After the Afterbirth: A Critical Review of Postpartum Health Relative to Method of Delivery

Noelle Borders, CNM, MSN

Disclosures

J Midwifery Womens Health. 2006;51(4):242-248. 

In This Article

Methods

A search of the literature for peer-reviewed journal articles was conducted in CINAHL, PubMed, and Cochrane Database of Systematic Reviews. Search phrases included, but were not limited to, postpartum health, health after childbirth, postpartum depression, postpartum urinary and bowel function, sexual function after childbirth, postpartum functional status, postpartum fatigue/tiredness. The search was not limited to the last 15 years; however, the vast majority of articles on postpartum health have been published since 1989. The policy document from the World Health Organization on Postpartum Care of the Mother and Newborn also informed this research.[4]

Traditionally, the postpartum period has been defined as beginning 1 hour after delivery of the placenta and lasting 6 weeks, at which time the uterus has regained its prepregnant size.[5] This narrow focus on the recovery of the mother's reproductive organs has resulted in neglect of the rest of a woman's physical and mental health. Both mothers and clinicians have voiced concern over the lack of knowledge about physical and psychological health after childbirth and the duration of postpartum recovery.[2] For the purposes of this overview, postpartum health will be considered in the following time periods: immediate postpartum (birth to 3 months), short-term (3 to 6 months), and long-term (>6 months). In reality, most postpartum health challenges that a woman faces overlap the time periods defined by researchers; some health issues may originate in the antenatal period.

Table 1 summarizes the most common postpartum symptoms reported in literature. In the immediate postpartum period, 87% to 94% of women report at least one health problem.[6,7] Backache, urinary stress incontinence, fecal incontinence, urinary frequency, depression and anxiety, hemorrhoids, extreme tiredness, frequent headaches, and migraines can pose problems for new mothers.[8,9,10] Perineal pain, constipation, increased sweating, acne, hand numbness or tingling, dizziness, and hot flashes are also common.[6,7,11,12,13] Up to one third of women have reported backache lasting up to 3 months after childbirth.[9] Rates of stress incontinence can range between 6% and 24% at 3 months postpartum.[14,15] Approximately 10% of women will experience depression in the immediate postpartum period; the prevalence rate any time during the first year is 7% to 30%, depending on how postpartum depression is defined and measured and when it is measured.[16,17,18]

Many women, whether lactating or not, report breast problems, including discomfort, sore nipples, and infection.[12,13] Sexual problems, including dyspareunia and decreased libido, have been reported by up to 53% of women in the immediate postpartum period, and have been shown to peak at 3 months after delivery. Breastfeeding has been demonstrated to decrease libido in the immediate and short-term periods, but this decrease does not extend long term for most women.[19] Two small studies attempted to assess new mothers' functional status at 6 weeks postpartum. Functional status was defined as a mother's ability and readiness to integrate her new role as mother with her other duties in the household, community, and workplace and to resume self-care activities.[20] None of the mothers had resumed full functional status per self-report by 6 weeks postpartum. Many women experienced inadequate social support, disturbed sleep patterns, and dissatisfaction with energy level and well-being.[20,21]

From 3 to 6 months after the baby's birth, many of the immediate problems slowly resolve. However, some women will experience new health issues. These issues appear for the first time, have been masked by other problems, or emerged in the early postpartum period but only over time are construed to be problematic. Exhaustion, back pain, headaches, depression, sexual problems, urinary incontinence, persisting perineal pain, constipation, hemorrhoids, breast complaints, muscle and joint pain, and relationship problems are all common.[7,12,13,22,23] Researchers have noted that women in the first 6 months postpartum also suffer from more upper respiratory symptoms, stomach illnesses, and infections than is typical for healthy women.[12,13,24] Women's functional status can continue to suffer from 3 to 6 months postpartum, perhaps indicating the cumulative effect of sleep deprivation in mothers of infants.[20]

In the United States, by 6 months postpartum the majority of women employed outside the home have returned to work and are balancing household and work responsibilities; in addition, women may also be grappling with physical and mental health issues. Some of these health issues, specifically fatigue, backache, and depression, have been demonstrated to actually increase over time.[25,26] Long-term backache, stress incontinence, sexual problems, hemorrhoids, and depression doggedly persist in a significant number of women beyond 1 year postpartum.[12,14,17,19,27,28] Urinary and fecal incontinence have the potential to become chronic problems, especially if the etiology included pudendal nerve damage.[29] In conclusion, postpartum morbidity lasts well beyond 6 weeks. Women experience an array of symptoms, the majority of which they may never report to health care providers.[6,17,30,31]

