A 29 years old woman delivered a healthy male baby after giving birth of 3 female babies previously. All family members were very happy and were busy with the baby boy. But the mother developed severe per vaginal bleeding within half an hour after delivery. She suffered from massive postpartum haemorrhage leading to irreversible shock which eventually lead to her death.
This is the 4th stage of labour, most vulnerable time after birth of a baby. Commonest cause of maternal mortality is postpartum haemorrhage in developing countries. The critical time a pregnant women faces death challenges are during delivery, first 2 hours after delivery and 7 days after delivery. More than one fourth (30%) of all maternal deaths across the world occurs during these crucial times, mostly because of unawareness, negligence and delay in initial management.
A delivery has 4 labour stages: starting from true labour pain to full dilatation of mouth of uterus, then complete delivery of baby followed by complete expulsion of placenta and membranes. After that, most important stage comes, the 4th stage — initial 2 hours just after delivery.
Puerperium is the time of 6 weeks after delivery when all maternal tissues which participated physical, physiological and psychological changes during pregnancy gradually returns back to their original pre-pregnant state. So in these critical junctures she needs utmost care, empathy and attention from family members and caregivers who assists her to become a successful mother.
For the purpose of management of these most critical lifesaving issues, we describe it in 3 phases.
First, 24 hours after delivery: To wipe out the unbearable pain and sufferings that she underwent during birth process, she critically needs both physical and mental rest, so better to provide her some pain reliever as well as some warm drinks plus meticulous follow up of her vital signs like pulse, blood pressure, amount of per vaginal bleeding etc.
If she is unable to pass urine because of trauma or difficult delivery, she may be assisted with an indwelling catheter. This will facilitate to see the amount, colour of urine at the same time emptying of bladder helps in contractions of uterus to prevent postpartum bleeding.
So all deliveries are to be conducted in well-equipped hospitals or at least by well-trained birth attendants. Blood and uterus contracting drugs must be available as well as antibiotics to prevent any catastrophe.
Secondly, first week: She must be provided a balanced diet (extra 300 kcal) than pregnancy. After normal delivery if there is no complication she can be discharged after 24 hours and after operative delivery she can be discharged after 3-4 days with adequate counselling so that gradually she can start her daily household activities.
She must be on absolute breast feeding for the baby (no other fluid other than breast milk) for 6 months with advice not to lift heavy weight as most of the village women do to prevent subsequent development of prolapse/descent of genital organs.
Any sort of excess bleeding, foul smelling vaginal discharge, breast tenderness, wound tenderness or discharge, high temperature, any sort of depression must be notified early.
Finally, next 2nd-6th week: look for overall well-being of both mother and baby. Now advise her regarding pelvic floor muscle exercise (KEGEL exercise) and also about family planning with possible contraception.
About 10-15% women might suffer from some depression or postpartum blues. Adequate bondage and homely environment can eliminate this depression so that she does not suffer from postpartum psychosis.
It is the sacred responsibility of a care-giver (doctor/midwife/skilled birth attendant) to counsel a pregnant woman and a women after delivery about the overall well-being.
Responsibility of the husband and family members is to provide her with all necessities to create a woman and baby friendly environment.
The writer is a Gynaecologist and Obstetrician working at Widad University College, Malaysia.