Mum’s Health

You’ve just been through a life-changing event.  Here’s how to cope with those first few days.

Your new body

It will take a while for things to get back to normal.  A postnatal body feels very different from a pregnant body.  Knowing what to expect can make things easier.

Lochia

After the baby is born, most women have a discharge called lochia, which is a bit like a period.  It may be heavy at first but gradually get lighter.  You may need to use two maternity-grade sanitary pads for the first few hours, then just one at a time.  The loss is bright red to begin with, then pinkish for a week, then brownish-yellowish-white.  If you pass blood clots of blood bigger than a 50 cent piece, tell your LMC, and save that pad in a plastic bag to show her when she calls.  It may be that not all of the placenta came away after the birth and some pieces were left behind.  Some bleeding may occur for 3-5 weeks following the birth.

Your lochia should not be very smelly.  If it is, discuss with your LMC as you may have an infection.

Afterpains

You may feel ‘afterpains’, like contractions, sometimes very strongly when you begin a breastfeed.  These can be particularly strong after second and subsequent babies.  Your LMC may suggest taking medication to help.  They only last for a few days and are a good sign that your uterus is shrinking back to its usual size.

A stitch in time

Stitches after a cut (episotomy) or tear, can feel quite uncomfortable for the first few days.  Try these tips:

• eat a diet rich in fibre so that passing a motion is easy
• keep the area clean and use soft tissues to pat the area dry
• practise your pelvic floor muscle exercises
• if they sting when you urinate, take a cup of warm water into the toilet with you and pour this over stitches as you go.  Or urinate in the shower or bath just before you get out!
• if you are worried about opening your bowels for the first time (and we all are!) fold a clean sanitary pad in half and hold this on your stitches while you go.

Perineal pain

Even if you haven’t had a tear or a cut, your perineum may feel very bruised and sore.  If you find it uncomfortable to sit down, your LMC can give you a support cushion.  An ice pack – applied for short periods – can also ease the pain.  You will be encouraged to get up and move around as soon as possible, even if you have had a caesarean; being active leads to a quicker recovery.  If your stitches are smelly or seem to be oozing, ask your LMC to check them.  There could be an infection and you might need antibiotics.

Coping after a caesarean

If you’ve had a section, you may find your postnatal recovery is slower than that of other mothers.  No wonder – you’ve had major surgery.  You’ll have:

A cut – it may look enormous at first, but it will gradually shrink along with your abdomen and eventually fade from red to a thin, fine white line.  You may also have a drain in the cut, a catheter in your bladder and a drip in the back of your hand!  All these things will gradually be taken out over the next 24 hours or so, making you freer to enjoy your baby.  If you need to cough or pass wind, it can be very painful.  Hold a pillow or both of your hands over the wound while you do so.

Stitches – depend on the surgeon.  Some are absorbable, others need to be removed.

Pain relief – you may be given injections or it is often given via a pump or through your drip.  Alternatively, you may be given suppositories which are put in your back passage, every few hours.  They are very effective in keeping you pain-free and are not harmful if you’re breastfeeding.  Do tell your midwife or LMC if you’re still in pain – it’s important that you’re comfortable enough to cuddle and feed your baby.

Wind – the surgery will have disturbed your digestive system and you may have wind in the lower bowel.  Eat plenty of fruit and drink plenty of fluids to keep things moving – it will soon fade.  Some women find that peppermint tea also helps.  Avoid fizzy drinks.

Advice on the best way to move, lift and feed your baby – you may need to try various feeding positions until you find one that’s comfortable.  Midwives will help you with this.  Keep your circulation working while you’re in bed by wiggling your toes and circling your ankles.

Most mothers find the first few days quite hard but then things improve quickly.  You may go home after about four or five days.  See if your partner, or a friend can help out in the first few weeks at home.

It can be a hard decision to go back to work after having your baby.  Here are a few helpful ideas to make that decision a wee bit easier.

