MEDICAL CARE DURING THE EARLY PUERPERIUM

Rest and Quiet

From the doctor’s point of view, the fewer the visitors during the complete hospital stay the better. In some progressive institutions visitors are restricted on maternity to the husband and parents. It should not be forgotten that the patient must recuperate from the last few uncomfortable weeks of pregnancy and the strain and fatigue of labor. Frequently the patient feels so well that she wants to see every person in the world; if permitted she is likely to pay for it by excessive weariness and a depressed, ‘let down’ feeling. During the whole puerperium the period between two and four in the afternoon should be held inviolable for the sacred purpose of afternoon rest.

Diet

With the increased simplicity of modern deliveries and the period of enforced starvation in the labor room, most patients return to the postpartum floor with the question, ‘When do I eat?’ The news is good news. Now, instead of starting off with unsatisfying liquids or soft mush, they are given a full tray with a general diet of about 3000 calories per day. Patients with rapid labors often pride themselves on not having missed a meal to have a baby. Of course, if a patient is nauseated post-delivery she will be given appropriate liquids by mouth, or intravenous fluids, until nausea disappears. If she is nursing, the postpartum diet includes three or four glasses of milk a day.

Getting Up

The length of rest imposed upon women after childbirth has varied widely from people to people, and from generation to generation. Among most primitive groups, it was customary for the woman to go about her regular duties the day after delivery. During the past several centuries it has become general practice in this country and Europe for upper-class women to remain in bed for two weeks or longer postpartum. Despite this general practice, there have been several dissenters—among them Charles White of England in 1773, Goodell of Philadelphia a century later, and Kustner of Germany in 1899. They revived the practice of early rising in the puerperium, allowing patients out of bed on the third day.

When I entered obstetrics thirty-five years ago, patients remained in bed at least ten days and usually two weeks post-delivery. This custom was rather generally adhered to until World War II. Then the first wide-scale modern experiment was forced upon England. During the Blitz it became practice to have the baby’s bassinet near the mother’s bed, and during an air raid each mother would grab her infant and make haste with it to the hospital air-raid shelter. It made no difference if the baby was a day or a week old. In preparation for such an eventuality, women were encouraged to get up on the day of delivery or shortly thereafter. Despite medical fears, observation proved that no harm resulted. Following notices in the British Medical Journal of the English practice, we allowed two hundred patients out of bed on the third and fourth days in the wards at the Sinai Hospital, Baltimore. No ill effects either immediately or after six weeks were found. Patients who had had babies according to the old rules enjoyed the innovation, they felt so much stronger than when they had gotten up after nine or ten days of complete bed confinement. Several other studies soon appeared, confirming and extending our preliminary observations.

Today it is customary to allow patients out of bed the day of delivery if they desire. The only results accruing are good ones. We try to discourage their walking about the first day, but only too often, when making late-afternoon rounds, I meet in the corridor the patient I delivered that morning. Daily shower baths are permitted, beginning the day after delivery. There is no conceivable harm in washing the hair in the shower or basin any time after the day of delivery.

Early ambulation has contributed to the short hospital stays of the modern puerpara (she who has borne). Many patients plan to stay in the hospital a week but feel so well by the fifth or sixth day that they plead for discharge.

Cesarean-section cases ordinarily do not get out of bed until the day after operation but by the fourth day they are usually as strong and vigorous as the others. It is customary to hospitalize them for a full week.

Exercises

With the patient going about normally so soon after delivery, the need for calisthenic exercises postpartum has disappeared. As a matter of fact, they have fallen in ill repute with some physicians, who now claim that chronic backaches may have their source in these exercises. Actually, I believe there is little data to show that they do any good or harm. The routine assumption of the knee-chest position for a few minutes twice a day during the early puerperium to prevent the uterus from assuming a backward tilt after delivery has fallen into the same disuse as postpartum calisthenics.

After Pains

During the first few days of the puerperium most multiparas and an occasional primipara complain of after pains. These usually begin soon after delivery but seldom last more than three days. They consist of painful contractions of the uterus, recurring irregularly and lasting about a minute. After pains are often initiated by the act of suckling; whenever the child is put to the breast the uterus reacts by contracting, and such contractions may cause a spurt of lochia or the passage of a small clot. In most patients no therapy is required, but others must be repeatedly given codeine and aspirin or some other analgesic.

The Blues ‘Postpartum blues,’ beginning a day or two after delivery and lasting several days, are frequently encountered. Periods of depression and crying without cause are common. If you are the victim of such a reaction, dismiss the family from the room and discuss it frankly with your doctor. He can reassure you that he has met postpartum blues many times in stable, well-adjusted, fundamentally happy women, who got over them in a few days without aftermath or treatment.

Baths

Many physicians allow patients to take full tub baths the day they return from the hospital; in fact, if the perineal stitches hurt or hemorrhoids cause pain, they may advise them to take shallow, warm, unmedicated baths several times a day. The fact that a patient is still bleeding is no reason not to take a bath. However, bathing in the early puerperium is still sufficiently controversial to make it necessary to clear the matter with your own doctor before getting into the bathtub.

