Thank you to everyone who responded to my questions about colostrum and how often they see women producing little or no colostrum on the first day. I have also noticed that sometimes putting the baby skin to skin on the mom for about 20 to 30 minutes prior to expression results in the mother then being able to express colostrum, but sometimes it does not. Hand expression was a huge revelation for us. We found that with it, probably about 80 to 90% of women can produce colostrum after delivery, but some can't. They usually do after a day or two with consistent pumping and hand expression. Usually the women who are able to express colostrum are very excited to see they are producing milk. I think many of them genuinely do not believe they are making milk or do not know how to tell if they are. But for the small percentage who can't express any milk, it can be very disheartening. Our staff works hard to try to build up their confidence at this time, it's so easy to crush their spirit with one wrong word. New moms take everything to heart and it's an extremely difficult situation when they can't express a drop of milk. They get frustrated with expression not resulting in milk and sometimes do not want to continue with it. 
Thank you to Genevieve who also mentioned that milk production is cyclical and sometimes sees women unable to express milk as well initially. I do also mention to my patients that many women will produce more milk at night or first thing in the morning. And we talk to them about the fact that they might produce less colostrum on day 2, and if so, don't worry about it, it seems to be normal. I have come across two theories about this. The first is that women express more milk right after delivery due to hormones, including a high level of estrogen. The second is that they initially are able to express milk that is stored in the breast prior to delivery, now their body needs to begin the process of producing more and it may take a little time to begin producing again. I think the lower volume on day 2 makes baby nurse more. Often moms who put baby to breast all night during the "second night syndrome" seem to get their milk in the next day.
So much is theoretical and not really known yet unfortunately, including whether or not natural childbirth or induction of labor has an effect on lactation. I would say that I have not really seen a relationship between the two. I can think of a number of women I have cared for who have gone into labor on their own and even had unmedicated deliveries with no risk factors for low supply and were unable to express any milk, many were young and healthy people. 
Yes, I agree that dense breasts are a risk factor for this. I have a feeling for those women, the milk may be in the breasts but we are really unable to effectively compress the tissue to extract it. Sometimes I am pretty shocked by who is unable to express milk. In my experience, no studies to back this up, teenagers often seem to produce the most milk. But I have on occasion run across a few with a natural labor, normal breast development and just unable to express milk for a few days, usually they end up making a full supply of milk. It's a mystery. I know there was one study of 30 women that showed a lower serum level of oxytocin on day two when they had an epidural at delivery, but that is a very small study and not at all conclusive proof of a correlation with milk production. More research needs to be done. 
Yes, of course, we would prefer to have them just directly breastfeed though, but sometimes that doesn't happen for a variety of reasons for a while. The baby is probably the best one at getting the thick colostrum from the breast when they are nursing well. However, many babies don't latch and often late preterm infants seem to struggle the most during colostrum production. Infants need to suckle at a higher pressure during this time. That is something that LPT's don't do well, suck strongly. Most suck a few times and can't maintain the intraoral pressure and keep coming on and off the breast until they give up and fall asleep. Anyway, we have a lot of LPT's and infant's transferred to the NICU. Hand expression has been wonderful for us and really reduced our use of formula. 
I find that most women will eventually produce milk normally especially if they have no risk factors such as PCOS, breast hypoplasia, breast surgery, etc., and they had some breast growth during pregnancy. If those risk factors exist though and they had no breast development and unable to express milk, that is usually an ominous sign for milk production. I'm sure stress does play a huge role in this as well. Whether mom has had a hemorrhage or she's stressed about her baby that is in the NICU and needs to have surgery. These patients often do not have ideal delivery scenarios. I hope more research is done soon to see if labor hormones are playing a role in early milk production. I would also love to see more research on the typical volume of colostrum an infant eats on day 2. From my research, I have not been able to find studies on this. The only ones I've seen like Santoro in 2010 looked only at the first 24 hours. The idea that babies consume a larger volume on day 2 versus day 1 seems to be something have presumed. 
Thanks for your help,
Tricia Shamblin


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