Transition is by far the most challenging, although the shortest, phase of birthing. This is when you might begin to feel overwhelmed and your focus might falter. This is the phase usually depicted in the media. These contractions are stronger and longer and finish dilating the cervix. They usually last 90-120 seconds with breaks of about a minute or two in between. Generally this phase only last for 30 minutes to 2 hours. You may also experience a time distortion in this phase that makes it seem to go more quickly. You may not remember much of this period after the birth. You may feel out of focus and a bit foggy here. Nausea can also set in as well as involuntary painless shaking from the intensity. You are especially vulnerable to suggestion here, which can be used for good or evil.

Transition is the storm before the calm that is pushing. It is by far the hardest part of birthing, but also the shortest. It is here that your focus might falter. This is the stage where you may doubt your ability to birth your baby and feel like you need medications. You may feel worried about how far you have left to go and how much more intense it will become. You will be suggestible and at this time are most vulnerable to accepting interventions whether they will be helpful or not. It is at this stage that your birth companion must be vigilant to your emotional needs and be the voice of reason should a cascade of interventions be suggested.

Find hope in the fact that if you do experience these feelings, remember that this means you are almost there. Labor does not keep getting harder and harder. Once the contractions get to a certain level, they don’t get any longer/stronger. Focus on the fact that in between each wave, you feel perfectly normal. Let them do their work. In this phase your dilation will go from about 7 centimeters to 10 centimeters of full dilation and 100% effacement.

WHAT & HOW YOU MAY FEEL
Contractions that are Longer and More Intense
Nausea
Time Distortion
Hot/Cold Flashes
Uncontrollable Shaking
Intense Pressure
Rupture of Membranes
Loss of Modesty
Loss of Appetite
Irritability
Loss of Resolve
Need for Emotional Support

BEHAVIOR & ATTITUDE
Feeling Out of Control
Foggy
Averse to Distractions
Disoriented
Self-Doubt

OTHER SIGNS & SYMPTOMS
Vomiting
Rectal Pressure
Inability to Find Comfortable Positions
Unable to Talk
Difficulty Breathing

MANAGEMENT STRATEGIES

This is the time to pull out every trick in your bag. You can benefit from any and all of the relaxation techniques and comfort measures. If you at any time you say, “I can’t do this”, what you are really saying is that you need to be reminded that you can, and are, capable of birthing your baby. Bring yourself back to the present. If you begins to fear what is to come and if birthing will become more intense, then your anxiety will rise as your relaxation decreases. If you say anything along those lines, it’s a good indicator that you are almost ready for the pushing phase that usually offers much relief from the intensity of transition.

If you can actively recognize that you are in transition, you will be able to handle the phase much more comfortably because you know it will soon be over. Hold your focus on the fact that with each contraction, you are one step closer to holding your child. This stage is fast and furious and will soon be over. Time may also seem distorted which can also help you manage this piece of your birthing.

WHAT YOU MIGHT DO
Change Positions Frequently
Focus Your Mind on the Present
Use Water
Get on Hands and Knees
Remember to Breathe
Use Visualization
Focus on the Baby

WHAT YOUR Birth COMPANION MIGHT DO
Cold Compresses
Massage Techniques
Emotional Encouragement
Cue Phrases
Tell Her She’s Almost Done
Keep Her Focus on the Present
Keep Her Environment Calm and Quiet
Whisper Affirmations

This is the stage where an unsupportive care provider may undermine your efforts. Needless interventions may be suggested or even forced upon you, knowing that you cannot resist nor make good choices. The birth companion is essential at this time in preventing this from happening. If such interventions are suggested, have the birth companion start by asking why it’s being suggested, what the options are, and if the situation is an emergency. If not, then take your time to evaluate your choices.

Active labor is more intense with longer, stronger, more intense contractions that may be 3-5 minutes apart and last up to 60 seconds. This is the beginning of the serious phase, where relaxation comes into play and the birth companion’s role becomes greater. Dilation is usually from 5-7 centimeters.

Active labor is when birthing becomes more serious. As you become more serious with each contraction, relaxation and breathing become very important. Tuning out distraction and creating a positive environment will be important. You may feel the desire to have your birth companion present but may not want to be touched or bothered at this point.

WHAT & HOW YOU MAY FEEL
Contractions that are Closer Together and Require Your Attention
Need for Physical Support
Need for Emotional Support
Less Interest in Eating/Drinking
Desire for Quiet so You can Focus

BEHAVIOR & ATTITUDE
Turning Inward
More Focused
Averse to Distractions
Restlessness

OTHER SIGNS & SYMPTOMS
Bloody Show
Diarrhea
Rupture of Membranes
Increased Pressure
Lightening
Nausea

MANAGEMENT STRATEGIES

For some women, active labor is still quite comfortable. For others, it will be more intense. The best tip for this phase is observation. This becomes especially important in a hospital birth when the focus can shift from the mother to readings on a monitor. During active labor, you may want to begin timing the intervals between each contraction and their duration. Time from the beginning of one to the beginning of the next. Note how long each one lasts. Don’t become too focused on this task because you’ll learn far more from observing her behavior than from the readings on a stopwatch. If your bag of waters ruptures, note the time. You will also want to check the color of the fluid. Note whether it is clear or has a greenish tint. Amniotic fluid should be colorless and odorless, but sometimes may have a slightly sweet smell. If it is greenish in color, this is a sign that the baby has passed meconium (its first bowel movement) which can be a sign of a postdate baby or one that is in distress. It is usually only a concern if the fluid is like pea soup. However, you will want to go to the hospital for a check when your waters break.

