Motherhood: The things they don't tell you

BY: Nation.co.ke

When she took to social media three weeks ago, former Citizen Television news anchor Janet Mbugua opened a Pandora’s Box that the society would rather mask.

Her seven-minute video, aptly titled Some of the Things They Don’t Tell You About Childbirth, was an instant Facebook hit. In the video, Janet talks about her experience with lochia, the vaginal discharge after giving birth — known in medical circles as puerperium — which contains blood, mucus, and uterine tissue. Many may cringe at this but it is an expected discharge which typically continues for four to six weeks after childbirth, the postpartum period.

While expected, it came as a surprise to Janet as she experienced it one month after delivery. No one had prepared her for it.

“No one really tells you how much you will need them post-birth. I learned the hard way! Ever heard of lochia? I experienced it in a salon,” she shared on her Instagram page accompanied by a photo of her holding an adult diaper.

And with that, Janet opened a box of pent up emotions by mothers who would have otherwise never spoken about how their bodies responded after delivery. Women — and, interestingly, men — opened up about childbirth, motherhood, parenting, and the groping in the dark that comes with it.

“I completely relate to this... as labour intensified so was the throwing up. I panicked! And on the delivery table I guess the poo and the baby came out together. That almost killed me. And, yes, the experience was scary, but I love him more,” wrote one mother in the comments section.

Then the conversation went beyond the delivery room to breastfeeding and how, unlike how movies and books present it, it is not an easy task.

Bleeding and discharge 

The world is not short of information on childbirth, delivery, and post-delivery, spurred by queries by women (and men) on motherhood and childbirth — the best time to have children, who should deliver one’s baby, how early in one’s pregnancy one should pack a bag for the hospital, what if one poops while one is pushing, or even how one will know when to go to the hospital.

So, in a nutshell, do you want to know what is a doula, and if you should get one? Do not worry. Go online!

Like everything else that Google has made easy, the search engine hosts countless links to sites that will help you before the baby comes, and immediately afterwards. It is all there, but even then, women still realise there is a huge difference between reading about something, and experiencing it.

In addition to online advice, expectant mothers get answers from their gynaecologists, mothers, aunts, sisters, cousins, and the well-intentioned-but-meddling-mother-in-law. But new mothers, when presented with the reality of motherhood for the first time, feel short of information on what the next chapter of their lives will look like.

One of the common things women go through after childbirth is bleeding and discharge. According to the online resource Baby Center, it is normal for a woman to bleed after delivery for a few days.

“You will seem to have a very heavy period because the amount of blood in your body rises by about 50 per cent during pregnancy to prepare your body for this normal blood loss,” explains the site.

Dr Nelly Bosire, a specialist obstetrician/gynaecologist, explains that when the placenta separates from the uterus, there are open blood vessels in the area where it was attached, which bleed into the uterus.

“After the placenta is delivered, the uterus continues to contract, closing off those blood vessels and in turn dramatically reducing the bleeding. If the mother had a tear during birth, she may bleed from that site as well until it is stitched up.”

Occasionally, the uterus doesn’t contract well after delivery, resulting in excessive blood loss, called a postpartum haemorrhage. But bleeding is different from discharge, which is also common after birth. Lochia is Greek word meaning relating to childbirth, and the vaginal discharge consists of blood, tissue shed from the lining of the uterus, and bacteria.

For the first few days after birth, lochia contains a fair amount of blood, so it will be bright red and look like a heavy period, explains Dr Bosire.

“You should have a little less discharge each day, lightening in colour. The lochia will taper off before it stops in another two to four weeks,” she says, adding that mothers can use heavy-duty sanitary pads to manage the condition.

However, a small number of women can continue having intermittent spotting for a few more weeks. If the discharge persists, one should seek a doctor’s advice.

At the same time, the hormones generated to sustain the pregnancy begin to reduce, and this comes with mood swings and loss of hair, among others.

But even then, it is not surprising to hear new mothers ask: “Why didn’t anyone tell me?”

What actually happens with Dr Nelly Bosire

Pregnancy is a state of massive hormonal changes to accommodate the miracle inside the mother, childbirth and post-partum period. The hormonal impacts are profound and varied and could affect a mother’s self-esteem. Here, the more recognisable effects:

Face: Some women may have acne and oily skin. Most get the mask of pregnancy, which is a hormone-mediated darkening of the skin. especially on the facial prominences. The nose may look bulkier and the lips fuller.

Breasts: These remarkably enlarge and are sensitive, especially in the first trimester, because of the increased capacity to produce milk.

Abdomen: The darkening on the face is also obvious along the midline of the stomach, known as linea nigra. Stretch marks also set in in some women towards term. Transit of food through the digestive tract is also slowed and may result in constipation and bloating.

