PUERPERIUM

Puerperium, the period of adjustment after childbirth during which the

mother’s reproductive system returns to its normal prepregnant state. It
generally lasts six to eight weeks and ends with the first ovulation and the return
of normal menstruation.

Puerperal changes begin almost immediately after delivery, triggered by a sharp

drop in the levels of estragon and progesterone produced by the placenta during
pregnancy. The uterus shrinks back to its normal size and resumes its pre-birth
position by the sixth week. During this process, called involution, the excess
muscle mass of the pregnant uterus is reduced, and the lining of the uterus
(endometrium) is re-established, usually by the third week. While the uterus
returns to its normal condition, the breasts begin lactation.

INVOLUTION: Is the process whereby the genital organs revert back

approximately to the state where before pregnancy. The women is termed as
puerperal.

Puerperium begins as soon as the placenta is expelled and lasts for

approximately 6 weeks when the uteri become regressed almost to the non-
pregnant size. The period is arbitrarily divided into-

1. Immediate-within 24 hours.

2. Early-up to 7 days.

3. Remote-upto 6 weeks.

Similarly change occurs following abortion but takes a shorter period for the
involution to complete.

INVOLUTION OF THE UTERUS:-

UTERUS: Immediately following delivery the uterus becomes firm and retracts
with alternate hardening and softening. The uterus measures about
20*12*7.5cms.and weight about 1000gm.at the end of 6 weeks, its
measurement is almost similar to that of the non pregnant state and weight
about 60gm.the placenta site contracts rapidly presenting a raised surface with
measures about 1.5cm.lower uterine segment immediately following delivery,
the lower segment becomes a thin, flabby, collapsed structure. It takes a weeks
to revert back to the normal shape and size of the isthmuseither part between the
bodies of the uterus or internal us of the cervix.

CERRVIX:-The cervix contracts slowely,the external os admits two fingers for

a few days but by the end of first week, narrows down to admit the tip of a
finger only. The contour of the cervix takes a longer time to regain (6weeks)
and the external OS never reverts back to the nulliparus state.

PHYSIOLOGICAL CONSIDERATION:-
The physiological process of involution is most marked in the body of the
uterus.
Changes occur in following component -
a) Muscles
b) Blood vessel
c) Endometrium.

Muscles -
There is marked hypertrophy and hyperplasia of muscle fibres during pregnancy
and the individual muscle fibre enlarges to the extent of 10 times in length and
5 times in breadth. During puerperium, the number of muscle fibres is not
decreased but there is
substantial reduction of the myometrial call size. Withdraw of steroid hormones,
oestrogen and progesterone, may lead to increase in the activity of the uterine
collagens and the release of proteolytic enzyme. Autolysis of the protoplasm
occur by the proteolytic enzyme with liberation of peptones which entre the
blood stream. These are excreted through the kidneys as urea and
creatinine .This explain the increase excretion of the products in the puerperal
urine. The connective tissue undergoes the same type of degeneration. The
condition which favours involution are -1.efficiancy of the enzymatic action and
2.Relative anoxia induced by effective contraction and retraction of the uterus.
Blood vessels -
The changes of the blood vessels are pronounced at the placental site. The
arteries
are constricted by contraction of its way and thickening of the intima followed
by
thrombosis. New blood vessels grow inside the thrombi.
Endometrium -
Following delivery, the major part of the decidua is cast off with the expulsion
of
the placenta and the membranes, more at the placental site. The endometrium
left
behind varies in thickness from 2-5 mm. The superficial part containing the
degenerated decidua, blood cells and bits of fatal membranes becomes necrotic
and is cast off in lochia. Regeneration occurs from the epithelium of the uterine
gland mouths and interglandular stromal cells. Regeneration of the epithelium is
completed by 10th day and the entire endometrium is restored by the day 16,
except the placental site it takes about 6 weeks.

