The postnatal period is also known by doctors,nurses and midwives as the puerperium. It includes the normal processes of physical and psychological adjustments during this period.
Some women in your postnatal care may not understand all of the normal changes which they experience after childbirth. They may become alarmed about changes that are perfectly normal, or ignore symptoms that are really danger signs. Some women ﬁnd mothering a new baby very easy and natural; for others the mothering role may be difﬁcult.
The important physiological events that occur during the puerperium include, among others, the return of the reproductive organs and the levels of the female hormones to approximately their pre-pregnant state.
The full term uterus has grown at least ten times bigger than it was before pregnancy. On its own it weighs approximately 1kg (not including the baby, placenta, amniotic ﬂuid, etc), where as its pre-pregnant weight was only 50-100 gm. Immediately after the baby is born, the uterus can be palpated at or near the woman’s umbilicus (belly button),as it contracts to expel the placenta and fetal membranes. It normally shrinks to its non-pregnant size during the ﬁrst six weeks after delivery, but most of the reduction in size and weight occurs in the ﬁrst two weeks. At around this time, the uterus should have shrunk enough to be located in the woman’spelvis, below her umbilicus.
The innerlining of the uterus (the endometrium) rapidly heals after the birth, so that by the seventh day, it is restored throughout theuterus, except at the placental site. The inside of the uterus, where the placenta was attached, undergoes a series of changes which reduce the number of blood capilliaries entering that site. The capilliaries that remain ‘leak’ blood plasma for a time, which results in anormal vaginal discharge called lochia.This discharge often continues for several weeks after the birth.
In the ﬁrst week, the lochia is bloody and brownish red, but it gradually changes overtime to a more watery consistency. Over a period of two to three weeks, the discharge continues to decrease in amount and the colour changes to paleyellow( straw coloured). The period of time the lochia continues varies, with an average duration of around ﬁve weeks, with awaxing and waning amount of ﬂow and colour. Each woman has her own pattern, with the various phases of the lochia lasting for different lengths of time.
Immediately after the delivery, the muscular walls of the cervix are relaxed, thin and stretched. The cervix may also appear swollen and bruised from the delivery, and it may have small breaks where the tissue was torn as the baby passed through. But within the ﬁrst day the cervix has usually narrowed and regained its normal muscular consistency. On vaginal examination with a gloved hand, you should ﬁnd the cervical opening about two ﬁngers in diameter by 24 hours after the delivery, and by the end of the ﬁrst postnatal week the opening narrows to one ﬁnger width.
Vagina and vulva
The vagina, which was stretched widely to allow the passage of the baby, gradually shrinks to its non-pregnant size and state over a period of about three weeks after the birth. By this date, the increased blood ﬂow and swelling of the vagina and vulva, which was visible immediately after delivery, should have disappeared. Sexual intercourse may resume when the lochia ceases, the vagina and vulva are healed, and the woman is physically comfortable and emotionally ready. Physical readiness usually takes about three to ﬁve weeks, but the woman may not feel ready for sexual intercourse for alonger period and she shouldnot be forced to accept it.
In most communities there is a norm for when sexual intercourse starts, which is often after the puerperium ends, at around six weeks from the birth. Remember that birth control is important to protect against another pregnancy following too soon after the previous birth. The ﬁrst ovulation is very unpredictable and the woman may get pregnant again even before the return of her ﬁrst menstrual period.
The perineum is the part of the body between the vaginal opening and the anal opening. It has been stretched and traumatized, and sometimes torn, during the process of birth. Or it may have been cut intentionally with sterilized scissors by a skilled birth attendant to widen the opening and help the baby out. Most of the muscletone (strength) of the perineum is regained by six weeks after the birth, with more improvement over the following few months. You can help the mother to regain the muscletone by encouraging her to contract and relax the muscles of the perineum ten times as soon as it is comfortable to do so, and to repeat this exercise several times everyday. Strengthening the perineum is important because it forms the ‘pelvic ﬂoor’ which supports her uterus, vagina and bladder.
