WHAT IS THE POSTPARTUM?

The postpartum (puerperium) is defined as the 6-week period of time beginning immediately after birth, during which the reproductive organs and maternal physiology return toward the pre-pregnant state. Catabolic processes cause the uterus to rapidly return from a weight of approximately 1000 g at the time of birth to approximately 50 g by the third postpartum week, through a process called involution. Although the vagina does not return entirely to its pre-pregnancy state, vaginal and pelvic tissue normally regains most of its pre-pregnant tone. The cardiovascular system likewise returns to its pre-pregnant level of vascular resistance and volume. Because of all of these changes in tissue size and fluid levels, women in the immediate week after birth experience marked diaphoresis and diuresis, accompanied by dramatic weight loss. In addition to these changes, women normally experience vaginal bleeding, the lochia, which begins as a menstrual-like discharge in the hours after birth, and tapers to a pale, thin, or mucousy fluid by three weeks after birth. Many women normally experience some lochial flow for up to 6 weeks or so postpartum. During the puerperium, women who choose to breastfeed also experience the physical changes (e.g., breast changes) that accompany lactation, whereas those who do not experience gradual drying of their milk supply with diminished breast engorgement over the first few postpartum days. Most women experience disturbance of sleep rhythm and regularity as a result of tending to their newborn, and emotional fluctuations as a result of hormonal and psychoemotional adjustments (see Postpartum Depression).

REDEFINING POSTPARTUM IN A WOMAN-CENTERED WAY

Many consider 6 weeks to be an arbitrary and terribly limited definition of time allocated for the postpartum, recognizing that it takes much longer than 6 weeks to fully physically and emotionally recover from the demands placed on a woman by pregnancy and birth, and much longer than this to adjust to the demands of motherhood. The postpartum is a time of enormous physical, emotional, psychological, and social change, whether associated with the birth of a first child or subsequent children. The adjustments are potentially much more difficult if there have been complications or loss associated with the birth. Each passage through birth and into motherhood is a journey into the unknown, with new hopes, fears, expectations, and demands. Although newborns are doted with kisses, praise, and gifts, most women receive little special attention and nurturing during this time, leaving many new mothers stressed, exhausted, or overwhelmed. The fact that women are no longer considered obstetric patients after 6 weeks also reflects the belief that women are expected to be physically recovered enough to resume their previous responsibilities. Defining the postpartum as a finite period of 6 weeks leads many new mothers to feel as if they are taking too long to “get it together,” or that they are overwhelmed by something that just should not be such a big deal.

Societal expectations also revolve around this arbitrarily allotted 6-week period. Many employers expect women to be back to work after 6 weeks; obstetricians’ and midwives care packages end at 6 weeks; and even husbands, other relatives, and friends expect mom to be able to cope on her own by then. Yet most women, when given the opportunity to express their feelings about their postpartum experience say that they needed more help, support, care, guidance, and understanding than they received, and for much longer than 6 weeks after birth (Box 17-1). Most mothers say that they don’t really begin to feel like their old selves for at least 6 to 8 months after birth, and many never feel quite like their old selves again. Most admit that they had feelings of profound joy as well as stress, anxiety, and confusion during those early days, weeks, and months of becoming a mother.

Postpartum women experience a significant rate of physical health problems; however, little attention has been given to research in this area beyond recent research into postpartum depression.^1,2 Substantial postpartum morbidity is known to exist and this is not routinely assessed as the postnatal assessment.³ In a study of 11,701 postpartum women, nearly half had health problems within 3 months after the birth that continued for more than 6 weeks, and that they had never experienced before. The symptoms of ill health that they confronted sometimes lasted for months or years afterward, and many of them never told their doctors about their problems.² In general, the cursory nature of postnatal care does not facilitate the intimacy required for women to express the nature of their physical complaints, and thus most obstetricians have not recognized the extent to which postpartum women experience health complaints. Interestingly, recent studies have questioned the effectiveness of postpartum medical visits in meeting the postpartum health needs of mothers, and have concluded that “the present six week postnatal examination does not appear to meet the health needs of women after childbirth: its content and timing should be reviewed.”³

Postpartum visits should focus on the challenges women face during this time, and should provide women with the opportunity to express their concerns and expectations, both physically and emotionally. In Reactions to Motherhood: The Role of Post-Natal Care, midwife Jean A. Ball states:

