Tuesday, August 2, 2011

What every doula should know about breastfeeding: Tip #3: A few must-knows for pumping

Preface: 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! Today is Tip #3: A few must-knows for pumping.

There are a number of reasons your doula client may want or need to pump, including increasing her milk supply/getting additional stimulation to bring in a good supply, and pumping for a baby who can't latch and/or is in the NICU. Some mothers will end up (short- or long-term) exclusively pumping, aka EPing. If your client is EPing because of latch issues including difficulty getting the baby to latch or pain with nursing, make sure she sees a good LC fast!

Like some other topics in this series, I am bummed to have to give many of these pumping tips to doulas, not because I don't think doulas should know this stuff, but because EVERYONE involved in caring for new moms/babies should know this stuff! Moms often do not get the support they need to make pumping successful. But knowing that doulas are there to fill in the gap, these are important things that you may be the only one to discuss.

These tips are by no means all anyone needs to know about pumping, but they are opportunities for the doula to fill in gaps in knowledge:

With that thought in mind, I am putting two very simple, very important tips first:

#1: Cleaning: On a Medela, the valve and flange come preassembled, like this:

So nobody realizes that the yellow valve and white membrane come off and come apart, like this:

On an Ameda, the valve and flange also come preassembled; their valve looks like this:

Every time the mother uses the pump, those parts should be completely taken apart, washed, and dried separately. If those pieces are not taken apart, milk and moisture can accumulate between them and cause problems like poor pump suction and mold growth (EW, I know.)

People just do not know this; I know people who pump for months or YEARS and do not know this. Tell your doula clients! Tell all your friends! Rent out a billboard! Pump valves come OFF THE PUMP!

#2) Flange fit.


Look at this picture:


Now look at this one:


(Both images taken from this simple, lovely page by Ameda.)

I carry a copy of these two pictures around with me at work (I know, I know... my job is so cool!) Any pumping mother, when asked, can tell you whether her pumping sessions look more like the first photo or the second photo (occasionally they'll say "well, kind of halfway between the two" which still suggests a tight fit.)

The wrong size flange can cause pain and low supply. Once again, mothers pump for YEARS with the wrong flange and say "The pump never worked very well for me" or "Pumping always hurt for me", never knowing there was any size flange but the one that came with the pump!

If you know a mother will be pumping a lot, show her these pictures and tell her in advance to keep an eye on flange fit (consider printing the pictures out and keeping them in your doula bag). Mothers may start out a pumping session with what looks like a good fit, and end it with a tight fit; those women should get a bigger flange. They may also be OK on one size for a while, then start to need a bigger size after a few days or weeks of pumping; those women should also get a bigger flange.

The "standard" size in the box is the 24mm flange. Both Medela and Ameda manufacture various sizes up to a 36mm flange, and Medela also makes a 40mm flange. They can be purchased at stores like Buy Buy Baby, Babies R Us, Target, local lactation consultants, or baby boutiques; or they can be ordered online.

Many mothers find that the Pumpin Pals brand shields are more comfortable for long-term use than the standard flange that comes with their pump kit; Pumpin Pals flanges can be used with a number of different pump brands. They're angled and more curved than standard flanges, so many mothers report they feel gentler on the breast, and they also allow the mother to lean farther back when she's pumping.

#3) Early pumping: As I noted in my hand expression post, pumps are usually NOT very effective at removing milk in the early days. Mothers of a fussy baby may sometimes ask to pump to see "if there's anything there". The pump will not help her with that! Counsel the mother who wants or needs to pump in the first 1-3 days that she may not see much with the pump, and help her learn hand expression to maximize the amount she can get out. Mothers who are totally pump-dependent are understandably discouraged by pumping and pumping and getting a single drop. Give them lots of cheerleading and support, and reassure them that they will see more milk within a few days.

#4) She needs a great pump, aka not all pumps are created equal: If your doula client needs to or decides to EP, DO NOT let her buy a crappy, low-power pump. I usually don't talk in such absolutes, but it has to be said. There are some women who can get and maintain a great supply on those $70 pumps; they are in the tiny minority. Usually women buy one of those pumps because they see the price of a Medela or Ameda as prohibitive, but once they've bought a crap pump they've now sunk $70 into something that causes supply issues, and quite possibly nipple trauma (
I'm looking at you here, Early First Years pump) AND they're looking at spending again on a high-quality pump. These situations just about break my heart. If the mother wants to provide exclusive breast milk, she needs a better pump.

