Article outline-

Introduction, Changes in Mother after Child Birth, Physiological Changes during Puerperium, Pathological Changes during Puerperium, Psychological Changes during Puerperium, Maternal Care, Neonatal Problems, Apgar Scoring, Neonatal Care, Homoeopathy and Postnatal Care, Bibliography

Introduction

Maternal and child health care or postnatal care or the puerperial care is extremely important to recover to the pre-pregnancy health. 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. The first 24 hours after birth, or the immediate puerperium, is a critical stage. This is the time when the uterus has to contract well, in order to stop the bleeding from the site of placental attachment. It is also the initiation of breastfeeding and bonding. Occasionally, this is the time that most life threatening complications of delivery manifest.

 

Changes in mother after child birth

1- Physiological changes during puerperium

a- Cardiovascular system

It reverts to normal during the first 2 weeks.

b- Lochia

For 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.

c- Skin

During pregnancy the hormones changes cause pigmentation and changes in the colour of skin. As hormones normalize, healthy glow returns. Acne sufferers may see their complexions completely clear up. However some women might suffer from a skin disease, which causes a red rash that, breaks out around the mouth and chin. Some women also experience extremely dry skin

d- Hair

Because of the fluctuating estrogen and progesterone levels, dramatic changes are seen in hair. These changes sometimes last up to two years. 

e- Breast

Pregnancy and breastfeeding reduce chances for breast cancer. However sagging increases after childbirth because the skin of the breasts becomes stretched and will continue to stretch if breastfeeding is continued. Sometimes, temporary leakiness may be seen, even if not breastfeed.Many mothers suffer from sore or cracked nipples 3-6 days after birth. These sore nipples range from nipple tenderness, which quickly goes away after the baby latches on.

f- Belly

Though abdominal muscles stretch to twice their normal size during pregnancy, with proper exercise these can be a flat tummy again. Labour makes the stomach muscles weak and since the internal organs become displaced, backache can be a major problem, and abdominal pain may also be experienced.

g- Bladder

During pregnancy because of the pressure of the baby on the bladder tendency to urinate more frequently is common. But after pregnancy this problem is gone and by doing pelvic floor exercises regularly it is fully recovered. However pressure on the urethra during delivery can make urination difficult after delivery.

h- Sex organs

Vaginal wall which is initially swollen, bluish and pouting, rapidly regains its tone although remaining fragile for 1-2 weeks. Perineal oedema may persist for some days.

After delivery of placenta, the uterus is at 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.

The vagina regains its prepregnancy muscle tone within the first few months and the cervix, forced open during delivery, closes painlessly over a period of 10 days. However intercourse for the first time after pregnancy will probably be slightly painful.

 

2- Pathological changes during puerperium

a- 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.

b- Micturition

It 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.

c- Bowel problems

Constipation may be a problem for a short time and stool softeners may be useful. Hemorrhoids 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.

d- Mastitis and cracked nipples

These may be due to failure to express milk from one part of the breast and can be treated by ensuring all milk is expressed and cold compresses. This may be complicated by infection with staphylococcus aureus making a breast abscess. Sometimes the soreness can be very painful and prevents mothers to breastfeed their baby.

e- 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.

f- Postpartum haemorrhage

Primary postpartum haemorrhage is defined as loss of more than 500ml of blood during first 24 hours. It may be associated with either an atonic uterus or placental remnants. Some cases are associated with laceration of the genital tract, rarely uterine rupture or blood coagulation defect. Secondary postpartum haemorrhage is abnormal bleeding after 24 hours up until 6 weeks postpartum. Its usual causes are poor epithelialisation of placental site and retained placental fragment and/or blood clots. Uterus is often found to be bulky and tender with cervix open.

g- Postnatal anaemia

It is common.

h- Puerperal pyrexia

Defined as temperature 1000 f or above during the first 14 days after delivery. 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.

i- Thromboembolism

It is more likely to occur in women who are overweight, over the age of 35 or have had a caesarean section. Deep vein thrombosis is 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. Pulmonary embolus causes 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.

