 5 of this session, here you know I am going to discuss about few issues that you can face you know when mother is breastfeeding, there are few problems that we experience in the field and I do want you to kind of know and understand what are the solutions for those problems, ok. So, starting from 45 points of counseling, first thing you know on cross-trial hold because it is not a hold which has been kind of you know practiced a lot in the field, most of these mothers they do not know this hold you know to be frank. So, I do recommend that you know to teach this mother as early as possible. So, during pregnancy see in last trimester of pregnancy, if you can show this tutorial 2 tutorials of cross-trial hold and latching, not only show them this 2 tutorials, but also kind of keep a breast model. So, you know you can make this breast model, we will also kind of create a tutorial on this how to make it. You can make it you know you can also use socks, put some cloth in it and you can be very innovative. There are some tutorials or some YouTube videos available on how to make artificial breast and then also you know buy like a really good baby doll like this you know make sure that it is at least 19 inches, you know 19 to 20 inches, so that is long enough. Do not buy very short ones because then it will be difficult for you to kind of teach mothers how to you know kind of put the baby in a right correct position, ok. So, here is a problem with you know problem that you will face in the field is because mothers do not know this technique, so it takes a little bit longer to train them, ok. Because what they have to do, they have to unlearn what they have learnt before, you know and of course if the cradle hold is working fine and if you can get that correct latch with cradle hold, please go ahead there is no doubt about it, please go ahead. But you know what we have seen in a lot of the studies that we have done at a district level you know in our program also that if the cross cradle was whole definitely you know the neck extension was much better you know all that I will explain to you what were the issues that we were facing with cradle hold you know and then you will understand that why I am pressing on cross cradle hold so much you know. So what happens in cross cradle hold actually that is a traditional hold, so the reason children were not gaining good amount of weight in my opinion is that most of the time because the baby is held with the same hand, ok. So here what happens a baby does not have any and baby would come like this, this is how most of the time babies are held in a cradle hold, ok. Now what happens here in this position babies neck is kind of bent forward because baby do not have any space to move the head backward so what is happening here kind of neck is getting pressed downward because this elbow is kind of blocking baby's extension of neck, ok. So in this position what I only saw that baby had a flexion of neck, ok. Meaning what I have not noticed that in this position because you know if you look at it most of the time the upper ila goes more in the mouth because in this position the nose is much higher when it comes to nipple than the lower. So here when the baby opens them out more of upper ila goes into the mouth than the lower. If you really want to have a lower ila in the mouth what you need to do with this cradle hold you have to really bring the baby like this you know and allow the baby to kind of you know get that head backward and this position is very very awkward for the mother. You can imagine see this is this is the position and nothing is here then the legs are not supported, ok. Head is also not supported it is just sitting on the angle of the you know of the elbow. So this is probably there are few more reasons that you know we felt that it was not comfortable for the baby and the mother to be in this position. So what happens is again if you are using the cross cradle hold here still look at this now you have a full body kind of support you know beautiful extension of the neck, ok extension of the head and then you baby can latch on beautifully, ok. So this is this is how this is a beautiful that is what we notice in our program you know that mother once she learned properly she had lot more confidence and then she could baby was much more relaxed. You know baby could get milk just within few minutes 5, 6, 7 minutes sometime you know the latches good and if they were hungry you know that milk transfer was happening because we could see amazing weight gain you know almost 50 to 60 grams weight gain per day, ok. So here again you know to unlearn from this you know to this it and what again in cradle hold most of the mothers they hold the breast like this, ok. So the thumb comes at 12 o'clock and the finger lower fingers I mean the you know index finger come at 6 o'clock and here in this position what happens the way baby holds the breast is like this. So when you suppose eating a vada power burger and if you are holding if your fingers are perpendicular to the lip so this is your lip, ok this is your lip and now your fingers are perpendicular not parallel but perpendicular then you will not be able to have a big bite, ok. So in this position if you look at you know I want you to observe those mothers breastfeeding and see how their breastfeed first always observe so they will know where they are going wrong. So in this position you know babies are basically diagonal most of the time, ok and then mother is holding the breast in a C shape. So here the lips are not parallel to baby's mother's fingers lips are perpendicular to baby's finger. So in this position most of the time nipple goes in the mouth, ok and maybe little bit of upper urulla but I hardly ever saw lower good lower urulla latch in this position, ok. So that is your one first point is to make mother unlearn and the best time to make her understand this concept is not after delivery because after delivery it is already you know she is going through so much of all this hormonal problems you know pain, lot of these people around her nurses are telling her few things, doctors are saying some things you know mother and mother-in-law will say that oh you are not getting enough milk, ok, ok, ok, you know she is so confused. So the best time to teach her is not post delivery the best time to teach her is during pregnancy