Obstetricians consider the puerperium as that time taken for a woman to have returned, physiologically, to her non-pregnant state. This is usually considered as six weeks, though for the purposes of notification of infections the puerperium is defined, in law, as the 14 days (England and Wales) or 21 days (Scotland) following confinement.
A midwife is required to attend a puerperal woman for a period of not less than 10 days after her confinement.
The uterus contains a raw bleeding surface — a wound. Infection must be prevented.
The newborn baby requires careful nursing and observation.
Breastfeeding must be initiated. If artificial feeding is recommended, for example, if the mother is HIV positive, then the breasts should not be stimulated and a well-fitting bra should be worn.
Muscles are of poor tone and ligaments slack after pregnancy and labour. Systematic exercises should be given to help prevent chronic postural defects, hernia and prolapse.
Motherhood is accompanied by dramatic effects on the psychology of women. Anxiety and lack of confidence are common and support must be offered.
Better physical and emotional preparation for childbirth, shorter and less tiring labours and early ambulation have led to a decrease in puerperal morbidity. Less nursing care is needed and many women can return to their families after only a short period of recovery in hospital. This is a desirable situation and requires an effective and well-integrated community midwifery service.
Involution is caused by the phenomenon of
Autolysis — enzymatic digestion of excess cytoplasm — and thrombosis and hyaline degeneration of vessels; but traces of fibroelastic tissue remain as evidence of pregnancy. The endometrium is regenerated by the 10th day, except at the placental site, where it takes 6 weeks.
The lochia (the discharges of childbirth) consist mainly of blood and necrotic decidua. They persist for about 2–3 weeks, gradually becoming colourless and scanty. They are sterile to begin with but by the 3rd–4th days the inside of the uterus is said to be colonised by vaginal commensals (non-haemolytic streptococcus,
E. coli, etc.).
This reduction in size is achieved partly by the removal of blood and blood vessels, and partly by digestion of a large part of the cell cytoplasm. The number of muscle cells is probably not much diminished, but the individual fibres are very much shorter and thinner than during the pregnancy.
The cervix never returns to its pristine appearance and although completely healed will always give evidence of parturition.
The vagina and vulva, considerably stretched during labour, have returned almost to their pre-gravid size by the 3rd week. Rugae appear in the vagina, and the labia regress to a less prominent and fleshy state than in the nulliparous condition. Only small sessile tags of hymen are left (carunculae myrtiformes — ‘pieces of flesh in the shape of myrtle’) and, like the parous cervix, are evidence of previous pregnancy.
CLINICAL ASPECTS
Pulse tends to be slower, about 60–70 per minute, probably because the woman is resting after the exertion of labour.
Temperature may be slightly elevated during the first 24 hours, but thereafter should remain within normal limits. Persistent pyrexia requires investigation.
Constipation is the rule for some days. Progesterone continues to inhibit smooth muscle motility. Haemorrhoids are a common, troublesome complication.
Urine — There is a diuresis during the 2nd to 5th days and urinary nitrogen is much raised. The body is getting rid of the excess fluid retained during pregnancy, and the high nitrogen excretion is a direct result of the autolytic process at work in the uterus. Urinary retention is relatively common, especially after instrumental delivery. It may be due to oedema of the bladder neck as a result of stretching or bruising or due to the pain of perineal sutures.
Lochia should gradually change colour from red to pale yellow over 10 days. There are great variations in this due to the fluctuations in the amount of blood being lost during this period. Excess fresh lochia suggest retained products.
Blood — The haemoglobin level is important and should be stable by the 5th day, when normal haemoconcentration is approached.
FEEDING THE NEWBORN
ADVANTAGES OF BREAST MILK
1. Chemical Composition
All mammalian animals feed their young on unique milk adapted by nature to their needs. Human milk fats are much better absorbed than the butter fat in unmodified cow’s milk which combines with calcium in the gut to reduce the absorption of calcium. Neonatal hypocalcaemia is associated with convulsions and perhaps with dental enamel hypoplasia and subsequent caries. The long-chain fatty acids, naturally occurring in breast milk, play an important role in brain development.
2. Protection against Infection
Human milk contains a large amount of immunoglobulin (IgA), including specific antibodies to E. coli and respiratory syncytial virus (RSV). IgA is resistant to digestion in the stomach and reaches the intestine undamaged where it acts on pathogenic organisms and inhibits their multiplication.
Human milk also supplies, from the lactiferous sinuses of the breast, the Bacillus bifidus which colonises the baby’s gut and, together with the Lactobacillus which is the other organism principally found in the alimentary tract of breastfed infants, reduces the pH level so that the growth of pathogens is inhibited in the same manner as in the adult vagina.
The action against bacteria is strengthened by the high proportion of lactoferrin (an iron-binding protein) in human milk. Once in the intestine, the lactoferrin reduces the amount of free iron below the level necessary for the growth of iron-dependent bacteria.
Breast milk will also supply smaller amounts of IgM and IgG.
3. Energy
Bottle-fed babies may ingest more calories and are more often overweight than breastfed babies. If the feed is too highly concentrated, the excessive sodium content makes the baby cry from thirst, and this is mistaken for hunger and more milk may be given. If rehydration does not occur, very high plasma sodium levels (hypernatraemia) may cause brain damage. This is avoided by the use of appropriately prepared modified cow’s milk formula.
PHYSIOLOGY OF LACTATION
OXYTOCIN, from the posterior pituitary, is responsible for promoting the ejection of milk from myoepithelial cells surrounding the glands to the nipples. Oxytocin levels respond to breast stimulation by the baby or by the mother expressing milk.
The quality of milk and calorie content are controlled by the FEEDBACK INHIBITOR OF LACTATION (FIL). If there is ineffective emptying of the breasts FIL builds up, reducing milk production from that breast. Effective emptying encourages more milk production.
All women should have had an opportunity to discuss the benefits of breastfeeding for both mother and baby and have enough information to make a fully informed choice.
FOR MOTHER breastfeeding reduces her risks of premenopausal breast cancer and ovarian cancer. It also reduces the risk of developing osteoporosis and consequent hip fractures in later life.
FOR BABY breast milk has antibacterial and antiviral properties and reduces the incidence of infection. Ear, throat, chest, gastro-intestinal, and urinary tract infection are less common in breastfed babies. This reflects the high antibody levels in the early breast milk, colostrum. Breastfeeding also affords protection against asthma, some allergies and eczema. Type 1 diabetes is less common in children who were breastfed.
Expectations of breastfeeding and predisposition to breastfeeding vary between and within different cultures.
Terminology
Supplementary feed: a feed given in place of a breastfeed.
Complementary feed: a feed given in addition to regular breastfeeding.
Supplementary and complementary feeds confer no advantage to the baby and restrict the establishment of effective breastfeeding.