Find out about flexible working

Parents of children aged 16 and under, or those who have disabled children, can request a flexible working pattern. This can help you balance caring for your child with work. Your employer has a legal duty to consider the request and must reply to you in writing.

Investigate Childcare Options.

Nannies/Daycare/Kindy which is the right choice for you? 

Babysitters/Nannies

A child must not by law be left alone in the care of a person under 14 years of age (this includes a sibling.)

• A personal recommendation for a sitter is usually best and ask for a reference.
• Stay with your baby and minder while they get to know one another.
• Ensure you leave explicit information regarding feeding, changing, sleep and how frequently to check baby.
• Leave your contact phone numbers and emergency numbers.
• Make sure your sitter knows how to get out in case of an emergency.
• Set ground rules regarding use of telephone, computer and having friends round.
• It is helpful if the babysitter has a first aid certificate.

Returning to work

If you were in paid employment prior to having your baby, you will probably have discussed your parental leave entitlements as they relate to your employment contract. See our Paid Parental Leave section for more details.

The childcare decision is never an easy one. Whoever you choose to care for your child, you must feel totally comfortable with your decision.

You will need to remember that many childcare centres and family day care schemes have long waiting lists, and options such as employing a nanny can be very time-consuming. Commonly asked questions regarding childcare include

• What is the staff to child ratio in the centre (how many children does one staff member care for)?
• Will my child be happy and well cared for?
• What sort of interactions will my child have with the carer?
• Will my child resent me not being there for him 24/7?
• Can I call in any time unannounced and will I be made to feel welcome?
• What childcare qualifications/skills does the carer possess?
• What are the health policies for this childcare centre and are they adhered to?
• What facilities and resources are available to help my child develop socially, creatively and developmentally?
• If something goes wrong while he’s in care will I be contacted immediately?
• Will they feed expressed breastmilk?

What about the cost of childcare?

Childcare can be very expensive. Make sure you know what entitlements you may claim.

New Zealand Family Assistance

The Inland Revenue Department website www.ird.govt.nz for Family Assistance provides detailed information about the payments available to you and your family. You can contact family Assistance by the free-call number 0800 227 773 (remember to have your IRD number handy) or www.smartstart.services.govt.nz.

Family Assistance is available as:

• Family Support
• In work payment
• Family Tax Credit
• Parental Tax Credit

Paid parental leave may also be an option for some families.  The amount you receive will depend on your total family income, and its source, and how many dependent children under 18 years of age are living with you. Each family situation is different and you should seek advice from IRD about your particular circumstances.

Childcare and OSCAR (Out of School Care and Recreation) subsidies are available, depending on your income. For information on Childcare Assistance 0800774004, or apply online.

www.workingforfamilies.govt.nz

If you are applying for Family Assistance for the first time you will need to provide the following information:

• Details about the principal child carer
• Your bank account details for payment
• Details of children (names, DOB, IRD numbers)

So how do you make that decision?

• Referrals – whatever childcare you are considering, referrals from friends and co-workers are the first and most reliable method.
• Visits – take your child with you to visit child care providers in your area.
• Spend time watching how the staff interact with the children.
• Enquire about the routines and educational programmes they have in place.

As a parent, you know your child best. Use that knowledge. To select a child care setting that’s right for him, consider your child’s activity level, his need for social interaction, and tolerance to new routines.

• Is your child adaptable, approaching new situations and new people with ease, or is he cautious and hesitant when faced with a new situation?
• Would he be more relaxed in a large group of children providing lots of opportunities for social interaction, or in a smaller group setting which might be less overwhelming?

Sleep

Some children’s sleep-wake patterns adapt easily to a group schedule, while others’ do not. Parents should look for centres that offer:

• individual schedules (vs group routines)
• separate sleeping areas
• appropriate lighting (dim), temperature (comfortable) and noise level (low).

Special Needs

• Are staff members open and enthusiastic about accommodating your child?
• Are staff trained and supported to accommodate children with special needs?
• Is the setting (including playground) accessible to your child?
• Do any books or toys feature children with special needs?
• Are staff willing to help your child develop the skills that your family believe are important?

