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The Post-Pregnancy Handbook

The Only Book that Tells what the First Year After Childbirth is Really all About â" Physically, Emotionally, Sexually

St. Martin's Press

A Great Physical Upheaval

In the hours after giving birth, most women feel a marvelous sense of well-being. This state of euphoria is caused by a rush of endorphins, the hormones that produce feelings of happiness and elation (the same ones that are stimulated by alcohol, drugs, and ... chocolate). Some women may feel drowsy, the way one feels after sitting in the sun for several hours, or have an irresistible urge to sleep. Others may experience a burst of energy and excitement that makes them extremely receptive to the new baby.

If you have given birth vaginally, you will be kept under observation for about two hours in the delivery room, then taken to your room and put to bed. Your temperature, pulse, and blood pressure will be checked, as well as the amount of blood on your sanitary pad, and the location and firmness of the fundus (top of the uterus).

Although you may be resting, your body is already going back to work. Its next job is almost as demanding as the task it accomplished over the past nine months. During pregnancy, it provided all the components necessary for the gestation of a human being. During the delivery, it opened itself up and became supple to allow the baby's passage. Now, it must undertake a process of healing and closure in order to return to its pre-pregnancy proportions. One aspect will be the elimination of the excess tissue, water, blood, and other fluids produced over the previous nine months. The driving force behind this enormous undertaking is the hormonal revolution required to overturn the functions of pregnancy. As we shall see, the process may be a bit bumpy and various problems may arise. Fortunately, remedies exist for each one.

The Hormonal Revolution

Throughout this book, we will refer frequently to hormones, the "links between the body and the mind" that play such an important part in controlling our emotions and many of the physical mechanisms in our bodies. Hormones (from the Greek word for "to encourage") are required to set in motion all vital functions. Their role is particularly important during pregnancy and the postnatal period. Medicine has not yet advanced enough to master hormonal changes. In fact, no linear cause-and-effect relationship has yet been found between the amount of a hormone secreted and the intensity of symptoms a woman feels. The way each of us reacts to a hormonal surge or dip depends on our physical and psychological health, and on our environment. Our reactions are therefore unpredictable, especially the first time we experience a major event such as childbirth.

During Pregnancy

During pregnancy, the ovaries secrete large doses of hormones such as estrogen, which will stimulate the development of the uterus and breasts, increase the production of proteins needed for fetal growth, and cause the body's muscles and ligaments to become more supple. Another hormone secreted by the ovaries, progesterone, inhibits the contraction of the body's smooth muscles so that the uterus does not go into premature labor (other smooth muscles such as the intestines or the urinary tract also slow down, which explains why so many pregnant women are constipated or have urinary infections). The other major "production center" for pregnancy hormones is the placenta.

After Delivery

With the expulsion of the placenta, the body suddenly stops producing these hormones. Within hours, their levels will plummet (estrogen levels, for example, drop by 90 percent!). For many women, the brutality of this drop is hard to take and contributes to emotional reactions such as "baby blues" and, in part, postnatal depression.

During pregnancy, the levels of the principal milk production hormone, prolactin, also multiplied by ten to twenty-fold. After delivery, prolactin levels drop, but still remain higher than normal for four to six weeks. If the mother is breastfeeding, she will experience prolactin peaks during this period. Afterwards, breastfeeding will function independently of this hormone.

Oxytocin, the hormone that stimulates uterine contractions, plays a very important role during childbirth and throughout the postnatal period. Oxytocin also is released when the brain recognizes that a baby is sucking on the breasts. This explains why women can feel their uterus contract while the baby is nursing (for some women, these nursing contractions are quite painful, for others, they are incredibly pleasurable, even close to the sensation of an orgasm).

Between the twenty-fifth and forty-fifth day after childbirth, estrogen is once again produced in sufficient quantity to initiate a menstrual cycle towards the thirty-fifth day after childbirth (nursing mothers may experience a much longer wait).

The Reproductive System

The uterus can be compared to a hot-air balloon anchored by ligaments to the front, rear, and sides of the pelvis. Uterine fibers stretch to some forty times their original size. The "balloon's" weight goes from two ounces (about the size of a small pear) to more than two pounds (the weight of a large watermelon). After delivery, it is faced with the massive task of contraction and shrinking to recover its normal volume. This is called involution. For nine months, the entire genital apparatus is engorged with the blood that is required to nourish the fetus. Once the baby is born, the body must dispose of all this excess blood.

