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When the midwife comes back the day after the birth to the home of the new mother, she should begin by appraising the environment for order and cleanliness. If she finds that the laundry or dishes have stacked up, or the cupboards and refrigerator are empty, she should be willing to lend a hand as necessary. The midwife needs to make sure that the mother is well nourished and has been receiving plenty of fluids to drink. It is good to make sure she has a fresh container of water by her bed and a freshly made jug of herbal tea in the refrigerator.
2 Parts Red Raspberry Leaf
1 Part Nettle Leaf
1 Part Alfalfa Leaf
1 Part Peppermint Leaf
Mix dried herbs thoroughly and use a portion to make up a half gallon to a gallon of tea. This blend makes a nice sun tea that can them be refrigerated for a refreshing iced tea to be consumed throughout the day. It provides red raspberry leaf for hormonal balance and uterine toning, Nettle and Alfalfa are high in blood building vitamins and minerals, and the peppermint leaf is good for soothing the digestive system and getting it back to normal as well as giving the tea a nice minty flavor. It tastes fine unsweetened, but if the mom would like a little sweetener, use honey. Honey is high in nutrients and digests easily. A great tea blend for not only pregnancy, but postpartum recovery. It makes a great tea blend for adding recovery tinctures to, if needed, since the flavor of the tea will help "hide" some of the flavors of the tinctures (not all of them taste good). Bulk herbs are available through Mountain Rose Herbs (see banner ads at the bottom of the page or click on the herb above. They have a nice selection of organic bulk herbs for a reasonable price).
If she has not showered yet, help should be given to get her into the shower and have her clean with fresh bed clothes and linens. The midwife should question the mother about how she has been feeling in general and whether or not she has been having any dizzy spells, extreme fatigue or any emotional upsets? How she feels depends on what kind of help she has been receiving from her partner, family and friends. Check to make sure she has a continued support system for the next several days. All too often, after the birth, the family and friends who were so excited about having a chance to attend a homebirth will unintentionally abandon the new mother after the midwives leave. They each think that the other members will be available to the mother, which may not be so.
It is extremely important that the midwife stresses the need for the new mother to take the first week to ten days as a time of total rest and relaxation. The mother is to follow her body's signals for sleep and nourishment just as she did while she was pregnant. She should have no other worries except for the care of her own personal needs and those of the new baby. If there are other children in the family, the partner should take over some or most of the family duties during this time, or arrange to have these duties covered by someone else besides the new mother. The mother's recovery will be faster is she is not overactive or over-stressed. Adrenaline will inhibit the recovery of muscle tone in the uterus and upper vaginal vault and the production of high levels of oxytocin, which is needed for the uterus to return to its normal pre-pregnant size (uterine involution). She will be more comfortable, look and feel her best and able to take on her responsibilities as a new mother sooner if her body is allowed to recover.
The main purpose of the Day-one Visit is to see that the mother is off to a good start. She should be relaxed, happy, comfortable with her baby, and well cared for. The midwife should wash her hands thoroughly before examining the mother, using aseptic technique when handling the baby, and universal precautions when in contact with any bodily secretions.
Things to check include:1. The nipple, for soreness or cracking. - If soreness is just developing, immediately look to the manner in which the mother is breastfeeding. The vast majority of breastfeeding difficulties are caused by improper positioning of the baby at the breast. Be sure the mother is lifting the baby to the breast, that it is not hanging from the nipple and is taking in the areola uniformly. Even though you may have demonstrated this to the mother immediately after the birth, she may have forgotten, or may have received conflicting advice from friends or relatives. Reassure her that she needn't limit how long the baby sucks, but must always remember to check that it is taking the nipple correctly. If the nipples are cracked, suggest she apply a bit of vitamin E oil between nursings. Stress how important it is to continue to breastfeed. Have her begin with the least tender breast, then switch to the sorer side once she has let-down.
2. The uterus, for normal involution. - It should be just below the mother's umbilicus, and should feel firm, not tender. Massage it briefly to expel any clots, and have the woman sit up for a few minutes before checking her flow.
3. The lochia, for color, amount, and odor. - Lochia is postpartum shedding of excess endometrium. On day one, expect lochia rubra, or red-brown flow in amounts like a heavy menstrual period. The odor should be fleshy, like menstrual flow. The woman may need to wear 1 or 2 heavy-super menstrual pads together with a supportive belt, externally, during this time and they should be changed often, as needed. The extra absorbent incontinence pads work better than regular menstrual pads. They are larger and more absorbent with less leakage problems. It is helpful if she has saved her pads from the time of the birth to the time of the midwife's first visit so the midwife may determine how much she has been bleeding. She should NOT be using tampons or any other internal type of padding or menstrual device (there are some that look like a diaphragm). These are very dangerous and could result in a pelvic infection.
4. The perineum, especially if there has been swelling, tearing or suturing. - All swelling should be gone, if not, suggest more ice, but also make certain the mother is rinsing her perineum twice a day with warm water and a bit of soap or Betadine. If swelling has increased and she complains of pain, check for a hematoma.
HEMATOMA
Hematoma is an asymmetrical and painful swelling of the perineal area. It is usually caused by soft tissue trauma in second stage, or by a faulty repair job, whereby hemostasis has not been achieved, i.e., bleeding vessels continue to seep below the skin or mucosal surfaces. Although these hemorrhages almost always cease spontaneously, the blood takes time to reabsorb. Pooled blood readily permits the growth of bacteria, thus the primary danger of hematoma is infection. This can lead to breakdown of the repair, because once sepsis develops, surfaces will not adhere and close properly. Traction on the sutures from swelling is another factor in repairs breaking open or rupturing.
