Verity prepares to use the gestalt method with 25-day-old Riku (conditioned dialling up, positional instability): steps 3 & 4

Disclaimer: the case below is an amalgam of multiple cases that have presented to me, and is not derived from any specific or identifiable mother-baby pair who have seen me as patients. Needless to say, all names are fictional.

Verity and her newborn prepare to experiment with the gestalt method

Riku has had difficulty coming on to the breast from birth due to positional instability, and has now developed a conditioned dialling up at the breast, too.

In this article, I tell you what Verity, baby Riku and I did in our consultation together after I'd properly assessed their situation and worked out what was going on. We discussed using the gestalt method first, step by step, since Riku was very sensitive at the breast and I wanted Verity to be ready before she tried bringing him on. Here we deal with steps 3 & 4.

Step 3. Turn on your baby’s breastfeeding reflexes

Hiromi continues to hold Riku, changing arms when the baby begins to dial up a little, which works to dial him down again. I continue sharing as much information as I can in our consultation, before Verity and I try Riku at the breast together. I use my doll to illustrate.

"There are three ways we switch on your baby’s breastfeeding reflexes. You know the concept of ‘baby-led’ or ‘laid-back’ breastfeeding? You were saying the midwives and lactation consultants had you trying these? Well, we are using these same principles."

Have the baby’s chest and tummy flat against you

"Firstly, have Riku's chest and tummy flat against you, which is easy when you’re in a deck-chair position. That means gravity pulls Riku into you, and you don’t have to hold his weight. Lie him tummy and chest flat across your body in a cradle hold, with his face buried into your breast above the nipple and areolar, and your forearm supporting his head."

"Because we don’t want to put strain on your wrist, you might find when you support his head with your forearm that your hand is sitting out in a relaxed, neutral position. It feels a bit weird but this is a normal position. The most important thing is that your forearm is a lever under the baby’s head that gives you control over the way he buries into the breast."

Baby’s hands are bare and pat and embrace the breast

"Secondly, we want his bare little hands embracing your breast and body, never between your and your baby’s bodies. Having Riku falling against you with chest and tummy held flat against you by gravity means that those the little hands and arms can’t get in between him and you, which would create breast tissue drag."

Start with a face-plant on upper half of breast above the nipple and areola

And thirdly, pressure on Riku's chin and lower lip will powerfully switch on his breastfeeding reflexes, and will trigger his mouth to open.

I tell Verity: "Often women hold the little one away from the breast, baby's face hovering over the nipple and areola as the woman tries to get a wide gape or line up nipple to nose, the way she’s been told. But the baby can’t get oriented without direct face contact on the breast."

"You switch on his breastfeeding reflexes by having his little face bury into your breast as a face plant above your nipple and areola, his head resting on your forearm." I illustrate all of this sitting semi-reclined in my chair, using the doll.

"As soon as the little face smooshes into your breast, he’ll start to work out where he is and his mouth will open reflexly. Then you use your forearm to help drop him down as he begins to bob and seek with his mouth and fall towards your nipple. Then it’s just mouth over your nipple and on, in whatever way works."

"It’s normal for babies to come on shallowly, and this doesn’t matter. Don’t worry about nipple to nose, or waiting for a wide gape, or trying to check that the baby’s tongue is over the lower gum, or taking the baby off to try again if he comes on shallow. None of that helps, and can often make things worse."

The ribcage wrap

This photo above illustrates a mother breastfeeding semi-reclined, with a soft squashy pillow in the small of her back and the baby in a rib-cage wrap.

"Riku is a newborn, and so we aim for a snug ribcage wrap. That means, we’ll actually lift your other breast, the one you’re not feeding from, and tuck him up around your ribcage under that breast, and then let your breast actually rest upon his little body. This may seem weird at first, but it seriously helps with the biomechanics of him coming on to the breast!" I explain.

"Some women tuck a breast pad under the nipple that is resting on him, to protect him from the letdown! Once he is bigger, he won’t be able to wrap around your side, and he’ll spread out further down the couch and be more diagonal across your body, but right now the ribcage wrap will really help."

This woman and her baby may benefit from a true rib-cage wrap, if she is dealing with breastfeeding problems. She would lift her right breast and tuck the baby right up under it, allowing her right breast to rest upon the baby's hip and body.

Create a paddle-hand and apply gentle pressure between the baby’s shoulder blades

"A paddle hand between his shoulder blades also really helps secure him." I show Verity what I mean, holding my hand out straight with the fingers closed, like a paddle. "You won’t need to carry any of his weight, because he is falling in against you in the semi-reclined position, but the paddle hand over the back of his heart turns on his ‘core stability’ and helps secure him against you. It helps tilt his head back a little, too."

"Then - what matters is what you do next! It doesn't matter how deep or shallow Riku comes on to the nipple."

Often, at this point – if we haven’t needed to start feeding before, because the baby is dialling up – we’ll be working together. I’ll illustrate the micromovements collaboratively with the woman, inviting her to let me take the weight of her forearm as we experiment with micromovements together.

But when a baby has a conditioned dialing up, like Riku, we need to be ready to give breastfeeding our very best shot within a short period of time, because of the baby’s sensitivity. So I do as sharing of information beforehand as possible, using photos, videos, my knitted breast, and my doll.

The mother above is semi-reclined and applying a paddle-hand to stabilise the baby, with a rib-cage wrap. She is using her right forearm to control the baby’s face-breast bury and micro-movements, and her left hand is sitting out in a relaxed neutral position. She has a firm pillow under the elbow supporting her.

