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.

She may prefer to stay in bed for the first 24 hours or longer if she has an extensive perineal repair. Curettage is only necessary if bleeding persists despite this. it is treated with ergometrine intramuscularly plus antibiotics. Uterine contractions continue after birth and some women suffer after-pains. Breast-feeding should be strongly encouraged (first-time mothers may need a lot of support and encouragement initially). -Postnatal anemia is common and may easily be overlooked. over the age of 35 or who have had a Caesarean section. Thromboembolism: -This occurs in <1/1. -Deep vein thrombosis: this is indicated by low-grade fever. Pulmonary embolus: -dyspnoea and pleural pain and cyanosis may develop later. -Most cases are due to anaerobic streptococci that normally inhabit the vagina. . the pelvic peritoneum. go to the toilet when necessary and rest when she needs to. as women may die within 2-4 hours. -Initially. Puerperal pyrexia: -Defined as temperature 38°C or above during the first 14 days after delivery. occasionally. and appropriate action for potentially life-threatening conditions. Initially. -Retained placental fragment and/or blood clots (usually detected by ultrasound). Maternal activity The mother should start walking about as soon as possible. -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. Breast.and bottle-feeding Women who chose to breast-feed or bottle-feed often need a lot of advice and support. This is an important time for the woman to be encouraged to breast-feed and learn to care for her infant. -Treatment is with IV heparin bolus followed by infusion. so confirmation is needed with colour Doppler ultrasound. raised pulse rate and a feeling of uneasiness. -Treatment is with low molecular weight heparin and then oral warfarin continued for 6-12 weeks. -All maternity care providers should encourage breast-feeding. especially with their first baby (but experienced mothers shouldn't be assumed to know everything and support and advice should always be available). Calf muscles are tender and painful on firm palpation.000 births and is more likely to occur in women who are overweight. particularly when breastfeeding. -The uterus is often found to be bulky and tender with the cervix open. they infect the placental bed and then spread either into the parametrium or via the uterine cavity to the Fallopian tubes and. -At the first postnatal contact. Clinical signs are unreliable (and D-dimer cannot be used in pregnancy and puerperium). Diagnosis is confirmed by a lung perfusion scan performed urgently. women should be advised of the signs and symptoms. Usual causes are: -Poor epithelialisation of placental site.-Secondary postpartum hemorrhage is abnormal bleeding after 24 hours up until 6 weeks postpartum. Postnatal care -This is based on NICE guidance. Friction rub is heard on the chest. and may require analgesics.

although the overall uterine size remains larger than prior to gestation. Breast engorgement may cause a lot of discomfort but is usually relieved by good bra support and analgesia. The baby is no more than 6 months old. Women who are unable to breast-feed or prefer to bottle-feed also need support and advice. Immediately postpartum. and the changes in the placental bed result in the quantity and quality of the lochia that is experienced. the etonogestrel implant and sterilisation. most of the reduction in size and weight occurs in the first 2 weeks. including feeding routines and sterilizing. 4. The combined oral contraceptive pill is not recommended. intrauterine devices (including the levonorgestrel-releasing intrauterine system). Reducing gastrointestinal problems. the progestogen-only pill. Contraception This is covered in detail in our separate article Postpartum Contraception. Immediately after delivery. By the 16th day. Over the next several weeks. 2. The woman is fully or very nearly fully breast-feeding. etc) weighs approximately 1000 g. fluids. 3. Boosting the baby's immune system. the uterus slowly returns to its nonpregnant state.Breast-feeding has many advantages 1. barrier methods. at which time the uterus has shrunk enough to return to the true pelvis. The size of the placental bed decreases by half. Reduction of autoimmune disorders later in life. Methods that are suitable choices for breast-feeding women include the lactation-amenorrhea method. placenta. the endometrium is restored throughout the uterus. Promoting bonding between the mother and her baby. The placental site undergoes a series of changes in the postpartum period. Uterus The pregnant term uterus (not including baby. as it interferes with lactation. Contraception is not necessary in the 21 days after childbirth. the contractions of the arterial smooth muscle and compression of the vessels by contraction of the myometrium ("physiologic ligatures") result in hemostasis. except at the placental site. the uterine fundus is palpable at or near the level of the maternal umbilicus. . injectable progesterone contraceptives. The endometrial lining rapidly regenerates. Reducing risk of cot death. 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. the uterus recedes to a weight of 50-100 g. In the 6 weeks following delivery. Thereafter. The lactational amenorrhoea method is 98% if: There is complete amenorrhoea. so that by the seventh day endometrial glands are already evident. 5.

