Low milk after a C-section or a stressful stretch: a lack or a blockage?

Around week 31 of her second pregnancy, a woman came to the clinic because she was afraid of history repeating itself. After her previous birth, her breasts had become severely engorged and painful, yet no milk came out. She could not breastfeed, and in the end she had to take medicine to stop her milk. This time, while she was still pregnant, her breasts were already tight and painful, with the pain spreading into her armpits.

Her record notes many small lesions scattered through both breasts, which she said were fibroadenomas (the clinic does not do breast ultrasound), as well as extra breast tissue in the armpits. The doctor thought her difficulty getting milk out might come from the structure of her breasts, from stress, and, in traditional medicine terms, from constrained fire of the Heart and Liver (心肝郁火 / 心肝鬱火, xīn gān yù huǒ: worry and pent-up frustration that, held in for a long time, turn into heat inside). Her biggest fear was having no milk again this time. Most of her prenatal visits went into easing those worries.

She had a vaginal birth at about week 38. On the fourth day, her breasts filled up and she felt as if her milk had come in, yet however much she expressed, nothing came out.

This article looks at two situations that often lead to low milk: after a C-section, and after a stretch of a lot of anxiety. She was in the second situation.

Day three or four, and your breasts still aren’t full

Milk comes in at a different time for each woman. Pooling many studies, mothers feel their breasts fill on average after about 50 to 73 hours; after 72 hours, the milk is considered to be coming in late (Pérez-Escamilla & Chapman 2001). Figures from the US: about 1 in 5 mothers have their milk come in after 72 hours (Dewey 2003), and among first-time mothers, nearly half (Nommsen-Rivers 2010). Milk coming in late goes along with babies losing more weight and mothers stopping breastfeeding early (Dewey 2003; Brownell 2012), so mothers need help early; milk coming in late does not mean you have no milk.

Mothers who have a C-section have a higher risk of their milk coming in late, about twice that of mothers who give birth vaginally, according to a study in Australia (Scott 2007), especially when the operation was not planned in advance (Chapman 1999). This is an observational study, showing that the two things often go together, not proving cause.

A hospital in Italy found that 71.5% of babies born vaginally were breastfed right in the delivery room, compared with only 3.5% of babies born by C-section (Zanardo 2010). The authors suggest the most likely explanation is that mothers after surgery cannot yet breastfeed comfortably right away. On top of that come pain, medication, tiredness and, with an emergency C-section, the long labor before it.

That gap can close. Another study in Australia found that babies born by C-section took in less milk from day 2 to day 5, but by day 6 they had caught up with babies born vaginally (Evans 2003). Once breastfeeding gets going, the share of mothers who had a C-section and are still breastfeeding at 6 months is no different from mothers who gave birth vaginally (Prior 2012). What you can do right away is hold your baby skin to skin and breastfeed early once you are alert enough, have someone help hold the baby, and take enough pain relief to be able to hold your baby. For breastfeeding positions while you still have a C-section wound, see the article "A healed C-section scar that still hurts, and breastfeeding".

The old traditional medicine books do not discuss C-sections, since they did not exist then; they only mention heavy blood loss (Hai Thuong Lan Ong, the classical Vietnamese physician), difficult labor and starting breastfeeding too late (Xia Guicheng, 夏桂成). A book by Chai Songyan (柴松岩) records a case of a C-section birth where, one week after the birth, the mother had little milk and tight, painful breasts, and was tense and low in mood. He classified it as Liver qi constraint and stagnation (肝郁气滞 / 肝鬱氣滯, gān yù qì zhì: worry, sadness and pent-up frustration making the qi stuck so it does not flow), and his commentary says nothing about the surgical wound. It is only one case, but it shows that after a C-section, the obstacle sometimes lies in worry.

When you are anxious, milk is slow to flow

A small experiment in Japan had 22 mothers breastfeed while doing mental arithmetic or listening to noise. The number of oxytocin pulses (oxytocin is the hormone that helps milk flow out) dropped by almost half. Prolactin (the hormone that helps make milk) and the amount of milk at that feed did not change (Ueda 1994). Stress in the moment makes it harder for milk to flow out rather than drying up the milk. If that happens again and again, the milk can gradually decrease because the milk in the breast is not removed enough (by the baby feeding or by expressing); how long-term stress affects things is still unclear (Dewey 2001).

A meta-analysis of 16 trials of listening to music, guided relaxation, mindfulness and breathing exercises found that milk volume increased, babies gained weight better, and mothers’ anxiety eased slightly, with moderate certainty (Levene 2024). Most of the studies were in mothers expressing milk for premature babies, and the rate of exclusive breastfeeding at 2 months did not differ. So relaxation may help, and a few minutes of music or breathing exercises before expressing is an easy way to start.

Xia Guicheng names specifically women who are "injured by fear, anxiety and tension after birth" as having Liver qi constraint and stagnation. In such a case, he says, "psychological unblocking must be carried out"; herbs that only release constraint and open the milk flow, on their own, cannot cure it.