Clinical assessment of involution -

The rate of involution of the uterus can be assessed clinically by noting the
height
of the fundus of the uterus in relation to the symphysis pubis. The measurement
should be taken carefully at fixed time every day, preferably by the same
observer.
Bladder must be emptied beforehand and preferably the bowel too, as the full
bladder and the loaded bowel may raise the level of the fundus of the uterus.
The uterus is to be centralised and with a measuring tape, the fundal height is
measured above the symphysis pubis. Following delivery, the fundus lies about
13.5 cm above the symphysis pubis. During the first 24 hour, the level remains
constant, thereafter there is a steady decrease in height by 1.25 cm in 24 hours,
so that by the end of second week the uterus becomes a pelvic organ.

ABSTRACT:- VanRees, D., Bernstine, R. L. and Crawford, W. (1981),

Involution of the postpartum uterus: An ultrasonic study. J. Clin. Ultrasound,
9: 55–57.

The involution of the uterus was studied between 1 and 40 days postpartum
utilizing serial ultrasonic scans. All pregnancies and postpartum periods were
uncomplicated. The decrease in uterine size was related to a diminution in
uterine length. No difference was observed between nullipara and primipara or
breast- or bottle-feeding mothers.

INVOLUTION OF OTHER PELVIC STRUCTURES:

VAGINA:-

Involution of the Vagina

The vagina involutes more slowly than the uterus. Immediately after the
delivery, it is swollen, toneless and appears bruised and red. The normal
rugosity (wrinkles) of the vaginal walls reappear at about the 3rd week of the
postpartum period. But the size and elasticity of the tissues never regain the pre-
pregnancy state. Broad ligaments and round ligaments require considerable time
to recover from the stretching and laxation.
Pelvic floor and pelvic fascia take a long time to involute from the stretching
effect during parturition.

LOCHIA:-

Lochia is the vaginal discharge after giving birth (puerperium) containing

blood, mucus, and uterine tissue. Lochia discharge typically continues for 4 to 6
weeks after childbirth. It originates from the uterine body, cervix and vagina. It
is sterile for the first 2–3 days, but not so by the third or fourth day.

ODOUR AND REACTION:-It has got a peculiar offensive fishy smell. Its
reaction is alkaline tending to become acid towards the end. It progresses
through three stages:-

1. Lochia rubra (RED) is the first discharge, red in colour because of the
large amount of blood it contains. It typically lasts no longer than 3 to 5
days after birth.
2. Lochia serosa is the term for lochia that has thinned and turned brownish
or pink in colour. It contains serous exudate, erythrocytes, leukocytes,
and cervicalmucus. This stage continues until around the tenth day after
delivery. Lochia serosa which persists to some weeks after birth can
indicate late postpartum haemorrhaging, and should be reported to a
physician.
3. Lochia Alba (or purulent) is the name for lochia once it has turned
whitish or yellowish-white. It typically lasts from the second through the
third to sixth weeks after delivery. It contains fewer red blood cells and is
mainly made up of leukocytes, epithelial cells, cholesterol, fat, and
mucus.

AMOUNT- The average amount of discharge for the 5-6 days, it’s estimated
to be 250 ml.
 NORMAL DURATION: Normal duration may extend up to 3 weeks. The
red lochia may persists for longer duration especially in women who get up
from the bed for the first time in later period. The discharge may be scanty,
especially following premature labour or may be excessive in twin delivery
or hydramnios.

CLINICAL IMPORTANCE:-

The character of the lochia discharge gives useful information about the
abnormal puerperal state. The valve pads are to be inspected daily to get
information.

ODOUR: If malodorous indicates infection .retained plug or cotton piece

inside the vagina should be kept in mind.

COLUR: Persistence of red colour beyond the normal limit signifies sub
involution or retained bits of bits of concepts.

DURATION: Duration of the lochia alba beyond 3 weeks suggest local

genital lesions.

GENERAL PHYSIOLOGICAL CHANGES:-

PULSE:-for a few hours after the normal delivery, the pulse rate is likely to be
raised which settle down to normal during the second day .however, the pulse
rate often rises with after-pain excitement.

TEMPERATURE: -The temperature should not be above 37.2degree C

(99degree F)with in the first 24 hrs. There may be slight reactionary rise
following delivery by 0.5degree but comes to the normal within 12 hrs .On the
3rd day there is slight increase in the temperature due to the breast engorgement
which should not last for more than 24 hrs .however, genitor –urinary tract
infection should be excluded if there is raise of temperature.

