View source for Health-and-Nutrition/C2/Hand-expression-of-breastmilk/English


{|border=1

| <center>Visual Cue</center>
|<center>Narration</center>

|-
|'''Slide Number 1'''
'''Title Slide'''
| Welcome to the '''Spoken Tutorial''' on hand expression of breastmilk. 

|-
|Image: Woman feeding breastmilk to a baby from a cup

GIF: Mother expressing breastmilk with her hand.

Image: Multiple pictures of mother expressing breastmilk

|In this tutorial we will learn,

* Benefits of expressing breastmilk
* How to express breastmilk by hand and
* How often should a mother express breastmilk

|-
|Image: Mother is expressing her breastmilk by hand.

GIF: Mother expressing breastmilk

Image: Mother with engorged breasts.

|Breastmilk expression is useful to:

* Relieve breast engorgement;

|-
|Image: Dry, sore and cracked nipples.

Image: Sore and cracked nipple

|
* To treat nipple soreness and dry skin on the dark area around the nipple;

|-
|Image: Mother in pain

Image: sore nipple

|
* To feed a baby if mother’s sore nipple is extremely painful while latching

|-
| GIF: Mother’s breastmilk supply increasing

|
* To increase or maintain mother’s breastmilk supply;

|-
|Image: Working mother

|
* To keep breastmilk available for a baby when the mother goes out or to work;

|-
|
Image: Full breast

Image: Baby trying to attach to a full breast

|
* To help a baby to attach to a full breast by softening the dark area around the nipple;

|-
|
Image: Foremilk.

Image: Hindmilk.

Image: Mother breastfeeding from right breast

Image: Mother offering left breast to the baby.

Image: Empty breast and breast full of milk.

|
* To check whether the baby has fed from one breast completely before offering the other breast.

|-
|Image: Bowl of complementary food with water added to it.

Image: Bowl of complementary food with breastmilk added to it.

Image: More than sign. (>)

|
* To make nutritious complementary food for a baby by using breastmilk instead of water or cow’s milk 

|-
|Image: Premature baby

Image: Sick baby

Image: Baby with poor muscle tone

Image: Baby with cleft lip

Image: Baby with cleft palate

Image: Baby is unable to latch deeply to the breast

|
* And to help in feeding milk to - 
** Premature babies
** Sick babies
** Babies with poor muscle tone
** Babies with cleft lip and/or palate and
** Babies who have difficulty in latching deeply to the breast

|-
|GIF: Mother expressing breastmilk

|Now, let’s learn how to express breastmilk.

|-
|Image: Mother expressing breastmilk by hand

|The most recommended way for a mother to express breastmilk is by using her hand.

|-
|Image: Red nipple and areola after expressing breastmilk

|Because this method causes less discomfort to the dark area around the nipple.

|-
|Image: breast pump

|
* Also, this method needs no appliance.
* So the mother can do it anywhere and at any time.

|-
|Image: Mother is practising expression of breastmilk.

|Expressing breastmilk by hand is a learned skill and will improve with practice.

|-
| Image: Soft breasts.

|It is easy to hand express breast milk when the breasts are soft.

|-
|Image: 1st and 2nd day after delivery.

Image: Calendar

|Therefore, a mother should learn this skill on the first or second day after delivery.

|-
|
Image: Wide mouth steel container

Image: Wide mouth glass container

|Before expressing breastmilk,

Mother should have a steel or glass container ready to collect the expressed milk.

|-
| Image: Wide mouth cup

Image: Wide mouth glass

Image: Wide mouth jug

Image: Wide mouth jar

|She should choose a cup, glass, jug or jar with a wide mouth.

|-
|Image: Mother is washing a wide mouth cup with soap and water

|She should wash the chosen container with soap and water.

|-
|Image: Cup is kept in boiling water

Image: Mother is pouring boiling water in the container

Image: Clock showing 10 minutes

|After that, she should either -

* keep the container in boiling water or
* pour boiling water into the container and leave it for a few minutes.

|-
|Image: Cup is air-dried completely

|Then, she should either

* air dry the container completely
* Or wipe it dry with an unused clean cloth

The container should never be dried with a used cloth such as a used kitchen cloth.

|-
|Image: Inside of the breast showing breastmilk release from the tissues in the ducts

|After the clean container is dried completely, next step is to release breastmilk from the breast.

|-
|Image: Mother is relaxing with the baby

|To help her milk flow, the mother should feel relaxed and emotionally connected to her baby.

|-
|Image: Mother is sitting quietly and privately

Image: Mother is sitting with a supportive friend

|Mother can try the following:

* She can sit quietly and privately or with a supportive friend.

|-
|Image: Mother is sitting with other mothers.

|
* Some mothers can express easily in a group of other mothers who are also expressing breastmilk.

|-
|Image: Skin-to-skin contact between mother and child

|
* She can hold her baby on her lap with skin-to-skin contact.

|-
|Image: Mother is looking at the baby

Image: Mother is listening to the baby’s voice.

