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Care
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Postnatal and Puerperium
Introduction
Throughout pregnancy, you were center stage: your partner, your
family, your doctor and you yourself were concentrating
on various aspects of your health and care in
pregnancy and labour. The foetus growing inside
you was a secondary patient. Now that you have
delivered, the focus of everybody’s attention,
including your own seems to have shifted suddenly
from you to the little bundle of joys (well, most
of the time joy, sometimes trouble!) next to you.
This is but natural, and we are sure you will
take it in your stride. However, there are many
things about your body that are still going to
change. This post delivery period is extremely
important, and to recover to your pre-pregnancy
health (if not better) you need to pay attention
to yourself too.
Puerperium / (Post
delivery period)
This is the medical term for the period following childbirth
during which the body tissues, in particular the
genital and the pelvic organs, return to the condition
they were in pre-pregnancy.This post delivery
period of change continues till about 6 weeks
(42 days) from delivery. At the end of this time,
you will be feeling almost back to normal, except
for some changes such as a little excess weight.
Perhaps this is the reason why, traditionally
the concept of 40 days (or ‘sava mahina’) of post-partum
confinement was and often still is, the rule in
most Indian homes. It gives you time to recover.
Immediate
Puerperium
The first 24 hours after birth, or the immediate puerperium,
is a critical stage. This is the time when
your uterus has to contract well, in order
to stop the bleeding from the site of placental
attachment. It is also the initiation of
breastfeeding and bonding 
Occasionally, this is the time that most
life threatening complications of delivery
manifest. These include postpartum excessive
bleeding, collapse of the circulation, cardiac
failure, etc. These are not common, but
even with normal vaginal birth there is
a risk of death of about 1 in 10,000 women.
This risk may be more in women with pre-existing
medical conditions like anaemia, hypertension or heart diseases.
It is also more with operative deliveries .
Hence you will be advised to stay in hospital
for at least 24 hours following childbirth.
Early
Puerperium
This refers to the 2nd to 7th day post
delivery where major changes start in your
genital tract. This is probably also the
time of maximum adjustment when you come
to terms with your new role as ‘mother’.
You will also be going home with your baby
in this period. There are many relatively
minor, yet significant bodily changes you
should be aware of. These include:
Lochia
/
Vaginal discharge
This term refers to the discharge from the vagina, coming mainly
from shedding of the inner lining of the
uterus. For the first 4 days, there is fresh
bleeding, like a heavy menstrual flow (Lochia
rubra). You may need to use 2 pads at a
time, changing 3 – 4 times a day. However,
if you find it very heavy, or large clots
keep coming out, you must inform your doctor.
Usually by the 5th day the flow
becomes much less, and may now be more of
a blood stained yellowish-brown discharge.
You may still require sanitary protection,
about 2 – 3 pads a day. This discharge called
‘lochia serosa’ usually stops by the end
of the second week after which it becomes
a plain white discharge. Good hygiene and
care of episiotomy will prevent infection.
Any foul smell in the discharge should be
reported to your doctor.
Urination
The first day you must pass urine at least 2 – 3 hourly, despite
pain in the stitches. This is because the
bladder may become overfull without you
realize it, which can cause problems, especially
infections later. During the first week,
you may notice that you seem to be passing
a lot of urine. This is because your body
is removing some of the excess water and
salt that was retained in pregnancy.
Stools
You may not have a good bowel motion for
the first 2 days following delivery, for
various reasons. One is that you have not
eaten much during labour, you are exhausted
and sleepy. Secondly you may be having pain
in the stitches of the episiotomy. It is
important to take a high fibre diet and
plenty of liquids to prevent hard stools.
You may need a mild laxative for a few days.
Breasts
The first day you will have only a watery,
yellowish discharge, not looking like ‘real’
milk coming from the breasts. This is called
colostrum and it is rich in many nutritive
factors that are needed by your baby. .
You must feed your baby at this time. By
the third day, the milk flow increases a
lot, due to hormonal changes in your body.
Regular feeding is important to prevent
engorgement.