After Childbirth

The uterus shrinks to the size it was during the fifth month of pregnancy. Once the placenta is expelled, it contracts and appears like a little ball, hard to the touch when prodded through the abdominal wall (this is why doctors and nurses will continually be poking your stomach in the days after childbirth). As soon as the uterus starts to soften, the brain automatically knows to set off a contraction that will tighten the uterine fibers and compress its blood vessels, in order to prevent them from bleeding. During the first twelve hours after childbirth, these after-pains can be as strong as labor contractions — though much less painful. Gradually weaker contractions may continue for as long as a week after childbirth.

After Each Successive Birth

Even after just one pregnancy, the uterus will forever be slightly lower. At each birth, a woman will have stronger and more frequent contractions since each baby will leave the uterus a little larger and less toned — thus requiring a little harder work to recover its normal size.

Involution is rapid in the beginning (the uterus can no longer be felt after about ten days and returns to its normal size in about fifteen days). The process slows down during the third week and is not fully complete until about two months after childbirth.

The Recovery Process

The recovery process begins with the expulsion of the placenta a few minutes after the baby's birth. The postpartum contractions described above compress the blood vessels that fed the placenta. At the same time, an army of white blood cells arrives to restructure the uterine lining (endometrium) by digesting the topmost layer of blood-starved cells. This waste is sloughed off and discharged as lochia (postpartum bleeding similar to menstrual flow). The average amount of lochia expelled is about one pint, three-quarters of which flows out within the first four days.

The discharge will be heavy and bright red for the first four days as it contains mostly blood from the implantation site and cells from the topmost uterine layer, as well as small clots and bits of mucus. Toward the fifth day, the discharge will become pale pink. At this stage, it contains the white blood cells that have accomplished their cleaning task, old uterine tissue, and excess fluids. Starting around the tenth day, the lochia turns yellowish-pink to creamy-white, as it contains primarily white blood cells and uterine tissue. While the top layer of the uterus is being broken down and sloughed off, new cells are building up a fresh uterine lining below. Within about three weeks, the restructuring of the inner surface will be complete, except at the implantation site of the placenta. A different process takes place here, in order to avoid any scarring which could obstruct future pregnancies. Over a period of six weeks, the cells gradually regenerate beneath the old tissue, healing the implantation site and completing the recovery process.

Bleeding

It is normal to bleed for up to four to six weeks. Women sometimes tend to bleed more heavily after a cesarean section and lose blood during surgery. These women therefore run a greater risk of anemia. While the uterus is sloughing off its topmost layer, it is quite common to find blood clots on your sanitary pad, ranging in size from that of a penny to a cherry tomato. When the clot is particularly large, it may cause some pain as it is expelled from the body. This happens most often while nursing (as we have seen, the baby's sucking sends a signal to the brain to release oxytocin, which causes uterine contractions) or after a particularly strong after-pain. Never hesitate to show your sanitary pad to a nurse (someone should check your pad regularly in any case) if you feel that something abnormal is occurring. If the uterus is very distended (due to a large baby, twins, excess amniotic fluid, or repeated pregnancies that may have overstretched the uterine muscles), a new mother can bleed very heavily — without it being considered a real hemorrhage. Heavy bleeding can also result if there were placental insertion problems during the pregnancy (placenta praevia), or if there are uterine fibroids or certain other abnormalities present. In these cases, the doctor can administer oxytocin to help the uterine muscles contract so that new mother will not lose great amounts of blood and suffer from anemia or intense fatigue.

How long does heavy bleeding last? Generally not longer than four days, or a week at most. But it is normal to soak five or six special "extra-absorbent" sanitary pads in the first twenty-four hours (never use tampons until after your postnatal check-up).

Even though maternity wards provide sanitary dressings that are longer and more absorbent than those found in drugstores, you may want to use two pads, one over the other. While you are lying down, blood tends to accumulate and coagulate in the vagina and can cause an unpleasant gush when you get up. It is handy to have an extra sanitary napkin close at hand, which you can add to your dressing, so that you can walk to the bathroom without leaving an embarrassing trail. For the first week after childbirth, plan to use disposable underwear or panties that you won't mind throwing away. You may also want to place a disposable "incontinence sheet" over your bottom sheet (available in most drugstores), as is done in many hospitals.

Caring for the Genital Organs

The Uterus

As described in the previous chapter, the contractions or "after-pains" that occur after delivery are necessary to compress the uterine blood vessels so as to prevent hemorrhaging. They usually begin during the first twenty-four hours after delivery and normally last between one and four days, or up to a week in some rare cases (if they persist longer than a week, it could be the sign of a uterine infection requiring immediate medical attention). During the first two days, after-pains can be so strong that they take your breath away.