Applied Kinesiology (AK), an examination method that uses muscle strength testing, also treats stress as one factor in milk supply. Walther’s AK textbook recalls an observation by Selye (a scientist who studied stress) in animals: severe stress made nursing mother animals stop producing milk. Selye believed that when the body puts its effort into coping with stress, the pituitary gland releases less of the hormones meant for reproduction (Walther 2000). That was an observation in animals, under very severe stress. In humans, as in the Japanese experiment above, stress in the moment mainly makes it harder for milk to flow out.

At the clinic, the doctor tests muscle strength while you think about the worry you are carrying, for example "I won’t have milk again this time", to see how far the stress reaches in the frontal lobe, the limbic system and the cingulate gyrus, the brain areas linked to emotion. If the muscle weakens when you think about it, the doctor lightly places fingertips on the two bumps of your forehead while you keep thinking about it, then tests again until the muscle holds firm (Walther 2000). You don’t need to put that worry into words.

The doctor may also test muscle strength with each breathing rhythm to find the rhythm that suits you, then have you practice it before expressing (Charles, ICAK Collected Papers). For mothers who had a C-section, the doctor also checks the scar once the stitches are out, as described in the article "A healed C-section scar that still hurts, and breastfeeding". These AK steps are only an addition; adjusting feeds and expressing sessions goes on as usual.

Soft breasts or full breasts

Many grandmothers and mothers in the family are used to feeling the breasts to guess whether the baby is getting enough milk: full breasts mean there is milk, soft breasts mean the milk has run out. Traditional medicine books also feel the breasts, but to tell apart two kinds of low milk.

Fu Qingzhu (傅青主), in his gynecology book Fù Qīngzhǔ Nǚkē (傅青主女科, Fu Qingzhu’s Gynecology), treats them in two separate sections. The first section speaks of a woman after birth who has "not a single drop of milk. People think « the milk channels are blocked ». Who knows that it is because « qi and blood are both dried up »". Milk is made from qi and blood; without enough qi and blood, what is there to make milk from? When the lack is like that, simply looking for herbs to open the milk channels is, in his words, "no different from going to a starving man to beg for food". The treatment is to nourish qi and blood until they are sufficient.

The second section speaks of a woman after birth who "suddenly meets with something that goes against her wishes, and both breasts become swollen full and aching", and he says clearly that this is "not because there is no milk"; the root is Liver qi constraint and knotting (肝气郁结 / 肝氣鬱結, gān qì yù jié: qi pent up and held in because of something unhappy). Once the constraint is released, the milk channels open naturally.

Xia Guicheng gives an easy way to tell them apart. Soft breasts with thin, watery milk point to deficiency (a lack); tight, painful breasts with fairly thick milk point to excess (a blockage). In practice the two kinds often mix. Xia Guicheng’s handbook notes that clinically "mostly deficiency and excess are mixed, with deficiency the main part".

Whether there is enough or not, you have to look at the baby: Xia Guicheng takes whether the milk "meets the baby’s needs as the standard". About half of mothers who stop breastfeeding give not having enough milk as the reason, and a baby’s crying is often mistaken for hunger (Huang 2022). Truly low milk does exist (Kent 2016), so count diapers and weigh the baby; how to do this is in the article "Eating well but still low on milk, when the obstacle lies outside your meals".

Breast structure is sometimes a real limit, but rarely. Insufficient glandular tissue (underdeveloped milk-making tissue) occurs in fewer than 5 in 100 women and is suggested when the breasts grow little during pregnancy and fill little when the milk comes in (ABM 2017; Neifert 1990). No study has shown that fibroadenomas reduce milk supply. Breast tissue in the armpit can also become swollen and painful when the milk comes in; the medical literature only has individual case reports (Viera 1999), so it needs a doctor’s examination.

Feeds, expressing sessions and the night feed

Xia Guicheng advises breastfeeding as early as possible, on schedule, and feeding the baby a lot at night. The book has a line that fits the habit of feeling the breasts to guess the milk very well: "some mothers, because their breasts are not full in the early stage, stop or cut down breastfeeding on their own, which often leads to low milk".

For mothers with low milk, breastfeeding guidelines put regular feeding or expressing first: enough feeds in the day, no very long gaps, including at night, and each time the baby needs a formula top-up, the mother also expresses once (ABM 2017). Express gently; you can massage and gently compress the breast while expressing, with no need to squeeze hard. Mothers who have too much milk or blocked ducts do things differently; the article "Blocked milk ducts that keep coming back: why, and how to prevent it" covers that separately.

Among mothers expressing milk for premature babies, the longest gap between two expressing sessions is linked to milk volume. Combining hand expression with a pump, with breast compression while pumping, gave about 48% more milk (Morton 2009). Give the baby the expressed breast milk first, then formula (NICE NG75). What rhythm of feeding and expressing suits each mother is best worked out by having a breastfeeding counselor sit in on a feed.

Conventional medicines or traditional herbs to increase milk are both for the doctor to weigh up, after feeding and expressing technique have been adjusted, because if milk is removed (by the baby or by expressing) too rarely or not effectively, medicine will not make more milk (ABM 2018). Herbs that can reduce milk are listed in the article on taking traditional herbal medicine while breastfeeding.

