Birthing room practices can either hinder or promote the initiation of breastfeeding. In Australia, midwives usually support mothers and newborns with the first breastfeed. The aim of this paper is to explore midwives reported practice, assisting mothers initiate breastfeeding in the birthing room. A self-report questionnaire that included open-ended questions was mailed to a national sample of Australian midwives. Open-ended responses to questions related to a birthing room practice scenario were analysed using content analysis to facilitate thematic description. Midwives reported that at the immediate time of birth, they offered support and choice to mothers. The midwives also identified that their practice was often impacted on by workplace structures and these were often barriers to their role at this time. Some midwives indicated that they would use a ‘hands-off’ approach at birth, although others indicated ways in which they would intervene including some who reported a ‘hands-on’ approach to assist mothers with the first breastfeed as soon as possible after birth. Lactation education support for midwives is required to change workplace culture and improve practice. More research is needed to establish best practice to support mothers with the first breastfeed. It could be that some level of ‘hands-on’ help provided skillfully may be effective. More research is needed to investigate the effect of ‘hands-on’ help described by skillful experienced midwives, and association with sustained problem free breastfeeding.