• This is the first six weeks following the delivery of the baby.
• During this period, there are significant changes in the levels of different pregnancy hormones in the body.
• The body organs return to their pre-pregnancy sizes.
• The mother adjusts to her new responsibility of caring for her newborn baby.
• Both mother and baby require support from family and healthcare providers to ensure smooth journey through this joyous but challenging process.
• In this lecture, we will be discussing some of the challenges that may emanate during the course of the puerperium.
• We shall look at how the challenges can be recognized at home by the mother and the roles of the mother and the hospital.
CHALLENGES IN THE PUERPERIUM
• Bleeding after delivery
• Abdominal pain
• Lochia abnormalities
• Breastfeeding issues
• Puerperal pyrexia
• Mood abnormalities
• Care of the newborn baby
BLEEDING AFTER DELIVERY
• It is normal to expect some slight bleeding after the placenta has been delivered.
• However, bleeding becomes worrisome when it is heavy as to warrant changing 2 pieces of sanitary pad in the first 2 hours or when it leads to dizziness, fainting spells or headache.
• Some of the causes of bleeding in the early period following delivery include: inadequate contraction of the uterus or any tears in the delivery tract (vagina, cervix or uterus).
o Inadequately Contracted Uterus
• Contraction of the uterus is important in stopping bleeding after delivery and in aiding the return of the uterus to it pre-pregnant size.
• The service provider will massage the patient’s uterus to stimulate contractions. If this is not successful, she may administer drugs to help achieve this. This may include injections of oxytocin (as either drip, through the vein or into your muscles) or tablets of misoprostol inserted into the anus of the bleeding patient.
• The cause of the bleeding may be because a part of the placenta or membranes is still in the uterus and may require removal by inserting hand into the womb to remove the retained pieces.
o Genital Tract Tears
• This usually follows bleeding from a tear in the vaginal wall, cervix or uterus.
• The service provider will check the site for the suspected tear. If identified, such will be sutured – medicine (anaesthesia) will be given before the repair is done.
• After delivery, the mother may feel abdominal pain. This usually result from contraction of the uterus as it returns to its pre-pregnant size.
• It is usually mild. If it does become severe, The service provider will prescribe some pain relieve medicine for you.
• There are other causes of abdominal pain. This will be discussed in the course of this lecture.
• Lochia is the discharge that comes from the uterus after birth.
• For the first 2 hours following delivery, lochia should be about the quantity of heavy menstrual flow and it should then continue to decrease until it stops.
• It is red in the first 3-4 days, becomes pinkish by the 4th to 10th day. Thereafter, it is clear and may continue to flow for up to 6wks after delivery.
• Abnormalities of lochia include:
-Persistence of reddish vaginal flow for more than 4 days may indicate the possible presence of placental fragments. This will need to be treated in the hospital.
-Smelly vaginal discharge after delivery will indicate the presence of genital infection. This will need to be treated by the administration of antibiotics. This may present with abdominal pain and/or fever.
• Establishing and maintaining breastfeeding for the newborn is a very important task in the puerperium.
• Continuous suckling of the breast by the baby is the stimulus that ensures that breastmilk continues to flow.
• Sometimes and especially in the early period after delivery, the breast milk may not flow as much as expected. The mother will need to take a lot of fluids, get some rest and continue attaching the baby to the breast. If these do not address the insufficient milk production, care should be sought in the hospital.
Some breast problems that may be experienced include:
• Breast engorgement, mastitis and cracked nipple.
• Breast engorgement occur when the baby does not suckle the breast and milk accumulates, thus, distends the channels that conduct breast milk. It usually resolved when the baby suckles the breast or the milk is expressed. Note that the baby should continue to suckle milk from an engorged breast.
• Mastitis: This occurs when the breast ducts become inflammed. The predisposing factors include: prolonged breastmilk stasis, infection of the breast ducts, a cracked nipple and an abscess.
• Usually the breast will be painful, swollen and usually there will be fever.