WHAT YOU MIGHT DO
Change Positions Frequently
Take a Walk
Use Water
Start Massage Techniques
Listen to a Relaxation Script
Use Visualization
Consider the Sleep Breathing Technique

WHAT YOUR Birth COMPANION MIGHT DO
Keep You Company
Remind You to Empty Your Bladder Frequently
Encourage Positional Changes
Fill the Birth Pool or a Tub if your water has not broke
Apply Light Touch Massage or Counter Pressure
Look for Signs of Tension
Protect Your Birthing Space (Keep it Dark and Quiet)
Praise You
Whisper Encouragement or Read a Relaxation Script
Call the Care Provider for Advice on Going to the Hospital or Birth Center
Call Your Doula

I can’t stress enough that staying home as long as possible even into active labor is one of the best ways to ensure a comfortable natural birth. Just setting foot in a hospital has been shown to increase discomfort in labor by raising anxiety levels and can cause labor to slow or even stop.

Before the birth day, take a dry run to the chosen place of birth to determine travel time and potential obstacles, such as construction or weather delays. This will give you a better indicator of when you will need to leave. If it’s a two hour drive, then you’ll most likely want to leave a bit sooner than later. If you arrive at the hospital sooner than expected, some couples will even check into a hotel for a few hours rather than go to the hospital too soon. You will want to bring a towel or some chux pads in case your water breaks, and maybe even a waste basket in case you feel carsick. It’s much better to travel prepared than the alternative. Consider bringing a CD player or iPod to listen to a relaxation audio if the ride is long.

Also in advance of the birth day, ask your care provider where to park, whom to notify at the hospital and what identification you need to bring. Also ask if videotaping is allowed so you can bring equipment if desired. Be sure to keep a copy of your birth plan with you at all times.

If you are planning a hospital birth, tour the hospital before the birth day. This way, you can ask what the admission procedures are, including where you register and any forms you need to read and sign. In many cases, you are able to pre-register before the big day and obtain advance copies of any consent forms for you to peruse and alter to fit your preferences. If you arrive at the hospital in active labor, you will not want the interruption of pesky consent forms. It’s very difficult to make informed decisions while your focus is on birthing your baby. Any pertinent discussions should take place at prenatal appointments well in advance of your due month.

Early labour is the initial phase that can last hours, days or even weeks, in the case of prodromal labour. This early stage of labor can be difficult for a first-time mom to detect. It is characterized by excitement and for some women, the nesting instinct kicks in and you feel the urge to clean and prepare your surroundings for the new baby. In this phase it’s important to stay active. Try not to dwell on each contraction and refrain from even timing them if they are easily ignored and do not interfere with your daily routine. Simply acknowledge them and move on with your typical activities. One of the best tips for natural childbirth in a hospital is to stay home as long as possible.

Early labor is usually the most fun and exciting. You may wonder if this is really “it”. Other women sleep through these light contractions or go about their day without really noticing a difference.

WHAT & HOW YOU MAY FEEL
Manageable Contractions
Low Backache
Loose Stools
Bloody show or increased mucus discharge (mucus plug)
Lightening (the baby dropping into position)

BEHAVIOR & ATTITUDE
Excitement
Energy
Anticipation
Nervousness

OTHER SIGNS & SYMPTOMS
Nesting Instinct
Increased Energy
Restlessness

MANAGEMENT STRATEGIES

You really probably won’t need to pull many tricks out of your bag at this stage of early labour. The best advice is to ignore the contractions as long as you can. Just conduct business as usual. The principle of a “watched pot never boils” applies here. The more attention you draw to the process, the more anxious you can become if it doesn’t seem to move as quickly as you’d expected.

General tips include regular breathing and activity as tolerated. You might want to take a nap or have something light to eat. You most likely want to avoid getting into a birthing tub at this point since full immersion can lower the oxytocin levels in your body and slow your birthing which is not desirable at this stage.

WHAT YOU MIGHT DO
Take a Walk
Finish Packing Your Bags
Take Some Last Pregnancy Photos
Play Cards
Go to the Movies
Rent a Video
Have a Date Night and Go to Dinner

WHAT YOUR Birth COMPANION MIGHT DO
Keep her Company, if She Prefers it
Encourage her to Move Around
Massage her Back or Feet to Promote Relaxation
Time Some Contractions
Praise Her
See if There are Any Last Minute Chores to Finish

It’s important during early labour to make sure an effective birthing pattern has started. Too much stress and anxiety over this phase can prolong your labor or make it less productive as stress hormones can interfere with cervical dilation and effacement. Try to stay in the moment rather than worrying about what lies ahead. Relaxation is key throughout all the stages of birthing.

