5.1 The puerperium 5.2 The return of the period 5.3 Post partum complications 5.4 The first medical check up 5.5 Adapting to the new family situation 5.6 Recovering the physical shape

After nine months of long wait and of an exhausting childbirth, many sensations and unknown emotions invade the mother.

In the following hours after the childbirth, the mother feel happiness euphoria for finally having her baby by her side, but the physical effort of the childbirth produces in her an enormous fatigue. In many cases this fatigue is increased by some anemia due to the loss of blood during the delivery.

Now she needs some time so that her body returns, little by little, to normality.

In this recovery phase that is called puerperium, it is possible that she feels some nuisances.

The puerperium is also called the postpartum or quarantine. It lasts approximately between 6 and 10 weeks, the time necessary for her organism to find its balance, and it concludes when the period reappears.

Getting up after the childbirth

If the childbirth has been a natural one and everything has gone normally, it is important that the mother begins to move as soon as possible to avoid hemorrhages and to prevent constipation.

The mother can get up 24 hours after the birth, but she should do so little by little and accompanied because she can feel sick.

While still in bed, she should move her legs and feet to favor mobility, stretch her muscles and foster blood circulation. The following step is to sit down in the border of the bed for a few minutes and lastly, to stand up with some help and to walk around the room.

After a Caesarean childbirth

A Caesarean operation is a surgical intervention that can be done with general or local anesthesia, such as the epidural. With the second kind of anesthesia, the after effects are less unpleasant for the mother and /she has the advantage of being able to be immediately with her baby.

After a Caesarean operation with epidural anesthesia, it is convenient that the mother gets up in the following 24 hours to avoid hemorrhages and other circulatory complications. After some days the mother can move almost normally and before the 10th day the stitches or staples will be removed and she will recover her freedom of movement. As the scar can perspire, she has to wash it with water and soap, dry it with a sterile gauze and to cover it with a dressing. At first, the skin around the scar will seem insensible but it will progressively return to normality.

When this intervention is practiced, the mother should wait until the 4th or 5th day to take a full shower. The intestinal and urinary traffic also take a little more to recover.

Although the childbirth has needed a Caesarean operation, the mother can breastfeed the baby. If the contractions and the area of the incision provoke very sharp pains, the doctor can prescribe a pain reliever that doesn't harm the baby.

The stay in the hospital

In average, after a normal childbirth, the stay in the maternity ward usually lasts between two and four days, and from six to eight days if the birth has been by Caesarean operation.

The mother should take advantage of this time to rest and to get acquainted with the baby. Visitors are comforting but they can end up burdening, for that reason they should be limited to the closest relatives while the mother and the baby remain in the hospital.

In these days the professionals of the hospital control the mother's evolution: the temperature to prevent (and if necessary to control) any type of infection, the involution of the uterus, the loss of blood, the state of the breast and of the episiotomy, etc.

This period is also very useful so that the mother can ask any questions she may have with regard to the care of the baby and for the recovery of her body.

The involution of the uterus

The uterus involutes (it begins to recover its normal volume) starting during the first few hours after the birth.

The lochia is a secretion of the mucous of the uterus that is expelled through the vagina. These bloody secretions are more abundant than the period, they contain small clots that are formed when the placenta comes off and tissue remains of the uterus and the vagina. In the first days it is possible that a big clot is expelled, but it is not important.

The losses that go from red to grayish and finally are whitish, become smaller progressively and they disappear after three or four weeks, although in some cases they last until the reappearance of the period.

The afterpains are some painful contractions that usually appear after the childbirth. They are necessary so that the uterus returns to its size and normal location. A few hours after having given birth, the bottom of the womb is located above the navel and one week later, it is located above the pubis.

The afterpains, besides provoking the return to normality of the uterus, have the important mission of preventing hemorrhages.

These contractions disappear 48 hours after the childbirth and they are more intense and more painful in the women that have had previous childbirths, increasing with the number of past childbirths. First timers notice similar nuisances to premenstrual cramps.

