OVERVIEW OF THE POSTDELIVERY (POSTPARTUM) PERIOD

OVERVIEW OF THE POSTDELIVERY (POSTPARTUM) PERIOD

 

The postdelivery (postpartum) period is the 6 weeks after delivery of a baby, when the mother’s body returns to its prepregnancy state.

 

After delivery, the mother can expect to have some symptoms, but they are usually mild and temporary. Complications are rare. Nonetheless, the doctor, hospital staff members, or health care plan usually sets up a program of follow-up office or home visits.

 

The most common complications are excessive bleeding (postpartum hemorrhage); infections of the uterus, bladder, kidneys, or breasts; problems with breastfeeding; depression. Postpartum hemorrhage may occur soon after delivery but may occur up to 6 weeks later.

 

HOSPITAL (WHAT TO EXPECT)

 

Immediately after delivery of a baby, the mother is monitored for at least 1 hour. If an anesthetic was used during delivery or if there were any problems during delivery, she may be monitored for several hours after delivery, usually in a well-equipped recovery room with access to oxygen, intravenous fluids, and resuscitation equipment.

 

Staff members check the mother’s pulse rate and temperature. Normally, within the first 24 hours, the mother’s pulse rate (which increased during pregnancy) begins to decline toward normal and her temperature may increase slightly, usually returning to normal during the first few days. After the first 24 hours, recovery is rapid.

 

Hospital staff members make every effort to minimize the new mother’s pain and the risk of bleeding and infection.

 

Bleeding

 

Minimizing bleeding is the first priority. After delivery of the placenta (afterbirth), a nurse may periodically massage the mother’s abdomen to help the uterus contract and remain contracted, thus preventing excessive bleeding. If needed, oxytocin is given to stimulate contraction of the uterus. The drug is injected into a muscle or given intravenously as a continuous infusion until the uterus is contracted. If women lose a lot of blood during and after delivery, a complete blood count is done to check for anemia before they are discharged.

 

Urination

 

Urine production often increases greatly, but temporarily, after delivery. Because bladder sensation may be decreased after delivery, hospital staff members encourage a new mother to try to urinate regularly, at least every 4 hours. Doing so avoids overfilling the bladder and helps prevent bladder infections. Staff members may gently press on the mother’s abdomen to check the bladder and determine whether it is being emptied.

 

Occasionally, if the new mother cannot urinate on her own, a catheter must be inserted temporarily into the bladder to empty the urine. Hospital staff members try to avoid using an indwelling catheter (a catheter that is left in the bladder for a period of time). This type of catheter increases the risk of bladder and kidney infections.

 

Defecation

 

The new mother is also encouraged to defecate before leaving the hospital. But because hospital stays are so short, this expectation may not be practical. Doctors may recommend that if she has not defecated within 3 days, she take laxatives to avoid constipation, which can cause or worsen hemorrhoids. If the rectum or muscles around the anus were torn during delivery, doctors may prescribe stool softeners.

 

Opioids, which are sometimes given after cesarean delivery to relieve pain, can worsen constipation. So if an opioid is needed, the lowest effective dose of such drugs is used.

 

Diet and exercise

 

A new mother can have a regular diet as soon as she wants it, sometimes shortly after delivery. She should get up and walk as soon as possible.

 

A new mother can start exercises to strengthen abdominal muscles, often after 1 day if delivery was vaginal and later if it was cesarean. Curl-ups with bent knees, done in bed, are effective. However, most women are too tired to start exercising so soon after delivery.

 

Cesarean delivery is major surgery, and women should not begin exercising until they have had time to fully recover and allow healing, which typically takes about 6 weeks. Women can resume their prepregnancy exercise routine after approval from their doctor at their postpartum visit.

 

Vaccines and immune globulin

 

Before the mother leaves the hospital, she is given the German measles (rubella) vaccine if she has never had rubella or never been given this vaccine.

 

Ideally, the tetanus-diphtheria-pertussis (Tdap) vaccine is given during each pregnancy, preferably between weeks 27 and 36. If a mother has not been given the Tdap vaccine during her pregnancy, it should be given to her before she is discharged whether she is breastfeeding or not. If family members who will have contact with the newborn have never been given the Tdap vaccine, they should also be given Tdap to immunize them against pertussisand thus reduce the risk of spreading pertussis to unprotected newborns.

 

If a new mother has Rh-negative blood and the baby has Rh-positive blood (called Rh incompatibility), she is given Rh₀(D) immune globulin within 3 days of delivery. This drug masks any of the baby’s red blood cells that may have passed to the mother so that they do not trigger the production of antibodies by the mother. Such antibodies may endanger subsequent pregnancies.