I seem to be getting quite a large collection of very good books that I would be more than happy to lend out. If you are interested in borrowing any of my materials, please call or email. I can bring what you are interested in to town for you to pick up at your convenience. I would be more than happy to discuss any of the material with you.

DVD’s and Videos

Begin with Love, The first three months: Connecting with your Child
A video that focuses on your relationship with your infant in the first three months of life. Based on the latest research in early childhood development, the video highlights five guidelines that will help all new parents create a responsive and enriching environment for their young baby - the key to helping her learn her new world.

Doulas Making a Difference
Explaining the Supports a Doula Provides.

Having Your Baby - A Complete Lamaze Prepared Childbirth Class (outdated but good breathing)
Lamaze Explained, Position and Relaxation Exercises, Stages of Labor, Actual Birth, All about Pain Medications, Comfort Measures

Comfort Measures for Childbirth with Penny Simkin
Join Penny Simkins class as she explains and demonstrates numerous physical and psychological comfort measures for labor. She will also show women in labor and their partners using these measures.

Labor of Love Childbirth Class 5 hour class in 2 segments
I a unique experience in childbirth education that prepares you for labor and delivery. Sherry Turney guides you through this comprehensive two day class.

Labor Support: A Comfort Guide
An up to date video featuring demonstrations of tried and true labor stratagies

Birth Day
A documentary exquisitely capturin gthe beauty of a natural home birth in the lush mountain countryside of Xalapa, Veracrux, Mexico

Dr. Jack Newman’s Visual Guide to Breastfeeding
This dvd helps you to understand how breastfeeding really works in a step by step comprehensive format. This aid provides evidence based, up to date information for parents and healthcare professionals.

Amazing Talents of the Newborn
For several decades, researchers have been unravelling the wonders of infant memory, perception and communication ability. What we have discovered is that the newborn - even in the first hour of life - greets the world with an array of remarkable talents.

The First Hour of LIfe - Marshall Klaus
We now know that the first hour and a half are what one calls a ’sensitive period’ for a certain number of processes to take place and for bonding to begin. This is a precious time which cannot be repeated. Learn about more evidence on this amazing subject.

Birth Into Being
Russian Spiritual Midwife, Tatyana Sargunas and her film maker husband Alexi, recorded five totally natural, incredible waterbirths. Their original footage takes you on a breathtaking expedition to witness two families birthing in the Black Sea, and into their home to see two of their daughters being born in a handmade clear birthing pool. Scenes of children and babies swimming with dolphins will delight and amaze audiences of all ages.

The Business of Being Born - Ricki Lake and Abby Epstein

Pocket Size Flip Cards

Labor Support Handbook

The Nurturing Touch at Birth: A Labor Suppport Handbook contains additional information about labor support techniques, tools and “tricks of the trade’ which offer maternity care personnel a myraid of options to offer the laboring mother.

Comfort Measures Using the Rebozo

Freedom of Movement: Positions and Stategies Cards

Books Available to Borrow

The Birth Partner A Complete Guide to Childbirth for Dads, Doulas and All other Labor Companions by Penny Simkin

Gentle Birth Choices - Barbara Harper

An Easier Childbirth - Peterson

Expecting Twins Triplets and More - Rachel Franklin

The Vaginal Birth After Cesarean Experience - Bergin and Garvey

What to Expect When you are Expecting - Eisenberg, Murkoff, and Hathaway

The book of Pregnancy (old midwives tales, quotes, superstitions etc.)

The Complete Book of Mother and Baby Care - CMA

Pregnancy, Childbirth and the Newborn - Simkin, Whalley and Keppler

The Simple Guide to Having a Baby - Whalley, Simkin, Keppler

The Mother of All Pregnancy Books - Ann Douglas - Canadian Version

Your Pregnancy and Newborn Journey - Lindsay/Brunelli

The Complete Book of Pregnancy and Childbirth - Sheila Kitzinger

The Doula Book - Klaus, Kennell, and Klaus

The Doula Advantage - Guervich

Your Amazing Newborn - Marshall Klaus, Phyliss Klaus

Mother Massage- Handbook for Relieving Discomforts in Pregnancy

Dr. Jack Newmans Guide to Breastfeeding - Dr. Jack Newman and Teresa Pitman

The Nursing Mother’s Companion - Kathleen Huggins

Blessingways - A Guide to Mother Centered Baby Showers - Maser

Massage and Aromatherapy

Medications Used for Pain During Labor and Birth - Penny Simkin

American Journal of Obstetrics and Gynecology

Ina May Gaskins Guide to Childbirth

Spiritual Midwifery - Ina May Gaskin

Roots of Emphathy -Changing the World Child by Child

Teach only Love - Gerald Jampolsky

The Red Tent: A Novel

The Birth House: A Novel

Yoga for Pregnancy

This method, developed by the French obstetrician Ferdinand Lamaze, has been used in the United States since the late ’50s and remains one of the most commonly taught childbirth classes. In the early days, the focus was on using controlled breathing techniques to cope with labor. But the vision of Lamaze educators has expanded a lot since then.

