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Sunday
Nov042012

Let's Get Started Breastfeeding

This is the handout I give clients who are going to breastfeed.

While breastfeeding is natural, it doesn’t always feel natural learning how to do it. Here, I offer some basic information that might help you get off on the right foot. 

-          It can’t be said enough… early and often. Having your baby on your body from the beginning is the best way to learn the patterns and rhythms of your newborn. Even though most babies do not nurse for about a half hour or so, occasionally, so nurse sooner. When the baby is on location, initiating nursing is on his schedule, not the hospital’s.

-          It is routine for hospitals to wrap babies in blankets, making them look like a burrito. I encourage women to unwrap their babies, put them skin to skin and cover both of you. Research does show that when a baby is skin to skin with mother, she retains her heat better than when she is in blankets alone.

-          When you have your baby in your arms and are ready to bring him to your breast, there are two main positions to try… and I do recommend trying different positions because each one has its benefits.

Cradle Hold – Put the baby’s head into the crook of your elbow and your same hand on the baby’s bottom or holding a thigh. Babies all have a way of making this more difficult than you think it should be, so don’t be discouraged; just keep trying. At first it can be a three-person job! Pull the baby’s bottom arm around your waist and hope the top hand doesn’t go right into her mouth, blocking the nipple action you are trying to do. Some women find it easier to swaddle the baby tightly before nursing. That can keep little hands hidden, but if he isn’t swaddled tightly enough; the hands find their way out of the blanket and the whole tangle begins again. It’s really okay. You will find your own style with your baby. Having the baby’s belly against yours helps align his mouth with your nipple. We say, “Belly to Belly” – if you remember that, it can make this hold a lot easier.

Football Hold – The baby’s legs are going to wrap around your waist, her head will be in your same-sided hand. Having the head in your hand gives a different type of control over the nursing experience. Many women find this easier because they can see the baby’s mouth and can pull the baby closer than in the Cradle Hold. No matter which hold you are doing, do not lean into the baby; bring the baby to you. Now, the baby has receptors from the  chin, across the cheeks and up around the temples and they need to be left alone because, as you touch them, the baby will think there’s a nipple there and turn his head in that direction. So, when you are holding the baby’s head in this position, your thumb and pinkie finger shouldn’t go closer than the hairline. This is not an exact science, so please don’t worry if your hand is further or closer than that; you and your baby will find your own way. With your opposite hand, compress your areola slightly to make it look like a “V” and then, when the baby opens her mouth wide, pull the baby into and onto your nipple.

NOTE! When learning to nurse, it is a trial and error experience that can last several weeks. Both you and the baby are learning at the same time and neither of you need judge each other. Patience will go far, especially when he’s screaming his head off hungry. Take a few moments, take a deep breath and try again. I promise, it will happen. If you need help, do not hesitate to ask for it! Your midwife, a La Leche League leader and Lactation Consultants are your first lines of defense and can help you overcome most obstacles without bottles. I tell women: If you think about giving your baby a bottle, that is your cue to call me. 

-          For the first day or two, your breasts will probably not change very much. However, if it is painful when you nurse, please call your midwife or your breastfeeding support person. (OBs aren’t versed at all in breastfeeding and Pediatricians are not knowledgeable unless they breastfed their own children successfully.) Nursing should not hurt! It can be uncomfortable or a strange sensation, but pain is your sign that something is wrong, usually with the baby’s mouth… either positioning or a suck issue. Both can be corrected with education.

-          When your milk does begin to come in, you will watch your breasts grow several sizes from their normal shape. It’s important to know that most of the swelling is breast tissue, not milk filling them. Just as when a man has an erection, the tissue swells with blood, not semen; it is similar with the newly lactating breast. Therefore, attending to the tissue swelling is the focus for these next couple of days. Nursing continues as needed, but women can be so uncomfortable with the milk coming in that they give bottles for relief. Here, I’ll give hints for helping without bottles.

Heat before/Cold after is the main rule. Hot, wet washcloths before nursing helps to soften the breast, especially the nipple (which can get so swollen it cannot be grasped). I encourage women to keep at least four washcloths in a crock pot on low, exchanging two washcloths as they cool, back and forth, as the baby begins waking up. Hopefully before he’s screaming his head off, but even if he is, take the time you need to prepare.