Legal Entitlement for Breaks

Make sure you know the latest entitlements for rest, food and breastfeeding at work. 

Employers must provide appropriate facilities and breaks for women who want to breastfeed at work. This can be unpaid or paid, depending on the workplace policy.

Employers have to give breastfeeding breaks and appropriate facilities for women who want to breastfeed or express milk for their babies at work or during the working day, where this is reasonable and realistic in the circumstances (taking into consideration the employer’s operational environment and the employer’s resources). The breaks are unpaid and in addition to rest and meal breaks (unless the employee and employer agree otherwise). If employers don’t do this, the Employment Relations Authority could make them comply or give them a penalty.

Providing appropriate facilities for breastfeeding in the workplace

The facilities for breastfeeding should be appropriate. This means different things depending on the industry, workplace and employer’s resources. Appropriate facilities shouldn’t have to be too expensive or complicated. In most cases, a woman just needs a private space with somewhere to sit, and maybe a power point and access to a fridge if she’s expressing milk.

Incontinence

Bladder control

Embarrassingly, 1 in 3 women who have had a baby wet themselves. Women who have one baby are nearly three times more likely to leak urine than women who have not had a baby.

Why does having a baby cause urine leakage?

When the baby moves down through the birth canal (the vagina), the canal is stretched. The nerves, ligaments and pelvic floor muscles that control the bladder opening (urethra), are also stretched.

This can lead to weakened muscles and less structural support around the bladder opening, resulting in less bladder control. The symptoms? Leaking urine with coughing, sneezing, lifting, exercise.

Is this leaking likely to go away by itself?

The leaking is not likely to go away unless you guard against further damage and exercise your pelvic floor muscles to help them to get their strength back. As you get older, your pelvic floor muscles will tend to get weaker.

If you do not get the muscle strength back after each baby you have, you are more likely to leak urine. Following menopause, there is a higher risk of having problems with urine leakage also.

How does my bladder work?

The bladder itself is a hollow, muscular pump. The bladder fills slowly from the kidneys. You should be able to hold on until there is about 300-400ml inside the bladder. The bladder closing muscles are called pelvic floor muscles. When you are ready, the pelvic floor muscles relax and the bladder squeezes the urine out. Then the same cycle begins over again.

What do my pelvic muscles do?

 These muscles do a number of things such as:

• Help to close off the bladder, the vagina and the back passage (the anus).
• Help to hold the bladder, the uterus and bowel in their proper place.

What happens if my pelvic floor muscles are weak after the birth?

• You might leak urine when you cough, sneeze, lift, laugh or exercise.
• You might not be able to control your wind (flatulence)
• You might feel a sense of urgency when you need to empty your bladder or your bowel.

Prolapse

When one or more of your pelvic organs sag down into your vagina, this is called pelvic organ prolapse.  Prolapse is very common and happens to about one in ten New Zealand women. If you have a feeling of ‘something coming down’, you might have a prolapse. See your doctor if you are not sure about this.

How do I exercise my pelvic floor muscles properly?

Position: Sit upright on a chair with your back supported. Relax your abdomen and thighs. Breathe normally – your abdomen should gently rise and fall as you breathe.

Pelvic Floor Muscle contraction: Imagine – ‘squeezing around the vagina entrance and lifting the vagina up inside’ or ‘squeezing around the bladder outlet and lifting the bladder up ’Feel the pelvic floor lift.

At first, the movement that you feel may be very small.

If your muscles are weak, you may feel very little at all. Make sure you keep breathing. If you draw your abdomen in strongly or hold your breath, this will hinder your ability to contract your pelvic floor muscles.  Make sure that you do not have any downward movement of your pelvic floor when you try to do a squeeze and lift.  The lower part of your tummy muscles should gently pull in as you squeeze and lift your pelvic floor muscles.  You might like to use a hand mirror to see your pelvic floor muscles working if you feel comfortable doing this. You will see an inward movement of the perineal body (the area between the vagina opening and the anal opening).

