The postnatal clinic, together with the postnatal examination, must be regarded as part and parcel of the overall management of a pregnancy. The anatomical and physiological changes that take place in the body throughout pregnancy do not return to normal at the moment of delivery, or even within the 7 or 10 days that are generally considered the usual resting period after confinement. It takes several days or weeks for some of the functions of the body to return to normal whereas other physiological processes may take up to 6 months. After discharge from hospital a return to normal life should be as gradual as possible and an adequate amount of rest and sleep must be taken, which is more easily said than done with a new baby in the house. No firm rules can be laid down regarding activity or progress after delivery, since these depend on how the pregnancy progressed and the ease of delivery. The doctor or midwife will readily offer instruction and advice on what can or should not be done, and will thereby help to plan your future activities.
An essential part of postnatal adjustment is attendance at the postnatal clinic. Its importance cannot be overemphasized. The postnatal clinic is usually visited 6 weeks after delivery. If the baby is delivered in hospital an appointment is given before discharge; if the baby is delivered at home the doctor arranges an appointment. This appointment should be delayed sufficiently to allow all uterine bleeding to cease but it should not coincide with the first menstrual period and should be sufficiently early for contraception to be discussed before the mother can possibly become pregnant again.
A baby delivered in hospital is examined by the paediatrician during his stay and before he leaves hospital. An appointment is made for the baby to attend the paediatric clinic, usually on the same day as the mother’s postnatal appointment. A report is sent by the hospital to the general practitioner, so that he has full details of the confinement, of the health and condition of the baby, and how he is being fed, and can quickly help the mother with the many small points and problems that often arise as the days go by.
Every birth is notified to the local Medical Officer of Health and a Health Visitor, who is a highly trained nurse with additional training in baby care, visits every mother at home, shortly after her return from hospital, to help either with practical matters concerning the care of the baby or any problems. They can also advise on the facilities offered by the local authority and on the ever recurring feeding problems of a new-born baby.
When a baby is delivered at home, the midwife and doctor are available to answer any questions, solve any problems that may arise, and give advice about the facilities provided by the local authority. The doctor will have examined the baby shortly after birth and usually re-examines him on about die 10th day. An appointment should be made to see the doctor for a postnatal examination 6 weeks after delivery, when he also examines the baby and will discuss any problems concerning his management or feeding.
After being checked into the clinic by a midwife or the clinic clerk, the woman undresses and produces a specimen of urine for routine testing. Her weight is recorded and if the rules regarding weight gain during pregnancy were obeyed she should have returned to her non-pregnant weight, although if she is still breastfeeding her baby an extra pound or two may be justifiable.
The value of a postnatal clinic falls roughly into three categories:
1 Immediate advice.
2 Medical examination.
3 Long-term advice.
The history of the pregnancy and confinement are available at the postnatal clinic.
A woman now discusses with her doctor what has happened since she left hospital. He will enquire about the lochia and will want to know if it has been red or brown and for how long it remained so. If she is breast-feeding he will want to know if any vaginal bleeding persists; and if she is not breast-feeding he will ask if she has had an actual menstrual period. This may be difficult to distinguish but is usually recognizable by the relatively sudden onset of a heavier flow for no particular reason starting about the 28th day after delivery. A period does not occur during complete breast-feeding.
The doctor must know about any pelvic or perineal discomfort and the amount and colour of any vaginal discharge. If the mother had an episiotomy and stitches at the time of delivery she must tell the doctor if her perineum is comfortable. If she had haemorrhoids at any time during pregnancy or at the time of delivery, she should tell the doctor what has happened to them and if the bowel habit has returned to normal.
