PHYSIOLOGICAL AND ANATOMICAL CHANGES

The endocrinological changes that occurred during pregnancy rapidly revert. Within hours of the expulsion of the placenta the levels of the placental hormones, human placental lactogen (hPL) and chorionic gonadotrophin (hCG), fall rapidly. Within 2 days hPL is undetectable in serum, and by the 10th day after birth hCG can no longer be detected. The serum levels of oestrogen and progesterone fall rapidly in the first 3 puerperal days, reaching non-pregnant levels by day 7. They remain at this level if the woman chooses to breastfeed; if she does not, oestradiol begins to rise, indicating follicular growth. In breastfeeding women human prolactin (hPr) levels rise following suckling.

The cardiovascular system reverts to the non-pregnant state during the first 2 puerperal weeks. In the first 24 hours the additional burden on the heart caused by the hypervolaemic state persists, after which time the blood and plasma volume return to the non-pregnant state. This occurs by the second puerperal week. In the first 10 days after birth the raised coagulation factors occurring during pregnancy persist, but are balanced by a rise in fibrinolytic activity.

MORPHOLOGICAL CHANGES IN THE GENITAL TRACT

Following the birth the perineum is either damaged or intact. The damage will have been repaired, but oedema of the tissues may have occurred and will persist for some days. The vaginal wall is swollen, bluish and pouting. It rapidly regains its tonicity, although it is fragile for 1 or 2 weeks.

The uterus undergoes the most marked changes. At the end of the third stage of labour the uterus is the size of a 20-week pregnancy and weighs about 1000 g. It rapidly becomes smaller, and by the end of the first puerperal week it weighs about 500 g. Its involution can be demonstrated by the fact that its size is reduced on abdominal examination by one finger’s breadth a day, to the extent that on the 12th day after the birth it cannot be palpated abdominally. Its involution continues more slowly after this time, but by the end of the 6th puerperal week it is only slightly larger than it was before the pregnancy.

Concurrently with the involution of the uterus, the placental site becomes smaller. After the birth it is rapidly covered with a fibrin mesh, and thrombosis occurs in the vessels supplying it. Beneath the placental site, macrophages, lymphocytes and polymorphs form a ‘barrier’, which also extends throughout the endometrial cavity. Within 10 days the placental site has shrunk to a diameter of 2.5 cm, and a new growth of covering epithelium has occurred, which also covers the remainder of the uterine cavity. The superficial tissues of the uterine lining and placental site continue to be shed for 6 weeks, and form part of the lochia.

The lochia is the term used for the discharge from the genital tract that follows childbirth. For the first 3–4 days it consists of blood and remnants of trophoblastic tissue, mainly from the placental site. As the thrombosed vessels of the site become organized the character of the lochia changes. From the third to the 12th day after the birth its colour is reddish-brown, but after this time, when most of the endometrial cavity has been covered with epithelium, it changes to a yellow colour. Occasionally some of the thrombi at the end of the vessels break, releasing blood, and the lochia becomes red once more for a few days.

CONDUCT OF THE PUERPERIUM

A recently delivered woman may start walking about as soon as she wishes, go to the toilet when required, and rest when she feels tired. Some women prefer to remain in bed for the first 24 hours after the birth, and women who have had an extensive repair of a torn perineum or a large episiotomy may choose to remain in bed for longer.

A function of the medical and midwifery attendants is to make sure that the tissues are healing properly, and that the uterus is involuting normally. However, this function is less important than encouraging breastfeeding and providing information about the care of the infant when the mother goes home.

Economic pressures now dictate that most women leave hospital 1–2 days after an uncomplicated delivery and 3–5 days after a caesarean section, with supervisory care at home being provided by a combination of visiting hospital and community midwives.

CARE OF THE NEONATE

Today most hospitals have facilities for rooming-in, the baby lying in a cot close to the mother’s bed, mother and baby being treated as a dyad. This has made the care of a healthy newborn infant much easier.

LACTATION AND BREASTFEEDING

During pregnancy the breasts develop considerably. Fat is deposited around the glandular parts of the breasts. Oestrogen leads to an increase in the size and number of the ducts, and progesterone increases the number of alveoli; hPL also stimulates alveolar development and may be involved in the synthesis of casein, lactalbumin and lactoglobulin by the alveolar cells.

In spite of this activity, lactation is inhibited during pregnancy, although levels of human prolactin (hPr) rise throughout the pregnancy. The reason for this is that the high levels of oestrogen occupy binding sites on the alveoli that prevent them from responding to the lactogenic properties of hPr. In late pregnancy the breasts secrete a thickish, yellowish fluid, colostrum, which is rich in immune antibodies. The production of colostrum increases after the birth until it is replaced by breast-milk production.