Step 4: The power of micro-movements

I continue to sit in my own office chair, semi-reclined as I use the doll to demonstrate.

"We tuck the baby’s bottom and hips right up high under your other breast, wrapped around your lower ribcage. Then use tiny, millimeter by millimeter movements of your forearm to help the baby’s face bury deeply and symmetrically into the breast without breast tissue drag."

"We tune into the sensations of your nipple and breast, and find the place that feels exactly right, with a deep drawing sensation but no unpleasant rubbing or pain. If you had pain, we’d be thinking: where is that on the pain scale? Then make a little micromovement and ask: is that better or is that worse?"

"But our problem here with Riku is not pain but a little one who is dialled up because he can’t get stable. We’ll deal with the conditioned dialling up later, as that needs special help, but the very first thing to deal with is his positional stability. When Riku is stable at the breast, he will stop fussing and backarching."

"These adjustments, the movements you make once the baby is on and suckling, are 'micro,' just one or two millimetres at a time. This is important because when I ask women to make a movement to adjust the fit and hold, they might be more likely to move the baby a few centimetres! Micromovements are surprisingly subtle, but very effective." I pause and laugh.

"Is this making sense? I’m doing a lot of talking!"

"No, it’s all good. It makes sense," Verity says. "Really different to what everyone else has said, but it makes sense."

"There are three directions to make micromovements," I continue. "The forearm is your lever – the forearm gives you control over your baby’s head, and how the little face buries into your breast."

Vertical micromovements

"The most common direction of breast tissue drag is downwards: baby is held too high relative to where the breast and nipple naturally want to fall with gravity."

I show with the doll and the knitted breast how bringing baby on with a deep face-breast bury can also mean we accidentally lift the whole breast up at the same time.

"This means that the breast tissue is falling down with gravity in the baby’s mouth, in tension with the vacuum from baby’s jaw drop. This causes baby to fuss or pull off, and can also cause pain for some women."

Then, I explain to Verity: "The forearm under Riku’s head gives you control over verticality. Is baby more stable or is there less pain if I drop lower, then lower, millimetre by millimetre? Sometimes a woman needs to bring her baby higher, but by far the most common problem is that baby is too high relative to her breastfall."

Horizontal micromovement

It is also very common to have the baby dragging the breast tissue too far off to the side. The arms of chairs can worsen this, as the baby kicks off the opposite chair-arm, and being ‘too far around the corner’ can commonly emerge as a problem as the baby grows and becomes longer. That is because women still hold the baby across their body as they did when she was smaller – and the feeds grow more and more fussy, or more and more painful, as the baby drags the breast tissue off to the side to feed. But the weight of the breast is being pulled by gravity more towards the midline, where it naturally wants to fall.

Sometimes, however, baby is dragging the breast too far towards the midline, still causing fussiness at the breast, or nipple pain.

I say to Verity: "You use tiny horizontal movements to bring Riku across your body either towards his feet, or in the direction of his nose. Millimetre by millimetre in one direction, asking yourself is that better or is that worse, is that better or is that worse."

Angle control micromovements

"Finally, your forearm gives you angle control," I say to Verity. "If we're needing to have breast tissue drawn up into his mouth without any breast tissue drag, we need to work out the angle at which the Riku's face comes into the breast."

Again, I’m illustrating with the doll. I hold the doll’s face into the knitted breast and show Verity what symmetrical and asymmetrical buries look like.

"We want to get both cheeks equally buried into the breast tissue. Your forearm may need to be towards the back of Riku's head, not tight up against his neck, so that you are able to control the angle with which he comes onto your breast."

The baby in the photo above has a lovely face-breast bury, visible from the side. The woman’s elbow is supported.

How will Verity know that Riku is stable at the breast?

"How will I know that it's working?" Verity asks, uncertainly.

"I know this can all seem too much at the moment, but as you experiment it'll all make much better sense. There are three ways you’ll know that Riku is stable."

"Firstly, from what you can see, although often women can’t see much and do it by feel. But we’re aiming to see a symmetrical face-breast bury from the side, and lovely deep bury into the breast from above, and the straight spine from the frontal view." I hold up large laminated photos to illustrate.

"Secondly, you’ll know he is stable from his behaviour. He’ll be deeply relaxed and content at the breast, suckling without fussing, grizzling, back-arching or pulling off."

"And thirdly, you’ll be at zero on the painscale of zero to ten. A lovely deep drawing sensation, but no rubbing, pinching, or pain. Luckily, that’s not been a problem for you. But you’d aim for zero on the painscale constantly throughout the feed, by applying experimental little micro-movements: is that better, is that worse?"

"Usually, your arm is out in the air when you’ve found that right fit. We’ll need to find a very firm cushion that's the right size to fit under your elbow, without moving you or your baby from that just-right position, so that you can relax your shoulder down and let the cushion or pile of towels take your weight."

I show Verity the small buckwheat pillows I use. But a bundle of folded towels can work just as well.

• You can find a video of me working with the gestalt method in a consultation with a mother and her baby here, and in demonstration with a mother and her baby here.

• You can find the story of the first four days of Riku's life and how difficult it was for Verity to bring him on to the breast here.

• You can find what has happened with breastfeeding for Verity and her newborn in the three weeks after they came home from hospital here.

• You can find out how I talked about steps 1 & 2 of the gestalt method with Verity and Hiromi here.

• You can find out how I talked about steps 3 & 4 of the gestalt method with Verity and Hiromi here.