Analfissure. One of the most unpleasant things that can happen to a woman after her delivery is the development of an anal fissure. This is a small crack in the skin just inside the margin of the anus, usually associated with piles, which is first noticed several days after delivery because opening the bowels is very painful. It causes intense pain at the time of defaecation, passes off after a few minutes and then causes no discomfort until the bowels are opened again. This should not be confused with the discomfort caused by piles or stitches. The pain at defaecation caused by an anal fissure often persists for many weeks if not treated. The treatment consists of passing a dilator, well lubricated with local anaesthetic ointment, into the anus twice daily; this soon cures the condition.
The bladder. Frequency of micturition is a common complaint during pregnancy, but shortly after delivery it should return to normal. However, in a number of women some frequency of micturition may continue for a few weeks after delivery and in others (especially after a difficult labour) there may be some difficulty in holding urine, especially on coughing or sneezing. Leakage of urine, known as stress incontinence, may begin during pregnancy and continue after delivery, or it may occur for the first time after delivery. Its cause is weakness of the muscles in the pelvic floor and the greater the leakage, the weaker the muscles. The pelvic floor returns to normal and the bladder symptoms are cured if postnatal exercises are regularly and consistently performed. This cannot be emphasized too strongly.
Weight. If extra weight has been put on during pregnancy it is very difficult to lose in the immediate postpartum period, but if a woman is overweight she should discuss an appropriate diet with the doctor, or arrangements can be made to see a dietician. There is only one way of losing weight and that is to restrict calorie, or food, intake. Usually, it is much better to do this voluntarily than to depend on so-called slimming pills or injections which artificially control the appetite.
Sexual intercourse is discussed, and if it has been resumed the doctor should be told of any pain, discomfort or lack of satisfaction.
If the postnatal examination is held in hospital, details of the baby’s feeding are discussed with the paediatrician. Enquiries are made about the condition of the breasts, regardless of whether the mother is breast-feeding or not.
During the few days before attending the postnatal clinic it is wise to write a list of questions to ask the doctor or midwife, and take this to the clinic. It is surprising how quickly even the most obvious questions are frequently forgotten.
The majority of doctors and midwives will advise women that external sanitary towels should be used until after the end of the first period and certainly until all continuous vaginal loss has ceased. There is always a fear that internal tampons may predispose to infection, especially if they are not changed frequently, although this has never been proved. Internal tampons must not be used until permission is obtained from the doctor and generally, if everything is normal and the loss is minimal, there is no reason why a woman should not begin to use internal sanitary protection about 3 weeks after delivery.
Breast-feeding. Bleeding stops more quickly in the woman who is breast-feeding her baby than in a woman who is not. If lactation has been established and full lactation is being continued, the uterus returns to its normal size more quickly than in the absence of breastfeeding. Rapid involution results in an early cessation of blood loss but it is impossible to forecast the exact duration of loss or its amount. When a mother is breast-feeding her baby it is most unusual, once the normal lochia has ceased, for there to be any bleeding until breast-feeding is partially or completely discontinued. The process of lactation causes the normal menstrual periods to be suppressed. If weaning is sudden a period may come in only a few days or not until 4 weeks or even more have passed, and if weaning is slow a period may come before breast-feeding has completely stopped, or may not arrive until several weeks later.
When a mother is not breast-feeding uterine bleeding frequently continues for up to 4 weeks, and may even go on for as long as 6 weeks after delivery; some women finish after about 2 weeks. Probably the commonest pattern is for bleeding to continue as a brownish discharge, which occasionally becomes pinkish or bright red when work or exercise is increased, until about the 28th day after delivery, when the first actual period may begin. This period is usually longer and heavier than a normal period, frequently lasting 7 or more days, but when it ends there is no further postpartum loss.
The exact timing of the first period after delivery is completely uncertain, and varies according to whether breast-feeding is being undertaken or not. In the absence of breast-feeding the first period may occur on or about the 28th day, but it may be delayed until up to 3 or even 4 months after delivery. Many instances are recorded where women have not had their first period until up to 6 or even 9 months after delivery. If there is undue delay a doctor should certainly be consulted, but a delay is rarely of any significance.