• When this occurs, continue breast feeding and expressing the affected breast and immediately come to the hospital for administration of safe antibiotics and pain relief medication.
• Cracked nipples: In this case the nipple becomes very painful. It usually occurs because of poor attachment of the baby to the milk. The correct attachment is for the baby to grasp –with the mouth- the nipple and the areola when breastfeeding.
• When this occurs, it is important that the attention of healthcare provider is sought.
• This is the occurrence of fever after delivery.
• It is important to address the causes of fever in the puerperium because it can stem from very serious complications that can impede breastfeeding and quality of life of the mother.
• Commonest causes include: genital tract infection, urinary tract infection, mastitis or breast abscess, thrombophlebitis (superficial vein blockage and inflammation).
• Mastitis have been discussed earlier.
• Genital tract infection can result from too frequent vaginal examinations during labour, infection and breakdown of a sutured genital tract lacerations, or infected retain products of conception. As stated earlier, this will usually be a cause of passage of foul smelling lorchia/vaginal discharge after delivery. This will need to be identified by the provider of care and the cause addressed.
• Urinary tract infection: This cause of fever will present with symptoms of painful urination, loin pains, frequent urination or vulvovaginal itching. It may result from infection before delivery or may be a new occurrence in the puerperium.
-The doctor will request the patient to do a urine culture and antibiotics and pain relief medication will be administered.
-It is important that the patient maintain good perineal hygiene to prevent occurrence and recurrence.
• Thrombophlebitis: This usually presents with pains at the site of intravenous fluid (drip) administration. The vein gets blocked and inflammation sets in. When this occurs, warm compression of the site and presentation to the physician is key.
• Constipation occurs commonly during early puerperium. Some of the predisposing factors include dehydration from labour, perineal pain from genital tract tears/episiotomy and inadequate fibre and water consumption.
• This can be addressed by:
(1) Liberal oral intake of oral fluids.
(2) Intake of high fibre diets.
(3) Doing sitz bathe for sutured genital tract laceration.
(4) If these measures do not provide relief, consult the service provider.
(5) Sometimes, constipation may result in anal pain either from some slight tear or engorgement of the anal veins, sitz bathe will provide relief and speed up healing.
• Mood changes may occur in the puerperal period. This include: “puerperal blues”, temporary depression and puerperal psychosis.
• Puerperal blues is common in the first week after delivery. The patient feels miserable and cries easily. During this period, the patient has not fully recovered from the stress of labour and delivery. And family appear to focus attention on the baby and neglect the mother. It is usually transient and with emotional support from especially the husband, she will recover.
• Postnatal depression. This lasts longer than puerperal blues and may go on for months or even years. In this instance, the patient loses interest in the environment, feels sad, loses appetite, loses sleep and may have suicidal thoughts. If the patient feels any of these symptoms, it is important to seek medical help soon.
• It is a very uncommon condition.
• This presents as negative change in the patient such as talking irrationally, hearing voices or seeing things that are not audible or visible to others; or thoughts of possession of powers that are irrational.
• Patients who feel this way should be brought to the hospital immediately so as to access care.
CARE OF THE NEWBORN BABY
• Beyond providing care for self, the mother of the newborn, plays an important role as a nurse to her baby. Routine roles include breastfeeding, care of the cord, changing diaper, care of circumcision site (for male children), and monitoring the newborn for any problems such as fever (hotness of the body), jaundice (yellowness of the body), eye discharge and any other problems that may be affecting the baby.
• If any problem such as these is/are noticed in the newborn, such should be immediately reported to the hospital – Avoid providing self-care because it may be dangerous!
• The puerperium is a period of excitement for the mother, family and the community. Yet, this period presents some changes that require close monitoring to unearth any deviations from normal. Thankfully, these problems can be prevented and treatments are easily administrable.
• The mother plays a leading role in providing care for herself and the newborn. This she does by monitoring any deviations from the normal and seeking appropriate and beneficial help.
• The family and community have a role in providing adequate support and understanding to the needs of the mother and her newborn during this time and subsequently.