Ovaries The resumption of normal function by the ovaries is highly variable and is greatly influenced by breastfeeding the infant. but it never returns to the nulliparous state. . Most women have a menstrual period by 12 weeks. nerve. Abdominal wall The abdominal wall remains soft and poorly toned for many weeks. In the breastfeeding woman. The red discharge progressively changes to brownish red. including how much and how often the baby is fed and whether the baby's food is supplemented with formula. and sometimes torn or cut. the resumption of menses is highly variable and depends on a number of factors. Fifteen percent of women have continue to have lochia 6 weeks or more postpartum. the discharge continues to decrease in amount and color and eventually changes to yellow (lochia alba). The mother who does not breastfeed may ovulate as early as 27 days after delivery. and connecting tissues . The woman who breastfeeds her infant has a longer period of amenorrhea and anovulation than the mother who chooses to bottle-feed. a large amount of red blood flows from the uterus until the contraction phase occurs. with more improvement over the following few months. Thereafter. 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. Often. The amount of flow and color of the lochia can vary considerably. the vaginal epithelium appears atrophic on smear. Vagina The vagina also regresses but it does not completely return to its prepregnant size. it is further delayed in breastfeeding mothers because of persistently decreased estrogen levels. depending on the extent of injury to muscle. Over a period of weeks. Resolution of the increased vascularity and edema occurs by 3 weeks. the external os closes such that a finger cannot be easily introduced. At this time. during the process of labor and delivery. is variable. The muscle tone may or may not return to normal. the volume of vaginal discharge (lochia) rapidly decreases. Perineum The perineum has been stretched and traumatized. the mean time to first menses is 7-9 weeks. Cervix The cervix also begins to rapidly revert to a nonpregnant state. By the end of the first week.Immediately after delivery. Most of the muscle tone is regained by 6 weeks. however. Half to three fourths of women who breastfeed return to periods within 36 weeks of delivery. women experience an increase in the amount of bleeding at 7-14 days secondary to the sloughing of the eschar on the placental site. and the rugae of the vagina begin to reappear in women who are not breastfeeding. The duration of this discharge. known as lochia rubra. The period of time the lochia can last varies. This is restored by weeks 6-10. The return to a prepregnant state depends greatly on maternal exercise. although it averages approximately 5 weeks. This is the classic time for delayed postpartum hemorrhages to occur. with a more watery consistency (lochia serosa). The swollen and engorged vulva rapidly resolves within 1-2 weeks.

Perhaps this is the reason why. There are many relatively minor. These include postpartum excessive bleeding. Over the first 7 days. the removal of milk from the breast stimulates more milk production. The milk continues to change throughout the period of breastfeeding to meet the changing demands of the baby. hypertension or heart diseases. and may now be more of a blood stained yellowish-brown discharge. which begins as an endocrine process. the prolactin levels decrease and return to normal within 2-3 weeks. Any foul smell in the discharge should be reported to your doctor. Immediate Puerperium The first 24 hours after birth. This is the time when your uterus has to contract well. is a critical stage.Breasts The changes to the breasts that prepare the body for breastfeeding occur throughout pregnancy. but even with normal vaginal birth there is a risk of death of about 1 in 10. return to the condition they were in pre-pregnancy. in order to stop the bleeding from the site of placental attachment. etc. with the continued presence of prolactin.000 women. Lactogenesis is initially triggered by the delivery of the placenta. You will also be going home with your baby in this period. This discharge called ‘lochia serosa’ usually stops by the end of the second week after which it becomes a plain white discharge. this is the time that most life threatening complications of delivery manifest. except for some changes such as a little excess weight. The process. You may need to use 2 pads at a time. If the mother is not breastfeeding. and suckling by the newborn triggers its release. or large clots keep coming out. which the baby receives in the first few days postpartum. The colostrum is the liquid that is initially released by the breasts during the first 2-4 days after delivery. You may still require sanitary protection. . traditionally the concept of 40 days (or ‘sava mahina’) of post-partum confinement was and often still is. the milk matures and contains all necessary nutrients in the neonatal period. coming mainly from shedding of the inner lining of the uterus. It gives you time to recover. However. this liquid is protective for the newborn. there is fresh bleeding. lactation can be established as early as 16 weeks' gestation. if you find it very heavy. like a heavy menstrual flow (Lochia rubra). Good hygiene and care of episiotomy will prevent infection. about 2 – 3 pads a day. the rule in most Indian homes. cardiac failure. At the end of this time. For the first 4 days. This post delivery period of change continues till about 6 weeks (42 days) from delivery. It is also more with operative deliveries Hence you will be advised to stay in hospital for at least 24 hours following childbirth. Puerperium / (Post delivery period) This is the medical term for the period following childbirth during which the body tissues. switches to an autocrine process. in particular the genital and the pelvic organs. These include: Lochia / Vaginal discharge This term refers to the discharge from the vagina. is already present in the breasts. Usually by the 5th day the flow becomes much less. collapse of the circulation. High in protein content. These are not common. you must inform your doctor. you will be feeling almost back to normal. It is also the initiation of breastfeeding and bonding Occasionally. or the immediate puerperium. yet significant bodily changes you should be aware of. If delivery ensues. The colostrum. This is probably also the time of maximum adjustment when you come to terms with your new role as ‘mother’. Early Puerperium This refers to the 2nd to 7th day post delivery where major changes start in your genital tract. This risk may be more in women with pre-existing medical conditions like anaemia. changing 3 – 4 times a day. which results in falling levels of estrogen and progesterone.

