Early establishment of breast milk supply in mothers of preterm infants; comparing hand expressing and massage within the first hour of birth to expressing in the first 6 hours.

Intervention is hand expressing and massage within one hour of birth. The education session will take approximately 30mins including education and demonstration and handing out the education materials. Massage will be taught by a lactation consultant at recruitment and undertaken by the mother within the first hour following preterm birth with the supervision of a midwife. Massage duration is 1-3 minutes prior to hand expressing. Massage steps include lifting the breast up and holding, while holding with one hand use the pads of the middle three fingers and rub in a circular motion around the entire breast so it shakes. Using same motion rub the pectoral muscle (at the top of the chest) to loosen and either side of your sternum (breast bone). Instruction for the massage and hand expression will be provided on a palm sized card for reference during massage Hand expression will be demonstrated at recruitment and the participant will demonstrate this back to the lactation consultant. The partner if available will also be educated to assist the participant. Hand expression education is as follows; Position your thumb and first two fingers about 2.5–4 cm behind the nipple. Place your thumb pad above the nipple and the finger pads below the nipple forming the letter "C". Push straight back into the chest wall. Press thumb and fingers together gently behind the nipple and then release. Repeat step two and three to establish milk flow. Rotate your thumb and finger position to milk the other ducts. Any handling of your breast should be gentle and non-painful. If discomfort occurs, move your fingers further behind the areola which should increase comfort as well as milk flow. Information handout will be given to the mothers as a reference guide. Participants will be asked to document the date and time of their first expression on an expressing log provided at recruitment, this will include an area for the participant to tick that massage was undertaken. Participants can use these techniques following the initial expression within the first hour and will document on their expressing log if they used massage or hand expression to express.