As the mammary glands and the uterus interact due to the hormones, the baby's suction the first days it provokes the release of oxitocyn that unchains the contractions.

The hematomas

Due to the baby's pressure during the expulsion phase, hematomas can appear in the area of the perineum that goes from the vagina to the anus, or around the opening of the vagina. These hematomas are cured spontaneously in a few weeks and they are not significant. 

The episiotomy

When the doctor has carried out an episiotomy during the childbirth, the mother usually feels tugs and other nuisances in the area of the incision.

The episiotomy is used more frequently in first timers because they have more possibilities to suffer lacerations. The wound is closed with organic thread and the stitches fall by themselves around the fifth day.

The stitched area should stay clean and dry. It should be washed two or three times a day and every time the woman urinates, using boiled water, with a soaked towel or by taking baths. Then it can be dried with sterile gauzes or using a hair dryer. It is necessary to avoid the use of panties of synthetic fabrics until the wound has closed.

The intensity of the nuisances depends on the length of the cut and of the sensibility of each woman to pain. If when urinating there is strong stinging in the scar it can be soothed by applying lukewarm boiled water in the area or placing a piece of ice in some sterile gauzes and passing it over the wound.

If the nuisances are intense when sitting down, a good solution is to place a soft cushion or a float on the chair.

The scarring concludes approximately in ten days, but if the woman notices swelling or heat in the area she should go to the doctor. If the tugs and nuisances persist after two or three months, the doctor can recommend a “surgical repair”, that is practically painless, of the area.

Hemorrhoids

At times, the efforts made by the mother to push during the childbirth, provoke the formation of hemorrhoids that can be painful. The doctor can prescribe an ointment or some general anti-inflammatory treatment that alleviates the nuisances without harming the nursing. Momentary, although not durable, relief can be obtained by applying cold in the area.

Constipation

The constipation is frequent after a childbirth because the intestine finds it difficult to recover its motility. This problem is increased with the presence of hemorrhoids and, mainly, by the apprehension of the mother that the scar of the episiotomy, may reopen, which is a strange thing to happen.

The mother should not wait to go to the toilet because this intensifies the constipation. A diet rich in fiber and plenty of liquids favors the intestinal transit, as well as some very mild exercise.

Laxatives are not advised during the period of nursing, but if the constipation is very severe, the doctor can advise the treatment to follow. 

Urinary problems

Frequent urination is normal after the childbirth due to the excess of liquids that have accumulated in the body during the pregnancy. It is not significant and it stops as the organism self regulates.

Urinary incontinence is frequent after a difficult childbirth. It is due to the effect felt by the muscles of the pelvic floor. These muscles take charge of sustaining the genital internal organs, the rectal and urinary organs. The effect provokes a small urinary incontinence with losses when the woman makes some effort (to laugh, to cough, to sneeze, etc.). Incontinence can also appear at the end of the pregnancy and after normal childbirths.

When epidural anesthesia has been applied in the childbirth it may be difficult for the woman to empty her bladder during the first two days because the anesthesia delays the return to normal of the urinary transit.

In the hospital they usually recommend some exercises to reeducate the perineum and to avoid urinary losses. Nevertheless, 8 or 10 days after the childbirth, the mother can accelerate the recovery by trying to close the muscles, as if avoiding that the urine comes out and, some seconds later, to relax them. She can repeat this exercise at three different times during the day and it can be done in any posture.

Sweating

When an excess of liquid is accumulated during the pregnancy, it can happen that the mother frequently feels the need to urinate after giving birth, but the body can also opt to expel the spare liquid by means of excessive sweating, mainly at night. The excessive perspiration disappears in a short time.

Cystitis

It can happen that the bladder is contaminated with germs that come from the vagina or of the urethras. If during the childbirth it has been necessary to place a probe to empty the bladder, this may have introduced germs or injured the urethra producing cystitis. When this occurs, the doctor prescribes an antibiotic that doesn't harm the nursing.