Most doctor use stitches. etc. hot water washes or hot water bag may be useful. a natural body hormone. or pain killer tablets (paracetamol. You have borne with labour pains. despite pain in the stitches. It is important to take a high fibre diet and plenty of liquids to prevent hard stools. This is because the bladder may become overfull without you realize it. especially infections later. Oral medications such as antibiotics to prevent infection. and washing with water should be done after passing urine. You may need a mild laxative for a few days. Remember. Infrared lamp to apply day heat to the area of stitches may be given to you in hospital. These measures make you feel better. always wash from front to back. After Pain The delivery is over. Ask your doctor if you need to come back to show the stitches. One is that you have not eaten much during labour. Metrogyl gel. This is usually done twice daily. Betadine E – com may be useful to prevent infection. For a seitz bath you need a round tub large enough for your bottom to fit in. Don’t worry. which dissolve on their own and / or fall off after a few days. ) should only be taken as advised by your doctor. for various reasons. you may notice that you seem to be passing a lot of urine. Breasts The first day you will have only a watery. in which hot water with dilute antiseptic solution is kept. This is called colostrum and it is rich in many nutritive factors that are needed by your baby. During the first week. after bath and before going to sleep at night. Stools You may not have a good bowel motion for the first 2 days following delivery. Care of Episiotomy If you have had stitches on your perineum there are a few things you need to do. with local dilute antiseptic solution like Savlon or Dettol. which occurs due to the uterus contracting in response to oxytocin. the milk flow increases a lot. Cleaning the area at least twice a day. you need to inform your doctor. you are exhausted and sleepy. due to hormonal changes in your body. This is more marked when you are breastfeeding. ibuprofen. This is because your body is removing some of the excess water and salt that was retained in pregnancy.Urination The first day you must pass urine at least 2 – 3 hourly.It is nature’s way of getting your uterus back to the normal size. By the third day. yellowish discharge. If the pain is severe. So now you may be worried that you are still getting a cramping lower abdominal pain off and on. which can cause problems. particularly in the first week. to prevent infection. or you are having other symptoms like fever or excess bleeding. to make yourself comfortable and keep healthy. not looking like ‘real’ milk coming from the breasts. You must feed your baby at this time. Secondly you may be having pain in the stitches of the episiotomy. This is a must after passing stools. Local application of antiseptic creams such as Soframycin. . Pain relieving methods such as hot seitz baths. Regular feeding is important to prevent engorgement. never the other way. there is nothing left inside! This is a normal phenomenon. usually.