URINARY TRACT: -It may be slightly uncomfortable to urinate for a few

days after your baby’s birth. Pain or burning when you urinate, or the urge to
urinate frequently, may indicate a bladder infection. Bladder capacity increases
the bladder may be distanced without urge to pass urine. Common urinary
problems are: overdistention, incomplete emptying and prence of residual
urine .dilated ureters and renal pelvis return to normal size within 8 weeks.
There is pronounces diuresis on the second or third day of perpurium.

GESTRO-INTESTINAL TRACT:-Increases thirst in early perpurium is due

to loss of fluid in during labour, in the lochia diurasis and perspiration
constipation is a common problem .

WEIGHT LOSS :- In addition to the weight loss (5-6kg) as a consequence of

the expulsion of the fetes, placentae, liquor and blood loss. A further loss of
about 2kg occur during purperium chiefly caused by diurasis.The weight loss
may continue up to 6 months of delivery.

FLUID LOSS:-There is a net fluid loss of at least 2 litters during the first week
and an addition 1.5litres during next 5 weeks .The amount of loss depends on
the amount retained during pregnancy, dehydration during labour and blood loss
during delivery the loss of salt and water are larger in women with pre elampsia
and eclampsia.

BLOOD VALUES:- Decrees in blood volume due to blood loss and

dehydration. Blood volume returns to the non-pregnant level by the second
week. Cardiac output increases soon after delivery to about 80%above the
prelabour values but slowly return to normal within one week.
RBC volume and haematocrit values return to normal by 8bweeks.Postpartum
after the hydraemia disapper.Lecocytes to the extent of 25,000per cu mm occur
following delivery probably in response to stress of labour. Platelet count
decreases soon after the separation of placenta but secondary elevation occurs
with increase in platelet count adhesiveness between 4-10 days. Fibrinogen
level high up to the second week of puerperium. A hypercoagulatin state
persists up to 48hrs postpartum and fibrinolytic activity is enhanced in first 4
day. The secondary increase in fibrinogen, factor viii and the platelet in first
week increase the risk for thrombosis the increase in fibrinolytic activity after
delivery acts as a protective mechanism.

MENSTRUATION AND OVULATION:-Onset of first menstruation period

following delivery is very variable and depends on lactation. If women does not
breast feed her baby, the mensuration returns by 6th week following delivery in
about 40%and 12th week in 80%of cases.

In non-lactatingmothers, ovulation may occur as early as 4 weeks. And in

lactating mothers about 10weeks after delivery.In lactating mother women who
is exclusively breastfeeding the contraceptive protection is about 98%upto 6
months postpartum. Lactation provide natural method of contraception.so
consell the patent to use contraceptive method from 3rd week for non lactating
mother or from 3 month for lactating mother.

SCHEME OF MACHANISM OF AMENORRHOEA AND ANOVULATION

IN LACTATING MOTHERS:-

BRESTFEEDING –SUCKING* * FREQUENCY

*INTENSITY

*DURATION
INCRESES PROLACTIN LEVEL

INHIBITS OVARIAN RESPONSE

GNRH SECRETION.

TO FSH SUPPRESSES THE RELEASE OF LH

NO LH SURGE

LESS FOLLICULAR GROWTH

HYPO-OESTROGENIC STATE ANOVULATION

NO MENSURATION

LACTATION

The secretion from the breast called colostrums which starts during pregnancy
becomes more abundant during the period.

Composition of colostrums: Deep yellow serous fluid, alkaline in reaction. It

has got a higher specific gravity, high protein, vit A, sodium and chloride
content but has got lower carbohydrate, fat and potassium than the breast milk.
It contains antibody (IgA).

ADVANTAGES: - 1. Provide immunity to the Baby.

2. Laxative action on the baby due to the large fat globules.

PHYSIOLOGY OF LACTATION:

DIVIDED INTO FOUR PHASES:-

 PREPRTATION OF THE BREASTS(MAMMOGENESIS)

 SYNTHESIS AND SECRETION FROM THE BREAST ALVEOLI
(LACTOGENISIS).
 EJECTION OF THE MILK (GALAKTOKINESIS).
MAINTENANCE OF LACTATION (GALATOPOIESIS).
MAMMOGENIS: - pregnancy is associate with a remarkable growth of both
the ductal and lobular alveolar system .intact nerve supply is not essential for
the growth of the mammary glands during pregnancy.

