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The timing of this visit depends on the mother's rate of recuperation. If her flow ceased at least a week prior to contacting the midwife, the midwife can assume her uterus is well involuted, her cervix firmed up, and that she is ready for her final checkup.
But if the mother had stitches, scheduling this checkup also depends on the condition of her perineum. If she is willing, ask her to wash her hands and gently insert her fingers to see if the area is sensitive to pressure; if so, she probably is not ready for sex or barrier method contraceptive fittings.
- MoonDragon's Contraception Information: Cervical Cap
- MoonDragon's Contraception Information: Diaphragm
Nevertheless, wait no longer than six weeks to see her, for if adequate healing has not taken place by this time, the midwife must determine the reason. Perhaps the mother had deep second degree tears. These can take a while to heal, but if her lochia flow has stopped and she is feeling fine, the midwife should have no worries.
Sometimes emotional conditions precipitate scheduling this visit sooner than later. For example, if a woman calls at four weeks to report feeling severely depressed or emotionally incapacitated, she should be seen at once, even though her physical recovery may still be weeks away.
One important reason for this checkup is to give the mother the OK for sex, along with suggestions on how to make the first occasion as pleasurable as possible. Recommend that she use plenty of lubrication, as breastfeeding will cause dryness and fragility of her tissues no matter how intense her desire. The midwife can also raise the issue of birth control for heterosexual women. Although rare, ovulation can occur as early as six weeks after a woman has given birth. It has been known that a few nursing mothers (giving no formula or anything else to the baby) have conceived in the first two months postpartum. It would be wise to recommend to the parents that if they are to resume sexual relations before considering future contraception, that using condoms is a choice available to them.
Things to check at the final exam include:1. The uterus.
It should be out of range of palpation, except by bimanual exam. If it is enlarge, she is probably still bleeding, and her cervix will feel soft by bimanual exam. All of these are signs of poor recovery. Pale discharge, or lochia alba, is all that should be present at this time. Prescribe rest, long relaxed nursing sessions to allow oxytocin to do its work, optimal nutrition, supplements as indicated, and involuting tea or tincture of black haw and shepherd's purse.
2. The cervix.It should feel firm, closed, and situated high in the vaginal vault as with initial pelvic assessment. However, some women do not regain their pre-pregnant cervical tone until they either stop or cut back significantly on breastfeeding, e.g., when solid foods are introduced to the baby.
3. Internal muscle tone.This should almost be back to normal by now if the woman has been doing vaginal exercises (kegels). If not, explain the importance of using the pelvic floor muscles for maintaining the uterus in its proper position, as well as revitalizing sexual desire and sensitivity. Check for tone high in the vaginal vault and just inside the vaginal opening. Often a woman has good tone in one area but little in the other.
4. Lacerations or episiotomy, for complete healing.If the woman sustained labial skin splits, they may still be somewhat tender as newly formed skin takes time to toughen up. This may cause some discomfort with sex, but adequate lubrication and creative positioning can help.
If the perineum feels rigid with scar tissue, encourage the woman to do perineal massage using evening primrose oil to soften the area, and to prepare for intercourse. This practice can be emotionally and physically reassuring for any woman nervous about having sex again.
5. The abdominal muscle tone.Have the woman lie down, then lift just her head and shoulders as you place fingertips along the juncture of abdominal muscles running from the umbilicus to the pubic bone. If there is any gaping, suggest simple abdominal exercises, starting with single leg lifts progressing slowly to full sit-ups (with knees bent). Most women have about half an inch separation in their abdominals, while other have very little. The mother may be referred to a postpartum exercise group or yoga class, if such are available, or suggest she meet informally with several other new mothers for exercise interspersed with baby massage and conversation.
6. The breasts, for tenderness or lumps.It is said that the hormones of pregnancy tend to accelerate abnormal cell growth if any is pre-existing. Even if the mother has seen a physician since the birth she may not have had a thorough breast exam, so the midwife should do this herself. This is also a good time to review self-breast exam techniques with her.
7. The cervix, by Pap smear.For reasons stated above, do a repeat Pap even if the mother was screened in early pregnancy.
8. The hemoglobin or hematocrit.This is especially crucial if the mother appears weak or exhausted, or if she has history of hemorrhage either with delivery or during the postpartum period.
9. The diet.It's common for a new mother to forget her own needs once pregnancy is over and she becomes completely focused on the baby. Often, she finds she has no time to cook, and hardly any time to eat. This may prompt her partner to take over food preparation, though perhaps not methodically enough to meet the breastfeeding mother's nutritional requirements. If she complains of chronic fatigue, nervous irritability, or upper respiratory infection, prescribe more protein, more calories, good sources of vitamins B and C, and trace mineral supplements. If her hematocrit is less than 37 or hemoglobin below 12 (non-pregnant standards), treat her for anemia with nutritional recommendations, herbal tinctures or teas, and supplements. If she is breastfeeding her baby, she should continue with her pregnancy diet plus 200 extra calories (preferably from a protein source).
MoonDragon's Nutrition Information Index - Nutrition guidelines and recommendations, diets, food analysis, supplements, recipes, and other helpful information for pregnant and lactating women.
10. Adjustment to parenting.This is a broad category of evaluation, but a few well-chosen questions will reveal any disturbing trends. Ask the mother how well she has been sleeping, how she and her partner are getting along, and how she is coping with the frustrations of mothering. It's wise to have the mother's partner present as you discuss these important issues, unless there is a reason to believe that the mother needs privacy to express herself candidly.
POSTPARTUM CARE INFORMATION
Postpartum Care: Index
Postpartum Care: Weight
Postpartum Care: Diet
Postpartum Care: Bowel Movements & Urination
Postpartum Care: Bathing
Postpartum Care: Breasts & Breastfeeding
Postpartum Care: Perineal Care
Postpartum Care: Vaginal Bleeding (Lochia) & Menstruation
Postpartum Care: Exercise & Back Care
Postpartum Care: Sexual Intercourse
Postpartum Care: Contraception
POSTPARTUM VISITS
PostPartum Visit: Day One
PostPartum Visit: Day Three
PostPartum Visit: Day Seven
PostPartum Visit: 4 to 6 Week Visit
POSTPARTUM CONCERNS
Baby Care & Concerns
Fatigue & Exhaustion
Postpartum Depression (The "Baby Blues")
NOTIFY YOUR MIDWIFE OR HEALTH CARE PROVIDER IF...
You or your family member has questions about postpartum care.
You or a family member develops any unexpected and/or unusual symptoms.
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