According to a study by Buchart et al., “Listening to women is an essential element in the provision of flexible and responsive postnatal care that meets the felt needs of women and their families.”⁵ By developing an open dialogue with women during pregnancy, care providers can help women to realistically prepare for the postpartum prior to birth, and overcome difficulties that might be inhibiting their recovery as well as their experience of motherhood. This chapter highlights the need for extensive family and social support for the mother after birth in the prevention of this potentially devastating problem. It must be recognized, however, that the need for such support is not limited to the prevention of PPD, but for the promotion of the overall wellness of the new mother, and by extension, her child and family. Indeed, many postpartum difficulties can be averted with adequate postpartum support of the mother, both from her immediate personal community (family, friends, coworkers, etc.) and from her health care providers.

Increasingly, the postpartum doula is becoming an important figure in the postpartum care of new mothers. In the United States, doula services are privately hired; however, in many European countries, postpartum visiting nurses are a common part of routine obstetric care. Beginning in the mid-1980s in the United States, postpartum mother care services, which now routinely employ certified doulas, began cropping up in major cities around the United States, providing in-home help and giving new mothers no-medical assistance and advice on such matters as breastfeeding and newborn care.

Unfortunately, the cost of such services is prohibitive to most. Optimally, doula care should be incorporated into maternal care services, as postpartum support has definitely been demonstrated to reduce postpartum morbidity, especially associated with depression (see Postpartum Depression).

THE USE OF HERBS FOR POSTPARTUM CARE

The use of medicinal herbs has been an intrinsic part of postpartum care in cultures throughout the world. Herbal teas and other preparations are given for a variety of reasons, including preventing infection, treating colic, and nourishing the mother and child. Herbs have been used both internally and topically to reduce bleeding, ease pain from cramping, increase breast milk production, heal and soothe the perineal area, and relax the mother. 6 7 8 9 10 References to traditional herb use after birth abound in historical and sociological references, although the ethnobotany is often not specific. For example, women in Thailand have been known to drink a mixture of tamarind, salt, and water to “strengthen the womb,” whereas women of the Seri Indian tribe of Mexico drank “seep willow tea” to “stop bleeding after birth.”¹¹ The Jicarillo women chewed the root of wild geranium to assist in “expelling uterine blood.”¹¹ Herb use was common in Colombia and Jamaica, as it was in Southeast Asia.¹² In Burma, a paste of tumeric is rubbed onto the body to prevent blood stasis and encourage good circulation while expelling the afterbirth blood.¹² In Micronesia, women are given baths of tumeric paste after birth.¹ In both Ayurvedic and traditional Chinese medicine, herbs are a routine aspect of postpartum care, and have been for thousands of years.

There is little evidence on the number of women in the United States using herbs for postpartum complaints; however, it is likely consistent with the volume of herb use during pregnancy, or slightly higher, as the use of herbal teas for increasing lactation is very popular, and women and care providers are often less hesitant to use herbs outside of pregnancy. Numerous articles appearing in nursing, medical, and midwifery journals describe the use of herbs for postpartum care. 6 7 8 9 10 Chapters 12 and 18 discuss the safety of herb use during lactation. The remainder of this chapter presents information on treatments for common postpartum problems.

COMMON POSTPARTUM COMPLAINTS

After birth women experience a number of common physiologic changes that can lead to discomfort (e.g., sweating, engorged breasts, after birth pains), problems resulting from pregnancy or birth (e.g., hemorrhoids), and discomforts associated with breastfeeding (e.g., engorgement, sore nipples). Hemorrhoids are discussed in Chapter 5, and problems associated with lactation in Chapter 18.

ETIOLOGY AND RISK FACTORS FOR PPD

Despite its prevalence, the etiology of PPD remains unknown.²² Smokers are at increased risk for PPD.²³ In a survey of 574 women in Ontario, of whom 9.9% were diagnosed with PPD, there was a higher rate of PPD among women with a prior history of depression, among women whose pregnancy was unplanned, among those who described the course of pregnancy as “difficult,” and among women who described their general health as “not good.”²⁴ Women with a history of premenstrual dysphonic disorder (PMDD) may also be at increased risk.²⁵ Breastfeeding mothers may be significantly less likely to develop postpartum depression than non-breastfeeding mothers, and breastfeeding may have unknown protective biological factors against PPD.^23,26,27 A recent revision of the predictive factors for PPD lists prenatal depression, child care stress, life stress, lack of social/marital support, prenatal anxiety, low marital satisfaction/poor relationship, history of depression, a difficult infant temperament, maternity blues, low self-esteem, low socioeconomic status, single motherhood, and unplanned/unwanted pregnancy as the most important risk factors for PPD. 28 29 30 31 32 33