Anemia

It is frequent after the efforts of a pregnancy and the loss of blood of the childbirth. Anemia can provoke a decrease of the blood pressure, sickness and even some fainting. The doctor may order some blood tests and prescribe a treatment with vitamin supplements and iron.

It is advisable that the mother follows a balanced diet, especially if she breastfeeds the baby. 

Fatigue

Although the mother's organs recover some weeks after the childbirth, the body needs several months to return to normality and to recover of the effort that the pregnancy and the childbirth have entailed.

It is indispensable that the mother sleeps and rests, especially on the following weeks to the birth. She should organize her family to have their help, the father, the grandparents, a sister or a friend can collaborate the first days with the house chores and to take care of the baby.

During the day she can make some pauses to rest making them coincide with the periods of the baby's sleep. A nap in the afternoon is beneficial to recover her strength and to avoid accumulating the tension of the day.

Although the baby demands a lot of time from the mother, she should reserve "some moments just for her", take care of her diet and avoid lifting heavy objects.

Pain in the back and legs

As it happened during the pregnancy, the mother can feel pain in the legs and in the back. Besides doing some exercises, massages alleviate the pain or the nuisances but they should avoid the area of the stomach because the muscles and the skin are still loose.

Bath or shower?

After a natural childbirth, the mother can take a shower from the first day. When a Caesarean operation has been used, the complete shower should be delayed until the fourth or fifth day.

It is necessary to wait to take baths until the lochia has ceased completely because this indicates that the neck of the uterus is closed and there is not risk of contracting infections. The first baths should not be very long and it is convenient that the water is not very hot, specially if there has been an episiotomy.

The pool is inadvisable until the closing of the neck of the uterus and vaginal irrigations are completely forbidden.

SELF CHECK QUIZ
SECTION 2 - BLOCK 5	CHAPTER 1	Date:
1. Quarantine is the same as the postpartum or puerperium. T r F r
2. To avoid hemorrhages, the mother should wait for 24 hours before getting out of her bed. T r F r
3. If there has been a Caesarean operation, the mother should wait 4 or 5 days before taking a shower. T r F r
4. The uterus involutes when it is recovering its normal volume. T r F r
5. The afterpains are secretions of the mucous of the uterus. T r F r
6. The scarring of the episiotomy takes about ten days. T r F r
7. Constipation and hemorrhoids are frequent after childbirth. T r F r
8. Urinary incontinence is due to the excess of liquids retained by the mother's body during the pregnancy. T r F r
9. When the mother suffers from anemia, she should rest and stop breastfeeding the baby. T r F r
10. Baths (in a pool or bathtub) should wait until the lochia has ceased completely because this is a sign that the neck of the uterus has closed. T r F r

The amenorrhea (absence of the period) has a different duration depending if the mother breastfeeds the baby or not, but in both cases the differences between women are considerable, and in the both cases the first periods are usually more abundant than habitually.

The women that don't breastfeed usually have their first period between the seventh and the ninth week after the childbirth.

If the mother is breastfeeding the baby, the amenorrhea can be prolonged more than sixteen weeks because the nursing blocks the normal operation of the ovaries. The first period is difficult to foresee because other factors such as the frequency of the breastfeeding influence it. When the baby's feeding is mixed, the period of amenorrhea is shorter. The period can reappear when the woman is still breastfeeding the baby.

It is advisable to use sanitary napkins when the first period appears after giving birth and not to use tampons until the second or third month because of the sensibility of the area.

Contraception after the childbirth

Sexual relationships can be restarted after the childbirth, however it is convenient that they are delayed a few weeks because of the fatigue, the lochia, the episiotomy, etc., usually do not favor satisfactory sexual relationships at first.

If the mother opts for breastfeeding her baby, or for bottle feeding, it is necessary to foresee the type of contraception that will be used. In the first menstrual cycles usually there is no ovulation, but this can happen even 25 days after the childbirth or later. The absence of a period doesn't mean that the mother cannot conceive and maternal nursing is not synonymous to contraception.