She should also NOT get a single-sided pump, or anything with a little motor like the Medela Freestyle. These pumps are OK for the occasional pumper, not for the EPer. Once again, some women can maintain a supply on these pumps, but if they can't they've just wasted a lot of money and are going to have to spend even more. If she chooses to rent a pump instead of buy, you are on safer ground as she will be renting a hospital-grade pump which are all double electrics and have good suction/motors. (If she is struggling with supply and using a good consumer-grade pump like a Medela Pump in Style, she should also consider upgrading to a hospital-grade rental. Moms with supply issues need the best stimulation possible!) When thinking about pump prices, help her think about the value of the milk she will be pumping out. Good pumps are expensive - but so is formula.

If your doula client has difficulty affording a pump, check to see if she is enrolled in WIC, and if not encourage her to try to enroll. Any mother on Medicaid will be eligible for WIC, but even if she is not on Medicaid her income may still qualify her. (She does NOT need to be a US citizen or resident to enroll in WIC; after all, her baby, the one who will be getting the milk, is a citizen.) Many WIC offices have loaner pumps available for mothers who need to pump for medical reasons. If she tells the WIC office she is enrolling because she needs a pump, they may expedite her enrollment to make sure she gets the pump quickly.

#5: Support! EPing is not easy (even though to some moms it may seem like a quicker fix for latch issues in the beginning.) These moms often struggle with low supply, and with the extra time and work it takes to clean pump parts, bottles, carry the pump everywhere, etc. Suggest EPing moms join an online support group - they can really use the support and camaraderie, and it is easy for them to feel like they are all alone when they don't know other pumping moms nearby.

Mothers who have issues with supply or pain issues while EPing should of course be referred to your favorite local lactation consultant! LCs are not just for direct breastfeeding; they can have excellent resources and advice on pumping comfort, ways to build supply, and may even be able to help get the baby back to the breast if that's possible.


I bet there are some long-term pumpers out there - what do you wish doulas (or birth professionals in general) knew about pumping?


Carla Fran said...

I love this series! It is soooooo helpful. I'm a doula, and was wondering if you could do a post about different breastfeeding positions. the one I always remember is the football hold, but it would be great to know alternatives to suggest, especially during early breastfeeding.
Right now, I'm working with somebody who is having great luck latching on one breast, but the baby doesn't get the same great latch on the other breast, and the mother has nixed football hold on that side because it's uncomfortable, and not working. Any ideas?

Kelley said...

this is a GREAT post and I will be sending people to it often!

Rebecca said...

@Carla: Thank you!! and thanks for the suggestion. There are a lot of different reasons a baby may have more trouble latching to one side than the other - different flow, different size nipple, some body/birth trauma issues that make it uncomfortable for the baby on that side, etc. The football hold can be a helpful tool in these situations, but I find a lot of moms nix football hold because they have never been shown how to do it comfortably. See if you can experiment with getting her more comfortable with it, and if that does not work I would refer her to an LC who can assess the situation. Good luck!

@Kelley: Thank you!!

Mollie Hartford said...

Another handy-dandy tip for the Medela valves. At least on mine, the yellow parts are SO HARD to remove from the rest of the mechanism. It took DAYS to figure it out (and therefore, days to properly wash it!). Tip: Take the tip of a spoon and wedge it under one edge and pop it off.

Rebecca said...

@Mollie: Great suggestion! I may use it myself. Sometimes the pre-assembled valves are so hard to get off, I can understand why no one knows they come apart. I have had some luck soaking them in warm water. I also had more success twisting+pulling, instead of just pulling.

M said...

Thanks! I'm a Doula in training, but I've nursed and pumped for a total of 3.5+ years so far, 9 months tandem, and much of it working full time. My first child was jaundiced and sleepy and had latch issues. When my Doula came for the postpartum visit around day 5 or 7, she identified right away that my baby wasn't really nursing or getting milk. I was engorged and in pain and hormonal. She did not know how to use my medela pump in style, and got kind of frantic because she was worried my baby was starving. She had me feeding the baby with an eyedropper while I cried. Though I am grateful that she realized something was wrong when I did not, her lack of knowledge on pumping, and her emotional reaction to the situation was not helpful at all. She didn't refer me to an LC or even stay with me until we found more experienced help. We ended up at an LC in tears a day or so later, who showed me how to pump, and how to skillfully use at nipple shield and then later wean from it. Knowing all this will surely help my future clients have an easier start than I had.