Fundamentals of Midwifery: A Textbook for Students (95 page)

To stimulate the baby to attach for a breastfeed by expressing a few drops onto the baby’s lips.

To collect colostrum, to syringe or cup feed, to a newborn baby which has not yet established effective baby-led breastfeeding.

To collect colostrum for a premature or sick baby on the neonatal unit and to stimulate theonset of copious lactation when the baby is unable to breastfeed directly.

To relieve an overfull or engorged breast.

To improve breast drainage post-feed, if engorgement is still an issue/if the mother has mas-titis or a blocked duct/or if the baby is unable to achieve adequate breast drainage due to prematurity, sickness or other clinical condition which may affect the baby’s ability to suckle effectively and transfer milk, e.g. Down syndrome; cleft lip and palate.

To encourage an increase in milk production by expressing post-feed, when lactation is falter-ing as part of a detailed feeding plan.

To support a mother’s choice of feeding, which may be to give her baby expressed breastmilkby bottle and teat. This may be undertaken occasionally, to enable others (including the father) to feed the baby (reflecting cultural changes to a more family-centred approach to newborn feeding), or regularly, at every feed time if the mother chooses not to put her baby to the breast but wishes to use her breastmilk as the ideal infant milk.

To provide breastmilk for the baby’s feeds, if the mother is going to be away from the babyfor period of time.

To maintain the breastmilk supply, when separated from the baby, by expressing at the timesthe baby would usually feed.
Hand expression
A clear explanation should be given to the mother, as to why this skill is important to enable her to learn how to manage breastfeeding and the variety of situations and challenges she may encounter. Gaining the ability to hand express, will help the mother to develop confidence and autonomy in relation to breastfeeding and will provide her with one of the ‘self-help’ strategies if a breastfeeding challenge arises.For mothers whose baby is being cared for on the neonatal unit, learning how to hand express effectively and frequently, gives both parents something very positive to do every few hours and helps them to feel as though they are contributing to their baby’s wellbeing. For premature babies, every drop of colostrum is regarded as an essential medicine to provide the safest milk to line the gut and reduce the risk of necrotising enterocolitis (McGuire and Anthony 2003; Heiman and Schanler 2006). It also provides vital immune factors produced by the mother to protect the baby from infections; hormones, which help maintain physiological stability; and enzymes, which aid digestion and absorption of nutrients. For this group of mothers, commenc- ing hand expression as soon as possible after the birth (within 6 hours wherever possible), is vital to facilitate the onset of copious lactation over the next few days. It is crucial to remove all available colostrum frequently, in order to trigger surges of prolactin from the anterior pituitary gland, which targets and ‘switches on’ the prolactin receptor cells for milk production. Delay in stimulation of these cells can lead to suboptimal lactation. This group of mothers should be encouraged to express at least 8 times in 24 hours, including once in the night to capitalise on the higher nocturnal prolactin levels.The same is true for mothers who have their newborn baby by their side, where the baby is not waking and breastfeeding well enough to remove colostrum frequently and trigger the release of prolactin. A baby will often pummel or pad the breast with its hands and bang its head on the breast, brushing past the nipple before latching on. These actions provide tactile skin stimulation to the nerve supply of the breast and nipple, increasing levels of oxytocin.
225226‌However, the secretion of oxytocin is inhibited by circulating adrenaline, which is released in response to fear, anxiety or stress. It is important, therefore, to use strategies to calm and relax the mother prior to commencing expressing and ensure she has privacy and comfort, otherwise it is unlikely that her milk will flow for collection, as a result of a lack of the MER reflex. Difficulty in producing milk at an expression can increase concern and anxiety in the mother who may become tearful and despondent.
Key points for teaching hand expression

It is vital to teach this technique in a quiet and unhurried manner, using a‘hands off’approach in order to achieve the optimal responses.

Show the mother how to stroke/massage her breast to trigger the tactile stimulation. [A knitted breast is useful to demonstrate with. A pattern to make one is available on Lactation Consultants of Great Britain website.

Ask her to gently stimulate the nipple tissue between the pad of her thumb and first finger. This encourages the muscle cells in the nipple tissue to contract, making it protrude more.

The mother should ‘cup’ the breast and form a ‘C’ shape with her thumb above the nipple, on the areola and her first finger below. Larger breasted mothers may benefit from support- ing the weight of the breast with her other hand.

To locate the correct area on the breast to elicit a productive flow of milk, the mother needs to gently feel where the lower milk cells are, by compressing the tissue with her thumb and first finger, beginning just behind the firm nipple tissue which usually feels quite soft and working backwards, away from the nipple until she can feel a change in texture – a firmness or knobbly texture.

She should be guided to press backwards into the breast tissue, towards her rib cage, and then maintaining this backwards pressure, gently compress the breast tissue for a few seconds between her thumb and first finger, and then release the pressure whilst retaining contact in the same place on the skin. Repeat the compress/release technique until the MER has been triggered and milk begins to flow, slowly at first and then more quickly. Continue in this area until the flow slows then rotate the thumb and finger and locate the correct area in the next segments of the breast and repeat the technique until sufficient milk has been expressed to meet the clinical need.

