What to Expect…AFTER you were Expecting

th_PregnancyWhile many women often saturate  themselves with extensive information about what they should expect while they are expecting a baby, for many new moms, they find that their research ended after they figured out how to write up their birth plan. Thus, there are a lot of unexpected realities that suddenly appear after they have the baby.

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To start, I’d like to present the definition of postpartum: “(post-par-tum) adjective, occurring in or being the period following parturition [birth]” (Merriam-Webster Dictionary, 2012). I find that many people not in the medical profession practically shudder at this word, as if they thought every time we referred to “the postpartum period” that we were automatically assuming she would have postpartum depression when she got her period. Actually, a patient really told me that. And it is something many other people might also falsely believe. So for clarification, postpartum, and postpartum depression are entirely different concepts, are not ever used interchangeably and postpartum depression will never be shortened or nicknamed to postpartum just for the heck of it (you can’t make this up people). When health providers refer to the postpartum period, we referring to the period of time (not bleeding) that occurs from the time you give birth for six weeks thereafter. While postpartum depression can occur during this time, there are many, many other changes your body will experience that can also be overwhelming if you aren’t prepared.

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One of the most uncomfortable complaints associated with the postpartum period is breast engorgement. This occurs when the breasts fill with fluid from an accumulation of milk and fluid in the tissues, causing the breasts to become very swollen, heavy, firm, and extremely tender (think like the first day after breast augmentation). This can happen in both breastfeeding and formula feeding mothers, and is equally distressing for each.

However, treating breast engorgement is very different depending on if you are breast feeding or not, so pay attention. For breast-feeding women, they best remedy is to continue nursing every 1-2 hours, and use heat therapy with warm compresses, or let warm shower water to run over the breasts. This will increase the circulation to the breasts, and will help to facilitate drainage of fluid accumulation from around the tissue back into circulation, and nursing often will help to empty the breasts and will relieve some of the pressure. Frequent breastfeeding may also be beneficial in preventing breast engorgement, by providing a steady and consistent outflow of milk, decreasing the accumulation of milk in the tissues. Now, for the mother that is not breastfeeding, disregard the previous information. Your best action to treat breast engorgement is to focus on cold therapy NOT heat therapy. Using cold compresses on the breasts will help to decrease the circulation and swelling of the breast tissue. 1427051_f260As crazy as it may sound, cabbage leaves are highly recommended; they are cool, to draw the fluid away from the breasts, relieving some of the pain and swelling. They are also convenient, as the leaves take shape around the breast, and can be easily placed inside your bra, so you don’t have to worry about stuffing your bra full of ice. Additionally, because the breasts will become heavier, both breastfeeding and formula feeding women should wear good supportive bras to reduce the pull on your back and stretching of skin and breasts, and can help to reduce the overall pain and discomfort.

Amongst many other common complaints, many women complain of the achy, cramping feeling in their belly in the day or so following delivery. I feel like a full physiological explanation of the reason for their cramping is sometimes more helpful than the ibuprofen we give you, so try to follow along with all the gory details. During labor, the uterus intermittently contracts and relaxes in order to dilate the cervix and expel the baby from the womb. Very soon after the baby is born, the same thing occurs when the uterus expels the placenta (the afterbirth). Now, the placenta is actually attached to the inner lining of the uterus, and is kind of like a connection (or barrier, however you want to look at it) between the baby’s blood vessels and circulation and the mother’s. As such, you can imagine the high blood supply the is provided to the placenta, and when it separates from the uterus and is delivered, there is basically an open wound of open blood vessels. 6934W It is a rather complex process, but we’ll keep it as basic as possible here…In order to control the bleeding, the uterus again starts to contract down on itself, firm and constant, in order to constrict the blood vessels to reduce the bleeding. This doesn’t always happen on its own, and so a common practice is to stimulate the contractions further by infusing pitocin (the same drug used to make contractions stronger during labor), or by “massaging” the uterus down into a contraction.

