October 2018 Newsletter: When Hand-Expressing Trumps Breast Pumps

By BMSG Editorial Team

While breast pumps might be a no-brainer purchase for working mothers when they return to work, for others, hand-expressing appears to be an easier option. We speak to three breastfeeding mothers, who are also our breastfeeding counsellors, who hand-express at work and on-the-go, doing away with the conventional breast pump.

CL Chan, a junior doctor, rushes to a toilet cubicle at the hospital she works in. She is on call and is anticipating a beep from the hospital at any time. CL, who is still breastfeeding her youngest baby, flips open a clean milk bottle and starts hand-expressing her milk. In just under ten minutes, she has a bottle filled with breast milk, which makes up one of the next day’s feeds for her baby.

For CL, a mother of three, working in a pressure-cooker environment compelled her to pick up hand-expressing as a skill. “For my first and second babies, I relied on my portable double pump, but often had difficulty finding a clean, private spot to set up my gear, put on my pump bra and start pumping,” CL added.

CL also found it cumbersome to bring along her pump with her on her rounds. “There was the added stress of dragging the pump, cooler bag and flanges around with me as I moved from ward to ward.” Feeling frustrated at having to cut short her pumping session many times due to the hectic and sudden nature of her job, CL chose to hand-express out of necessity.

Mummy CL Chan with her youngest daughter, Ellie, whom she is still breastfeeding. [Photo courtesy of CL Chan]

Convenience of hand-expressing a Strong Motivation

For Jasmine Tan, 35, being an exclusively-pumping mother for her second child triggered much exhaustion. It was her first day back at work, lugging her heavy breast pump and work bag despite on a part-time contract, that forced her to look for other options. It was not until later on, during a three-week holiday, that she decided enough was enough and figuratively threw out her breast pump in frustration.

“I didn’t want to always be stuck in the nursing room while on holiday, always having to worry about milk storage and warming it up,” said the corporate relations manager, whose baby had poor milk transfer while latching, due to a tongue tie.

As she got better at hand-expressing during the vacation, she began to realise that the convenience was the best motivation for her. “Gaining mastery at hand-expressing just before a baby’s feed did it for me; no washing, sterilising, pumping, storing, or warming was required. It was the best alternative to my baby to direct latching,” she added.

For Jasmine Tan (right), hand-expressing seemed to her to be the only viable option for her as an exclusively pumping (EP) mum. [Photo courtesy of Jasmine Tan]

Jasmine was also the only lactating mother at work and there was no nursing room at her workplace. She also had to travel frequently for work, giving her the extra push to rely on hand-expressing especially when time was tight. Jasmine also frequently thought about how mothers coped in the past. “I was always thinking what the last few generations of mothers would have done in my situation. With no pumps back then, hand-expressing came to mind,” Jasmine said.


Correct Technique Key to Maximum Output

For the uninitiated, hand-expressing may sound cumbersome. Some mothers who have attempted it may also complain of poor output the first few times. But according to Nur Hafizah Rafie, who hand-expressed her breast milk for her two children for almost four years, it helped her produce more than when she was using a breast pump.

The family researcher, who was working in an office setting previously, experimented with multiple breast pumps. From electric to manual pumps, and even single and double pumps, Hafizah found that her output from hand-expression trumped what she got when using pumps. “It took me a longer time to have a good output,” she said, adding that she got better at hand-expressing from practicing.

Hafizah has grown so adept at hand-expressing that she would complete two of her three hand-expressing sessions at her desk instead of the nursing room. This also saves her time at work. “I hand-express at my desk with just a nursing cover,” she added.

Hafizah with her two daughters, both of whom she had hand expressed for to provide them with breastmilk when she was at work. [Photo courtesy of Hafizah Rafie]

Jasmine, who did not hand-express for her first child, understands that the first few tries might be difficult especially for one who has just started out. But like the other mothers, she found practice makes perfect. “No doubt, it was at first tiring for the hands and my breasts were bruised in the initial stages as I was trying too hard. But after hand-expressing eight to ten feeds a day, over weeks and months, it just became second nature,” said Jasmine.

For CL, watching a video from Stanford University won her over to hand-expressing. “It was life-changing for me. Using their technique of placing your fingers, pushing back into the chest wall then rolling forward, hand-expression is virtually painless!”

