After Delivery - The Postpartum Experience -- Pain

Last time we discussed lochia, the hallmark characteristic of the postpartum period. This time we will discuss postpartum pain. specifically pain related to an episiotomy.

If you have labored, whether you delivered vaginally or by C-Section, you will likely feel very tired. Labor is very hard work (that's why it is called labor), and you may feel sore in places you didn't expect. If you pushed for a while, you may find your shoulders, upper back and neck are sore. The most common pain of the postpartum period, however, is related to related to the birth canal and perineum, especially if an episiotomy has been performed.

Episiotomy

If you delivered vaginally, you may also have had an episiotomy, an incision in to the perineum (the tissue between the vagina and the rectum) to give more room for the baby's head during delivery. You will likely be very sore in that area and may find it difficult to sit comfortably in a normal position. You may find sitting on a pillow is helpful. When you have to sit on a hard surface, contracting your buttocks muscles before you sit can help protect the sore tissues and make you more comfortable.

The stitches of the episiotomy usually absorb and heal within 10 days to two weeks. It can take a good deal longer for all the pain and soreness to resolve, however.When thinking of the soreness of the episiotomy site, it is important to realize that even women who have not had an episiotomy or a laceration (a spontaneous tearing of the same tissues) may still have considerable pain and discomfort in the perineal area. The process of birth involves the stretching of the pelvic floor muscles and the tissues of the perineum to allow for the birth of the baby. If you think of any other time you have had muscles or tissues stretched, you know that it sometimes takes weeks for that soreness to subside.

At your postpartum visit with your health care provider, your physician or midwife will inspect your episiotomy site to make sure the incision site, or the site of the laceration if one occurred, has healed correctly and completely. If your episiotomy site is healed and your lochia has diminished to only a scant whitish discharge, your health care provider will most likely give you the approval to resume your previous activities. This usually means intercourse. Let’s talk about this for a moment.

Resuming intercourse

Just because your health care provider says that your stitches have healed and that from their point of view you are ready for intercourse does not necessarily mean you feel ready for intercourse. Let me give you an example from my own life. Several years ago I had surgery on my hand for Carpal Tunnel Syndrome. After two weeks my surgeon removed my stitches. Seven weeks later, he said that my hand had healed sufficiently for me to return to work and do any activity I would like to do. Well, that was well and good for him, but my hand was still incredibly sore. I couldn’t put much pressure on it without wincing. I had to be very tender with it for another three or four weeks. Gradually, I could go about my duties without thinking about my hand, but it didn’t happen just because the surgeon said so.

Perhaps your health care provider says everything is healed and you are ready for intercourse. If you try it and you are still very tender and sore, you will most likely want to wait awhile and try again in a few days or a week. Also, if you are breastfeeding, your estrogen levels will remain suppressed which will result in vaginal dryness. This has nothing to do with how you feel about intercourse, you simply don’t have enough of the hormone to produce the natural lubrication you need. This vaginal dryness, especially combined with any residual soreness you may have, will only increase the discomfort you may feel. You will have to supply some lubrication! Be sure to use a water-soluble lubricant such as Astroglide, or KY jelly. Using oil-based or petroleum-based products can lead to infection.

How long it takes to be comfortable after an episiotomy depends partially upon the episiotomy itself and the type of delivery you had. There are different levels of episiotomy from a very superficial incision of only the skin, to involvement of underlying muscle, which can include even the rectum. The greater the degree of the episiotomy, usually the longer it will take to resolve the pain issue. The bigger the baby, then the more probability for muscle soreness.

How to take care of an episiotomy

There are things you can do in the immediate postpartum period, however, to help minimize your pain later on.

Exercise

Stay mobile. While you may find it uncomfortable to move around, this will increase circulation and increase healing.

Performing Kegel exercises immediately postpartum will increase circulation to the perineal area, increase muscle tone and increase healing. At first it may feel almost impossible to do even one Kegel, but work up until you can do 60-100 per day.

Ice and warmth

Placing ice on the perineum in cycles on and off for the first 24 hours will help reduce and prevent swelling and will help diminish pain.After the first 24 hours, using a sitz-bath can be very comforting and will increase circulation and promote healing. A sitz bath sits over a toilet and enables water to continuously flow into the bath so it doesn't get cold. The excess water flows into the toilet.

Medications, ointments and sprays

Your health care provider may prescribe an anesthetic spray or cream for you to apply to the area which will be soothing. You may also have pain relievers of different strengths ordered for you. Do not wait until your pain is severe to utilize medication. This will only necessitate the need for higher doses of medication. By dealing with your pain when your pain is at lower levels, you will actually use less medication over time.

Cleaning the area

Keep the perineal area clean as long as the lochia continues. Wash your perineal area with soap and water daily during your bathing routine. After each urination or bowel movement use warm water to pour gently over the perineal area downward toward the rectum. Some health care providers will recommend an iodine-based solution for this, which can be purchased over-the-counter at most pharmacies if you are not allergic to iodine. Once you are finished cleansing the area, pat gently, do not rub the area. Always wipe from front to back, not only during the postpartum period, but for the rest of your life. This helps to prevent urinary tract infections.