If you have difficulty isolating a pelvic floor muscle contraction, try lying on your side. In this position, it is easier to relax your abdominal muscles and therefore easier to feel your pelvic floor muscles tighten.

Pelvic Floor Muscles exercise programme

Step One: Isolation.

It is important that you are correctly contracting your muscles. (see the steps above on how to exercise your pelvic floor muscles) it does not matter if you cannot hold your muscles for long or if they feel weak. The technique is the most important first step.

Step Two: Strengthen – gentle lifts

Positions: lying down or sitting

Begin by gently lifting and squeezing. See if you can hold for 1-2 seconds then build up to 5-10 seconds. This is a gentle lift, not a ‘hard/strong lift’. Once you can hold for longer, see if you can keep breathing while lifting your pelvic floor muscles.

Step Three: Strengthen – strong lifts

Positions; lying down, sitting, standing leaning forwards, straight back and with hands on a bench or table.

Once you are able to control gentle lifts, aim to lift your muscles more strongly. Focus on a quick and strong lift. You will not be able to hold as long as a gentle lift.

Aim to hold for 2-3 seconds then build up to 5 seconds. This will take time and remember to keep your technique correct. Watch that your abdomen does not ‘suck in’ strongly, however, the more strongly you contract your pelvic floor muscles the more you will feel your abdomen tighten but it should remain flat (not suck in or bulge out).

The following is a suggested guide for exercising your pelvic floor muscles.

Lift and hold strongly: 1-5 seconds

Let go completely and rest: 2-5-seconds

Repeat: 8-12 times

Do this routine 3 times per day, daily for up to 5-6 months or until you have reached your goal which could take more or less time.

Step Four: Maintenance

To maintain the good strength and function of your pelvic floor muscles, keep exercising them often by following the above routine 3 times per week aiming for strong lifts.

Throughout the day, think of doing gentle sustained lifts when you are feeding your baby, driving your car or when exercising. Balance type exercise is good for this. For example, sitting on an exercise ball or standing on one leg. Aim to feel your pelvic floor muscles automatically tighten as you keep your balance.

It is also recognised that general exercise is good for improving pelvic floor muscle function. Walking swimming or doing low impact exercise at the gym are beneficial.

Aim to control your weight to a level that suits your height and build. Being overweight can lead to decreased control over your bladder and/or bowel and may also weaken your pelvic floor muscles.

Step Five: Functional

This means to use your pelvic floor muscles during activities of each day especially those activities which may cause urine leakage.

For example:  Lift strongly before you cough, sneeze, laugh or lift your child. This is sometimes called ‘the knack’.

Relationships

Your perception of a continence problem may affect your personal and/or intimate relationships and how you feel about yourself. Pelvic floor muscles play an important role in bladder and bowel control and also affect sexual function and sensation. If resuming sexual activity is concerning you, talk about it to someone who is knowledgeable and sensitive to this aspect e.g., your GP or midwife. Unfortunately, this issue is frequently overlooked or considered unimportant.

How can I be sure that I have good bladder habits?

It is normal to:

• Go to the toilet about 6-8 times each day. Try not to go “just in case”.

• You should pass about 300-400ml each time you go to the toilet.

• It is OK to get up once each night to pass urine. Try not to go just because you have to get up to the baby.

Try to:

• Drink at least two litres of fluid each day, which is 6-8 cups at 250mls per cup. If you are breastfeeding you may need a few more cups per day. You should have mostly water in your total daily fluid intake. Eg. 4-6 cups of water and 2-4 other drinks.
• Avoid too much caffeine or carbonated drinks, limit to 2-3 cups per day. That is coffee, tea, coke, other fizzy drinks. Try a herbal or fruit infusion tea.

You should ask for help if you notice any of the following:

• Any leaking of urine that is not improving
• Needing to go urgently to the toilet. Sometimes you may not be able to hold on and leak before you reach the toilet.
• Burning or stinging as you pass urine.
• Having to strain to start the flow of urine.
• Blood in the urine.