LACTOGENISIS: - milk secretion starts actually on day 3rd or 4th postpartum

day. This time breast become engorged. Tense and feel warm in spite of high
prolactin level in pregnancy milk secretion is abeyance. Steroids-estragon and
progesterone is circulating so it makes unresponsive to the prolactin when after
pregnancy estragon and progesterone level decreases and prolactincomes into
the action and secretion of milk occurs.
GALACTOKINASIS: - Discharge of the milk from the mammary gland not
only depends on the sucking of the baby but also on the contractile mechanism
of which expresses the milk from the alveoli into the ducts. Oxytocin is a major
gelectokinetic hormone.

Discharge of milk from the mammary glands of breast depends upon the suction
exerted by the baby during suckling. Contractile mechanism also helps by
expressing the milk from alveoli into the ducts.

During suckling,a conditioned nervous reflex is set up. The impulses start
from the nipples to Supraoptic nucleus in brain and thence along the
hypothalamus-pituitary axis to posterior pituitary. It appears to be so
complicated and essentially when the love of baby is there, all this is simply a
loving privilege of Moms!

Oxytocin is secreted from posterior pituitary which exerts several effects on the
uterus and breast. In breasts, there iscontraction of the epithelial cells of
alveoli and ducts containing the milk. This is the "milk ejection" or "milk
let down"reflex that forces the milk down into the lactiferous ducts. From
lactiferous ducts milk is expressed either by the mother by hand or sucked out
by the baby.

A sensation of rise in pressure in the breast is felt by the mother at the beginning
of suckling. It is called"draught". This effect can be produced artificially by
the injection of Oxytocin hormone.

The milk ejection reflex is inhibited by several factors like pain in breasts
or body, breast engorgement, psychological upsets. In addition this ejection
reflex might be weak for several days following breast feeding and it results in
breast engorgement.
GALACTOPOISE:

The hormoneProlactinappears to be the single most important factor for

maintenance of lactation.Sucking is also essential for maintenance of
lactation. Sucking is essential for the removal of milk from the glands in breast
but also for the release of Prolactin.

Secretion of milk is a continuous processunless suppressed by congestion or

emotional disturbances. Milk pressure reduces the rate of breast milk
production. So periodic breast feeding is necessary to relieve the pressure that in
turn maintains the secretion of milk inside the breast.

MILK PRODUCTION:-Healthy mother produce about 500-800ml milk a day

to feed her baby.

Inadequate milk production (lactationfailure) it may be due to the infrequent

sucking or due to endogenous suppression of prolactin .pain
anxiety .unrestricted feeding at short interval (2-3hrs)

Drugs to improve milk production: - metocloperamide10 mg thrice a day

increase milk volume by increasing prolactin level.

Management of normal puerperium

Immediately following delivery, the patient should be closely observed. She

may be given
a drink of her choice or something to eat, if she is hungry.
Principles -
- To give all out attention in to restore the health status of the mother.
- To prevent infection.
- To take care of the breasts, including promotion of lactation and nursing of the
child.
- To motivate the mother for contraception.

General management -
Rest and ambulance -
It is indeed difficult to categories an uniform period of rest. After a good resting
period,
the patient becomes fresh and can breast feed the baby or moves out of bed to
go to the
toilet. Early ambulation is encouraged. Advantages of early ambulation are:
- Provide a sense of well-being.
- Bladder complications and constipation are reduced.
- Facilitates uterine drainage.
- Hastens involution of uterus.
- Lessens puerperal venous thrombosis and embolism.

Hospital stay -
Early discharge from the hospital is an almost universal procedure. If adequate
supervision
by trained health visitors is provided, there is no harm in early discharge.

Diet -
The patient should be on normal diet of her choice. If the patient is lactating,
high calories,
adequate protein, fat, plenty of fluids, minerals and vitamins are to be given.

