Common puerperal problems

Perineum: -If the perineum has been damaged and repaired it may cause considerable pain, requiring analgesia, and women may prefer to sit on a rubber ring. -If the perineum is painful, it is important to check the sutures and check for any signs of infection. Occasionally, sutures may need to be removed. Micturition: -Retention of urine can occur (possible secondary to pudenda nerve bruising) and can occasionally require catheterization. -Approximately 50% of women will develop some urinary incontinence and this usually takes the form of stress incontinence. This may persist after the pregnancy. Pelvic floor exercises should be taught and encouraged. Bowel problems: -Constipation may be a problem for a short time and stool softeners may be useful. -Hemorrhoids may be more painful after the birth than before. These can occasionally appear for the first time prenatally and these normally disappear within a few weeks. Mastitis: -This may be due to failure to express milk from one part of the breast; it can be treated by ensuring all milk is expressed and with cold compresses. -It may be complicated by infection with Staphylococcus aureus and require treatment with flucloxacillin. -Very occasionally, a breast abscess develops and requires incision and drainage. Backache: -This may persist after the birth and affects approximately a quarter of women. -Pain may be considerable and last for several months. Psychological problems: -'Third day blues': on days 3-5, a large proportion of women become temporarily sad and emotional. -Approximately 10% of women suffer from postnatal depression which may present at any time during the first year after delivery. -The precise cause of this is unknown and may involve hormonal changes, reaction to excitement of childbirth and doubts by the mother about her ability to care for the child. -Management consists of reassuring the mother and explaining what is happening. Postpartum hemorrhage: -Primary postpartum hemorrhage is defined as loss of more than 500 ml of blood during the first 24 hours. -Normally, 200-600 ml blood lost before myometrial retraction plus strong uterine contractions stop flow. -The majority of cases are associated with either an atonic uterus or placental remnants. The rest of cases are associated with laceration of the genital tract, rarely uterine rupture or blood coagulation defect. -Treatment in situations where the placenta is still in the uterus is combining controlled cord traction with fundal pressure. If this fails, manual removal of the placenta under general anesthetic is carried out. -If the placenta has already been expelled, treatment includes massaging the uterus, intravenous (IV) ergometrine or syntocinon, or misoprostol, blood transfusion, correction of coagulation defects, bimanual compression of the uterus; urgent transfer to theatre for surgery may be required.

-Secondary postpartum hemorrhage is abnormal bleeding after 24 hours up until 6 weeks postpartum. Usual causes are: -Poor epithelialisation of placental site. -Retained placental fragment and/or blood clots (usually detected by ultrasound). -The uterus is often found to be bulky and tender with the cervix open. -Initially, it is treated with ergometrine intramuscularly plus antibiotics. Curettage is only necessary if bleeding persists despite this. -Postnatal anemia is common and may easily be overlooked. Puerperal pyrexia: -Defined as temperature 38C or above during the first 14 days after delivery. -Most cases are due to anaerobic streptococci that normally inhabit the vagina. Initially, they infect the placental bed and then spread either into the parametrium or via the uterine cavity to the Fallopian tubes and, occasionally, the pelvic peritoneum. Thromboembolism: -This occurs in <1/1,000 births and is more likely to occur in women who are overweight, over the age of 35 or who have had a Caesarean section. -Deep vein thrombosis: this is indicated by low-grade fever, raised pulse rate and a feeling of uneasiness. Calf muscles are tender and painful on firm palpation. Clinical signs are unreliable (and D-dimer cannot be used in pregnancy and puerperium), so confirmation is needed with colour Doppler ultrasound. -Treatment is with low molecular weight heparin and then oral warfarin continued for 6-12 weeks. Pulmonary embolus: -dyspnoea and pleural pain and cyanosis may develop later. Friction rub is heard on the chest. Diagnosis is confirmed by a lung perfusion scan performed urgently, as women may die within 2-4 hours. -Treatment is with IV heparin bolus followed by infusion.

Postnatal care
-This is based on NICE guidance. -Women should be offered information to enable them to promote their own and their baby's health and well-being and to recognize and respond to problems. -At the first postnatal contact, women should be advised of the signs and symptoms, and appropriate action for potentially life-threatening conditions. -All maternity care providers should encourage breast-feeding.

Maternal activity
The mother should start walking about as soon as possible, go to the toilet when necessary and rest when she needs to. She may prefer to stay in bed for the first 24 hours or longer if she has an extensive perineal repair. This is an important time for the woman to be encouraged to breast-feed and learn to care for her infant. Uterine contractions continue after birth and some women suffer after-pains, particularly when breastfeeding, and may require analgesics. Breast- and bottle-feeding Women who chose to breast-feed or bottle-feed often need a lot of advice and support, especially with their first baby (but experienced mothers shouldn't be assumed to know everything and support and advice should always be available). Breast-feeding should be strongly encouraged (first-time mothers may need a lot of support and encouragement initially).

Breast-feeding has many advantages

1. 2. 3. 4. 5. Boosting the baby's immune system. Reduction of autoimmune disorders later in life. Reducing risk of cot death. Reducing gastrointestinal problems. Promoting bonding between the mother and her baby.

