The gestalt method: education strategies, innovative models, what's not included
Education strategies for delivering the gestalt method
| Education strategy | Rationale |
|---|---|
| Consenting hands-on support (placed on mother's forearms) | Demonstrates the effect of micromovements on painscale and infant behaviour |
| Use of knitted breast | Illustrates concepts of landing pad, breast tissue drag, and optimal intra-oral breast tissue volume which protects nipple |
| Short videos | Illustrate healthy sucking; lying down breastfeeding |
| Parent's mobile phone | Photo from above baby's forehead to illustrate symmetrical face-breast interface; photo from front to illustrate infant spinal alignment in cradle hold; photo from mother's view above to illustrate face-bury |
Innovative models integrated into the gestalt method of fit and hold
| Innovations | Implications | References |
|---|---|---|
| Gestalt model of biomechanics of infant suck | Intra-oral vacuum not tongue action drives milk transfer; Positional instability results in conflicting vectors which compromise intra-oral breast tissue volume, impairing milk transfer and damaging nipples; Positional instability causes unsettled infant behaviour; Don't need to try to bring baby on with wide gap | Douglas & Geddes, 2017; Geddes and Sakalidis, 2016 |
| Neurobiological model of unsettled infant behaviour | Positional instability from suboptimal fit and hold results in difficulty latching on or staying on the breast, back-arching, crying and fussing at the breast, and in some, conditioned SNS hyperarousal | Douglas & Hill, 2013 |
| Psychological strategies from Acceptance and Commitment Therapy | Workability not perfection; Deep breathing; Conscious muscle relaxation; Cognitive defusion; Mindful focus on breast sensations and infant cues | Whittingham & Douglas, 2016 |
| Avoid 'breast is best' and concepts of a natural, instinctive or right brain approach | Pressures and disempowers women who feel they have failed if their body doesn't appear to 'work' | Burns, Schmied, Fenwick & Sheehan, 2012 |
Adapted from: TABLE 4 in Douglas PS, Keogh R. Gestalt breastfeeding: helping mothers and infants optimise positional stability and intra-oral breast tissue volume for effective, pain-free milk transfer. Journal of Human Lactation. 2017;33(3):509-518.
Popular techniques not used in the gestalt method
| Techniques to be avoided | Rationale |
|---|---|
| Breastfeeding pillows supporting the infant's body | Interferes with activation of breastfeeding reflexes; risks conflicting vectors (baby too high relative to breast fall) |
| Visible lips | If lips are visible, intra-oral breast tissue volume is compromised |
| Pulling breast tissue back to check lips | Creates a conflicting vector and draws breast tissue out of oral cavity |
| Flanged lups ("flip them out") | Lips are neutral during breastfeeding and do not need to flange; pulling lips out or having them visible compromises intra-oral breast tissue volume |
| Hand or fingers on back of baby's head or neck | Interferes with breastfeeding reflexes; may trigger back-arching; flexes cervical spine and interferes with intra-oral breast tissue volume |
| Sitting upright | Gravity creates a conflicting vector, intra-oral breast tissue volume is compromised, and baby pulls off or slips off the breast, and fusses |
| Leaning forward | Gravity creates a conflicting vector, intra-oral breast tissue volume is compromised, and baby pulls off or slips off the breast, and fusses |
| Lifting breast, shaping breast (c-hold, sandwich hold) | Conflicting vectors created when mother lets go of breast, compromising intra-oral breast tissue volume |
| Pushing breast into baby's mouth | Conflicting vectors created when mother lets go of the breast, compromising intra-oral breast tissue volume |
| Traction on skin of breast to lift nipple and areolar up level with baby's mouth | Conflicting vectors created when mother lets go of the breast, compromising intra-oral breast tissue volume |
| Taking baby off breast if attaches shallowly | Risks conditioned SNS hyperarousal at breast |
| Breast massage or compression while breastfeeding | Conflicting vectors created, which compromise intra-oral breast tissue volume |
| Pumping while breastfeeding | Unable to optimise fit and hold |
| Persisting if baby is fussing | Risks conditioned SNS hyperarousal at breast |
| Bra or clothing touching baby's face | Interferes with activation of breastfeeding reflexes |
| Baby wrapped for feeds | Interferes with activation of breastfeeding reflexes |
| Baby's hands between bodies | Interferes with activation of breastfeeding reflexes; creates conflicting vectors and compromised intra-oral breast tissue volume |
| Counting sucks and swallows | Interferes with mother's capacity to relax and attend to breast sensations and infant cues |
| Lie back to control high milk flow | Lying back helps baby co-ordinate suck-swallow-breath due to optimised positional stability but this does not alter effect milk flow, since flow depends on intra-oral vacuum and mammary duct contraction only |
| Football hold | Planes of contact not parallel and head tilt compromised, so that intra-oral breast tissue volume is compromised |
TABLE 3 in Douglas PS, Keogh R. Gestalt breastfeeding: helping mothers and infants optimise positional stability and intra-oral breast tissue volume for effective, pain-free milk transfer. Journal of Human Lactation. 2017;33(3):509-518.
Selected references
Burns E, Schmied V, Fenwick J, Sheehan A. Liquid gold from the milk bar: constructions of breastmilk and breastfeeding women in the language and practices of midwives. Social Science and Medicine. 2012;75:1737-1745.
Colson SD, Meek JH, Hawdon JM. Optimal positions for the release of primitive neonatal reflexes stimulating breastfeeding. Early Hum Dev. 2008;84:441-449.
Douglas PS, Hill PS. A neurobiological model for cry-fuss problems in the first three to four months of life. Med Hypotheses. 2013 A;81:816-822.
Douglas PS, Geddes DB. Practice-based interpretation of ultrasound studies leads the way to less pharmaceutical and surgical intervention for breastfeeding babies and more effective clinical support. Midwifery. 2018;58:145–155.
Douglas PS, Keogh R. Gestalt breastfeeding: helping mothers and infants optimise positional stability and intra-oral breast tissue volume for effective, pain-free milk transfer. Journal of Human Lactation. 2017;33(3):509–518.
Douglas PS, Perrella SL, Geddes DT. A brief gestalt intervention changes ultrasound measures of tongue movement during breastfeeding: case series. BMC Pregnancy and Childbirth. 2022;22(1):94. DOI: 10.1186/s12884-12021-04363-12887.
Schmied V, Beake S, Sheehan A, McCourt C, Dykes F. Women's perceptions and experiences of breastfeeding support: a metasynthesis.* Birth*. 2011;38:49-60.
Wang Z, Liu Q, Min L, Mao X. The effectiveness of laid-back position on lactation related nipple problems and comfort: a meta-analysis. BMC Pregnancy and Childbirth. 2021;21:248.
Whittingham K, Douglas PS. "Possums": building contextual behavioural science into an innovative evidence-based approach to parenting support in early life. In: Kirkaldy B, editor. Psychotherapy in parenthood and beyond. Turin, Italy: Edizioni Minerva Medica; 2016. p. 43-56.