Image: Mother is listening to her baby’s voice on phone.

|
* Or she can look at her baby or hear her baby’s voice.

|-
|Image: Mother is looking at baby’s photograph

Image: Mother is smelling baby’s blanket and clothing

| Sometimes-

* even looking at a photograph of her baby or smelling her baby’s clothing helps.

|-
|Image: Mother is drinking a hot drink from a cup

Image: Tea

Image: coffee

Image: alcohol

|
* She can take a warm soothing drink.
* But, the drink should not be coffee, strong tea, alcohol or any stimulant.

|-
|Image: Mother is applying warm compress on breasts

Image: Mother is taking a warm water bath

|
* She can also warm her breasts to help her milk flow.
* To warm her breasts, she can-
** apply a cloth soaked in hot water to her breasts,
** or have a warm water bath.

|-
|Image: Mother is gently pulling or rolling her nipple and areola

|She can stimulate her nipples and the dark area around them by-

* gently pulling
* or rolling them with her fingers.

|-
|Image: Mother is massaging her breasts using circular movements

|She can massage her breasts lightly using circular movements.

|-
|Image: Helper is rubbing mother’s back

|Mother can ask a helper to rub her back.

|-
|Image: Mother is sitting. Helper is standing close to her.

Image: Mother is leaning forward. Helper is standing close to her.

Image: Mother has folded her arms on a table in front of her. Her head is on her arms. 

|For the back rub, the mother should-

* sit down,
* lean forward,
* fold her arms on a table in front of her and
* rest her head on her arms. 

|-
|Image: Mother’s breasts are unclothed and hanging loose

|Her breasts should be unclothed and hanging loose.

|-
|Image: Helper is rubbing down both sides of mother’s spine.

|The helper should rub down both sides of the mother's spine.

|-
|Image: Helper’s fist is closed with thumbs pointing forward.

|She should use her closed fist with her thumbs pointing forward.

|-
|GIF: Helper massaging mother’s back

|She should press firmly making small circular movements with her thumbs. 

|-
|GIF: Helper is massaging mother’s back. 

Image: 2-3 minutes clock

|She should work down both sides of the spine at the same time from the neck to the shoulder blades.

She should do this for two or three minutes.

|-
|Image: Oxytocin reflex

|All these steps will help in releasing the breastmilk.

This release of breastmilk is called '''Oxytocin reflex''' or '''let down reflex'''.

|-
|Image: Mother washing her hands.

Image: Mother showing her dry and clean hands.

|After the '''oxytocin reflex''' begins, the mother must wash and dry her hands thoroughly.

|-
|Image: Mother is sitting comfortably

|Then, the mother should sit comfortably.

|-
|Image: Mother is leaning forward slightly

|She should lean forward slightly.

|-
|Image: Mother is holding the container with her left hand near her right breast

|She should hold the container near her breast.

|-
|Image: Mother has placed her right thumb and fingers on her right breast in a C shape hold from the side.

Image: C shape hold

|Now, she should place her thumb and fingers on the breast in a C shape hold from the side.

|-
|Image: Mother is using left hand to hold her right breast in C shape hold.

Image: Mother is using her right hand to hold her left breast in C shape hold

Image: Mother switches from her right to her left for holding her right breast in C shape hold.

|
* She can use either hand for holding either breast.
* And she can switch to the other hand when the first one tires.

|-
|Image: Highlight mother’s right thumb on the upper part of the right breast

|While holding the breast, her thumb should be on the upper part of the breast.

|-
|Image: Highlight mother’s fingers on the lower part of the breast

|And her fingers should be placed opposite to the thumb on the lower part of the breast.

|-
|Image: Mother’s right thumb, nipple and fingers are in a straight line. Nipple is in the centre.

|Her thumb, nipple and fingers should always be in a straight line.

|-
|Image: Nipple is in the middle of the thumb and the index finger

|And the nipple should be in the middle of the thumb and the index finger.

|-
|Image: Distance of 2 fingers between the nipple and her thumb

Image: Distance of 2 fingers between nipple and mother’s fingers

|There should be a distance of 2 fingers between-

* the nipple and her thumb and
* the nipple and her fingers. 

|-
|Image: Mother’s thumb and fingers very close to the nipple and pinching it. Very less milk is coming out.

|If the fingers are too close to the nipple, the milk may not flow for long.

|-
|Image: Mother’s thumb and fingers are at a distance of 2 fingers from the nipple.