Care of the bladder -

The patient is encouraged to pass urine following delivery as soon as
convenient. If the patient
fails to pass urine, catheterisation should be done. Catheterisation is also
indicated in case of
incomplete emptying of bladder.

ABSTRACT:-2

Saadia, Z., Roshdy, S., Sagir, F. and Abidin, S. (2013), Dietary practices of
Saudi women during puerperium. Journal of Obstetrics and Gynaecology
Research, 39: 799–805.

Poor maternal health sometimes can be a consequence of practicing different

myths during puerperium. This cross-sectional study describes the practice of
different myths regarding diet among Saudi women.Using method of comprised
women attending the postnatal clinic at the Mother and Child Hospital in
Buraidah from January to December 2011.hence shows that Almost 65.9% of
women were using a combination of herbs such as ginger (zingiber officinale),
hilba (fenugreek) and black seeds (nigella sativa). The multinomial logistic
regression of herbs on age, education, occupation, parity and mode of delivery
was statistically significant (χ2 [48] = 214.645, P < 0.001). Hilba was more
commonly used by women with instrumental delivery. It was common for
women to avoid different fruits and vegetables (33.89%). Eggs were avoided by
16.5% of women and 11% avoided cold drinks. The multinomial logistic
regression of diet on age, education, occupation, parity and mode of delivery
was statistically significant (χ2 [72] = 389.861, P < 0.001). Individuals below
college level education were more likely to avoid fruits, vegetables and cold
drinks in their diet. It proves that Health education programs are needed to
improve knowledge about dietary malpractices during puerperium. This may
help eliminate myths regarding avoidance of certain dietary components.

Care of the bowel -

The problem of constipation is much less because of early ambulation and
liberalisation of the
dietary intake. A diet containing sufficient roughage and fluids is enough to
move the bowel.
If necessary, mild laxative such as Igol (isogon husk) two teaspoons may be
given at bed time.

ABSTRACT:-3

John M. Thorp,Peggy A. Norton,Urinary incontinence in pregnancy and the

puerperium: A prospective study American Journal of Obstetrics &
Gynecology,Volume 181, Issue 2, Pages 266–273, August 1999

Objective: Pregnancy and childbirth are commonly thought to be associated

with the development of urinary incontinence and lower urinary tract
symptoms. The purpose of this study was to assess the relationship, if any,
between pregnancy and the development of lower urinary tract symptoms.
Study Design: A prospective study of lower urinary tract symptoms was carried
out in a cohort of pregnant women who answered a series of symptom
questionnaires and kept a 24-hour bladder chart on which frequency of urination
and volumes voided were recorded throughout pregnancy and for 8 weeks after
birth. Results: A total of 123 women participated in the study. Mean daily urine
output (P = .01) and the mean number of voids per day (P = .01) increased with
gestational age and declined after delivery. Episodes of urinary incontinence
peaked in the third trimester and improved after birth (P = .001). White women
had higher mean voided volumes and fewer voiding episodes than did black
women. Ingestion of caffeine was associated with smaller voided volumes and
greater frequency of urination. Conclusion: Pregnancy is associated with an
increase in urinary incontinence. This phenomenon decreases in the puerperium.
Pregnancy and childbirth trauma are important factors in the development of
urinary incontinence among women. These findings warrant further
investigation. (Am J Obstet Gynecol 1999;181:266-73.)

Sleep -
The patient is in need of rest, both physical and mental. So she should be
protected against
worries and undue fatigue. Sleep is ensured providing adequate physical and
emotional support.
Care of the vulva and episiotomy -
Shortly after delivery, the vulva and buttocks are washed with soap water down
over the anus
and a sterile pad is applied. The patient should look after personal cleanliness of
the vulvar
region. The perinea wound should be dressed with spirit and antiseptic power
after each act
micturition and defecation or at least twice a day.
Care of the breast -
The nipple should be washed with sterile water before each feeding. It should be
cleaned
and kept dry after the feeding is over. Nipple soreness is avoided by frequent
short feeding
rather than the prolonged feeding, keeping the nipple clean and dry.