Can constipation cause urine leakage?

Yes! Excessive straining to pass a bowel motion can weaken and damage the pelvic floor muscles and supporting ligaments of your pelvic organs. This includes the bladder and bladder outlet. With strong straining, the bladder is also forced downwards leading to an increased risk of urine leakage problems. Constipation can also give the sensation of needing to go frequently or urgently to pass urine. In severe constipation, the bladder outlet can get obstructed causing difficulty in passing urine. The urine flow may be ‘stop/start’, ‘slow and trickly’ or ‘hard to start’.

How can I avoid constipation?

• Drink plenty of fluid (at least 2 litres per day) especially if you are breastfeeding.
• Eat high fibre bread and breakfast cereals.
• Eat fruit, three pieces each day. Include kiwifruit.
• Use a natural fibre supplement – Eg. Metamucil, Benefiber or Phloe. You can get these from the supermarket or pharmacy. Psyllium husks are much cheaper (get these from a health food shop).
• Vegetables and lentils or pulses are all high in fibre.
• Sit correctly on the toilet to pass a bowel motion. Follow the instructions below:
• When you sit on the toilet, raise your heels or put your feet on a low stool.
• Keep your back straight as you lean forward slightly.
• Relax your pelvic floor, and gently bulge your tummy. It feels like the beginning of when you bear down. You will feel the sides of your tummy bulge and the lower part of your tummy will bulge forwards slightly. (If you overstrain, you will feel your pelvis and back move backwards. That is – round your back. This is incorrect.)
• Do not rush. Work with the natural urge to pass a motion. If you try and push and strain too much, this hinders effective and complete emptying.
• When you have finished, tighten your pelvic floor muscles a few times while still sitting on the toilet.

Special notes:

• Always use this sitting position. This is not just for when you have had a baby.
• Normal frequency to pass a bowel motion is 3 times per day to once every three days and your bowel motion should be soft but formed like a sausage, not too hard and not too soft!
• If you have some swelling and/or stitches in your pelvic floor area after having your baby, you may need to support your perineum while passing a bowel motion. With some toilet paper around your hand, place it over the area between the vagina opening and back passage as you pass a bowel motion.
• If you having problems passing a bowel motion or with faecal leakage or uncontrolled wind (flatulence), let your GP or midwife know. They can advise you on what to do or refer you to a health professional.

 CHECKLIST TO KEEP YOUR PELVIC FLOOR IN CHECK

1.  Maintain good bladder and bowel habits.
2.  Learn how to exercise your pelvic floor muscles correctly and aim to strengthen them. When they are stronger, lift your pelvic floor muscles before you lift, cough, sneeze etc
3.  Start some general low-impact exercise like walking. As time and energy allow try some other types of exercise.
4.  Aim for a healthy body weight. It is normal to have put on weight after having a baby but don’t allow it to ‘hang around’ set goals of healthy eating and exercising to reach your ideal weight.
5.  Avoid heavy lifting, straining and high-impact exercise.
6.  Avoid prolonged periods standing or being upright especially in the early weeks and months post-partum.
7. Have some rest periods for yourself and for your pelvic floor.

If you have trouble with your bladder or bowel do not despair! The chances for a cure for an incontinence problem are good if you seek the right advice. Enjoy your pregnancy and your baby. Both before and after your baby is born, remember that it is important to take care of yourself.

 Need Help?

For information on managing incontinence:

• This might be your GP, your specialist or your midwife.
• Speak with the healthcare professional who is helping you after the birth of your baby
• Many local hospitals have continence advisors. Please phone the Bladder Help Line for a contact list or view at www.continence.org.nz

They can also provide you with the name of the physiotherapist nearest to you who has a special interest in helping women with pelvic floor problems.

Discuss continence with your health professional. You should ask each of your health professionals how any aspect of care during your pregnancy, delivery or post-natal period could affect your bladder or bowel control (e.g. epidural, induction, repair of episiotomy or tears). Consider this information when making any decisions regarding your pregnancy, delivery and after-care.