After Pain
The delivery is over. You have borne with
labour pains. So now you may be worried
that you are still getting a cramping lower
abdominal pain off and on. Don’t worry,
there is nothing left inside! This is a
normal phenomenon, which occurs due to the
uterus contracting in response to oxytocin,
a natural body hormone. This is more marked
when you are breastfeeding.
It is nature’s way of
getting your uterus back to the normal size.
If the pain is severe, or you are having
other symptoms like fever or excess bleeding,
you need to inform your doctor.
Care of
Episiotomy
If you have
had stitches on your perineum there are
a few things you need to do, particularly
in the first week, to make yourself comfortable
and keep healthy.
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Cleaning the area at least twice
a day, with local dilute antiseptic
solution like Savlon or Dettol.
This is a must after passing stools,
and washing with water should
be done after passing urine. Remember,
always wash from front to back,
never the other way, to prevent
infection.
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Local application of antiseptic creams such as Soframycin,
Metrogyl gel, Betadine E
– com may be useful to prevent infection. This is usually
done twice daily, after bath and
before going to sleep at night.
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Pain relieving methods such as hot seitz baths, hot
water washes or hot water bag
may be useful. For a seitz bath
you need a round tub large enough
for your bottom to fit in, in
which hot water with dilute antiseptic
solution is kept. These measures
make you feel better, usually.
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Another way of getting pain relief
is local application of ointment
such as 2% xylocaine,
which acts as a local pain-reliever.
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Infrared lamp to apply day heat
to the area of stitches may be
given to you in hospital.
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Oral medications such as antibiotics
to prevent infection, or pain
killer tablets (paracetamol, ibuprofen,
etc. ) should only be taken as
advised by your doctor.
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Most doctor use stitches, which
dissolve on their own and / or
fall off after a few days. Ask
your doctor if you need to come
back to show the stitches.
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Post
Partum Blues
There are many changes, which have happened to you in the past
9 months, and even more are happening now.
You may be feeling a little left out or
dissociated from your surroundings. The
swings in your hormone levels are maximum
in the first week. Your baby may be keeping
you awake all the time, your breasts feel
sore, and your stitches are hurting …….
Many things add up to make you feel down.
Many women feel low or depressed soon after
delivery – in fact, it is so common that
there is a medical team for it, called ‘fifth
day blues’! Talk to your partner, your friends,
an older relative or your health care persons.
Ask for help with the baby if you are tired.
Have a good cry. Take a break, sleep for
a while and you will feel better. If this
feeling of depression does not settle in
a few days, then perhaps you should see
your doctor for help, Sometimes an underlying
hormonal problem like low thyroid function
may be causing these feelings.Remember that
these feelings are not uncommon. You are
not the only mother who is not feeling ‘100%
maternal love’ all the time, particularly
soon after delivery. Be good to yourself,
pamper yourself also, and talk about what
you feel. Soon, you too will feel on ‘top
of the world’!
Resuming
Activities
As discussed earlier, it takes
up to 6 weeks for your body to recover from
the changes of pregnancy. So, be patient
with yourself. Listen to your body and do
as much as you feel up to, Different women
have different abilities to deal with their
health changes. However, in most cases,
after a normal vaginal delivery, you will
be able to resume your daily personal care
activities within a day, and your household
routine within a week, Don’t overexert yourself
– This is the time you need to devote to
yourself and your baby. Take help, involve
your partner, ,
and others available to make your life easier. After a complicated childbirth, or after a caesarean delivery
your recovery may take twice as much time,
so be patient.
Postnatal Exercises
Sexual Activity is best avoided in the early post delivery period.
This is because your stitches may be raw
or painful, and your genital tract is prone
to infection, particularly in the 1st
week. Complete restoration of the lining
of the uterus, including the placental site,
is not complete. Hence traditionally some
advise abstinence till 6 weeks following
delivery. However, if you have had an uncomplicated
birth, and are not having any problems,
you could resume your sexual life earlier.
You and your partner may have been deprived
of each other, particularly in the last
month of pregnancy. Hence, it is not unusual
to feel the need to renew your sex – life.
Until you feel comfortable for actual penetrative
sexual intercourse, other displays of caring
and affection can suffice. Hugging, kissing,
petting or touching is not forbidden at
anytime during pregnancy or post-delivery.
