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6.1 Practical skills

Baby Friendly Step 5 and Point 4

Step 5 of the Ten Steps to Successful Breastfeeding, and Point 4 of the Seven-point Plan for the Protection, Promotion and Support of Breastfeeding in Community Health Care Settings both require health care professionals to teach women about the maintenance of breastfeeding.
Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants .
Support mothers to initiate (establish) and maintain (exclusive) breastfeeding (to 6 months). United Kingdom, Canada, New Zealand

Inform women and their families about the management of breastfeeding and support them to establish and maintain exclusive breastfeeding to 6 months. Australia
As well as assisting mothers to breastfeed their infant, as in the previous topic, these Points/Steps require staff to teach mothers the techniques of manual expression of breastmilk.

Expressing breastmilk

Some mothers may not be aware that they can remove breastmilk from their breasts for feeding to the baby later. In the case of low-birth-weight infants, breastfeeding success may depend on early and effective support with expressing breastmilk. Having the knowledge and skills to do it will encourage them to continue to provide essential breastmilk and for later, knowledge of expressing will encourage continued breastfeeding after a return to work, or during other times of separation.

Hand expressing

Many mothers prefer hand expression rather than using a pump because:

  • Hands are always with you, and there are no parts to lose or break.
  • Hand expression can be very effective and quick when the mother is experienced.
  • Some mothers prefer the skin-to-skin stimulation from hand expression rather than the feel of plastic and sound of a pump.
  • Hand expression is usually gentler than a pump, particularly if the mother's nipple is sore.
  • There is less risk of cross-infection since the mother does not use equipment that may be also handled by others.

Even a mother who does own a pump may have more success hand expressing

  • to collect small volumes of colostrum antenatally, anticipating a postnatal medical problem, or
  • to get just a few drops of milk to entice baby to latch, or
  • to apply to a damaged nipple, or
  • to remove just enough milk to allow her baby to latch to her engorged breast, or
  • to relieve the discomfort from an engorged breast, or
  • to clear a blocked duct, or
  • to obtain milk for her baby who is unable to breastfeed, or
  • to obtain milk for her baby when they are separated, or
  • to obtain milk to pasteurize for her baby if she is HIV positive.

Many health professionals also find hand expressing more effective and less wasteful for collecting colostrum.

Workbook Activity 6.2

Complete Activity 6.2 in your workbook.

How to hand express

  • Preparation
    • Mother should wash her hands;
    • Prepare a clean wide-necked receptacle for the milk - a medicine cup, tea cup or bowl may be appropriate depending on volume expected.
  • Technique
    • Mother may sit or stand comfortably - possibly where she can rest her arm or lean forward slightly over the container;
    • Gently massage the breasts, running hands over the nipple and areola to stimulate the milk ejection reflex;
    • Position the first finger and thumb on opposite sides of the nipple, at about the edge of the areola or about 2.5cm (1") from the base of the nipple;
    • Push directly back towards the chest wall, then compress the breast between finger and thumb, and follow through by moving the pressure towards the nipple without sliding the fingers on the skin of the breast;
    • It may take a minute or so to stimulate the milk ejection. Milk only flows easily during a milk ejection so continue expressing while milk flow is good for approx 2-3 minutes. Colostrum is quite viscous, so be patient;
    • Swap breasts and repeat. The mother may like to do this on each breast several times;
    • Stop expressing when milk flow slows to drips or the goal has been achieved (eg. areola is softened enough for infant to latch, or volume needed is achieved).
    Note: 1. the finger and thumb placement; 2. the pressure back towards the chest wall before, 3. compressing the breast tissue between finger and thumb.

    Note: 1. the finger and thumb placement; 2. the pressure back towards the chest wall before, 3. compressing the breast tissue between finger and thumb.
    Photograph © S.Cox, IBCLC


    Video © Australian Breastfeeding Association. Used with permission.

    Pumping breastmilk

    There are many different types of breastpumps available on the market. All staff must be aware of the safety issues surrounding each pump, including adequate cleaning, and its correct use. Either get other competent staff to demonstrate its use, or ask the company representative to give a short educational session for the staff.

