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Postnatal Pain

The puerperium

The puerperium is a name given to the period following delivery. Conventionally, the puerperium lasts six weeks but this figure is really only for convenience and is not marked by any particular milestone. The puerperal period is a continuum with changes taking place, both physically and emotionally, following the period of pregnancy and eventual delivery.

 

For the majority of women, this period passes relatively smoothly, with realization of their hopes and adjustments to motherhood more or less as they had expected. For a very significant minority, things do not go according to expectations. Problems can range from the relatively minor to quite serious and complex ones, as we shall see below.

Pain after delivery

 

For those women who achieve a successful vaginal delivery, be it spontaneous or with some instrumental assistance, an episiotomy may be applied to ease delivery. This is repaired immediately but, for the first day or two, the area may be quite sore.

 

Alternatively, in the course of delivery there could be a tear (which is also repaired immediately after delivery) and/or bruising in the vaginal and vulval areas. These could produce soreness, which tend to make sitting and walking uncomfortable. The healing is quite rapid and usually the pain continually subsides and is gone within about three or four days.

 

Other sources of pain post-delivery

Hematoma (blood-clot) formation within the vaginal wall is another significant source of perineal or vaginal pain occurring shortly after delivery. The pain is usually progressive, starting only a few hours after delivery. If it remains undiagnosed for a lengthy period of time, it may lead to urine retention. Examination will readily reveal the swelling, usually in the vaginal canal.

 

If the injury leading to the hematoma formation is high in the genital tract, the hematoma may form in the pelvic cavity and an ultrasound is the readily available means of establishing the diagnosis.

 

Hematoma after delivery

Trauma of delivery can cause rupture of blood vessels underneath the vaginal skin. The bleeding is concealed under the skin. Consequently, there is no surface evidence of the damage and that's why it may remain undetected for hours, even days.

 

Alternatively, a haematoma may result from an inappropriately repaired episiotomy or tear. Laceration to the cervix may also lead to a pelvic haematoma.       

 

Treatment for a vaginal hematoma

The clot has to be accessed and drained. The bleeding vessels are then secured with absorbable stitches. This is followed by instant and almost total relief of the pain.

 

Postpartum hematoma forming in the pelvis

Sometimes the hematoma is in the pelvic cavity. If this is not progressive, which is usually the case; the preferred approach is conservative management.

 

Pain associated with a pelvic hematoma is usually adequately managed using ordinary pain-control medication such as codeine and acetaminophen (paracetamol) or a combination of these. The hematoma will clear up with time. The only risk, albeit small, is that it could get infected, where a change of plan becomes necessary. We discuss this in the section on postpatum infection.

 

Progressive pelvic hematoma

If the hematoma appears to be getting bigger, with evidence from serial - usually daily - ultrasound scans and/or falling blood count (hemoglobin), then there is no choice but to perform an operation to stop this. A laparotomy (where the abdomen is opened) will be performed and the clot evacuated. An option of doing this laparoscopically can be considered if the appropriate expertise is available. The bleeding points are sought and secured. This is a fairly major operation, especially if done through the open (laparotomy) route. That will therefore prolong the new mother's hospital stay for probably four to seven days.  

Secondary Postpartum Hemorrhage (PPH): Next Page