Discussion of the impact of delivery method on postpartum health is complicated by several factors. First, the vast majority of research in this area was conducted in the United Kingdom, Australia, New Zealand, and Scandinavia, where midwives perform a large portion, and in some cases, the majority, of obstetric care. Furthermore, cesarean birth rates are substantially lower and postpartum care is much more comprehensive than in the United States. Second, most studies did not define whether episiotomy was performed or if assisted vaginal birth was accomplished by forceps or vacuum extraction. Third, researchers rarely indicated whether cesarean birth was planned or emergent. For all these reasons, generalizability of these findings to a US population of postpartum women should be made with caution.

Glazener et al. surveyed 1249 women in Scotland at 1 week, 8 weeks, and 12 to 18 months postpartum. They determined that during the initial postpartum period, women with a cesarean birth or assisted vaginal birth fared significantly worse than women after spontaneous vaginal birth. Specifically, 93% of the cesarean birth group, 96% of the assisted vaginal birth group, and 84% of the spontaneous vaginal birth group reported at least one health problem. Women having assisted vaginal birth were more likely to report at least one health problem: most commonly, painful perineum, constipation, hemorrhoids, and breakdown of stitches. At 8 weeks postpartum, 7% of women who had a normal spontaneous vaginal birth reported a painful perineum, irrespective of episiotomy, compared with 30% of women after assisted vaginal birth.[6] Other studies also found that after assisted vaginal birth, women had significantly more perineal pain and sexual problems.[7,19,23,32,33] MacArthur and colleagues surveyed 7879 women in Scotland, England, and New Zealand. Women who delivered by forceps had almost twice the risk of developing fecal incontinence within 3 months than women who delivered spontaneously; vacuum extraction did not increase a woman's risk for developing fecal incontinence. Although cesarean birth did offer some protection against fecal incontinence, some women who delivered by cesarean birth did develop fecal incontinence, so this protection should not be overstated.[10]

Women experiencing cesarean birth have reported higher levels of tiredness, breastfeeding problems, constipation, depression, anemia, headache, difficulty voiding, abnormal bleeding, urinary tract infection, abdominal pain, and vaginal discharge than their counterparts who had a spontaneous vaginal birth.[6,34] The International Randomized Term Breech Trial followed 1596 women and reported that although women who had a cesarean birth were less likely to have urinary incontinence and perineal pain than women experiencing vaginal delivery, the groups reported no difference in rates of dyspareunia (17% of cesarean birth and 18% of vaginal birth).[34] In a study of 971 women in Washington State at 7 weeks postpartum, Lydon-Rochelle et al. reported that half of the women reported no problems at all when going about their usual activities after spontaneous vaginal birth, compared with one third of the women after cesarean birth. Compared with the postpartum problems experienced by women who had a spontaneous vaginal birth, women who experienced a cesarean birth reported more bodily pain, and women who experienced an assisted vaginal birth reported more bodily pain and troubling urinary or bowel issues.[33]

Although urinary symptoms have the potential to increase over time, these problems do not seem to be related to assisted or spontaneous vaginal birth.[6,15] In a study by Thompson et al., cesarean birth protected against urinary stress incontinence at 8 weeks, but this association did not last. Danish researchers also noted that cesarean birth protects against stress incontinence only in the immediate postpartum period.[7,14] By 6 months postpartum, women who were delivered by cesarean birth were more likely to report other urinary problems than women in the other two delivery groups.[7] One study indicated that having three or more cesarean deliveries negated any protection that cesarean birth offered against incontinence.[15] Backache occurred most commonly after cesarean birth, and hemorrhoids after assisted vaginal birth; neither headache nor tiredness were related to method of delivery.[6,7] Perhaps more intriguing because of widespread belief to the contrary is that depression at any time postpartum appears unrelated to method of delivery.[6,7,16,34,35,36,37]

Readmission to the hospital after the birth of a baby is a relatively rare event. Although data are not collected nationally, the proportion of women readmitted to the hospital in the postpartum period is estimated at 1.2% to 3%.[6,38] Lydon-Rochelle et al. discovered that after cesarean birth and assisted vaginal birth, women had an 80% and 30% increased risk of rehospitalization, respectively, compared to women after spontaneous vaginal birth.[38] Thompson et al. found the same association between cesarean birth and assisted vaginal birth and hospital readmission.[7] Women have an increased risk for rehospitalization due to postpartum hemorrhage, uterine infection, obstetric surgical wound complications, cardiopulmonary and thromboembolic conditions, gallbladder disease, genitourinary tract conditions, pelvic injury, and appendicitis after cesarean birth or assisted vaginal birth, compared with her counterpart after spontaneous vaginal birth.[38,39] Although readmission to the hospital may occur relatively infrequently, the women who are admitted are very ill. The sequelae of their illness impact not only their postpartum recovery but also the physical and mental health of their newborns and family.

