Postnatal Issues
The First Poo
Everyone is nervous about their first POO after giving birth! Whether you have had a Caesarean or a Natural Birth, you will no doubt be dreading the first time you have to try and do a number two. The softer the stool (poo), the easier it will be to get out and the less strain it will put on your abdominal muscles and perineum (area between vagina and anus).
Kiwi fruit are a natural and mild laxative and eating a couple after you have given birth can be a great idea to get things going!
If you don’t like Kiwi fruit then of course many other fruits and vegetables can also act as mild laxatives.
If you suffer fromconstipationthat does not seem to respond to a good diet then a product like Fybogel which contains Ispaghula Husk should help. You can get this over the counter or on prescription with yourMaternity Exemption Certificate.
Do see your doctor or midwife if your constipation continues.
Lochia- Bleeding after Birth
Your body needs to get rid of the lining of your uterus after the baby is born. At first this will be bright red and heavy. You may be shocked about how much there is and the consistency and smell of it. It does not smell like ordinary period blood and may be lumpy at the start. Gradually this will change to pink, then brown and then yellow straw-like discharge. This may last anywhere from 2-6 weeks, Sometimes it may seem like it is stopping and then become heavy again, this is usually normal and may signify that you are perhaps doing too much.
At the start you may need to change your maternity pad every hour or so, or sometimes even more often. Do not use tampons as this can introduce an infection.
Although it smells different from a period, it should not smell horrible. If you are still bleeding bright red blood after a week, or you are getting any abdominal pains, or fever or chills, then speak to your doctor or midwife.
Episiotomy
An Episiotomy is a cut performed by a doctor or midwife late in second stage of labour in order to assist the delivery of the baby. This is usually performed with the use of a local anaesthetic and the cut is made at about “7 o’clock” at the centre of the back wall of the vagina so as to avoid the rectum.
It is no longer done routinely and is now only done to assist delivery in certain circumstances such as fetal distress, to prevent severe trauma or assisted delivery. An episiotomy slightly reduces the chances of a third or fourth degree tear (a rip from your fanny to your bum) and is easier to repair than a random tear. However, it may be more uncomfortable afterwards than a tear.
Often the decision about making an episiotomy is not made until last minute, depending on circumstances, but it is always done with the patient’s consent.
It is not done routinely with a Ventouse delivery, but is almost always done with a forceps delivery.
Rips or Tears
Most women will experience some form of tear or damage to the vagina and surrounding tissues during their first vaginal delivery. Most cause only temporary problems and will have no long-term effect on future health. The extent of the damage is related to many factors such as the size and position of the baby, the time spent pushing, the type of delivery, and the woman’s pelvic floor and its ability to stretch and withstand the traumas of pushing out a baby.
There are 4 degrees of vaginal tear.
1stDegree Tear- This is limited to the inside of the vagina only. This is unlikely to give any problems either at the time of delivery or later. It rarely needs stitching unless there is heavy bleeding. Healing is usually very straight forward.
2ndDegree Tear– This involves the vagina and the bridge of tissue between the vagina and the anus, called the perineum. It does not involve any damage to the rectum or the sphincters of the rectum, but may include some damage to some of the deeper muscles. It usually involves some stitching to bring together the deeper muscles and rebuild the perineum and close any defect in the vagina and skin. This stitching usually requires either local anaesthetic or gas and air, or the topping up of an epidural if one is in place. You will usually have to be in stirrups and this can take anything from 5 to 40 minutes. You can normally still hold the baby or hand it to the father.
3rdDegree Tear- This means that the tear has extended into the sphincter of the rectum. This will need to be repaired carefully to prevent any future problems with the back passage, such as incontinence. This repair is normally done under optimum conditions which are in an Obstetric Operating theatre. It may seem like a big performance at the time and a complete annoyance after a difficult birth, and may even feel like it is delaying bonding with your baby, but it is worth it. It is best done by an experienced doctor and may need some extra treatment afterwards to keep your motions (poos) soft and regular and a course of anti-biotics is usually given to prevent infection. You will need careful follow up appointments with physiotherapists and a post natal gynaecological team is usually advised.
4thDegree Tear- This is just like the 3rddegree tear but the tear actually goes into the rectum, repair is as above but a little more detailed and longer.
3rd and 4thdegree tears happen in approximately 5% of vaginal births.
The important thing is to make a diagnosis and for the lesions not to be missed but this may mean a sometimes uncomfortable examination shortly after the birth, including often a finger up the bottom.
Vaginal tears may be associated with increased bleeding after delivery and is usually more extensive the greater the blood loss.
Most heal nicely with a good result and minimal disruption to the bowel, the bladder or sexual function. The stitches dissolve and rarely need to be removed.
Sadly however, there are sometimes complications. Infection may occur after a few days, heralded by pain, redness and sometimes a breakdown of the wound with some extra bleeding. Rarely, the wound needs re-stitching but it is usually best left to heal completely before making a decision at a later date.
Occasionally there is delayed healing which may require some extra treatment such as cautery (being cauterised) or minor surgical procedures.
By 6 weeks things should be almost back to normal. If not, you should seek advice.
Perineum
Most women having their first vaginal birth will experience some damage to the perineum or pelvic floor. (The Perineum is the area between your vagina and your anus with underlying muscles that support the pelvic floor). Usually this is recognised immediately after delivery and is treated by careful repair of the vagina and deeper tissues by a midwife or obstetrician. This is usually performed immediately after delivery using either a local anaesthetic or an epidural and is generally performed in the delivery room. Occasionally this may need to be done in an obstetric operating theatre which will allow for better positioning of the patient, good lighting and assistance if required. For most women this experience is only a temporary problem which improves with the passage of time and is helped by pelvic floor exercises and other simple measures.