As mentioned earlier, the level of oestrogen falls rapidly in the 48 hours following childbirth. This permits circulating hPr to act on the alveolar cells to initiate and maintain lactation.

Lactation is encouraged by early and frequent suckling, as this reflexly causes the pituitary gland to secrete hPr (Fig. 9.1). On the other hand, negative emotions, including the fear of failing to breastfeed, may reduce the secretion of prolactin, by promoting the release of the prolactin-inhibiting factor (dopamine) from the hypothalamus. The onset of lactation may be delayed in women who were delivered by caesarean section or following a traumatic labour and birth.

Fig. 9.1 The prolactin reflex.

By the second or third day after the birth hPr has induced the alveolar cells to secrete milk, which is thin and bluish in colour. Initially the milk distends the alveoli and the small ducts, causing the breasts to become full, engorged and tender. Turgid veins can be seen beneath the skin, and the milk ducts can be felt as tender strings in the breast tissue. The engorgement is due to the absence of ejection of milk through the large ducts to the nipple.

Milk ejection reflex

The milk filling and distending the alveoli is unavailable to the infant until myoepithelial cells (Fig. 9.2) that surround the alveoli and smaller ducts contract in response to the milk ejection (or ‘let-down’) reflex. The reflex is initiated by suckling and is mediated via the hypothalamus and pituitary gland, which release oxytocin into the bloodstream (Fig. 9.3).

Fig. 9.2 Myoepithelial cells surrounding a partially filled villus.

Fig. 9.3 The milk ejection reflex.

The oxytocin causes contractions of the myoepithelial cells and milk is ejected from the alveoli and small ducts to flow to the large ducts and the subareolar reservoirs. Oxytocin may also inhibit the release of dopamine from the hypothalamus, further encouraging the secretion of milk.

Negative emotional and physical factors can reduce the let-down reflex, with the result that for lactation to be established the mother must be confident that she can breastfeed. The medical attendants should encourage her to be confident.

A joint statement by WHO and UNICEF summarizes the support needed for successful lactation (Box 9.2).

Box 9.2 Ten steps to successful breastfeeding

Every facility providing maternity services and care for newborn infants should:

1. Have a written breastfeeding policy that is routinely communicated to all healthcare staff.

2. Train all healthcare staff in the skills necessary to implement this policy.

3. Inform all pregnant women about the benefits and management of breastfeeding.

4. Help mothers initiate breastfeeding within a half hour of birth.

5. Show mothers how to breastfeed and how to maintain lactation even if they are separated from their infants.

6. Give newborn infants no food or drink other than breast milk unless medically indicated.

7. Practise rooming-in. Allow mothers and infants to stay together 24 hours a day.

8. Encourage breastfeeding on demand.

9. Give no artificial teats or pacifiers (also called dummies and soothers) to breastfeeding infants.

10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from hospital or clinic.

MAINTENANCE OF LACTATION

The most effective way of maintaining lactation is regular suckling, so that both the prolactin and the milk ejection reflexes are initiated frequently, and abnormal distension of the alveoli by milk is prevented. If distension occurs, the alveoli are unable to secrete milk efficiently and at the same time suckling is avoided because of pain in the breasts. Consequently, the inhibition of the reflex that prevents the release of dopamine from the hypothalamus is lost and alveolar activity diminishes, with a further reduction of milk secretion.

Technique of breastfeeding

The mother should be shown how to stroke the infant’s mouth with her nipple, to induce the ‘rooting’ reflex in which the baby opens her or his mouth and searches for the nipple.

She then holds her breast with the nipple between her forefinger and middle finger, so that the nipple becomes more prominent and the infant is able to put its gums on the areola and not on the tender nipple itself (Fig. 9.4C). This technique enables the baby to breathe when suckling (Figs 9.5 and 9.6).

Fig. 9.4 Ideal position of nipple in infant’s mouth. In (A) and (B) the nipple is being chewed; in (C) the nipple is well within the baby’s mouth.

Fig. 9.5 The baby’s lips are pursed awaiting attachment to the mother’s breast.

Fig. 9.6 Good attachment of the baby.

The mother is shown how to detach the infant’s mouth from the nipple without causing her pain. This is done by putting her little finger into the corner of the baby’s mouth to break the suction before detaching it from her nipple.

As mentioned earlier, very few babies managed in this way require additional fluids in the first 4 days of life. However, if the baby becomes clinically dehydrated, water may be given by a spoon or dropper after a feed. A feeding bottle should be avoided as it may stop the baby learning how to suck properly at the breast.

