The postpartum period is a massive change in the body. Women ask about pregnancy and childbirth, but there is silence when it comes to the postpartum period

Would you agree with me that the postpartum period is one of the more neglected female topics?

Definitely, yes. Very little is said about it both in the public space and in the gynaecologist’s office. I, for one, have never received a question from a patient about the postpartum period, and I’ve been in practice for almost 10 years now. Women ask about the course of pregnancy, about childbirth, and the postpartum period gets lost somewhere in all this.

Then they get to the hospital, the eagerly awaited little person comes into the world and all the attention focuses on them. And yet the postpartum period begins as soon as the baby is born and lasts six weeks.

What happens in a woman’s body during that time?

Any changes that occurred in it during pregnancy are reversed. The amount of circulating blood is reduced by 1-2 litres. There is a sharp decline in pregnancy hormones, including progesterone, oestrogen, and placental lactogen.

The uterus, which weighed a kilogram at birth, shrinks down to 70-100 grams, which means that it has to get smaller gradually. The most intense time of shrinking is a few days after delivery. The uterus also cleanses itself of the remains of the fetal membranes, ruptured and dead vessels, and the remains of the placenta, hence the lochia. In the first week they are more bloody and quite profuse, but they shouldn’t resemble a haemorrhage.

The wounds after an incision or rupture of the perineum or a caesarean section wound heal gradually. Pain in the lower abdomen is, unfortunately, something that is quite normal. That’s when we take painkillers, such as paracetamol or ibuprofen. Here I would caution: never take NO-SPA because it has a diastolic effect.

During the first few days of the postpartum period, usually between the third and sixth day, it is also normal for breasts to become engorged, that is to be overfull with milk. The breasts become swollen, hard, and very painful.

This was one of the more difficult experiences for me after Marysia was born. I advise all ladies to stay in contact with a Certified Lactation Consultant (CDL). There is a website with the names of all of those who are properly certified.

What helped you then?

Putting the baby to the breast as often as possible to empty it naturally. Additionally, I pumped my breast milk with a breast pump. Not all of it, just until I felt relieved. I warmed my breasts before feeding, which caused the blood vessels to dilate and made it easier for the milk to flow out. After feeding I would apply a cool compress to my breast. In addition, I lubricated the damaged nipples with a healing agent.

A cool compress of cabbage leaves, like our grandmothers and mothers?

Sure. Keep the cabbage in the fridge, it is good to cut the leaves to release the juice. If the engorgement persists, and a fever is present, it is necessary to contact a doctor, because inflammation in the breasts may have started and an antibiotic should be used.

Breastfeeding accelerates shrinking of the uterus and wound healing?

Yes. As the milk flows out, oxytocin is released, which helps the uterus and blood vessels shrink. Therefore, at the very beginning, during breastfeeding, a woman’s lower abdomen often hurts and more lochia appears. This is also physiology.

In online forums, women complain of heavy sweating and frequent urination.

Sweating has to do with hormonal changes and getting water that accumulated during pregnancy out of the body. You may even experience cold and night sweats. If accompanied by severe fatigue or weakness, consult a doctor.

Urinary incontinence results from a weakening of the pelvic floor muscles. Usually by the end of pregnancy they are already very stretched and therefore weakened. Urinary incontinence is more common after natural childbirth.

It also increases with subsequent pregnancies or the birth of a baby over 4 kg. If we have a perineal incision, the pelvic floor muscles may have been damaged. The incontinence should go away after about three months.

Many women say that healing the perineum after an incision is a horror story. In Poland, the incision is still performed too often, as if routinely.

It definitely is an overused procedure. In Europe, a perineal incision is performed in almost 10% of those giving birth, in Poland in 60%, and among women giving birth for the first time in almost 80%.

There is still a misconception that an incision is a form of perineal protection and is better than a natural, uncontrolled rupture because the wound has even edges and is easier to suture. I was taught this myself during my specialisation, just six years ago. Fortunately, more and more doctors are using the WHO recommendations, which say that we make a perineal incision only if absolutely necessary. This should never be a routine procedure.