Lactational Amenorrhoea
While you are exclusively breastfeeding, the hormonal changes is your body act on the
genital tract to suppress ovulation and
menstruation.
.
You may not get your periods for a few months. Some women
do not start menstruating for up to a year,
depending on the pattern and frequency of
breastfeeding.
| Timing |
No
lactation |
If
lactation established |
| Menstruation |
6 – 12 weeks |
36 weeks (average) |
| Earliest ovulation |
4 weeks |
12 weeks |
| Average time for ovulation. |
8 – 10 weeks |
17 weeks (variable) |
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Does
this mean you cannot get pregnant? The answer
is NO. About 5% of women get pregnant before
they start menstruating, post-delivery.
Lactational amenorrhoea (absence of periods)
does protect you from pregnancy to some
extent. However, you can rely completely
on Lactational amenorrhoea as a method of
preventing pregnancy ONLY IF ALL 3 preconditions
listed below are satisfied:
Contraception
If you are relying on lactational amenorrhoea,
you may be protected. If not, that brings
us to the important question: Are you ready
for another pregnancy? You need to give
your body time to recover, your baby time
to grow up and yourself time to adjust to
the new role of ‘mother’. Of course, it
is a question of personal choice but a minimum
gap of 2 years is recommended between successive
pregnancies .So, How can you prevent pregnancy
during the post-delivery period?
There are many methods available. .
During
the post partum period, however, certain
factors need to be kept in mind:
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Whether breastfeeding or not.
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Frequency of sexual intercourse.
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For how long pregnancy prevention is required.
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The final choice is also influenced by your personal needs
and experience.
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Others
Condoms
Condoms are a good, locally acting method,
which are reliable if used correctly and
consistently. They have no side effects
and are useful for couples with less frequent
sexual intercourse.
IUCDs or ‘loops’
These are a very reliable method, requiring one visit to the
doctor for insertion, which can be done
easily without anaesthesia. They are effective
for average 3 – 5 years (depends on the
device) and are independent of the sexual
act, unlike condoms. This is a very popular
method for women with one or more children.
Infact, can be used as an option to permanent
procedure. The IUCD can be inserted at the first postnatal visit. (6 weeks
from childbirth)
or later, even if
you do not have periods, provided your internal
checking is normal.
Oral
Contraception Pills
During the period of exclusive breastfeeding the combined Oral
Contraception pills (containing Estrogen
+ Progesterone) may reduce the breast milk
flow. Hence are not popularly recommended.
Once weaning is begun, there can be used
safely.
Progesterone
Only
contraception like monthly injections (Noristerat,
----- or Depo-provera, ----------)
or implants (Norplant I & II) can be
safely used in the post partum period. They
are very reliable, and do not cause any
reduction in milk output. The only problem
is that they cause period to be irregular
– which does not really matter much in post
partum as the cycles are in any case irregular
due to hormonal changes.
Sterilisation
This is a permanent method, which can be opted for after you
have completed your family. This is a procedure
which can be done easily immediately post-delivery
(puerperial sterilization) or at the time
of caesarean section. For both these options,
you need to discuss the pros and cons with
your doctor and spouse before delivery,
ideally in one early antenatal period. Some prefer to wait until the youngest child is older, preferably
above 1 year old, before doing this permanent
procedure. As an interval procedure, 6 weeks
or more after delivery, it is usually done
by laparoscopy.
First Postnatal Visit
You and your baby have been through a lot.
After you go home, and you recover from
childbirth, your doctor will need to see
you at least once to confirm that your recovery
is complete. The first check up is usually
6 weeks from delivery. It may be earlier,
about 3 weeks, if you have needed special
care or had any problem in delivery.
At the first visit, your doctor will check
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Your weight.
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Blood pressure.
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Signs of anaemia.
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Your breasts.
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Your episiotomy scar (should be dissolved by now).
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Your uterus (to see if it is shrinling back to normal
size).
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You may need to do some tests. You need to discuss the following
issues with your doctor
You are now at the end of your journey – How was it ? How did
it go ? Give us your feedback at Email
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