According to Lamaze International, the goal of Lamaze classes is to “increase women’s confidence in their ability to give birth.” Toward that end, women learn various simple coping strategies, of which breathing is only one. The classes aim to help women “learn how to respond to pain in ways that both facilitate labor and increase comfort.”

The Lamaze philosophy of birth stipulates that “birth is normal, natural, and healthy” and that “women have a right to give birth free from routine medical interventions.” But Lamaze courses typically don’t take a hard line against pain relief medication during labor. The curriculum emphasizes giving women the information and tools to feel confident about giving birth and empowered to give true informed consent about medications and other interventions.

What should I expect in a Lamaze course?
The typical Lamaze class consists of at least 12 hours of instruction and includes no more than 12 couples.

Here’s what the class covers:

• Normal labor, birth, and the early postpartum period (using videos of real births)

• How to be active and informed participants during childbirth

• Focused breathing techniques for labor

• Other relaxation techniques and natural strategies to help you work with labor pain, such as massage, walking, position changes, and hydrotherapy

• Tips to help your partner be encouraging and supportive during labor

• The value of one-on-one professional support during labor

• How to communicate with your healthcare team so your needs are met

• Complications that could arise during labor and birth, and interventions that might be medically necessary

• Epidurals and other options for managing pain with medication

• Early interaction with your baby

• Breastfeeding

Hypnobirthing is the use of hypnosis to achieve complete relaxation, comfort, and relief during vaginal childbirth. It’s important to note that hypnosis really refers to deep relaxation. It feels similar to daydreaming, or the feeling you get when you are lost in a book or movie. Women who’ve used this technique report feeling relaxed, calm, aware, and in control.

Hypnobirthing was founded on the work of Dr. Grantly Dick-Read, an English doctor. He wrote of his experiences as an obstetrician, specifically when he was called to a delivery in the middle of a rainy night. He arrived at the house to find the laboring woman alone in a rickety shack, the rain from the leaky roof dripping on her as she lay on the makeshift bed. He assisted her throughout her delivery, awed that she never cried out in pain nor requested medications. After the birth, he then asked her if she needed anything for the pain. She simply gazed at him and inquired, “Was it supposed to hurt?”

This question was to change his life. He went on to author Childbirth without Fear in 1944, where he detailed these experiences and his revelations on childbirth, specifically the Fear-Tension-Pain syndrome which he theorized causes the pain of vaginal childbirth by diverting necessary blood flow from the uterus and by inhibiting the body from effectively using contractions to guide the baby down and out the birth path.

He theorized that using deep relaxation such as in hypnosis, this “Fear-Tension-Pain” cycle could be broken, thus enabling women to give birth naturally without pain.

His work developed into Hypnobirthing, which was founded by Marie F. Mongan, affectionately known as “Mickey”. Her book, Hypnobirthing: The Breakthrough Natural Approach to Safer, Easier, More Comfortable Birthing - The Mongan Method, 3rd Edition , (wheh, what a mouthful!) is my all-time favorite childbirth book. It is a concise book that is well-written and engaging. A huge benefit of this method is that classes are not required. You can order the book and audio CDs to learn via self-study. I think the course is highly beneficial but this is a viable alternative if a certified instructor is not available in your area.

How Does it Work?
Hypnobirthing uses relaxation scripts, positive affirmations, visualizations and mental imagery to teach a woman to relax her body, guide her thoughts, and control her breathing. This can be self-directed or with the support of a labor companion, class instructor, or hypnotherapist.

What is The Bradley Method®?
The Bradley Method® teaches natural childbirth and views birth as a natural process. It is our belief that most women with proper education, preparation, and the help of a loving and supportive coach can be taught to give birth naturally. The Bradley Method® is a system of natural labor techniques in which a woman and her coach play an active part. It is a simple method of increasing self-awareness, teaching a woman how to deal with the stress of labor by tuning in to her own body. The Bradley Method® encourages mothers to trust their bodies using natural breathing, relaxation, nutrition, exercise, and education.

How is The Bradley Method® Unique?
1. The Bradley Method® teaches couples ways to stay low risk. While occasionally there are risk factors out of your control, staying healthy and low risk can help to avoid complications. Low risk mothers have more choices.
2. Relaxation is the Key to The Bradley Method® during labor. It is the safest and most effective way to reduce unnecessary pain and to handle any pain that you do experience. While other methods seek to control the sensations of labor (emphasizing distraction as their Primary labor control technique), The Bradley Method® encourages mothers to trust their bodies (emphasizing relaxed abdominal breathing and relaxation throughout labor).
3. The term Bradley® is a registered trademark to ensure you are getting quality childbirth education. All Bradley® instructors are highly trained to help you learn how to give birth.