I myself had a perineal incision, I really didn’t want it, but there were medical indications. After that, I had to take painkillers for two weeks. And still, every time I got out of bed, every time I took Marysia in my arms I felt pain.

How can you help yourself?

It is very important to take care of hygiene. Wear mesh panties and replace cotton panty-liners as often as possible. You should also wash yourself with water and household soap as often as possible and dry yourself thoroughly with a towel.

What do you mean by ‘as often as possible’?

Two or three times a day and definitely after every bowel movement. After that, it’s best to spread an underpad on the bed and lie down without panties.

It is important to air the perineum as often as possible. It’s all about constant air access to the wound. At night, it’s a good idea to sleep on an underpad. When breastfeeding, don’t wear a panty‑liner but tuck it under your bottom.

A caesarean section wound should be taken care of in the same way as an incised perineum. We should also air it as often as possible, wash with water and household soap. It is best not to put any plasters on it. Also, do not walk around in leg warmers, tight trousers, or leggings.

We’ve talked a little bit about this already, but let’s get into specifics – what symptoms should concern us?

If you have severe abdominal pain, do not pass stool or gas, have heavy bleeding with clots, foul-smelling discharge, swollen breasts with hard lumps, purulent discharge from the wound after a caesarean section, high fever, then you urgently need to see a doctor.

Are the baby blues normal?

Yes, they occur a few days after giving birth and may last up to two or three weeks. As many as 80% of women complain of low mood, tearfulness, irritability, sleep problems and even short-term panic attacks. This is due to sudden hormonal changes and a new life situation. The woman becomes accustomed to the child, often only now realising her responsibility, the fact that her life has irrevocably changed. And if she had a sugar-coated idea of motherhood, the clash with reality may be more difficult.

This is not helped by the Instagram accounts of many celebrities, on which the woman is in great shape almost immediately after giving birth and almost immediately returns to full activity.

That’s true. We see girls a few days after giving birth in full make-up, smiling, well-groomed. Most women don’t look like that then. Fortunately, there are also accounts without sugar-coating, such as the one of Zosia Zborowska, who did not hide the fact that she endured a difficult postpartum period and showed herself with dark circles under her eyes and no make-up.

A few days after Marysia’s birth, you wrote openly on Facebook about how you felt mentally, that ‘motherhood doesn’t just consist of smiles, little feet, a fragrant butt and a gushing happy mum’.

I was going through a really big crisis at the time. It was hard for me to breastfeed because my breasts were swollen, my nipples were sore and every time I latched her on to my breast, it hurt terribly. It was even hard to find a comfortable position because my butt hurt no matter how I sat down. I also found it difficult to separate the joy of having a baby from the pain, to isolate it. There was the stress of whether or not I was doing something right. The big discomfort for me was the discharge and the sanitary pads. Before, I always used tampons or a cup during my period.

Oh, and the emotional dysregulation was difficult. Waves of love mingled with feelings of immense powerlessness. And there may be times when the child stirs up anger or even resentment. Difficult emotions are natural in the postpartum period, it’s just a question of how we deal with them. If we can recognise them, tame them, and think about why they occur, they are not a bad thing.

But if we happen to vent our anger and helplessness by yelling at the child, beating them or leaving them unattended, it is essential to talk to a psychologist or psychiatrist about it.

As many as one in five women struggle with postpartum depression. And unfortunately, many don’t get help from a psychiatrist. It’s a bit of a taboo subject. Can the baby blues shift imperceptibly into depression?

They can. If the symptoms of the baby blues persist beyond three weeks or become stronger and more frequent, if you constantly feel that caring for your baby is beyond you, you need help. You can’t handle it alone any more.

On your Facebook page, one woman wrote in a comment that ‘love for a child does not always come at first sight’. This can be very difficult for a woman because many of us think that loving a child is instinctive.

