6.1 Practical skills
Baby Friendly Step 5 and Point 4
Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants .
Support mothers to initiate (establish) and maintain (exclusive) breastfeeding (to 6 months). United Kingdom, Canada, New Zealand
Inform women and their families about the management of breastfeeding and support them to establish and maintain exclusive breastfeeding to 6 months. Australia
Expressing breastmilk
All mothers are to be taught how to hand express their breastmilk. Many mothers will also have a manual or electric breast pump they intend to use and you may like to see that they know how to use it correctly too.
Hand expression is a simple, cost-free and effective method of milk removal.1,2
Hand expressing
Many mothers prefer hand expression rather than using a pump because:
- Hands are always with you, and there are no parts to lose or break.
- Hand expression can be very effective and quick when the mother is experienced.
- Some mothers prefer the skin-to-skin stimulation from hand expression rather than the feel of plastic and sound of a pump.
- Hand expression is usually gentler than a pump, particularly if the mother's nipple is sore.
- There is less risk of cross-infection since the mother does not use equipment that may be difficult to clean effectively.
- There is no cost.
Even a mother who does own a pump may have more success hand expressing
- to collect small volumes of colostrum antenatally, anticipating a postnatal medical problem, or
- to get just a few drops of milk to entice baby to latch, or
- to apply to a damaged nipple, or
- to remove just enough milk to allow her baby to latch to her engorged breast, or
- to relieve the discomfort from an engorged breast, or
- to clear a blocked duct, or
- to obtain milk for her baby who is unable to breastfeed, or
- to obtain milk for her baby when they are separated, or
- to obtain milk to pasteurize for her baby if she is HIV positive.
Hand expressing is THE most effective and least wasteful method for collecting colostrum.

Workbook Activity 6.2
Complete Activity 6.2 in your workbook.

Don't underestimate the value of hand expressing
This is important for you to know and to share with mothers who may need to be pumping for whatever reason in the weeks ahead:
Breastmilk production at week 8 postpartum is significantly increased when mothers
- hand express 5 or more times per day in the first 3 days
- combine hand expressing and pumping after secretory activation (hands-on pumping)1
How to hand express
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Preparation
- Mother should wash her hands;
- Prepare a clean wide-necked receptacle for the milk - a medicine cup, tea cup or bowl may be appropriate depending on volume expected.
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Technique
- Mother may sit or stand comfortably - possibly where she can rest her arm or lean forward slightly over the container;
- Gently massage the breasts, running hands over the nipple and areola to stimulate the milk ejection reflex;
- Position the first finger and thumb on opposite sides of the nipple, at about the edge of the areola or about 2.5cm (1") from the base of the nipple;
- Push directly back towards the chest wall, then compress the breast between finger and thumb, and follow through by moving the pressure towards the nipple without sliding the fingers on the skin of the breast;
- It may take a minute or so to stimulate the milk ejection. Milk only flows easily during a milk ejection so continue expressing while milk flow is good for approx 2-3 minutes. Colostrum is quite viscous, so be patient;
- Swap breasts and repeat. The mother may like to do this on each breast several times;
- Stop expressing when milk flow slows to drips or the goal has been achieved (eg. areola is softened enough for infant to latch, or volume needed is achieved).

Note: 1. the finger and thumb placement; 2. the pressure back towards the chest wall before, 3. compressing the breast tissue between finger and thumb.
© E.Grunis, IBCLC
Video © Australian Breastfeeding Association. Used with permission.
Pumping breastmilk
There are many different types of breastpumps available on the market. All staff must be aware of the safety issues surrounding each pump, including adequate cleaning, and its correct use. Either get other competent staff to demonstrate its use, or ask the company representative to give a short educational session for the staff.
Manual and electric pumps can be equally as effective - the mother will need to consider cost and skills required to use each piece of apparatus. For example, some manual pumps can cause wrist strain which may exacerbate carpel tunnel syndrome; other mothers prefer the versatility of carrying a manual pump to work; electric pumps are very efficient for long term expressing circumstances.

Who is best to demonstrate pump usage to mothers?
The pump company representative's job is to sell more pumps and encourage as many mothers as possible to use their pumps for as long as possible. Your role is to show a mother how to safely use a pump for only as long as it is absolutely necessary.
Do not ask the company representative to speak to mothers about their pump.

Do you assist mothers who need to pump long-term?
Watch the video linked to the title of this box. The techniques you will learn will benefit the mothers in your care. (Note also the demonstration of breast massage and compression).
Storing breastmilk for a healthy baby
If the mother is not going to use the expressed milk within the next few hours, store it safely. Glass and plastic containers with lids are suitable for use, as are breastmilk storage bags.
There should be a means of noting the time and date of expressing the breastmilk on each container. For hospital use the identity of the mother and baby should also be clearly written.
- All storage equipment will be thoroughly clean.
- Refrigerate milk that will not be used within the next few hours.
- Freeze milk that will not be used within two days.
Storing Breastmilk for a Healthy Baby 3 4 5 | |||
---|---|---|---|
Breastmilk status | Room temperature 26°C or lower | Refrigerator (5°C or lower) | Freezer |
Freshly expressed into container | 6 - 8 hours; when refrigerator available store milk there |
< 72hrs store at back where coldest |
2 weeks freezer compartment inside refrigerator (-15C); 3 months in freezer section of refrigerator with separate door (-18C); 6 - 12 months in deep freeze (-20°C or lower) |
Previously frozen; thawed in refrigerator, but not warmed | 4 hours or less; that is until the next feeding |
24 hours | Do not refreeze |
Thawed outside refrigerator in warm water | For completion of feeding | 4 hours or until next feeding | Do not refreeze |
Infant has begun feeding (ie. contact with baby's mouth) |
Only for completion of feeding | Discard | Discard |
Note: Chilled breastmilk may be safely stored at 15°C for up to 24 hours. This is the temperature maintained in an insulated container with a freezer block, eg blue ice. 6