Psychological: Some women are pretty sensitive to hormonal influence on their mood. Some become overly sensitive or emotional while others may have the opposite response. However, lack of a good social support system may predispose a woman to psychological challenges that may not be healthy. This impacts on the post-natal state.

Hair: Most women will have a burst of hair growth with thickness and body during pregnancy. At delivery, the hormones drop and the hair may break, sometimes more obviously than in others.

Hip joints: Hormones markedly relax joint ligaments, leading to joint laxity. This explains the waddling gait pregnant moms will acquire towards term

Legs and feet: Poor blood return to the heart from the lower limbs predisposes the mother to swelling of feet and legs, especially after long periods of standing or sitting

Lochia: Post-natal vaginal bleeding that occurs from the time of delivery, lasting two to three weeks. It is really the shedding off of the inner lining of the uterus that was responsible for supporting the placenta. It is markedly thickened in pregnancy and at delivery must reduce down to normal thickness of a non-pregnant uterus. The blood loss continuously reduces in amount and is expected to have ended in about two weeks.

Lactation and breastfeeding: Initiation of milk letdown and ability to breastfeed the baby. This should never be assumed to be automatic. Mums need to be supported as they initiate breastfeeding and we have lactation specialists for this. This will help prevent cracking of nipples, breast engorgement, mastitis and breast abscesses. It also promotes mum and baby bonding and instills confidence in the mum on her ability to do a good job at mothering.

Uterine involution: A normal uterus measures about 7x5x3cm with a total weight of 70-80g. At term, it has grown to almost 1,000g. This happens by increase in the number of smooth muscle strands in the middle layer of the uterus, which supports the process of labour. After delivery, the uterus reduces to the level of the umbilicus. In the subsequent days, it continuously reduces back to near pre-pregnancy size. This process involves some of the excess muscles dying off to lose the bulk. This is the process of involution that is checked daily in the wards and in the subsequent clinics. Delay in involution may signal infection.

Episiotomy: This is a cut made in the perineum (the firm spongy muscle area between the vagina and anus) to create more room for the baby to come out during delivery without overstretching or tearing this muscle. It is repaired immediately after and heals well. It may get infected if not properly cared for after mum goes home.

Post-partum blues: This is a mood disorder that women may experience after delivery that is inappropriate. It has been shown to be hormonally linked. Mild cases are often missed but in extreme forms, the mum may present with complete psychotic episodes referred to as post-partum psychosis. The condition requires quick recognition and treatment to enable the mother to live a full life and care for her baby. Psychiatrists are involved in patient care.

Post-partum sepsis: An infection in the mother that follows delivery, it commonly involves the reproductive tract but may spread to cause severe septicemia and organ damage that threatens life. May result from unsanitary delivery conditions, early breaking of waters in the labour process without preventive measures thus allowing bacteria to ascend into the uterus and cause infection, severe immunosuppression, retention of products of conception (placenta bits or pieces of membranes) in the womb after delivery, and unsanitary Caesarian section or poor wound and episiotomy care after delivery. It is a high ranking (number 2) cause of maternal mortality and is taken very seriously to avert death.

What to expect 

There are a lot of changes that a woman’s body goes through during pregnancy. What are some of the immediate changes that her body experiences 24 hours after birth, and in a week?

At delivery, the most immediate noticeable change is the removal of the load off the abdomen. The pregnant uterus carries five to six kilogrammes — 3.5-4kg of baby, 0.5kg of placenta, 1kg of amniotic fluid and 1kg of uterus — by the time of delivery. Delivery of the baby takes that down to just about 1kg. This provides relief to the spine that has been straining to maintain balance.

Right after delivery, there is an adrenaline-mediated shivering. This is immediate even before she leaves the delivery bed. This is the reason immediately after she has been settled in bed, she is offered a hot drink, mostly drinking chocolate or tea, to counter the shivering.

There is also immediate redistribution of blood in the mother’s system. She’s been pumping 600-700ml of blood to the uterus to meet the demands of the baby; with the sudden removal of placenta, this volume is redirected to other organs. Normal blood loss at birth is to also reduce maternal volume to manageable amounts. Normal volume should be approximately 500mls. The mother will notice reduced awareness of heartbeat (palpitations) which she has been experiencing with pregnancy, especially at term as her heart has been struggling to cater for them both.

The bladder is suddenly relieved! It’s been squashed down so much with no space to expand much, hence fills up fast. Suddenly there is room to hold a lot more urine. This may lead the new mother to forget to go to the toilet often enough. She needs to be reminded so as to prevent complications.

The breasts fill up and start lactating. A few women will notice milk in the days just prior to delivery, but for most, it happens after, some right off the delivery table. The baby suckles and stimulates further fill-up and if not attended to, can lead to breast engorgement.

Pregnancy cravings disappear real fast, those who have been spitting finally get respite, and now the new mum finally feels cold! The high metabolism of pregnancy that made her feel hot all the time drops and she asks for an extra blanket.