The medical examination at the postnatal clinic is a very straightforward routine examination. The urine is examined. The blood pressure is recorded and compared with the blood pressure at the commencement of pregnancy, noting any rise that happened during pregnancy. The breasts are examined to ensure either that lactation is proceeding satisfactorily or that the breasts have returned to normal following the suppression of lactation. The abdomen is examined to ensure that there is no abnormality and that the muscles of the abdominal wall have regained their strength. A woman may be asked to cross her hands on her chest and sit upright while the doctor gently lays a hand on the abdomen to make sure that the muscles are strong and that the separation between them in the mid-line has closed spontaneously. This separation, known as divarication, happens during pregnancy, especially in the presence of twin pregnancy, and can only be corrected by careful and religious postnatal exercising. The legs are examined for the presence of varicose veins. A specimen of blood may be taken to exclude anaemia.
An internal examination is performed, special care being taken to observe the presence of haemorrhoids or anal fissure. The perineum is examined to ensure that it has healed satisfactorily. Gentle vaginal examination confirms that internal stitches have healed satisfactorily, that the vaginal walls have returned to normal, that the cervix is healthy and that the uterus has involuted to its normal size, shape and position. No one would pretend that the reproductive pelvic organs have really returned to their normal physiological state as early as 6 weeks after delivery, but the majority of the changes have taken place and the experienced doctor soon knows if everything is satisfactory.
If a diaphragm (Dutch cap) or intrauterine device (coil) is to he used as a contraceptive it is fitted at this postnatal examination.
Any other special points which have arisen during the course of pregnancy or upon which the doctor’s advice is sought, or which may require examination, are dealt with at this time. If haemorrhoids, piles or pain on defaecation have been a feature of the pregnancy or delivery, the rectum will be examined.
The majority of gynaecologists consider that the body does not return to its non-pregnant state until about 6 months after delivery or until 3 months after the cessation of lactation. A full discussion with the doctor about future health is an essential part of the postnatal visit. Iron and vitamins should be continued for at least 3 months after delivery, and longer if so instructed. A woman should discuss lactation with her doctor, how long she should continue to feed her baby and what she should do when she wants to discontinue breast-feeding. He will also advise on postnatal exercises, which should normally be continued for several months after delivery.
Sexual intercourse may be recommenced as soon after delivery as desired. Obviously the presence of stitches in the perineum will make sexual intercourse painful or uncomfortable until the perineum has healed completely. It will usually heal in 5 or 6 days but the soreness will persist for 2 or 3 weeks and it is unwise to attempt intercourse before the soreness has disappeared. The majority of women will obviously wait until all vaginal bleeding has ceased before sexual intercourse is recommenced, but there is no medical reason why intercourse should be deferred until all bleeding has stopped. It may not be socially and aesthetically acceptable, but so far as is known no possible harm can ensue if intercourse begins while some vaginal bleeding is still present.
Pregnancy. It is extremely rare for a woman to ovulate sooner than 7 weeks after her confinement. It is, therefore, extremely rare for conception to occur before 8 weeks after delivery even if lactation is suppressed at the time of delivery (i.e. the mother is not breastfeeding) and no contraceptive precautions are taken. It is also extremely rare for ovulation to begin while full lactation is present. If the baby is fully breast-fed, therefore, pregnancy is most unlikely.
As soon as the baby is weaned or a few breast-feeds are discontinued, ovulation may begin and if no contraceptive precautions are taken, the mother may become pregnant. It follows that pregnancy is extremely rare before the sixth week after delivery (or the attendance at the postnatal clinic) or during the course of a full lactation. A discussion on contraception is an essential part of the attendance at the postnatal clinic.