Immediately refer any woman with signs of hematoma to a health care provider; she should begin antibiotics as soon as possible. To reduce swelling, have her alternate hot and cold soaks, which stimulate circulation and encourage reabsorption of the hemorrhage. Also make sure the mother pours warm water with a bit of Betadine over her vaginal area each time she uses the toilet, and remind her to dry and air her perineum thoroughly afterwards. If the repair does break down, plastic surgery may be necessary. The midwife and mother should do their best to prevent this!
Also check the stitches to be sure they've held; the flesh should be pulling together, with wound edges dry and clean. Signs of infection include inflammation, pain and discharge; consult a health care provider if these are noted. If the mother complains of tenderness but the area looks healthy, recommend sitz baths three or four times daily. Fresh ginger simmered in water relieves burning and itching, and stimulates circulation. Even plain hot water speeds healing.
The midwife needs to check to see if she's had any pain with urination. If so, remind her to pour warm water over her vaginal area as she urinates. And check to see if she has had a bowel movement. Often, women are afraid their stitches will come out when bearing down. For comfort's sake, suggest a bit of counter pressure with a folded tissue.
5. The mother's temperature record. - If the mother's temperature is elevated, she may be dehydrated or may have a uterine infection.
UTERINE & PELVIC INFECTION
Symptoms of uterine infection include fever over 101°F, pelvic pain, elevated pulse, and subinvolution of the uterus. Risk factors include PROM, prolonged labor with numerous vaginal exams, manual rotation or other manipulations of the fetus during labor, maternal exhaustion, delayed delivery of the placenta, hemorrhage, uterine exploration (as for manual removal of the placenta or sequestered clots), postpartum dehydration, or improper perineal hygiene.
A prime cause of uterine infection is over-activity and exhaustion in the first few days postpartum. Most women do not resume care for other children and immediately resume normal activity after the birth unless there has been a totally uncomplicated delivery, with none of the precipitating factors cited above. Even then, the mothers should use common sense and take care of themselves completely, if they do feel good and can be up and about. The midwife should warn mothers having easy deliveries that bed rest is necessary postpartum not just to recover from birth, but from the entire pregnancy. Adequate rest permits oxytocin to involute the uterus, tone the vagina, and facilitate breastfeeding, whereas stress and over-activity cause counter-effects of adrenaline to slow recuperation.
Sepsis may not only affect the uterus, but pelvic ligaments, connective tissue, and/or the peritoneal cavity. These become infected only if uterine sepsis is untreated, and cause more severe symptoms of vomiting, chills, and extreme pain. Rarely, the tubes and ovaries may also be affected, usually be a preexisting gonorrhea infection which has flared up again.
6. The mother's pulse. - If it is elevated, see above.
7. The mother's blood pressure. - This is particularly important if it rose during or immediately after labor.
8. The baby's cord stump. - It should look clean around the base, not red or swollen. Be sure that parents are folding diapers back so urine won't irritate it, and are swabbing the cord regularly with alcohol or hydrogen peroxide. If the midwife has used a cord clamp, remove it only if the stump is completely dry. If the midwife has used umbilical tape (cotton-shoestring-like tape), then it is not necessary to remove it.
9. The baby's skin color, inspecting for jaundice. - Depress the flesh on the baby's chest and extremities, checking for yellow undertone. Jaundice is unusual on day one, and should therefore be referred to a pediatrician, Depending on degree, the baby may need a bilirubin count.
MoonDragon's Obgyn Pediatric Information: Neonatal Jaundice
10. The baby's skin consistency, for dehydration. - If the baby's wrists and ankles look cracked and wrinkly, it needs to nurse more often. Also note the temperature of the room -- is it too warm, or is the baby overdressed? Dehydration can also develop in very hot weather. It's more apt to be a problem with postmature or SGA (small for gestational age) babies, as they tend to have very little subcutaneous fat.
11. The baby's elimination pattern. - It should have passed meconium by now, and should be urinating frequently. If it has not had a bowel movement or urinated by 24 hours, consult a pediatrician.
12. The baby's nursing pattern and behavior. - Sleeping (especially after a long labor) is normal for the first day. Lethargy (characterized by drowsiness, apathy, disinterest in nursing, and lack of muscle tone) is of concern. The lethargic baby should be checked by a pediatrician, particularly if the mother's temperature is elevated or if neonatal jaundice is noted.
13. Anything unusual in the Newborn Exam. - Re-evaluate if parents have not yet seen a pediatrician.
Usually the parents are in a state of bliss and happiness at this point. If they look frazzled or unhappy, you must try to find out why. It's quite common for the mother's partner to be totally exhausted, in delayed reaction to the energy demands of labor support and loss of sleep. If this is the case, suggest they send out for dinner, spend time in bed together with the baby, and take the phone off the hook until they feel a bit more stable. Many midwives also suggest a note be posted on the front door, to the effect of,"We had the baby, it's a _____, we're fine but tired, please call in a few days so we can plan to have you over."
The parents may also wish to talk about the birth, particularly if it has been difficult. The midwife will need to make herself fully available for this discussion (although parents typically want basic reassurance at this point more than detailed review).
If anything unusual is noted on day one, visit again on day two to follow up. It is better not to attempt reassessment by phone, as even minor physical concerns can increase the severity of emotional breakdown in this fragile period. Specific indications for prompt reexamination at 48 hours include any problem with perineal repair, elevated maternal pulse or temperature, excessive blood loss, difficulties with breastfeeding, or signs of neonatal jaundice or dehydration. If everything was normal on day one, a follow up call on day two is sufficient.
HELPFUL POSTPARTUM CARE SUPPLIES
MoonDragon's Client Handouts about nutrition and diet for pregnant and breastfeeding mothers are available at the links below. Examples of sample diets and menus are given, including some holistic suggestions. Nutritional analysis for various foods and nutritional therapy information is also available.
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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