PUERPERIUM

Postnatal Care 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.

Phases of Puerperium:

 Taking - In Phase The taking -in phase, the first phase experienced, is a time of reflection for a woman. During this period, the woman is largely passive. She prefers having a nurse minister to her to get her a bath towel or a clean night gown, and make decisions for her rather than doing these things herself. This dependence is due partly to her physical discomfort from possible perineal stitches, afterpains, or hemorrhoids; partly to her uncertainty in caring for newborn; and partly from the extreme exhaustion that follows childbirth.  Taking - Hold Phase After the time of passive dependence, a woman begins to initiate action. She prefers to get her own washcloth and to make her own decisions. Women who give birth without anesthesia may reach this second phase in a mater of hours after birth. During the taking - in period, a woman may have expressed little interest in caring for her child. Now, she begins to take a strong interest, as a rule therefore, it is always best to give the woman brief demonstration of baby care and then allow her to care for the child herself with watchful guidance. Although a woman’s action suggest strong independence during this time, she often stills feels insecure about her ability to care for her new child. She needs praise for the things she does well to give her confidence. Do not rush a woman through the phase of taking - in or prevent her from taking hold when she reaches that point. For many young mothers, learning to make decisions about their child’s welfare is one of the most difficult phases of motherhood. It helps if the woman has practice in making such decisions in a sheltered setting rather than first taking on that level of responsibility when she is on her own.  Letting - Go Phase In this 3rd phase, called letting go, the woman finally refines her new role. She gives up fantasize image of her child and accept that real one; she gives up her old role of being childless or the mother of only one or two. This process requires some grief work and adjustment of relationships similar to what occurred during pregnancy. It is extended, and continues during the child’s growing years. A woman who has reached this phase is well into her new role.

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. 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 5<sup>th 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 labor, you are exhausted and sleepy. Secondly you may be having pain in the stitches of the episiotomy It is important to take a high fiber diet and plenty of liquids to prevent hard stools. You may need a mild laxative for a few days.  Breast: 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. Link to engorged breast in Breastfeeding .  After - Pains: The delivery is over. You have borne with labor 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. Link to letdown reflex in 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. 

These include:

POST PARTAL EXERCISES MUSCLE STRENGTHENING EXERCISE

1. Abdominal Breathing - abdominal breathing maybe started on the first day postpartum, because it is a relatively easy exercise. Lying flat on her back on sitting, a woman should breath slowly and deeply in and out 5 minds, using her abdominal muscles. 2. Chin - to chest - chin to chest exercise is excellent for the second day. Lying on chin forward on her chest without moving any other part of her body while exhaling. She should start this gradually, repeating it no more than 5 times the first time and then increasing it to 10-15 times in succeeding. The exercises can be done 3 to 4 times a day. She will feel the abdominal muscles pull and tighten if she is doing it correctly.

3. Perineal Contraction - If a woman is not already if she is doing it correctly. Of alleviating perineal discomfort, it is a good one to add on the third day. She would tighten and relax her perineal muscles 10-15 times in succession as if the trying to stop voiding. She will feel her perineal muscles working if she is doing it correctly. 4. Arm Raising. Arm raising helps both the breasts and the abdomen return to good time is a good exercise to add on the fourth day. Lying on back, arms at her sides, a woman moves arms out from her sides until they are perpendicular to her body. She time raises them over her body until they are perpendicular to her body. She then raises them over her body until her hands touch and lowers them slowly to her sides. She should rest a moment, then repeat the exercise 5 times. 5.Abdominal Crunches. It s advisable to wait until to 10 th and 12th day after delivery before attempting abdominal crunches. Lying flat on her back with knees bent a woman folds her arms across her chest and raises herself to a sitting position. This exercise expenses a great deal foe effort and tires a postpartum woman easily. She should be cautioned to begin it very gradually and work up slowly to doing it 10 times in a row.

