A health care professional should be familiar with the technique of manual expression and be able to diagnose improper technique.
Technique
All breastfeeding women should be familiar with the basic technique of manual expression of milk from the breast, and ideally this technique is acquired before discharge from the hospital and with the assistance of the nursery or postpartum nursing staff.
Reasons to express breast milk include the following:
- 1.
To initiate flow and assist an infant to grasp the breast properly
- 2.
To encourage production of milk early in lactation when an infant is premature or ill
- 3.
To relieve engorgement
- 4.
To remove milk when it is not possible to nurse an infant at a given feeding
- 5.
To maintain lactation when an infant cannot be fed
- 6.
To pump and save milk for feeding an infant at another time
- 7.
To contribute to a milk bank
- 8.
To pump and discard milk while temporarily on a specific medication
Manual expression is appropriate to initiate flow before applying a hand pump or an electric pump. Not many women can manually pump large volumes over time without mechanical assistance. The breast should always be massaged, and flow initiated, before applying any pump.
Procedure
Step 1 . Always wash hands before handling a breast.
Step 2 . Breast massage: Whether planning to manually express or mechanically pump, preparing the breast for ejecting the milk facilitates the process. The release of oxytocin and the ejection reflex are stimulated by external stimuli: a baby’s cry, a picture of the baby, or gentle handling of the breast. Prolactin release and milk production are stimulated by “sucking” stimulation.
After the mother finds a comfortable sitting position and is relaxed, the breast is exposed and gently stroked with the fingertips from periphery to areola ( Figure E-1 ). As this stroking is intensified, one should avoid slipping the hand across skin and irritating tissues. Gently massage. A warm washcloth soak is also helpful in initiating flow through the ducts. Gentle fingertip massage around all quadrants should follow and be repeated several times during extended mechanical pumping. It should not leave red marks or hurt.
Step 3 . Position hands on the breast: Usually placing the fingers below and thumb on top is natural for most women. One hand placed above and one hand placed below the areola may be easier when the hand is small compared with breast size. The target area is beyond the ampullae, which are the collecting areas of the main ducts that radiate out from the nipple to the areola. The ampullae are approximately 3 cm from the nipple base, which may not be at the edge of the areola. Press toward the chest wall, and then compress the thumb and fingers together ( Figure E-2 ). Continue to compress the breast while moving the hand away from the chest wall in a “milking” action toward the nipple ( Figure E-3 ). (Avoid pulling, squeezing, or rubbing motions.) Perform this motion in a repeated rhythmic manner at a comfortable, but not abrasive, rate. Infant suckling does not involve movement (stroking) of the tongue along the elongated areola and nipple, but an undulating motion of the tongue itself. Simulating that motion is the goal of manual expression. This action is similar to a peristaltic motion. The hand should be rotated around the breast to massage and stroke all quadrants, including the periphery and the axillae.
Use one or both hands to find the most productive grasp. Preventing trauma is essential; thus, avoid squeezing, rubbing, or pulling the breast tissue. Every mother develops her own natural pattern, so rigid adherence to methods may be counterproductive. Effectiveness is measured by the comfortable release of milk.
Total emptying of the breast will require 20 to 30 minutes of manual stimulation. Warm compresses, hot showers, or suspending the breast in a bowl of warm water may help, especially if engorgement or mastitis is present. Leaning over and gently shaking the breast may help stimulate flow. Manual expression while leaning over may help empty the lower quadrants.