ABSTRACT:4

- Winani S1, Wood S, Coffey P, Chirwa T, Mosha F, Changalucha J Use of a

clean delivery kit and factors associated with cord infection and puerperal sepsis
in Mwanza, Tanzania. J Midwifery Womens Health. 2007 Jan-Feb;52(1):37-43

Our objective was to determine the effectiveness of an intervention that

incorporated education about the "six cleans" with the use of a clean delivery kit
in preventing cord infection and puerperal sepsis. A stepped-wedge, cross-
sectional study was conducted in 10 surveillance sites across two rural districts
of Mwanza Region, Tanzania. A total of 3262 pregnant women between the
ages of 17 and 45 years were enrolled in the study. Village health workers
administered questionnaires to each mother at 5 days postpartum and inspected
the infants' umbilical cord stumps for signs of infection. Newborns whose
mothers used the delivery kit were 13.1 times less likely to develop cord
infection than infants whose mothers did not use the kit. Furthermore, women
who used the kit for delivery were 3.2 times less likely to develop puerperal
sepsis than women who did not use the kit. Women who bathed before delivery
were 2.6 times less likely to develop puerperal sepsis than women who did not
bathe, and their infants were 3.9 times less likely to develop cord infection.
Single-use delivery kits, when combined with education about clean delivery,
can have a positive impact on the health of women and their newborns by
significantly decreasing the likelihood of developing puerperal sepsis or cord
infection.

Maternal-infant bonding -
It starts from first few moments after birth. This is manifested by fording,
kissing, cuddling
and gazing at the infant. The baby should be kept in her bed or in a cot besides
her bed.
This is not only establishes the mother-child relationship but the mother is
conversant with
the art of baby care so that she can take full care of the baby while at home.

Asepsis and antiseptic -

Asepsis must be maintained specially during the first week of puerperium.
Liberal use of
local antiseptics, aseptic measures during perinea wound dressing, use of clean
bed linen
and clothing are positive steps.

Immunization -
Administration of anti-D-gamma globulin to unimmunized Rh-negative mother
bearing
Rh-positive baby. The booster dose of tetanus toxoid should be given at the time
of
discharge, if it is not given during pregnancy.

ABSTRACT:-5

Mohamed Issa Ahmed, Mohamed Alkhatim Alsammani, Rabie Ali

babiker,Puerperal Sepsis in a Rural Hospital in Sudan,2013; 25(1): 19-22

Background: increasingly, women in rural areas in Sudan reported to hospital

with puerperal infections. Aims: This study was design to identify the common
pathogens causing puerperal infections and their susceptibility to current
antibiotics. Subjects and methods: We prospectively studied 170 women from
January, 2011 through January 2012 attended Hussein Mustafa Hospital for
Obstetrics and Gynecology at Gadarif State, Sudan. We included patients if they
met the criteria proposed by the WHO for definition of maternal sepsis. Blood
was collected on existing infection guidelines for clean practice and
equipments. Results: Out of the 170 samples, 124 (72.9%) were pathogen-
positive samples. Out the 124 positive cases, aerobes were the predominant
isolates 77 (62.1 %%) which included Staph.aureus 49 (39.5%), Staph.
epidemics 7 (5.6%) and Listeria monocytogenes 21 (16.9%). The anaerobes
isolates were Clostridium perfringens 34 (27.4 %) and Entrobactor cloacae 13
(10.5%). Standard biochemical test were for bacterial isolation. Higher rate of
infections followed vaginal delivery compared to Cesarean section 121 (97.6%),
3 (2.5%) respectively. All strains of Staph were sensitive to Vancomycin,
Gentamicin and Ceftriaxone. C. perfringens were sensitive to Ceftriaxone,
Penicillins, Vancomycin and Metronidazole, while E. cloacae were sensitive to
Gentamicin and Ceftriaxone. Conclusion: despite the limited resources in the
developing countries, treatment based on cultures remains the only solution to
reduce maternal morbidity and mortality rates following puerperal infections.

POSTNATAL CARE:-
Take your medicine as directed:
Call your primary healthcare provider if you think your medicine is not working
as expected. Tell him if you are allergic to any medicine. Keep a current list of
the medicines, vitamins, and herbs you take. Include the amounts, and when,
how, and why you take them. Take the list or the pill bottles to follow-up visits.
Carry your medicine list with you in case of an emergency. Throw away old
medicine lists.