Breast engorgement may cause a lot of discomfort but is usually relieved by good bra support and analgesia. Women who are unable to breast-feed or prefer to bottle-feed also need support and advice, including feeding routines and sterilizing.

Contraception
This is covered in detail in our separate article Postpartum Contraception. Contraception is not necessary in the 21 days after childbirth. Methods that are suitable choices for breast-feeding women include the lactation-amenorrhea method, barrier methods, intrauterine devices (including the levonorgestrel-releasing intrauterine system), the progestogen-only pill, injectable progesterone contraceptives, the etonogestrel implant and sterilisation. The combined oral contraceptive pill is not recommended, as it interferes with lactation. The lactational amenorrhoea method is 98% if: There is complete amenorrhoea. The woman is fully or very nearly fully breast-feeding. The baby is no more than 6 months old. Methods that are suitable choices for women who are not breast-feeding include all those for breastfeeding women but combined oral contraceptives can also be use An overview of the relevant anatomy and physiology in the postpartum period follows.

Uterus
The pregnant term uterus (not including baby, placenta, fluids, etc) weighs approximately 1000 g. In the 6 weeks following delivery, the uterus recedes to a weight of 50-100 g. Immediately postpartum, the uterine fundus is palpable at or near the level of the maternal umbilicus. Thereafter, most of the reduction in size and weight occurs in the first 2 weeks, at which time the uterus has shrunk enough to return to the true pelvis. Over the next several weeks, the uterus slowly returns to its nonpregnant state, although the overall uterine size remains larger than prior to gestation. The endometrial lining rapidly regenerates, so that by the seventh day endometrial glands are already evident. By the 16th day, the endometrium is restored throughout the uterus, except at the placental site. The placental site undergoes a series of changes in the postpartum period. Immediately after delivery, the contractions of the arterial smooth muscle and compression of the vessels by contraction of the myometrium ("physiologic ligatures") result in hemostasis. The size of the placental bed decreases by half, and the changes in the placental bed result in the quantity and quality of the lochia that is experienced.

Immediately after delivery, a large amount of red blood flows from the uterus until the contraction phase occurs. Thereafter, the volume of vaginal discharge (lochia) rapidly decreases. The duration of this discharge, known as lochia rubra, is variable. The red discharge progressively changes to brownish red, with a more watery consistency (lochia serosa). Over a period of weeks, the discharge continues to decrease in amount and color and eventually changes to yellow (lochia alba). The period of time the lochia can last varies, although it averages approximately 5 weeks. The amount of flow and color of the lochia can vary considerably. Fifteen percent of women have continue to have lochia 6 weeks or more postpartum. Often, women experience an increase in the amount of bleeding at 7-14 days secondary to the sloughing of the eschar on the placental site. This is the classic time for delayed postpartum hemorrhages to occur.

Cervix
The cervix also begins to rapidly revert to a nonpregnant state, but it never returns to the nulliparous state. By the end of the first week, the external os closes such that a finger cannot be easily introduced.

Vagina
The vagina also regresses but it does not completely return to its prepregnant size. Resolution of the increased vascularity and edema occurs by 3 weeks, and the rugae of the vagina begin to reappear in women who are not breastfeeding. At this time, the vaginal epithelium appears atrophic on smear. This is restored by weeks 6-10; however, it is further delayed in breastfeeding mothers because of persistently decreased estrogen levels.

Perineum
The perineum has been stretched and traumatized, and sometimes torn or cut, during the process of labor and delivery. The swollen and engorged vulva rapidly resolves within 1-2 weeks. Most of the muscle tone is regained by 6 weeks, with more improvement over the following few months. The muscle tone may or may not return to normal, depending on the extent of injury to muscle, nerve, and connecting tissues .

Abdominal wall
The abdominal wall remains soft and poorly toned for many weeks. The return to a prepregnant state depends greatly on maternal exercise.

Ovaries
The resumption of normal function by the ovaries is highly variable and is greatly influenced by breastfeeding the infant. The woman who breastfeeds her infant has a longer period of amenorrhea and anovulation than the mother who chooses to bottle-feed. The mother who does not breastfeed may ovulate as early as 27 days after delivery. Most women have a menstrual period by 12 weeks; the mean time to first menses is 7-9 weeks. In the breastfeeding woman, the resumption of menses is highly variable and depends on a number of factors, including how much and how often the baby is fed and whether the baby's food is supplemented with formula. The delay in the return to normal ovarian function in the lactating mother is caused by the suppression of ovulation due to the elevation in prolactin. Half to three fourths of women who breastfeed return to periods within 36 weeks of delivery.

Breasts
The changes to the breasts that prepare the body for breastfeeding occur throughout pregnancy. If delivery ensues, lactation can be established as early as 16 weeks' gestation. Lactogenesis is initially triggered by the delivery of the placenta, which results in falling levels of estrogen and progesterone, with the continued presence of prolactin. If the mother is not breastfeeding, the prolactin levels decrease and return to normal within 2-3 weeks. The colostrum is the liquid that is initially released by the breasts during the first 2-4 days after delivery. High in protein content, this liquid is protective for the newborn. The colostrum, which the baby receives in the first few days postpartum, is already present in the breasts, and suckling by the newborn triggers its release. The process, which begins as an endocrine process, switches to an autocrine process; the removal of milk from the breast stimulates more milk production. Over the first 7 days, the milk matures and contains all necessary nutrients in the neonatal period. The milk continues to change throughout the period of breastfeeding to meet the changing demands of the baby.