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I was very fond of my instructor Jane, who always said “Ok darling, we’re just going to mash a bit on your belly now to stop the bleeding.” To me, this is a more accurate description than “massaging.” Over the next few hours to days, the mother may feel that cramping as the uterus tries to maintain a firm contraction. This may occur in several situations, one of them being while breastfeeding. As if breastfeeding wasn’t already the best thing to do for the baby, it is great for the mother too. Nipple stimulation by the baby suckling produces a hormone called Oxytocin. This probably reminds you of that medicine I mentioned earlier, called Pitocin, which is actually the synthetic version of Oxytocin. If you received Pitocin during labor, you can recall that the contractions started or got stronger after getting this med. Similarly, secretion of Oxytocin also stimulates uterine contractions. While this is also known as the “love hormone,” which is associated with feelings of motherly instinct and love towards the baby, this hormone plays a major role in keeping the uterus contracted to control bleeding, thus explaining why some women may feel somewhat crampy during or after breastfeeding.

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But rest assured, this discomfort is temporary, and will go away within a day or so,  and so please do not let this be a discouragement to breastfeeding! Another situation that may increase the cramping is when there is a full bladder. Think about the limited amount of space in the pelvis (I know, its hard to think of it as being anything but small after pushing out that baby). When there is a full bladder taking up space, it can push the uterus up and away from the pelvis, distorting the space needed for a contracted uterus, and thus, it may become soft, or “boggy.” In an attempt to compensate, the uterine contractions may become irritable and more uncomfortable. Additionally, there may be increased vaginal bleeding as a result of a soft uterus. This brings us to our next topic…

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Vaginal bleeding can understandable be a nuisance to the woman who has not had a period for the last 9-10 months. Bleeding is a result of a couple different factors including the process of involution (see above paragraph), as well as any lacerations or tears in the vaginal or cervix. Small tears in the vagina are common, and do not necessarily require stitches if they are not bleeding, though a midwife may throw a few stitches to enhance the healing process and prevent bleeding or infection later. The first day the bleeding is usually the heaviest, and should usually subside to a light period within the next day or 2, though the bleeding may increase if there is a full bladder (see above paragraph), so it is very important to be mindful of going to the bathroom and urinating every couple of hours to prevent the uterus from getting boggy, and reduce the amount of blood loss. Occasionally, I hear some concern from women that they start to bleed more or pass clots after they get up, especially in the morning. This then leads to the mindset that they should stay resting in bed to keep from bleeding more. While you should never ignore a noticeable increase in bleeding, it is common to notice more bleeding after getting up, especially after laying in bed for a few hours. This is because the vagina is basically a hollow vault, and when you are laying down, the pelvis is in a horizontal plane rather than vertical while standing, instead of dripping out, the blood tends to pool in some of the spaces and corners in the vagina and around the cervix. Then, when you change to a sitting or standing position, gravity works, and then the bleeding becomes evident. Additionally, blood tends to become clotted when it is still, so if you are laying for a few hours with pooled blood in the vagina, it may become somewhat thick or clotted, and come out when you stand or use the bathroom. As most other aspects of pregnancy, bleeding will eventually subside, most women will probably have at least some spotting for a couple of weeks after giving birth, and it may then become a whitish discharge before it stops completely. Now, for some women who are breastfeeding consistently, the bleeding (resuming your period) may not return for several months. images-4Aside from abstinence, lactational amenorrhea is one of the oldest and most natural methods of contraception, and is recognized by many cultures and religions around the world in which modern contraceptive alternatives are prohibited. Breast feeding is essentially Mother Nature’s way of naturally spacing out pregnancies (assuming ancient ancestors breastfed exclusively for the first many months to years of life). However, there is a catch! Do not foolishly assume that just because you are breastfeeding means that you won’t get pregnant. images-3In order to rely on the lactational amenorrhea method, breastfeeding should pretty much take place consistently, every 1-3 hours throughout the day. Pumping, formula supplementation, and prolonging time between feedings increase your chances of getting pregnant again, and if your feeding practice includes any pumping, use of formula, or you are only breastfeeding every few hours (such as when the baby starts to sleep through the night), you should consider yourself fertile, and at risk of getting pregnant again, even if you have not gotten your period yet. You should then consider using another form of contraception.