Maternity pads

Wash your hands before and after changing maternity pads. Replace maternity pads often and each time you go to the bathroom. Wear panties with a cotton crotch as this will allow more air to circulate in the area.

Notify your health care provider

If you find that even with adequate time to heal, the pain persists, you may want to discuss this with your health care provider. The area of your episiotomy should be inspected again for proper healing and to ascertain if there are any problems that were not readily noticeable before.

What about pain from a C-Section?

Next time we will discuss the pain you may experience if your baby is born by Cesarean Section.

After Delivery - The Postpartum Experience -- Lochia

Throughout your pregnancy, most of your focus might have been on the hours of labor and the moment of delivery, and rightfully so. This will be one of the most momentous events of your life, the memory of which you will cherish forever.

What about after the baby is born? What can you expect in the hours, days and weeks after the baby is born? The return of your body, specifically your uterus, to normal is called involution. This process takes your body a few weeks. We'll take a look at what you can expect in the weeks following delivery and we'll do so by looking at particular topics.

LOCHIA

Perhaps the hallmark characteristic of the postpartum period is lochia. This vaginal discharge is comprised of blood and the tissue from the site where the placenta was implanted. As this site begins to heal, the tissue will begin to slough off as discharge.

Initially the lochia is comprised more of blood because the implantation site is rich in blood vessels. In the beginning, lochia is usually bright red, called lochia rubra, and of quite a bit of volume. The lochia will be bright red for only 1-2 days.

The uterus begins to shrink in size due to the contractions after delivery, which can be facilitated either by breastfeeding or by an infusion of Pitocin (a synthetic form of the hormone oxytocin, secreted by the Pituatary gland to cause uterine contracitons). This will help control the amount of uterine bleeding in the initial period.

Next the lochia will turn a reddish brown, or even pink color. This is called lochia serosa. This may last for 3-10 days and will be lighter in volume as well.

Gradually the lochia serosa will change to lochia alba, which is a yellow-white discharge. In some women this discharge can be a light brownish color. It is even lighter in volume than the lochia serosa. It will usually last for 10-14 days, but can last for 3 weeks and be normal.

Lochia has a charasteristic odor, similar to menstrual bleeding. You will notice more odor the longer the pad has been in place, or if you should also be perspiring. If you notice a foul odor at any time, you should report that to your health care provider immediately, as this can be a sign of infection.

Once lochia has changed from red to pink or yellow-white, it should not change back to red again. If it does, it is a signal from your body that you are doing too much and need more rest. If you continue to have bright red bleeding after resting, you should notifty your health care provider.

You should always used pads when dealing with lochia and never use tampons, which can lead to infection of the uterus. Also, be sure to change pads frequently.

Next time, we'll discuss pain and the episiotomy site.

Little Boy Blue

It had been a long day, beginning at 530am and ending at 653pm and seemed even longer than the thirteen hours marked by the clock. When I got home, I peeled off my scrubs and looked forward to a hot meal and an early bedtime, I was exhausted. I was sitting down to eat, when the phone rang.

A familiar voice on the other end said, "I think my water just broke.” Every cell of my body wanted to scream back, "No it didn't. I know it didn't!" Somehow, instead, I heard myself telling her, with a ring of cheerfulness in my voice, I would meet her at the hospital.

The phone call was from Julie, the wife of one of our dearest friends, who in the three years we had known her, had become a dear friend in her own right. Scheduled for an induction in a few days, this little boy was making his appearance a few days early, on a weekend, after a long and tiring shift.

I pulled the scrubs back on and headed to the hospital. Halfway through the two-mile trip it began to dawn on me what was going to happen this night.

I had anticipated this delivery before the conception even occurred, had followed this pregnancy from the beginning, and had been the one to answer many of Julie’s questions. Together, we had planned the details of the delivery, and now that delivery was upon us. Emotion overwhelmed me and I began to cry.

“I really need to stop this," I thought, "I'm not even at the hospital yet and already I'm blubbering!" As I got out of the car I told my husband I would call him when the baby was here, knowing it may be hours and hours before I would be returning home.

I raced up the stairs to make sure all was perfect before Todd and Julie arrived. In the nine months of thinking about this birth, I had thought for some inexplicable reason of Labor Room 1 and envisioned her delivering there. It was one of my favorite rooms, partly because it was directly across from the Nurses' Desk. I knew, however, that Julie's doctor hated that room. "It has bad juju,” she would say. On this Friday night, Julie's doctor was out of town, Dr. Bennett was on-call, and Labor Room 1 was empty. Once I arrived in the unit, I went to work to have everything in that room just the way I wanted it to be. My daughter had made the new baby a welcome sign, and I wanted to put it where it would be the first thing they saw. The next thing I knew Todd was pushing Julie through the door in a wheelchair and I took one final picture of them before parenthood indelibly wrote upon them the titles of "Mom" and "Dad”.