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. Dont 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 natures 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. 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. 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. 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. Infrared lamp to apply day heat to the area of stitches may be given to you in hospital. Oral medications such as antibiotics to prevent infection, or pain killer tablets (paracetamol, ibuprofen, etc. ) should only be taken as advised by your doctor. 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.

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. 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.

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, Dont 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.

Phases of Puerperium
1. Taking-in Phase

- This is the time of reflection for a woman. - The woman is passive letting other people (husband, nurse, etc.) do things for her and make decisions for her. - This dependence is probably due to her physical discomfort and exhaustion from the labor process. - The woman may want to talk about her labor. Encourage her to talk about the wonderment of birth. 2. Taking-hold Phase - This is the phase where the woman begins to initiate action herself. - Unlike in the previous phase, taking-hold shows a woman with great interest on caring for the baby. - Although this increased independence is good, the woman during this phase may still feel insecure about her abilities in caring for the child. This is the time where the nurse should provide relevant instructions and adequate praise for the things she does well to help increase her confidence. 3. Letting-go - The woman finally defines her new role. - She gives up the fantasized image of her child for the real one.

How Soon Can You Get Pregnant After Childbirth?

After the birth of a baby, many women wonder when their menstrual cycles and subsequently, fertility, will return. The answer to this depends on several factors, including whether or not the mother is breastfeeding her baby. Childbirth takes a toll on the mother's body, and therefore, achieving pregnancy in the weeks immediately following the birth of your baby is not recommended by most health care professionals. Because of this, it is important for mothers to know when they could become fertile again and take precautions to avoid pregnancy.

Ovulation after Childbirth

Most women experience three to eight weeks of bleeding following childbirth. In the first days immediately following the birth of your baby, this bleeding is bright red in color. As time passes, this bleeding, also known as lochia, will become lighter in flow and color, signaling the mother's uterus is nearly fully healed. The chances that a mother will ovulate during the first six weeks after giving birth is relatively low, although not impossible. Once the postpartum bleeding has stopped and if the mother is not exclusively breastfeeding, she likely will resume ovulation around 10 weeks after childbirth. In fact, 80 percent of all women who do not breastfeed report that their period has returned by this time. Because of this fact, it is possible for a woman to become pregnant before she ever has a period. If a woman is not exclusively breastfeeding, she should talk to her health care provider about contraceptive options at her six-week postpartum checkup. Breastfeeding amenorrhea method, has been proven to be 98 percent effective in preventing ovulation when used in this way. The reason breastfeeding is so effective at preventing ovulation is because the hormone prolactin is produced in large amounts every time the baby suckles at the breast. Prolactin naturally suppresses ovulation. Mothers should be aware that this method will only work as long as they continue exclusively breastfeeding. Once the baby begins to take more solid foods, or begins sleeping through the night thereby increasing the amount of time between feedings, mothers should begin to use another form of birth control because ovulation could resume at any time.

Resuming Sex
Most doctors advise mothers to wait at least six weeks after child birth has occurred before resuming sexual activity. This is because the mother's body takes at least this long to heal and recover from the trauma of childbirth. Many woman find sex to be uncomfortable for several months to a year following the birth of their baby. This is very normal, but women should discuss any concerns they have with their doctors. Around six weeks after giving birth, most women will return to their doctor for a postpartum checkup. At this visit, the doctor will examine the patient and make sure she is healing properly. Around this time, most doctors give the green light to resume intercourse and also will discuss appropriate birth control options.

POSTPARTUM DIET
Caloric Intake
Many mothers choose to breastfeed their babies. Breastfeeding mothers have to be more careful about the calories they intake. Their nutritional choices must be more sound, and this may lead to further weight loss. Non-breastfeeding mothers can reduce their caloric intake with no negative effect on the development of their babies but run the risk of cutting too many calories or making poor food choices. All new mothers should aim to eat balanced diets that include approximately 45 to 65 percent unrefined carbohydrates, 10 to 15 percent lean protein and about 20 to 35 percent unsaturated or monosaturated fats. When to Diet It is important not to try to lose post-partum weight for at least six weeks after you have the baby. Within this time you will naturally lose weight because you will lose much of the water you retained during the last weeks of your pregnancy. At this time you are also healing from childbirth and need more calories to recover from this process. Newborns rarely sleep for more than a few hours at a time, and your body will need energy to help you function on such little rest. Any diet you begin, therefore, should wait until your baby is nearing her second month. Unless you are breastfeeding, your diet does not have to be different than it was before you had your baby.

Post Partum Exercising

Exercise is a good way to regain your fitness after giving birth and can be a big part of a post-partum weight loss plan. It is important to begin exercising slowly, particularly if you did not exercise before or during your pregnancy. Most women generally have a six week post-partum checkup with their obstetrician.