Partial breastfeeding is still precious

The UK postnatal care guideline (NICE) states that breastfeeding is beneficial even for a short time. A baby can have some formula alongside breastfeeding, and parents are shown how to keep up the milk supply while the baby is being topped up (NICE NG194). Xia Guicheng’s traditional medicine handbook also counts treatment as successful when the mother’s milk meets about two thirds of the baby’s needs.

When a baby is breastfed and also has formula, there is still breast milk every day, especially when the mother expresses once for each top-up feed. You have done nothing wrong if your baby needs top-ups.

When to call the clinic, and when to take your baby to a doctor right away

Let the clinic know, book a pediatric visit or ask someone to watch a feed (no emergency care needed yet) when:

• By day 3–4 after birth your breasts still haven’t filled and your milk hasn’t come in;
• You had a C-section, a long or difficult labor, this is your first baby, or you are overweight, have diabetes or lost a lot of blood, because these factors tend to make milk come in late; ask someone to watch a feed early, in the first week or two;
• You had low milk last time, have had breast surgery, or your breasts changed little during pregnancy; you also need early breastfeeding support like this;
• Your baby regularly needs formula top-ups, or you want to start them, so you can be shown how to express to protect your supply;
• At about 2 weeks your baby has not yet regained birth weight; this is not rare, especially in babies born by C-section (Paul 2016), but have the baby weighed again and seen by a pediatrician to check the feeds;
• There is a new lump in your breast, or one that grows quickly or hurts while you are breastfeeding (Kulkarni 2020);
• You have long-lasting anxiety, sadness or trouble sleeping.

Take your baby to a doctor right away when:

• Your baby is very drowsy, hard to wake for feeds, or feeds very weakly;
• Your baby has very few wet diapers, or a dry mouth and lips;
• On day 4 your baby is still passing very little stool, or on day 5 still has meconium;
• Your baby’s jaundice spreads quickly or turns deep yellow.

If your baby loses more than 1/10 of birth weight (for example, a baby born at 3 kg who loses more than 300 g), have your baby seen by a pediatrician soon, the same day; if this comes with weak feeding and few diapers, go right away.

Warning signs in the mother that need immediate care (fever, a lot of pain, abnormal lochia, a red, hot, swollen breast…) are in the article "Warning signs after birth that need care right away".

Back to her story

By the end of the first week, the baby was breastfeeding directly on both sides, with some formula top-ups. The doctor suggested she express one extra time at night, around ten or eleven o’clock, and the diagnosis at that point included both sides: constraint (a blockage from stress) and blood deficiency (not enough blood to make milk). At two weeks, milk was coming in evenly on both sides, and the pain in her armpits was gone. At three weeks, she was able to drop one morning formula feed. In the fifth week she lost her appetite and felt bloated; the doctor advised an extra expressing session at dawn and a snack after expressing. At around seven weeks, about every three hours she would feel her milk come in, and she expressed about 110 ml each time.

At the visit around two and a half months, the night feeds were entirely breast milk; during the day the baby still had formula top-ups, but half as much. The baby had gone from 4.9 kg at two months to 5.5 kg, and she began to feel hungry after breastfeeding. Over time she leaned more toward deficiency, so the treatment also shifted gradually: from releasing constraint plus strengthening the Spleen and nourishing blood (easing stress, strengthening the Spleen, that is, digestion, and nourishing blood) to strengthening the Spleen and boosting qi, nourishing blood and promoting milk flow (strengthening digestion, adding strength, nourishing blood and helping the milk flow evenly).

In the fourth month, both mother and baby fell ill, the baby fed less, and she was exhausted. By about the sixth month, the baby had started solids and bottle feeding; she breastfed on and off and then stopped completely because she felt tired, after a long road of effort since week 31 of her pregnancy.

After her previous birth, her breasts were engorged and painful and she could not breastfeed. This time, her baby was breastfed for more than six months, with a stretch when even the night feeds needed only breast milk. For her, that was already a remarkable feat.

What to bring to your visit

If your milk is slow to come in or you have low milk, you can come in to the clinic. Bring a few notes on feeds and expressing sessions from the last two or three days, the number of diapers each day, your baby’s most recent weight and your hospital discharge papers. The doctor will ask about your sleep and your worries, look at your tongue, take your pulse, and then work out with you whether you lean more toward a lack or a blockage.

Worth keeping

• Count diapers and weigh your baby; don’t guess your milk from how your breasts feel or from your baby’s crying;
• After a C-section, ask to hold your baby skin to skin and breastfeed early as soon as you are alert enough;
• Keep up enough feeds or expressing sessions in the day, including one at night;
• Each time your baby needs a formula top-up, express milk once;
• Give your baby expressed breast milk first, formula second;
• Express gently, massage and gently compress the breast, no hard squeezing;
• Spend a few minutes listening to music or doing breathing exercises before expressing.

References

Sources in Vietnamese

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