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. Link to introduction of puerperium 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 you. 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, Link to Father’s role, 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 1<sup>st 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:

Link to lactation amenorrhoea in preventing pregnancy. While you are exclusively breastfeeding, Link to exclusive breastfeeding in Breastfeeding, the hormonal changes is your body act on the genital tract to suppress ovulation and menstruation. Link to female reproductive, tract, 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) Does this mean you cannot get pregnant? The answer is NO. About 5% of women get pregnant before they start menstruating, post-delivery. Lactation 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. 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: 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. Link (6 weeks from childbirth) or later, even if you do not have periods, provided your internal checking is normal. Oral Contraception pills: These are a type of hormonal contraception. 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. Sterilization: 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

You may need to do some tests. You need to discuss the following issues with your doctor

ESTABLISH SUCCESSFUL LACTATION In most of the hospital they require the mothers who delivered there to breast reed as soon as possible because the baby will receive colostrums that contains gamma globulins. Advantages of breath feeding to the mother are: It is economical in terms of money and effort, more rapid involution, loss incidence of cancer of the breast. For the baby: closer mother infant relationship, contains antibodies that protect against common illness, less incidence of gastrointestinal diseases and always available at the right temperatures.

BREASTFEEDING

Breast milk is preferred method of feeding a newborn because it provides numerous health benefits to both the mother and the infant. It remains the ideal nutritional source for infants through the first year of life. Nurses can play a major role in teaching women about the benefits of breastfeeding and providing anticipatory guidance for problems that may occur by implementing steps such as:  Educating all pregnant woman about the benefits and management of breastfeeding.  Helping women initiate breastfeeding within half an hour of birth.  Assisting mothers to breast-feed and maintain lactation even if they should be separated from their infant.  Not giving newborns food or drink other than breast milk unless medically indicated.  Not giving pacifies to breastfeeding infant.  Practicing rooming- in (allow mothers and infants to remain together) 24 hours a day.  Encouraging breastfeeding on demand.  Fostering the establishment of breastfeeding support groups and referring mothers to them on discharge from the birthing center or hospital. The mother gains several physiologic benefits from breast feedings, such as: breastfeeding may serve as a protective function in preventing breast cancer, the released of oxytocin from the posterior pituitary aids uterine involution and successful breastfeeding can have an empowering effect because it is a skill only woman can master. Breastfeeding also reduces the cost of feeding and preparation time. Many women feel that breastfeeding enhances the formation of a true symbiotic bond with their child. Breastfeeding has major physiologic advantages for the baby. Breast milk contains secretary immunoglobulin A, which binds large molecules of foreign proteins, including viruses and bacteria and keeps them from being absences to the GIT into the infant. Prolactin An anterior pituitary hormone, acts on the acinar cells of the mammary gland to stimulate the production of milk. In addition, when infant’s sucks at the breast, nerve impulses travel from the nipple to the hypothalamus to stimulate the production of prolactin releasing factor. Colustrum The acinar breast cells starting in the 4th month of preganancy secrete a thin watery, yellow fluid composed of protein, sugar, fat, water, minerals, vitamins, and maternal antibodies. Lactoferin Is an iron binding protein in breast milk that interferes with growth of pathogenic bacteria? Lysozyme In breast milk apparently actively destroys bacteria by lying their cell membranes, possibly increasing the effectiveness of antibodies. Leukocytes In breast milk provide protection against common respiratory infections invaders. L bifidus Interferes with the colonization of pathogenic bacteria, in GIT. the incidence of diarrhea. Breast milk also contains ideal electrolyte and mineral composition for human infant growth .

Advantage of breastfeeding

Little controversy exist about breastfeeding as the best nutrition for human infants, but the decisions to breastfeed depends on what would please the woman the most and make and make her most comfortable. If she is comfortable and pleased with what she is doing, her infant will be comfortable and pleased, will enjoy being fed, and will thrive.

