The Puerperium

The Puerperium

For 9 months the body has been gradually adapting itself to the very complex condition of pregnancy. There have been extensive physical changes, not only in the uterus, the vagina and the breasts, but also throughout the whole body and these culminated finally in labour and delivery. Extensive and very far reaching emotional changes have also been occurring. The safe arrival of the baby may have brought massive relief to the tensions and fears with which his arrival had been anticipated, but the mother must still undergo a slow and gradual psychological change which takes several months to complete. This is entirely normal and accompanies the physical changes that occur during pregnancy and which must now be reversed in order to return the body to normal. While the majority of the physical changes are rapid and dramatic, it is nevertheless several months before the body returns to its normal non-pregnant state. This is particularly applicable during breast-feeding.

The puerperium is defined as being the first 4 weeks after the delivery of a baby, but for the purposes of this narrative we ate only really interested in the first few days after delivery, during which most of the dramatic changes occur. After the end of the first week return to normality is very slow and completely automatic providing certain very basic rules, which are detailed later, are obeyed.

Physical Changes

The Uterus and Vagina

Immediately following delivery it will be noted with some astonishment that the abdomen has become completely flat. It may seem quite extraordinary that an enormous pregnant lump has disappeared in only a few minutes, but careful examination of the abdomen will reveal that there is, in fact, a small swelling just below the umbilicus. This is the uterus, which has now contracted down following the expulsion of the baby and the placenta. It will be firm and hard, partly because this is the normal response of the uterus after delivery and partly because an injection has been given to make it contract. Contraction of the uterus is essential, because without it excessive bleeding occurs from the place at which the placenta was attached.

If a hand is gently run over the abdomen it is possible to feel the firm, hard, round, smooth swelling of the uterus, which may feel slightly tender. This is completely normal and indeed the uterine contractions may continue to be so powerful that some uterine cramps may be felt rather like period pains. This discomfort is perfectly normal.

The PuerperiumThe return of the uterus to its normal state is known as involution, The total involution of the uterus takes approximately 2 months, although the vast majority of the changes occur within the first 2 weeks. Immediately after delivery the top of the uterus reaches almost to the umbilicus. As each day passes the top of the uterus will get lower and lower, until after about 7 days it will no longer be possible to feel it in the abdomen. Another interesting fact is that when the bladder is full it will push the uterus upwards and to one side, usually the right, and the uterus will resume its normal position in the mid-line after the bladder has been emptied.

One of the great marvels of labour and delivery is the manner in which the neck of the womb or cervix is gradually opened in order to allow the passage of the baby without any damage occurring. Immediately after delivery the cervix is open and patulous. It rapidly resumes its former shape and after 2 or 3 days will have re-formed and re-fashioned a cervical canal, although it will still be about 1 cm. dilated.

At the end of the second week after delivery the uterus and cervix will have returned to their normal shape and position, but the uterus will still be about three times its normal size. During the next 4 weeks the uterus will gradually become smaller, so that at the postnatal examination it will have returned to its normal size. Thus the changes which took 9 months to accomplish have been almost completely reversed within 6 weeks of delivery.

After pains. The uterus contracts and relaxes rhythmically throughout life. This is frequently noticed in the non-pregnant state by girls who suffer from painful periods, when uterine cramps may occur every time the uterus contracts. These contractions have also been appreciated as the Braxton Hicks’ contractions during pregnancy, quite apart from the uterine contractions of labour itself. Contractions continue after delivery so that the uterus may involute normally and they may occasionally cause discomfort, known as ‘after pains’. They are far more likely to affect a woman who has had her second or subsequent baby than to affect a woman who has just had her first child. After pains may last for as long as several days and can usually be relieved by simple analgesics, such as aspirin or paracetamol. They are a perfectly normal phenomenon.

Breast-feeding. Many women notice that uterine contractions of sufficient severity to cause after pains begin as soon as a baby starts to feed at the breast. This is perfectly normal since stimulation of the breasts provokes contractions of the uterus. Breast-feeding a baby, therefore, will not only make the uterus contract but will help in the normal process of involution of the uterus.