PSYCHOLOGICAL PROBLEMS IN THE PUERPERIUM

The birth of a baby places considerable stress on the mother. She has the responsibility of caring for a demanding infant, her nights are usually disturbed, and she may not feel competent or confident about her ability as a mother. It is not surprising that it takes time for her to adjust to being a mother and that she may suffer psychological disturbances.

A large number of women – probably 50% – experience a heightened state of emotional reactiveness 3–5 days after the birth and about 10% become more severely depressed. Postnatal depression is mentioned here and discussed more fully on page 187.

SEXUALITY AFTER CHILDBIRTH

After childbirth the demands of the new baby occupy a good deal of a mother’s time. Moreover, if the mother has had a perineal tear or an episiotomy repaired – in fact if she has needed any stitches – her perineum and vagina may be tender for several weeks or months (see p. 79). It is not unexpected that her desire for sexual intercourse is reduced. Some women who breastfeed may have a reduced libido and develop vaginal dryness, both of which are reversed when they cease breastfeeding. Intercourse is not the only way of obtaining sexual pleasure, and she may welcome touching, cuddling and stimulating her partner if he wishes. When she is ready the couple can resume intercourse. Women may consult a doctor about their lack of sexual feeling after the birth, and supportive advice is helpful.

PERINATAL BEREAVEMENT

About 12 babies in every 1000 are either stillborn or die in the first 28 days of life. These constitute perinatal deaths, and many of these babies are born preterm and are of low birthweight, and about 25% have severe congenital malformations. Parents whose baby dies in the perinatal period have grief reactions similar to those that follow the loss of any loved person. At first the mother (and often the father) feels numb and shocked. After a few days the reaction changes to a desire to understand why the baby died, or to expressions of anger or guilt about events in pregnancy or during labour. Over the next 2 or 3 months many parents are likely to review the events surrounding the baby’s death, often repeatedly. More than 50% of mothers suffer from depression and anxiety, which may last for months, but in time the couple adjust, often embarking on a new pregnancy.

The severity and duration of the bereavement reaction may be reduced if the parents are given the opportunity to talk with the attending medical and midwifery staff soon after the baby’s death. The talk should take place in a quiet private area, not in an open ward. Most parents want to understand what has gone wrong, and to have it explained in clear, simple language. A few become angry, blaming the staff for the child’s death. The doctor or midwife should listen to the parents with sympathy and understanding and explain as clearly as possible the events surrounding the death.

In addition, the staff member should give information to the parents about the grief reaction that may be expected, and should provide reassurance that nothing the mother did, or failed to do, caused the death of the child.

Parents who wish to see their dead child (even if malformed) should be given the opportunity, so that they may mourn their loss. If they do not wish to see the child at that time, a photograph, a footprint and perhaps a lock of the child’s hair should be kept with the mother’s records, as later the parents may regret their decision not to have seen their child.

Before the parents see the baby they should be told how the infant will look. If there are deformities they should be described (perhaps with the aid of a photograph). The baby is presented to the parents clothed and wrapped, and when they become accustomed to him or her, the baby can be undressed by them. This procedure is often emotional, and support from a health professional may be invaluable. The parents should be told that they can spend as much time as they wish with the baby, and should be encouraged to name the child. Many parents wish to have a photograph of their dead baby. When the mother leaves hospital it is important to suggest that she makes contact with her family doctor (or health visitor), and she should be told about community-based help organizations in her area.

One woman in every five whose baby is stillborn, or who dies in the neonatal period, will suffer severe symptoms of bereavement (sleeplessness, depression and withdrawal). Women who have little or no support from husband, partner or family, who are cared for by insensitive health professionals and who lack a caring environment are more likely to be severely affected. These women in particular need help from sympathetic health professionals who listen, communicate and counsel.

There is some evidence that parents cope better, psychologically, with the next pregnancy if conception is delayed for a few months, but the decision has to be made by the couple, rather than imposed by a doctor. During the pregnancy continuity of care is important, and supportive, communicating, sympathetic health professionals help to reduce possible mothering difficulties and puerperal problems.

POSTNATAL CHECK

It is usual for the mother and her baby to be asked to return for a postnatal check 6–8 weeks after the birth. The purpose of this visit is to discuss her:

The doctor also examines the woman and her baby.

The maternal examination includes inspection of the perineum and vagina to ascertain that any damage has healed, to find out whether she has urinary or faecal incontinence, and to determine the muscle tone. A vaginal speculum is used to visualize the cervix and a Pap smear is taken if indicated. A bimanual examination is made to check that the uterus has involuted completely.

Follow-up examination of the newborn is made (see Box 9.1) and immunization discussed.