We imagine that we will be flooded with an ocean of love after giving birth, and it doesn’t always appear immediately. And then the woman thinks that maybe something is wrong with her, maybe she is not cut out for it, maybe she should not be a mother at all.

Love for your child really doesn’t have to come with the day of birth.

Rest assured, it will come, it just sometimes takes a while. If this bothers us, it is worth seeking a psychotherapist’s advice, even online.

What surprised you during your postpartum period even though you are a physician?

I have a feeling that everything did. I have experienced pregnancy and childbirth many times before with my patients. I’d read about leaving the hospital and going home with the baby in books, so it wasn’t all new, but...

I had a hard time accepting the physiology of the postpartum period and my reaction to it. I’ve already mentioned how hard the early days of feeding Marysia were for me. I couldn’t get over the immense pain that accompanied this for about two or three weeks.

I knew that Marysia was learning to grasp the nipple and was frustrated too, because she was hungry. But it really is terribly hard when every feeding, every touch of the baby hurts. The lactation consultant advised me to use breast pads, I probably used them twice and didn’t get much relief.

Did you have thoughts like ‘I’ve had enough of this, I’m switching to bottle feeding’?

At the very beginning, when my breasts were becoming engorged. At the time, I even had thoughts in my head that it would be better not to have this milk at all.

I was crying in pain. I would put Marysia to my breast for a few days, and every time I thought I was doing it for the last time, that I couldn’t take it any more.

It was as normal a reaction as possible, because if something hurts us, we want to avoid it. Girls, don’t get caught in the trap of thinking that you are bad mothers because you don’t want to breastfeed your babies.

Women write in forums that social pressure on breastfeeding is enormous, that if someone decides not to breastfeed, she is a bad mother because she deprives her child of the most precious nourishment.

My sister-in-law had her baby at the same time as me. She had much more trouble breastfeeding than I did. She heard a very wise thing from a lactation consultant – that breastfeeding, first of all, should be comfortable for the woman, secondly, it should give a sense of security to the woman and the baby, and only in third place are the nutritional properties of breast milk.

Feeding modified milk, which has poorer nutritional parameters, but with a good attitude, in an atmosphere of tenderness can be better for both the woman and the baby.

A woman should not blame herself for not breastfeeding?

She shouldn’t blame herself, but I think it’s worth asking yourself why I don’t want to breastfeed, it’s worth taking a deep dive into it, going deeper and understanding what’s behind it. We are able to work through a lot of things. If we confront the fear, if we analyse it, most often it disappears.

It is much like childbirth. There is a group of women who at the first visit to the gynaecologist say that they do not want to give birth naturally, but want a c-section. And natural childbirth, whenever possible, is definitely more beneficial for the woman and the baby. I always try to find out why a woman makes such a decision, and sometimes the patient changes her mind after talking to me or a psychotherapist. And sometimes some things just don’t depend on us, we have no influence on them and that’s why in life in general, but especially during pregnancy, childbirth and the postpartum period, I recommend a great distance and openness to what life will bring.

Any natural birth can end in a caesarean section, and natural lactation can end in artificial feeding. This does not define us as bad mothers. It’s okay.

Anyway, back to feeding. I was in terrible pain, and at the same time I really wanted to feed naturally. Each time, I comforted myself that the pain would eventually pass, I just needed to hold out a little longer. And it did. Now feeding is completely painless, I can see how Marysia calms down at the breast.

You wrote on Facebook about your mum’s invaluable support.

During pregnancy, my attitude was that after birth I would manage it all together with my partner. But that changed after the delivery.

I felt that Piotr didn’t quite understand me. Today, looking back, I know it was hard for him, too. It was a huge change for him too, a lot of emotions. He didn’t know how to help me, and was often as helpless as I was. I definitely had high expectations towards him. I wanted him to make the pain stop, and that just wasn’t possible.

