permission to post. saw a mom in hospital with a surgical delivery after long grueling labor. baby 
almost reached a 10% weight loss. poor transfer likely due to infant tongue tie (scheduled for release shortly). signs of LII third day post op. marked swelling of feet and lower legs. breasts engorged poor transfer/little relief at breast. used supine positioning and rps successful on left breast. on right breast we continued supine positioning, rps, hand exp, symphony breast pump, 30mm flanges, 36mm flanges, put baby to breast, iced breast, warm shower, everything under the sun to soften breast, remove milk, relieve engorgement. nothing seemed to work. we did not do cabbage as had none in hospital : (.  I advised mother to alternate rest with engorgement mgmt techniques and suggested f.o.b. go out for cabbage.  When  I returned to unit in the AM learned mother had fallen asleep with symphony pump (36mm on lowest setting) and pumped for better part of an hour and had swelling of areola. she was very distressed and decided to rest her breast and left it alone until I came to see her. She had gone 12 hours without attempting to feed/remove milk. We started again. by this point she was feeding well on left breast and baby was up an ounce. rps on right side moved out a few drops. I observed baby at right breast. he went directly into a "shutdown" mode. hand exp and ebp could only remove a few ccs and did not provide any relief. mother went home with basic engorgement instructions and a plan for follow up. 
it appears right breast has involuted. It is markedly smaller than left with little production. Mother told me today she has hx of benign breast cysts in right breast. also: right nipple is dimpled. opens like a flower. left is normal.
questions: how might nipple anomaly/hx of cysts bring to bear on let down/output? 12 hours with no attempts to remove milk is trouble for building/maintaining supply, but why should milk removal have been so difficult? Yes baby has tt but mother's problems are only on right side? What else could I have done?  I have advised mother that she can make a full supply on left and that many women have a side that produces more than the other. baby is gaining and scheduled for frenuplasty. but this mother wants more answers than I have....
thank you
Kristen Panzer, MS IBCLC
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