Activity
Locate the guidelines to hand expressing and safe breastmilk storage that is provided for mothers in your Unit. Discuss this leaflet with each mother and give her a copy as she is taught this essential skill. Keep a copy of the leaflet in your Workbook.
If there are no guidelines in your Unit for hand expressing and safe breastmilk storage:
Form a small group to research and develop a suitable leaflet in conjunction with the relevant stake holders.
Using the expressed breastmilk
The order in which to use expressed breastmilk is
- First choice: All milk expressed in the first 4 days (colostrum); assures baby receives the antibody-rich colostrum as soon as possible
- Second choice: Freshly expressed milk prior to refrigeration; fresh breastmilk has the most active protective properties
- Third choice: Refrigerated breastmilk, using the oldest first; decreases the need to freeze milk, which has a greater effect on immunological properties
- Finally: Frozen breastmilk that has been stored the longest; to reduce the need to discard milk that has passed the use-by date
Skills Competency #3

Hand expressing and safe milk storage
When you have successfully completed this topic and practiced what you have learned you will be ready to do your Skills Competency. Click on the title of this box to download Hand expressing and safe milk storage competency form for you to complete with your Supervisor.
Supporting mothers who are separated from their infants
- infant or mother requiring hospitalization (eg neonatal intensive care; medical or surgical event for mother or infant)
- maternal appointments (eg dentist, solicitor, etc)
- maternal work commitments
- or perhaps just a child-free day of leisure for the mother.
Occasional separations are usually easily handled by having some breastmilk already stored in the refrigerator or freezer for the child-carer to give to the infant.
Employment and breastfeeding
An increasing number of women spend large amounts of time away from a baby or child who is still in the age range prior to earliest age of weaning ... ie the first two years. Returning to the paid workforce is the most common reason for regular separation of mother and baby, and a common reason given for premature weaning.
Leaving her baby to go to work can be a highly emotional time for the mother. Continuing to provide breastmilk can
- present many challenges, but also
- help her to maintain an emotional connection to her baby, despite her physical absence,
- avoid the acute and chronic illnesses associated with artificial infant formula, and
- make breastfeeding when they are reunited a very special, and close time.
During the prenatal period you can guide mothers by
- educating them on the value of continuing to provide breastmilk for baby, despite separation.
- discussing the issues she will need to address to be successful.
- providing her with contacts for peer-support services, to talk with other women in her situation.
- informing mothers of their right to breastfeed, and what workplace legislation will protect her right.
Enlisting her support network will assist the mother to meet her breastfeeding goals. An encompassing approach including her family, the child carer, her work colleagues and employer will provide support beneficial to continuing to provide breastmilk during periods of separation.
Prenatal preparations
There are numerous challenges mothers will face, many unique to individuals. Addressing the foreseeable challenges is best begun during pregnancy.
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Discuss with her employer
- working shorter hours each day, or less days per week, at least initially
- bringing her baby to her for breastfeeding, or her going to her baby
- a venue that will be suitable for her to use to pump, or breastfeed
- the advantages to her employer of her continuing to breastfeed, particularly that her child will suffer less illnesses, requiring her to have less absences from work
- If necessary, inform her employer of her legislated rights.
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Choosing her potential child carer
- one who has knowledge of breastmilk storage and care, and supports exclusive breastmilk-feeding for the first 6 months
- proximity to either her home, or her place of work, with possibility of going to or having baby come to her during the period
- one who has knowledge of breastmilk storage and care, and supports exclusive breastmilk-feeding for the first 6 months
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Will she need to pump her breastmilk?
- Begin researching pumps to find one that will suit her.
- Where will she keep her pumped breastmilk?
- (Don't forget to share the information about ensuring a continued good breastmilk production by hand expressing colostrum and combined hand and pump milk removal next.)
What should I remember?

- Teaching hand expression of breastmilk is an essential part of protecting, promoting and supporting breastfeeding.
- The effect of hand expressing colostrum and hands-on pumping on milk production.
- The potential circumstances that may lead to expressing of breastmilk.
- How to hand express and teach this skill to mothers.
- The safe storage times and temperatures for each breastmilk status.
- The order in which to use expressed breastmilk.
- How you can support mothers who must be separated from their infants.
- To complete the Hand Expressing competency.
Self-test quiz
Match an item from the column on the left with an item from the column on the right. Click on an item in one column, then on its matching response from the other column
Notes
- # Morton J et al. (2009) Combining hand techniques with electric pumping increases milk production in mothers of preterm infants.
- # Becker GE et al. (2011) Methods of milk expression for lactating women.
- # Academy of Breastfeeding Medicine Protocol Committee et al. (2010) ABM clinical protocol #8: human milk storage information for home use for full-term infants (original protocol March 2004; revision #1 March 2010).
- # National Health and Medical Research Council (2012) Infant Feeding Guidelines: Information for health workers
- # Slutzah M et al. (2010) Refrigerator storage of expressed human milk in the neonatal intensive care unit.
- # Hamosh M et al. (1996) Breastfeeding and the working mother: effect of time and temperature of short-term storage on proteolysis, lipolysis, and bacterial growth in milk.