I just dealt with a mom who presented with an unusually tough case of
engorgement.  Her original call to me was milk not coming in and baby
getting mad at breast (4 days pp).  Once her milk came in, she became
severely engorged in a matter of hours, and her small, more passive baby
just couldn't pull it down--- 3 sucks and she was outta there.  This is a
second time around mom who successfully navigated this stage with a
larger and more vigorous baby #1.

I tried the baby positioned better first, then the pump, then massage and
pump, then later ibuprofen plus cabbage leaves plus pumping.  The next
morning she was still struggling with a baby who wasn't getting enough,
and pumping only 1/2-1 oz per breast every 2 hrs.  I massaged her during
feeding and during pumping, which resulted in occasional spurts of
drainage to some areas, but continued massive stasis deep in the upper
breast area, not the traditional armpit engorgement.  On day 3, I
suggested she have her husband do a spine-walk to elicit those the
"shivers" that we used to give each other as kids with a quick run of the
thumb up someone's spine; that did it!  It triggered a let-down and her
engorged areas finally started draining and flowing normally.

Now why didn't I try that first?  ;-)

-Lisa Marasco, BA, IBCLC