Why Natural Childbirth?
The kind of pregnancy, labor, and birth our children experience has a profound and lifelong effect on their health, including their mental, emotional, and physical health. The Bradley Method® attempts to give babies the best possible start in life by teaching how to have a natural pregnancy and a natural childbirth.

Why should I choose a Bradley® Instructor?
Your local Bradley Method® instructor is a professional trained to help pregnant couples obtain the birth experience the desire. Bradley® instructors are experts in the field of natural childbirth. All Bradley® instructors have gone through intensive training with the American Academy of Husband-Coached Childbirth® and are required to re-affiliate each year in order to continue teaching The Bradley Method®. The American Academy of Husband-Coached Childbirth® is proud of its affiliated teachers for their personal attention and outstanding success in training natural childbirth students.

How much do classes cost?
The cost of Bradley® Classes varies depending on individual teachers and the area in which the classes are offered.

When should I start?
Healthy nutrition, appropriate exercise, and pregnancy information can be of benefit throughout the entire pregnancy. For most couples, the fifth month is the suggested time to begin a Bradley® class series as they seriously start training for labor and for their upcoming role as parents. The earlier you start, the better prepared you’ll be physically, emotionally, and mentally. In many areas, early pregnancy classes are also offered.

How long are classes?
A Bradley® class series is 12 weeks and is designed to give both mother and coach adequate preparation time for the birth of their child. Labor can be a strenuous physical activity, but mothers and coaches can prepare both physically and mentally and with the help of their Bradley® Instructor to make their birth experience an even more beautiful and joyous event.

What does The Bradley Method® Teach?

1. Natural childbirth - Nearly 90% of Bradley® moms having vaginal births do so without pain medication.
2. Active participation by the husband as coach.
3. Excellent nutrition (the foundation of a healthy pregnancy and baby).
4. Avoidance of drugs during pregnancy, birth, and breastfeeding, unless absolutely necessary. No drug has been proven safe for an unborn baby.
5. Training: “Early Bird” classes followed by weekly classes starting in the 5th month and continuing until the birth.
6. Relaxation and NATURAL breathing - can be effective pain management techniques with training according to the National Institutes of Health.
7. “Tuning-in” to your own body and trusting the natural process.
8. Immediate and continuous contact with your new baby.
9. Breastfeeding, beginning at birth provides immunities and nutrition.
10. Consumerism and positive communications.
Parents taking responsibility for the safety of the birth place, procedures, attendants, and emergency back-up.
Parents being prepared for unexpected situations such as emergency childbirth and cesarean section.

Are there any books I should read before I start?
There are numerous good books on childbirth and pregnancy at your local bookstore, library, or even on-line. Books that we have found helpful and recommend include:
Husband-Coached Childbirth by Robert A. Bradley, M.D.
Natural Childbirth The Bradley ® Way by Susan Mc Cutcheon, AAHCC
The Womanly Art of Breastfeeding distributed by La Leche League International
The Thinking Woman’s Guide to a Better Birth by Henci Goer
Sweet Dreams - A Pediatrician’s Secrets by Dr. Paul Fleiss, M.D., M.P.H., F.A.A.P.
Children at Birth by Marjie and Jay Hathaway, AAHCC * Currently Being Revised - Available at some local libraries

Located at the Old Mill Plaza between Fields and the Liquer Store

Free Programs for birth to six years

Family Place Drop In and Play, Mom and Tots Program

Monday to Friday 10am to 12:30pm 

Mothergoose

Mondays from 10am to 11am

Kids Cafe

Fridays 11am to 12:30pm

Art Classes

Saturdays by Donation $2-$3

Ages 5-8 10am to 11am

Ages 9 - 18  11am to 1pm

Belly Dancing

Mondays from 4:45pm to 5:30pm

Infant Massage

Infants 0 - 12months Register for programming at 250-256-7877

Many women are under the impression that it is necessary to own or use a pump to breastfeed.  This is not so.   You do not need a breast pump to breastfeed; uninformed use of a breast pump can lead to premature weaning. There are very few circumstances under which it is necessary to express your milk.  Certainly, if baby is not yet latching then mother needs to pump.  However, it seems that women are being encouraged to pump their milk and give it to baby via bottle for the most unnecessary reasons: Weddings, doctor’s appointments, shopping…why not take the baby with you?  How can babies not be welcome at weddings?  Or, if it is necessary to leave the baby with someone else, why not use a cup (handout Finger and Cup Feeding)?   We often hear that the father or partner would like to feed the baby.  While this is very noble and often offered to give mother some rest, there are other ways partners can help.  Giving a baby a bottle is not one of them and may often interfere with mother’s hard-earned efforts to breastfeed.  Fathers and partners can help mother by sitting with her during the feeding, doing breast compressions to help the feedings be more efficient, and cup feeding the baby who does not yet latch.   

The pump should not replace the baby as mother and baby receive numerous benefits in addition to nutrition by breastfeeding.   There is more to breastfeeding than the breastmilk.  Do note, a pump is not as efficient as a well-latched baby and so a baby who breastfeeds well is the best pump, but, granted, some babies don’t breastfeed well.   