Image: More milk is coming out from the milk ducts beneath the areola. 

Image: Milk flowing inside the breast.

|Mother will release more milk when-

* she compresses the milk ducts beneath the dark area around the nipple.

|-
|Image: Mother is holding her right breast in a C shape hold with her right hand

|In this picture, the mother is holding her right breast correctly with her right hand.

|-
|Image: Mother is pressing the breast slightly inwards towards her chest wall by applying steady pressure.

|Now, she should - 

Press the breast slightly inwards towards the chest wall by applying steady pressure.

|-
|Image: In that pressed position, without moving the hand, mother is gently compressing the breast between the thumb and fingers.

|Then, without moving the hand -

gently compress the breast between the thumb and the fingers.

|-
|Image: Mother releases the pressure on the breast and comes to the starting position.

|And then, release the pressure on the breast.

|-
|Image: All 3 steps together

GIF: Mother is expressing breastmilk in these 3 steps

|The mother should repeat these 3 steps-

* Press back
* Compress
* And release.

|-
|GIF: Mother is pressing the breast slightly inwards towards the chest wall

|The first step of pressing back towards the chest wall is an important step.

|-
|GIF: Mother is pressing towards the nipple and very little milk is released.

|Pressing only towards the nipple will give very little milk.

|-
|GIF: Correct expression technique and more milk is released.

|But when the breast is pressed back, milk from the dense breast tissue is released.

|-
|GIF: Mother is pressing too far back and too hard

Image: Blocked milk ducts

|But, avoid pressing too far back, because that can block the milk ducts.

|-
|GIF: Mother is expressing milk the right way but only a few drops come out.

|When the mother starts expressing breastmilk by hand, very few drops of milk may come out at first.

|-
|Image: Let down reflex

Image: Mother is still expressing breast milk and milk is dripping out.

| As the '''let down reflex''' starts, milk starts to drip out.

|-
|GIF: Mother is expressing breastmilk and milk is dripping out slowly

GIF: Mother is expressing milk and milk flows in streams

Image: Mother’s confidence increases when she breastfeeds for a long time.

Image: Mother’s confident increases when she expresses breastmilk for a few days.

|
* In the first few attempts, it is common for the milk to drip out or come slowly.
* Later, breastmilk may flow in streams.
* As with breastfeeding, expressing breastmilk is a skill that comes with practice. 

|-
|Image: Few drops of colostrum coming out of mother’s breast when she is expressing breastmilk

Image: Colostrum protects the baby from diseases

|
* '''Colostrum''', the first milk after birth, may only come in drops but is enough for the newborn.
* The thick, often yellow milk, has enormous protective benefits for the baby.

|-
|Image: Step 1 of hand expression. Mother is pushing her breast back towards the chest.

Image: Step 2 of hand expression. Mother is pressing the breast.

Image: Step 3 of hand expression. Mother has released the pressure.

Image: Breastmilk flows in a drip

|The mother should repeat the 3 steps until the flow of milk slows down to a drip again.

|-
|Image: Mother is holding the breast in U shape hold 


|Then, she should reposition her fingers to express milk from other parts of the breast.

|-
|Image: Mother checking the breast for fullness and compressing.

|She can feel for where the breast seems fuller, and compress those areas.

|-
|Image: Clock 3-5 minutes

Image: Milk flow slows down

|She should express milk from one breast for at least 3 to 5 minutes until the milk flow slows down.

|-
|Image: Mother is expressing milk from the other breast

|Then, she should express milk from the other breast in the same way from all the areas.

|-
|Image: Mother is expressing milk from both breasts again
|And then again express milk from both breasts a second time.

|-
|Image: clock showing 20-30 minutes

Image: clock showing 45 mins

Image: Expression in first few days

Image: 5-10 minutes clock

|
* Expressing breastmilk from both breasts adequately takes 20 to 30 minutes.
* It may take more time, especially in the first few days
* As in those days, only a little milk may be produced.
* It is important not to try to express in a shorter time.

|-
|Image: Mother is feeling the pain while expressing milk

Image: Cross mark

|Remember, 

* Expressing breastmilk by hand should not hurt.
* If it hurts, the technique is wrong.

|-
|Image: Breast tissue

Image: Mother is rubbing fingers towards nipple.

