Postnatal period and subsequent check-ups

Postnatal period and subsequent check-ups

Introduction
The puerperium is the period after the birth in which the woman ‘loses her pregnant state’. The first 7 to 10 days of this is termed the confinement period. During this period the mother and the newborn are cared for and monitored by a maternity assistant (in the case of a confinement period at home) or a nurse (in the case of a confinement period at a hospital; the clinical confinement period). The medical check-ups are performed by a midwife or a physician. These check-ups are not just aimed at detecting pathology but also at preventing it.

Monitoring the condition of the child
Besides the general monitoring of the newborn’s state of health, specific attention will have to be given to the feeding, defecation, micturition and growth of the infant.

Growth
A full-term newborn has a length of 48 to 52 cm.
The weight of a healthy newborn is 3000 to 3500 g. On average boys are heavier than girls and children from multiparae are in general heavier than children from primiparae.
A newborn will lose weight during the first days of its life. A weight loss of up to 10% of the birth weight is normal. At about the 10th day after birth the child should have returned to its birth weight. The normal weight gain from an age of several weeks onwards is about 150 g per week during the first year of life.
Infants usually drink 150-180 ml of milk per kilogram bodyweight per day. However, more important than the quantity of milk is whether the child puts on sufficient weight. One method for giving children the correct quantity of milk is feeding on demand; the number of feeds and the volume of milk is adjusted to the baby’s hunger.

Micturition and defecation
Micturition and defecation normally occur within two days after the birth. The first bowel movement after birth is a dark brown, almost black, sticky substance: the meconium. Meconium consists of remnants of swallowed amniotic fluid, vernix, excreted epithelial cells, lanugo hairs, gall and gastric juices. Around the third day the appearance changes; the faeces become less dark and sticky. These are the transition faeces and change to normal stools within several days. The bowel movement frequency of children who are bottle-fed is about once per day. Children who are breastfed usually have more frequent bowel movements, but can also have them only once every two to three days. Almost all children urinate within 48 hours after the birth. If the child has not urinated within 24 hours then, in principle, this requires further investigation. A healthy newborn urinates four to six times per day.

Temperature
The normal (rectally measured) temperature of a newborn is 36.5-37.0°C. Newborns have a large skin surface area in relation to their body weight as a result of which they find it difficult to maintain their body temperature. A normal body temperature is best maintained at an ambient temperature of 32-34°C.
During the confinement period it is normal practice to check the temperature of the child twice a day.

Inspection of general condition
To assess the general condition of a newborn, they should be undressed. Whilst undressing the child a good impression can be obtained of its muscle tone and motor function.

Colour
A healthy neonate of Caucasian origin has a reddish-pink skin. Hands, feet and the area around the mouth can be blue after the birth. This peripheral cyanosis is not a cause for concern during the first 48 hours postpartum, if the general condition of the child is good and there are no indications of central cyanosis. For dark-skinned babies the colour of the mucous membranes and lips is noted for the assessment of anaemia and cyanosis.
In half of all full-term newborns, hyperbilirubinaemia occurs during the first days of life. If the serum bilirubin concentration rises above 120 µmol/l, jaundice will be visible. Of all full-term newborns, 15% develop overt jaundice. Physiological jaundice is the most frequent form of neonatal jaundice. Usually the maximum bilirubin level is attained on the third day after birth and after a week the jaundice will have disappeared. In children who receive breastfeeding, jaundice can persist for longer. Jaundice that is already present on the first day of life is not physiological.
If the concentration of (unconjugated) bilirubin is high, there is a risk of nuclear jaundice. In this situation the nuclei in the brain stem will be damaged with severe irreversible mental and motor abnormalities as a result. For every case of neonatal jaundice that does not fit within the clinical picture of physiological jaundice, a pathological cause (blood group incompatibility, perinatal infection) should be suspected.