To avoid an unexpected pregnancy, the couple can use a different type of contraception, such as the condom until the rule reappears.

 

The types of contraceptives advised after childbirth are the following:

• The condom. It is the most advisable and it doesn't have any counter indications.

• The pill with very low hormonal dosage. If the mother is not breastfeeding, and there are no other complications, she can begin to take 10 days after the childbirth. This pill is compatible with the nursing so the doctor can also prescribe it in these cases. The minipill should be taken at specific times and it can provoke small losses.

• Spermicides, either in cream, sponges or ova, but following the instructions for use rigorously.

SELF CHECK QUIZ
SECTION 2 - BLOCK 5	CHAPTER 2	Date:
1. The duration of the amenorrhea is marked by the duration of the breastfeeding. T r F r
2. When baby formulas are used for feeding, the first period usually appears between the seventh and ninth week after the childbirth. T r F r
3. For a better hygiene, it is convenient to use tampons in the first periods after the postpartum. T r F r
4. Sexual relations can not be restarted until after the end of the quarantine. T r F r
5. The condom is the most advisable contraceptive method until the period reappears. T r F r

In the following fifteen days after the childbirth the mother should be attentive to the changes and symptoms of her body. As the complications usually have an infectious origin, it is important to watch over the increase of temperature that are not related with the ascent of the milk, specially if there are also losses of blood or pains in the abdomen, the breasts, the legs or the pelvis.

As the infection can be located in the mucous of the uterus (endometriosis), in the bladder (cystitis), an abscess in one of the breasts, in the scar of the Caesarean operation or of the episiotomy, etc., she should consult immediately with the doctor so that he indicates the appropriate treatment.

Another type of complications that can arise in the following five days after the childbirth are those provoked by the formation of clots formation in the veins (thrombophlebitis). This problem is usually detected, and controlled, during the days that the mother spends in the hospital. Although the complication has been controlled, the mother should consult immediately with the doctor if the pains or the nuisances persist in one of her legs.

SELF CHECK QUIZ
SECTION 2 - BLOCK 5	CHAPTER 3	Date:
1. In the following five days after the childbirth, clots can form in the veins. T r F r
2. The more frequent complications after the childbirth usually have an infectious origin. T r F r
3. If the mother's temperature goes up in the following fifteen days after the childbirth, it is always due to the ascent of milk. T r F r
4. After the childbirth there is the risk that the mother may suffer of endometriosis or cystitis. T r F r

Normally, the gynecologist will see the mother forty days after the childbirth for her first check up, although this visit may be carried out sooner when there are suspicions that they can be complications or when the mother is concerned about some problem related with the puerperium.

In this first visit, the doctor reviews the mother's medical history and, based on the family background, the evolution of the pregnancy, the childbirth, the puerperium and the baby, he will check the followings:

•  Weight and blood pressure.

•  The abdomen, checking the level of distension of the abdominal muscles and of the skin. When there has been a Caesarean operation, the doctor verifies the scarring.

•  The perineum, verifying the elasticity of the muscles by means of a vaginal palpation, and the scarring of the episiotomy.

•  The uterus, feeling the vagina and the abdomen, examining the recovery of their position and volume.

•  The vaginal mucous and the neck of the uterus, obtaining samples to carry out a cervix and vaginal smear if he considers it opportune.

•  The breasts, and an exam of the nipple if the mother breastfeeds the baby.

If the mother is concerned or uncertain about some problem related with her recovery or with the use of a birth-control method, this medical visit is the suitable moment to express her doubts.

SELF CHECK QUIZ
SECTION 2 - BLOCK 5	CHAPTER 4	Date:
1. The gynecologist sees the mother for her first check up after the puerperium. T r F r
2. If the mother observed any suspicious signs before the first check up, she should not go to the gynecologist but to her family doctor. T r F r
3. In the first check up after the childbirth, the doctor checks the condition of the abdomen, the perineum, the vaginal mucous, the neck of the uterus and the breasts. T r F r
4. The mother should talk about contraception with her family doctor. T r F r

As we already saw in previous chapters, after giving birth, the body of the mother needs a period of time to recover from the pregnancy and the childbirth. As important as this physical recovery is the process of adaptation of the mother to the family new situation.

