Nancy, from your description, I'm inclined to look at the milk
production pathways. The first things I look at in this circumstance is
mom's own nutrition and fatigue factors. If she is too strung out with
demands, etc to eat, and if she tolerates dairy, have her drink "instant
breakfast" type powdered meals. There are many available brands
including plainwrap store brands in order to preserve the Nestle boycott
(Amway makes a good one). Otherwise suggest quick protein foods: cold
drumstick, piece of cheese, yogurt, granols bars. Is her fluid intake
adequate (drink enough to pee every 1-2 hours)? How is her sleep? Does
she need one *real good* night sleep? (Have dad spell her for one night
with a bottle - see my previous posting on "In support of bottles - sort
of"). Did she have breast development during pregnancy (increased cup
size)? It is very rare, but agenesis of breast tissue has been
documented. Also, is her stress level - and hence adrenalin level -
negating whatever prolactin she has? Stress and adrenalin, belonging to
the sympathetic nervous system, will always win in a "veto" over the
parasympathetic nervous system of which the milk-ejection reflex and
hormones belong to. Definitely try fenugreek (some of my moms respond
better to the actual tea rather than the capsules. Add peppermint tea to
the brew to improve taste and also gain the benefits of peppermint,
which relaxes smooth muscle of which the milkducts are composed). Also,
she should use a double pump for no more than 10 minutes per pumping
(dbl pumps we know boost prolactin, but research shows longer than 10
min w/a dbl pump can actually decrease prolactin). Pump at almost
exactly the same times every day (actual times don't matter, but ideally
should be when baby nurses). In my experience with super-premie moms and
low supply, diurnal consistency (for lack of a better term; ie "same
time every day") for pumping makes a huge difference after 48 hours or
so. I teach moms that the endocrine system is in control of milk supply
and likes regularity, but is "suspicious" and will not increase supply
until it recognizes a pattern of stimulation. Since she was a cesarean,
I *presume* there are no placental fragments retained which will put a
big kibosh on milk production. I have also been a nurse long enough to
know one should not assume anything - ask her if she still has a vaginal
discharge (lochia) either red or brown, and if yes, send her in to her
OB for a D&C. (This happened to one of my clients once - premie twins at
26 weeks gestation, one died, other came home at 42 weeks gestational
age when I saw them in the home, 1 oz pumping - and a brown lochia for
16 WEEKS!! told "normal" by the doctor's receptionist who refused mom an
appointment when she asked at 8 weeks. Yup, a thumbnail sized placental
fragment had been missed during the c-section and was happily churning
out progesterone which prohibits prolactin. D&C done. Voila! Her milk
finally came in!  :-)

Katharine West, BSN, MPH, FNP in-training
Sherman Oaks, CA