What every doula should know about breastfeeding: Tip #1: Hand expression

I've learned a number of things as an LC that I wish I had known earlier as a doula, and that I would like to share with other doulas! I've decided to do a mini-series of tips called "What every doula should know about breastfeeding". All doulas get basic training in breastfeeding (and doulas are an evidence-based way to increase breastfeeding rates!) Doulas are generally excellent supports for helping normal breastfeeding get off to a good start. But often as a doula, before I became an LC, I would encounter situations in the hours after the baby was born, or at postpartum visits, where I wasn't quite sure what to suggest; or looking back, I realize I could have done something differently. I've decided to share some tips with other doulas about things that I wish I had known long ago!

A disclaimer: my breastfeeding tips for doulas aren't meant to turn you into an LC, or offer the same support as an LC does - one of my tips is going to be how to know when to refer to an LC and how to help your doula clients find advanced breastfeeding support (and you will find suggestions to refer to an LC liberally sprinkled throughout the tips as well!) They are meant to help you become a doula who is better at supporting breastfeeding in the doula role, and filling in some of the gaps in breastfeeding education and support that sadly still exist in our system.

So without further ado, the first tip of the series is... hand expression!

I had kinda sorta heard about hand expression before I became an LC. I knew you could theoretically express milk without a pump, but I confess to having wondered why you would WANT to. Couldn't a pump do the same thing, but faster and easier?

Now I teach hand expression on a daily basis, and I find it an incredibly useful tool. Yet many postpartum nurses, and even some LCs, don't know how to teach mothers how to hand express or when it can be useful. A knowledgeable doula can help fill that gap by recognizing when hand expression might be helpful and helping the mother learn how to do it.


WHEN and WHY to help with hand expression:

When are times that, as a doula, you might help a mother begin hand expression? Here are a few that I can think of:

1) The baby who doesn't latch. All doulas should have the training to help the mother get started breastfeeding just after birth, when the baby is most awake and alert. But sometimes, even with assistance, that first latch doesn't go as smoothly as we would like. The baby bobs around, mouths the nipple, pops on and off, or fusses at the breast and doesn't latch. Some babies just aren't ready to feed right away; for example, babies born with a vacuum-assist often seem to have trouble getting their suck organized at first, or a baby whose mother has had IV medication soon before the birth may be sleepy and not interested in latching.

Once that initial period of wakefulness has passed, the baby often falls into a deep sleep for hours and only wakes to feed a few times during the first day. Like so many breastfeeding "problems", it's not an actual problem for the baby, but it tends to cause anxiety for the parents and sometimes also prompts suggestions of supplementation from the medical staff. Sometimes the mother asks for a pump and is discouraged to see that after 15 minutes of pumping, all she has on the pump flange is a drop or two of colostrum. She starts to wonder if she really has any milk at all. If the baby is still struggling to latch, the next step is often a bottle, even when the mother really wanted to avoid formula, and the bottle can further compromise the baby's ability to latch.

If your doula client's baby hasn't latched by the time you leave, try teaching her hand expression so she has an alternative way to feed her baby. Pumps generally don't get out much colostrum compared to hand expression; a mother who pumps for 15 minutes to get a single drop can easily fill a teaspoon in a couple of minutes by hand expressing (and remember, a one-day-old baby's tummy is only made to hold a couple of teaspoons). All she needs is a plastic spoon from her meal tray to express into; when she's got a little colostrum in the spoon, she can spoon feed it to the baby or simply let the baby lick or suck drops off of her finger. A couple spoon feedings often reassure the mother and the nurse that the baby is taking food in, and give the baby time to rest and get ready to start latching and eating. When you leave the hospital after the birth and you know breastfeeding's not off to the perfect start, you can feel more confident that breastfeeding will ultimately go well if you've given the mom this tool to use.

2) Engorgement. This is particularly important for mothers who have had a highly interventive birth with lots of IV fluids - long inductions, many hours with an epidural, a c-section. These mothers tend to end up fluid-overloaded and their breasts fill up with extra fluid as well. When their milk comes in, they may have lumpy, hard, painful breasts that feel like they're full of milk, but only be able to pump a few drops. When you do your postpartum visit, you may discover this situation along with a very uncomfortable and unhappy mother.

I explain to these moms that they can think of their situation like this: There are a hundred people in a room, and they're all trying to get out one narrow door. They all pack around the door and squeeze up against it and there's just no room to open the door. We need to push some of the people away from the door so things can flow more freely. The breast is the room, and the people are the milk and intracellular fluid built up in her breasts. The pump may just pull more and more "people" towards the door. Instead, have her push back on her areolas for a few minutes to soften them (known as reverse pressure softening, with an excellent explanation and illustration here), then gently use hand expression to push a few "people" at a time towards the door. She can express into a bottle or cup to save the milk. Once the breast is somewhat softened, sometimes you can start the electric pump again, but sometimes you need to keep hand expressing for several sessions before the mother is able to pump.