Umbilical stump
An umbilical cord that has been cut through is an open wound and should be kept as sterile as possible. After the umbilical cord has been cut through, check that the stump does not continue to bleed. If the bleeding has stopped, the stump should be covered with a sterile gauze. The umbilical stump should be folded upwards to minimise the chances of it becoming wet from urine. During the first 24 hours postpartum the umbilical cord must be checked regularly for continued bleeding. The sterile gauze should be replaced at least six times per day. The navel should be checked each day. If the skin around it becomes red there is probably an infection (be aware of sepsis).
If the umbilical cord is clamped with an umbilical cord clamp, and this clamp causes skin irritation, the clamp can be removed from the third or fourth day postpartum onwards.
When the umbilical stump falls off, the navel should still be covered with sterile gauze until the wound is completely dry.

Monitoring the mother’s condition
The medical check-ups during a clinical confinement period (during which pathology or a significantly increased risk of pathology is present) are performed daily. For a confinement period at home the usual practice is to check the woman and child daily during the first three to four days postpartum and thereafter every other day.
New mothers and newborns are cared for by maternity assistants at home and by nurses in hospital.
The new mother needs to have sufficient rest on the one hand and be sufficiently mobilised on the other.
The temperature and heart rate of the mother, the position of the fundus, and the quantity and appearance of the lochia are checked twice a day. The physical and psychological well-being must also be carefully observed. During the confinement period several changes take place at once (parenthood, marked change in the hormonal status, possible stay in the hospital), each of which can affect the stability of the new mother. On the third or fourth day postpartum many new mothers experience mild (transient) depression. This depression is often termed the ‘baby blues’.

Measurements

Temperature
During the first few days postpartum the temperature may be slightly elevated, but in general it will not exceed 38°C (rectally measured). A temperature increase during the confinement period is observed, for example, in the event of infections, breast engorgement and thromboembolitic events.

Pulse rate
An increase in pulse rate is seen in the case of disorders that also lead to an elevated temperature. Additionally an increased pulse rate may be a symptom of anaemia during the confinement period. An increased pulse rate that precedes a rise in temperature is indicative of a thromboembolitic event.

Blood pressure
If the blood pressure was elevated antepartum, it should be regularly monitored during the confinement period. About 25% of eclamptic attacks occur during the first 48 hours postpartum.

Micturition and defecation
The increased volume of interstitial and intravascular fluid during pregnancy must be excreted postpartum. This leads to increased urine production.
Oedema of the urethra and bladder floor and the possible pain associated with pelvic floor damage, can give rise to difficult and painful micturition. Consequently there is an increased risk of urinary retention, with bladder distension and a urinary tract infection as possible consequences. It is therefore important to enquire about the micturition frequency.
During the confinement period new mothers show a tendency to be constipated. Many women are administered a single dose of laxative on the third or fourth day postpartum.

Breasts
Especially if breastfeeding is given, nipple hygiene needs to be monitored. Lots of rest and a plentiful fluid intake are important for optimal lactation. Vascular congestion (several days postpartum) can usually be distinguished from mastitis (usually unilateral).
If a woman does not intend to breastfeed, it is important to start with lactation suppression at an early stage (conservative or medicinal).

Legs
As the risk of thromboembolic processes (in the legs and pelvis) is increased during the confinement of period, as in pregnancy, early mobilisation of the new mother is important.

Uterus and lochia
The uterus, which post partum will reach to a few centimetres beneath the navel, will involute back to under  the pubic synthesis during the first weeks of the postnatal period. During the confinement period the uterus should feel firm. The lochia is checked for quantity, colour and smell. The smell of normal lochia is sweet and sickly, while infected lochia is foul-smelling. An inspection of the fundus and lochia allows the possibility of an early diagnosis of uterine subinvolution and endometritis.

Perineum
After the birth the perineum can be painful, even if no damage has occurred. Episiotomy wounds, and to a lesser degree tears, can cause a great deal of pain. Pain relief can be provided by administering paracetamol, for example.
A perineal tear or an episiotomy wound usually heals after suturing. However, sometimes the wound may become infected. This is associated with pain symptoms and sometimes with a raised temperature. Treatment may consist of a brief bath (maximum 10 minutes), several times per day to clean the wound. Vulvar haematomas can cause severe pain. They can extend deep into the loose connective tissue in the lesser pelvis. Small haematomas are treated conservatively. For large haematomas surgery is sometimes indicated.