The Lochia

The lochia is the vaginal discharge after delivery. Immediately following delivery the lochia is bright red and the amount is noted by the nurse. The quantity of bleeding for the first few hours after delivery will be about as much as a normal-period, or even slightly more. Occasionally a few small blood clots are passed. The lochia remains red for the first two or three days and then gradually changes to a reddish brown, and by the fourth or fifth day the lochia will be brown. The colour and the amount of lochia arc noted and recorded by the midwife. The lodiia continues to be brownish, or pinkish brown, for several days but when the mother gets up and starts to be more active, doing her household duties or the shopping, the colour changes and may for a few hours again become red. This is quite normal, and the colour will change back to pink or brown within a few hours, or at most within a few days. The lochia continues as a yellowish brown or pinkish loss with occasional interludes of bright red until it ceases altogether. There is no standard duration of bleeding following delivery. In some women the lochia dries up altogether after about 14 days, whereas in others it may continue for as long as 6 weeks. The average is about 21 days. Frequently, and especially if the baby is not breast-fed, the lochia finishes after the first period which may come approximately 4 weeks after delivery, when the loss suddenly becomes heavier and brighter for several days.

The amount and the colour of the lochia indicate the degree of involution of the uterus. The more rapidly the uterus involutes the more rapidly will the lochia become brown and cease altogether. Breast-feeding helps the uterus to involute more rapidly and the lochia will therefore dry up more quickly in a woman who is breast-feeding than in a woman who is artificially feeding her baby.

Not only will the midwife make a note of the amount and colour of the lochia, but she will also note any offensive smell that may be associated with it. This may be of no significance but may indicate that there is some mild form of infection in the uterus.

The Breasts

There will be no sudden or dramatic change in the breasts or in their condition immediately after delivery. A woman who has been wearing breast shells during her pregnancy should continue to wear them after delivery. The breasts and nipples show very little change during the first 24 hours after delivery, and although the baby may be suckled at the breast for a short time he is unlikely to get anything except a few drops of colostrum, which is the yellow fluid secreted by the breasts before the actual milk is formed.

During the second day after delivery the breasts may begin to ‘fill’. They become firmer and heavier and it is at this stage that satisfactory support with a good brassiere is essential. On the third day the milk will usually ‘come in’. This means that the breasts start to produce milk in reasonable amounts. They may become quite firm and even tender and certainly increase considerably in size. The routine varies in different hospitals but the baby is usually put to the breast twice on the first day and three times on the second day. He is put to the breast every 4 hours on the third day and as he sucks off the milk so the breasts soften and become less tender, only to re-fill and again become firm in readiness for the next feed.

The law of supply and demand applies to breast-milk as it does to most other things in the world and the breasts soon become accustomed to producing and supplying the amount of milk that the baby requires. In other words, the more he sucks and removes, the more are the breasts stimulated to produce more milk. On the fourth or fifth day the discomfort disappears from the breasts and they become slightly smaller and quite soft immediately after feeding, only becoming firm again in time for the next feed. This recurrent change in the condition of the breasts continues throughout breast-feeding.

Circulation

One of the less obvious changes that takes place after delivery is in the circulation. The normal circulating blood volume is about 5 litres and during pregnancy this increases by about 30 per cent in order to supply the demands of the uterus and of the growing baby. Since this demand ceases on delivery, the circulating volume returns to normal over the next 2 or 3 days and is accompanied by passing quite large quantities of urine.

Weight

At the time of delivery and during the first 2 or 3 days immediately afterwards a woman automatically loses a certain amount of weight. The amount is usually about 6.4 kg.., consisting of: baby—3.2 kg., placenta-68 kg., liquor—1.1 kg., and extra circulating blood volume—1.4 kg. If she does not breast-feed her baby a woman loses a further 91 kg. as the breasts gradually return to their normal size. One further kilogram is lost as the uterus gradually involutes during the first 2 weeks following delivery. Thus a woman who is not breast-feeding loses approximately 7-5 kg. automatically after delivery.