I helped a mom like this recently. She was so engorged it took her an HOUR to soften a single breast with hand expression, but she got two and a half ounces when she was done! She said that neither the pump nor the baby had gotten more than a few drops since her milk came in. When I left she was starting the slow process of getting two+ ounces out of the other side, but at least she was able to move the milk out, get comfortable, and offer breastmilk to her baby.

I have never forgotten the big bold sentence in my breastfeeding educator training book that said "Unresolved engorgement is a breastfeeding emergency!!!" Unresolved engorgement can cause mastitis, compromise a mother's milk supply, and lead to nipple trauma if the baby is no longer latching well on the overfull breast. Hand expression can be a vital tool for working through severe engorgement. Be especially alert to the possibility of severe engorgement when you have seen a lot of IV fluids go into the mom and notice that her hands and feet are very puffy from the fluid retention; check in with her about her engorgement when you talk to her after the birth. If she is engorged and only getting advice to pump, pump, pump and not having much success, suggest hand expression as an alternative; and help her find a lactation consultant ASAP who can help her with issues that may be contributing to or caused by her engorgement.

3) NICU moms. Remember how I mentioned above that pumps are often not very effective at getting out colostrum? This is by far the most discouraging for the NICU mom whose baby is not able to go to breast due to prematurity or other medical complications. These moms may pump and pump and get almost nothing! Days of pumping a few drops at every pumping session are also discouraging and can lead the mom to cut back on her regular pumping schedule, which can compromise her supply. And the baby misses out on much of the colostrum which is one of the best medicines available!

There is also some preliminary research from Dr. Jane Morton at Stanford University showing that "hands-on" pumping and hand expression after pumping can increase the supply of mothers who are exclusively pumping. This is so important for NICU mothers who so frequently struggle with supply!

If you work with a mother whose baby goes to the NICU after birth, help advocate for her by requesting a pump right away. Help her get set up with the pump and use it for 10-15 minutes. Then show her how to hand express afterwards. Ask for a very small container to express into - we use little vials that are just 10 ml. Much less is lost that way and the mother can really see that in comparison to her baby's tummy, she's actually getting a pretty big meal! Encourage your client to follow every pumping session with hand expression. If the pump is slow to arrive, encourage her to go ahead and hand express every 3 hours - don't wait to start until the pump arrives! The earlier she starts, the better for her supply.


HOW to teach hand expression:

Okay, so hand expression is great and all, but how do you DO it?

Hand expression is a learned skill, and not one I learned especially quickly, so be patient and encourage your doula clients to be patient as well.

The single best tool I have seen for learning and teaching hand expression is this video from Stanford's Newborn Nursery (featuring Dr. Morton who is doing the research on hand expression and increased supply!) Watch it - multiple times - and practice the technique on yourself or on a cloth breast model. When teaching, try to find a way for your doula clients to watch it as well - they may have brought a laptop with them, or there might be a computer in the room. (And tell me if you can figure out a way to get it to work on a smartphone.) If you can't have her watch the video, demonstrate (discreetly) on yourself, use a breast model (or even a soft pillow!), or offer with her permission to demonstrate directly on her breast.

The main tips I have for teaching hand expression, which are also highlighted in the video, are to help the mother keep her fingers well back from the areola. The instinctive thing to do seems to be to spread the fingers apart, and then squeeze in right up to the nipple, often pulling the nipple far forward. This generally makes the mother sore and doesn't get her much milk for her effort. If it's helpful, place your hand over hers as she practices and repeat the rhythm of "press, compress, relax" while keeping the fingers in the same place on her breast. That said, if the mother finds an easy comfortable way to express milk, and it's not the "right" way, she should do whatever is working for her and her body.

Sometimes the mother will report soreness or tenderness in the breast when I am trying to teach her how to hand express hands-on, even when I'm trying to be as gentle as possible. When that happens, I suggest the mother be the only person to do the hand expression. It is usually much more comfortable when she is the one doing the compressions on herself.

It's also normal to have some mothers who can easily hand express a lot of colostrum, and some who, even with good technique, still barely get a drop. Encourage the mother to keep practicing and to be patient. Reassure the mother that hands are better than pumps, but NOTHING is designed to get milk out like a baby! The colostrum IS there, and when her baby is ready to latch on well, it will flow. Hand expression is NOT a test to see "if there's anything there" - it's just a tool to see whether in the absence of the baby, we can still get more milk out and stimulate a better supply.

I hope you and your doula clients find this helpful! Please comment with thoughts and if you have had situations where you think hand expression would have been helpful, and if there are other scenarios in which you think your clients might use it.