Of these changes, what is normal, and what isn’t?

All the above changes are considered normal, but abnormalities occur when they deviate. For instance, breast engorgement is fairly common but must not be allowed to persist. If the baby is not able to empty the breast, the extra must be expressed out. If this is not done, it can lead to infection (mastitis) and even breast abscess.

Lochia loss must also be within normal limits. Blood loss mimics periods. Therefore, excessive blood loss is definitely not normal. Most critical is the first six hours after delivery. The mother must also empty her bladder hourly to prevent a full bladder, which can cause post-partum haemorrhage. At this time, there is close monitoring by the midwives to ensure the blood loss is acceptable. As days go by and the flow reduces, any sudden resurgence of heavy flow is not a good sign. It may herald delayed post-partum haemorrhage which may result from uterine infection.

Any convulsions and or loss of consciousness in a woman who is within 42 days of delivery are deemed post-partum eclampsia until proven otherwise. The care should be provided by a gynaecologist as the primary caregiver and other specialists brought on board as needed. The post-natal visits look out for blood pressure to ensure it is normal, and hence are very critical.

Do antenatal clinics offer expectant women information on what to expect after delivery? What are some of them? Is it standardised information to be shared by all healthcare providers?

Ante-natal clinics are a great location for patient education, more so in a hospital setup. As the mothers wait to see the doctor, they are educated on pregnancy, danger signs to look out for, nutrition for themselves and the newborn, vaccinations, prevention of mother-to-child transmission of HIV, preparing a birth plan, and the importance of mother and baby clinics after delivery. The current government booklet for antenatal care summarises this information very well.

Sometimes women may experience post-partum depression and others pre-eclampsia, what are some of the red flags to note?

A post-partum mum is cared for by the gynaecologist as the primary caregiver until after 42 days. So any complications arising are to be directed to post-natal clinics or acute emergency care departments for maternity. The post-partum mother is treated just like the pregnant one for these emergencies.

Samoina Wangui, 28, Self-employed mother

In 2012 I had a normal delivery and after two days I went home with my baby boy. I was single and jobless in my pregnancy, and because I knew babies were expensive, this fueled my fear of labour. Now I know I was depressed during pregnancy and post-delivery only made it worse. Breastfeeding was a shocker, the pain was unimaginable and I would start crying whenever I thought about doing it because my nipples were cracked and excruciatingly painful.

Although I knew that babies cry a lot when they are young, I did not realise it would be a life of waking up every 15 minutes to deal with diapers and feeding. It was exhausting and slowly I was edging towards post-partum depression.

For four months, we were sleep-deprived, I did not have a memo about childhood. Sleep deprivation turns mothers into monsters. I would ask myself, time and time again: “Why do I hate my baby so much?” When I started having suicidal thoughts and felt so overwhelmed, I decided to Google and find out if there were any mothers who were experiencing or had experienced what I was going through. I was frustrated to open up about what I was going through because in the eyes of the society, mothers are like angels — perfect.

So I could not imagine going on social media to share my experiences because you only share the nice things about motherhood. Facebook is a just a façade that many mothers try to keep up with. But I would not also tell my parents, who had taken me in with the baby, that I did not want my son. It is considered abnormal to reject your own baby.

Eventually, the symptoms eased in 2013 and, in 2015, after seeking help, I learnt that post-partum depression does not have an exact cause but might be contributed to by a drop in hormones, which brings about anger, irritability, and suicidal thoughts. As a result of this knowledge, I began a blog about the experiences women go through in motherhood. If I, a university graduate, did not know about post-partum depression, what about women in rural areas?

Today, when I look at pictures taken when my baby was young, I cry because I do not have memories of my baby’s infancy. I just can’t remember how I was feeling because it was a robotic period. Motherhood goes beyond pink ribbons and blue socks and Spiderman t-shirts. While it is hard, it is also beautiful and they grow up.

Fiona Okadia, 24, University student and founder of Amira Africa

I brought my son into the world through a normal delivery in 2013. The labour was not hard but I was stitched. I knew most of the things regarding taking care of the little being, but I did not realise that beyond the body aches and fatigue, I would have to endure chilling pain.

To heal from the stitched wound, I was required to sit in hot salty water four times a day, which felt like having a thousand ants biting you at once. I was not prepared for the pain and, worse, I had to nurse the baby and change its diapers in the middle of it all.

Breastfeeding was not an easy task. Do not be fooled by those effortless pictures you see of babies latching on their mothers’ tits with the mother smiling. It goes beyond that! No one told me that my nipples would crack as the baby breastfed and the abdominal pains from the uterus contraction would be unimaginable. My son then developed colic for three months, which added to my woes of motherhood due to the sleepless nights.

But I learnt that, as a mother, you have to wear your crown.

Credit: Nation.co.ke