    Manual and electric pumps can be equally as effective - the mother will need to consider cost and skills required to use each piece of apparatus. For example, some manual pumps can cause wrist strain which may exacerbate carpel tunnel syndrome; other mothers prefer the versatility of carrying a manual pump to work; electric pumps are very efficient for long term expressing circumstances.

    Who is best to demonstrate pump usage to mothers?

    The pump company representative's job is to sell more pumps and encourage as many mothers as possible to use their pumps for as long as possible. Your role is to show a mother how to safely use a pump for only as long as it is absolutely necessary.

    Do not ask the company representative to speak to mothers about their pump.

    Storing breastmilk for a healthy baby

    If the mother is not going to use the expressed milk within the next few hours, store it safely. Glass and plastic containers with lids are suitable for use, as are breastmilk storage bags.

    There should be a means of noting the time and date of expressing the breastmilk on each container. For hospital use the identity of the mother and baby should also be clearly written.

    • All storage equipment will be thoroughly clean.
    • Refrigerate milk that will not be used within the next few hours.
    • Freeze milk that will not be used within two days.
    NHMRC 2003
    Storing Breastmilk for a Healthy Baby
    Breastmilk status Room temperature 26°C or lower Refrigerator (4°C or lower) Freezer
    Freshly expressed into container 6 - 8 hours;
    when refrigerator available store milk there
    3 - 5 days;
    store at back where coldest
    2 weeks freezer compartment inside refrigerator; 3 months in freezer section of refrigerator with separate door; 6 - 12 months in deep freeze (-18°C or lower)
    Previously frozen; thawed in refrigerator, but not warmed 4 hours or less;
    that is until the next feeding
    24 hours Do not refreeze
    Thawed outside refrigerator in warm water For completion of feeding 4 hours or until next feeding Do not refreeze
    Infant has begun feeding
    (ie. contact with baby's mouth)
    Only for completion of feeding Discard Discard

    Note: Chilled breastmilk may be safely stored at 15°C for up to 24 hours. This is the temperature maintained in an insulated container with a freezer block, eg blue ice.1

    Locate the guidelines to hand expressing and safe breastmilk storage that is provided for mothers in your Unit. Discuss this leaflet with each mother and give her a copy as she is taught this essential skill. Keep a copy of the leaflet in your Workbook.

    There are no guidelines in your Unit for hand expressing and safe breastmilk storage? Recreate the table of safe storage times and file it in your workbook; form a small group to develop a leaflet that can be presented at a Unit meeting to familiarise the staff with its content.

    Hand Expressing Competency

    Click on the icon on the left and print the Hand Expressing Competency. Take this to your course facilitator or mentor and ask them to observe your practice and complete the assessment.

    Using the expressed breastmilk

    The order in which to use expressed breastmilk is

    1. First choice: All milk expressed in the first 4 days (colostrum); assures baby receives the antibody-rich colostrum as soon as possible
    2. Second choice: Freshly expressed milk prior to refrigeration; fresh breastmilk has the most active protective properties
    3. Third choice: Refrigerated breastmilk, using the oldest first; decreases the need to freeze milk, which has a greater effect on immunological properties
    4. Finally: Frozen breastmilk that has been stored the longest; to reduce the need to discard milk that has passed the use-by date

    What should I remember?

    • Teaching hand expression of breastmilk is an essential part of protecting, supporting and promoting breastfeeding - even if the mother intends to use a pump.
    • The potential circumstances that may lead to expressing of breastmilk.
    • How to hand express and teach this skill to mothers.
    • To complete the Hand Expressing competency.
    • The safe storage times and temperatures for each breastmilk status.
    • The order in which to use expressed breastmilk.

    Self-test quiz

    Match an item from the column on the left with an item from the column on the right. Click on an item in one column, then on its matching response from the other column

    Notes

    1. # Hamosh M et al. (1996) Breastfeeding and the working mother: effect of time and temperature of short-term storage on proteolysis, lipolysis, and bacterial growth in milk.