rather than take the chance of discouraging a mother from trying to nurse, it was better not to examine the function of the nipples, let alone suggest any intervention. I told her my past experience gave me a strong difference of opinion about their conclusions. I offered to come for home visits after delivery till nursing was well established, no matter what she chose to do prenatally. It was agreed that I would do this in exchange for my own clinical education to follow the results. She chose essentially to do nothing, wearing the shells "occasionally for 20 minutes" she said, and massaging the breast itself at bathtime. I loaned her Renfrew/Fisher/Arms "Bestfeeding" to read. At 42 weeks g.a., she had a midwife-attended birth in a hospital, of a 6#9 oz. boy (no circ), with what I would call a minimum of labor, delivery and nursery intervention COMPARED to MOST women in our city. The tight frenulum was recognized, but the pediatrician said "Wait and see", but also ordered a small supplementation with glucose water (to avoid dehydration). Unfortunately, the nurses fed/provided the parents with a rubber nipple. Her perception was that the baby had been "latching fine" and eagerly until the rubber nipples. My question is whether milk sinuses were being reached. (What the pediatrician had not seen were the mother's nipples. Due to the size of the baby's mouth, It was a classical case of "oroboobular disproportion" even without the frenulum problem.) I first saw her on the evening of day 4, a Saturday. No wet diapers for preceding 16+ hours. No severe engorgement, but obvious firmness in the lobules, indicating beginning milk production to me. She understands what a good latch is supposed to be and she is coordinating nicely. The frenulum was clipped on Monday, day 6. Better nursing attempts followed. Being as encouraging as I can and as conservative as I feel it safe to be, so far, I have felt it necessary to have her use an electric pump, a plastic medicine dropper at the breast with formula, then finger feeder (mostly by dad while she pumps), and now breast compression with an SNS. About all the "fiddly stuff" available. Even tried a nipple shield. Nipple wouldn't fit inside it, and baby wouldn't take it anyway. On my last visit on the 8th day, though pumping was only yielding 45-60 cc after 20 minutes, I was pleased to see how little compression it took to at least express a "steady ooze" of colostrum from the nipple, Despite the disproportion between the nipple and the mouth, the baby appeared to be latching as well as possible, and I thought we were "on our way". I was ready to eat "humble pie" about my prenatal assessment of potential for problems. The baby is now 12 days old, and I can tell she is very discouraged. In retrospect, re the finger feeding sessions, especially by dad, I may not have cautioned enough about not being too aggressive. The baby is refusing all attempts at the breasts with clamped lips and turns the head away. I am supplying plentiful encouragement and will take over a copy of Diane W's "The Labor of Nursing" tonight. I have encouraged her to drop direct attempts to latch for a while, and hold the baby skin to skin at the breast while feeding with a finger feeder till I can observe them tonight, and to check for possible thrush in his mouth. In retrospect, I'm now sorry I chose to approach it this way prenatally. Surely, primitive women somewhere in the world have not been "skittish" about handling the breast and the areola prenatally? Or has good genetics and loose/no clothing and/or other factors made this unnecessary? Else how has the human race survived? I know. Many babies haven't. And "wet nursing" etc. probably saved many. I will continue to "doula" this mother, but I would appreciate comments. K. Jean Cotterman RNC, IBCLC Dayton, OH USA ___________________________________________________________________ Get the Internet just the way you want it. Free software, free e-mail, and free Internet access for a month! 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