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Miscellaneous Postpartum Issues

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Our culture tends to be very undereducated about the importance of sensible postpartum recovery.  Women bounce back much more quickly and easily when they are pampered for the first few weeks.  And new babies are less likely to have colic.

Here's a good book to read BEFORE baby comes, because you'll be too busy afterwards:

The Keys to Postnatal Rejuvenation

How to Avoid Colic, Avoid Postpartum Depression, Experience Deep & Profound Rejuvenation
"Many cultural traditions use the same principles after childbirth, the ones which statistically don't have problems. The language is the same - mothering the mothers with TLC, warmth, oiliness (internal and external), massage, simplicity, moisture, favoring sweet, sour and salty tastes, specific foods, freshly cooked (not raw) soupy foods, herbs, and of course rest - these are keywords to favor. The details even of these considerations are significantly more under guidance (and communication with/advice of your primary care provider is essential with pre-existing medical conditions)."

Dear Mothers: We’re Not Meant to “Bounce Back” [8/19/16] - We’re not meant to “bounce back” after babies. Not physically, not emotionally, and definitely not spiritually. We’re meant to step forward into more awakened, more attuned, and more powerful versions of ourselves. Motherhood is a sacred, beautiful, honorable evolution, not the shameful shift into a lesser-than state of being that our society makes it seem.

It’s Startling How Little We Know About Good Postpartum Care By Elissa Strauss [4/1/16] - Stuebe is working on a new program called The Fourth Trimester Project, which is trying to fill what she sees as a distressingly large gap in postpartum care. [Ed: They might ask home-based midwives who have been providing joint care for mothers and babies after birth.  With a strong emphasis on breastfeeding success, this necessarily focuses on the well-being of the mother as the lynchpin in baby's long-term well-being.

Why Are America’s Postpartum Practices So Rough on New Mothers? - America is hyperfocused on mothers bouncing immediately back after childbirth, yet most other cultures allow for an extended period of pampering and rest.

After the Birth, what a family needs [10/28/08]

9 Reasons You Should Never Have House Guests Right After Having A Baby - the exception is if their sole purpose in coming is to HELP by doing ALL the cooking, cleaning and laundry and are content to hold the baby only when asked.  This is often a one-person gig since more people just increases the amount of work to be done.

 How to REALLY Help Someone After They’ve Had a Baby, According to an OB Nurse [1/16/15]

Announcing the new book and new website, www.newmothercare.com. The website  features a new e-book: New Beginnings for New Moms. Written by Rannie Boes, Ph. D. This book is meant as a tool for new moms to empower themselves during the transition into new motherhood. It provides a powerful self-help home care program for new mothers to start just after childbirth to quickly regain vitality and energy.

The essential elements of good postpartum care

Birth Trauma Revisited - Theresa Warner, DC & Stuart Warner, DC

Promoting Effective Recovery from Labor - The PERL Project team consists of experts in nursing, midwifery, medicine, and bioengineering who care about safe, healthy, and satisfying birth.  We bring a wide range of specialized knowledge about childbirth and urinary incontinence to the project.

California Mandates Longer Hospital Stays
IMPORTANT NOTE - This law empowers consumers to negotiate for in-home care instead of hospital care. The law requires HMOs and health insurers to cover at least a 48-hour hospital stay for a mother and newborn or to provide for a follow-up exam within two days after discharge. Astute consumers can use this law to negotiate for care to be provided in their home. You can arrange for an in-home visit by a Licensed Midwife and a week of household help for less money than it costs for a single day in the hospital. This will allow you to recover in the comfort and safety of your own home, away from antibiotic-resistant germs, surrounded by the people of your choice, while providing access to the health care and practical help you may need.

You can read the law in the California Insurance Code, section 10123.87. [You have to search for section 10123.87 on that page.]

I've found the OptiVite multivitamin/mineral,designed actually for those with PMS to be helpful for women having difficulty with postpartum recovery issues.

Postpartum Fatigue

Many new mothers feel fatigued from sleep deprivation and long hours of work.  If your fatigue seems extreme, it makes sense to have your thyroid levels and iron levels changed, as these can both be affected by pregnancy and birth and are related to fatigue.  If those are fine, you might consider the possibility of food allergies.  Pregnancy can change immune function, which could cause the development of allergies; it's relatively simple to do an elimination diet for a week or so.  (Note that simple is not the same as easy!)  It makes sense to try lactose (milk) and gluten or all wheat products first.  Or, if you really can't handle the elimination diet, you could try making sure to take lactase tablets with all dairy products and general digestive enzymes with all your food.  If the food is broken down better before it gets to your intestines, it's less likely that whole, recognizable proteins will be absorbed and cause food allergies.  (You might also try the test of eating raw or cooked beets and noticing whether your pee turns pink.  If so, you need more hydrochloric acid to digest your food, so get digestive enzymes with HCl.)

Postpartum Surveys/Client Satisfaction

Schedule of Postpartum Followup Care

I do all my pp visits in the home so my moms don't have to drive anywhere after giving birth. I used to do 3 and then they came in for the 6 week visit. Lately my moms seem to have less support/help and two of them got postpartum infections (one was a UTI ). Now I'm doing several more visits, sometimes between 5-8. I just wondered how many pp visits others were doing ?

I do visits at 1 day, 3 day, 5 day, 10 day, 2 wk, 4 wk, and 6wk. The first 4 are home visits and the last 3 are in my office unless they were having problems and need me to come to them instead. For those who don't want all the visits, I am flexible. I also am willing to go over more often if there is any sort of issue.

I go back the day after the birth, then phone within the next 24-48 hours; at one week; and after the Newborn Screening results return (around 3 weeks).  If there are problems/concerns, we do more, but depending on what it is, it may be just by phone.  They have my phone numbers, and I encourage them to call any time if anything seems unusual or worrisome.

Usually I see them again around 6-8 weeks, but in a few cases folks have just not wanted to make the long trek to see me then (I do visit them instead if I'm going to be within a few miles, but even then, some will decline the visit).  Sometimes I wonder too what it is that we need to see them for - bleeding's done, no stitches, don't need Pap or Birth Control, baby fat and happy.  The rest of the stuff I can cover by phone (questions assessing PPD, lifestyle, support, rest, etc).

I do 2 or 3.  One at 12 hours pp, and another once the milk is in and do the PKU/newborn screen, at that time.  Then follow-ups are at 8-12 wk pp in
office.  However, moms are given a list of things to watch and call me regarding, if anything crops up.

I do similar, Maybe a few more in early days. I leave a couple hours after birth, go out for breakfast and quick review with assistants, then go back for quick check. Usually 4 to 6 hours at that point. Then back at roughly 24 and, then on day 3 or 4, then about day 10, and about 3 weeks.
VERY close phone contact -- at least once a day check-in for the first week, and always available by phone or to visit if needed.

First time moms without helpers need more visits. Grand multips may want less. it varies.

BabyMoon / Special Extended Postpartum Care 

In my midwifery training, we were told that women ultimately recover better and more quickly if they rest well in the first few days.  After all, their body is still "laboring" for 10-14 days after the birth, continuing to have contractions to keep the uterus well contracted.  Many people don't realize that after the placenta is delivered, it leaves a placental "wound" that is as large as the placenta, usually the size of a 10-inch dinner plate.  The blood flow to this site before the baby is born is about two cups per minute.  If the uterus isn't able to contract and stay reasonably well contracted, the woman would have significant bleeding from this site.  So when women try to "get back to normal" too soon after the birth, they run the risk of using up the energy that is supposed to be going to keep the uterus well contracted to keep her bleeding to death.  I strongly encourage my clients to respect this miraculous aspect of birth and stay in bed completely until the milk is in, and then to continue resting in bed or in a relaxed environment in a common room until the baby regains the birth weight.

NOTE - I've seen the word "babymoon" co-opted to describe a pre-baby "second honeymoon".  Those are great, too, but they're a completely different concept.  The importance of the post-birth babymoon is for the woman's body to recover physically, which she can't really do before the birth.  :-)

Why Are America’s Postpartum Practices So Rough on New Mothers? [8/15/13] - America is hyperfocused on mothers bouncing immediately back after childbirth, yet most other cultures allow for an extended period of pampering and rest. Hillary Brenhouse on why U.S. moms are missing out.

Motherhood Rooted - Asian and Pacific Islander moms in the US embrace ancient post-birth traditions.

The babymooners - Should you rush back to work after childbirth? Vicky Allan talks to those who prefer to take this post-natal business lying down

Postpartum Cervical Exam Not Necessary

Yes, I was taught in school to always take the ring forceps and sort of pull the cervix down and take a good look to see if there were any lacerations. Do I do it? No way!, Unless there is unexplained bleeding, bright red, and the uterus is nice and firm. Then I will look for a laceration. The cervical lacerations I have seen were all done by residents using forceps, or vacuums incorrectly, or trying to manually dilate a slow cervix. They all bled like crazy and were tough to repair. Checking the cervix seems to really hurt the mom, and I see no reason to do it unless there is a lot of unexplained bleeding.

When I was interning, I learned a really easy way to visualize the cervix, and it didn't seem terribly uncomfortable for the mom.

You use two fingers of your non-dominant hand as though you were doing a vag exam. Slide them in gently, then turn your hand (using the whole arm) until the ulnar surface of your fingers are (is?) holding the anterior vaginal wall up, one finger on each side of the urethra. Your elbow will be pointing toward the ceiling. Two fingers of your other hand are gently pressing down. This opens up the vagina, and you can see all the way to the cervix.

This actually seems more gentle to me than gradually opening up the vagina with a gauze pad in each hand, sort of "walking" your way up. Something I've seen done a lot.

[from ob-gyn-l]

I was trained to evaluate the cervix at every delivery with ring forceps. I stopped doing it 10 years ago after I realized that the only time I sewed a cervical laceration was when there was bleeding.

We are all critically evaluating everything we do, and we are all learning that much of the dogma we learned is just that. However, playing the devil's advocate, this one examination adds no expense (if ring forceps are on your tray), takes 15 to 30 seconds, and doesn't have morbidity that I can figure. It may save a problem very infrequently, and prevent a return to the OR. Thus, my simple logic (believe me, I'm simple) dictates that this is cost effective. What do you think, you learned Ob-Gyn and MBA student?

Well, your point is well taken, however, it is difficult to examine the cervix when a patient is delivering in bed without stirrups as we do almost all of our deliveries. this removes the expense of drapes, etc which does reduce the expense. If you were to do what is called "cost accounting" and computed the cost of autoclaving instruments, packaging, and taking them to central supply etc, you would see that there actually is an expense. Experience has shown in 15 years of practice(in which we've never had a patient back to the OR except for 2 vulvar hematomas-probably secondary to a vessel in spasm at the time of delivery)that cervical examination in the absence of vaginal bleeding is probably not necessary. One could probably argue this re: manual inspection of the endometrium.

Postpartum Shakes and Cramping

My maternity book, dated 1996 says there are 2 theories. One is that "this shivering response is caused by a difference in internal and external body temperatures(higher temp inside the body than n the outside). Another theory is that the women is reacting to fetal cells that have entered the maternal circulation at the placental site."

Many people shake after birth, whether vag. or c/s, drugs or none. It is my impression that it is like riding a bike or running as fast as you can for a long time, then stopping without a cool down. Your legs shake like jello. That is the way the body reacts after contracting for so long, then stopping with the birth of the baby.

When your moms get the shakes for whatever reason, try squeezing the arches of the feet to reduce shaking

If anyone is interested, I have a cal/mag spray that I keep in my birth bag for muscle cramps and shakes. It is an herbal base. You spray it into your client's (or your own) mouth. It has a 90% absorbency and is in your bloodstream in 22 sec. Because it is absorbed through the oral mucosa it completely bypasses the digestive tract. The ingredients (directly off the label): calcium as calcium ascorbate, magnesium as magnesium ascorbate, vitamin c (ascorbic acid), vitamin d as cholecalciferol, cayenne, fennel, marshmallow root, sage, white oak bark, alfalfa, catnip, ginger, gota kola, red clover, rosemary, valerian root, wood betony, and other natural vitamins, minerals and herbs. To me it has a light, fruity taste.