NSAIDs:
No steroidal anti-inflammatory (NSAID) medicine may decrease swelling and
pain or fever. This medicine can be bought with or without a doctor's order.
This medicine can cause stomach bleeding or kidney problems in certain
people. Always read the medicine label and follow the directions on it before
using this medicine.

Follow-up visits:
Ask your caregiver when to return for a follow-up visit. Often, caregivers will
want to see you six weeks after having your baby. Your caregiver may do a
vaginal exam at your visit. Tell your caregiver if you are having any pain or
other symptoms. Keep all appointments. Write down any questions you may
have. This way you will remember to ask these questions during your next visit.

Activity:
After having a baby, you may be very tired. It is very important to get enough
rest after having a baby. For a while after delivery, try to keep all activities
short. You may be able to do some exercise soon after having your baby, such
as walking. Kegel exercises may help your vaginal and rectal muscles heal
faster. You can do Kegel exercises by tightening and relaxing the muscles
around your vagina. Kegel exercises help make the muscles stronger, and may
prevent gas and urine from leaking out. Talk with your caregiver before you
start exercising. If you work outside the home, ask your caregiver when you can
return to your job.

Breast care:
When your milk comes in, your breasts may feel full and hard. If you plan to
breastfeed, ask caregivers to show you how to hold and breastfeed your baby.
Ask caregivers for more information about how to care for your breasts even if
you are not breastfeeding. Also ask your caregiver about breastfeeding while
taking medicines.

Constipation:
Do not try to push the bowel movement out if it is too hard. High-fibre foods,
extra liquids, and regular exercise can help you prevent constipation. Examples
of high-fibre foods are fruit and bran. Prune juice and water are good liquids to
drink. Regular exercise helps your digestive system work. You may also be told
to take over-the-counter fibre and stool softener medicines. Take these items as
directed.
Haemorrhoids:
Haemorrhoids are swollen veins in or around your rectum. Pregnancy can cause
haemorrhoids to stick out or swell. You may have rectal pain because of the
haemorrhoids. Ask your caregiver about preventing and caring for
haemorrhoids.

Perinea care:

 Your perineum is the area between your vagina and anus. To help heal
your perineum, keep the area as clean and dry as possible. This will also
help prevent infection. You can wash the area gently with soap and water
when you bathe or shower. Ask your caregiver about any special wound
care needed if you had an episiotomy. An episiotomy is an incision (cut)
in your perineum.
 Your caregiver may suggest using sits baths to help decrease your pain.
During a sits bath, you will sit in a bathtub filled with warm or cold
water. A cold sits bath may decrease your pain right away. To make a
cold-water sits bath, sit in slightly warm water and add ice cubes to the
water. Stay in the sits bath for 20-30 minutes, or aslong as your caregiver
suggests. Ask your caregiver for more information about sitz baths and
other ways to decrease your pain.

Vaginal discharge:
You will have a vaginal discharge, called lochia, after your delivery. The lochia
is bright red the first day or two after delivery. By the third or fourth day, the
amount decreases, and it turns a red browncolour. About 7 to 14 days after
having your baby, you may have a heavier flow of blood. Sometimes the colour
of the lochia changes to a yellow-white colour and may have an odor (smell).
You may need to wear a pad and change it many times each day. You may be
able to use tampons if you can insert them without any problems. Caregivers
may advise you not to use tampons at night time to lessen the risk of infection.
It is normal to have lochia up to eight weeks after your baby is born.

Monthly periods:
Your period may start again within 7 to 12 weeks after your baby is born. If you
are breastfeeding, it may take longer for your period to start again. You can still
get pregnant again even though you do not have your monthly period. Talk with
your caregiver about a birth control method that will be good for you if you do
not want to get pregnant.

Mood changes:
Many new mothers have some kind of mood changes after delivering their
baby. Some of these changes occur because of lack of sleep, hormone changes,
and caring for a new baby. Some mood changes can be more serious, such as
severe (very bad) postpartum depression (deep sadness). Talk with your
caregiver if you feel unable to care for yourself or your baby after delivery.