Indeed, successful hand-expressing requires the right technique and pressure, and is often a chosen way to help new mothers provide colostrum and breast milk to newborns at the hospital. While we are inclined to assume that lots of hard pressing is required to extract milk from the breasts, it is actually the exact opposite. According to the World Health Organization (WHO), hand-expressing should be painless and comfortable. There should be no rubbing or sliding fingers along the skin, and the nipples should not be pinched. It is also recommended to switch sides a few times during each hand-expressing session until milk flow is slow from the start.


Triggering a Letdown

Similar to using a breast pump, the key to producing enough for a feed when hand-expressing is to trigger a letdown. A letdown occurs when the brain receives the necessary stimulation from the breasts to open the floodgates to express breast milk out from the milk glands in the breasts. This is always more successful when the environment and stimulation at the breast are when mothers are at their most comfortable.

For Hafizah, being relaxed is helpful. “I will make sure my chair is comfortable by using a good cushion to support my back. I drink a hot drink before I begin and then massage my breasts to prepare for hand-expressing. I also place a warm compress on my breasts to help trigger a letdown,” she said.

Fear and anxiety may hinder a letdown, so Hafizah also sometimes watches a drama while hand-expressing to keep her mind off how much milk she is making. “The thing with hand-expressing is that you can do other things like watching television without looking at the bottle. By not looking at the bottle, it prevents me from thinking about how much output I should get in one session. When I was still using a pump, I kept staring and checking the bottle to see if I have gotten enough for the session. It somehow added more stress for me instead,” said Hafizah.

Finding a comfortable spot is a proven challenge for CL as she is always on the move in the hospital. But viewing videos of her baby given to her from home helps her to achieve a letdown when she is able to get a bit more time to sit down and hand-express. “I also found being gentle and rhythmic in the initial part of a session, even if you don’t yield a significant amount, helped stimulate a letdown much like the massage mode on a pump. Once you achieve a letdown, then not much work is needed to extract the milk. Switching sides two to three times per session also helped increase my yield,” said CL.

CL took this picture for her husband on her first day being posted to work at a location away from the hospital. Despite having to sit in an empty storage room, CL is grateful for being able to hand-express as it still allows her to provide breast milk for her baby . [Photo courtesy of CL Chan]

Not a Popular Choice, Yet These Mums Won’t Choose Otherwise

All three mothers concur that people’s reactions to them hand-expressing were always one of shock and disbelief. “Many people will go on to share their extremely painful or bruising experience with hand-expressing, or comment about how tired your hands must be. But as I mentioned earlier, with the right technique to trigger a letdown, no “force” is needed to squeeze the milk out,” CL said. “Some people are just shocked. I guess it is something that my body is used to and it is faster and fuss-free for me because all I need is just a bottle and a milk storage bag,” chips Hafizah. Jasmine agrees, too, that it was not easy to begin with but became easier as time went by. “The pros definitely outweigh the cons,” she added.


Tips for Comfortable hand-expressing
(adapted from the WHO Publication Infant and Young Child Feeding – Model Chapter for textbooks):

The mother should:

  1. Have a clean, dry, wide-necked container for the expressed breast milk;
  2. Wash her hands thoroughly;
  3. Sit or stand comfortably and hold the container under her nipple and areola;
  4. Put her thumb on top of her breast and her first finger on the underside of her breast so that they are opposite each other about 4 cms from the tip of the nipple;
  5. Compress and release her breast between her finger and thumb a few times. If milk does not appear, re-position her thumb and finger a little closer or further away from the nipple and compress and release a number of times as before. This should not hurt – if it hurts, the technique is wrong. At first no milk may come, but after compressing a few times, milk starts to drip out. It may flow in streams if the oxytocin reflex is active;
  6. Compress and release all the way around her breast, with her finger and thumb the same distance from the nipple;
  7. Express each breast until the milk drips slowly;
  8. Repeat expressing from each breast 5 to 6 times;
  9. Stop expressing when milk drips slowly from the start of compression, and does not flow;
  10. Avoid rubbing or sliding her fingers along the skin;
  11. Avoid squeezing or pinching the nipple itself.

Mothers may also want to massage their breasts, stimulate their nipple, or get someone else to massage their back in order to stimulate the oxytocin reflex to kickstart a letdown.