.This is the time of reflection for a woman. After a complicated childbirth. and your stitches are hurting .Although this increased independence is good. then perhaps you should see your doctor for help. Hence. Until you feel comfortable for actual penetrative sexual intercourse. and others available to make your life easier.The woman is passive letting other people (husband. This is because your stitches may be raw or painful. However. in most cases. . Hugging. Listen to your body and do as much as you feel up to. Complete restoration of the lining of the uterus. Letting-go . If this feeling of depression does not settle in a few days. or after a caesarean delivery your recovery may take twice as much time. Resuming Activities As discussed earlier. and even more are happening now.Many things add up to make you feel down. and are not having any problems. Postnatal Exercises Sexual Activity is best avoided in the early post delivery period. . Taking-hold Phase .This dependence is probably due to her physical discomfort and exhaustion from the labor process. particularly in the 1st week.) do things for her and make decisions for her. involve your partner. the woman during this phase may still feel insecure about her abilities in caring for the child. nurse. and your household routine within a week. and your genital tract is prone to infection. Hence traditionally some advise abstinence till 6 weeks following delivery. be patient with yourself. you will be able to resume your daily personal care activities within a day. So.The woman may want to talk about her labor. . Take help. Different women have different abilities to deal with their health changes. You and your partner may have been deprived of each other. if you have had an uncomplicated birth.She gives up the fantasized image of her child for the real one. 2. etc. Taking-in Phase . The swings in your hormone levels are maximum in the first week. it is not unusual to feel the need to renew your sex – life. petting or touching is not forbidden at anytime during pregnancy or post-delivery. 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. particularly in the last month of pregnancy. Don’t overexert yourself – This is the time you need to devote to yourself and your baby. so be patient.The woman finally defines her new role. Sometimes an underlying hormonal problem like low thyroid function may be causing these feelings.This is the phase where the woman begins to initiate action herself. . . your breasts feel sore. other displays of caring and affection can suffice. sleep for a while and you will feel better.Post Partum Blues There are many changes. Your baby may be keeping you awake all the time. Remember that these feelings are not uncommon. is not complete. You may be feeling a little left out or dissociated from your surroundings. Phases of Puerperium 1.Unlike in the previous phase. including the placental site. Take a break. 3. Encourage her to talk about the wonderment of birth. taking-hold shows a woman with great interest on caring for the baby. kissing. . it takes up to 6 weeks for your body to recover from the changes of pregnancy. Have a good cry. Many women feel low or depressed soon after delivery. you could resume your sexual life earlier. Ask for help with the baby if you are tired. which have happened to you in the past 9 months. after a normal vaginal delivery. However.

achieving pregnancy in the weeks immediately following the birth of your baby is not recommended by most health care professionals. 80 percent of all women who do not breastfeed report that their period has returned by this time. or begins sleeping through the night thereby increasing the amount of time between feedings. signaling the mother's uterus is nearly fully healed. . Once the postpartum bleeding has stopped and if the mother is not exclusively breastfeeding. has been proven to be 98 percent effective in preventing ovulation when used in this way. Childbirth takes a toll on the mother's body. Prolactin naturally suppresses ovulation. will return. although not impossible. Breastfeeding amenorrhea method. mothers should begin to use another form of birth control because ovulation could resume at any time. Mothers should be aware that this method will only work as long as they continue exclusively breastfeeding. she likely will resume ovulation around 10 weeks after childbirth.How Soon Can You Get Pregnant After Childbirth? After the birth of a baby. Because of this. will become lighter in flow and color. As time passes. she should talk to her health care provider about contraceptive options at her six-week postpartum checkup. and therefore. 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. Once the baby begins to take more solid foods. In the first days immediately following the birth of your baby. also known as lochia. Because of this fact. Ovulation after Childbirth Most women experience three to eight weeks of bleeding following childbirth. fertility. The chances that a mother will ovulate during the first six weeks after giving birth is relatively low. this bleeding is bright red in color. this bleeding. it is important for mothers to know when they could become fertile again and take precautions to avoid pregnancy. If a woman is not exclusively breastfeeding. it is possible for a woman to become pregnant before she ever has a period. many women wonder when their menstrual cycles and subsequently. including whether or not the mother is breastfeeding her baby. In fact. The answer to this depends on several factors.

It is important to begin exercising slowly. Breastfeeding mothers have to be more careful about the calories they intake. . Their nutritional choices must be more sound. therefore. 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. the doctor will examine the patient and make sure she is healing properly. most women will return to their doctor for a postpartum checkup. This is very normal. should wait until your baby is nearing her second month. most doctors give the green light to resume intercourse and also will discuss appropriate birth control options. This is because the mother's body takes at least this long to heal and recover from the trauma of childbirth. Any diet you begin. 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. Around this time. 10 to 15 percent lean protein and about 20 to 35 percent unsaturated or monosaturated fats. At this time you are also healing from childbirth and need more calories to recover from this process. and your body will need energy to help you function on such little rest. particularly if you did not exercise before or during your pregnancy. 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. Unless you are breastfeeding. At this visit. and this may lead to further weight loss. All new mothers should aim to eat balanced diets that include approximately 45 to 65 percent unrefined carbohydrates. POSTPARTUM DIET Caloric Intake Many mothers choose to breastfeed their babies. Around six weeks after giving birth. Newborns rarely sleep for more than a few hours at a time. When to Diet It is important not to try to lose post-partum weight for at least six weeks after you have the baby. your diet does not have to be different than it was before you had your baby.Resuming Sex Most doctors advise mothers to wait at least six weeks after child birth has occurred before resuming sexual activity. Many woman find sex to be uncomfortable for several months to a year following the birth of their baby. Most women generally have a six week post-partum checkup with their obstetrician. but women should discuss any concerns they have with their doctors.