The puerperium (Latin: ‘a child’ + ‘having brought forth’) has been arbitrarily defined as the first six weeks following the completion of labor. It is a period of rapid recuperation and readjustment from the pregnant to the nonpregnant state. Physiologically it is distinguished by two conspicuous phenomena—the return of the uterus to its nonpregnant condition, and the appearance of milk in the breasts, though many less obvious alterations occur, such as diminution in blood volume and the loss of excess tissue fluid.
The Return of Uterus to Nonpregnant Size
When the puerperium begins, the uterus is a two-pound mass of muscle, and by the end of six weeks it has diminished to two ounces. During the first few days of the puerperium it is a smooth, hard, gourd-shaped organ with its apex just below the navel. By the end of the first week it weighs one pound and has descended to two inches above the symphysis (the bone forming the front of the pelvic girdle). By the tenth day its top can just be felt above the symphysis, and after this it sinks within the pelvis and can no longer be felt when one palpates the abdomen. The process of shrinkage of the uterus (involution) progresses more rapidly when the woman nurses. The diminution in size and weight continues, and after five or six weeks the uterus is once more the size and weight of a pear. This cycle of growth followed by involution which the uterus repetitively undergoes in each pregnancy and puerperium is unique in physiology. No other organ multiplies itself twentyfold and then regresses back to its basic size. The growth is caused by a vast increase in the size of each individual muscle fiber forming the uterus, not by an increase in the number of fibers.
Puerperal Vaginal Discharge
The puerperal vaginal discharge, called lochia (Greek: ‘pertaining to childbirth’), has a bright red blood-color for the first three or four days; from the fourth to the tenth day it becomes paler and pinkish; and from about the tenth day on it is yellow-white, often with a little blood admixed. Ordinarily all discharge disappears between the third and fourth weeks. The lochia is often incorrectly called menstruation; the origin and constitution of the two are very different. The ordinary type of menstrual napkin should be worn; intra-vaginal tampons, such as Tampax, are forbidden, until at least two weeks post-delivery.
Return of Menstruation
True menstruation first returns at variable times after delivery. If the woman does not suckle her child, the menses usually reappear within four to eight weeks. In the woman who nurses there is the most extraordinary variability; the menses may return at any time from the second to the eighteenth month, the average being five months. The amount of bleeding and the interval between the periods may be quite unusual for the first several months in both groups. In some, it appears that the rhythm-producing mechanism requires an adjustment period for complete regulation. Painful menstruation, dysmenorrhea, is almost always improved by a pregnancy; in many the pain, which may have been incapacitating, never returns.
The breasts are prepared for the secretion of milk throughout pregnancy by the mammary-growth-stimulatingproduced by the placenta. These same chemicals prevent the pituitary gland from manufacturing its specific milk-producing chemical, the lactogenic hormone. With the abrupt withdrawal of the placental hormones, concurrent with delivery of the placenta, their inhibitory influence disappears and the lactogenic hormone of the pituitary gland is promptly released. The immediate result is the marked increase in the amount of colostrum, the thin, sticky, colorless fluid secreted by the breasts, which changes to milk within sixty to seventy-two hours after delivery. Colostrum in some animals, notably cattle, is very rich in immunizing substances—antibodies— and unless the young partake of it they are likely to acquire a fatal infectious diarrhea. In cattle, as opposed to human beings, antibodies do not pass across the placenta from the mother’s bloodstream to that of the . Human colostrum apparently has no specific value, unless it be that of a gentle cathartic. Synchronous with the establishment of lactation, on about the third postpartum day, the breasts suddenly become larger, firm, hot, and painful, the pattern of superficial blood vessels beneath the skin becoming more prominent. This phenomenon, known as breast engorgement, rarely lasts more than twenty-four to thirty-six hours. Now, on pressure, a small amount of bluish-white fluid—the milk—will exude from the nipple. At this time the patient may feel fatigued; she may have a headache, throbbing pains in the breasts, and a low-grade fever. If there is breast tissue in the axillae (armpits), as there is occasionally, she may develop painful lumps under the arms. As the engorgement subsides, the breasts soften, the pain lessens, the milk becomes thicker, slightly yellowish, and more abundant.