If a woman has gained weight in excess of this amount during her pregnancy this is either fluid (which is also lost during the first few days after delivery), or it is fat, in which case it is there to stay until she goes onto a rigid diet. In other words, if a woman has gained only 8 or 9 kg. during her pregnancy then she will, after her delivery, return to her pre-pregnant weight and rapidly regain her figure.

Emotional Reaction

A mother’s reactions following delivery are extremely complex. They vary from individual to individual and it is impossible to predict a pattern for any one person. Reactions after delivery depend upon basic psychological make up, together with the fears and anxieties that have been present during pregnancy and the manner in which these have been answered by the doctors and midwives. They are also affected by labour and by the-presence or absence of a husband both during labour and at the time of delivery. There are, however, several basic emotional reactions common to almost every woman who is safely delivered of a normal baby. Although these reactions may vary with the second, third or subsequent baby they nevertheless remain basically the same.

A woman’s first reaction on hearing that her baby is safely delivered, and especially on hearing him cry, is usually one of extreme relief that he has arrived safely and that he is normal. This emotion of relief is associated with an immense release of tension, and while it sounds very simple when written on paper it is the most profound and one of the most deeply moving emotions that a woman ever experiences. This lasts for only a very short time and is superseded by one of thanks and appreciation. Thoughts of gratitude that pass through the mind immediately after the sense of relief are also very profound and very real. They may encompass an immense scope ranging from gratitude to God, to people who have helped and who are held dear, to whoever has been responsible for the delivery, to a husband (more especially if he has been present during the delivery), to an immense gratitude to the new baby for having arrived safely. The depth of this sensation also passes very quickly.

When a mother first holds her baby she is usually filled with a sensation of wonder and disbelief that she has been able to grow this baby within her body and that he is now being held in her arms, alive and healthy, while a few moments previously he was still inside her uterus. This wonder verges on disbelief and is tinged with a certain amount of awe and reverence that nature should be able to accomplish such a feat. If it is her first baby she may also be rather apprehensive and perhaps a little shy and embarrassed because she does not know how to hold him properly. If it is her second or subsequent baby she will compare him with her previous children, but will still marvel at the wonderful manner in which this new child has been created and delivered. She will probably search for some resemblance to her husband or herself and even if there is none she will imagine it. As a mother holds her new baby in her arms she also experiences a sensation of emotional and physical fulfilment that here at last is what she has been waiting to see and she is also emotionally fulfilled by producing a child for the man she loves.

All these emotions, feelings and sensations which pass through her mind, or which she experiences during the first few minutes after her delivery, gradually subside and are replaced by much more gende emotions of thankfulness and peace.

Not all mothers react in this way; some feel detached from or even dislike the new baby, especially if they have been given a lot of drugs or an anaesthetic. These apparendy inappropriate emotions are quite normal and need not, give rise to anxiety or depression because they are only temporary.

During the next day or two when she is becoming acquainted with her new baby, especially if it is her first baby, a mother may well feel inadequate and incompetent at handling and looking after her new charge. This is a perfectly normal experience and she should be comforted with the knowledge that even the most experienced midwife or doctor goes through the same sensation of inadequacy when presented with her own first child. As mothers they are no more capable than anyone else. All a new mother needs is a little time and practice and then she is able to handle and look after her baby just as well as anyone else has looked after theirs.

You will, of course, feel anxiety at various times. Anxiety first of all as to whether your baby is normal, whether he has the right number of fingers and toes and whether he looks reasonably presentable. Later you may become anxious about any small aspect of either your child’s behaviour or your own progress that may cause you the slightest concern. Usually such anxieties are without any real foundation and can be easily relieved by asking your midwife or doctor. It is surprising how often a new mother becomes anxious about a particular problem which, deep down inside, she knows to be completely irrelevant but because she fails to ask she is never reassured and her anxiety continues. If a mother has a worry she must ask about it; if it has a basis it will be dealt with and if it has no basis she will be reassured. Either way, she can only benefit by asking.