Women who have an assisted vaginal birth continue to have more problems after 6 months postpartum than women experiencing spontaneous vaginal birth. Brown and Lumley gathered information via postal survey from 1336 Australian women at 6 to 7 months postpartum. They found that of the women they surveyed at 6 to 7 months postpartum, those experiencing assisted vaginal birth (which was accomplished almost exclusively by forceps) had the highest rates of morbidity.[31] These women were 5 times as likely to report perineal pain and twice as likely to report sexual problems, urinary incontinence, bowel problems, and hemorrhoids than women who delivered spontaneously. The association of assisted vaginal birth with perineal pain and sexual problems remained significant even after adjustment for differences in infant birth weight, length of labor, and perineal trauma.[31] In a study of 1942 primiparous women in Massachusetts, Robinson et al. found that women who delivered by forceps with or without episiotomy were 10 times as likely to experience significant perineal trauma than women who delivered by vacuum extraction without episiotomy.[40] Various researchers have noted that persistent perineal pain is associated with assisted vaginal birth, especially forceps delivery.[6,19,23] Glazener's survey found that 91% of women had a health complaint from 2 to 18 months after assisted vaginal birth.[6,19] In their study, Brown and Lumley noted that fewer than 1% of women with an intact perineum, including women after cesarean birth, reported problematic perineal pain; furthermore, women with an episiotomy were much more likely to report perineal pain and sexual problems than women having a repaired laceration.[31] Johanson et al. analyzed the postpartum health of 313 women in the United Kingdom who had been randomized to either forceps or vacuum delivery and found that in the second year postpartum, 21% of women after spontaneous vaginal birth and 37% of women after assisted vaginal birth reported having dyspareunia. Women who had sustained perineal injury experienced dyspareunia at a rate of 35% compared to 17% of women with an intact perineum.[32] In a 5-year follow-up of 228 of these 313 women who had assisted vaginal birth, the authors found that maternal morbidity was very common, almost half of the women had some degree of urinary incontinence, 44% experienced bowel habit urgency, and 20% had loss of bowel control sometimes or frequently. Bowel and urinary dysfunction were equally prevalent between women who had had a vacuum extraction or forceps delivery.[41]

After cesarean birth or spontaneous vaginal birth, women report generally similar rates of morbidity in the long term.[6,31] Glazener et al. detailed that from 2 to 18 months postpartum, 73% of women after spontaneous vaginal birth and 77% of women after cesarean birth reported one or more health concerns. Women after spontaneous vaginal birth are more likely to have issues with urinary incontinence, hemorrhoids, and perineal pain, whereas women after cesarean birth report higher levels of tiredness, problems breastfeeding, backache, headache, vaginal discharge, and other infections, although these differences did not all reach statistical significance.[6,31] After cesarean birth, women are also at increased risk for formation of adhesions, intestinal obstruction, and bladder injury during subsequent laparotomies. In later pregnancies, placenta accreta, placenta previa, and uterine scar dehiscence are more likely to occur in women after cesarean birth than after vaginal birth.[42] Several researchers concluded that tiredness was common beyond 6 months postpartum and not related to method of birth.[6,7,31]

Despite the consistent finding that delivery mode is not associated with postpartum depression, a study of 245 British women revealed some intriguing findings about maternal satisfaction with the birth experience over time. Women who had a normal spontaneous vaginal birth experienced high feelings of fulfillment and low levels of distress or sense of being cheated at 72 hours after delivery. These feelings persisted after 6 months, and women's perceptions of difficulties at delivery had decreased. Women who had assisted vaginal birth or cesarean birth under general anesthesia had low levels of fulfillment and high levels of distress, perception of delivery difficulties, and sense of being cheated at 72 hours and at 6 months postpartum.[43] Women who experienced emergency cesarean birth also reported that reliving the birth was problematic in the postpartum period.[31] Table 2 highlights some postpartum symptoms relative to delivery method.

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