Generally, you are advised to avoid sex or anything in the vagina (tampons, fingers, douches) for six weeks after you give birth. If you are not nursing regularly, frequently, or formula feeding, you should consider some contraceptive alternatives, which should be discussed with you before you leave the hospital, and again at your 6 week follow-up appointment. As mentioned above, breastfeeding is an effective and easy way to prevent another pregnancy right away if the method is used properly, however, even then, it is reasonable to still use alternative methods for additional protection.images-2 If your last pregnancy didn’t occur because you forgot to take your birth control pill, you might be a good candidate for the birth control pill (just kidding!). Birth control pills are great forms of contraception for most women after having a baby (should not be used in women with history of or current blood clots, smokers over 35, breast cancer, conditions mentioned on all the commercials, etc). Depending on if you are breastfeeding or not however, will determine the kind of pill you can take. For women that are breastfeeding, pills containing estrogen may reduce the milk supply, and so it is recommended to use a progestin-only pill, also known as a mini-pill. These are considered to be safe to the breastfeeding baby, and are highly effective when used correctly (make sure you don’t miss a pill, take it at the same time every day, or you may get spotting, your period, or another pregnancy). If you are not breastfeeding your baby, either progestin-only or combination contraceptives (combination estrogen/progestin pills are the usual common pill) are appropriate. Additionally, breastfeeding or formula feeding women can also receive Depo Provera shots, we often encourage you to return to your clinic about 2 weeks after you deliver to get the shot. Another excellent method to consider at your 6 week appointment is the IUD, both the hormonal (Mirena) and non-hormonal IUD (Paraguard) are safe for breastfeeding and very effective for preventing pregnancy (see my blog ‘Got IUD?’ for info).

mch_postpartum_hair_lossAnother cause for concern brought by women after having a baby is that they notice their hair is falling out. While this can be very distressing, it is usually not a cause for concern. During pregnancy, hair and nails tend to grow faster, thicker, and seem healthier. Unfortunately, after pregnancy, hair and nail growth returns to normal, and women may shed the excess hair and fullness that grew during pregnancy. This may be very upsetting, thinking all of your hair is falling out, when in reality, the hair is just returning to the way it was before pregnancy.

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As mentioned at the beginning of this blog, postpartum depression is another problem that may occur in the weeks to months after having a baby. It is not uncommon to initially have feelings of sadness, anxiety, and crying in the first few days after having your baby. This is usually temporary, and should normally reside within a few days. Postpartum depression on the other hand is a much more serious condition, which usually has symptoms occurring after a few weeks to months after having the baby. Signs of postpartum depression may be very generalized, such as feeling tired, sad, stressed, or loss of interest in activities and things you used to be interested in. These should be considered early warning signs of the possibility for postpartum depression, and you should contact your midwife or OB as soon as possible to discuss your feelings. Many women may feel hesitant to express concerns about such feelings, for fear of being judged, labeled “a bad mother,” getting their baby taken, or being locked away in a crazy house. It is so important to not let these fears cloud your own judgement of talking to your provider; we are not here to pass judgement or labels on your parenting, and pretty unlikely to lock you away or take your baby. But that’s why it is so important to seek help early on, so that we can help you from becoming a harm to yourself and your baby.

While I hope this blog is useful and informative to many women, please take all information carefully, and do not substitute this info for professional medical advice or diagnosis. This blog is merely a briefing of some common discomforts of the normal postpartum period, but sometimes these discomforts can prelude to serious complications, and should never be ignored. If you do have concerns especially heavy bleeding, severe cramping, breast pain, odorous vaginal discharge or fever (just to name a few!) notify your doctor as soon as possible to be evaluated. Thanks for reading!

This blog is in dedication to Cody, one of my best friends, who just gave birth to beautiful baby Kaya on January 3.

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