Breastfeeding is contraindicated in only a few circumstances, such as:

An infant with galactosemia (such infant cannot digest the lactose in milk Herpes lesions on the mother’s nipples Mother is on restricted nutrient diet that prevents quality milk production Mother is receiving medications that are inappropriate for breastfeeding, such as lithum or methotrexate. Maternal exposure to radioactive compounds, as could happen during thyroid testing

Advantage for the mother

A woman gains several physiologic benefits from breastfeeding, including: Breastfeeding may serve a protective function in preventing breast cancer The release of oxytocin from the posterior pituitary gland aids in uterine involution Successful breastfeeding can have an empowering effect because it is a skill only woman can master. Breastfeeding also reduces the cost of feeding and preparation time. Many women feel that breastfeeding provides the best opportunity to enhance the formation of a true symbiotic bond with their child. Although this does occur readily with breastfeeding, a woman who holds her baby to bottle- feed can form this bond equally well. Some woman believes that breastfeeding is a foolproof contraceptive technique. Some feel breastfeeding will help them lose their weight gained during pregnancy. This also is not true, and women who arebreastfeeding need to concentrate on eating a well balance diet to ensure that her milk is rich in nutrients. Some woman are reluctant to breastfeed because they fear that having to be available to feed the baby every 3 or 4 hours will tie them down.

Advantage for the Baby

Breastfeeding has many physiologic advantages for the baby. Breast milk contains contains immunoglobulin A (IgA), which binds large molecules of foreign proteins, including bacteria and viruses. Thus keeping them from being absorbed through the gastrointestinal tract into the infant. Lactoferin is an iron binding protein in breast milk that interferes with growth of pathogenic bacteria. Lysozyme in breast milk apparently actively destroys bacteria by lying their cell membranes, possibly increasing the effectiveness of antibodies. Leukocytes in breast milk provide protection against common respiratory infections invaders. L bifidus interferes with the colonization of pathogenic bacteria, in GIT. the incidence of diarrhea. Breast milk also contains ideal electrolyte and mineral composition for human infant growth. Breast milk contains more linoleic acid, an essential amino acid for skin integrity, and less sodium, potassium, calcium and phosphorous than do many formulas. Breast milk also has a better balance of trace elements, such as zinc, than formulas do. These levels of nutrients are enough to supply the infants needs, yet they spare the infant’s kidneys from having to process a high renal solute load of unused nutrients. One disadvantage of breast milk is that it may carry microorganisms such as hepatitis B and cytomegalovirus, although the

risk to infant is small. HIV is carried at a high enough level in breast milk that women who are HIV positive are advised not to breast -

feed.

Preparing for Breastfeeding
Ask all women during pregnancy whether they plan to breast- feed or formula feed their newborn. Thinking about feeding in advance allows couples to make informed choices. Some fathers experience jealousy at the thought of breastfeeding. Physical preparation such as nipple rolling, advised in the past as a way of making the nipple more protuberant is no longer advised. This is unnecessary because few women have inverted or non-protuberant nipples, plus oxytocin, released by this maneuver, could lead to pre-term labor (nipple rolling is used to create uterine contractions for stress test). Practicing breast massage to move the milk forward in the milk ducts (manual expression of milks) maybe helpful. This can help a woman who feels hesitant about handling her breast to grow accustomed to doing so, allowing her to assist with milk production in the first few days after birth. Manual expressions consists of supporting the breast firmly, then placing the thumbs and forefinger on the opposite sides of the breast just behind the areolar margin, first pushing backward toward the chest wall and then downward until secretion begins to flow. Teach woman not to used soap on their breasts during pregnancy because soap tends to dry and crack nipples. The occasional woman who has inverted nipples may need to wear a nipple cup (a plastic shell) to help the nipples become more protuberant.