¨       Obviously, if you can pump a lot, you are producing a lot, but if you cannot pump a lot, this does not mean your milk production is low.  Do not pump to find out how much you are producing.  This is an inefficient way to judge milk supply and often results in emptier breasts for baby to feed.

¨       The most effective artificial pumps are high-powered, double, electric, and hospital-grade with adjustable pressure/suction and speed. There are many pumps on the market that are just not very good.   Some hand pumps are adequate for occasional pumping.

¨       Hand expression can be very effective and certainly is the least expensive. See below.

¨       Improper use of a breast pump can lead to problems. Read all instructions thoroughly.

¨       It is important that milk be expressed and/or pumped after the feed as the breasts should be as full as possible for the baby’s feeding.  Babies respond to fast flow (see Handouts Protocol to Satisfy Baby and Breast Compression), and pumping before the feed will reduce the amount of milk in the breast. 

Pumping method

¨       Pump immediately after the feed–waiting an hour or so decreases the likelihood the breast will be full as possible for the next feed.

¨       Wash your hands

¨       Place nipple in the center of the flange (unlike nipple placement in baby’s mouth, which should always be off-centre and pointed toward the roof of baby’s mouth (see Handout When Latching). 

¨       Put the pump on the lowest setting that extracts milk, not the highest setting you can tolerate.

¨       Pump for a maximum of 15 minutes each side.  If breasts run “dry” before 15 minutes is up, pump until dry then add 2 minutes.

¨       Remember, pumping should not hurt.   If it hurts:

o   Lower the suction setting

o   Ensure the nipple is centered in the flange

o   Pump for a shorter period of time

Cleaning the pump

¨       All pumping equipment should be sterilized before first usage, thereafter it only requires washing with hot, soapy, water or by dishwasher.

¨       After each pumping: either place the pumping kit (not the tubes or motor) in the refrigerator until the next pumping, or if not pumping the same day, hot-water wash and hot-water rinse well, then air dry.

¨       Remember to take apart all pieces of the pump for cleaning—including the smallest pieces, and to ensure that no milk has clumped in the flange shaft. 

Hand expression

            Many women find that hand expression is an efficient way to pump when only occasional expression is required.   In fact, when colostrum is present and the milk production is not abundant (as in the first few days); it is often easier to get milk with hand expression than with a pump and many women find this the easiest way to express mature milk as well.

¨       Wash your hands

¨       Place thumb and index finger on either side of the nipple, about 3 to 5 cm (1-2 inches) back from the nipple. 

¨       Press gently inward toward the rib cage 

¨       Roll fingers together in a slight downward motion

¨       Repeat all around the nipple if desired 

Breastmilk storage

Unlike formula, breast milk is anti-infective, antibacterial, antifungal, and antiviral.

¨       Breastmilk will stay good:

o   At room temperature for up to 8-12 hours.

o   In the fridge for up to 8-11 days.

o   In the freezer, at the back, for many months.

o   In a deep freeze for much longer

Get used to the taste and smell of breast milk so you’ll always know if it is good.

¨       Due to the high fat content of breastmilk, storage of any kind will produce a separation in the liquid.  This is normal; a gentle mixing will give it a homogeneous look once more.

¨       Breastmilk may taste different after freezing; this is normal

¨       Never heat breastmilk in the microwave.

¨       Babies will often take cold milk, but if heating is desired, or if milk needs to be defrosted, place container or bag of milk in a cup of warm water for a minute or two. 

Encouraging the M.E.R. (milk ejection reflex) or “let down”

                  The Milk Ejection Reflex or “let down” is the sudden rushing down of the milk.  It begins to flow quickly and may do so whether baby is on the breast or not.  May women do not feel their M.E.R. and this is normal.   You do not need to feel or be aware of the milk ejection reflex in order to make milk.  Some women may feel thirsty, sweaty, sleepy, or dizzy during a let down.  However, many women do not feel this milk ejection response ever in their whole breastfeeding experience.  Some women only become aware of it after the first few weeks.  This has absolutely no bearing on milk supply. 

If your baby is not present, you can encourage the “let down” reflex artificially by thinking about having your baby in your arms or at your breast, or having a picture of your baby to look at, or keeping a piece of his clothing next to you. 

¨       Wash your hands

¨       Apply a warm wet cloth to your breasts.

¨       Massage the breasts in small circular motions around the perimeter of the breast.

¨       Gently stroke your breasts with your fingernails in a downward motion toward the nipple

¨       Lean forward and gently shake the breasts.

¨       Gently roll the nipple between your finger and thumb. 

You may feel the milk ejection reflex or notice your breasts leaking or you may not.  You are likely to pump more milk faster if you pump both breasts at the same time. Breast compressions, while pumping, can be very effective at increasing the amount expressed, it may be a bit awkward at first, but it can be done (mothers have fixed the cups so that they sit inside the bra and then use compressions) or the partner can do it. 