Nursing mothers gain temporary relief with the sucking of the infant. In non-nursing mothers, a supportive brassiere, codeine and aspirin, and occasionally the local application of ice bags are indicated. The day of tight breast binding, the use of a pump, and the restriction of fluids is past. Some physicians prescribe a single injection of one of the milk-suppressing hormones or daily tablets of the same material for a few days, to inhibit lactation completely in those not planning to nurse. Others oppose this therapy on the grounds that when the medication is discontinued abnormal vaginal bleeding or engorgement of the breasts may result.
Many substances taken by the mother promptly appear in the milk. This is particularly true of the vegetable cathartics, sedatives, and. If the latter is imbibed in large amounts, the child may be affected, since alcohol appears approximately in the same concentration in the milk that it is in the mother’s blood. Certain foods, such as onions, may give the milk a harmless pungency.
A woman’s ability to produce milk cannot be gauged by physical examination or laboratory tests. The size of the breasts or the amount of breast tissue seems to bear no relationship to this peculiar gift. The only index is the test of performance. As a rule, placid, emotionally stable women are better able to nurse than those who are tense.
A large number of preparations are sold as galactogogues (substances to increase the flow of milk), but none have any proved value. It was thought that an excessive fluid intake, particularly of beer and porter, adds a favorable influence on milk production, but even this has recently been disproved. However, milk production is affected by several factors: emotional upsets diminish it, and moderate outdoor exercise increases it. The quality of the milk is dependent in part upon the food taken by the mother: a diet rich in protein increases the proportion of fat A nursing mother does not have to stuff herself to feed her child adequately, but her diet should be abundant and varied. She needs only to supplement an ordinary, well-balanced diet with a quart of cow’s milk daily. Smoking in moderation—less than ten cigarettes a day—and alcohol in small amounts—one drink—have no injurious effects on either the mother’s milk or the infant. Menstruation, contrary to some old wives’ tales, exerts no serious effect on the quality of the milk. The child may become mildly upset during the days of menstruation, but since it returns to normal as soon as the menstrual period is over, there is no necessity to wean it. Nursing is a strain, and for this reason alone the infant should be weaned when a new pregnancy is diagnosed.
Conception during Nursing
During the first nine months the likelihood of impregnation is significantly less in a woman who nurses than in the woman who does not nurse. But after ten to twelve months of nursing the risk of impregnation is equal for both. It is also true that the woman who breast feeds completely is less likely to become pregnant during the first nine months than is the woman who partially breast feeds, using a bottle as supplement.
It is rare but possible for a woman to conceive before her menses have returned. Many case histories attest this fact. Ordinarily fertility is not restored until after the first or second menstruation.
In a fertile stock of human beings who nurse their infants and use no contraception one may expect infants to be born about twenty-four months apart. If the same group did not nurse, births would occur every nineteen months.
Weaning a Baby
When it is decided to stop breast feeding, weaning of the infant may be either gradual or abrupt. The former is accomplished by the progressive substitution of artificial feedings for the breast at one, then two, then three nursing periods during the twenty-four-hour schedule. When the weaning is carried out over a period of a week to ten days, it usually causes very little discomfort. Following completed weaning, the breasts continue to leak milk for several days. Within a week they should return to the nonpregnant status. There is the occasional instance of women who harbor small amounts of milk in their breasts for years. Except for the inconvenience, it causes no harm. When weaning must be done acutely, a tight brassiere is helpful. If the breasts become very hard and painful, ice bags may be applied during the interval the brassiere is not worn. Also a dose of Epsom salts or citrate of magnesia in addition to restricting fluids of any variety helps. In cases of extreme discomfort, stilbestrol or testosterone medication may be indicated, by injection or orally.
The average patient one hour after delivery weighs about 13.5 pounds less than before. An additional 3.5 pounds is lost between the first postpartum hour and the twelfth day. At the sixth week postpartum the total weight loss averages 17.75 pounds. Any excess weight present over the pre-pregnant figure is made up of fat and, in those who nurse, of increased breast tissue.