Postnatal Care (Puerperium)

The puerperium covers the 6-week period following birth during which time the various changes that occurred during pregnancy revert to the non-pregnant state. Physiological changes during this time include:

• The cardiovascular system reverts to normal during the first 2 weeks. The extra load on the heart from extra volume of blood disappears by the second week.
• The vaginal wall is initially swollen, bluish and pouting but rapidly regains its tone although remaining fragile for 1-2 weeks. Perineal oedema may persist for some days.
• After delivery of the placenta, the uterus is at the size of 20-week pregnancy, but reduces in size on abdominal examination by 1 finger-breadth each day such that on the 12th day it cannot be palpated. By end of puerperium it is only slightly larger than pre-pregnancy.
• For the first 3-4 days, lochia comprises mainly blood and remnants of trophoblastic tissue. During days 3-12 the colour is reddish-brown but then changes to yellow. Occasionally, lochia may become red again for a few days due to thrombi at end of vessels breaking.

• Perineum:
  • If the perineum has been damaged and repaired it may cause considerable pain, requiring analgesics, and women may prefer to sit on a rubber ring.
  • If the perineum is painful, it is important to check the sutures and check for any signs of infection. Occasionally sutures may need to be removed.
• Micturition:
  • May be difficult in first 24 hours and may occasionally require catheterisation.
  • Around 1 in 10 women have urinary incontinence and this usually takes the form of stress incontinence. For most women this has resolved after a few weeks. Pelvic floor exercises should be taught and encouraged.
• Bowel problems:
  • Constipation may be a problem for a short time and stool softeners may be useful.
  • Haemorrhoids may be more painful after the birth than before. These can occasionally appear for the first time perinatally and these normally disappear within a few weeks.
• Mastitis:
  • May be due to failure to express milk from one part of the breast; can treat by ensuring all milk is expressed and cold compresses.
  • May be complicated by infection with Staphylococcus aureus and require treatment with flucloxacillin.
  • Very occasionally a breast abscess develops and requires incision and drainage.
• Backache:
  • This may persist after the birth and affects approx. a quarter of women - 50% of these women suffered backache before pregnancy.
  • Pain may be considerable and last for several months.
• Psychological problems:
  • 'Third day blues': on days 3-5, a large proportion of women become temporarily sad and emotional; approximately 10% of women suffer from postnatal depression which may present at any time during the first year after delivery.
  • The precise cause of this is unknown and may involve hormonal changes, reaction to excitement of childbirth and doubts by the mother about her ability to care for the child.
  • Management consists of talking to the mother and explaining what is happening.

• Postnatal psychosis:
  • Affects 1-3/1000 women and usually appears as mania or depression but women sometimes present with apparent schizophrenia.
  • Usually begins abruptly at 5-15 days, initially with confusion, anxiety, restlessness and sadness.
  • There is rapid development of delusions e.g. baby has died or is deformed or hallucinations with deepening melancholia.
  • The woman must be admitted to hospital, preferably with her baby.
  • There is limited evidence for the effectiveness of treatment specifically for puerperal psychosis. Treatments used for affective psychoses in general are also appropriate for puerperal psychosis, e.g. one or more drugs from the antidepressant, mood stabilising or neuroleptic groups and occasionally ECT.^1,2
• Postpartum haemorrhage:
  • Primary postpartum haemorrhage is defined as loss of more than 500 ml of blood during first 24 hours.
    • Normally 200-600 ml blood is lost before myometrial retraction plus strong uterine contractions stop flow.
    • 80% of cases are associated with either an atonic uterus or placental remnants. Rest of cases are associated with laceration of the genital tract, rarely uterine rupture or blood coagulation defect.
    • Treatment in situations where placenta is still in uterus is combining controlled cord traction with fundal pressure. If this fails, manual removal of the placenta under general anaesthetic.
    • If the placenta has already been expelled, treatment includes massaging the uterus, IV ergometrine or syntocinon, or misoprostol, blood transfusion, correction of coagulation defects, bimanual compression of the uterus; urgent transfer to theatre for surgery may be required.
  • Secondary postpartum haemorrhage is abnormal bleeding after 24 hours up until 6 weeks postpartum.
    • Usual causes are:
      • Poor epithelialisation of placental site (80% cases).
      • Retained placental fragment and/or blood clots (usually detected by ultrasound).
    • Uterus is often found to be bulky and tender with cervix open.
    • Initially treated with ergometrine IM plus antibiotics. Curettage is only necessary if bleeding persists despite this.
• Postnatal anaemia is common and may easily be overlooked.
• Puerperal pyrexia:
  • Defined as temperature 38 °C or above during the first 14 days after delivery.
  • Now occurs in only 1-3% of all births.
  • Most cases are due to anaerobic streptococci that normally inhabit the vagina. Initially, infect placental bed and then spread either into parametrium or via uterine cavity to Fallopian tubes and occasionally pelvic peritoneum.
  • Alternatively may be breast infection or UTI, or non-infective cause such as thrombophlebitis or deep vein thrombosis.
• Thromboembolism:
  • Now occurs in <1/1000 births and more likely to occur in women who are overweight, over the age of 35 or have had a caesarean section.³
  • Deep vein thrombosis: indicated by low-grade fever, raised pulse rate and feeling of uneasiness. Calf muscles are tender and painful on firm palpation. Clinical signs are unreliable and need confirmation with colour Doppler ultrasound. Treatment is with IV heparin plus oral warfarin continued for 6-12 weeks.
  • Pulmonary embolus: dyspnoea and pleural pain and cyanosis may develop later. Friction rub heard on chest. Diagnosis confirmed by lung perfusion scan performed urgently as women may die within 2-4 hours. Treatment is with IV heparin bolus followed by infusion.

