Recently I met a mother whose story I am sharing with her blessings.
We don't yet know how it will turn out in the long run. I'm not
requesting input, but if anyone has experience from similar situations
that might help this mother please feel free to post suggestions.

Mother became pregnant spontaneously at age 40, after 16 years with
the same man and never having used contraception. She had had surgery
in her early twenties for what seems to have been pelvic inflammatory
disease, it was in another country and we don't have the records.
Following the surgery she was told her chances of having children were
about nil. Still, her ob/gyn at the time 'forbade' her to have the
reduction mammoplasty she longed for (large breasts, headaches,
musculoskeletal pain from heavy breasts, and low self-esteem about her
physical appearance) in case they were mistaken and she did have a
baby someday. She followed the doctor's advice.
She was diagnosed with PCOS some time after the surgery, and she has a
lot of the features associated with it.  Around the same time, she
developed type II diabetes which progressed until she needed insulin
to control it, and she gained a lot of weight, so much that she
qualified for bariatric surgery. She had a gastric bypass in 2012,
lost about 80 pounds toward her goal of nearly 110, and then she found
she was pregnant.  During pregnancy her weight went back up nearly to
where it had been before her surgery but she was OK with that, and
very happy to be pregnant.
She had good control of her blood sugar during pregnancy, went to term
and had a vaginal birth which was concluded with lift-out forceps for
slow progress in second stage. Baby went to NICU as per procedure for
infants of insulin-dependent mothers but was transferred to postpartum
with mother after 24 hours in NICU in which all blood glucose checks
were fine (she was fed three-hourly with banked milk during that
time). After transfer to postpartum, where banked milk is no longer
available, she was fed formula three hourly for another day.
I met her on day three. I'd heard the staff discussing her the day
before and the opinion was that her breasts were highly abnormal and
would not be likely to work for breastfeeding. They said the skin on
her areolae was like leather and it was not possible to hand express
because her nipples and areolae were too large and too
non-protractile. I was pretty sure she simply had a lot of edema and
that turned out to be the case. The areolae were about 9 inches across
and her nipples were about an inch in diameter.
On day three before my shift she had tried to pump for the first time.
She saw some moisture on the inside of the flange and assumed it was
sweat. Together we used RPS and hand expression, and were able to get
about 1.5 ml of milk over the course of nearly an hour. She was
astounded, and happy.
Her edema was so profound that she needed full-time help just to do
RPS and express, and she was also expected to care for the baby and
cope with painful stitches after the forceps delivery AND control her
own blood glucose which plummeted during the first few days because
she didn't dare reduce her insulin as much as everyone advised her to
do. Still, within 24 hours of that first real attempt at expression on
day 3, she could express 50 ml at a time from one breast.
On day five she was exhausted, we are not able to give mothers that
degree of personal attention over time so she was having to do too
much on her own. She decided very reluctantly to stop attempting to
express for every feed, and do what she could manage. I was pretty
sure things would get easier when her edema had subsided but she
couldn't share my optimism, unsurprisingly. Getting baby to breast
seemed an impossibly long way off and she was desperate for some
breathing time between feeds.  She was still in hospital because her
own blood sugar had not been stabilized.
She used cabbage leaves and a cultured dairy product we call kesam,
and Germans call quark, both applied directly to the skin of her
breasts to relieve engorgement. I'd never seen kesam in use before and
I must say I was impressed. Have no idea whether there is any research
to support it but in this case it did wonders for her well-being. The
consistency of both breasts went from stiff with edema to soft and
pliable during the rest of her stay.
Over the course of the next day and a half she expressed milk about 6
times all told, and had reconciled herself to having a mostly
artificially fed baby.
I wanted to review hand expression and pumping techniques with her
before she left for home, because she had gotten a hospital grade pump
from her well-child center free of charge and planned to keep
expressing as much as she feels able to do. With my hands-on help she
expressed about 30 ml from one breast. The other side leaked copiously
while she was expressing that, but as soon as the pump flange came in
contact with that breast, the milk stopped, probably because she had
to lift her breast up to be able to hold the pump flange onto it, and
that put a crimp in the ducts, but she seemed not to like having the
pump in contact with her breasts either. I went to get a syntocinon
nasal spray and left her to do some more RPS and try to hand express.
It took longer to get back to her than I'd planned, and we were out of
the spray. I went in dreading her disappointment.  Opened the door and
she was looking triumphant. She had, on her own, expressed no less
than six ounces total from both breasts, using the pump. She stopped
because her nipples were getting sore.  Her breasts are so large that
double pumping is not practicable unless she has a personal assistant
to hold one of the breasts and the collection set. Earlier on, we
tried supplementing at the breast with a shield and a tube both, but
neither she nor the baby really enjoyed that.  It's possible she will
manage with a shield again, or she may wait til baby is a little
bigger, or she may continue pumping and bottle feeding. Hard to know
how it will play out.
This woman was totally prepared to not produce milk. Her plans for
breastfeeding were all based on what she had read about PCOS,
diabetes, and BF after bariatric surgery, and she assumed she would
produce drops of milk, if that, and would have to supplement with
formula and then continue on with formula alone. She had no
contingency plan about how to cope with oversupply, engorgement, or
how to get a baby on her breast. She would have had a very challenging
time no matter what, but I think it might have been better if she had
been encouraged to be open to all possibilities, including the one
that actually occurred.
So: two serious medical conditions predisposing for low supply,
history of an intervention which can impact supply, a complicated
birth which lessened the chances that the baby would be able to feed
effectively from day one, massive generalized edema post partum, very
little stimulation in the first 48 hours and sporadic expression from
then on - and still she was producing more milk than many of the
'healthy' mothers on our ward.

All this illustrates is that you really never know whether anyone is
going to make a ton of milk or hardly any. I continue to hold that all
mothers should be cared for with the assumption that breastfeeding
will work until proven otherwise, by skilled and knowledgeable people
who are able to keep an eye out for complications as they emerge so
they don't get a chance to become insurmountable. This case did not
*really* teach me anything new, except perhaps that even quark works
for engorgement if you expect it to.

with utmost respect for the work of mothers,
Rachel Myr
Kristiansand, Norway

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