Questions? Email Jack Newman at drjacknewman@sympatico.ca, or Edith Kernerman at breastfeeding@sympatico.ca or consult: Dr. Jack Newman’s Guide to Breastfeeding (called The Ultimate Breastfeeding Book of Answers in the USA) or our DVD, Dr. Jack Newman’s Visual Guide to Breastfeeding; or The Latch Book and Other Keys to Breastfeeding Success; or L-eat Latch & Transfer Tool, or the GamePlan for Protecting and Supporting Breastfeeding in the First 24 Hours of Life and Beyond.  See our website at www.drjacknewman.com.  To make an appointment email breastfeeding@ccnm.edu and respond to the auto reply or call 416-498-0002. 

Handout. Expressing Milk, Revised May 2008
Written by Edith Kernerman, 2005
Revised by Edith Kernerman, IBCLC, and Jack Newman, MD, FRCPC © 2008

 This handout may be copied and distributed without further permission,
on the condition that  it is not used in any context that violates
the International WHO Code on The Marketing of Breastmilk Substitutes

Mastitis is a bacterial infection of the breast that usually occurs in breastfeeding mothers. However, it can occur in women who are not breastfeeding or pregnant, and can occur even in small babies of either sex. Nobody knows exactly why some women get mastitis and others do not. Bacteria may gain access to the breast through a crack or sore in the nipple, but women without sore nipples also get mastitis, and most women with cracks in the nipple do not. 

            Mastitis needs to be differentiated from a plugged or blocked duct, because a plugged or blocked duct does not need treatment with antibiotics, whereas mastitis often, but not always, requires treatment with antibiotics.  A blocked duct presents as a painful, swollen, firm mass in the breast. The skin overlying the blocked duct is often quite red, similar to what happens during mastitis, but less intense. Mastitis is usually also associated with fever and more intense pain as well. However, it is not always easy to distinguish between a mild mastitis and a severe blocked duct. Both are associated with a painful lump in the breast.  Without a lump in the breast, one cannot make a diagnosis of mastitis or a blocked duct. It is suggested that a blocked duct can, apparently, go on to become mastitis. In France, physicians also recognize something they call lymphangite that is fever associated with skin which is hot and red, but there is no underlying painful mass. They do not believe this requires treatment with antibiotics. I have seen a few cases that fit this description in my practice, and indeed, the problem resolves without antibiotics. But then, often a full-blown mastitis also resolves without antibiotics. 

            As with almost all breastfeeding problems, a poor latch, and thus, poor draining of the breast sets up the situation where mastitis is more likely to occur. 

Blocked Ducts

            Blocked ducts will almost always resolve spontaneously within 24 to 48 hours after onset, even without any treatment at all. During the time the block is present, the baby may be fussy when nursing on that side, as milk flow may be slower than usual, probably due to pressure causing collapse of other ducts.  Blocked ducts can be made to resolve more quickly by: 

1.       Continuing breastfeeding on the affected side and draining the affected area better. One way of doing this is to position the baby so his chin “points” to the area of hardness. Thus if the blocked duct is in the outside, lower area of your breast (about 4 o’clock), the football hold would be best.  Another way of achieving better draining of the breast is using breast compressions while the baby is feeding, getting your hand around the blocked duct and using steady pressure as the baby sucks (See handout Breast Compressions). 

2.       Applying heat to the affected area (with a heating pad or hot water bottle, but be careful not to injure your skin by using too much heat for too long a period of time). 

3.       Trying to rest. (Not always easy, but take the baby to bed with you.) 

4.       Bleb or Blister: If the blocked duct is associated with a small blister on the end of the nipple, you can open it with a sterile needle.  A bleb or blister without a painful lump in the breast is not considered to be a blocked duct. Flame a sewing needle or a pin, let it cool off, and puncture the blister. No need to dig around. Just pop the top or side of the blister. Sometimes you can squeeze out a little toothpaste like material from the duct and the duct will immediately unblock.  Or, put the baby to the breast and he may unblock it for you. Opening the blister has the added benefit of decreasing nipple pain, even if the blocked duct does not immediately resolve. Come to the clinic if you cannot do it yourself. 

5.       Ultrasound: If a blocked duct has not settled within 48 hours (unusual), therapeutic ultrasound often works. This can be arranged at a neighbourhood physiotherapy office or sports medicine clinic. Many ultrasound therapists are not aware of this use for ultrasound.  If two treatments on two consecutive days have not worked, there is no point in continuing with ultrasound. Get the blocked duct re-evaluated at the clinic or by your own physician.  Usually, however, if ultrasound is going to work, one treatment is all that is needed.  Ultrasound also seems to prevent recurrent blocked ducts that always occur in the same part of the breast.

The dose is: 2 watts/cm², continuous, for five minutes to the affected area, once daily for up to two doses. 

6.       Lecithin is a food supplement that seems to help some mothers prevent blocked ducts.  It may do this by decreasing the viscosity (stickiness) of the milk, by increasing the percentage of polyunsaturated fatty acids in the milk.  It is safe, inexpensive, and seems to work in some cases.  The dose is 1200 mg four times a day.   