In a short time, Dr. Bennett was here and our questions answered. Yes, her water was broken. Yes, she was staying and yes, she was going to have a baby tonight. I told Dr. Bennett that these were my close friends and this was a very special baby, but I don’t think he believed me until later.

I wanted everything to be so perfect for my dear friends and I did all within my power to make it so. I often pray for my patients, their families and babies, but tonight I prayed at every turn in the road…"Please let this IV only be one stick, Lord"; "Please let this be a perfect and effortless epidural."; "Please let this be an easy labor and a smooth delivery.”

The night was long and quiet. Todd and Julie had decided early in the pregnancy that her best friend Elizabeth and I would be the only ones with them throughout labor and delivery. The quiet of the night hours and the stillness in the room gave an air of tranquility to the whole event. Julie napped, thanks to that perfect epidural. Todd and Elizabeth rested, and I watched the heart rate of the baby of my precious friends throughout the night.

I was experienced enough to know that even in the mother with no risk factors, things can take a turn for the worse unexpectedly. I knew if this were to happen, I could handle the situation, although I would most likely collapse in a heap of tears later. I believed too that somehow Julie would do all right. My concern was for Todd. He had lost an infant son once before and I didn't know how I was going to care for Julie and the baby and Todd. He alone might need all I had to give. The night, however, held no surprises and baby William was a marvelous baby in labor. He was saving it all for later.

I can remember toward early morning how thrilled I was when Julie's labor had progressed and she was ready to begin pushing. All traces of vanished and expectancy and excitement took its place. My new prayer, whispered with all I did, was "Please Lord, let this baby fit through.”

Made specifically for birth, the ends of birthing beds come off prior to delivery. Preparing for Julie’s delivery, I put her legs in stirrups and removed the end of the birthing bed. I needed to move her closer to the end of the bed before performing the perineal prep. Dr. Bennett was in the room putting on his booties and hat as I stood at the end of the bed and reached under Julie’s buttocks, to grasp her hips, so that I could pull her where I needed her to be. At that point, she reached down toward me, put her arms around my neck, and said, “I love you!”

Of course, my answer was to put my arms around her, hug her back, and say, “I love you, too!”

Dr. Bennett cocked his head to one side, and with a quizzical expression said, “I guess you DO know each other!”

A few minutes later, as the sun was beginning to rise over the city, Dr. Bennett handed William Ethan Woring into the waiting arms of his mother. Little baby cries blended with happy mother and father tears, congratulations from the doctor and nurses and from two very happy friends, who felt honored to be a part of such a blessed moment. In the minutes that followed, however, little William aged me by at least ten years.

Babies are normally a purple color at birth and slowly pink up. At birth their whole circulatory system reverses, and often it takes a few minutes for babies to pink up. William too had started out with that purplish color and had begun the color transition, but somewhere in the process, he jumped across the color wheel. Instead of turning pink, he began to turn a dark bluish color. I knew I would have to help him some, but I did not want to alarm my friends.

I took him from his mother, dried him off, and placed him under the radiant warmer to assess the problem. He was breathing, but from the raspy sound he was making I could tell thick mucus was clogging his throat. After all these years I had no qualms about suctioning a baby and passed a tube down his mouth and throat to clear out the secretions, all the while keeping a constant flow of talk to baby William. This was my habit when caring for newborns in the delivery room, as it often helped to calm the parents and me too. I suctioned the baby, but William stayed blue. I gave him some vigorous stimulation on his feet, but William stayed blue. I gave him a few breaths of oxygen-enriched air, but William stayed blue. Dr. Bennett came over and gave William some more stimulation, but William stayed blue. Why, oh why was William still blue? All the while, Elizabeth kept the video camera going. Why couldn't a camera battery die when you wanted it to? I felt that if I could just clear William’s throat, everything would be fine.

An eerie quietness had fallen over the room. Concerned new parents are quick to ask for reassurance, “Is everything ok?”, “What’s wrong with my baby?”, “Why isn’t he crying?” Todd and Julie didn’t ask, however, they just watched, and for me the silence was almost tangible. It was a while before I realized they were probably praying! The thought struck me as well that this little baby resembled Brady, the son that was lost. Surely, for Todd, too, this must be where his thoughts were leading. Oh why, oh why was William still blue?

I could almost feel Todd's and Julie's concern, but their quietness spoke to me of their confidence in me. At that moment, I felt no confidence in myself, however, but only in the Lord. This was His situation and I was sure wishing He would hurry and make it better! Then, not because of anything I had done, our little boy blue began to pink up. Lips, chin, chest…hands and feet would be blue for awhile yet, but now he was pink enough to wrap up and give back to his mother. What a joy indescribable to give a brand new little baby to a brand new mother, but oh, how much more so when that mother is a dear, beloved friend, and when the father is closer than a brother. What a wonderful feeling!

This wife waited for, the marriage that had been longed for, the baby prayed over from before his conception. Now here I was, putting perfect little black footprints on everything I could find and handing a little bundle of baby boy into an adoring daddy's arms, with the words I had waited so long to say, "Todd, here is your son".