After nursing, ice packs on the entire breast feel heavenly. Many women use frozen vegetables because they mold nicely on the breast. The ice helps relieve the tissue swelling, just as we ice a swollen ankle. You can put the ice packs on for 20 minutes and then off for 20 before putting them back on again. As needed between nursings, you can do as much of this routine as you like.

Cabbage leaves are a great home remedy that help the swelling diminish like magic. A chemical in the leaf relieves engorgement within a day or so. I encourage women to take the cabbage leaves off whole and put them in the freezer so when they use the leaf on their breast, it is also cold, taking care of the swelling with two methods at once. Use the cabbage leaves for 20 minutes out of every hour and only use them for two days because they can also diminish milk supply if used for too long.

Ibuprofen, by its nature, helps with swelling and pain at the same time. Many women find they need to augment with medication for pain and Ibuprofen is the best way to do that while nursing. I recommend 600 mg every 6 hours for 2 days. Ask your own care provider what he or she recommends.

Some women find homeopathics or herbs help with the swelling. Be sure to ask your holistic provider to tailor the care to you and your baby.

-          What if your nipple is so engorged the baby cannot grasp the nipple? Many women find that, while using the heat before nursing, you can express some of your milk to soften the nipple. When hand expressing, be sure to put your thumb and forefinger behind the areola and press down and then towards the nipple (which, technically, is the very tip of the areola, the darker part of the breast). It can help if you are able to lean over in a filled-with-hot-water sink, letting gravity help you with expression. You can also do this in a hot shower, letting the water spray on your breasts as you hand express to soften your nipple. Be ready to nurse, though, because very shortly after expressing, the nipple will fill again.

-          All of this can be extremely uncomfortable but really is important in helping you, ultimately, not be so engorged. The major discomfort should last no more than 2-3 days.

-          DO NOT PUMP! Pumping will only make your breasts think you have another baby to nurse and will make even more milk. The small amounts of hand expression will not do this, but pumping should be a last resort, only to soften a bowling ball breast so the baby can grasp the nipple or to relieve a crying-in-pain mother. Pumping hurts, too, when the breast is that engorged, so really is a last resort.

-          If there is ongoing pain or nipple damage, have a Lactation Consultant come and see if there might be a technical issue… the baby sucking on a lip, the baby not sucking properly, the baby having a tongue tie, etc. She will be able to diagnose the problem fairly quickly and get you on the road to recovery sooner than later.

-          Find support through La Leche League meetings. They are awesome. If you don’t like one group, go to another. You’ll find one that fits you perfectly.

-          Hang in there! You can do it. Nursing takes a lot of practice. But the practice pays off in a wonderful relationship with your child.

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Reader Comments (11)

Hello, and thank you for this.

Have you worked with many women with saline breast implants? I don't have a child yet, nor am I pregnant (TTC), but my doctor recently told me that I could have trouble breastfeeding and I may need to pump to keep the supply up in the beginning. Do you (or your readers) have any encouraging stories of successful nursing with implants?

Thanks!

November 4, 2012 | Unregistered CommenterAnon

I would caution against being overly cautious about pumping. Normal engorgement should only last 24-48 hours after the milk comes in, and there should be at least some softening of the breast. Pathological engorgement, that lasts more than two days and results in breasts that never get hard, can bruise the duct tissue and take weeks to heal. The stimulation from expressing milk depends not only on how much milk is removed, but how often, so incorporating pumping into a blockfeeding regimen can bring significant relief, avoid fore/hindmilk imbalance, and help the baby to feed, without overly increasing supply. There was a study done on what they called "full drainage and blockfeeding" that I've used to great success as a breastfeeding peer counselor. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2075483/

November 4, 2012 | Unregistered CommenterKatherine

I use pillows and couch arms/chair arms and the like to figure out how best to sit to feed baby. I've had 8, every child is a bit different and my body has changed. Babies are so tiny when they are first born, I usually am uncomfortable bringing baby high enough. But, as baby grows, this becomes easier. I found that propping the football hold with pillows was really great.

In the hospital, for some reason, nursing in that bed is just a pain for me. I eventually move to their little couch.