Care of the perineum after delivery requires regular effective pain relief, good hygiene with a bath, shower or bidet and making sure that the bowels are kept soft and regular. Your first poo is never as bad as you expect and is nothing when compared with delivering a 3.5 kg baby! By this stage, a Midwife should be calling round on a regular basis, at least up until 10thday, and will give you advice on general care.
If however, you experience increasing pain, tenderness and redness over the perineum, this may indicate early signs of infection. Sometimes there may be a fever, and if untreated this may lead to severe pain followed by a discharge of blood and pus giving rise to great relief. Infection in the perineum is more common after assisted deliveries and where there have been lots of internal examinations and extra bleeding. Sometimes infection is related to a collection of blood under skin, called a haematoma. If there is a significant infection it is usually only the superficial layers that are involved and there is usually a good outcome which rarely needs further surgery. If there are any concerns about infected perineum you must consult your midwife or doctor.
The stitches used during perineum repair are almost always dissolvable and do not need removing. They tend to fall out sometime between the 2ndand 6thweek depending on their thickness. Occasionally a stitch may be uncomfortable and annoying and this can usually be removed without any local anaesthetic. Again, you should see your doctor or midwife about this. Fortunately the tissues are very well served with a good blood supply so generally speaking the perineum heals nicely by about 6 weeks. There will be continued improvement of any tenderness and or swelling for the next 6-12 weeks.
Occasionally there is a complete breakdown of the repair and this may require further surgery in theatre either at the time or at a later date, approx 6 weeks later when tissues are clean and healthy.
Sometimes some scar tissue persists and can cause increased blood stained discharge and pain on touching or when attempting intercourse. This fleshy bit of scar tissue which is characteristically bright red is called Granulation Tissue. It is easily treated, usually in a clinic, by twisting it off and touching the base with a little stick of silver nitrate. This stick looks like a matchstick and it cauterises the area and encourages rapid healing.
Occasionally the area is unsuitable for treatment as an outpatient and may require a small operation under a short general anaesthetic usually performed as a day case. The procedure will get rid of any scar tissue and restore tissues to a normal shape and size.
Prolapse
Unfortunately some women do develop significant prolapse after pregnancy and childbirth. It seems to be more common after difficult vaginal deliveries rather than caesarean sections. It can occur after a normal delivery but is more common after births with prolonged pushing and a forceps delivery. A Ventouse delivery does not seem to increase chances of a significant prolapse.
Some women are unlucky and may develop a prolapse even though they have had a caesarean section as this method of delivery it is not completely protective. Sometimes pregnancy itself can weaken or damage the pelvic floor. One of most common factors affecting the incidence and degree of pelvic organ prolapse is genetic. If your mother had a prolapse you may be more likely to get one.
The symptoms vary considerably. Some women may have a prolapse and have no symptoms. The most common complaint is that of feeling “something coming down”, and you may be able to feel or see a lump. You may notice some urinary symptoms such as passing urine frequently or have difficulty passing urine. The most common symptom is that of stress incontinence. This is the leakage of urine when there is increase in abdominal stress such as coughing, sneezing, laughing, doing star jumps or sometimes having intercourse. Other symptoms include difficulty in emptying the bowel, or concerns about the vagina being lose or a different shape.
Usually there is significant improvement as the body gradually returns to normal. Weight loss and pelvic floor exercises may have a dramatic effect. The tissues will improve their blood supply and the muscles will get stronger once you have finished breastfeeding.
Occasionally if symptoms persist you may need other treatment. Surgery may be needed but usually this is best reserved until you have finished having all your babies. Happily most of the problems occur after the first baby is born and you usually don’t get additional symptoms with subsequent vaginal deliveries. In fact subsequent vaginal deliveries are usually quick and easy and without trauma.
If surgery is required and if it is successful then all subsequent babies would be best delivered by elective caesarean section.
Postnatal Infection
The most serious infection is that of intra-uterine infection, Endometritis, this is more common after an operative delivery or if there are retained products of conception left inside the uterus. It may occur through poor hygiene and is potentially quite contagious. The symptoms include, a high fever and lots of abdominal pain and increased smelly blood stained lochia (vaginal discharge after giving birth) and feeling unwell. If you have an inter-uterine infection you will need to be admitted to hospital, isolated, given intravenous antibiotics and general resuscitation. Most women will make a good recovery with no effect on the baby.
Symptoms you should look out for are swelling, redness, warmth, increasing pain or discharge at the site of any wound or in your breasts. If you develop a fever or have difficulty passing urine then you should inform your midwife or doctor quickly as an untreated infection can quickly become serious. Fortunately these infections are not contagious and respond to the usual treatments of antibiotics very quickly. You should seek the advice of your midwife or doctors if you think you have any form of infection.
Feeling down after Having a Baby
There are 3 types of psychological problems after childbirth.
“Baby Blues”
To a certain extent all women may suffer from this, especially first time mothers who have had a long drawn-out or difficult labour. By the time the baby is born they have probably not slept for 3 nights and are suddenly expected to know how to look after a screaming baby. By the end of the 3rdday after the baby has arrived, you may be short of sleep, with a sore bottom, sore nipples, sore abdomen, with a hungover or equally sleep-deprived partner and feel overwhelmed by visitors and phone calls!