Feeding

Breastfeeding
If the mother chooses to breastfeed, this form of feeding should be supported as much as possible. In terms of composition, breast milk is the most appropriate form of infant nutrition. It contains, amongst other things, antibodies that protect the child against infections. Breastfeeding is also hygienic, cheap and always available at the right temperature. Formula milk comes in powder form and must be made up according to strict rules. Once it has been made up, formula milk can be kept under hygienic conditions for 24 hours. The risk of incorrect use is higher than with breastfeeding.
In principle, every woman is able breastfeed, irrespective of the size or shape of her breasts or nipples.
A lot of advice is given about the preparation of the breasts and nipples for breastfeeding (e.g. nipple massage, warm/cold bathing). However, the effectiveness of most of these recommendations has not been demonstrated. Good information about breastfeeding should of course be provided during pregnancy.
Prolactin and oxytocin initiate and maintain milk production and are responsible for the let-down reflex. The prohormone prolactin stimulates milk secretion from the breast glands. The prolactin level rises during the course of the pregnancy, but can only initiate milk production once the concentration of placental hormones drops after the birth of the placenta to a level where oestrogens in particular can no longer inhibit the effect of prolactin. The time between the birth of the placenta and the start of milk production varies from 48 to 96 hours. During the first few days after birth the breasts secrete colostrum. This colostrum is produced by the breasts during pregnancy. As the breast gland tissue gradually enters the secretion phase under the influence of prolactin, milk is produced and secreted. The new mother can then experience congestion.
There are two types of congestion:

• vascular congestion which occurs around the third day postpartum
• breast engorgement which manifests about the fifth day postpartum.

Vascular congestion occurs due to a temporary reduction in blood flow out of the breasts.
Breast engorgement arises because it is still difficult for the milk to pass through the milk ducts and because the child does not yet sufficiently empty the breasts.
The blood level of prolactin remains high due to the stimulation of the nipples by the child’s sucking action.
The let-down of milk is a reflex response stimulated by oxytocin. Initially oxytocin enters the mother’s blood due to stimulation of the nipple, but the longer she breastfeeds the more oxytocin is released due to conditioned auditory and visual stimuli (seeing and/or hearing her child).
To initiate and maintain breastfeeding it is important that the child is put to the breast soon after birth and drinks regularly from the breast thereafter. Under physiological circumstances the quantity of milk produced by the breasts depends on the quantity of milk drawn from the breasts. In other words: the more the baby drinks, the more milk is made.
Breastfeeding frequency depends on what the mother and baby want. Some mothers and babies appreciate a fixed feeding scheme in which the baby is fed first every three hours and subsequently every four hours. Other mothers prefer the baby to indicate when it is hungry. A total of six to eight feeds per day may be given. If the mother and child are happy with how breastfeeding is proceeding and the child is growing well, it is wise not to intervene in this process. Breast milk contains little vitamin K. This could lead to haemorrhagic diathesis during the first few weeks of life. The Dutch Association for Paediatricians advises administering vitamin K to all newborns who receive breastfeeding. The standard dosing schedule is as follows: immediately postpartum 1 mg vitamin K orally and subsequently from the eighth day postpartum onwards 0.025 mg (= 25 microgram) each day. This last dosage should be continued for as long as breastfeeding is given.

General advice for the mother
An important advice is that the breastfeeding woman should take sufficient rest, especially during the first few weeks after the birth. Rest during the day is often hindered by the presence of other children. However, it is usually possible to lie down when breastfeeding. This often gives a feeling of rest which is essential for the success of breastfeeding.
Plenty of time must be taken for the feed; it must not be done hastily between two activities.
Washing with water is sufficient to keep the breasts clean. Cleaning the nipples with alcohol solution is advised against. Soap and alcohol increase the risk of painful nipples developing. If the mother wears a bra, it is important that this provides good support and does not pinch anywhere. If the breasts leak a lot, breast pads can be useful. These should be changed regularly. After breastfeeding the nipples must be dried. The best method is to allow the nipples to dry in the air.
The effectiveness of using ointments, sprays, oils et cetera to prevent painful and cracked nipples has not been demonstrated.