 

3- 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. Many mothers begin to feel depressed, increasingly despondent and hopeless soon after the baby is born. They may feel terribly miserable and sad for no particular reason and may find that they spend a large part of each day in tears. Sometimes the mother may feel rejected by her partner, family, friends, or even by the new baby; these feelings usually have no foundation. The depressed mother may feel permanently tired and lethargic, unable to cope with household tasks. She may give up bathing, dressing properly or making-up. Sometimes, the care of the baby is too much for the mother whilst she is unwell and someone else must be found to 'take over' until she has recovered. 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.

a- Postnatal psychosis

It is sometimes present with apparent schizophrenia and 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.

b- Anxiety

A depressed mother may feel extremely anxious about a variety of subjects and situations. She may be worried about her health, possibly having felt unwell since the birth of the baby. She may experience severe pain for which the doctor can find no satisfactory explanation. This pain is often in the head or neck. Other mothers suffer backache and chest pains which they fear are due to heart trouble. The mother may have a number of minor medical complaints which can cause undue distress. Anxiety may take the form of unjustified worries about the health and wellbeing of other members of the family, especially the baby.

c- Panic

A depressed mother is often very confused by everyday situations and may experience feelings of panic. These feelings are unpredictable and often very distressing. She is unable to calm down.

d- Tension

Feelings of tension are often associated with depression. The mother who experiences these feelings finds them extremely distressing. She is quite unable to relax however much she is encouraged to do so. She may feel as if she is about to explode when the tension is at its worst.

e- Obsessional and inappropriate thoughts

A mother suffering from depression commonly has some obsessional thoughts. These may be about a person, a situation or about a certain activity. Some mothers become very frightened and believe that they may harm a member of their family especially the baby.

f- Baby blues

The baby blues are a period of mild depression which can occur about three or four days after the baby is born. About 50% - 80% of all mothers go through a patch of baby blues which lasts for a few hours, or, at most, for a few days and then it disappears. Symptoms of baby blues are-

·              Mild depression

·              Being very emotional and upset

·              Tearfulness for no apparent reason

·              Being tense and anxious

·              Difficulty sleeping

·              Constant worry about minor problems

·              Some mothers have pains for which there is no medical cause

·              Being unwell generally with no apparent cause and symptoms

·              Impossible to cheer up

·              Most mothers who have the blues feel very tired and lethargic most of the time

 

Maternal care

a- Maternal activity

This is an important time for the women to be encouraged to breast feed and learn to care for her infant. Uterine contractions continue after birth and some women suffer after-pains, particularly when breast feeding, and may require analgesics.

b- Exercise

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.

c- Pelvic floor muscle exercises

The bladder may show incontinence of urine after having a baby, particularly during a cough, laugh or sneeze. Daily pelvic floor exercises are essential to help with this problem.

d- Rest

It is very important to have a good sleep or rest.

e- Coping with changes

Post natal life is changed dramatically.

f- Support

Support and reassurance are essential, particularly in the early days and weeks.

g- With Multiple births

The arrival of multiple newborns presents certain medical, logistical, financial, and emotional challenges for a family. But the upswing in twins, triplets, quadruplets, and more also means an increase in resources to help those families. Often, parents who are expecting multiples find that other families who've been through the experience are a great help.

h- Stretch marks

Stretch marks, also known as stria atrophica and striae distensae, are tears in the dermis. Stretch marks are thin reddish streaks that usually occur on belly, breasts, thighs and bottom. Stretch marks represent a flattened, thin epidermis overlying gaps in the dermis left by stretched or torn elastin fibers. There are ways to remove them-

• Exercise

• Plenty of protein and foods rich in vitamin c and vitamin e

• Massaging the body with olive oil or vitamin e may help.

• Quit smoking. Tobacco is known to cause skin to lose its elasticity.

i- Cracked nipples

To avoid nipple soreness, the following measures may be taken-

• Correction of positioning and latch is essential.

• Varying nursing positions for at least the first week.

• Limiting the amount of time of nursing on the sore nipple, always starting with the side that is not sore.

• Use of bra pads, and changing them frequently to keep nipples dry.

• Breastfeeding frequently and regularly to avoid nipple confusion and sore nipple.

• Massage a little hand expressed milk into the nipples after finishing the nursing, and letting them air dry.

• One can also express a little milk before breastfeeding to regularize the flow of milk.

• Use of nipple protectors as long as nipples don't heal.

 

j- Sexual pleasure

Post-childbirth there will be changes in a woman's sexuality. There are physical as well as emotional changes in her. She may be extremely exhausted and sleep-deprived. Her pelvic nerves and muscles may also have been damaged during delivery, lowering genital sensitivity. Breastfeeding lowers levels of estradiol, the hormone responsible for keeping the urogenital tract lubricated and flexible thereby decreasing her urge for sexual pleasure. It also raises the prolactin hormone, which suppresses sexual desire and lowers testosterone. Thus post childbirth sex maybe not is the first thing on her mind. 

k- Problems faced by couples in their sex-life after childbirth

It is normally seen that mothers are too tired of nursing, feeding and looking after the baby that they totally neglect their partners who in turn feel undesired. Due to the physical changes in the mother caused due to pregnancy, mothers start feeling undesired themselves and they shun away from their partner. There are changes in a woman's sexuality after the birth of the baby. There will be some temporary changes in the shape and sensitivity of the vagina; and sometimes permanent changes in the shape and "look" of the external genitals. This also causes problems in sexual pleasure.

 

Neonatal problems

a- Umbilical cord

The stub of the umbilical cord is white, translucent and shiny, right after birth. The stump of the umbilical cord must be kept clean and dry as it shrivels and, within a few weeks, eventually falls off. A sticky material that sometimes collects where the base of the stump meets the skin should be cleaned.  Care should be taken for-

• Pus at the base of the cord

• Red skin around the base of cord

• Crying on touch the cord or the skin next to it.

b- Umbilical granuloma

Occasionally, after the umbilical cord has fallen off, the remaining area continues to be moist and may swell slightly. This is called an umbilical granuloma.

c- Umbilical hernia

If the baby's umbilical cord seems to push outward when he cries, he may have an umbilical hernia. This is not a serious condition, and it usually heals by itself in the first 12 to 18 months.

d- Care of the uncircumcised penis

One of the first decisions you will make for your new baby boy is whether or not to have him circumcised. If you have chosen not to have your son circumcised, there are some things you should be aware of and teach your son as he gets older.

e- Foreskin retraction

The foreskin, which covers the head of the penis, will separate from the glans. Some foreskins separate soon after birth or even before birth, but this is rare. When it happens is different for every child. It may take a few weeks, months or years.

After the foreskin separates from the glans, it can be pulled back away from the glans toward the abdomen. This is called foreskin retraction.

f- Smegma

When the foreskin separates from the glans, skin cells are shed. These skin cells may look like whitish lumps, resembling pearls, under the foreskin. These are called smegma. Smegma is normal and nothing to worry about.

g- Neonatal jaundice

Neonatal Jaundice is an excessive amount of bilirubin in the blood. This yellowy substance can make the baby's skin appear yellow or very tan. About 50 percent of all newborn babies have a problem with jaundice. It is more common in premature infants. While the baby is still in the womb the mother, through the placenta, rids the baby’s body of excess blood cells. When the baby is out of the womb sometimes their liver is unable to get rid of the blood cells as fast as they build-up. As the liver matures and catch up quickly to filtering out the bilirubin, the jaundice is vanished. But if the baby can not eliminate it quickly, this can be dangerous. Too much bilirubin can harm brain cells. Another problem that jaundice can indicate is the total absence of the ducts in the liver that drain the bile secretions; this is called obstructive jaundice. This is why it is important to monitor any baby with jaundice carefully by doing bilirubin tests to find out the level of bilirubin in the blood.

The sunlight is a treatment for jaundice if the baby is normal. If the baby has a bad case of jaundice the exposure to UV light in the hospital to speed up the recovery is essential.

Apgar Scoring

The Apgar score is a standardised way of checking the health of a newborn baby. It was named after its creator, Dr Virginia Apgar, Professor of Anesthesiology at Columbia University in the USA, who died in 1974. The Apgar score was designed to assess a baby’s health quickly: the checks are conducted at one minute and 5 minutes after birth.

The score is based on 5 elements, which are sometimes named after the letters in Apgar’s name: Appearance, which relates to the pinkness or blueness of the baby’s skin tone; Pulse, which relates to its heart rate; Grimace, which tests the baby’s reflexes and response when the sole of its foot is stimulated; Activity, which checks the baby’s muscle tone; and Respiration, which assesses the rate of the baby’s breathing. Each element is given a score of 0, 1 or 2 to provide a total score of 10.

A score of 7 or more is considered normal. However, if the baby has a low score at one minute and a normal score at 5 minutes, this, too, is considered normal, particularly if the birth took a long time.

A low Apgar score gives a warning signal that the baby has hidden health problems, such as breathing difficulties or internal bleeding.

Newborn care

a- Handling a newborn

Here are a few basics to remember:

• Baby’s head and neck should be carefully supported.

• Newborn should not be shaken whether in play or in frustration.

b- Bonding and soothing

Babies, especially premature babies and those with medical problems may respond to infant massage. Certain types of massage may enhance bonding and help with infant growth and development.

Babies usually love vocal sounds, such as talking, babbling, singing, and cooing. Some babies can be unusually sensitive to touch, light, or sound, and might startle and cry easily. Swaddling keeps a baby's arms close to the body and legs snuggled together. Not only does this keep a baby warm, but the surrounding pressure seems to give most newborns a sense of security and comfort. Swaddling works well for some babies during their first few weeks.

c- Diapering

• Diaper should be clean

• A fastener (if cloth is used) should be used

• Diaper ointment should be used if the baby has a rash

Diaper rash is a common concern. Typically the rash is red and bumpy and goes away in a few days with warm baths, some diaper cream, and a little time out of the diaper. Most rashes occur because the baby's skin is sensitive and becomes irritated by the wet or poopy diaper.

d- Bathing

The baby should be given a sponge bath until:

• The umbilical cord falls off (1–4 weeks)

• The circumcision heals (1–2 weeks)

• The naval heals completely (1–4 weeks)

A bath two or three times a week in the first year is sufficient. More frequent bathing may be drying to the skin. Tub bath may be started as the baby starts sitting.

e- Feeding and burping

A newborn baby needs to be fed every 2 to 3 hours. Some newborns may need to be awakened every few hours to make sure they get enough to eat. Babies often swallow air during feedings, which can make them fussy. This can be prevented by burping the baby frequently.

f- Sleeping

It's important to place babies on their backs to sleep to reduce the risk of sudden infant death syndrome (SIDS).

 

Homoeopathy and Postnatal Care

ABDOMEN - DELIVERY agg.; during- Arn. bell. bry. Cham. coloc. hyos. lach. nux-v. puls. sep. verat.

Abdomen - distended, tympanitic, inflated, etc. - parturition,after- lyc. Sep.

ABDOMEN - ENLARGED - delivery; after- Coloc. SEP.

ABDOMEN - INFLAMMATION - Peritoneum - delivery; after- acon. bell. bry. Merc-c. pyrog. spig. sulph. ter. ust. verat-v.

ABDOMEN - Large - abdomen large, from child birth- Coloc. Sep.

ABDOMEN - PAIN - Inguinal region - delivery; during- cimic.

ABDOMEN - PAIN - Umbilicus - Region of umbilicus - delivery; during- IP. NUX-V.

ABDOMEN - PENDULOUS abdomen - delivery; after- podo.

Albuminuria - pregnancy - during - and after delivery- merc-c. pyrog.

Axillae - abscess - delivery, after- rhus-t.

BACK - DELIVERY; after - difficult delivery- nux-v.

BACK - DELIVERY; after- Phos.

BACK - PAIN - Coccyx - delivery; after- hyper. tarent.

BACK - PAIN - descends - delivery; during- Nux-v.

BACK - PAIN - Dorsal region - delivery; during- petr.

BACK - PAIN - extending to - Upward - delivery; during- GELS. Petr.

BACK - PAIN - Lumbar region - delivery - after - difficult delivery- Nux-v.

BACK - PAIN - Sacral region - delivery; after- phos.

BACK - PAIN - Sacral region - extending to - Down legs - delivery; after- phyt.

BACK - PAIN - Sacral region - instrumental delivery, after- HYPER.

BACK - PAIN - Sacroiliac symphyses - extending to - Down region of sciatic nerves - delivery; during- Cimic.

bell. kali-p. lach. phos. sec.

BLADDER - PARALYSIS - delivery; no desire after- ARS. canth. CAUST. ferr. Hyos. kreos. nux-v. phos. zinc.

Bladder - paralysis - parturition, after- ars. caust.

BLADDER - URINATION - dribbling - delivery; after - forceps delivery- thlas.

BLADDER - URINATION - dribbling - delivery; after- Arn. tril-p.

BLADDER - URINATION - dribbling - involuntary - delivery; after- Arn.

BLADDER - URINATION - dysuria - delivery - after - forceps delivery- thlas.

BLADDER - URINATION - frequent - delivery; during- cham.

BLADDER - URINATION - involuntary - delivery; after- Arn. ARS. bell. caust. hyos. tril-p.

BLADDER - URINATION - urging to urinate - constant - delivery; after- op. Staph.

BLADDER - URINATION - urging to urinate - delivery; during- Kreos. nux-v.

BLADDER - WEAKNESS - delivery; after- ARS. caust.

Bladder - weakness - parturition, after- ars. caust.

Blood vessels - inflamed, phlebitis - forceps delivery, after- all-c. caul. CHAM. Hyos.

CHEST - ABSCESS - Axillae - delivery; after- rhus-t.

CHEST - Aggravation - weaning, after- puls.

CHEST - DELIVERY; after- Carb-an.

CHEST - HEMORRHAGE of lungs - delivery - during - puerperal fever; in- ham.

CHEST - INDURATION - Mammae - delivery; after- phyt.

CHEST - Mammae - weaning, effects of- Bell. Bry. CALC. LAC-C. PULS.

CHEST - MILK - absent - delivery; after- acon. agn. bell. bry. CALC. Caust. cham. coff. merc. Puls. rhus-t. stict. sulph. urt-u.

CHEST - MILK - thin - watery; and - long after weaning- Con.

CHEST - OPPRESSION - delivery; during- Chinin-s.

CHEST - PAIN - Heart – delivery- Cimic.

CHEST - PAIN - Mammae - delivery; after- CASTOR-EQ.

CHEST - PAIN - Mammae - Nipples – weaning- dulc.</