The puerperium

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Chapter 9 The puerperium

CHAPTER CONTENTS

Physiological and anatomical changes 85
Morphological changes in the genital tract 86
Conduct of the puerperium 86

Care of the puerperal woman 86
Urinary tract problems 86
Bowel problems 87
Backache 87
Care of the neonate 87

Checking for congenital abnormalities 87
Care of the umbilical cord 88
Weight loss 88
Dehydration fever 88
The stools 88
Jaundice 88
Infant feeding 88
Lactation and breastfeeding 88

Milk ejection reflex 88
Nutritional needs in lactation 89
Maintenance of lactation 90

Establishment of breastfeeding 90
Technique of breastfeeding 90
Breast engorgement 91
Breast problems during lactation 91
Suppression of lactation 92
Breast-milk substitutes 92
Psychological problems in the puerperium 92

Postpartum blues 92
Adjustment to parenthood and postnatal depression (puerperal depression) 92
Child abuse 93
Sexuality after childbirth 93
Perinatal bereavement 93
Postnatal check 94

By convention the puerperium lasts for 6 weeks from the day of the birth of the child. During this time the physiological and morphological changes that occurred during pregnancy revert to the non-pregnant state. It is also a time when the woman takes on the responsibility of caring for a dependent, demanding infant. This may cause problems, particularly if she finds it difficult to adjust to being a mother.

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 puerperal woman

Regular checks are made of the temperature and pulse. The perineum is inspected each day to observe the degree of oedema (if any) and the sutures. Many women who have a damaged and repaired perineum experience considerable pain. The woman may need analgesics; perineal pain is discussed further on page 82.

The character and amount of the lochia are observed and recorded, and the height of the uterine fundus above the symphysis is checked daily.

Uterine contractions continue after childbirth. They are usually painless, but some women experience painful contractions (afterpains), especially when breast feeding. The woman may ask for analgesics.

Urinary tract problems

Micturition may be difficult in the 24 hours after childbirth because of a reflex suppression of detrusor activity caused by the pressure on the bladder base during birth. As a diuresis occurs following the birth, the woman may be uncomfortable. If she is unable to pass urine, catheterization may be required. This is more likely to occur in the puerperium rather than later, because the pregnancy-induced dilatation of the renal pelvis and ureters and the relaxation of the bladder muscle take about 3 weeks to disappear.

About 10% of puerperal women experience urinary incontinence (usually stress incontinence). In all but a few women this persists for a few weeks and then ceases. Pelvic floor exercises (see p. 311) may speed up the resolution of the problem.

Bowel problems

A few women become constipated during the puerperium. In most cases relief is spontaneous; if not, stool softeners such as oral sterculia with frangula bark granules (Normacol) or bisacodyl rectal suppositories may be prescribed.

Women who have haemorrhoids during pregnancy often complain that they are more painful in the postpartum period. One woman in 20 develops haemorrhoids for the first time during the birth, but in most cases these settle in 2 or 3 weeks.

Backache

Backache often occurs in the last quarter of pregnancy and persists after the birth, or it may occur for the first time in the puerperium. Backache affects about 25% of puerperal women, but over half of them have complained of backache before becoming pregnant. The pain can be considerable, particularly if the new mother has no help in caring for her baby. It may persist for months, but eventually settles.

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.

Checking for congenital abnormalities

A check for major abnormalities is made immediately after the birth and before the baby is given to the mother to celebrate the event. A full check is made during the baby’s first day of life. The procedure is described in Box 9.1.

Box 9.1 Examination of a newborn baby

Examine the baby preferably when settled 1/2–1 hour after a feed. Examine gently and with warmed hands and in the mother’s presence. Commence the examination with the baby clothed to accomplish as much of the examination as possible (especially steps 1–4) without disturbing the baby. Only undress the baby as required by the examination.

1. Observe the posture and any spontaneous movement; listen for audible breathing sounds.
2. Feel the anterior fontanelle.
3. Listen to the precordium for cardiac murmurs (this can be done initially through the inner garments to avoid the touch of the stethoscope on the skin – all but the softest murmurs will still be heard).
4. If the baby is still relaxed, gentle abdominal palpation is best done next, feeling especially for liver, spleen or kidney enlargement, or other tumour.
5. Commence a systematic examination commencing at the head, face and neck:

a. Examine the head for bruising, swelling and its shape.
b. Examine the face for abnormal features, symmetry, birthmarks.
c. Open the mouth, examine for cleft palate, other abnormalities of palate, tongue and gums.
d. Examine the eyes for position, strabismus, conjunctival haemorrhage or inflammation, red light reflex.
e. Examine the neck for sternomastoid tumour, goitre, other swellings or pits, redundant skinfolds.

6. Examine the chest for shape, symmetry, signs of respiratory distress, air entry.
7. Check the umbilicus, looking for infection, hernia; check the number of vessels.
8. Examine the external genitalia; in boys check for undescended testicles, hydroceles, hernias, hypospadias; in girls check for hymenal skin tags, imperforate hymen, labial fusion. Check for imperforate anus.
9. Feel for the femoral pulses.
10. Examine the extremities and spine; observe the posture, length of limbs, range of movement; look for deformities of hands or feet – posture, size, shape and number of digits.
11. Examine the hips.
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