Image: Sliding

Image: Pulling

Image: Breast soreness

|
* Breast tissue is delicate.
* Avoid rubbing, sliding or pulling the fingers along the skin, towards the nipple.
* This can cause breast soreness.

|-
|Image: Tightening or stretching the skin over areola

|Avoid tightening or stretching the skin over the dark area around the nipple.

|-
|Image: Pulling the nipple

Image: Less milk comes out when mother presses the nipple

Image: Baby is nipple-feeding

|
* Also, avoid squeezing or pulling the nipple.
* Pressing or pulling the nipple cannot express enough milk.
* It is the same as the baby sucking only the nipple.

|-
|Image: Container covered with cloth

Image: Container covered with plate

|After expressing breastmilk, the mother should cover the container with a clean cloth or plate.

|-
|Image: Container is stored safely in fridge

Image: Container is stored safely in the room

|Then, she should store her breastmilk safely for later use.

Safe storage of breastmilk and feeding stored breastmilk to the baby are explained in another tutorial. 

|-
|Image: Mother expressing breastmilk multiple times in a day

Image: Initiating and maintaining breastmilk production

Image: Milk supply in a container

Image: Low birth weight baby

Image: Sick newborn baby

Image: Mother is expressing breastmilk within 6 hours after delivery

|Let’s now discuss how often a mother should express milk.

If the purpose is to initiate and maintain breastmilk production

Or to feed a low birth weight baby or sick newborn baby, then-

* She should express milk as soon as possible after delivery.

|-
|Image: Mother is expressing few drops of colostrum

Image: Breastmilk production begins

Image: Baby breastfeeding in the delivery room in laid back hold.

|
* She may only express a few drops of '''colostrum''' at first.
* This helps breastmilk production to begin
* It acts similar to a baby suckling soon after delivery.

|-
|Image: Mother is expressing breastmilk as often as baby breastfeeds

Image: Mother is expressing breastmilk every 3 hours for 24 hours

Image: Mother is expressing breastmilk after 3 hours. Breastmilk output is low.

|
* The mother should express as much as she can
* And as often as her baby would breastfeed.
* This should be at least every 2 to 3 hours, including during the night.
* If there are long intervals between expressions, she may not be able to produce enough milk.

|-
|Image: Mother’s milk supply is increasing from 350ml to 850ml. Mother is happy.

Image: Mother’s milk supply is low 350ml. She is sad.

Image: Mother is breastfeeding the baby every 1-2 hours.

Image: Immediately after breastfeeding, mother is expressing breastmilk.

Image: Baby is sleeping for more than 3 hours.

Image: Mother is expressing milk between 2 breastfeeding sessions.

|Next, if the purpose is to build up mother’s milk supply -

And if it seems to be decreasing after a few weeks:

* She should express breastmilk every 1 to 2 hours immediately after breastfeeding the baby and
* If the baby is expected to sleep for more than 3 hours, then she can express in between feeds.

|-
|Image: Breast engorgement

Image: Leaking of breastmilk at work

Image: Mother expressing breastmilk

Image: Mother gets relief from breast engorgement

Image: Leaking of breastmilk at work stops

|If the purpose is to relieve symptoms such as engorgement, or leaking of breastmilk at work:

* The mother should express only as much as is necessary.

|-
|Image: Mother is expressing a small drop of breastmilk.

Image: Mother is rubbing the small drop of breastmilk on her nipple.

Image: Mother is bathing.

Image: Mother is breastfeeding.

|If the purpose is to keep nipple skin healthy:

* The mother should express a small drop of breastmilk to rub on her nipple.
* She should do this after a bath and after breastfeeding.

|-
|Image: Mother is working

Image: Father is feeding milk to the baby from a small cup

Image: Mother is expressing milk at work

Image: Mother is expressing milk at home

Image: Mother gives the expressed milk to father who is holding the baby

|If the purpose is to keep milk for her baby while the mother is out at work:

* The mother should express milk while at work to help keep up the supply.
* And the mother should express breastmilk before going to work
** and leave it for the carer to give to the baby.

|-
|Image: Refrigerator

Image: Expressed breastmilk stored in fridge

Image: Mother is expressing breastmilk after feeding the baby

Image: 60-90 ml expressed breastmilk

Image: Father is adding more milk than 90 ml to the container for feeding the baby

Image: Mother is at work

|For doing this -

* Mother can plan few weeks ahead if she has a fridge.
* She can express extra milk and store it for later use.
* Mother can express even after the baby has breastfed.
* Mother should leave about 60 to 90 milliliters of milk for each feed
* More breastmilk can be given as per baby’s need while mother is away.

|-
|Image: Mother is expressing breastmilk more often

Image: Mother is comfortable while expressing

Image: Milk is flowing from the tissues to the milk ducts beneath areola

Image: Mother is producing more milk 750 ml

|Remember,

* The more frequent hand expression is used-
** the easier it becomes to express milk,
** the faster the milk releases
** And the more milk mother will make.

|-
|'''Slide Number 2'''

'''Acknowledgement'''

|This brings us to the end of this tutorial.

Thank you for joining.

|}