I think the most important thing a guy can do at that point is to signal that he’s just there all the time. He can do the shopping, make dinner, give hugs, and be involved. And my mum... I had a strong sense that she had once gone through the same thing I had, that she knew without any explanation how I felt.

Her care was so genuine, motherly... She shopped for me and cooked me delicious dinners. I didn’t have to explain to her what to buy.

I feel like I wouldn’t have made it without her. I would handle the baby, but not making something good to eat after sleepless nights.

What should a woman not do during the postpartum period?

Definitely carry or lift anything over 5 kg, regardless of whether she gave birth naturally or by caesarean section. Be careful with the pram and baby carrier. After a perineal incision you should not get up abruptly; try to do so by lying on your side first. Hold off on physical activity until your first visit with your gynaecologist after six weeks of postpartum. You can’t take baths, just showers. Don’t follow any special diet, this is definitely not the time. Don’t insert tampons into the vagina.

What about sex?

I would approach it on a case by case basis. If a woman has not had her perineum stitched and the discharge has stopped after three weeks, it is safe to begin intercourse. No need to wait until six weeks have passed.

I strongly encourage women to visit a urogynaecological physiotherapist, because sometimes it is necessary to massage the scar after perineal incision or caesarean section. The therapist will assess the condition of your pelvic floor muscles and teach you how to take care of them properly. The hormonal state of a nursing woman weakens the libido. Fatigue, sleepless nights, and exhaustion due to caring for a baby are also not conducive to night-time activities. Here, too, I recommend mutual understanding.

When do we go back to contraception?

When we begin intercourse. While the risk of pregnancy is low during lactation, it is there. Ovulation might also occur before your period returns. We have pills, contraceptive implants, IUDs, there is a lot to choose from.

Can my period come back during nursing?

It can, there is no rule for that. In women who are only breastfeeding, it usually appears with the expansion of the diet – in the fifth or sixth month after childbirth. In those who feed using modified milk, a little earlier – in the second or third month. It may also not appear until after you have finished nursing. Remember that lactation is not a method of contraception because ovulation comes first, before menstruation.

What if your period doesn’t come back after you stop nursing? How long should its absence not concern us?

If it does not return within three months, the woman should see a gynaecologist. And you should remember to have a gynaecological check-up at six to eight weeks after childbirth. It is also important to get a cytology and a breast ultrasound once a year, also while nursing.

If we had painful periods before pregnancy, could it be different afterwards?

Yes, the nature of your periods may change, both the soreness, the abundance, and the duration.

More and more women are having their first child in their 40s. Is the postpartum period harder for them?

Not necessarily. 40-year-old women who are disease-free, slim, and take good care of themselves can go through the postpartum period very well. And 25-year-old girls with obesity, hypertension, and gestational diabetes may have a much harder and longer recovery from childbirth.

Can you prepare for the postpartum period?

Only to a certain extent. For me, the most significant thing was realising beforehand how much was going to change in my life. And that I definitely wouldn’t have a flat belly a few days after giving birth. You also have to give yourself time for tears and frustration that I don’t have time to wash my head, blood is pouring down my legs, my butt hurts or my breasts hurt. It is also very important to believe in yourself, to give yourself permission to make mistakes. You need to give yourself time to recover because your body and head have done a tremendous amount of work related to pregnancy and childbirth.

You need to give yourself love and to be proud of yourself. Enlist the help of loved ones. I also recommend holding on to the thought that nothing lasts forever, the pain from the incision in your perineum will pass, the engorgement will end... and the teething will begin.

 

Anna Parzyńska – gynaecologist, graduate of the Jagiellonian University Medical College, consultant in prenatal tests at Bielański Hospital, on Instagram and Facebook as Doctor Ashtanga. Yogini, mother of three-month-old Marysia

Author: Alina Mrowińska

Illustrated by Marta Frej

The text was published in „Wysokie Obcasy” a magazine of „Gazeta Wyborcza” on 22 January 2022