On very rare occasions a woman has a very high level of antibodies in her blood during pregnancy. Antibodies are created in response to the introduction into the body of almost any foreign matter or bacteria, such as German measles or the Rhesus factor. The majority of tests performed in the laboratory for the presence of antibodies are done on a small amount of serum that has been taken from another patient who has developed a high level of antibodies against the same factor. Serum containing such a high level of antibody is comparatively rare and is difficult to obtain but is essential if the satisfactory testing of other patients is to continue. If, therefore, a woman has a high level of antibody to a particular factor in her blood, she may be asked after her confinement to donate some of her blood so that it can be used for testing other women. Please do not think that such a request is made because someone in a laboratory wants to do some experimental work. It is hoped that anyone will readily acquiesce to giving some blood for this purpose. The actual donation of blood is completely painless and is indeed very little different from the many blood tests that were taken during pregnancy.
Those who consider that they have a problem associated with heredity or genetics can obtain advice from their family doctor. The science of genetics, however, is very modern and highly specialized. If there is an unusual or complicated problem he will probably refer to a genetic specialist. For those who are particularly interested in heredity and genetics, Human Heredity by Dr C. O. Carter (Penguin, 1970) is to be recommended.
The science of genetics can offer considerable help to those who have some abnormality in their family or to anyone who has a handicapped baby and needs to know the possibility of the abnormality recurring. It is commonly believed that a marriage between related people (cousins or half-cousins) is more likely to produce congenital abnormality than that between people who are not related. A discussion with a genetic counsellor will help to make sure that the couple are not exposed to an undue risk. The most up-to-date and extensive information may be able to tell them the mathematical chances of any trait being handed to their child; whether a particular disease is capable of being transmitted or when precautions or preventive steps should be taken because an abnormality is possible or likely. Whether the couple accept the advice is up to them once they have been presented with the available facts. Even the genetic expert is not able to answer all questions, but he can at least guide and help many people to reach a sensible and constructive answer to their problems.
Queen Victoria inherited the genes of haemophilia, which is a rare disease that prevents clotting of blood. The disease itself does not occur in girls, although it is transmitted solely by the female. The disease only affects boys, but is not transmitted by them. This particular disease has caused considerable trouble in the families of Queen Victoria’s ancestors but fortunately she transmitted only normal genes to Edward VII so that haemophilia died Out of Britain’s Royal Family. This example illustrates how genetic counselling may help to explain the hereditary nature of some disease, or how it is possible in some circumstances to explain why a disease is likely or unlikely to be transmitted to the offspring of a particular couple.
Some genes are dominant and will prevail in any circumstances over their opposite number, while others are recessive and will not produce their particular trait unless matched by a similar gene in the other chromosome of its partner. This means that some inherited traits pass from father or mother to all the children, while others only occur on rare occasions. It also explains why some hereditary factors skip a generation, which may happen when a potentially dangerous but recessive gene is dominated by a dominant but otherwise normal gene.
Mental illness is frequently considered to be hereditary and, although this may be true in certain circumstances, it must be borne in mind that i in every 25 members of the population suffers from some sort of mental illness at some stage in their life and an even greater number suffer from a ‘mental breakdown’. It therefore follows that some of the genes concerned with mental instability must be present in nearly every family. Epilepsy, on the other hand, contrary to popular belief, is not usually hereditary, save in less than 2 per cent of people who suffer from it. Consultation with a genetic expert may easily reassure a couple who are seriously worried because there is epilepsy in their families. Diabetes may, under certain circumstances, also be hereditary, although not all instances are, and an expert can give a couple a statistical answer as to the likelihood of their children developing diabetes, based on the incidence of diabetes in their families.
Mongolism, hydrocephaly, hare lip, cleft palate, club foot, are some of the conditions in which a genetic specialist may be of particular help. It is possible today for scientists to detect abnormalities in chromosomes. A small amount of blood is taken from a vein of both the woman and her husband and after the chromosomes in the white blood cells have been examined, a more accurate opinion can be given of the possibility of abnormality occurring in their offspring.
The science of genetics is one in which knowledge is accumulated only by slow and painstaking investigation. It is made up of a mix-ture of common sense, complex statistics and highly complicated scientific investigations.