during last trimester let her understand what are these 45 points let her understand the concept, ok, of what different points that we are mentioning and then let her practice on the baby doll and the breast model let her practice it, ok. Once she delivers of course you know as I mentioned in my other tutorials that the breast crawl is important you know breast crawl during cesarean section is important. So all that will be taken care of by doctors and nurses but if mothers know all these points she will demand for it she has to demand if you do not demand doctors will not do it. So tell her to demand for it tell her to tell doctors that I want to breastfeed as soon as baby is born you know tell her that she needs support most of the time you know team they do not know this cross cradle and 45 points so she has to be what I recommend is to not only teach her but teach the whole family, ok. So teach grandmother like her mother-in-law, mother you know husband or sister-in-law whoever sister whoever are going to be there with her they all need to learn because believe me after delivery it is them who will be helping mothers, ok. If sisters and doctors are there if they know proper technique I will be very happy but unfortunately we you know this technique has not been taken up by many doctors, ok. So anyway so the first point is as I mentioned that mother has to understand during before delivery after delivery then she is going to be there in the hospital for sit 24 to 48 hours, ok. So I do recommend every time that she kind of breastfeed she needs to remember those 45 points. So I kind of recommend that she should have those 45 point PDF those charts with her so that you know even if she does not have any support she can just look at those charts and remember what she has learnt during pregnancy and she can follow those points and she can practice on the baby. Also if mothers and mother-in-laws if they know this 45 points they can help her you know they can they can burp the baby they can you know help mother with rest with different holes side line hole other hole, ok so that is important, alright. So now couple of points that you will see that mother will struggle with, ok this is one point which you will definitely see that mothers do not kind of tuck babies you know kind of legs in the armpit. So make sure that you know you teach her completely you know the example that I give for this particular point is that you know women they lot of time when they go out they carry this clutch purse, clutch purse it is just a small purse and they hold it very tight you know. So I always give this example that if you are holding the clutch would you hold the clutch like this or would you let that clutch fall down and they will say no no no no you know women are very kind of possessive about the person you know. So I always say the same thing I said if you are so possessive about your clutch this is your baby you do not want the baby to slide down. So I tell mothers to hold the legs very tightly, ok and then put it in under arm you know and then hold it tightly and then let that hip little bit sit in front like this. So that hip is sitting so in this position what will happen that legs will not slip because if it is not kind of tucked properly you know slowly slowly that leg will slip down, ok. So I tell mothers to make baby sit so if suppose baby is sitting like this so this would be the position. So if I just pull the baby out this is the position that baby is sitting, ok and this is how normally also we would love to sit and eat, right we want to kind of be as comfortable as position in this position. So here if I just put this baby back again, ok and then just let baby sit, yeah so this is this is the position that I am yeah this is the position now baby is sitting, ok and one more point which is again I see all the time is fingers, fingers always kind of put like this. Please remember that fingers should be kind of at the back of the you know ears on that mastoid bone, ok. So this is important and one more thing which I always see that baby is brought so far kind of lateral towards this side you know that whenever baby opens the mouth to have the breast in the mouth baby has to bend the neck forward, ok. So do not do this, do not basically bend you know do not allow baby to bend the neck forward, ok. So in this position what you want to do you tell mother to bring the baby little bit towards the other side this way. Here in this position when the nose is little bit lower than the nipple you know then you can basically try to lift the neck forward, ok here this way and then we can open the mouth and then the lower part of the ear can go in the mouth. So this is very very important with where you are bringing the again I am going to repeat because many times what I see when they bring the baby to the breast this neck is completely either straight like this or it is like this, like this, ok either bent forward or it is straight that is wrong, both this position of the neck is wrong. You want the neck of the position, neck of the baby to be in a slightly extended position, slightly in other side. So for that you will have to pull the baby more towards the other side of the where the legs are, ok and then it would be easy for the baby to extend the neck, ok. So here then baby is coming from lower down and then attaching, ok, alright. Then third point which I always see the problem is baby is kind of brought correctly but mother tends to have a C shape. She tends to hold the breast by C shape and this is so common because she is taught that where she has seen everybody doing that. Now this will completely kind of you know allow baby to have only nipple, not the lower latch. So remember cannot to hold C shape in C shape your you know your fingers are not parallel to baby's lips in this position, ok because in this position the lips are vertical, ok. So you will have to put your fingers either up in a vertical position, ok like this or in a lower down in this position and make sure that this dip of the U shape is more at 6 o'clock. So bring your hand closer to you. So then it will be easier if it is like this, if it is kind of extended then what will happen that you know your dip is going more towards 5 o'clock, ok on left hand side, ok. So just bring your hand little bit closer, so here it is over here I am bringing it closer