 

Before discharge

 

Before a new mother leaves the hospital, she is examined. If mother and baby are healthy, they commonly leave the hospital within 24 to 48 hours after vaginal delivery and within 96 hours after a cesarean delivery. Sometimes discharge is even earlier than 24 hours if no general anesthetic was used and no problems occurred.

 

The mother is given information about changes to expect in her body and measures to take as her body recovers from having a baby. Regular follow-up visits are scheduled.

 

CONTINUING FROM HOSPITAL TO HOME

 

Coping with some changes begins in the hospital, depending on how soon hospital discharge occurs, and continues at home.

 

Discharge from the vagina

 

New mothers have a discharge from the vagina. Staff members give them pads to absorb it. Staff members also check the amount and color of the discharge. Usually, it appears bloody for 3 or 4 days. Then it becomes pale brown, and about 2 weeks after delivery, it becomes yellowish white. The discharge may continue for up to about 6 weeks after delivery.

 

About a week or two after delivery, the scab over the site where the placenta was attached in the uterus comes off, causing vaginal bleeding of up to about a cup. Sanitary pads, changed frequently, may be used to absorb this discharge. Comfortably fitting tampons, changed frequently, can also be used unless they interfere with healing of an episiotomy incision or tears in the area between the vaginal opening and the anus (perineum).

 

Drugs

 

Mothers who are not breastfeeding may safely take drugs to help them sleep or to relieve pain. For women who are breastfeeding, acetaminophen and ibuprofen are relatively safe pain relievers. Many other drugs appear in breast milk (see Taking Drugs While Breastfeeding).

 

Genital area

 

The area around the vaginal opening is usually sore, and the area may sting during urination. Tears in the perineum or episiotomy repairs can contribute to the soreness and cause swelling. Immediately after delivery and for the first 24 hours, ice or cold packs may be used to relieve the pain and swelling. Anesthetic creams or sprays can be applied to the skin.

 

Later, washing the area around the vagina with warm water 2 or 3 times a day may help reduce tenderness. Warm sitz baths can help relieve pain. Sitz baths are taken in a sitting position with water covering only the perineum and buttocks. Women should be careful when sitting down and, if sitting is painful, use a doughnut-shaped pillow.

 

Hemorrhoids

 

Pushing during delivery can cause or worsen hemorrhoids. Pain caused by hemorrhoids can be relieved by warm sitz baths and applying a gel containing a local anesthetic.

 

Breast engorgement

 

The breasts may be enlarged, tight, and sore because they are engorged with milk. Engorgement occurs during the early stages of milk production (lactation).

 

For mothers who are not going to breastfeed, the following can help:

• Wearing a snug-fitting bra to elevate the breasts and thus help suppress milk production

• Applying ice packs and taking analgesics (such as acetaminophen or ibuprofen) to help relieve discomfort until milk production stops on its own

• Refraining from manually expressing milk, which can increase milk production

 

For mothers who are breastfeeding, the following can help until milk production adjusts to the baby’s needs:

• Feeding the baby regularly

• Wearing a comfortable nursing bra 24 hours a day

• If the breasts are swollen and very uncomfortable, expressing milk by hand in a warm shower or using a breast pump between feedings (however, this measure tends to stimulate milk production and prolong engorgement)

 

If the breasts are very swollen, the mother may have to express her milk just before breastfeeding to enable the baby’s mouth to fit around the areola (the pigmented area of skin around the nipple).

 

Mood

 

Sadness (baby blues) is common during the days after delivery. Women may also feel irritable, moody, or anxious and may have difficulty concentrating or sleep problems (too much or too little). These symptoms usually disappear after 7 to 10 days. However, if these symptoms continue for longer than 2 weeks or interfere with taking care of the baby or doing daily activities, new mothers should talk to their doctor. In such cases, postpartum depression or another mental health disorder may be present.

 

HOME (WHAT TO EXPECT)

 

A new mother may resume normal daily activities when she feels ready. Eating a healthy diet and exercising regularly can help a new mother return to her prepregnancy weight.

 

She may resume sexual intercourse as soon as she desires it and it is comfortable. Sexual intercourse should be delayed until the affected area heals if delivery caused tearing; an episiotomy was done; the delivery was cesarean.

 

A new mother may take showers or baths shortly after delivery, unless delivery was cesarean. The genital area should be washed from front to back. If the area is sore, using a spray bottle of water or taking sitz baths may be more soothing.