November 4, 2012 | Unregistered CommenterDawn

For positioning, I would add the cross-cradle hold. It's the same (for the baby) as the cradle hold, but you hold them with your opposite arm with their head in your hand and their bum in the crook of your arm. This gives you more control as you aim them at the nipple. Plus, if you hold your breast with the same-side hand, it makes a good nipple sandwich to present to baby's mouth. Your fingers are the bread with the areola squished between. You want the bread parallel to baby's lips (imagine eating a sandwich sideways!) to get the best latch, and that's harder to do when you're holding your breast with the opposite-side hand.

November 4, 2012 | Unregistered CommenterJen

What about incorporating some info on the breast crawl and biological nurturing (in the positioning section)?

November 4, 2012 | Unregistered CommenterVW

I would add laid-back nursing as a great option for some mama-babies. I have seen several (first babies especially) struggle with latching and staying awake in the cross-cradle/cradle/football holds who really take to nursing in the laid back position. It is usually more comfortable for moms and allows the baby to be more active and in charge of his experience.

November 4, 2012 | Unregistered CommenterLinsey

For Anon who wants to breastfeed with implants, check out BFAR.org, especially the fora. It's for women breastfeeding after reduction surgery, but we also have moms with implants or other breast surgeries, as well as non-surgery moms with low supplies. You definitely CAN breastfeed, but it may not be as simple as "lift shirt insert boob". I've nursed three children since my reduction surgery, including a set of twins. I couldn't have done it without BFAR.org.

November 4, 2012 | Unregistered CommenterJen

I agree with Katherine that I am not overly cautious about pumping & engorgement. I see women suffer with pathological engorgement and babies who are getting all they can, or not getting as much as they should, and not sufficiently softening the breasts (or mothers who have decided not to breastfeed and so no milk has been removed at all). I tell them engorgement is hormonally driven and their breasts will keep overproducing for the next 24-48 hours whether we pump or not. We pump to comfort - not to empty - so as not to set them up for oversupply, but to give them relief from intense discomfort and sometimes a lot of difficulty latching (which has then compounded the problem). Usually good emptying/softening once or twice in a row helps get them back on the right path! I do NOT have moms pump routinely though - only when engorgement has tipped over into pathology.

My understanding is that engorgement is not normal. Full breasts are, engorgement is not and there is a difference between the two. For engorgement, I have found that having a woman lean over a basin of warm water and submerge her breasts until the milk starts to flow. This ideally will soften the areolas up enough for baby to latch. But ideally we want to prevent engorgement with short, frequent feeds with baby activly sucking and activly transferring milk when at the breast.

I absolutely love the biological nurturing approach...especially for the first time baby goes to the breast 45-90 minutes after birth. Since I've started doing this with doula clients I have found that babies nurse so much better and much more often in the first 4 days when allowed to be the leader for latching on rather than mom actively putting baby on the breast. I've also seen fewer issues since I started doing this with clients. I also use it when I do lactation home visits, especially if mom has been doing RAM. I really feel like we would see less issues and more nursing over the first week if we just let baby lead the way for that first time to breast and for the next few days. .

And lastly, I've been working hard to move away from the phrase "when your milk comes in." Instead I've started to say "when your milk transitions" to help them to understand that the colostrum their baby is getting is milk and is enough. Again, I've seen less worry about baby not getting enough in the early days once I started using this phrase.

November 7, 2012 | Unregistered CommenterCatie

Teach me. What is Biological Nuturing?

November 8, 2012 | Registered CommenterNavelgazing Midwife

I think there can be a place for pumping. I had oversupply and overactive letdown. On the fourth day of her life my daughter wasn't able to nurse well because she kept getting sprayed and couldn't deal with it. My breasts were hard as rocks and she was increasingly hungry and upset. We took her to the emergency room that day for an unrelated reason, and this problem worsened over the course of several hours until shift change brought a nurse who was a breastfeeding mom of 6. She had me pump to get past that initial deluge, nurse my daughter, and then pump until my breasts weren't hard anymore. This worked great. The next day I went to a breastfeeding support group and the leader (an LC) said she wasn't concerned about that one isolated incident of pumping boosting my supply because it wasn't something I was going to do repeatedly. We did fine after that--we still had to deal with the oversupply & overactive letdown, but pumping that once helped "reset" things so we could function.

I take the point that getting into the *habit* of pumping stimulates your body to make more milk rather than less, but pumping one time is a lot different than pumping multiple times a day for days on end--repeated pumping is what will make the problem worse.

November 12, 2012 | Unregistered CommenterElaine

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