A healthy diet is sufficient for breastfeeding women. In principle they can eat and drink normally. In general, breastfeeding women feel more hungry and, in particular, more thirsty. If they satisfy their hunger with healthy food and satisfy their thirst with dairy products or fruit juices, they will obtain sufficient food and fluid. It is not necessary to prescribe a certain quantity of fluid to safeguard the milk production.
Furthermore, it is not necessary to drink a lot of milk. However, on warm days or if she has a fever or high temperature, the lactating woman must continue to drink enough.
Sometimes the mother may be under the impression that her child is reacting badly (e.g. inconsolable crying, swollen stomach, vomiting, rash) to certain foods she has eaten. In such cases she may be advised not to consume this food for a period of two weeks. If the child’s complaints recur after the mother has started eating the food concerned again then the mother should omit this food from her diet. Some substances that can elicit such an allergic reaction are: cow’s milk protein, chicken protein, nuts, peanuts, fish, shellfish, chocolate, citrus fruits and pork.

Positioning and latching on

Procedure

• Ensure that the mother is sitting or lying in a position that she finds comfortable.
• Ensure that the mother supports the child’s neck, without fixing the head too firmly and without touching the cheeks.
• Place the baby close to the mother so that the mother’s nipple and the child’s mouth are at the same height.
• When positioning the baby at her left breast, the mother must hold the areola of the left breast with her right index and middle fingers. The middle finger should lie under the areola and the index finger should lie above.
• Now have the mother gently stroke the child’s upper lip with her nipple.
• Wait until the baby opens its mouth wide. If necessary moderate pressure on the chin may encourage the mouth to open wide. When the mouth is open wide the baby is ready to latch on.
• Instruct the woman to move the child gently towards the breast.
• The baby will now take the nipple and areola in its mouth and start to suck. The child’s chin should lie against the mother’s breast.
• Check whether the child is properly latched on:
  • the entire mouth is filled with the nipple, areola and breast tissue
  • the lower lip is curled outwards under the areola
  • the nose is unobstructed, if necessary the mother can push the breast inwards slightly to keep the nostrils unobstructed
  • the baby holds the breast firmly without letting it slide in and out of its mouth
  • the jaw muscles move rhythmically.
• Let the baby drink for 15 to 20 minutes. Note, however, that for the first few feeds the child should only be put to the breast for a few minutes.
• After breastfeeding allow the mother to remove the child from the breast. If the baby does not release the breast it should not be pulled away as this can damage the skin of the nipple. If the mother places a little finger in the corner of the child’s mouth, it will suck less strongly and release the nipple.

Problems during breastfeeding

Inadequate let-down reflex
If a woman feels that her breasts are no longer ‘filling up’ as her baby starts to drink and the child is not growing well, this might be due to an inadequate let-down reflex. This is often caused by the mother not being able to relax enough when she feeds, due to stress, insufficient rest, pain, etc.
Several simple recommendations are:

• feeding in a quiet, familiar environment
• no people around her who might criticise her breastfeeding technique
• drinking something herself before putting the baby to the breast and concentrating on the forthcoming feed or thinking about something pleasant.

Cracked nipples
Cracked nipples are fissures of the nipple. They can develop due to the baby sucking or playing with the nipple too long or due to the baby not being properly latched on during the feed. Cracked nipples are very painful. First of all the woman will have to be observed during the feed to see whether the baby is latched on correctly, whether it takes both the nipple and the areola in the mouth and that it does not play with the nipple too much. The use of a nipple shield may also be advised. This makes feeding less painful. The nipples should be left open to the air for a short time to dry.
Some health care providers recommend wearing metal tea sieves in the bra. This keeps the nipples from getting too wet, there is some ventilation and the bra does not rub against the nipple. Many types of nipple creams and sprays have been used over the years but the effect of these is controversial and may sometimes even be harmful. Pain relief in the form of oral medication may sometimes be necessary if the mother cannot tolerate the pain. The pain symptoms caused by cracked nipples are often a reason for a woman to stop breastfeeding.