The Care of Special Areas

The vulva (entrance to the vagina). As soon as delivery is completed, a sterile sanitary pad is placed over the vulva and held in place with a sanitary belt. Usually the patient is supplied with a paper bag of sterilized pads which she keeps in a bedside cabinet, and she changes them herself as need be. The day of messy irrigations and flushing of the perineum with antiseptic solutions after voiding and defecation is a thing of the past. Episiotomy wounds and perineal tears require no special treatment unless they cause pain. Among the remedies for pain are: an ice-collar, warm salt or boric irrigations, alcohol or Epsom-salt compresses, dry-heat emanations from an electric-light bulb, and the application of various medicated ointments.

The bladder. Previous to our modern era of early ambulation it was not uncommon, particularly after a forceps or breech extraction, for a patient to be unable to void for several days. Today, with the almost immediate use of toilets or commodes instead of constraining bedpans, inability to void postpartum is an uncommon happening. In the rare instance that the patient cannot empty her bladder, she is catheterized every six to ten hours, or a permanent indwelling catheter is left in place for forty-eight hours or longer. If this becomes necessary, a prophylactic antibiotic is begun, to protect against a urinary-tract infection.

The abdomen. It is a very old custom to swathe the abdomen after childbirth. It was believed that after the disappearance of the large abdominal mass, the woman’s insides would rattle around in a dangerous fashion unless they were securely held in position. During the Renaissance a most elaborate ritual of swathing grew up, even resorting to the skin of freshly killed sheep.

Ever since the time of Mauriceau, in 1668, the art of swathing has grown simpler and simpler, until now most obstetrical authorities have completely abandoned the use of postpartum abdominal binders and corsets. Their use in no way contributes to the restoration of the figure; in fact, there is pertinent evidence that they retard its acquisition. I grant that this is difficult for all great-grandmothers and most grandmothers to accept, but I sincerely believe it.

The bowels. With early ambulation and the virtual elimination of that awful contraption the bedpan, regulation of the bowels postpartum is far less of a problem than it used to be. Nightly cathartics may be used, and if necessary occasional enemas, unless the patient’s perineal tear or episiotomy was extensive enough to involve the rectal sphincter or the rectum.

The Discharge Examination

Some obstetricians make it a routine procedure to perform a vaginal examination on all patients before they leave the hospital. Since by the early time of discharge customary today the perineum is only partially healed, the examination must be done very gently and incompletely. Many doctors defer the examination until the routine visit a month after discharge from the hospital.

Summary of Home Care after Leaving the Hospital

I have stated dogmatically my own rules for the management of pregnancy, and I do the same for the first few weeks after leaving the hospital. However, I again issue the sincere warning that if the rules which follow differ from your own doctor’s, utterly disregard mine and follow his scrupulously.

On the day before the patient leaves the hospital I give her the following farewell speech. It is meant only for the normal case who has had an uncomplicated vaginal delivery and in whom convalescence has been uninterrupted. The patient delivered by Cesarean section, or in whom there was some complication, receives different instructions.

Overhearing myself, I sound like this: ‘Your case was delightfully normal. When you go home tomorrow, walk up the steps; more people are killed by being carried up than by walking up. ‘Stay on the same floor for three or four days after getting home from the hospital, if convenient. If not, you may go downstairs once a day, perhaps for dinner; if you do, you might as well stay down for the evening. Rest for most of the afternoon, if possible sleeping for two hours. ‘When you have been home three or four days, reduce the afternoon rest to two hours. On this same day you may walk downstairs and, if the weather is nice, go outdoors for a five-minute stroll. The next day you may go out a little longer; each day increase your activities. When you have been home ten days you may do nearly what you please— go downtown to movies, go out to dinner, do light house- work, et cetera. Don’t assume unrestricted heavy household duties until the baby is three or four weeks old. ‘You may ride in a car when the baby is two weeks old, and drive it yourself when the baby is four weeks old. ‘You may eat, drink, and smoke what you want. If you are breast feeding, you must drink a full quart of milk each day and go lightly on cigarettes and drinking, for both nicotine and alcohol are excreted in the milk—perhaps nature’s attempt to build up tolerance early in life. ‘You may take a full bath as soon as you get home, and bathe at least once a day. If stitches or hemorrhoids pain you, the more often you bathe the better. You may douche after the baby is three weeks old if you wish to, but it is rarely necessary. If you decide to douche, use a can or bag and lie with your hips elevated in the bathtub. Use either two teaspoons of sodium perborate, three tablespoons of white vinegar, two tablespoons of salt, or some proprietary deodorant powder in an amount indicated on the label. I would not douche more often than every other day. ‘In regard to clothing, wear any clothing which is comfortable. Do not wear a girdle constantly, since it acts like a splint to the abdominal muscles and retards them from getting their tone back. ‘Make an engagement to see me at my office when the baby is about a month old, and don’t have sexual intercourse until I check you. Come alone—leave the baby at home. ‘If any problems arise, telephone me as usual.’