After the emotional commotion of the childbirth, the mother feels vulnerable and experiences sudden changes in her mood. After the immense happiness of seeing the baby there are doubts if she will know how to be "good mother" or if she will be attractive again for her couple. The hormonal changes, the fatigue, the nuisances of the puerperium, the lack of sleep due to the baby's takings, etc., provoke that the mother goes through a stage of depression and fleeting melancholy.

Melancholy or transitory sadness

It is very frequent, mainly in the first time mothers, those that have given birth by a Caesarean operation or those who lack family support.

This melancholy can last several days (even weeks), and should not be mistaken with true postpartum depression postpartum that only happens in exceptional cases.

Throughout the preparation sessions for the childbirth information and resources are offered to the couple to confront postpartum melancholy. Nevertheless, some general advice can help her to overcome this transitory situation:

When the mother feels this sadness it is important that she shares the doubts and fears with her couple, with her parents or with friends that can offer her the emotional support that she is needing. She should not look for the "perfection as a mother" because the “ideal" mother doesn't exist, and "practice also makes teachers" in this task.

The mother should be flexible with the domestic chores, ask her couple or the family for help and accept that the house won't be so clean and ordered as it was before the baby's arrival.

It is very important that her diet is healthy and balanced to recover her physical state and psychological security, besides fighting the risk of anemia.

 

The mother should take advantage of the times when the baby is sleeping, to also rest. If, instead the mother starts doing domestic tasks, she will accumulate bigger fatigue that will prevent her to be relaxed when she assists the baby later.

After the birth, the mother and the baby need quality time to get acquainted. The newborn experiences sensations (hunger, sleep, cold, heat, happiness, anxiety, etc.) and expresses them by crying. The mother needs time and practice to learn how to decipher his cries and it is normal that in occasions she experiences contradictory feelings and desperation, this happens to all human being when they are emotionally implicated in their relationships with others.

It is advisable that the mother reserved some time for her alone. She should dedicate time for her personal care, to use beauty products to buy new clothes, to put on some make up, etc.

She should go outdoors and do some exercise, this will help her to feel better, it is still soon for sports or gymnastics to try to recover her figure, but mild exercise will stimulate her organism so that it liberates endorphins that facilitate relaxation.

Emotional dysfunctions

Postpartum depression . It happens when the state of sadness and melancholy doesn't go away, but rather it is intensified. The abrupt changes in mood, the feelings of guilt, phobias, fears, etc., prevent the mother to go on with her normal life.

This emotional problem is not very frequent and it requires the consultation with a psychologist to avoid that it takes root.

Puerperal psychosis. It is an important dysfunction that requires psychiatric treatment. It is only given in very exceptional cases of women with psychological alterations prior to the pregnancy.

SELF CHECK QUIZ
SECTION 2 - BLOCK 5	CHAPTER 5	Date:
1. Frequently, the mother suffers postpartum depression after the childbirth. T r F r
2. The melancholy or sadness felt by the mother usually lasts several days but, some times, several weeks. T r F r
3. When the mother has these feelings it is better if she does not share them because people could think that she does not love her baby. T r F r
4. If the mother suffers from anemia, she should not follow any treatment, especially if she is breastfeeding the baby. T r F r
5. Postpartum depression and puerperal psychoses are serious emotional disturbances and require specialized treatments. T r F r

For the mother to recover her physical form, figure and beauty means a great help to achieve emotional balance.

Her body deserves all the attentions after the effort that it has done during the pregnancy and the childbirth, but she should not be obsessed to attain a perfect body as soon as possible, this would demand of it another unnecessary great effort.

Slow and progressive recovery

Before thinking of recovering her figure, the most important thing is to rest. The body will need one year to go back to its shape before the pregnancy.