Coping with After-pains

Anticipate the spasms. Since after-pains often occur while breastfeeding, make certain that you are comfortably seated in a calm environment. Try a few breathing exercises (see here) to relax before nursing.

Empty your bladder frequently, especially before nursing. As the bladder fills, it pushes back the uterus, which prevents it from contracting properly. The uterus will continue attempting to contract, which will cause prolonged, though ineffective, after-pains. It is therefore advisable to urinate frequently, especially the second and third day.

Lie on your stomach with a pillow under your abdomen, to put pressure on the uterus. If your breasts are squashed, elevate the top part of your chest with another pillow in order to create a hollow for the breasts (see diagram).

Do breathing and relaxation exercises (see here).

Sleep on your side or on your stomach, with a pillow pressed against the uterus. This hurts for a few minutes in the beginning, but as soon as the uterus hardens it will feel better. It is also possible to nurse in this position with the baby properly propped among cushions.

If you are having a spasm, stop whatever you are doing. Close your eyes and concentrate on your abdominal muscles so that they relax as much as possible. With one hand, press on the pubic bone. Cross your legs. Bend forward. With the palm of your other hand, press on the uterus, which you will feel through the lower part of your belly. Gently jiggle your stomach if it is not too painful. Breathe deeply.

Massaging the Uterus

External massages are useful to assist the uterus in its shrinking process and to soothe after-pains. This exercise also is useful just before nursing. The harder the uterus, the less it will contract under the surge of oxytocin released by the baby's sucking (but this massage is just as important if you are not breast-feeding).

Feel the uterus by prodding your belly between the navel and the pubic bone. If you can't feel it, move upwards a bit towards your chest, pressing quite hard. A nurse can also guide you.

• Rub the area in small circles, about two inches around the navel.

• The uterus should react by contracting: you may feel a small, hard ball developing, about the size of a grapefruit.

• Try to massage yourself every four hours, especially just before nursing, so as to minimize the contractions.

• Beware: You may notice that your bleeding increases following a massage. This is the uterus regenerating itself. The contraction stimulated by the massage will cause the uterus to work harder at sloughing off its spent lining. You may want to wear an extra sanitary napkin, or have one on hand for a fresh change.

If the after-pains are severe, you may be offered nonsteroidal antinflammatories such as ibuprofen (Advil or other) or acetaminophen (Tylenol). Occasionally, you may need stronger pain medication such as Percodan or Tylenol with codeine. These should be taken between feedings to minimize the amount transferred to the baby.

The Birth Canal

For the first twenty-four hours following a vaginal delivery, the whole genital area will feel tender but rather numb. Then, as sensation returns, the dull ache will be replaced by the soreness associated with bruising. The intensity of any pain will depend on how much the passages have been dilated by the delivery, and whether any medical intervention was required (episiotomy, forceps, etc.).

The cervix will remain a little dilated for up to a week. Then it will thicken, shrink, and return to its initial shape. By looking at the cervix, a medical practitioner can tell if a woman has given birth vaginally, as it will appear like a line, whereas before the cervix resembled a small hole at the end of a tube. The cervix sometimes tears slightly, but in almost all cases, the wound will heal by itself.

The vagina is swollen and smooth for a day or two. During the following three or four weeks, it will shrink and return almost to its original dimensions. The vaginal walls, pelvic muscles, and ligaments will remain more supple for two to three months.

The external genitalia also changes: both the large and small lips double in size, the vulva and the anus have slackened (few women realize that stools and urine also were ejected during the expulsion of the baby).

Even if the delivery occurred smoothly, without an episiotomy, the pressure of the baby's head on the perineum and the distension of the vagina (it opens more than four inches) will inevitably cause some bruising and irritation. The genital area will therefore be very sensitive during the week that follows delivery.

Possible Complications

Hematomas (swelling or collection of blood beneath the skin): This can occur after an episiotomy or repair of a laceration. Very rarely, a rupture in the deeper blood vessels creates a painful pocket of blood or a clot in the blood vessel (thrombus). Hematomas must be watched because they can become infected. More frequently, the vessels around the anus break and small clots of blood form beneath the skin, especially if you push too hard during bowel movements.

Tears: Despite the perineum's extraordinary capacity to distend, the skin and even the muscles frequently tear (30 to 60 percent of women who do not have an episiotomy tear during their first delivery).

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Excerpted from The Post-Pregnancy Handbook by Sylvia Brown, Mary Dowd Struck, Christiane Schaeffer. Copyright © 2002 Sylvia Brown with Mary Dowd Struck, R.N., M.S., C.N.M.. Excerpted by permission of St. Martin's Press.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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