 

After a cesarean delivery, nothing, including tampons and douches, should be put in the vagina for at least 2 weeks. Strenuous activity and heavy lifting should be avoided for about 6 weeks. Intercourse should also be avoided for 6 weeks. The incision site should be cared for in the same way as other surgical incisions. Showering can typically be resumed 24 hours after surgery. Care should be taken not to scrub the incision site. Baths should be avoided until the wound is completely closed and any staples or sutures have been removed. The incision site should be kept clean and dry. Any evidence of increasing redness or drainage from the incision should be brought to the doctor’s attention. Pain around the incision site can last for a few months, and numbness can last even longer.

 

Abdomen

 

The uterus, still enlarged, continues to contract for some time, becoming progressively smaller during the next 2 weeks. These contractions are irregular and often painful. Contractions are intensified by breastfeeding. Breastfeeding triggers the production of the hormone oxytocin. Oxytocin stimulates the flow of milk (called the let-down reflex) and uterine contractions.

 

Normally, after 5 to 7 days, the uterus is firm and no longer tender but is still somewhat enlarged, extending to halfway between the pubic bone and the navel. By 2 weeks after delivery, the uterus returns to close to its normal size. However, the new mother’s abdomen does not become as flat as it was before the pregnancy for several months, even if she exercises.

 

Stretch marks do not go away, but they may fade, but sometimes not for a year.

 

Breastfeeding

 

Doctors recommend that women breastfeed without supplementing with other foods for at least 6 months. Then women should continue to breastfeed for another 6 months while introducing other foods. After that, women are encouraged to continue breastfeeding until they or the baby is no longer interested. If mothers cannot breastfeed or do not want to for various reasons, bottle-feeding can be done instead.

 

Mothers who are breastfeeding need to learn how to position the baby during feeding. If the baby is not positioned well, the mother’s nipples may become sore and cracked. Sometimes the baby draws in its lower lip and sucks it, irritating the nipple. In such cases, the mother can ease the baby’s lip out of its mouth with her thumb. To remove her nipple from the baby's mouth, the mother should first slide her finger into the baby's mouth to break the suction caused by sucking. This maneuver can prevent the breast from being damaged and becoming sore.

 

After a feeding, the mother may let the milk dry naturally on the nipples or gently pat them dry. If she wishes, she can dry her nipples with a hair dryer set on low. After breastfeeding, women can apply 100% lanolin to the nipples. Doing so can relieve soreness and help protect the nipples. When a mother breastfeeds, the breasts may leak milk. Cotton pads can be worn to absorb the milk, but plastic bra liners can irritate the nipples and should be not be used.

 

While breastfeeding, mothers need to increase their caloric intake by about 500 calories per day. They should also increase their intake of most vitamins and minerals, such as calcium. Usually, eating a well-balanced diet (including enough dairy products and green, leafy vegetables) and continuing to take a prenatal vitamin with folate once a day are all mothers need to do. Prenatal vitamins should contain at least 500 micrograms of folate. They should drink enough fluids to ensure an adequate milk supply. Mothers on special diets should consult their doctor about the need for other vitamin and mineral supplements, such as vitamin B₁₂ for vegetarians.

 

Family planning

 

Use of contraceptives is recommended when intercourse resumes because pregnancy is possible as soon as the mother begins to release an egg from the ovary (ovulate) again. Mothers who are not breastfeeding usually begin to ovulate again about 4 to 6 weeks after delivery, before their first period. However, ovulation can occur earlier. Mothers who are solely breastfeeding tend to start ovulating and menstruating somewhat later, closer to 6 months after delivery. However, sometimes a mother who is breastfeeding ovulates, menstruates, and becomes pregnant as quickly as a mother who is not breastfeeding. Mothers who are breastfeeding should talk to their doctors about when to start using contraception.

 

Full recovery after pregnancy takes about 1 to 2 years. So doctors usually advise a new mother to wait at least 6 months and optimally 18 months before becoming pregnant again (although she may choose not to follow that advice). At her first doctor’s appointment after delivery, a new mother can discuss contraceptive options with her doctor and choose one that suits her situation.

 

Whether a mother is breastfeeding affects the choice of contraception used. Oral contraceptives that contain estrogen and progesterone can interfere with milk production and should not be used until milk production is well established. Progesterone-only contraceptives can be used, but methods that do not use drugs (such as barrier contraceptives) are even better. A diaphragm can be fitted only after the uterus has returned to normal, usually after about 6 to 8 weeks. Before that, foams, jellies, and condoms can be used. Intrauterine devices can be inserted about 6 weeks after pregnancy.

 

A new mother (or any woman) who has just been vaccinated against German measles (rubella) and/or chickenpox (varicella) must wait at least 1 month before becoming pregnant again to avoid endangering the fetus.

 

Source: http://www.merckmanuals.com/home/women-s-health-issues/postdelivery-period/overview-of-the-postdelivery-postpartum-period