and then only the tip not the whole thing only the tip and it should be 3 fingers away from the nipple, ok. Only the tip let us say it is exactly U, it should not be V shape, it should not be V, ok. It should not be full breast holding the you know I do not want full finger to be on the breast just the tip not the full finger like this, ok not like this, this becomes V. It should be just a tip and bend beautifully in a round shape, ok and pressing the breast, ok because otherwise you know that finger will come in the way and maybe we will not be able to have a good low error latch, ok, alright so that is done. Now third time third thing which I always see is you know when mother is kind of holding the breast and then she keeps holding it you know, so just tell her that once a latch is good you examine the latch she forgets to examine this is another point which is very important you tell her you examine the latch 3-4 points that she has to see, first point how big is the mouth, ok, second point is whether lower lower latch is there or not for that she has to see where is the lower lip of the baby which is at the border of lower ear and on the breast, third thing is both lip and the chin should be embedded in the breast she should not be able to see it because if she is seeing that lip and the chin that means just too far, ok and the another thing what I want you to do is once that is done then she has to bring that hand and put it around to not leave this hand over here from the neck otherwise baby will detach and then again will become a nipple latch, ok. So, that is important remember that it has to be you know just baby mother holding the hip of the baby, like this, alright. So, this is done this are the skills that I see lot of issue with and if you teach her proper skills and if you know what you know what problems that you may face in the field and if you can if you know the solution it will be much easier for mother and the baby to have a proper breastfeeding success, ok and there are some content that you already know do ask mothers because if you do not ask them or if you do not teach them you will not know what the issue is, ok. So, the questions as I said that how many times she is feeding during daytime the she know early hunger queues or not. So, instead of daytime I ask about 24 hours because lot of time you know the daytime becomes very kind of confusing. So, I do ask mothers in 24 hours how many times you feed 10 to 12 times, night time out of that night time how many times she feeds. So, I recommend at least 3 to 4 times you know another thing about the hind milk do spend good 10 minutes talking about hind milk, ok. Do spend 10 minutes explaining how to express breast milk, press, compress release is called PCR remember PCR press, compress release, ok. Look for whether the milk is watery or thick, ok. Watery milk will basically if mother is giving only watery milk that baby will not put on weight, ok and then she will baby will pass urine because water is going in you know, but the thick milk that hind milk fatty milk is not going in, ok. So, that baby will have difficulty putting on weight. So, do think about those important points that why baby is not putting on weight, ok. Another thing also I see a lot of issues in the field is they do not press feed on both sides you know or they feel they would feed on both side, but little bit over here little bit over there. So, they are getting only 4 milk you know in both the breast the babies are not getting hind milk. So, tell her to completely empty on one side examine whether she has 4 milk or hind milk given completely then go on the other side, ok. Many times even if baby is fed on other side she baby can still feed on the third time again on the first bread. There is another point which I want to discuss is alternate your breast. For example, suppose in first feeding you give this side first and then you give this, ok. After hour and half baby wake up baby woke up then what you want to do is to feed on this side first and then go on this side. So, you alternate because what happens in when you feed when the baby feeds first few minutes that sucking is very hard. So, that that breast will get empty very fast, ok. So, what we do is we tell mothers alternate first time give this first and then second feeding give this and a third feeding give this side first again so alternate, ok. So, both side get equal stimulation otherwise lot of time what happens we see mothers who just lot of time they come and tell us that oh baby prefers to breast feed on right side only, ok. So, we tell them no because left side is difficult you take you teach baby how to feed on left side first. So, when baby is hungry you know they will learn they will cry but you know you have to teach them. So, in those condition we tell mothers to try to feed on the difficult side first you know let baby learn and then she can basically alternate, ok. So, that is another important point which is really important and you know there are other things about nose. So, nose is another thing which lot of mothers are very very afraid of, ok to not freak out. If you freak out then mothers will freak out you know you teach them that your baby's nose is getting pressed like this not like this. So, nothing to worry about but if you worried you can just kind of you know here suppose baby's nose is getting pressed you just lift up the neck backward little bit like this. So, the nose kind of comes off the breast and the chin will go more deeper into the breast, ok. But what I notice in our technique we from beginning we bring the baby like this, ok. If we bring the baby directly immediately like this say in a in a extended neck position you know then we do not have a problem of nose suppression or nose compression at all, ok. Here if baby is brought like this or baby is brought like this in this situation that nose will get compressed. So, again you observe the baby and the mother and if you know the nose is getting compressed that means baby is not like this, baby is blended just directly on the breast straight like this not like this. If baby is come just like this or maybe like this, ok. So, this are few points if you remember I think you will do well. Again if you kind of face any problem in the field feel free to contact us and we will be more than happy to answer your questions, ok. Thank you.