Many hormones have been investigated for their possible causative roles, and PPD is commonly attributed to the rapid change in hormones in the postpartum period; however, the role of hormones in PPD remains inconclusive.^22,34 PPD has also been attributed to thyroid insufficiency (hypothyroidism), which is commonly found in the 2 to 5 months after birth. Recent research suggests that the abrupt physiologic drop in insulin levels that occurs during the postpartum period after the slow rise throughout pregnancy may induce mood disorders by affecting serotonin secretion in the brain. Low blood sugar can also have a dramatic effect on mood; therefore, postpartum women must ensure adequate caloric intake through a well-balanced diet to minimize the risk of depression resulting from hypoglycemia. It has been suggested that a carbohydrate-rich diet in the postpartum period may be a preventative or adjunctive treatment of postpartum mood disorders.²² Inadequate intake of essential fatty acids, protein, B vitamins, zinc, and iron also have been associated with PPD. Women who have experienced significant blood loss at birth may be predisposed to depression caused by anemia and its accompanying increased fatigue, tendency to infection. Fatigue also appears to be highly correlated with PPD, especially persistent fatigue occurring by day 14 postpartum.³⁵

Lack of social and emotional support during pregnancy, the labor and birth, and in the postpartum period have all been associated with an increased risk of developing PPD. One PPD study found that poor support with newborn care showed a positive correlation with PPD, whereas affiliation with a secular group was a positive preventative factor.³⁶ A study looking at the impact of a supportive partner in the treatment of PPD found a significant decrease in depressive symptoms in the group where the partner provided the mother with significant support, whereas another discovered that women with postpartum depression “reported less practical and emotional support from their partners and saw themselves as having less social support overall.”³⁷ Clearly, adequate social support is an important variable in preventing postpartum depression. Even a therapist can lead to significant improvement in PPD. In one study, interpersonal psychotherapy was demonstrated to reduce depressive symptoms, improve adjustment, and was shown to be an alternative to drug therapy, especially for breastfeeding mothers.³⁸ It is important for women who are experiencing extreme or prolonged symptoms to seek help.

A study conducted in Switzerland found that among the most significant risk factors for postpartum depression are social or professional difficulties, deleterious life events, early mother–child separation, and negative birth experience.³⁹ Birth experience may have a dramatic impact on a woman’s self-perception as she enters motherhood, yet is generally overlooked. Assisted delivery (cesarean, forceps, and vacuum extraction) may be associated with higher rates of postnatal depression, as are bottle-feeding, dissatisfaction with prenatal care, having unwanted people present at the birth, and lacking confidence to care for the baby themselves after they leave the hospital.^40,41 A study by Edwards et al. indicated that there is an increase in rates of postpartum depression among women who have had cesarean sections, a finding that women themselves report.^42,43 Although this finding has been debated, clinical experience suggests that disappointment in the birth experience effect a new mother’s self-confidence. Considering that 25% to 40% of American women now deliver by cesarean section, this certainly illuminates the need to both reduce cesarean rates and provide counseling and support for those women who have birthed operatively. Furthermore, one study indicates that women who were cared for by midwives had lower rates of depression in the postnatal period, whereas another study revealed a significantly lower rate of depression among the women who had given birth at home compared with hospital vaginal delivery.⁴⁴ Women reported that a sense of control and being informed about choices in their health care greatly improved their psychological state.

Few women experience all of the symptoms of PPD; some may exhibit only a few, some many. It is the duration, severity, and complexity of the symptoms that distinguishes postpartum depression from the common and normally occurring “baby blues,” which occurs in 50% to 70% of new mothers. Baby blues is thought to be a result of normal postnatal hormonal and other physiologic adjustments, and is self-limiting, usually beginning at about day 3 or 4 postpartum and lasting only up to about 14 days.⁴⁵ Symptoms include crying, irritability, fatigue, anxiety, and emotional lability.¹⁶