The period just after delivery is called puerperium. The puerperium is the time following labour and delivery during which the pelvic organs return to their normal pre-pregnant conditions. By Convention, the puerperium is said to last for 6 weeks after delivery, although it may take longer for some organs to completely return to normal. The management of the early puerperium consist of keeping careful watch upon the physiological processes during that time and being prepared to intervene if they should show signs of becoming pathological. Attention is given to the general mental and physical welfare of the mother and her new born baby.
KEY MANAGEMENT AREAS OF THE PUERPERIUM
Prevention of infection
Every precaution is taken to prevent the implantation of exogenous pathogenic organisms in the birth canal during labour and the puerperium. The woman can be allowed to leave her bed to the toilet within hours after delivery and may be allowed to have a shower or bath a day after delivery. There is no need to clean or swab the vulva and vagina or pour antiseptic solution over them during the puerperium. The vulva should simply be cleaned and covered with a dry sterile pad which is changed whenever it is soaked or soiled. It is important to keep woman from possible source of communicable infections from relatives or health workers and from nosocomial infections from the hospital especially staphylococcus aureus and hemolytic streptococcus.
Time of ambulation
After the physical and mental strain of pregnancy, labour and delivery, the woman needs a period of rest from hard work and mental worry. If the time spent during labour has been normal and there was no gross injury to the pelvic floor or other complications, the woman can be allowed to go out of bed the day after delivery. The average number of days before ambulation is 3 days. Ambulation is advised to encourage the recovery in the tone of the pelvic floor, improve circulation in the legs and reduce the risk of venous thrombosis. Operative deliveries may be kept longer than 3 days before ambulation is allowed.
Temperature and pulse
The temperature may briefly rise to 37.9 degrees Celsius in the first 24 hours after delivery but should fall to normal and remain so soon afterwards. Daily monitoring of temperature in the morning and evening is necessary. If temperature remains high for more than a few hours with corresponding increase in pulse rate, infection from the genital tract should be suspected until proven otherwise. Any fever during this period should be carefully investigated. The pulse rate also rises a few hours after delivery and then returns to normal by the 2nd day. A persistent rise in pulse rate with high temperature should be considered seriously. It may be an indication of severe anaemia, venous thrombosis or infection.
Onset of lactation
During pregnancy, there is considerable hypertrophy of glandular tissues of the breast but secretion of milk does not start until after the delivery of the baby. Women who intend to breastfeed are advised to put the baby to the breast within minutes after delivery. The activation of prolactin makes the breast become more active and there is increased vascilarity. Breastfeeding usually becomes established at the 4th or 5th day post delivery.
Involution of the uterus
Involution of the uterus is defined as the return of the uterus to its non pregnant state after delivery. Immediately after delivery, the fundus lies at about 4cm below the umbilicus. The height of the fundus diminishes daily and it is not supposed to be felt on palpation after the 10th day. The uterus rapidly decreases in size in the first week and then becomes slower and completely involuted at the 8th week. The weight of the uterus at the end of labour is about 1000g and 500g after 1 week post delivery and then 70g by the end of puerperium. Delay in involution occurs when there is uterine infection, fibroid or retention of placental products.
Retention of urine
A few women have difficulty in passing urine for the first day or two after delivery. Urine retention is liable to occur after a difficult labour which caused bruising or laceration in the vulva, after epidural anaesthesia or when many perineal stitches had to be done. If retention of urine occurs or residual accumulated urine becomes infected, a catheter should be passed with careful aseptic precaution.
Incontinence of urine
This is quite rare but true incontinence can occur from vesicovaginal fistula due to a tear involving the bladder from instrumental delivery or pressure on the soft tissues from long difficult labour. Stress incontinence or leaking of urine when coughing, laughing or sneezing is not uncommon in late pregnancy and may worsen after delivery. This is a temporal occurrence and resolves spontaneously. If it doesn’t, surgical intervention may be required.
Cystitis and pyelonephritis
Urinary tract infection with high fever may arise in the first week of puerperium. Symptoms such as frequency and discomfort of micturition are often absent in puerperal UTI but tenderness over the kidneys may be present more commonly on the right than on the left kidney. Treatment is by encouraging the woman to drink adequate quantity of fluid and antibiotics if indicated.
The woman’s food intake is usually interrupted during labour and dehydration may also occur during labour. These factors including the relaxed abdominal muscles and perineal lacerations make defication painful and difficult. Laxatives, suppositories and enema can be used to manage constipation.
Lochia is defined as the vaginal discharge after delivery which comes from the placenta site. For the first 3 or 4 days, it is red in colour as the site starts healing. The discharge decreases is amount and the colour becomes pink and finally serrous. Lochia usually disappears after the 10th day but may linger up to 3 or 4 weeks in some women. Offensive lochia is indicative of uterine infection and should be treated accordingly.
Sleep and anxiety
It is important that the mother gets good afternoon rests in addition to a good night rest free of disturbance as much as possible. Pain from perineal stitches or engorged breasts are the common causes of sleeplessness and anxiety. Sedatives may be given for the first few nights after delivery.
Normal diet should commence a day after delivery. During lactation, the woman will need adequate but not excessive amount of fluids. Animal fats, fruits and vegetables will supply the necessary vitamins and protein intake should be increased.
Care of the breast
During the first 2 or 3 days after delivery, the breast secretes only colostrum and it is important to put the baby to the breast to stimulate bonding between the mother and baby and secretion of milk. The mother should be taught on how to position the baby at the breast and teach the baby to suck. Maintaining breast hygiene is very important to protect mother and child from infection.
Ambulent women have no need for this but women with special need are given breathing exercises, exercise for the abdominal and pelvic wall, and exercise for the legs to prevent venous thrombosis.
Family planning advice
It is important to discuss the need for adequately spacing of future pregnancy with the woman and her spouse. The need to also stop or limit future pregnancies for high risk women should be properly discussed with the couple and the contraceptive methods available should be explained to them with all their pros and cons for their decision making.
Geoffrey Chamberlain, “Normal puerperium ” Obstetrics by Ten Teachers (6th edition)