Mastitis 

1.       At the onset of symptoms, mother should get to bed quickly. Rest helps fight off infection.  

2.       Continue breastfeeding, unless it is just too painful to do so. If you cannot, at least express your milk as best you can in the meantime. Restart breastfeeding as soon as you are up to it, the sooner the better.  Continuing breastfeeding helps mastitis to resolve more quickly. There is no danger for the baby. 

3.       Heat (hot water bottle or heating pad) applied to the affected area helps healing. 

4.       Fever helps fight off infection. Treat fever if it makes you feel terrible, not just because it is there. 

5.       Within the first 24 hours of symptoms, you may find that applying raw potatoes to the breast, in slices, to be very helpful in reducing the pain and the swelling and redness of the infection.  Many mothers have reported that this is extremely effective, works quickly, and often eliminates the need for further treatment.

·         Cut 6-8 washed, raw potatoes (preferably lengthwise) into thin slices, approximately 1/8” to ¼” thick.  Place in a large bowl of water (room temp.) and leave out.

·         Apply wet potato slices to breast and affected areas.  Leave in place for 15-20 min.

·         Remove and discard used slices.  They should feel hot and softened. Apply fresh slices from bowl. 

·         Repeat process two more times, totalling approximately 3 applications per hour.  Take a 20-30 minute break and then repeat procedure. Adapted from Bridget Lynch, Community Midwives of Toronto  

6.       If symptoms have been consistent for less than 24 hours, we would give mother a prescription, but suggest she hold off starting the medication.  See below. 

7.       If, over the next 8-12 hours, her symptoms are worsening (more pain, more spreading of the redness, enlargement of the hardened area), then the mother should start the antibiotics.  

8.       If, over the next 24 hours, the mother has not worsened, but not improved, she should start the antibiotics.  

9.       If the mother has symptoms consistent with mastitis for more than 24 hours, she should start antibiotics.  

10.   However, if symptoms are starting to decrease, there is no need to start the antibiotics. The symptoms usually will continue to resolve and will have disappeared over the next 2 to 5 days. Fever will usually be gone within 24 hours, the pain within 24 to 48 hours, and the breast hardness within the next few days. The redness may remain for a week or longer or disappear more rapidly than the lump in the breast. Once improvement begins, with or without antibiotics, it should continue. If the course of your mastitis does not follow this pattern, contact the clinic. 

11.   Note: Amoxicillin, plain penicillin, and some other antibiotics often prescribed for mastitis are usually useless for mastitis. If you need an antibiotic, it must be effective against Staphylococcus aureus.  Effective for this bacterium are: cephalexin, cloxacillin, flucloxacillin, amoxicillin-clavulinic acid, clindamycin and ciprofloxacin.  The last two are effective for mothers allergic to penicillin. You can and should continue breastfeeding while taking these medications. 

12.   Medication (ibuprofen, acetaminophen, others) for pain may help. You will feel better and the amount that gets to the baby is insignificant.  Acetaminophen is probably less useful as it does not have an anti-inflammatory effect. 

Abscess: An abscess occasionally complicates mastitis.  You do not have to stop breastfeeding, nor should you, not even on the affected side.  In the past, an abscess was almost always drained surgically.  Now, more and more, repeated needle aspiration or drainage under radiographic control is done, and interferes less with breastfeeding.  If you need surgery, the incision should be kept as far away as possible from the areola.  Contact the clinic. 

A lump which isn’t going away:  If you have a lump that is not going away or getting smaller over more than a couple of weeks, you should be seen by a breastfeeding-friendly physician or surgeon.  You don’t have to stop breastfeeding to get a breast lump investigated (Ultrasound, mammogram, and even biopsy do not require you to stop breastfeeding even on the affected side).  A breastfeeding friendly surgeon will not tell you that you must stop breastfeeding before s/he can do tests for a breast lump. 

Questions? Email Jack Newman at drjacknewman@sympatico.ca or Edith Kernerman at breastfeeding@sympatico.ca or consult: Dr. Jack Newman’s Guide to Breastfeeding (called The Ultimate Breastfeeding Book of Answers in the USA) or our DVD, Dr. Jack Newman’s Visual Guide to Breastfeeding; or The Latch Book and Other Keys to Breastfeeding Success; or L-eat Latch & Transfer Tool, or the GamePlan for Protecting and Supporting Breastfeeding in the First 24 Hours of Life and Beyond.  See our website at www.drjacknewman.com.  To make an appointment email breastfeeding@ccnm.edu and respond to the auto reply or call 416-498-0002.

Handout Blocked Ducts ad Mastitis Revised May 2008
Written and Revised by Jack Newman, MD, FRCPC 1995-2005
Revised by Edith Kernerman, IBCLC, and Jack Newman, MD, FRCPC © 2008 

This handout may be copied and distributed without further permission,
On the condition that it is not used in any context that violates
The International WHO Code on the Marketing of Breastmilk Substitutes