What a challenge your place provides! What are they going to do without
you while you are gone? Do you suppose anyone will try to jump in and use
some of your techniques? Or will you go back to find more bottles in use
again?

<2) Why don't we have at least one quadrant of the ducts functioning?
She said that the cyst was about one cm in diameter.>

Even if the external incision was only af 5:30 to 1 o'clock, that was
probably  just to "Peel it back to get a good approach" to the cyst. The
doc probably never gave future BF a thought, especially BF twins, and
probably didn't want to frankly amputate the nipple as they do in some
cancer surgery to reattach at the end for cosmetic purposes. But that
doesn't mean that all the ducts may not have been  interrupted further
back in cutting across them to get at it if the cyst was deeply imbedded.
Sad for her, but not fixable now.

<3) Should I photo this?  I didn't want to ask  her today because she was
in so much pain both from the op and the engorgement.>

Would certainly make a good illustration for a case report.

<start cabbage leave treatment on the blocked side with
intermittent  ice packs. How long can I expect the reabsorption to take
given that there is no outlet for milk?>

Hard to tell. Maybe faster than if there were an outlet for milk.  A
couple of other thoughts to consider:  If swelling gets marked on that
side, having the mom lie on her back and massaging TOWARD the axilla, the
sternum, and the clavicle might hasten resolution of any edema plus add
to back pressure in the alveoli.

I have recently heard of several BF mothers locally who went to the ER
for engorgement. The ONLY "help" they were given was that they  were
bound bilaterally with ACE bandages. (Do we still have some HCP's here in
the dark ages, or what?) Maybe unilateral binding with a comfortable
amount of pressure might help avoid some problems. Maybe a small elastic
abdominal binder applied over the opposite shoulder diagonally? Just a
thought.

<The mom seemed a little  overwhelmed and weepy today from pain and
stress, so I just want to take it slowly with her, one step at a time.>

You are sensitive and wise. Part of what you are actually seeing may the
grieving process for the loss of 50% of her perceived lactational
capacity. But then, we had a mother locally who, 20+ years ago, nursed
quadruplets exclusively for 3 months before she began one afternoon
bottle to allow her to give occasional dinner parties! So there is often
much more capacity in one breast than a mother could imagine without a
little help from an openminded LC (hint, hint).

<Any idea for protocols for unilateral nursing of twins.  One will get
the fore milk and the other the hind milk and then next time they will
switch?  Pre-feed pumping?  We have time before they go to breast so
any  solutions would be greatly appreciated!>

Just thinking randomly here. May depend on which of the twins is most
vigorous or the weaker of them as to who gets the hindmilk oftener. Then
again, if the MER is elicited first and breast massaged, or even
partially pumped first, the foremilk might be a little more mixed. Maybe
the first twin could feed for 10-15 minutes or so, second twin nurse 30
minutes or so, and first twin go back for another 10 minute. Reverse who
goes first each time?

It occurs to me that the shortage of a second nipple is one of the main
problems this mom faces. But then again, nerves were cut too so if they
both wake hungry at same time, pacify one on non-functional side while
nursing the other?

If time and her stress level permit, maybe eventually SNS and pumped milk
on non functional side as to be able to feed them simultaneously? Naw!
Too much fiddling.

I have known moms of twins to nurse each one individually, both for the
one-on-one of it all, but also because it drove them ape with one twin
having a completely different rhythm than the other. So just
encouragement to expect to devote nearly all of her time between bathroom
breaks and meals to breastfeeding for a while? It seems like she's still
going to spend less time than if she had to bottlefeed each without
help!And she can snooze part of the time she's doing it once she gets the
hang of it!

Good luck.

Jean


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