Inverted nipples
A number of women have naturally flat nipples. Most of these women can breastfeed without any major problems if they receive some extra attention when learning how to breastfeed. The nipple itself has a minor role in the process of breastfeeding and good positioning and latching on appear to be more important than nipple size.

Bottle feeding
If, for whatever reason, breastfeeding is not given, infant formula milk is the indicated alternative.
Infant formula milk refers to preparations that duplicate the composition of breast-milk. Various brands and types of formula milk are available. Although there are slight differences between these, in general it can be stated that formula milk contains more vitamin K, protein, iron, calcium, phosphorous and magnesium than breast milk. The calorific value of formula milk is equivalent to that of breast milk.
The first feed is given two to four hours postpartum. The first day the baby should be given 20 ml/kg/day spread over six to eight feeds. Each day the quantity is increased by 20 ml/kg until it reaches an amount of 160-180 ml/kg/day. As with breastfeeding, a certain degree of flexibility is recommended with respect to the frequency and quantity of the feed. The mother will intuitively learn her baby’s feeding pattern. During the first few months of its life, an infant’s feeding pattern is strongly determined by its sleep rhythm. In the first few weeks the baby will wake up about every three hours. This also explains why young infants need a night feed during this period.

Conclusion of confinement period

Contraception
As the first postpartum ovulation can occur after four weeks, it is important to discuss the desirability of contraception with the couple during the confinement period. In women whose lactation is medicinally inhibited, ovulation may take place even sooner postpartum.

Child health centre
From the age of 2 to 3 weeks onwards, the infant’s growth and development are monitored at a child health centre or by the family’s GP. The child health centre staff check the physical and mental development of the child, provide advice and also implement the national vaccination programme.

Post-confinement check-up
It takes quite some time for the body to return to the non-pregnant state after having given birth. The physical changes associated with pregnancy and childbirth disappear to a certain extent, although this does not happen at the same pace in each organ or organ system.
There is also a return to the non-pregnant psychological state.
About six weeks after childbirth a routine check-up takes place.
Focal points:

• the condition of the child. Is the baby growing, how much feed does the baby receive, does it cry a lot, does it sleep through the night, PKU/CHT result, is the mother attending the child health centre with her baby?
• the general physical and mental condition of the mother. How does the mother feel: good, tired, dizzy? Is she working outside of the home or is she intending to resume work shortly? Are there specific complaints: vaginal discharge, involuntary loss of urine? Can she cope well with the new situation? If not: does she have help, is she sleeping well (look carefully for signs of postpartum depression)?
• breastfeeding. Is the woman (still) breastfeeding?
• If not: when did she stop? If yes: are there problems, is the child receiving prophylactic vitamin K?
• the menstrual cycle. Is there still blood loss? If yes: quantity, appearance. If not: when did the blood loss stop and has menstruation already taken place?
• contraception. Has sexual intercourse already taken place and did this proceed without problems? Were contraceptives used? If not, does the woman want to use contraceptives?
• blood pressure. Is the blood pressure the same as before the pregnancy? If not: make an appointment for a further check-up (GP)
• the abdominal wall. Have the abdominal muscles recovered (particularly after considerable distension)? If not: advise abdominal muscle exercises
• inspection of the vulvar region. Note: healing of scars, discharge, blood loss
• inspection of the internal genitals.

Pay particular attention to:
vagina: healing of scars in the vagina, vaginal infections, discharge, blood loss, prolapse.
cervix: closed, healing of any tears.
If necessary, a PAP smear may be taken: as screening, as a repeat procedure or because a PAP smear taken during pregnancy showed no endocervical cells present in the sample. If the woman is still breastfeeding the smear should be postponed until the menstrual cycle has started again. While breastfeeding, the woman is in a hypoestrogenic state due to the high plasma concentration of prolactin. The quality and interpretability of the cervical smear is reduced as a result of this.

Bi-manual examination:
Pay particular attention to:

• cervix: closed
• uterus: involution (uterine size about 8 to 10 cm), tenderness
• adnexa: parametria: masses, painfulness, cervical motion tenderness.