BEGINNING BREASTFEEDING

Breastfeeding should begin as soon as possible, ideally while the woman is still in the delivery or birthing room and while the infant is in the first reactivity period. This practice has several advantages infant suckling stimulates release of oxytocin which in turns stimulates uterine contracts to prevent hemorrhage, promotes closer maternal and infant relationship, prevents breast engorgement: If it is not possible to start breastfeeding right after delivery, initiate breastfeeding, then, after 4 to 8 hours when the mother has already rested on her condition and stable.

HOW TO FEED
1. Instruct mother to relax first before feeding, anxiety and fatigue interferes with the let down reflex 2. Wash hands and assumes a comfortable position. The mothers can breastfeed lying down or sitting, which ever is comfortable for her and her baby. 3. If the baby is asleep or sleepy talking or rubbing baby’s soles will gently wake him or wake up breastfeeding is more effective if the baby is awake. 4. Guide baby to the breast by stimulating rooting reflex, touch the cheek nearest the breast. The baby will respond by turning his head and opening his mouth. 5. Press the breast away from the nose with a finger if the breast blocks the baby’s nose. 6. Let the baby’s mouth grasp both the nipple and areola. 7. Feed the baby for only 2 to 3 minutes during the first time, then, increase feeding time by one minute each day until the infant is fad for ten minutes on each breast 8. When removing the baby from the breasts, pull the chin down or place a finger in the corner of the mouth to break the suction. Pulling the baby from the breasts is painful and can cause sore nipple. 9. On the next feeding, place infant on the breast where she or he last fed during the previous feeding. 10. Instruct mother to burp infant after feeding by placing baby on her lap on a prone position or positioning him or her in sitting upright. 11. Signs of proper feeding:  the baby’s mouth group both nipple and areola.  the other breast flows with milk. Infant sucking stimulates release of oxytocin, which in form stimulates milk let down reflex.  the mother feels after pains or uterine cramping while breastfeeding, this is due to release of oxytocin. 12. It is not unusual to haves scanty milk supply during the first few days after delivery. There is no need to offer milk formula to the infant. Placing infant regularly on the breasts will stimulate milk production. Maintenance of successful lactation requires that breasts are completely emptied at each feeding so that they will completely fill again. The more the baby suckles, the more milk is produced. 13. Instruct the mother to avoid:  Smoking  Oral contraceptives because they decrease milk supply  Drugs passed to infant via breast milk.

Problems of breastfeeding:

1. Breast Engorgement Breast engorgement usually occurs during the 3 rd to 4th day after delivery. The mother complains of pain and tenderness, the breast are reddish, tense, shiny, hot to touch and feels firm and nodular. Breast engorgement is not cause by milk or infection but by lymphatic and venous congestion. When the breast are engorged, the infant will not be able to grasp the nipple effectively and pain can cause the mother to avoid or refused breastfeeding. Management:  Give analgesics before feeding to provide pain relief  Give breast more often to empty breast with milk and prevent further engorgement  Initiate breastfeeding as soon as possible after delivery to prevent engorgement.  Let warm water run over the breast or apply warm compress to improve circulation and promote comfort if the mother plans breastfeed. If the mother does not plan to breastfeed, apply ice packs.  Reassure mother that engorgement is temporary and it will subside after 24 hours. 2. Sore and Crack Nipples Causes:  Forceful pulling of the infant after feeding  Improper sucking - infant grasping only the nipple during feeding  Breastfeeding too long  Nipple remaining moist for a long time due to leakage of milk Management:  Expose to air after feeding to let nipples dry  Use of loose fitting clothing and leaving bra unsnapped to let air circulate in the breast for a few minutes  Limit amount of time of feeding to allow nipple to healed  Use of nipple shield  Express milk usually or by breast pump if breastfeeding causes too much pain to maintain milk supply  Sore nipples are not contraindication to breastfeeding unless the mother cannot tolerate the discomfort caused by infant suckling. She can express milk from her breasts and give it to infant using feeding bottle.