One theory I've come across about postpartum shakiness was that it is caused by an infusion of fetal blood into the maternal system, but I don't know how it was originated.

There was a thread on the perinatal nursing list about pp shakes. The nurses said that they put the mom on O2 and the shakiness usually dissipated immediately.

I read somewhere that the pp shakiness was from adrenaline. That is the way it is dissipated, like shaking after a scare.

I have found that getting the mom to down 2 big glasses of juice or Gatorade immediately after the birth has virtually eliminated postpartum
 shakes in my practice. Just about the only time I see them is when mom won't do it, or we neglect to get that second glass down.

have you tried good ald fashioned rescue remedy - i use it on ladies who get the shakes immediately after birth - seems to have a very good effect. whether its the remedy itself or me boring them to tears explaining what it is i dont know.


I think we see less postpartal bleeding, less after-cramps, and decreased episodes of heavy clotting , with early walking.

I was going to say the same thing about staying in bed! [Grin]

I've never tied a woman to the bed to keep her there, but most seem to be relieved that they don't have to get up if they don't want to. Give's them a "prescription" from their midwife to stay in bed and be taken care of!

It's been years since I've encouraged a mother to get up after birth in less than 3 hours! Before then I would let them get up to go to the bathroom and to shower, but saw way too many fainting episodes (I don't remember anyone jerking or seizing). Now I advise them to hang out in bed for a few hours (I have them urinate in the chux pads or hold it) and I have them drinking and eating before I leave.

Gee.. I let 'em get up as soon as they feel like it -- I like to encourage it within an hour (upright and walking is said to help the uterus get rid of clots, membranes, and any other nasties -- and to promote faster return of bladder function).

we take it slow though and in stages.... sitting in bed for a moment, then at the side of the bed for a few minutes, then standing at the side of the bed for a moment, then walking slowly with one (or two ) of us beside her ... If she gets at all woozy, we go back a stage.

(anecdote warning!) - I think we see less postpartal bleeding, less after-cramps, and decreased episodes of heavy clotting , with early walking. I really like for moms to have an empty bladder, and getting up to the bathroom is the only way some of them will be able to pee.

Haven't had anyone get fainty when we take it slow like this. Never seen one of these seizure things some have described....... Don't know what they could be - - exhaustion maybe? Acidosis? Can't hazard a guess!

Discharge Time or Duration of In-Home Monitoring

See also: Medical Necessity of Care in the Immediate Postpartum for the United States

These are from outside the United States.

In the Netherlands, most of them are discharged these days 2 hours pp. That is after the baby has nursed, they had something to eat/drink and a shower. I like them to have urinated, but I don't make a big deal out of it if they are not bleeding too much. Quite often they cannot pee in the hospital and go first thing in their own bathroom.

The nurse has a checklist on which she ticks things off and gives to the client when she goes home.

The freestanding birth center I worked in in the Philippines was 6 hours. It could be longer, as there was a "checklist" of sorts that needed to be completed before discharge.  This was in one of the top 10 most poverty-stricken areas of the world, so there were hemorrhages, IUGR, anemia, etc., so they were watched for quite a while to make sure all was well.

Bathing After Birth

See also:  Bathing with PROM

As doulas and moms, we are wondering what advice is given to mothers about getting into a tub after birth.  The common advice we are hearing is that a mom should not get into a tub for 6 weeks after the birth.  Is this just a cultural thing?

25 years ago we used to tell women this.  But then midwives having babies were getting into tubs to soak away achy joints, perineums, etc.  So I changed and started telling women they can take baths any time they want to.

It was common advice in the US until the late 60s and then abandoned (in most regions) when research showed there was no risk of infection from bathing --and that water doesn't even enter the vagina -- and that healing was more rapid, and comfort was increased with bathing.

In my region doctors and hospitals haven't forbidden bathing since at least the early '70s... although a few midwives still do.

I've always encouraged my clients to bathe and soak after birth. I think it is very good and healing. (and I have NEVER had a postpartum infection). Statistically, infection is LOWER when women take baths than when they are restricted to only showers.

Some think that prolonged bathing might make absorbable sutured dissolve too quickly, but I don't think it can really affect them much if at all. Perhaps one should consider this if mom has a large repair (but then, why would a siztbath be OK if a tub bath is not?).

I find it very ironic that some would forbid bathes but encourage SITZ baths! If you think about it, a sitzbath concentrates all fluids making a prime breeding ground for bacteria -- if bacteria could breed in water - while a full bath disperses fluids and makes bacterial growth difficult. If there "was" any chance of water causing infection, it would happen much more often from sitzbaths than from tub baths. yet it doesn't' happen.

But... research is VERY clear. There is no medical reason to forbid bathing after birth. .. and there are many benefits.

If your hospital needs to see something in black and white saying it is "OK" for women to bathe, refer them to the Guide to Effective Care in Pregnancy and Childbirth. It is a handy concise reference for these common questions.

Or, just use the common sense approach. Would anyone  forbid their kid to bathe if he has a scraped knee? What's the first advice we give to anyone with a wound -- "wash it". And if someone has an inflamed cut, what do we say "Soak it". Water is GOOD for healing.

When I lived in Hawaii, our aunties had one answer everytime we were sick or sore. "Go swim", they would say. And darned if they weren't always right! Whether it was a migraine headache, or sore ankle, or an infected cut.... the ocean made it better.

Nutrition and Nutritional Supplements

The special nutritional needs of the postpartum are often ignored.  This site focuses on the benefits that might be offered by nutritional supplements in the postpartum period.  "Sound Formulas is dedicated to helping women through the postpartum period with the use of nutrients that can be depleted during pregnancy and childbirth.  Dr.'s. Raffelock and Rountree offer a book, A Natural Guide to Pregnancy and Postpartum Health, and they also sell the supplements, which seems to be the most important part of this site.  I'm including such a commercial site in my web pages because there are so few resources about postpartum nutrition, especially for preventing or treating postpartum depression.

I personally worry about a book by doctors that downplays the importance of the personal attention and interest that in-home midwifery care offers.  In particular, you can see that many of the benefits of their supplements were provided by placebo, so one could expect they would also be provided by midwifery's personal attention, in addition to the in-home lactation assistance and attention to the various minor discomforts and adjustments.

Postpartum Vulvar Swelling

Sometimes the vulva becomes so swollen that there is very poor venous return.  It's as if the swelling closes off the vessels and ducts that drain the vulva.  This can be remedied by applying gentle pressure to the vulva . . . just enough pressure to overcome the pressure of the swelling on the ducts and vessels.  Over time, this restores equilibrium.

After Birth Herbs and Homeopathics

My second birth took place in Germany. My midwife there recommended that I use a full dropper full of chamomile tincture in my peri bottle. I loved it! It smelled good and felt great. When I came back to the States I found an article in an old "Mothering" magazine that told about the anti-inflammatory and healing properties of chamomile.

We make our own comfrey root decoction (simmer about 6-8 ozs of dried comfrey root for about 30 min. until the water is thickened and brownish. Strain out the root, keep the fluid, pour into a clean jar. Put in fridge. Use peri bottle when needed.)

We do this at the birth. I grow my own comfrey (plant placentas there too) and dry the root. Fresh leaves are good blended and added to the sitz bath water. What a wonderful plant. Encourages cell growth so rapidly that my herbal cautions to use on clean wounds only.

We're thinking of trying comfrey decoction also as a cold compress...pour a little on an ob pad and freeze (only takes about 20 min. to get really cold)...haven't done it yet, just an idea at this point. Traditional Chinese Medicine would say not to use cold, but these frozen pads (we usually just wet them with boiled water then freeze) really do seem to get rave reviews...and do prevent swelling. Anyone out there familiar with whether freezing would somehow damage the healing action of comfrey?

I have the mother and the baby get into an herbal bath after all the "work" --sutures, newborn exam, etc--is done. The mother and the baby love it. The herbs we use are 2 cups of comfrey, 1 cup each of shepherd's purse, uva ursi, garlic, salt, and fourth cup of rosemary powder. I tie the herbs up in a knee high hose so as to not have to strain them after the infusion. I infuse the herbs for a while then pour that tea off. Then refill the pot and simmer them until the baby is born. We scrub the bathtub seriously, rinsing even more seriously. We use candles for light so the baby will open its eyes and relax. Herbs are good for mother's bottom and baby's skin. Helps with swelling and aid clotting.

I found another recipe for bath-herbs in my files

Boil large pot of water.. Add herbs, and simmer 30 minutes to an hour. Strain. Add sea salt and pureed garlic..

Notes: garlic and sea salt-- antiseptic. Uva ursi -- healing for female organs. Comfrey -- soothing and is said to aid healing by causing the edges of wounds to grow together. Shepherd's purse, -- preventing and controlling heavy bleeding. though guys: I gotta confess total mystification as to why "bathing" in shepherd's purse would help control excess bleeding! I understand why it would work when you "drink" it as a tea or tincture -- but why "soaking" in it? Is it one of those things which is absorbed through the skin? Help me someone.......

Another simpler recipe from one of my clients: 2 hands full of Comfrey, 1 handful salt tied into a clean sock... Simmer in water, throw sock and tea into the tub (well cleaned of course!). this client added a dropper of St Johns Wort oil and Arnica oil to the water when she got into the tub... Said it helped a lot with soreness......

Note: I've carried St Johns Wort oil ever since -- seems to help pain in labor when rubbed on back or tummy!

All of the sitzbath mixtures that you can order cost so much.

I order my herbs from Frontier herbs and make them myself. We use a 2 cups of comfrey, 1 cup of shepherd's purse, 1 cup of uva ursi, 1/4 cup of rosemary. Mom supplies a cup of salt and a bulb of garlic. This only costs about $5 for that large quantity. And makes a great bath.

I make LARGE quantities of post-partum herbal baths. I use 100% Organic Comfrey leaf and root, Shepherd's Purse, Uva Ursi, Myrrh, Lavender Flower, and Sea Salts. I don't like the garlic because it smells awful. So the Myrrh replaces it. Then, because I am such a crafty lady, I sew them into 100% natural, un-dyed, un-bleached cotton gauze like fabric, with my serger. (this is a huge time, and mess saver.) I then tie them with a nice ribbon, and a tag with the instructions on how and when to use, along with the ingredients. You would just boil the whole bag for about 30 minutes, and pour the tea into the tub, and it smells mildly lovely because of the lavender. It can be used again the next day, except you would have to steep it longer.

"The drugs used for surgical or dental anesthesia can linger in the body for quite some time. One dose of homeopathic Phosphorous 30C can help to cleanse the body of anesthetic drugs and relieve any unwanted side effects."  For other tips on homeopathics, see the EMAZING.com archives of the Homeopathic Health Tip of the Day

After Pains / Afterpains

I have a lady on baby number 7 who has a history of incredible afterpains, lasting 5-6 days.  It is severe enough that she found herself handing baby off after nursing just a few minutes because of the pain. She is into natural remedies and has tried one herbal remedy (sorry, don't remember the name), which didn't do anything.  Does anyone have any suggestions?  She ended up using Vicodin last time.

Afterease with liquid cal 10 minutes before nursing can ease the after pains and before she tries vicodin she could take the ib and Tylenol cocktail.600-800 mg ib 2 ty in between to extend relief.

Did she use After Ease by Wishgarden Herbs?  I liked it, I used it after my 5th baby.  The key though is to use enough of it.  A lot of times I find that moms will say "it doesn't work" but only to find out they took 1 dropperful.  You have to use it to desired effect.  I also like having them lay on the bellies for a short while with a pillow.  Makes the afterpains hard for a short bit then better.

I second this suggestion - liquid calcium (even have had clients put a straw in it and drink it quite continuously after delivery!).  And a big "yes!" to the Ibuprofen - we have our clients take 600-800 mgs. of Ibu. immediately after the placenta delivers - it seems that it works best if you get on it right away.  Then they continue that amount q 4-6 hours.  I also remind the client to empty her bladder, often.  For some it seems to help to coax the uterus back to the center (so often we find it off to the right - even w/ an empty bladder).  I have done a gentle repositioning of it and it seems to help for a while.

And about the Afterease, they need to take a nice amount of it and often.  I may have to try the idea of having them lie on their tummies - sounds interesting and its good to know that it may make them worse before better.  I wonder if this helps the uterus get repositioned?

I recommend After Ease if they are prone to herbal things. I have them take two dropper full every 15 to 20 minutes the first few hours. I also highly recommend them to check uterus for blood clots and making sure bladder is empty. The more blood clots released and bladder empty will help reduce after pains. If not I recommend Motrin.

Did she use After Ease by Wishgarden Herbs?  I liked it, I used it after my 5th baby.  The key though is to use enough of it.  A lot of times I find that moms will say "it doesn't work" but only to find out they took 1 dropperful.  You have to use it to desired effect.  I also like having them lay on the bellies for a short while with a pillow.  Makes the afterpains hard for a short bit then better.

That is what we do and has tremendously reduced the afterpains.    We begin the Afterease,  Crampbark & liq Cal/Mag, immediately after birth plus sit the women up and immediately begin with the ib/ty which they make take every 5-6 hrs.  The cal/mag, Afterease and Crampbark are taken every 20 minutes. And be aggressive the first day and then they won't have a problem.

We go back for a 12 hr pp visit at which time we put them on their bellies and give them a good back rub. Besides working with the whole pelvis are during the back rub, I rub out from the spine out to the right side, just under the ribs.  Why that helps I am not sure.  Read about it to help relieve menstrual cramps.  During the back rub I ask how it is going with the afterpains and all say "surprisingly quite well'.

I have had several women over the yrs with this kind of pain for Afterbirth. This is what I have used and it works well. Advil 800 mg, & Loratab 500mg and an extremely snug postpartum belt. Repositioning that uterus is a bigggg help. They take the combo of meds within 20 minutes after the birth. retake every 6 to 8hrs. The belly belt within the same amount of time. Time is of the essence with these moms.

What about giving the ibuprofen immediately after delivery of baby, prior to placenta?  I've got a client who gets violently ill as soon as placenta delivers.  Has happened with her two previous deliveries and she's pg again.  We'd like to get something in her before this hits this time.  I'm afraid that if I wait for placenta, the ibuprofen won't have time to take effect.

I use any Cal/Mag (liq prob abs sl quicker)  and take 400-500mg 4-6x/dy (unless diarrhea) Herbs: Piscidia, Cimicifuga, Trillium, Spikenard, Viburnum op., Hypericum is what I was taught - I don't think I have spikenard or trillium these days, though...  and I agree - lots. along with the ibu/tyl is what i recommend - plus urinate before nursing and belly binding.

I have a lady on baby number 7 who has a history of incredible afterpains, lasting 5-6 days. It is severe enough that she found herself handing baby off after nursing just a few minutes because of the pain.

We have a few ladies like this.  I think tight abdominal binding, or resting a large weight on the uterus constantly helps, as well as lying on the belly whenever possible.  And I think if you need an Rx I think Toradol is more helpful than narcs without the side effects for both mom and baby.

I use several things, 30c Arnica works for most but when it doesn't we make a strong tea out of valerian, chamomile, shepherds purse that seems to work great.

I recently started using homeopathic Mag. Phos. for afterpains and been very pleased with the results.

Mountain Meadow Herbs makes an After-Pain Relief formula that they say "really works"!, partly because the Crampbark relieves spasms and cramping.  If you have good results with this, please send e-mail to username "midwife" at this domain. Thank you!

Chamomile is quite amazing for helping with afterbirth pains and menstrual cramps. The results are almost immediate. It is also useful for cranky babies. Caution: Don't use too soon after birth as it relaxes the uterus and can cause an increase in bleeding. Usually, I don't give my mothers chamomile until about 8 to 12 hours after the birth, depending on need and bleeding.

I've got a client who gets violently ill as soon as placenta delivers. Has happened with her two previous deliveries and she's pg again. We'd like to get something in her before this hits this time. I'm afraid that if I wait for placenta, the ibuprofen won't have time to take effect.

A compounding pharmacy can also make ibuprofen into a topical cream, to be applied to "thin skin" spots like the inner wrists.  It works more quickly and avoids the nausea, especially for women not used to taking high doses.

for severe afterpains especially with a grand multip i often give her methergine tab q 6 hrs for the first 24 hours..i know it sounds like it would make it worse but it keeps the uterus "clamped down" and therefore does not get soft and then have to work real hard to get hard again...works very well

I have found that when I need to give misoprostol postpartum to control a severe bleed, the mom seems to have fewer afterpains that you would expect.  This must be working on the same principle as the methergine.  It would be great if there were some research about this!  Until then, I tell them they can take 200 mcg misoprostol every 6 hours.  She might have a slightly elevated temperature without feeling uncomfortable, and they may have softer stools, but I've never heard a postpartum mom complain about loose stools!

I have always used Motherwort tincture for after-birth pains. The mothers think it really helps better than the drugs.

Have used St. John's Wort tincture or tea for after pains with good results, dosage varies, some women I know used only about 8-10 drops of tincture every few hrs., another used 15-20 drops every few hrs., Have only had maybe 3 women drink the tea one drank it 1/2cup just about every hour, others drank it at no set intervals but did have some already steeped waiting for the times they needed it, mixed with raspberry leaf tea.

We use

  1. Afterease tincture or calcium,
  2. hot water bottles or heating pads
  3. have the mom lay on her stomach with a pillow underneath her
  4. lying in the fetal position
  5. Aleve (anaprox sodium)
  6. Tylenol

Afterbirth pains, in fact any fixed, stabbing pain, is characterized in Chinese medicine as blood stasis. There is a saying in Chinese that translates as "Where there is pain there is no free flow, where there is no free flow there is pain."

The cause of afterbirth pains is the blocked flow of lochia (even though you see some). Other symptoms will include dark purplish-red or clotted discharge, and a purplish hue to the tongue body, often in the center only. These women may be the ones that have heavy lochia a few days with clots, and then it stops before 10 days and you think it's normal. It's blood stasis. The menses may also have exhibited some signs of stasis.

The drugs, valerian, shepherd's purse, chamomile, all might lend symptomatic pain relief, but they do nothing to correct the pattern by resolving stasis. Therefore, they are only symptomatic and not curative. Red raspberry and St. John's Wort have secondary properties that likely move blood a little, and are therefore more effective, but are still not directly curative. Most of the herbs, even St. John's Wort, have sedative effects as their primary action. While this is helpful symptomatically, the mother doesn't need sedating; this does not correct the flow.

What is called for are techniques described as moving blood to breaking blood stasis. The herb midwives know for this condition is motherwort. It is a moving blood herb, and I can guarantee that drinking 1/2 cup of motherwort as a tea will stop afterbirth contractions 95% of the time. For severe cases, a few days doses may have to be given. To make two days worth, simmer 15 grams of motherwort in about 3 cups water. Simmer down by 1/2 (about 45 minutes). Take 3 oz. 2 times a day. It is really vile.

Other herbs that move along these lines are safflower (also vile), peach seed, calendula, and for very intense cases, frankincense and myrrh. (These latter two seem poetically like just the right thing, but again, are vile tasting, and should be used for only the most severe cases, and then only for perhaps one dose or so. They are very dispersing, and not exactly the kind of action you want to promote postpartum.)

Often the herbs that are best for fixed stabbing pain are the ones with emmenagogue properties. And you are thinking, "promote flow after the blood loss of birth?" to which my answer is "Yes! The pain is CAUSED by stasis, and until you remove the cause, you have not effected a cure, and may be setting the woman up for more pain next time. Where there is pain...there is stasis, and it is appropriate to move stasis where there is pain. Motherwort is one of the safest of these emmenagogues (Western parlance)/ blood movers (Asian parlance).

This question illustrates my perhaps overemphasized point on line. There is no system in Western herbology for describing or understanding the underlying patterns of disorder. I really wish there were. I believe that we need to consider our herbs as pharmaceuticals, and we need to know more about how to apply them, why they work, which ones to choose than to say, "this is good for that." I realize fully that this is an enormous study, but if you're using herbs, you can be more exact by learning the Asian medicine descriptions. Best place I know of to start is with Michael Tierra's work. His book Planetary Herbology should be a standard for anyone using herbs in their practice. A home study course is available through him and advertised in the book.

Try the motherwort, and let me know your results (and remember, it tastes really vile, but it really works).

Suggest 2 extra strength Tylenol and 2 ibuprofen (Advil) at the same time, then reduce dosage. They seem to provide good pain relief togeth. Also, lay on her tummy, maybe with hot water bottle under tummy too. This really helps, more than you would believe. And keep that bladder empty!

More ibuprofen....800mg. every 4-6 hours....I've never seen it not work!

The obvious:

  1. Keep bladder empty - have her do some I&O's for a while to check for residual urine/urinary retention.
  2. Offer ice or heat to abdomen as needed
  3. May lay on her tummy with a small pillow under her belly to tamponade the uterus. I have the women lie with their feet overhanging the bed which puts more direct pressure on her belly.
  4. Ibuprofen 600mg 4x/day as needed, Herbal teas i.e. Chamomile
  5. I would not rule out a retained clot, in my experience severe after birth contractions may be caused by exactly that. I would have the woman massage her uterus when sitting on the toilet, gravity and massage may help her to pass it. Tell her not to be shocked if it is good size.

The homeopathic Sabina is very good for some. Also the herb liferoot. Is she having worse cramps after eating?

My strategies (depending in some degree on setting and mom's preference):

  1. Hot compresses to abdomen
  2. Ibuprophen 800 mg q 6 hours
  3. Blue cohosh or black cohosh, tea or tincture
  4. Raspberry leaf tea
  5. St John's wort tincture -- 1 dropper q 1/2 hr as needed. May be combined with skullcap. This is very short term but works well and fast while waiting for other measures (I discovered this one this summer).
  6. Have mother lay on her tummy with a rolled up towel or blanket underneath -- this sometimes hurts worse at the very start but is one of the most effective means I know of as it keeps the uterus contracted firmly.
  7. Obviously, make sure that mom has an empty bladder, and make sure that mom is not retaining clots which can cause severe cramping.
  8. If all else really fails, tylenol 3 combined with other measures. I also would consider using either Toradol (an NSAID which is equivilent to 12.5 mg morphine in pain relieving ability or Durac, a new NSAID, which is an excellent analgesis) for one time use for very severe pain as I have occasionally seen in grand multips if I had access to these meds readily (this is not always the case). I would not recommend other than brief use for breastfeeding moms as there are safer NSAIDs out there (that we have more experience with) for repeated use, but have been with a few women who experienced after birth pains that were worse than labor for whom almost nothing worked where I think it would have been worth considering trying this route.

I personally found that having good calcium supplements made a world of difference. I use arnica and an afterbirth tincture for afterpains and rarely have them so bad it can't be handled.

In lieu of or in addition to Tylenol, I find lying on the stomach with a pillow under the abdomen helps immensely. I guess it puts pressure on the fundus and keeps the uterus well contracted.

Worked great last week on a primip who was shaking and sweating the pain was so great. Ruled out other pathology and it seemed simply to be cramps. Never had a first timer seem to feel so much pain without retained tissue or clots, but never mind it worked and she was happy with in 10 minutes.

Also an ice pack on the fundus helps to keep it well contracted.

I didn't have any with the first two - maybe I had so much perineal pain because the nice man in the white coat did a hummer of a job with his scalpel, that I didn't notice the afterbirth pains.

My first homebirth (#3 baby) they were horrendous.  In fact, every time I put him to the breast I got very sick and threw up.  I used the rice bag with lavender which helped a lot, but I ended up taking tylenol.  When a pain would hit, I started shaking and sweating.  Awful stuff...

With #4, I read everything i could get my hands on to prevent them and started taking Liferoot tincture a few weeks before my due date.  Also had catnip and motherwort on hand, too.  I'm not sure which one(s) worked, but something did because while they were still there and I did throw up once, they were NOTHING compared to #3 - and they didn't last as long.

I had them with #2, 3, 4, and 5 but absolutely NONE with #6 and 7 (my two homebirths)!!! I hope I am that lucky again this time!!!

Yes, for me the afterpains were worse than the labour itself:

  1. they always came at feed time when I was (sitting and couldnt move) trying to relax and enjoy - and by day three the afterpains were competing with the sore nipples - double ouch !
  2. unlike labour they didn't have pauses between contractions and you never had any idea how long each pain might last
  3. no one could tell me how long till they went away
  4. unlike labour there was no reward at the end of the pain
  5. taking painkillers made you feel bad when you were breastfeeding a newborn

I will say , that until my milk came in, laying on my belly with a hot rice sock felt wonderful.  Also a nice warm tub bath was great comfort too.  (Avoid these in the first 12 hours or so postpartum so they don't increase the bleeding!)

Don't be afraid of the pains, most of the time the strong ones only last for a day or two.  Keeping your bladder empty is a MUST.

I am looking after a mother G4P3 now at 36 weeks who has asked me if there is anything she can do about after birth pains.  She had severe suffering after her last two and would like to avoid if possible.

Can they actually be avoided?  and if so could that mean that there is a risk that her uterus will not contract down strongly and therefore she may bleed heavily.

The most likely cause for the awful afterpains is that she has a uterus that is very efficient uterus which contracts very firmly but  painfully.  Synto of course makes this ten times worse.  And nursing baby causes uterine contractions to increase  With a woman with this history I would advise a physiological 3rd stage and have a nice hot water bottle or hot pad available and consider analgesics, paracetamol or ask medic to prescribe voltarol (diclofenac) the anti-inflammatory used post CS. which is very effective but woman may not wish to have.

I had severe afterpains with my *first*, less with my second (I know that's not the usual way round - both physiological 3rd stages though I'd had syntocinon in first stage first time) Used TENS for 2 weeks post birth with my first, one with my second.

If she's into alternative stuff, there are various homeopathic remedies that are said to help - consult a homeopath for details. If she's more into conventional medicine, she could get a prescription for voltarol (100 mg pr is probably more effective than the 50 mg po) - she'll probably find she needs to use it for at least 3 or 4 days after the birth. She might need to top up with oral analgesia shortly before  a breast feed (if she gets enough notice that the baby's about to feed!). I have looked after one client who had had 11 children and who found the afterpains stronger than the labour pains, and used entonox after the birth rather than before; she also used her TENS post-natally, so that might be worth looking into.  The problem with after pains is that they're unpredictable - while labour pains intensify as labour continues, after pains vary so you might get several mild ones, then a whopper that makes you feel sick to your stomach, then some more mild ones and apart from the obvious link to flow of oxytocin with feeding, there's no particular rhythm to them which you can use to 'ride' them as you do labour pains.

One of my moms was taking Cytotec (200 mcg q 6 hours) for excessive bleeding, and she mentioned that it also seemed to reduce the afterpains for her.  I'd like to see a study of the use of Cytotec for afterpains.


I have been reading a new book about herbs, this might blow you away but they said to put a slice of an onion on a hematoma, bruise, etc. I've since tried it and it works also takes soreness out. The book said that if there was a bad one then add sea salt to it and make a poultice or tape it in place and it doesn't matter how old the site is. This may be too late to help your lady with the hematoma, but for future reference. sounds weird but there were lots of documentations.

I am tired of seeing weird, unusual things -- ok? I did a long, tedious birth today for an Amish primip -- finally gets to complete - and then pushes quickly to birth baby -- She had been complaining of a pain in her labia, that she thought her husband had caused by too vigorous perineal massage. She was separating her labia for me when i checked her so i wouldn't hit the spot -- i thought I could see a tiny purple spot --

As the head was being born, and a minute or 2 for shoulders, a huge hematoma formed before our eyes. By the time baby was out it was softball sized -- grew to be as big as my hand (I have big hands) in about 5 minutes -- We quickly put ice on it. It stopped growing, she was stable, and we transported -- haven't heard anything yet about what they did, or how they treated her, etc.

Is there anything we could have done to prevent it growing so big?-- or could we have drained it at home? -- we called a friendly doc who wouldn't drain it in his office.

It was so frustrating after this nice birth, to have to transport her -- I felt so ignorant -- have never seen anything like it -- her perineum, by the was totally intact -- no tearing as far back as I could see.

Also, by the time we got her to a friendly hospital, she was 2 hours postpartum -- is that too late to effectively treat a hematoma?

Right after applying the ice, I would have also given her a dose of homeopathic Arnica (at least 1M potency). 10-15 mins. later I would give her another dose. If there wasn't already a big change in the size,

I would give her a third dose at 30 mins., en route to, or at the hospital. Even if the Arnica itself didn't take care of the hematoma (and I know it would make a big difference!) then the doses will help insure a much faster and easier recovery after draining and stitching it. In fact I would give her another dose after the procedure and again the next day.

Postpartum Belly Binding

I have used a belly binder so to speak for the mom after the birth and everyone that uses it just loves it. It is made by Body Glove and you can get them at Big 5 for about $5-8. It is velcroed and fits all. Well worth it. I am one that when I had my babies and would stand up my innards felt like they were hanging in empty space and I had a hard time breathing. When I used some kind of binder I could stand and function. It feels great!!!! But for the mom not the baby. I tell all my clients about this in one of my hand outs and the majority get one. They all love it.

I know of a few grand multips who bellybind postpartum. They think it helps with diastasis recti. They also say it can't be properly done by oneself. Does anyone know how to do this if we should be asked?

We have done it a couple times the last few years when a mom requests it ..And I still remember from the old days!

Mom usually gets cleaned/showered while you change the bed sheets, When she comes back you have a large bath towel (or a twin sheet, folded in half) laying across the bed; she lies on the towel on her back, with the bottom edge just about level with the lower edge of her pubic bone -- level with her "hips bend". You want the towel to cover from just under the breasts down, so you might need to fold the edge.

You pull the towel snugly around her tummy, usually fastening at her side with large diaper pins.. We used to start from the bottom and work our way up... It should be snug but not uncomfortable so.. If the uterus is a bit boggy or she's having lots of after cramps you can snug in a folded washcloth or baby diaper over the fundus to act as a constant irritant[Grin]and prevent relaxation and bleeding. The OB pads can be pinned to the lower edge of the binder -- nice way to get a snug fit with the pads.

If mom tore or had stitches we used to put the binder on a bit lower -- so mom had to walk as if she were wearing a tight skirt (to limit perineal movement).

Moms used to keep these on for at least 24 hours and maybe three days...

Stretch Marks

For postpartum stretch marks, try either topical Emu Oil or topical Hyaluronic Acid .  A well-respected local doctor recommends Complementary Prescriptions Pure Hyaluronic Acid Serum.  You just need to put a drop on the skin and rub in a small amount daily.  Anyone can get it at 5% discount from retail through the online store.

Closing the Diastasis Recti

I would greatly appreciate some help with the issue of how to teach women to tone up their abdominal muscles postpartum to close up the diastasis recti abdominis.

I learned about this in the mid-90's when Elizabeth Noble was considered the expert.  She taught to lie flat, cross your arms over your belly in an X to hold your sides together, and exhale as you raise your head, not your whole upper body.

I always teach my moms while I'm holding my fingers in the diastasis, so I can be sure the exercise they're doing is toning the right muscle.

Elizabeth Noble further taught that you should bring the "long abs" together before working on the transverse or oblique muscles, as they simply pull the "long abs" (recti) further apart.  This all made a lot of sense to me. (Oh, and I think it's the Pilates people who teach to start with a Kegel to stabilize the pubis symphysis as you begin the head lift.)

There is now a buzz on the web about how this is all wrong. Julie Tupler is holding herself out as the current expert on the subject, and she is teaching that crunches make the diastasis worse. Now I understand that there's a difference between the head lifts that Elizabeth Noble taught and a full out crunch, either curling the shoulders up or lifting the entire upper body.

But the teaching now seems to be to start working on the obliques and transverse muscles more than the "long abs". The obliques and transverse muscles do not cross the abdominal midline, is that right?  So how would exercising them bring the recti together?

Elizabeth Noble is the doyenne of prenatal and postpartum exercises.  She taught that the best exercise for closing the diastasis is to lie flat and exhale as you raise your head, not your whole upper body.

This is how I teach it.

From a well-respected physical therapist:

Diastasis correction is a head lift technique with minimal shoulder involvement to not overuse the rectus abdominis.  You need to use the exhalation muscle ( trans. abd. muscle) with this to ensure transverse closure of the abdominal wall and the slight neck flexion for the rect. to contract in combination with the cross over hand position for closure.

I like the brace idea!!!  It is not that expensive and is possible more specific than the Medela postpartum brace that I used.  Tummy sucks with exhale and long holds help the trans. abd. close to approximate the midline. Fast twitch ( quick holds) and slow twitch ( long holds) fibers need to be trained and training in functional positions with correct neutral spine posture is a must for true motor learning!!

Squatting, leaning over a changing table for diapering, sitting correctly upright for breast feeding and working on breathing and closing are great opportunities.  Correct transfers in/out of bed are vital to recovery.

Ms. Tupler is a passionate nurse who has benefited us all through her research.  There are not that many folks out there doing clinical research for women's health issues. And having a diastasis can disrupt a lot of stuff.  Defecation, orgasm and pleasure, appearance and protection of organs.

About diastasis:
Lay on your back, and start lifting your head and shoulders as if beginning a sit-up.

Look at your belly. Do you see a bulge in the middle? Bad sign.

Push on your belly while keeping your abs contracted. Can you feel the two long muscles running on each side from your ribcage to your hips?Now check around your belly button for a gap between the two. If you find one (and postpartum there usually is one) see how many fingers you can fit in there (perpendicular to the gap). 3 fingers and less is fixable through PT. Above that... not good.

Whatever you do avoid classic ab crunches like the plague until you have talked with somebody knowledgeable about the subject. Most (all?) of the PT for ab separation revolves around strengthening the set of deep abdominal muscles going *around* your waist. Until they are back in shape getting the long abs back in shape will only increase the separation.

When carrying your baby (or your toddler, or your grocery bags, or getting out of bed, or... doing anything that uses those abs) remember to contract the deep abs first (by sucking your belly in). Contract them as much as you can, actually.

This is exactly the opposite of what I've heard.
What I've heard is that if you exercise the muscles going *around* your waist, they will pull the "long abs" further apart.  After all, they are anchored to the rectus muscles.  I don't see why tightening them isn't going to further separate the rectus muscles.

Does anybody have a good online reference about this?

I dug out my maternal fitness books, and there's a huge contradiction between teachings from before and after 1995.  I am suspicious that modern teachings are focused on commercial ventures which sell special devices for closing the diastasis.  (The Rehab Splint costs $38 for a band w/velcro; the whole kit costs $68 - $75.)  In particular, I can't find any mention in Julie Tupler's materials about the head lift, which leaves the shoulders flat and is very different from a real crunch.  The head lift is free and is very effective in my experience.

I start assessing the diastasis on Day 5 postpartum, teach the head lift exercise (different from a crunch), and reassess on Day 10 and at six weeks postpartum. I teach the exercise by holding my fingers inside the diastasis to make sure that I feel the muscles closing around my fingers as the mom lifts her head. I can assure you that this does close the muscles around my fingers, and moms who do this exercise regularly often have it close up completely by six weeks.

Note that if moms start doing this before the uterus has reduced in size, then the muscles might try to come around the outside of the uterus, which isn't good. So I don't recommend that moms start the head lifts until the uterus has shrunk at least halfway down to the pubic bone.  And it can be a good idea to cross the arms over the belly button to hold the sides together.

By the way, I've also heard (from the Pilates people) that it's beneficial to start tightening the Kegels to stabilize the pubic bone before "continuing" the tightening up the recti muscles with the head lift. So this is what I've been teaching, and it seems to get good results.

The proof is in the pudding, of course, and every once in a while, I encounter a mom with musculature that allows her to lift her head without closing the recti muscles.  So we keep trying until we find the movement that does close the muscles, and then she just does a lot more of those.

None of the abdominal muscles cross the midline. Although I can see that toning the obliques and transverse muscles will reduce the side diameter, how can they bring the recti muscles together?

Here a good diagram.

How is tightening the pink muscles going to bring the yellow muscles together?  :-)

Julie Tupler's web pages reference some research done at Columbia University on this topic, but I haven't been able to find anything either in PubMed or on the columbia.edu web pages.  If anyone else has a reference for this, please pass it along.  Thanks.

I think I finally understand the confusion about "The Tupler Technique".

This is from her article, NO MORE CRUNCHES…….EVER…. by Julie Tupler, RN

"That is why when doing backlying exercises you should just bring the head off the floor…not the shoulders. "

So, her primary beef seems to be that classic crunches can worsen the diastasis.  This is consistent with what the midwifery texts say about not doing any other exercises until the diastasis is closed.  But she seems to think the head lift is fine to close the diastasis. I haven't had a chance to read her book to see why classic head lifts won't do the trick to close the diastasis.  The key is to feel your belly to make sure that what you're doing is, in fact, closing the muscles.

I've had plenty of clients get great results with just the head lift.  Maybe this is because we get right on it after the first baby, or the first baby they have with me.  Maybe moms who've had a diastasis worsen with each of several pregnancies need more advanced physical therapy.

OK, I got serious about this and wanted to get closer to source materials, so I poked around a bunch on the web.

The most academic material I could find about the Tupler Technique was from Julie Tupler's presentation at a breakout session at the ACNM 2009 conference in Seattle.

From the ACNM 2009 Exhibiting Companies Descriptions

Maternal Fitness Inc.
DIASTASIS REHAB: Closing the gap with the Tupler Technique, a Columbia University Research-Based program. The program closes a Diastasis no matter when woman has had her baby. A Diastasis, if not corrected, can cause low back pain and put a woman at risk for a Ventral Hernia.

The slides from her talk are available online, which is a gift to all women!  Thank you, Julie!

In these notes, Julie Tupler writes, "The Tupler Technique is supported by published research from Columbia University:
A study was conducted March 01, 2001 at Columbia University, Program in Physical Therapy on the effect of exercise on the diastasis recti (separation of outermost abdominal muscles) during pregnancy. Results demonstrated that women who had taken the Maternal Fitness® program had a smaller diastasis than the control group of women who did not exercise during their pregnancy. This study was published in the Journal of Women’s Health Physical Therapy, Volume 29, No.1, Spring, 2005

This study is about the effect of prenatal exercise and has nothing to do with closing the diastasis postpartum.  The Tupler Technique appears to be about closing the diastasis postpartum.  How, then, can she say that a study about prenatal exercise supports her program for closing the diastasis postpartum?

Although Julie Tupler has some useful information, I find that her teachings are not based on research and lack a certain rigor.  I also find her focus on appearance to be a little confusing coming from a health professional.  The slides from her talk include photos of body builders with a visible diastasis recti, and I'm pretty sure these people don't have any functional problems from their diastasis, and I'd be surprised if they felt the need to close them.  In truth, the diastasis adds definition, which is generally considered a bonus in the body building world.  And closing the diastasis would reduce their dimensions, which I think is generally  not considered a bonus in the body building world.

Is Julie Tupler's material really all about vanity and not about health?  It is just about trying to regain your pre-pregnancy waistline?  There's nothing wrong with that, but it's not healthcare.

In her slides for the educational breakout session at the ACNM 2009 conference, Julie gets more specific about exactly which exercises can worsen the diastasis.  However, the information is not consistent.

One slide says:

Types of Forward Forceful Pressure
• Doing abdominal exercises incorrectly (i.e.
crunches or Pilates hundreds)
• Performing day-to-day functional movements
(getting up and down) incorrectly
• Pressure of a growing uterus or a beer belly

Then, a later slide says:

Forward Crossover Movements
That make diastasis larger:
– Cross-over crunches
– Golf
– Tennis

Notice that she does not list standard symmetric crunches in this more explicit slide.

She also says that an uncorrected diastasis from the first pregnancy is the reason that women show sooner in a second pregnancy.  Hmmmm, I'm pretty sure that's not based on medical knowledge.  It might be part of the picture, but how about the fact that the uterus itself has been tenderized by the involution process after the first pregnancy, so the uterus does not have the same firm structure as with the first pregnancy?

I think Julie Tupler's Maternal Fitness book is a great resource for pregnant women, and I love her BAKS BAsics.  I have multiple copies of this book in my lending library and encourage first-time mamas to follow the program during pregnancy.  I can't say the same good things about her postpartum Tupler Technique.  This isn't to say that it doesn't work.  It's just that it's not clear that it has any more benefit than simple head lifts, and it's a whole lot more expensive and demanding of postpartum mamas.

What is Diastasis? from BelleFit - Medical-Grade Childbirth Recovery

In poking around the web, I found some interesting mistruths about diastasis:

Not every new mom has a diastasis. In part, its pure genetics (like everything else).  No, it's not pure genetics.  If you have a baby that is small relative to your frame, you are much less likely to have a diastasis than if you have a baby that is large relative to your frame or you have a lot of amniotic fluid or you have twins or you have more than one baby.

I'll say it again.  You need to feel the diastasis to make sure that the exercise you're doing is actually closing it.  It can be a little tricky to do this since you need to have your arm muscles completely relaxed to make sure that it's the exercise that's closing the diastasis and not what you're doing to feel it that is activating the right muscles.  :-)  You could get someone else to help you, or you could just keep feeling the diastasis while you exercise.  Heck, if that's what's closing the diastasis, then just keep doing it!

How I Got My Goddess Figure Back In 4 Weeks – After Having 2 Babies After Age 40 By Lana, March 16, 2012, In Better Baby Book, Better Baby Diet, Fertility - "I couldn’t believe it when I saw tighter abs and thighs after only THREE sessions of T-Tapp. It was too good to be true, I thought. Yet here I was, 20 minute sessions, in my living room, three times per week, and after 4 weeks, I looked toned all over, fit, felt good, had noticeably increased core strength and the best WHR of my life: 0.74. "

Diastasis Rectified - My journey to heal postpartum diastasis recti

The rectus muscles connect to the top of the pubic bone, and the Kegel muscles connect to the bottom.  If her Kegel muscles are very weak, that may prevent proper toning of the rectus muscles.

Mother Roasting

Moxabustion, or moxa, is an ancient element of Chinese Medicine.   It involves the use of artemesia, Chinese mugwort, to heat, nourish, and invigorate the mother's belly following a birth in order to draw energy and help replenish the substantial loss that took place there.  Women love the sensation of deep heat as the herb is burned over their abdomen, and any soreness or prolapsed sensations often disperse after just a few applications.  Traditionally, this procedure has been called "mother roasting" and should take place around a week after giving birth.

I have also heard the phrase "mother roasting" used to describe practices that involve keeping the mother and newborn very warm after the birth, sometimes putting hot bricks under the bed to keep them comfortably warm without using any energy of their own.  Like moxabustion, this helps to restore qi or life force to the mother's body.

Mother roasting, belly wrapping and other restorative postpartum practices.  This also details some ways to do self massage.

Removing Bloodstains

I can't remember whether other people have written about this, but hydrogen peroxide is great for getting blood out of clothes, linens, whatever.  Just pour it on and blot it up with paper towels or rags or regular towels.

We use plain old peroxide, and keep pouring and blotting until it doesn't bubble up anymore.  Then we use water to get up the peroxide so it doesn't bleach the carpet.

Peroxide, peroxide, peroxide - if you use enough and you are persistent enough, you will get it all.  Avoid the preparations that promise blood removal - they set the stain -- like spray carpet cleaners - I have been back to houses after births where someone used a stain remover rather than peroxide, and there is always a big stain - peroxide works every time, but you have to get ALL the blood out.

Ammonia gets blood out too. My homebirth midwife swore by it--I'd never heard it before--and she said she'll leave bloodstained clothes in a pile for weeks and it'll still work! (We didn't wait quite so long.) My DH does the laundry and has for years (I am not making this up), so I'm not positive but I think he just threw it into the washer with the detergent, and maybe he soaked a few really messy things in ammonia & water. Everything that got yucky at our birth came clean with the exception of one light yellow spot from blood on my white bed skirt, which no one notices but me & I kind of like the reminder that I birthed in my own bed, right there where we started her.

Be careful with ammonia, it's strong stuff, don't combine with anything containing bleach--fumes can be deadly, so I've heard.

Sharing a tip I learned last night for blood stains on fabric. We discussed this a while back and I don't remember this being suggested: Murphy's Oil Soap. Spray it on, soak in water for an hour or so, wash normally.

Baby Wipes take out almost anything, including blood, from even white carpets. Sparkling water works, and peroxide is pretty good, but pretest it on an inconspicuous area first. For the blood you don't find til the next day, try dampening the area and sprinkling meat tenderizer on it, let sit for 30 minutes and then start with the above list. Don't use meat tenderizer on wool or wool blends.

The Afterbirth After Birth - the Placenta / Placenta Encapsulation

A Lactation Consultant's Perspective on Placenta Encapsulation [9/6/17] - I now discuss this information with all women who I see in their pregnancy, and advise them against consuming their placenta. I point out to them that there are no valid research studies that prove that placenta consumption either improves or suppresses lactation, but that risking milk supply is not a decision to be taken lightly and that my colleagues and I are seeing a concerning trend.

Placenta Encapsulation is not safe if mother or baby have symptoms from GBS infection.

Group B Strep and Placenta Encapsulation Safety

From time to time, I'll get e-mail from people looking for more information about placenta recipes or about eating placentas in general.  This is all the information I have.  If you have more information or additional links to suggest, please contact me with the info.  Thanks!

UNLV researchers author first-ever scholarly report on experiences of placenta-eating moms [3/1/13]

UNLV anthropology professor Daniel Benyshek and graduate assistant Sharon Young . . . are analyzing the nutrient and hormone content of the human placenta and testing the best ways to prepare it for human consumption. Eventually, they hope to discover what, if anything, makes the placenta so potent a remedy for the baby blues, and whether there are any risks involved.

Assessing the risks of maternal placentophagy: An analysis of environmental metals in human placenta capsules [4/10/14]

The 83rd Annual Meeting of the American Association of Physical Anthropologists (2014)

Maternal placentophagy, postpartum ingestion of the afterbirth by the mother, is ubiquitous among mammals but conspicuously absent in the ethnographic literature. . . . Thirteen human placentas were analyzed in both the unprepared and dehydrated forms using X-ray fluorescence analysis for 15 heavy metals in order to address whether environmental metal accumulation in the placenta might affect the metal content of the dehydrated organ. Analysis revealed that unprepared placenta retained detectable concentrations of iron and rubidium, while dehydrated tissue contained higher concentrations of these metals in addition to zinc and strontium. These results suggest that while some beneficial metals are retained in the placenta in both forms, potentially harmful metals may also be retained, warranting further investigation of heavy metal accumulation in placental tissue. Further analysis in mothers regularly exposed to smoke inhalation is needed to address the effects of smoke exposure on placental metal accumulation.

Placenta Medicine: My Story by Tiffany Rosenbrock [2009.4.9] from Midwifery Today

PLACENTA PRINTS! They start with a placenta and some sketching paper...and here's how they are made... the result is a beautiful "tree of life"!

What Can I Do With This Placenta? from virtualbirth

Medicinal Uses of the Placenta

Placenta Benefits.info - Mother Nature, for Mothers. Avoid the baby blues and enjoy a natural, healthy postpartum period with your new baby.  "What if you could avoid the baby blues... The placenta contains your own natural hormones and is perfectly made for you, by you. Experts agree that the placenta retains hormones. Reintroducing them to your system is believed to ease postpartum and menopausal hormonal fluctuations.  . . . The key to Postpartum Wellness is inside you.  Women who take placenta capsules report fewer emotional issues, have more energy and tend to enjoy a faster, more pleasant postpartum recovery.

OK, really and truly, I have NEVER known anyone to eat their placenta, but here's an article about it:
A strange cure for the baby blues - By HELEN WEATHERS [10/24/06]

Various Uses of Placenta, including as Food

I am curious to know what the taste and texture are like.

It's firm and a little rubbery, kind of bland and dry.

Instructions Upon Leaving Birth

Instructions Upon Leaving Birth - Handout

Actually it was the 'Discharge Information for Home Health of Mother and Baby'.

The hospital pamphlet listed these signs as Normal for Mother:

Vaginal Flow - (bleeding pattern):

It listed these signs as unusual for mother and suggested talking to your doctor

I try to say as little as possible, so they won't get too paranoid. I used to talk about resp distress, but clearly they had no idea what I was talking about. Now I go over normal in detail, assuming they will then be able to recognize abnormal. Under resp I cover the funny sounds they make, stuffy noses and bulb syringes/ saline drops, normal irregular breathing, sometimes (if the baby seems particularly strong willed) I run over that thing they do when they cry so much that they take a deep breath and don't breathe and turn blue for a second. I go over normal feeding pattern, spitting up, really reinforce watching poops and pees and other sings of dehydration (dark or crystallized urine, skin tenting, really sleepy or really irritable baby). We talk about best way for everyone to get some sleep (cuddled up in bed). Once I have covered all the usual weird baby stuff, they seem a lot more relaxed. Oh, the first thing I tell them is hiccuping and sneezing (very important, they all are convinced the baby has a cold, esp. when the baby sneezes during the bath) is normal. I also tell them to expect cool/bluish hands and feet as a sign the baby is not over heated.

I run down a short list - advising them to watch the babies color and breathing - and we watch the baby together a moment --- but then tell them the only real thing they have to remember... "Your baby should stay as pink and healthy as he does right now -- if anything changes -- call me"! It sort of puts things back into perspective[Grin] and is a way to alert parents to potential problems without scaring them...

Postpartum RhoGAM

If the baby is positive, then the mother's blood is tested to determine the amount of fetal cells. The blood bank usually does this. Then depending on the calculation of fetal blood that has passed to the mom, the rhogam dose is adjusted. The test is called Kleihauer, but I have come across it named "fetal screen".

The test is a Kleihauer-Betke, and estimates amount of fetal blood cells in the mom's blood. One dose of Rhogam is considered sufficient to deal with 15 mg of fetal blood cells. Under most circumstances that's enough in a normal home birth. We weren't doing them for a long time because no commercial labs in the area were doing their own, and it would take 8 days to get the results back from wherever they sent them out. A bit late for our purposes. Now my lab does them in-house, so it has become doable for us. I did labor support for a gal who had been sensitised because she was not given enough Rhogam after her c-sec. Kleihauer said 57 mgs fetal cells, which works out to 4 doses. They gave her 2, said "that's all we ever need". Wrong.

Her next 2 pregnancies were nightmares of interventions, multiple specialists, weekly amnios for bili levels, and one induction because they couldn't get at a pocket of AF to draw any at 38 weeks. Babies were Rh - , after all that. [Ed: Thank goodness there are tests now to determine baby's blood type from the pregnant woman's blood!]

just one little tidbit I learned a few years ago when attending a conference on prenatal issues where rhesus isoimmunization was discussed. The 72 hour cutoff which is normally touted as being the cutoff for giving Rhogam is an artifact from the original study which was done on prisoners over a weekend. It is felt that it is safe to give Rhogam up to about 2 weeks which is about how long it takes for the body's immune system to respond.

from the RhoGAM product insert: There is little information concerning the effectiveness of Rh Immune Globulin when given beyond this 72-hour period. In one study, Rh Immune Globulin provided protection against Rh immunization in about 50% of subjects when given 13 days after exposure to Rh-positive cells.21

Effect on primary Rh immunization of delayed administration of anti-Rh. [Full text]
Samson D, Mollison PL.
Immunology. 1975 Feb;28(2):349-57.

An intramuscular injection of 100 mug of anti-Rh, given 13 days after an intravenous injection of 1 ml of Rh-positive red cells appeared to suppress primary Rh immunization: at 6 months, none of thirteen subjects so treated had detectable anti-Rh in their plasma, whereas anti-Rh was present in five out of twelve control subjects injected with Rh-positive cells alone (P equals 0.015, Fisher's exact test, one-tailed). Primary immunization was not suppressed in all treated subjects since, following a second injection of Rh-positive cells, 7-day survival was subnormal in three subjects, all of whom had anti-Rh in their plasma after a further 2 weeks. In three other treated subjects, primary Rh immunization appeared to be completely suppressed: survival was normal, or initially normal, following a second injection of Rh-positive cells and anti-Rh was detectable only after a third injection.

From the package insert: "If delivery occurs within three weeks after the last antepartum dose, the postpartum dose may be withheld, but a test for FMH should be performed to determine if exposure to >15 ml of red cells has occurred."  If I am reading the package insert correctly, it says that the half-life is 24 days.

Coccyx Pain / Tailbone Pain

There are a few physiotherapy techniques for pain following coccyx injury.

There is a joint between the coccyx and the sacrum which can be damaged by trauma, usually by falling onto your bum  - but some births can result in what is effectively a "sprain".

Previous injury or simply poor posture can cause stiffness of this joint (can be associated with low back pain, but is often asymptomatic)

An immobile coccyx will reduce the space in the pelvic outlet - so giving birth can cause further damage to the joint causing pain and stiffness.

It can be mobilised quite easily, either directly onto the joint or by stretching the muscles and ligaments which attach to the bone.  The techniques are all fairly intimate and some involve a rubber glove - but they do work, and patients are usually in such discomfort with this that they will try anything!

I had the tailbone pain too.  It was pretty bad after delivery as well.  The one thing that helped me also was the special seat pad that has a cut out where your tailbone is.  It takes the pressure off of it, kind of let's it hang.  I have two, and the soft one made from memory foam is useless.  It squished down too much and didn't work.  I have a one made from a stiffer material that works great.  I still use it on my nursing chair where I read to my 15 month old. Since I'm pregnant again, I'm starting to get the soreness, so it will come in handy again.  

Also, my chiropractor recommended ice.

Yep, I've had that during mine. Chiropracty made it even worse for me (though it has helped others). I ended up buying a $100 specialized seat cushion from Relax the Back (and make sure you try them all) to make my tailbone feel better. It was the only thing that ended up working for me.

I had problems with my coccyx during last pregnancy (but not fractured) just all the ligaments used to go into spasm. I got some useful tips from a chiropractor and also homeopathic hypericum, which is supposed to specifically target nerve-rich areas, such as the coccyx.

St Johns Wort is good for any joint /nerve pain either in tincture form, as an oil for massage or as already mentioned , homeopathically as hypericum. If used as a tincture then adding skullcap is of additional benefit. Both these plants work on nerve endings and neuralgia (pain) .

It's important to avoid compounding the problem by sitting asymmetrically. Perhaps try one of those cushions designed for hemorrhoid use.

Vulvar Pain

See also: Vulvodynia / Vulvar Vestibulitis / Pelvic Pain

After I had my first baby, I had some abrasions on my lateral vaginal walls.  I chose not to have any stitches and let them heal naturally though my midwife said she could've put a stitch or two in.  They healed fine, but every time I had my period, I would feel a soreness in the area where they were.

Hair Loss / Balding

One of my clients had severe hair loss in the months after her birth.  Any suggestions?

Long ago I knew a woman who had this problem, which she fixed by taking lots of extra calcium (I believe) and protein.

You know how a lot of women say that their hair gets thicker during pregnancy?  Well, eventually that extra hair starts falling out.  And then, they have less estrogen postpartum than before pregnancy, so the new hair growth is also less.  They may feel like they're going bald, but this is a normal hormonal change in the postpartum period.

We do just check your Thyroid just in case but in my experience that is normally OK and it is just a case of taking time for the hormones to readjust! I promise that I have NEVER seen a bald mother! There is no harm in treating your hair gently not over washing and of course using kind ingredients that are natural rather than the high chemical shampoos and conditioners that are more usual.

De-stressing helps too - ha ha - but overall try not to worry your hair will come back even more beautiful once it stops falling out!

Vaginal Dryness

Vaginal dryness in the post partum period is associated with breastfeeding. Bottle feeding women also have low estrogen levels in the first weeks postpartum until ovulation returns. Estrogen levels can remain low during the entire period of lactation. This can cause the vaginal epithelium to be very thin and secrete less fluid - leading to atrophy of the vaginal mucosa. Women who are breastfeeding may need to use KY or other water based lubricants. Estrogen creams may also be helpful but it should be noted that estrogen may be quickly absorbed and possibly decrease milk supply. (Riordan - 1993 - in Breastfeeding and Human Lactation)

I don't think drinking extra water will increase vaginal lubrication - although severe dehydration would of course make us all pretty dry everywhere I would guess. With regards to fluid intake and breastfeeding - Just got off the phone with Kathleen Auerbach - who assures me that women should just be counseled to drink to thirst when lactating. The old recommendation of a glass an hour thing is a bit of overkill. In fact - the La Leche League's Breastfeeding Question and Answer Book cautions: It is not beneficial for the mother or her milk supply to force extra fluid. Not only is forcing fluids uncomfortable, but one study found that mothers did not produce any more milk when they drank 25% more fluids than when they drank to thirst. A good acid test of adequate hydration is the absence of concentrated urine and presence of regular soft formed stools.

This is something that a lady shared with me recently. I've run across this problem before and haven't known what to recommend.

This lady has had extreme vaginal dryness since her last birth. Her baby is about 7 months old, and breastfeeding. The walls of the vagina were cracked and red, very sore by her account.

She went to see an OB/GYN who recommended an estrogen cream. She didn't want to use it, so tried Replens, which didn't work so she tried the estrogen cream, which she says didn't help either. I don't know how long she used it.

She did some research on her own, and began taking flax seed oil, and says that now she is completely fine.

Flax seed oil is one of the ingredients in the Progesterone cream I use. It along with other ingred. are there for balancing the hormones. She would be having a lot of estrogen in her blood stream and body since she is nursing. The reason for the vag dryness. The flax seed is one of many things that could correct this problem.

actually, nursing results in a hypoestrogenic state...that's the reason for the vaginal dryness..not enough estrogen.

Vertigo, Dizziness, Lightheadedness


Uterine Prolapse

Alternatives to Surgery for Pelvic Organ Prolapse or Urinary Incontinence

Pelvic Prolapse Is Not Always Chronic and Progressive  CME [Medscape registration is free]

Treating Uterine Prolapse

Prolapse and Pelvic Relaxation and Prolapse Problems Before and after Pregnancy from

PELVIC POWER.® - We are the manufacturers of the audio-cassette series of guided movement lessons for pelvic floor awareness development.

Fembrace - A revolutionary new support garment for relief of the painful symptoms of Genital  Prolapse (Prolapsed Uterus, Cystocele, Rectocele, Enterocele) and Varicose Veins of the Vulva (Vulvar Varicosities).

For someone early postpartum we would have the woman lay on a bed and walk her feet up a wall, put a  clean rolled up sock between the pubis and uterus. then belly band this on.

She can do the yoga "Bridge Pose" at bedtime to tilt the uterus back up high again and let it sit there in the higher position while sleeping. The point is to position it so that the ligaments will naturally tighten, kind of like when a woman wears high heels all the time and eventually the muscles, ligaments, and tendons begin to shorten and hold the foot at the same angle as the shoes...It may take a few months, but eventually the uterus will return to a normal position.

I attended a fabulous workshop on "The Female Pelvic Floor" with Candice Garrett.  She recommends these books:

The Female Pelvis Anatomy & Exercises by Blandine Calais-Germain

Ending Female Pain: A Woman's Manual - The Ultimate Self-Help Guide for Women Suffering from Chronic Pelvic and Sexual Pain by Isa Herrera

A Headache in the Pelvis: A New Understanding and Treatment for Chronic Pelvic Pain Syndromes by David Wise and Rodney Anderson

Leslie Howard also offers lots of Pelvic Floor Resources.

Our local physical therapists recommend that women birth in the side-lying position to prevent a uterine prolapse.  Hmmm, some people just say that not encouraging her to push prematurely will do the job.

Uterine Rupture

Uterine rupture can happen either from obstructed labor in an unscarred uterus or for a variety of reasons in a uterus with a scar from a previous cesarean.  Both are very uncommon, but they can be devastating when they happen.

Here's a support group for those who have experienced uterine rupture.

Lochia / Long-term Postpartum Bleeding

The duration and character of postpartum bleeding among breast-feeding women.
Visness CM, Kennedy KI, Ramos R.
Obstet Gynecol. 1997 Feb;89(2):159-63.

CONCLUSIONS: Lochia lasted substantially longer than the conventional assumption of 2 weeks. It was common for postpartum bleeding to stop and start again or to be characterized by intermittent spotting or bleeding. Return of menses is rare among fully breast-feeding women in the first 8 weeks postpartum.

I would estimate that about 25% of my clients report a sort of mini-period right around 6 weeks postpartum.  They'll say that the bleeding seemed to have stopped a few weeks earlier, but then they had a period that was sort of 1/2 to 2/3 of a regular period for them - the bleeding had a sudden onset and was continuous for a few days, and then stopped completely.

Yes, the WHO references this mini-period as an "end-of-puerperium" bleeding episode.

The World Health Organization multinational study of breast-feeding and lactational amenorrhea. IV. Postpartum bleeding and lochia in breast-feeding women. World Health Organization Task Force on Methods for the Natural Regulation of Fertility.
Fertil Steril. 1999 Sep;72(3):441-7.

OBJECTIVE: To describe and compare the duration of lochia in seven groups of women; to investigate the occurrence of a possible "end-of-puerperium" bleeding episode; and to determine the frequency of bleeding episodes before postpartum day 56, which applies to the practice of the lactational amenorrhea method of contraception. DESIGN: Prospective longitudinal study with fortnightly follow-up, beginning within 7 days of delivery. SETTING: Five developing and two developed countries. PATIENT(S): Four thousand one hundred eighteen breast-feeding women. INTERVENTION(S): Postpartum lochia and all days of bleeding per vaginam were recorded. MAIN OUTCOME MEASURE(S): Duration of lochia, frequency of an end-of-puerperium bleeding episode, and frequency of postlochia bleeding episodes within 56 days of delivery. RESULT(S): The median duration of lochia was 27 days; it varied significantly among the centers (range, 22-34 days). In 11% of the women, lochia lasted >40 days. An end-of-puerperium bleeding episode around the 40th day postpartum was reported by 20.3% of the women. Bleeding within 56 days of delivery (separated from lochia by at least 14 days) occurred in 11.3% of the women and usually was followed by a confirmatory bleeding episode 21-70 days later. CONCLUSION(S): The duration of lochia varied significantly among the study populations, and long durations were not unusual. The significance of the end-of-puerperium bleeding episode is unknown. Most users of the lactational amenorrhea method will not experience a postlochia bleeding episode before postpartum day 56.

Slow Perineal Healing

The postpartum drop in estrogen in a breastfeeding mom can result in slow perineal healing.  Some moms benefit from a little topical estrogen cream applied to the outside of the perineum, on the skin.  (You can get it over-the-counter at Whole Foods.) Because estrogen cream applied to the skin is not absorbed well into the bloodstream, it's not likely to affect breastfeeding.  But a mom using estrogen cream needs to be paying close attention to her supply and stop the estrogen cream if it affects her milk supply.

Estrogen cream and breastfeeding - a nice discussion from a mothering.com forum.

Six-Week Postpartum Exam

See also: Midwife Assistance with Postpartum Integration of Birth Experience

As of 2005, rubella is no longer considered endemic to the United States; you have to wonder whether it still makes sense to recommend rubella vaccination for those with a non-immune status.

At the six-week exam, I give my clients a Breast Self-Exam Shower Card and a Kegels reminder card.

Other resources for Breast Self Exam:

Sign up for your free L.I.F.E. kit - L.I.F.E. is a program created by The Brookwood Women's Medical Center's Breast Health Center

Small J, Lumley J et al (2000) Randomised Controlled trial of midwife led debriefing to reducce maternal depression after operative childbirth, BMJ,
321: 1043-1047

Lavender T et al (1998) Can midwives reduce postpartum psychological morbidity? A randomiszed trial, Birth 25:4  215-219

Postpartum Surveys/Client Satisfaction

In Ontario the midwife is the primary caregiver for mom and baby until 6 wks.

Mom, review antenatal records, i.e. ?last PAP, (we do every 2 years once a normal pap times 3) rubella immune status, discuss perineal healing (if necessary) but always review bladder control i.e. Can you stop your urine flow? If not offer to check perineal muscle tone, finger in vagina, can she squeeze? ( I am very big on keeping my clients out of ATTENDS) Assess emotional status, if I am concerned administer Edinburgh PP scale. Otherwise provide community resources. Then discuss breastfeeding resources in community, resumption of intercourse/sex, need for extra foreplay, lubrication, birth control. Handouts on birth control, PP depression, breast self examination, and baby massage.

We provide a copy of birth records to the woman. A short summary is sent to the family MD, including the baby's measurements at birth and 6 wks, plus comments if appropriate.

We just use the 6 wks pp control for a chat. I ask if anything is OK if she has any questions about her pregnancy or delivery, if the stitches( if any) are giving discomfort, how the bf is going and what kind of contraception she uses. If she has any trouble holding her urine or passing faeces and that is it. The baby is being taken care of at the babywell clinic and paps are done her every 5 years. And gp's do that. If the stitches are still hurting I may have a look or do an internal exam, but not as a rule.

I was taught to delay PP paps until 3 months after birth, since so many will show inflammatory changes at the 6-8 week follow-up. This is not what my texts said, but my preceptor had vast experience, so I took her word for it. Just have a woman come back at 12 weeks PP for the pap. Good time for additional check on breastfeeding and how her contraceptive choice is working.

One local OB/GYN delays the PAP until 12 weeks; I will do it at 6 weeks if she is comfortably having sex, but otherwise, I figure it doesn't make sense to use a speculum on such tender tissues!

Postpartum Sexuality

Post-Partum Sexuality by Elena Tonetti-Vladimirova [August 11, 2014]

Is There Sex After Baby? The New Mom Dilemma
from Aviva Romm

Recipe: Creamy Coconut “Get Some” Ice Cream (Paleo friendly) - About an hour after eating this special blend of high fat awesomeness, your body gets a signal that says, “I am in a land of plenty,” which translates, in evolution-speak to, “It is time to mate. NOW.” Women in particular are most impacted by this side effect of ice cream,

Sex After Children from Mother Nurture

Is There Sex after Birth? from Fathering Right from the Start by Jack Heinowitz

Is There Sex after Childbirth? from Becoming a Father - How to Nurture & Enjoy Your Family by William Sears, M.D.

Postpartum Sex from Having a Baby, Naturally by Peggy O'Mara, Editor and Publisher of MotheringMagazine

The following two references have disappeared from the Internet, which is a real loss as there are so few good articles about postpartum sexuality:

THE CHANGING SEXUALITY SURROUNDING CHILDBEARING WOMEN - A Guide for Doulas and Families in the Postpartum Period

"When sexuality comes to the forefront, encourage partners to communicate their intimate needs to one another. Exploring new avenues of gratification with a partner in lovemaking can be fulfilling and comforting. This is a time for compromise and emotional support. Suggest that a couple take a few moments each day to tell each other what felt good or gratifying in the relationship recently. The postpartum period is always a time for personal growth and change."

[When I followed the link to the following article, my security software went bonkers.  I eventually found a safer way to their website, and their archives have no record of the Fall 2011 issue.
I have no idea why.]

Favoriser la sante sexuelle postnatale des couple lors d'un suivi avec sage-femme
Promoting the Sexual Health of Couples During Postnatal Follow-up with Midwife by Danielle Beausejour and Josee LaFrance
The Canadian Journal of Midwifery Research and Practice (CJMRP) Fall 2011 issue
This article was published in French only.  The abstract only was translated in the publication.

Please contact me with links to more information.  Thank you!

Relaxin and Postpartum Joint Flexibility

I've heard that relaxin remains in the mother's system for up to 6 months after the birth.  A Traditional Chinese Medicine practitioner told me that relaxin levels will remain elevated until the mother weans.  Please contact me to let me know if you have a good source of information for this.  Thanks.

Postpartum Night Sweats

Can you help me with my client. She is 11 weeks postpartum mother of lovely twins. She has horrible night sweat problem. Is there any way to decrease this?

Vitex can help, but it takes time to work AND it may bring back the menses. [from a respected herbalist]

Postpartum Rash

During pregnancy the mother's immune system changes the ratio of T-helper cells between Th 1 and Th 2.  It's understood to reduce immune response to the fetus.  When the T-helper cells are further suppressed by exogenous steroids or severe maternal stress (emotional, physical, nutritional) the immune system can have "inappropriate" responses after delivery.  This would be more likely in an atopic person.

I've used herbal anti-histamines with good success.  Also, the stabilized aloe powder Mannapol helps a lot.

Postpartum Urinary Incontinence

Urine Leakage Not Due to Childbirth - Study of Sisters: Blame Genes, Not Kids, for Later-Life Urinary Incontinence

Urinary incontinence in nulliparous women and their parous sisters.
Buchsbaum GM, Duecy EE, Kerr LA, Huang LS, Guzick DS.
Obstet Gynecol. 2005 Dec;106(6):1253-8.

CONCLUSION: Vaginal birth does not seem to be associated with urinary incontinence in postmenopausal women. Considering the high concordance in continence status between sister pairs, and considering that the majority of parous women are continent, an underlying familial predisposition toward the development of urinary incontinence may be present. LEVEL OF EVIDENCE: II-2.

There's a new way of thinking about incontinence, although it might be more about incontinence due to aging than after childbirth.  But the theory is that if the Kegel muscles are too tight, they can pull the coccyx forward, thus reducing the distance covered by the PC muscle, creating more slack.  Hmmmmm, maybe.  Anyway, the theory is that you need to strengthen your glutes instead, in order to pull the coccyx back out, which will make the PC muscle more taut.

Pelvic Floor Party: Kegels are NOT invited.

Postpartum women should probably start with regular Kegels since the muscles do need toning as the progesterone and relaxin leave your system and allow your muscles to regain more tone.

But if you still have incontinence issues even with good Kegel tone, then you might benefit from the squats recommended to tone the glutes.

hab-it Pelvic Floor exerciser: "When I run . . . When I jump . . . When I sneeze . . . "  If you're living with symptoms of incontinence, this is the place to start taking back control.  Their web pages have educational and instructional video.

More Squats and Fewer Kegels: What Your Pelvic Floor Really Wants by Nicole Crawford - she says that long-term pelvic health benefits more from squats than Kegels. [Ed: it seems obvious to me that postpartum Kegels are beneficial for toning the PC muscle;  let's face it . . . it just had to open to 10 cm to allow a baby to pass through and is still under the influence of relaxin.   But if you have good PC tone and still are having problems with urinary incontinence, then it makes sense to pay attention to squats.]

Stop Doing Kegels: Real Pelvic Floor Advice For Women (and Men)

The Kegel muscles are a sling between the pubic bone and the coccyx.  It makes sense that if there are no muscles holding those firmly in place, then tightening the Kegel muscles may still not be able to provide a firm sling.  However, it also makes sense that the Kegel muscles also need to be well toned.

And although squatting can be a great position for labor because it helps to open the pelvis, many midwives feel that it can contribute to very bad perineal tearing during the actual emergence of the baby.  If a woman feels that she wants to squat for the birth, she might just put one knee down on the floor once the baby's head is in a good crown.

The natural hormones of pregnancy and the fact that the Kegel muscles have to open to a diameter of 10 cm for the baby to pass through mean that the Kegel muscles are going to need toning postpartum, just as the abdominal muscles benefit from toning.  In fact, they're also related, since the abdominal muscles connect to the top of the pubic bone, and the Kegel muscles connect to the bottom of the pubic bone.

Pilates teachers recommend that women toning their abdominal muscles start with a Kegel to stabilize the pubic bone and give the abdominal muscles a stable anchor to contract against.

AND . . . if Kegels don't seem to help with urinary incontinence, then by all means give the squatting theory a chance!  But most postpartum mamas do not have a problem with a tight pelvic floor!

The Kegel8 e-stim home kit has been helpful, and the Myself Trainer for Biofeedback.

The Hab-It and PFilates DVDS are also somewhat good. And the exercises in "The Female Pelvis" by Blandine Calais-Germain are the most specific I've seen - much more then lifting and squeezing, it breaks up the PF muscles into separate components.

A Simple Solution for the Treatment of Urinary Stress Incontinence: LadySystem® Vaginal Cones - Regain Control of your Bladder and Say Goodbye to Urinary Stress Incontinence!

Stimulating the Tibial Nerve Helps Incontinence

New Device is Effective for Recurrent Female Urinary Incontinence [6/2/10] – An investigational minimally invasive device, known as the Adjustable Continence Therapy (ACT, Uromedica, Inc.) system, seems to be an effective treatment for women with recurrent episodes of stress urinary incontinence (SUI) associated with intrinsic sphincter deficiency, researchers reported here at the American Urological Association 2010 Annual Scientific Meeting.

NICE issues new guidance on urinary incontinence in women [10/06] - Doctors in England and Wales have been given new guidance to improve the care and treatment of millions of women who have urinary incontinence.

Alternatives to Surgery for Pelvic Organ Prolapse or Urinary Incontinence

Using a TENS unit to help re-tone the Kegel muscles after birth can be one of the most time-effective methods for busy moms.  MamaSure is a British unit designed for this purpose.

I am getting furious when people talk about incontinence as a result of childbirth... yes it is a result of non physiological childbirth.
Kegels are a great way to bring things back to place... and it really works!

I feel that women that try to avoid vaginal childbirth and try not to mess with the pelvis and the vagina as a way to restore their youth and their sexuality are actually doing the opposite, they don't develop relationship with their vagina and prefer to ignore this area. Sex is not only for young women with tight vaginas. Actually vaginas are not necessarily tighter before childbirth, it depends on how one uses those muscles.

Another thing that no one tells women is that childbirth can actually benefit their sexual response. Some women find their orgasmic response much more reliable and intense after vaginal childbirth (well not immediately after childbirth) - but this is another topic that needs an in depth research.

Promoting Effective Recovery from Labor - The PERL Project team consists of experts in nursing, midwifery, medicine, and bioengineering who care about safe, healthy, and satisfying birth.  We bring a wide range of specialized knowledge about childbirth and urinary incontinence to the project.

Ankle Dorsiflexion May Increase Pelvic Floor Muscle Activity  CME [Medscape registration is free]

Mode of Delivery and Pelvic Floor Dysfunction: a Systematic Review of the Literature on Urinary and Fecal Incontinence and Sexual Dysfunction by Mode of Delivery  [Medscape CME/CE]

Acupuncture May Be Effective for Overactive Bladder - Acupuncture may be effective therapy for overactive bladder, according to the results of a
randomized study reported in the July issue of Obstetrics & Gynecology. [Medscape registration is free]

Acupuncture for overactive bladder: a randomized controlled trial.
Emmons SL, Otto L.
Obstet Gynecol. 2005 Jul;106(1):138-43.

CONCLUSION: Women who received 4 weekly bladder-specific acupuncture treatments had significant improvements in bladder capacity, urgency, frequency, and quality-of-life scores as compared with women who received placebo acupuncture treatments.

Randomised controlled trial of conservative management of postnatal urinary and faecal incontinence: six year follow up.
Glazener CM, Herbison GP, Macarthur C, Grant A, Wilson PD.
BMJ. 2004 Dec 22

"The moderate short term benefits of a brief nurse-led conservative treatment of postnatal urinary incontinence may not persist, even among women with no further deliveries. About three quarters of women with urinary incontinence three months after childbirth still have this six years later."
[Ed.  I'm not sure, but I think this means you need to keep doing your Kegels!!!]

Physiotherapy Helpful for Persistent Postnatal Stress Urinary Incontinence  CME [Medscape registration is free]

Urinary incontinence predictors and life impact in ethnically diverse perimenopausal women. - Medscape commentary [Medscape registration is free]
Sampselle CM, Harlow SD, Skurnick J, Brubaker L, Bondarenko I.
Obstet Gynecol 2002 Dec;100(6):1230-8

"Large numbers of perimenopausal women experience urinary incontinence with 25% wearing protection or changing undergarments on several days per week. Mutable factors predicting severity included body mass index and current smoking."

Pelvic floor muscle training during pregnancy to prevent urinary incontinence: a single-blind randomized controlled trial.
Morkved S, Bo K, Schei B, Salvesen KA.
Obstet Gynecol 2003 Feb;101(2):313-9

"Intensive pelvic floor muscle training during pregnancy prevents urinary incontinence during pregnancy and after delivery. Pelvic floor muscle strength improved significantly after intensive pelvic floor muscle training."

Medscape resources about urinary incontinence [Medscape registration is free]

PELVIC POWER.® - We are the manufacturers of the audio-cassette series of guided movement lessons for pelvic floor awareness development.

Kegelmaster from Susan Lark's web pages - DrLark.com

Research has shown that gentle electrical stimulation can be very effective in toning the Kegel muscles and reducing urinary incontinence.  One approach was to have the woman sit on a chair with gentle electrical stimulation.  You can apparently also purchase vaginal probes to be connected to a TENS device.  Weston's in the UK has a Discreet Stimulator Pre-Programmed Single Channel Pelvic Floor Stimulator.

This is just a wild guess about what might work to strengthen Kegel muscles - try taking more vitamin D!

Higher Vitamin D Levels Linked to Lower Risk for Female Pelvic Floor Disorders

Postpartum Fecal Incontinence

Fecal Incontinence - from the AAFP

Does cesarean delivery protect the pelvic floor?

Nelson RL, Furner SE, Westercamp M, Farquhar C. Cesarean delivery for the prevention of anal incontinence. Cochrane Database of Systematic Reviews 2010, Issue 2. Art. No.: CD006756. DOI: 10.1002/14651858.CD006756.pub2.

Some women experience leakage of stool or gas while their perineum is healing in the postpartum period, and for some women this problem can become chronic. With age, the number of people with anal incontinence rises, and an estimated 1.4% to 11% of adults and over 50% of nursing home residents have this problem. Cesarean delivery has been proposed as a way to protect the integrity of the pelvic floor and avoid incontinence. A new systematic review explores whether cesarean section is associated with lower rates of anal incontinence than vaginal birth.

This review includes 21 observational studies that compared the odds of anal incontinence following 6,028 cesarean births with the odds of the problem following 25,170 vaginal births. No randomized controlled trials on the subject were found. The quality of the studies was assessed, and because observational studies are subject to more bias than randomized controlled trials, the authors included in their quality assessment whether the studies were prospectively designed, adjusted for maternal age, parity and delivery history, and whether incontinence was measured after 4 months postpartum when the perineum had time to heal. The studies of highest quality were also analyzed separately to see if the results differed from those of lower quality studies. No high quality studies showed any significant difference in incontinence of stool and none of the studies showed any difference in leakage of gas between women undergoing cesarean delivery and those giving birth vaginally.

The take-away: This review shows no evidence that cesarean delivery protects a woman from future anal incontinence compared to vaginal birth. US cesarean rates have increased by 50% in the last decade and are currently at a record high of 31.8% as of 2007. Some have suggested that "maternal demand" cesarean section is contributing significantly to the rising rate of c-section, a practice associated with numerous increased risks when compared to vaginal birth. The authors of this review cite research that suggests avoiding incontinence is the main reason women with no medical indication for c-section elect to have their babies this way. Both of these suggestions are controversial. Just one mother out of 252 in the Listening to Mothers II survey reported that she had a first cesarean birth at her own request with no medical reason, and only one woman reported a cesarean delivery in the belief that it would help prevent future incontinence.

Fecal Incontinence: Failure of the anal sphincter to prevent involuntary expulsion of gas, liquid, or solids from the lower bowel (Tabers Cyclopedic Medical Dictionary, 1993).

Obstetric events leading to anal sphincter damage.  [Related articles]
Donnelly V, Fynes M, Campbell D, Johnson H, O'Connell PR, O'Herlihy C
Obstet Gynecol 1998 Dec;92(6):955-61

Instrumental delivery and a second stage of labor prolonged by epidural analgesia are the obstetric factors that pose the greatest risk of injury to the anal sphincter mechanism in primiparous vaginal delivery.

I have a client who delivered almost 2 weeks ago. Her first baby, 8lbs even, 3 hours active labor, pushed 25 minutes. Baby did have a nuchal arm that was pressing right into the rectum. Other than very minor skid marks, the perineum was intact.

Since she delivered, she's had a couple of episodes of unexpectedly passing stool. Once in the bathtub, and 3 times while standing holding baby.

Her anal sphincter seems to be intact and with normal tone. Her uterus is slightly retroverted and may slide down into the rectum when she stands. She saw an MD and he didn't find anything abnormal.  He actually told her that since she's asymptomatic, he wouldn't try to treat it!

I have her doing knee chest and slant board exercises and Kegels. She doesn't seem to be having trouble with the Kegels - can do 50 at a time pretty easily. I'm having her do fewer each session but holding a lot longer.

Any other ideas? She's afraid to leave the house.

I just read about this in my Nurse Midwifery Handbook by Linda Wheeler. She says that this is a very underreported problem and actually quite common. She claims "1 out of 10 primiparas and 1 out of 5 multipara who deliver vaginally may experience fecal urgency or the involuntary loss of flatus or feces." She goes on to say the symptoms usually disappear after 6 mos. and encourage Kegels. I did not see any other response to this question on the list. Were there a lot of private responses? Now I'm really wondering if others have had women with this problem and if most are routinely inquiring. I find those #'s hard to believe, but maybe with the high rates of epidurals, episiotomies, forced pushing, etc., they are correct. We probably are seeing much less in our practices.

Homeopathic Apis Mellifica can help.


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