Puerperal Blues

It is said that every new mother should experience ‘the blues’. This is a period of fairly acute depression which starts for no apparent reason and disappears for no reason. It usually lasts for 12 to 24 hours generally between the third and the sixth day after delivery. She may feel rather miserable and will certainly burst into tears at the slightest provocation, or even without provocation. Most midwives and doctors consider that an attack of ‘ the blues ’ is almost essential to relieve tension after delivery. If a woman does not experience this so acutely she will almost certainly have a good cry for no apparent reason.

Care of the Mother

Cleanliness

Cleanliness is of the utmost importance, especially as it helps to prevent infection in the mother and her baby. Soon after delivery the mother is gently washed or sponged down, her bedclothes are changed, and she puts on a clean nightdress. She will have been given a sterile maternity sanitary towel. This attitude towards cleanliness should permeate the whole of the pueCare of the Motherrperium. The midwife adopts similar principles in the care of the baby. She makes sure that the clothes in which he is first wrapped are dean and that his cot is clean and tidy.

Apart from general cleanliness there are three particular ways of observing cleanliness in order to prevent infection. Firstly in handling the baby; everyone should wash their hands before doing any-thing to him such as picking him up, changing his nappy or giving him a feed. Always ensure that his clothes are dean and, if he is being artificially fed, that his bottles, teats and milk have been properly sterilized. Secondly, in breast-feeding, the breasts should always be carefully washed and dried before and after feeding so that the nipples are absolutely clean prior to a feed. Thirdly, the vulva; keeping the vulval area clean prevents vaginal and uterine infection and the routine adopted varies from hospital to hospital and from midwife to midwife. Generally speaking only sterilized or surgically dean maternity pads should be used. In some maternity units the vulval area is washed with an antiseptic solution three times each day, as well as after micturition or defaecation, for the first 3 or 4 days after delivery. In others, antiseptic washing is restricted to twice on the first day, and thereafter only when a large number of stitches have been necessary. Other units use bidets. The sanitary pad may be held in place with a sanitary belt or with a bandage tied round the waist, but probably the most satisfactory and efficient method is to wear disposable paper pants.

Temperature, Pulse and Respiration

After delivery, either before or immediately after the mother has been washed and tidied, her temperature is taken and her pulse rate and blood pressure recorded. Thereafter if everything proceeds satisfactorily the temperature and pulse rate are recorded daily for the first 1o days, or for as long as she remains in hospital. Slight movements in the temperature or pulse rate may occur frequently but these are not generally of any significance. A mother who is breast-feeding may have engorged breasts on the third or fourth day after delivery, causing the temperature to rise to 990 or 99’5°F (3 8°C) and the pulse to about 100.

Observations on the Lochia

Observations on the lochia are recorded daily by the midwife, including the colour and the amount, as well as any offensive smell. She may also measure and record the height of the uterine fundus each day to ensure that involution is normal. This is done after the bladder has been emptied, because a full bladder pushes the uterus upwards and to one side. Many doctors and midwives no longer consider that the height of the uterine fundus is significant, because it is affected not only by a full bladder but also by the presence of faeces in the bowel, and the fact that not everyone’s uterus involutes at exactly the same rate. More important than the actual height of the uterus is pain or tenderness. Immediately after delivery the uterus may be quite tender and painful because of the strong contractions which follow the administration of the oxytocic drugs. During the next day or so there may be slight tenderness on one side at the site of the attachment of the placenta. Apart from this, however, tenderness should gradually diminish with each succeeding day and if it increases or pain begins, it should be reported to the midwife or doctor.

Bathing

There is a great deal of prejudice and tradition involved in the care of a woman during her pregnancy and shortly after delivery; bathing after delivery is one of the major areas of disagreement. It used to be believed that bath water entered the vagina and thereby gained access to the uterine cavity, so causing infection within the uterus itself. This is now known to be untrue, and there is no reason why a woman should not bath as soon after delivery as she can comfortably do so; similarly she may have a shower as soon as she wishes. The fact that she is bleeding is no reason for avoiding a bath, although for the first day or two it should not be too hot. The skin is very active during the puerperium and a daily bath or shower is necessary; twice daily is even better if the facilities are available.

Lactation

Lactation begins early in the puerperium. For the last few weeks of pregnancy and immediately after delivery die breasts contain a thick, milk-like substance called colostrum; during the third and fourth days the amount of milk will steadily increase until lactation is established. The baby is usually put to the breasts twice on the first day and three times, on the second day and thereafter every 4 hours, except during the night, and spends longer at the breast on each succeeding day as more milk becomes available.

Before each feed the nipples should be cleaned. It is important to get into a comfortable position for feeding and it is equally important that the baby is held comfortably and feels secure. The midwife will guide and help with the feeding regime and is a valuable source of information concerning breast-feeding. On the second or third day after confinement the breasts feel rather tender, heavy and uncomfortable, but this disappears as the baby gets hungry and takes more milk from the breast. Breast-feeding is the best and the most natural way to feed a baby; while he is being fed he also receives comfort and assurance.

The Bladder

Most women will have either emptied their bladder during labour or will have been catheterized so that immediately after delivery the bladder is empty. It is the modern practice to allow women who feel quite fit and well up to the lavatory or the commode as soon as they wish after delivery and to encourage them to pass urine within an hour of delivery, although they may not wish to do so for 5 or 6 hours. It is much easier to pass urine on the lavatory than when perched precariously on a bed pan. After passing urine for the first time there is no reason why a mother should not go to the toilet perfectly normally as, often as she wishes.

Occasionally, especially after a long and difficult labour or a forceps delivery, a woman may be unable to pass water because of bruising around the base of the bladder. When this happens a small catheter is passed into the bladder and may be left draining continuously for i or perhaps z days after which she will be able to pass water normally. If an in-dwelling catheter is used an antibiotic will be given to prevent any infection developing in the bladder.

The Bowls

Women have a tendency to become constipated during the puerperium because a lot of fluid is lost from the body in the urine, through perspiration and in the milk. Constipation can cause discomfort and perineal stitches may lead to a natural reluctance to exert any pressure in the area. The bowels will need less artificial stimulation if the diet contains sufficient roughage and a lot of fluid. Senokot is a useful laxative if dietary measures are not satisfactory.

Sutures. Perineal stitches are often necessary and consist of catgut or synthetic material. Both are rapidly absorbed and do not need to be removed, though this may be done to increase comfort and allow a woman to move about much more and empty her bladder and bowels more easily. It is important to keep the stitch line clean and as dry as possible to promote quick healing.

Convalescence

It is quite natural that tremendous excitement should follow the delivery of a new baby when everyone wants to visit to offer congratulations and good wishes, and much as one may wish to see them, most women find visitors extremely tiring. If it were possible to limit the visits to one minute or two minutes each, then quite a number could come, but when someone has travelled a long distance it does seem rather unfair to say that they can only stay for a few minutes, especially if they consider themselves to be a favourite aunt or best friend. The easiest way out of this situation is to restrict visitors to husband and immediate family for the first two or three days when a woman really needs to settle down after the excitement of pregnancy and delivery. After this most women feel more able to cope with the disturbance that visitors and their children inevitably bring with them. When a woman has had her baby at home, it is extremely difficult to restrict visitors. Those who have been in hospital or who have had a baby know how tiring even the best intentioned visitors can become if they overstay their welcome, so everyone should bear in mind that while the new mother will be delighted to see her friends, they need only stay for a short while even if she, out of courtesy, presses them to stay longer.

Since most hospitals now have ‘open visiting’ your husband can usually visit you at any time except when the ward is closed at feeding times or during the resting hours. If you already have children, ask the sister in charge when they may visit you.

Rest

Rest, which does not necessarily mean sleep, is most important. After a normal delivery a woman is not an invalid, but she must rest to allow her body to readjust after the pregnancy and confinement. Most of the first day should be spent in bed, except to get up to go to the lavatory or pick up the baby. From the second day onwards she may get up for meals as well, but when there is nothing definite to do she should rest in bed, and this regime should be continued for the first week. It is certainly true that a normal mother may feel like doing more and she may feel as though she ought to be doing more, but it cannot be too strongly emphasized that the body requires rest to readjust and the more she rushes about the longer will it take to return to normal. An adequate amount of sleep is essential, so she should settle down and try to sleep as soon as the 10 o’clock feed is over. For the first few days a new mother may be spared having to get up in the night to give her baby a night feed, especially if she is in hospital, but she ‘will be woken at 6 o’clock for the first morning feed. It is surprising how quickly the night passes and 7 hours’ sleep is not really sufficient. Most midwives insist on their patients resting during some part of the day. The best advantage should be taken of this time for relaxation and sleep, because not only is it beneficial to the woman herself but, if she is well rested, it also helps her baby.

For some strange reason most mothers do not sleep well on the first night after delivery. After a long and tiring labour it would seem that a woman should feel so tired that nothing could keep her awake, but even in these instances the excitement of delivery and the new arrival seems to overcome tiredness. Thereafter she usually sleeps well and it is of paramount importance that she has adequate sleep. Any woman suffering from insomnia or waking during the night should report this to her midwife. The necessity for an adequate amount of sleep cannot be too strongly emphasized.

It is a very mistaken belief that rest in hospital for 7 or even 10 days after delivery is something in the nature of a light-hearted holiday; nothing could be further from the truth and having a baby at home is certainly not a holiday unless there is a great deal of help – in the house. Rest after delivery is even more important than it was during pregnancy. It is really surprising how the day is occupied so that there is, in feet, very little opportunity to relax and a certain amount of time .must, therefore, be set aside each day for a formal rest period which should, if possible, be for 1 hours. Relaxation taught during pregnancy is for use during labour, but it is just as important that the resting time after delivery should provide as much relaxation as possible. The longer the rest and the better the relaxation during these days the more easily will a woman cope with the many problems which are bound to crop up from time to time.

During pregnancy everyone is enthusiastic about looking after the pregnant woman, and her husband is actively encouraged to do so. After delivery, however, people are frequently more interested in the new baby or busy congratulating the father as well as being full of guidance and advice concerning how to divide time, love and energy in looking after two people instead of one. They all seem to forget that the mother has also to look after herself. A complete book could be written on how a mother should look after herself after having a baby, not only for the next few days or even the next few months, but also the next few years, and this, like so many things in life, is far from easy but extremely important.

Just as time must be found to rest and relax, so must time be found to wash, bath, put on make-up, comb your hair, put on a clean nightgown, see that the bedclothes are tidy, that flowers are properly arranged, that the baby is clean and that his cot is tidy as well as a thousand other little jobs that can only be accomplished if a simple straightforward plan is made to organize the day’s work early in the morning.

Diet

The traditional treatment in Britain for a woman who has just had a baby is a nice cup of tea, and this should herald a return to a normal unrestricted diet. After having a baby a woman may start eating a normal diet as soon as she feels like it. Good eating habits are essential during the puerperium, particularly as a nursing mother requires a wholesome diet to build up her strength and enable her to produce sufficient breast-milk. This refers to the kind of food that is eaten, not the quantity. Regular meals of protein, fruit and, vegetables are better than snacks consisting mainly of carbohydrate which is fattening. As some women are anaemic at this time, foods rich in iron should be included in the diet, though iron supplements should be continued after leaving hospital especially if there is any sign of anaemia.

The diet in the puerperium should contain:

Proteins. Good sources of protein are meat, fish, cheese and eggs. All cuts of meat, bacon, ham and poultry are equally good. White fish should be included. An egg every day is a cheap source of protein.

Calcium. Milk provides protein as well as calcium, used in milky drinks, puddings, soups and cereals. A piece of cheese three or four times a week helps to supplement the calcium in milk and also provides protein.

Vitamins and minerals. Good sources of iron are liver, kidney and heart. These should be eaten once or twice a week as well as other meats, eggs and green vegetables, especially spinach.

Vegetables. At least two helpings of vegetables or salad a day should be eaten. Potatoes and high carbohydrate vegetables should be limited.

Fruit. Fresh fruit should be eaten at least once a day. Oranges, 428 grapefruit and tomatoes are excellent sources of vitamin C which helps to keep the skin and gums healthy and to give vitality.

Cereals. Foods such as bread, breakfast cereals, rice and semolina are all necessary to increase the bulk and provide variety. Too much of these foods, however, leads to unnecessary increase in weight.

Fluid. If you are breast-feeding your baby you should drink plenty of fluid, at least i litre a day, of which at least a half should be milk.

When the bowels have returned to normal the mother should take the iron and vitamin tablets she was taking during pregnancy and should continue to take these for 3 months after delivery.

Position

Following delivery a woman is encouraged to move about as soon as possible and free movement of the legs is essential while still in bed. After a normal delivery she usually remains in bed for the first sis hours, and is then allowed up to the bath and toilet. Her position in bed does not matter; she may lie on either side, whichever is more comfortable, or sit up. For many years it has been the custom for women to lie on their tummy for an hour a day to prevent the uterus becoming retroverted. Lying on the abdomen for an hour’s relaxation is to be encouraged but it has no influence on the position of the uterus.

Abdominal Distension

Immediately after delivery the abdomen is flat. It must be remembered, however, that during pregnancy the abdominal muscles have been stretched and it takes them a little time to return to normal. For the first few days after delivery a woman looks as though she is about 20 weeks pregnant. This abdominal enlargement is caused by gaseous distension within the intestine, associated with the slack abdominal muscles. If too much weight has been gained during pregnancy there may also be some extra fat.

The return to normal of the abdominal outline depends on the weight gained and the return to normal of the abdominal muscles. This may take up to several months. If a mother practises postnatal exercises her muscles will recover more quickly and she will regain her figure sooner. There is no need to wear an abdominal support immediately after delivery unless one was worn before or during pregnancy. An abdominal support, however, does not strengthen the muscles but rather weakens them, because once they come to rely on the support they gradually become weaker and weaker.

Ambulation

Nowadays women are allowed out of bed as soon as they wish after their delivery. Over the centuries fads and fancies have changed but there is certainly nothing new in early ambulation after delivery. In many parts of the world it is common practice for women to have their babies and immediately return to their daily tasks. It is generally believed in this country that a certain amount of rest is beneficial to a new mother. The accent, however, is on rest rather than confinement to bed, and after a normal delivery a mother may get up as soon as she wishes to go to the lavatory and attend to her baby. If she has had a prolonged or difficult labour the midwife or doctor may decide that she should stay in bed for 24 hours, but if she is fit and well enough, she will be allowed to get up. It is a matter for individual decision and no firm rules are laid down. When a woman gets up she must always put on slippers, which should be properly constructed with the same height of heel as that normally worn during the day time and not casual slippers without heels. She should not walk around bare-foot.

Blood Tests

A routine blood test is usually taken on about the fourth or fifth day after delivery to ensure that the mother is not suffering from puerperal anaemia, even if the delivery was absolutely normal and the blood count has been satisfactory throughout the pregnancy.

Examination on Discharge

It is the routine in many hospitals for a woman to be examined by the house surgeon immediately before discharge. This includes a pelvic examination to assess the condition of the perineum and to be certain that the sutures are healing satisfactorily. It also checks that the cervix is closing properly and the uterus is involuting normally. There may also be a more complete examination, with examination of the breasts and the abdomen, to note the degree of uterine involution. The blood pressure is recorded and blood taken for a further haemoglobin estimation.

Many hospitals no longer have discharge examinations, reserving most of the points until the postnatal examination 6 weeks after delivery. It is important to attend the postnatal clinic, especially if an examination was not performed before discharge from hospital.

Advice on leaving Hospital

After a normal delivery and a stay in hospital of approximately 7 days, a woman needs some advice on what she is allowed to do when she gets home.

She should continue with more or less the same routine that has been established in hospital; this is particularly important for her baby. She may walk up and down stairs, but should obviously do no more climbing than is essential. She should rest in the afternoon and, if possible, try to get 2 hours’ sleep, and should certainly go back to bed after the 6 a.m. feed for a further rest. If her husband can be persuaded to get breakfast, so much the better. She should get someone to do the shopping for 2 weeks after which she can go out and do it herself, but should avoid carrying heavy parcels or doing heavy household chores for about 4 weeks after delivery.

When organizing the daily routine always leave a few spare minutes for going to the lavatory otherwise you will find that you are too busy to go when the need is felt, or alternatively you will rush and strain because there is insufficient time. Both are equally bad. The former eventually leads to constipation and straining, and the latter causes discomfort and will strain the muscles of the pelvic floor, eventually predisposing to prolapse and piles.

A mother should not drive a car until 3 weeks after delivery because judgment is often impaired. The exact date when a job can be re-sumed depends on the exact nature of the work, but it is most inadvisable to return to work before 6 weeks after confinement. It is inadvisable to take a new baby visiting until he is at least 4 weeks old, unless there is some very special occasion, or to subject him to the risk of infection (e.g. Aunt’s common cold).

Postnatal Exercises

Postnatal exercises are even more important than antenatal exercises. In the antenatal period a woman is taught how to relax her muscles but after delivery she has to make certain that any muscles which might have been stretched or bruised during delivery are encouraged to return to normal as soon as possible. This refers in particular to the muscles of the back, the abdomen and the pelvic floor. Details of postnatal exercises are given below. They fall into three groups:
1 The care of the back.
2 The care of the abdomen.
3 The care of the pelvic floor.

The muscles in the back must not be allowed to get slack. Correct posture and sitting in the correct position is one of the best ways of ensuring that they are maintained in the new strength they have developed during pregnancy.

The muscles in the anterior abdominal wall return to normal providing too much weight has not been gained and that the proper exercises are performed regularly.

The muscles of the pelvic floor are not only the most important but the most difficult to return to normal because in the first few days after delivery, and especially if stitches have been inserted, they may be too sore and bruised for the mother to feel like starting pelvic floor exercises. It is so easy, therefore, to forget them, but they must be done not once or twice a day but many times each day. The muscles of the pelvic floor can be tightened up and pelvic floor exercises repeated while feeding the baby, washing up or doing almost anything. Details of special pelvic floor exercises will be given by your midwife or physiotherapist.

The postnatal exercises below restore the tone of the abdominal and pelvic floor muscles which have become overstretched during pregnancy and labour, stimulate the circulation and encourage good posture.

a Lie on the back with knees slightly bent and the feet flat on the bed. Draw the abdominal muscles in firmly, then raise the head. Hold the position for a few seconds while breathing naturally, then lower the head slowly. Repeat 10 times.

b Lie on the bed with one knee bent. Draw the abdominal muscles in firmly. Lengthen and straighten the leg by sliding the heel towards the foot of the bed, then draw it upwards from the waist to shorten the straight leg. Repeat 5 times with each leg.

c Lie on the back with knees bent and feet flat on the bed. Draw the abdominal muscles in firmly, then reach across the body to place one hand on the opposite side of the bed on a level with the hips. Return to starting position. Repeat 5 times each way.

d Lie flat on the floor on the back with the feet tucked under the edge of a heavy piece of furniture. Cross arms on chest. Raise up slowly to a sitting position and slowly lie back. Keep the back very straight. Repeat 10 times.

e When (d) can be done easily repeat with the arms fully extended above the head. Repeat 10 times.

German Measles (Rubella) Immunization

Where antenatal testing, available in some hospitals, has shown a mother to be ‘susceptible to rubella’ this means that she has never built up immunity to the disease by developing it, being in contact with it or by being immunized. To prevent the possibility of contracting the illness during a future pregnancy, immunization may be offered in the first few days of the puerperium. Should such an injection be accepted, the mother must not get pregnant for at least three months, and adequate contraceptive advice is usually offered at the same time.