•  One or two weeks after the childbirth, she can begin doing mild exercises to strengthen the more affected areas: the pelvic floor or perineum, the abdomen, the column and legs.

At the beginning the objective of the exercises is to stimulate blood circulation and to strengthen the affected muscles, mainly the perineum and the abdomen. Activities such as walking, bicycling or swimming (after the closing the neck of the uterus) are beneficial after the first weeks.

•  Two or three months after the childbirth the mother is better physically and psychologically. The fatigue, small nuisances and melancholy have disappeared. She is more adapted to the new family situation and she is learning how to interpret and satisfy the baby's needs. Now she feels like beginning to take care of herself a little more, it is a good moment to begin some mild gymnastics.

•  After a Caesarean operation, the exercises to strengthen the perineum can begin immediately because that area has not suffered lesions during the childbirth. To strengthen other affected areas such as the uterus or the abdomen she has to wait one month or month and half so that the muscles scar.

•  The scarring of the incisions made during the childbirth is very important. Besides the hygiene in the area of the episiotomy or the Caesarean operation, it is necessary keep them dry. Until there is a good scarring the woman can not lift heavy weights or begin strong gymnastics. She can stimulate her blood circulation and strengthen her muscles, but without forcing them.

•  She can exercise at home, although it is convenient that an expert recommends the most suitable exercises for the postpartum. In the preparation sessions for childbirth they usually indicate the more advisable exercises for this period.

•  Mild exercising doesn't harm the nursing. Some specific exercises can be done to strengthen the pectoral muscles, Tonic showers, massages and moisturizing creams are also beneficial.

•  The mother should keep in mind that, whether she is breastfeeding the baby or using baby formulas, her breasts have experienced an excess of weight during the pregnancy and the muscles that sustain them have been loosened, for that reason it is difficult that they recover the stability they had before the pregnancy.

•  Several months will have to go by before the pregnancy mask disappears as well as the coloration of the areolas of the breasts and the dark line of the abdomen. Although the mother follows a treatment, it doesn't speed the disappearance, the time is needed to lose the action of the hormones that influenced during the pregnancy. The cares that the mother's skin requires are the daily application of a moisturizing cream and solar protection.

•  After the childbirth women may observe a sudden fall of their hair. This happens because during the pregnancy the normal fall stops due to the effect of the hormones and when these stop exerting their influence, all the hair that should be had lost during the nine months falls off. To favor the blood circulation in the scalp, the mother can massage it softly for a few minutes when she washes her hair, and if it continues to fall after some months, she should see a dermatologist.

•  The loss of weight after giving birth is progressive, although the mother doesn't seek to lose weight. In the childbirth she loses about 5 or 6 kilos and with the elimination of liquids and the involution of the uterus 2 or 3 more. If she breastfeeds the baby the loss of weight is quicker because to produce milk her organism needs a great quantity of fat. Most women recover their habitual weight between 6 and 12 months after giving birth.

•  To recover the muscular tone of the legs it is advisable to walk or to ride a bicycle, and to improve the blood circulation, besides mild exercises, it is convenient to place the legs at a height during some minutes several times a day.

Little by little the mother sees her body recover the agility and lost elasticity. At the same time the baby goes growing and becoming more lovable for his parents and the mother starts to deploy the dynamism and enthusiasm that have been part of her character again.

The wonderful experience of being parents develops the human potential that we all have inside and it fosters the noblest and altruistic feelings that enrich us as people.

SELF CHECK QUIZ
SECTION 2 - BLOCK 5	CHAPTER 6	Date:
1. The mother should start exercising the day after giving birth to recover her physical shape. T r F r
2. One or two weeks after the birth, the mother can begin doing mild exercises to strengthen the pelvic floor, the abdomen, the column and legs. T r F r
3. The exercises after a Cesarean, are the same as for a natural birth. T r F r
4. It is advisable to follow a beauty treatment to have the pregnancy mask disappear. T r F r
5. The woman who has given birth recovers her habitual weight in about two months. T r F r