• Women should be offered information to enable them to promote their own and their babies' health and well-being and to recognise and respond to problems.
• At the first postnatal contact, women should be advised of the signs and symptoms, and appropriate action for potentially life-threatening conditions.
• All maternity care providers should encourage breastfeeding.
• At each postnatal contact, women should be asked about their emotional well-being, what family and social support they have and their usual coping strategies for dealing with day-to-day matters.
• Women and their families/partners should be encouraged to tell their healthcare professional about any changes in mood, emotional state and behaviour that are outside of the woman's normal pattern.
• At each postnatal contact, parents should be offered information and advice to enable them to:
  • Assess their baby's general condition.
  • Identify signs and symptoms of common health problems seen in babies.
  • Contact a healthcare professional or emergency service if required.

• The mother should start walking about as soon as possible, go to the toilet when necessary and rest when she needs to. She may prefer to stay in bed for the first 24 hours or longer if she has an extensive perineal repair.
• This is an important time for the women to be encouraged to breastfeed and learn to care for her infant.
• Uterine contractions continue after birth and some women suffer after-pains, particularly when breastfeeding, and may require analgesics.

• Women who chose to breast or bottle feed often need a lot of advice and support, especially with their first baby (but experienced mothers shouldn't be assumed to know everything and support and advice should always be available).
• Breastfeeding should be strongly encouraged (first time mothers may need a lot of support and encouragement initially). Breastfeeding has many advantages, including:
  • Boosts the baby's immune system.
  • Reduction of autoimmune disorders later in life.
  • Reduces risk of cot death.
  • Reduces gastrointestinal problems.
  • Promotes bonding between the mother and her baby.
• Breast engorgement may cause a lot of discomfort but is usually relieved by good bra support and analgesia.
• Women who are unable to breastfeed or prefer to bottle feed also need support and advice, including feeding routines and sterilising.

• Contraception is not necessary in the 21 days after childbirth.
• Methods that are suitable choices for breastfeeding women include the lactation-amenorrhoea method, barrier methods, intra-uterine devices (including levonorgestrel-releasing intra-uterine system), the progestogen-only pill, injectable progesterone contraceptives, the etonogestrel implant and sterilisation. The combined oral contraceptive pill is not recommended as it interferes with lactation.
• The lactational amenorrhoea method can be used provided:⁵
  • Complete amenorrhoea, and
  • Fully or very nearly fully breastfeeding, and
  • No longer than 6 months since birth of the baby.
• Methods that are suitable choices for women who are not breastfeeding include all those for breastfeeding women but combined oral contraceptives can also be used.