Depending on the reason for hand expressing, the mother may be encouraged to express both breasts to drain and collect all available colostrum/milk.

Small amounts of colostrum are best collected in a 1 mL or 2 mL syringe, by whoever is helping the mother. If the milk is not being used immediately and requires storing in the designated fridge at 4°C or taking to the neonatal unit, a sterile ‘stopper’ needs to be placed on the end of the syringe and the body of the syringe needs to have a label attached which identifies the mother/hospital case note number/ward/bed/date and time of collection.
Equipment for breast pump expressing
Using a hand pump
The choice of hand pumps is extensive but all work in a similar way. They require the user to follow the manufacturer’s instructions for safe cleaning, sterilisation of parts and correct assem- bly. Hand pumps are significantly cheaper than electric pumps and for intermittent or occa- sional expressing, they are ideal. The mother may benefit from triggering a ‘milk ejection reflex’ using the technique described above in Key Points for Teaching Hand Expression, points 2–6, prior to placing the funnel of the breast pump against her breast.Once the milk is beginning to flow, the mother places the funnel of the breast pump against her breast ensuring that the nipple is placed in the centre of the aperture, to avoid any rubbing or chafing. Some manufacturers provide a choice of funnels and apertures to accommodate different sized nipples. The funnel should be held close enough to provide a good seal, but the mother should be guided to avoid excessive pressure because this could restrict the flow of milk along the ducts.She will need to hold the funnel and support the breast with one hand and depress the lever of the pump with the other. Initially, repeated depressions will need to be made, to create a vacuum and then the milk will begin to drip and then spurt. Once this is underway, the mother can manage the milk removal, by only depressing the lever far enough to create the vacuum pull. Milk can be observed spurting out like jets of milk.It is very important that the mother does not create too much vacuum pressure because that can cause nipple pain and nipple tissue trauma. Mothers should be warned against the tempta- tion to try and pump too fast and too vigorously as this can be counterproductive, leading to poor milk drainage as a result of increased levels of anxiety. Much better milk expression is achieved if the mother expresses slowly and gently, in a private and calm environment, which enhances oxytocin secretion. When the milk flow slows right down and or the breast feels well drained, she can repeat the whole process on the other breast, depending on the reason for her expressing milk.When the expression is completed, the breastmilk should be stored safely or fed to the baby, according to the clinical situation. The pump parts must be separated, cleaned and sterilised according to the manufacturer’s instructions.
Further reading activityFor more information about hand expressing and safe storage of expressed breastmilk look atthe following resources [Available online] www.mothersguide.co.uk and http:// www.unicef.org.uk/BabyFriendly/Resources/Resources-for-parents/ Off to the best start: Information about feeding your baby
227
Using an electric pump
As with hand pumps, there are many manufacturers of electric breast pumps and the choice of pump should be based on clinical effectiveness, ease of assembly, guidance from knowledge- able lactation consultants and the price. For regular or long-term expressing, an electric pump is probably more suitable.The mother should ensure the pump parts have been appropriately cleaned and sterilised following any previous expression and then assemble them. A minute or two of pre-expressing breast massage can begin to stimulate oxytocin secretions. Having some calming music playing, or watching a favourite TV programme can help the mother remain relaxed during the expres- sion and if she is separated from her baby, for example the baby is on the neonatal unit, then looking at a photograph of her baby can enhance oxytocin secretions.After placing the assembled breast pump gently against her breast, she should switch on the stimulation phase button, if the pump has one, and wait for the MER and then proceed to the expression phase. If the mother is expressing to relieve a blocked duct, engorgement or mastitis, it is helpful to use her spare hand to gently massage the breast tissue beneath the skin in the area which feels congested, as this can aid the flow of the milk down through the lactiferous ducts and out through the nipple pore openings. Sometimes, milk which has been blocked in228‌‌
the breast over many hours can look thick and congealed as it begins to be released, but will gradually return to normal consistency as it flows more freely. It is all safe to be fed to the baby. It is important to ensure the mother understands that to turn the vacuum button up to maximum, is unlikely to achieve optimum milk flow or good breast drainage because if the vacuum is too high it will create too much suction, drawing the walls of the lactiferous ducts closer to each other and restricting the flow of milk. In addition, excessive vacuum may also cause nipple tissue damage and pain. Some mothers who are expressing frequently and over a lengthy period can be drawn into thinking that to turn the pump up to maximum vacuum will result in reducing the time taken to complete the expression, but this will more likely result in reduced milk flow, poor breast drainage, pain and disappointment. Each mother should determine the most effective settings, for each of her breasts. The breasts are two separate organs, which are likely to have different speeds of MER and need slightly different levels ofvacuum to achieve optimal expression.It is milk removal from the breast, either by the baby feeding effectively or by using a breast pump, which triggers the secretion of prolactin from the anterior pituitary gland, which in turn stimulates the prolactin receptor cells in the cells of acini in the breast tissue. This results in milk production to replace what has been removed.
Identifying and managing common breastfeeding problems
Many of the pathological conditions can be traced back to either: