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After Birth Procedures Involving The Mother

In The Delivery Room

DELIVERY OF THE PLACENTA. Immediately after the delivery of the baby, the doctor or nurse will feel your uterus through your abdominal wall to be sure it remains firm. Next, the doctor will be watching for signs that the placenta has separated from the wall of the uterus; this occurs with the aid of continued uterine contractions. Signs of placental separation are: a firmer, globular-shaped uterus; a sudden gush of blood; the rise of the uterus into the abdominal cavity as the separated placenta descends into its lower part and farther down into the vagina; and the protrusion of the umbilical cord farther out of the vagina. These signs sometimes occur within the first sixty seconds after the baby is born, but more usually within five minutes. As soon as the doctor determines that the uterus is firm, he or she may ask you, if you are awake, to “give another push for the placenta.” If you are not awake, or if you have been given a regional anesthetic, he or she might press on your fundus, the top part of the uterus, through the abdominal wall, to urge the placenta down into the vagina. An oxytocic drug may be given to you to stimulate contractions of the uterus and aid the delivery of the placenta. This may be given through an injection or the intravenous catheter. Usually, if an I.V. had been set up prior to this moment, this is the route chosen.

After the placenta is expelled, the doctor will examine it closely to be sure that no part of it has broken off and remained inside the uterus, a situation which can cause hemorrhaging. If there is any doubt, or if it is the doctor's practice to routinely do so, he or she will perform a quick examination of the inside of the uterus and, if any piece of placental tissue is there, the doctor will remove it.

SUTURING OF THE EPISIOTOMY. If you have had an episiotomy (incision into the perineum beginning at the rear of the vaginal opening), the doctor will begin suturing it at this time, if the procedure was not already begun before the placenta was delivered. If you are awake and have had an epidural (regional anesthetic) or a pudendal block (extensive local anesthetic) prior to delivery, it will still have its numbing effect. If you did not receive either the doctor may administer a local anesthetic into the perineum (area between the vaginal and anal openings). This injection will be felt as a burning sensation and will numb the area for the suturing. Sometimes the anesthetic is not as effective as one would like and you might feel some of the suturing. If you do, try to release all your muscles and use breathing techniques to minimize your discomfort.

Suturing techniques vary. Some physicians use a “running stitch,” leaving the beginning and end of the suture loose and unknotted, on the theory that such technique allows for normal swelling of tissues without undue straining at the sutures (which causes later pain). Other physicians use the stitch-and-knot method of tying off individual sutures. Whatever the technique, sutures dissolve in about ten to twenty-eight days.

New mothers ask the number of sutures used because they believe this is related to the size of the incision or the discomfort afterward. The number of sutures has no bearing on the size of the incision; some doctors use more, some fewer, sutures per given area. The number of sutures also does not always relate to later discomfort; all you need is one tight stitch to have pain. The length of the incision, the direction in which it extends, how tightly the stitches were made, and how much swelling there is have more to do with later discomfort than the number of sutures used.

During the suturing, keep your vaginal muscles as released as possible. If you tighten these muscles during the suturing, the normal swelling of the perineal tissues the next day may pull against the stitches and cause you more discomfort than usual.

After the suturing has been completed, your vaginal area will be washed with an antiseptic solution or soap and water. The lower end of the delivery table which had been pushed down and “broken” under for the birth will now be replaced. The surgical drapes will be removed, both your legs will be lowered from the stirrups slowly and at the same time; a sterile perineal pad will be put into place.

If the new father has been present for the birth, he may remain in the delivery room during the expulsion of the placenta and whatever suturing may be necessary. He can stay at the head of the table with you and together you can admire your newborn, who might be placed on your chest, in your mate's arms, or in a heated crib or unit nearby.

ANTILACTOGENICS. While still in the delivery room, a nurse will probably ask you if you will be breastfeeding or not. If your answer is “no,” and if this is the procedure at your hospital and used by your doctor, she will inject you with an antilactogenic hormone to “dry up” your milk without painful engorgement. This is routine in many hospitals. This injection is given in your hip area, is frequently described as painful, and you may feel soreness in your hip for days afterward. If your doctor prefers to use an antilactogenic hormone in pill form, you will be given this later on in your room. Antilactogenic hormones do not invariably prevent painful engorgement.

It is important for you to know that this hormone is optional. If you prefer not to take it, speak to your doctor in advance and remind him or her about it in the labor and/or delivery room.

RH FACTOR. If you are Rh negative and the father of the baby is Rh positive, you should be given an injection of RhoGAM (unless there is a contraindication for this) within seventy-two hours after delivery. RhoGAM is an immune globulin containing a concentration of Rhoantibodies. This serves to protect future babies by preventing maternal Rh antibody production. There are situations in which RhoGAM cannot be given or may not be helpful, so it is advisable for you to discuss all possibilities with your doctor in advance of delivery.

From the delivery table you will be asked to lift yourself onto the stretcher or bed which has been placed alongside it. You will be covered with a blanket, which may or may not be enough to warm you if you experience post-delivery chills.

The Recovery Room

The recovery area or special recovery room will be your next destination. There you will remain for an hour or two, depending on your hospital's procedure. If your hospital does not have a separate recovery room, you may remain in the delivery room for this period. If you are awake and there are no medical contraindications, your mate and baby may remain with you for a while - approximately fifteen minutes or longer - depending on your hospital's policy, your physical condition, your baby's condition, how much and which kind of medication you had received, and during which nursing shift you happen to have given birth! If you want to breast feed your baby and have not already done so in the delivery room, you might do so in the recovery room. Be prepared to experience uterine contractions resulting from the baby's sucking at your breast.

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If you are asleep or otherwise in no condition to hold your baby, he or she is taken to the nursery to be cleaned, weighed, and measured (if this has not already been done in the delivery room) and the new father may be able to watch these procedures, if he so requests.

While in the recovery room, your pulse and blood pressure will be checked. If your membranes had ruptured prior to admission into the hospital, the nurse will be especially alert to pick up signs of possible infection. Your temperature will also be taken.

FIRMING THE UTERUS. Your uterus will be checked through the abdominal wall to be sure it continues to contract, becomes firm, and begins to descend. If your uterus is not firm enough, an oxytocic drug may be given to you to stimulate stronger contractions and the nurse will help it along a bit by massaging the uterus through your abdominal wall. This feels uncomfortable to some women and downright painful to others. However, the procedure only lasts a few minutes and can be made more tolerable if you use some relaxation and breathing techniques. It may be difficult for you to muster up the necessary concentration to force yourself to do a special breathing pattern (such as Lamaze slow chest or slow panting described in the exercise section) and to release your arm, leg, and abdominal muscles, but this does help.

As a result of the abdominal pressure applied by the nurse, you will feel oozing of blood and possibly passage of some clots from your vagina. This will be caught in the large, disposable bed-pad beneath your buttocks, which the nurse will remove from time to time as it becomes necessary. She will also check your bloody discharge (lochia) by observing your sanitary pad approximately every half hour for the first two or three hours after delivery and perhaps once a day thereafter to be sure there is no abnormal bleeding or clotting.

The intravenous usually started in the labor room has followed you through delivery and into the recovery room, affording the medical team easy and prompt access to your veins in case of need. In some hospitals, an oxytocic drug is routinely administered through the I.V. to ensure continued uterine contractions and prevent hemorrhaging. If no I.V. had been set up, you might be given this drug by injection. If you are planning to breastfeed your baby, you might discuss in advance with your doctor the possibility of breastfeeding immediately after delivery, which is nature's way of causing the uterus to contract. Your baby's sucking triggers the release of natural oxytocins, hormones which contract the uterine muscles. Perhaps you can prearrange a wait-and-see policy with your doctor, and if your uterus is contracting well enough from breastfeeding you can forego the additional medication.

PERINEAL CARE. Your perineum will be checked for signs of infection at the episiotomy site. It is slowly becoming accepted procedure in more hospitals to apply an ice pack to the perineum as a preventive before swelling occurs. A routine of alternating ice applications fifteen minutes on and fifteen minutes off while in the recovery room is usually safe and effective. (Note: you might need your doctor's advance premission recorded on your hospital chart in order for the nurse to give you an ice pack.)

URINATING. You will be urged to urinate into a bed-pan while still in the recovery room. If you have difficulty urinating, some nurses will wait until you are able to walk around a bit in order to stimulate natural urination but will usually make every effort to have you urinate no later than four hours after delivery. If you have received a regional anesthetic, you might not be aware of a full bladder due to the numbing effect of the medication. If you received or are still receiving intravenous fluids, there is even more likelihood that your bladder will be full and therefore must be emptied. If permitted, sit upright on the bed-pan with your feet over the side of the bed so gravity can help you. If you cannot urinate by yourself within several hours, it is common for the nurse to withdraw urine from your bladder through a catheter inserted into your urethra. This can sometimes be an uncomfortable procedure and may possibly be avoided if you encourage the passage of your urine by contracting and releasing your vaginal muscles several times every fifteen or twenty minutes. These Kegel exercises are often difficult to do soon after childbirth because you may not have full sensation in the vaginal area due to the extreme stretching of the tissues by the baby during delivery and/or the local anesthetic you may have gotten for suturing of the episiotomy. Try anyway, no matter how weak your muscles seem at the time, because this may encourage urination.

Do not be afraid to urinate after delivery. It should neither hurt nor burn, although it may feel a bit strange at first.

After The Recovery Room

In some hospitals the nurse walks with you on your first trip from the bed to the bathroom and remains posted outside the open door to be sure you don't become faint and fall. In some hospitals, your output of urine is observed and/or measured for twenty-four hours by having you urinate into a special pan within the toilet bowl.

If urination is accompanied by a burning sensation it might be a sign that your urine needs diluting before it passes through your urinary tract, which is especially sensitive and swollen after the stress of the birth process. Your doctor may advise you to drink at least two quarts of water each day. This usually helps the burning sensation to go away after twenty-four hours. If burning persists or if you develop a fever, consult your doctor.

Urinating may feel strange at first, but each day it will become easier. In fact, you will probably notice a frequent need to urinate as well as heavy perspiration by the second or third day. This is your body's way of ridding itself of excess fluids during its return to the pre-pregnant state. You might want to take a shower and wash your hair soon after delivery, and there is usually no reason why you shouldn't, except for the possibility of your feeling weak or faint. This is why most nurses try to postpone your first shower until the second day after delivery when you have more strength.

On your first trip to the bathroom you may be given a “peri” (for perineum) or “irrigation” bottle - a plastic container holding an antiseptic solution. After urinating or defecating, while you are still seated on the toilet this liquid is to be poured over your vagina and perineum. This is to prevent the possibility of infection reaching the uterus, which is still highly susceptible to invading organisms. In some hospitals, another plastic bottle containing water is used to wash off the antiseptic.

When patting dry or wiping the area after defecating, always remember to do so from the front toward the back - from the vagina toward the anus - never the other way, and drop the paper into the bowl after its use; if more wiping is necessary, use a fresh piece of paper each time. If you do not already have these very important habits, start today to develop them. This prevents the introduction of infection into the vaginal canal which is always a possibility at any time of a woman's life, not just during the postpartum period. It is wise to teach your daughters to develop this habit while they are young.

If you do not have a bowel movement by the end of the second day after delivery, the doctor may prescribe a bowel softener (not a laxative) to encourage normal bowel function before you leave the hospital. If you have added fresh or cooked fruits, vegetables, prunes, figs, dates, whole-grain cereals, or bran to your diet, chances are you will not need other aids. If you are hesitant to strain while moving your bowels for fear of adding stress to your perineal sutures, you might be more comfortable if you hold a piece of sterile gauze pad against your perineal area. The external pressure you apply will give your pelvic floor support while you defecate. After, drop the gauze into the toilet bowl, and follow the usual hygiene routine - wipe or pat dry, rinse with peri bottle solution, etc.

You will be encouraged to get out of bed within the first twenty-four hours after delivery. Early mobility helps you regain your strength and encourages bladder and bowel function. Until then, while you have been reclining, blood probably will have accumulated in your vagina. Therefore, when you stand up, you might feel a sudden gush of blood which can be frightening if you are not prepared for it. You will be wearing the hospital's sanitary napkin which, although larger than the usual size available in retail stores, may not be adequate for this accumulated flow. As a precaution, therefore, we suggest that you place the disposable bed-pad between your legs, diaper-style, before getting to your feet.

Another word of advice: do not attempt to get off the bed or walk to the bathroom the first time without assistance! You might feel weak or faint from the sudden blood flow, especially after having been reclining for hours; it is usually wise to have a nurse at your side at this time.

Some hospitals provide sanitary napkins which must be worn with panties to which they will adhere when you remove the specially designed strips. Be sure to bring panties you don't mind staining. If the hospital does not provide the self-adhering napkins, you will need a sanitary belt - which some hospitals provide - to keep pads in place.

It is important to follow the doctor's instructions concerning sanitary napkins versus tampons. There is less chance of uterine infection if a free flow of blood is permitted; tampons restrict this flow. When you are eventually permitted to use tampons instead of napkins, you may find them difficult to insert. You might want to try applying a small amount of lubricating jelly (such as KY) on the tip of the tampon to solve this problem.

It is recommended that you wear the hospital's nightgowns to sleep in so you will spare your own lingerie from the possibility of being bloodstained. Or, you might prefer wearing your own short nightgowns for the same reason. If you prefer wearing longer nightgowns when visitors are expected, be sure to lift the bottom when you sit.

The sutures will dissolve in about ten to twenty-eight days. Do not be alarmed if you notice what appear to be black, string-like fragments in the toilet bowl after voiding; these are pieces of sutures that fall out of your perineum before dissolving completely.

To prevent the possibility of infection of the episiotomy site and to promote healing, be sure to keep your vaginal and rectal areas as dry and clean as possible. Shower daily and change your sanitary napkins often. You might ask your doctor about using special antiseptic swabs or continuing to rinse with an antiseptic solution after urination and bowel movements when you are home from the hospital, and for how long to do so thereafter.

If your episiotomy sutures are causing you a lot of pain, there are ways you can make simple acts like sitting down and standing up much less of an ordeal. If you are sitting and wish to stand up, you should tighten your vaginal, rectal, and buttock muscles, and hold them tight while you stand up. After you are on your feet, you can slowly release the muscles and go about your business. When you are ready to be seated again, you should tighten the muscles and sit down while they are still contracted. Once seated, you can slowly release these muscles. You will be surprised at the difference this kind of control can make. Sitting on pillows or rubber tubes only prolongs your inability to sit comfortably without them.

For relief of pain in the perineal area, you can choose from several treatments recommended by many physicians:

1) Apply ice packs on for fifteen minutes, off for fifteen minutes. This relieves and hopefully will reduce the swelling.

2) Soak your entire bottom in warm sitz baths several times each day (continue this at home). Some doctors recommend this even when there is no swelling in the perineum, since it is soothing and promotes healing.

3) Set up a heat lamp a few feet away from your perineum. Keep the heat on only for ten to fifteen minutes at a time. When your doctor permits you to take regular tub baths, be sure to use clear water with no bath crystals or powders added; these can irritate your genital area if the episiotomy site has not completely healed.

4) Apply gauze soaked in ice-cold witch hazel.

If sanitary napkins cause discomfort or pain by pressing or catching at your stitches, ask your doctor if you can use a cream or alcohol compress to soothe the area. Some women find the napkins that adhere to their panties more comfortable than those that are attached to a sanitary belt. Remember to find out if your hospital supplies sanitary belts or if you must bring your own or if the hospital uses self-adhesive napkins. After coming home, while your blood flow is still heavy, you can purchase hospital-size napkins at many pharmacies.

If you are not breastfeeding, you can help stop milk production by reasonably limiting your consumption of liquids (do not stop drinking altogether). If you ordinarily would drink more water to aid your bowel movements, you can substitute fresh fruits and other such foods to stimulate bowel function. Some doctors advise wearing a tight bra or “binding” the breasts with a towel, sheet, pillow case or diaper wrapped firmly around your chest for about twenty-four to forty-eight hours. Many doctors prescribe ice packs to be applied alternately for fifteen minutes on and fifteen minutes off and/or a mild painkiller such as acetaminophen (e.g., Tylenol) if you are in pain.

During each day of your hospital stay, a nurse may check your breasts, episiotomy, and uterus. In most cases, you will be leaving the hospital on the third or fourth day after a vaginal delivery and on the fifth to tenth day after a Cesarean delivery.

The actual coming home from the hospital, with all it entails - dressing yourself and the baby, saying good-bye, leaving the building, entering the car, the ride home, the walk from the car to your house - is surprisingly exhausting. It is advisable that you and your baby both go to bed and rest after you get home.

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During the first two weeks of your recuperation, climbing steps should be avoided or extremely limited. Lifting heavy objects or moving furniture around should not be done at all. Tub baths are approved by some doctors only when about four inches of water are used. Douching is not advised unless specifically prescribed by your doctor.

The Postpartum Examination

Obstetricians vary on how soon they want you to return to their office after the baby is born for your postpartum check-up. Some ask you to come in when the baby is six weeks old; some, when the baby is four weeks old and again at six weeks; and we know one obstetrician who sees patients at two, four, and six weeks postpartum. The doctor will check your general physical condition, weight, blood pressure, and urine and look for possible anemia. Among the other things the doctor will check are the size and location of your uterus; the condition of your abdominal wall; whether or not your cervix has closed, and whether there are lacerations of the cervix. The doctor will also examine your vaginal walls and genitalia to be sure any tears, abrasions, or lacerations are healing and, if you've had an episiotomy, will check for proper healing. If lochia is present, the doctor will observe its color and consistency and be wary of any foul odor, which would be a sign of infection. A Pap test may be taken, although it is not routinely done by many doctors at the six-week checkup because the cellular structure of the cervix may not as yet be back to normal. This therefore is the reason your doctor may ask you to return six months later for a Pap test. If a test is taken at six weeks, and shows some abnormal cell structure or inflammation, do not be alarmed. This is a common occurrence. A later test will most likely produce normal results.

The doctor may examine your breasts for lumps that should not be present if you are not breastfeeding. Nursing mothers often notice lumpy areas where milk has accumulated. For the most part, these are perfectly normal. Your nipples should be examined for cracking, bleeding, or infection. If contraception has been discussed and a diaphragm or I.U.D. decided upon, this is usually the time for having it fitted and/or inserted.

Once the uterus has involuted, the cervix has closed satisfactorily, bleeding has ceased, the episiotomy (if present) has healed, there are no vaginal or cervical erosions, tears, or infections, your breasts and nipples are normal, you are not anemic, and the subject of contraception has been discussed, the doctor usually pronounces you healthy and sends you on your way with congratulations, good wishes, and permission to resume sexual relations. As far as your doctor is concerned, the postpartum period is over and involution is practically complete.

Health | Reproduction | Pregnancy


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