The abdominal wall remains soft and relatively poorly toned for many weeks after the birth, but it gradually becomes stronger overtime. The extent of return to the muscular tone of the pre-pregnant abdomen depends greatly on the amount of exercise the woman takes as she returns to full ﬁtness. For rural women, who work in the ﬁelds as well as in and around the home, the problem can be putting too much strain on their abdominal muscles (for example to lift heavy weights) too soon after the birth.
The resumption of normal function by the ovaries is highly variable and is greatly inﬂuenced by breast-feeding the infant. The woman who exclusively breastfeeds her baby has alonger period of amenorrhoea (absence of monthly bleeding) and delayed ﬁrst ovulation after the birth, compared with the mother who chooses to bottle-feed. A woman who doesnot breastfeed may ovulate as early as four weeks after delivery, and most have a menstrual period by twelve weeks; the average time to the ﬁrst menstruation for a woman who is not breastfeeding is seven to nine weeks afterthe birth.
In the breastfeeding woman, the resumption of menstruation is highly variable and depends on a number of factors, including how much and how often the baby is fed, and whether the baby’sfeed is supplemented with formula milk. Ovulation is suppressed in the breastfeeding woman by a hormone released from the pituitary gland in the woman’s brain whenever the baby suckles. Half to three-quarters of women who breastfeed their babies exclusively, including during the night, will beg in their ﬁrst menstrual period within 36 weeks after the birth.
Breasts and initiation of lactation
Another important event that happens soon after the birth is the initiation of lactation, that is the production of colostrum and then milk by the breasts, and the release of these nutritious ﬂuids when the baby suckles the mother’s nipple. The breasts begin to develop the capacity to produce milk as pregnancy progresses, in response to hormones circulating in the mother’s blood. For the ﬁrst few days after the birth, the breasts secrete colostrum (a creamy yellow substance).
Colostrum is rich in nutrients for the baby and also has maternal antibodies which protect the newborn from infection. Thus, it is very important that all babies are fed colostrum.
Three days after delivery, in response to increased hormones from the pituitary gland in the brain, which stimulate milk production, the breasts become ﬁrm and milk supply begins. They rapidly become distended, hard and warm because of increased blood ﬂow; this state of the breasts is called engorgement. It lasts about 24-48 hours and will resolve spontaneously.
There after, the breasts are not so hard and do not feel excessively warm, but they become ﬁrm and some what tender as they ﬁll with milk between feeds, and they soften and reduce in size when emptied as the baby suckles milk. On going milk production is stimulated by the suckling of the baby. The more the baby feeds, the more milk the breasts will produce.
Suppression of lactation in non-breastfeeding women
There are circumstances when the mother cannot or will not breastfeed, for example if the baby is born dead or dies in the ﬁrst few weeks, or when the mother strongly prefers to feed her baby with formula milk from a bottle. To reduce the discomfort of prolonged breast engorgement, it is recommended to wrap a tight compression bandage around the woman’s chest, covering the breasts, for the ﬁrst two to three days after the birth. Care should be taken not to stimulate the breasts in any way that would encourage milk production. Ice packs can be applied to the breasts and pain-control tablets containing aspirin or paracetamol may be given to relieve the breast tenderness.
Excretion of excess body ﬂuids
During thepregnancy, the woman’sbody contains more body ﬂuids than in the non-pregnant state. Some of this additional water is held in her tissues, some in her increased volume of blood, and some in the uterus. This excess water is rapidly eliminated after the birth. The amniotic ﬂuid drains away through the vagina. From the second day after the delivery, the urine volume will increase up to three litres per day for a few days, but within one week it returns to the normal pattern of urination. The bladder increases its capacity during the period in which excess body ﬂuids are being eliminated, ﬁlling with between 1,000 to 1,500 ml of urine without discomfort. If urine is retained for long periods in the bladder, because the urethra is obstructed by swollen or bruised tissues after the birth, it increases the risk of urinary tract infections developing.