Prep for baby, postpartum, and ‘fourth trimester’

Podcast: Certified nurse midwife Kayla Quinn defines what’s normal, what’s not after delivery

Prep for baby, postpartum, and ‘fourth trimester’

Episode Transcript

Kayla Quinn, CNM:

For most families in general, it’s just the unexpected, right? You don’t have any idea what to expect if it’s your first baby. And so, it’s the, “I have no idea what this is going to be like. How will I know what a contraction feels like? How will I know if my water breaks what should I bring to the hospital?” There are so many questions, so with our patients, we try to address all that in our prenatal visits.

Courtney Collen (Host):

Hello and welcome to “Her Kind of Healthy,” a health podcast series brought to you by Sanford Women’s. I’m your host, Courtney Collen with Sanford Health News.

We want to start new conversations about age-old topics, from fertility to managing stress, healthy living, and so much more. “Her Kind of Healthy” is designed to bring you honest conversations about self-care, happiness, and your overall well-being with our Sanford Health experts.

In this episode, we are focusing on postpartum and what women can expect those first minutes, hours, days, weeks after pregnancy, labor and delivery, often referred to as the fourth trimester. I have with me Kayla Quinn, who is a certified nurse midwife at Sanford Medical Center in Fargo, North Dakota. Kayla, so glad to have you. Thanks for being here, and welcome.

Kayla Quinn, CNM:

Thank you.

Courtney Collen:

Full transparency, and a note for the audience – I just reached 34 weeks in my pregnancy, so I’m very thankful to have this conversation as I look ahead to my own labor and delivery at Sanford Health in Sioux Falls. But in talking to my provider, reading about this process, trying to get as much education as I can, Kayla, it really is an overwhelming journey. So, I wonder, as a midwife working with women in this same journey what do you hear and how might you be able to ease any anxious feelings or fears during this time as we look ahead?

Kayla Quinn, CNM:

For most families in general, it’s just the unexpected, right? You don’t have any idea what to expect if it’s your first baby. And so, it’s the, “I have no idea what this is going to be like. How will I know what a contraction feels like? How will I know if my water breaks what should I bring to the hospital?” There are so many questions. So, with our patients, we try to address all of that in our prenatal visits.

Courtney Collen:

OK, so let’s move to some of those common side effects or symptoms, post labor and delivery. We know Kayla, there will be blood. Talk about what we can expect and, and how long the bleeding might last. What care products we might need to bring or might Sanford be able to provide. How much bleeding is too much bleeding? Let’s just dive right into that real quick.

Kayla Quinn, CNM:

Absolutely. There’s a lot of blood and it’s always going to look like a lot more to you than it does to us. So, you can expect to see the most bleeding immediately after delivery. That’s when there’s going to be a lot. After that, our goal is for it to not be super heavy, but I do tell people expect it to be like a moderate to heavy period for at least one to two weeks. The first week is usually kind of the worst, where it’s a little bit heavier. You might have some small clots, and that’s OK. Really the ones that we want you to be concerned about is if they’re kind of like a golf ball size or bigger. If you’re having clots that are golf ball size or bigger while you’re in the hospital, definitely let your nurse know.

If you’re having gushes of bleeding that are filling up an entire pad an hour, let your nurse know. And same thing goes for when you go home from the hospital. The good news is we have all the pads you could ever want when you’re in the hospital. We start you out with a diaper pretty much, and hopefully by the time you go home, sometimes we can have you down to more of a normal sized pad. But we’ll start you out with diapers at the hospital. Don’t worry. Every postpartum mom gets to experience the diaper and the mesh underwear.

Courtney Collen:

So, mom and baby both get a diaper?

Kayla Quinn, CNM:

Mom and baby both get a diaper. Yes, absolutely. So, Sanford does have the disposable underwear and pads for you there. So you don’t have to bring any of that with. If you want your own underwear, I do recommend you bring some that are a little bit bigger than normal and usually more high-waisted. Especially in case you do have to have a cesarean section and there is an incision, we want them to sit above where that incision would be just for comfort. But again, you’re sticking a diaper sized pad in there, so you’re going to need a little extra room in your underwear. But otherwise, yes, Sanford provides those.

Once you get home, I recommend that people have kind of a variety of different unscented pads when you get home because it does, it just gradually decreases and you’re going to start with kind of like a moderate period, and then it’ll go down to spotting, and then it might increase again for a day or two and then go back down to that spotting and really light.

So, having everything from some overnight pads all the way down to pantyliners. So, you kind of want a little bit of a variety. You don’t have to have jumbo packs of everything. Your bleeding really should only last about three to five weeks. But the heaviest will be in that first one to two weeks. Once you get home, if you are having a pad on and you saturate that in one hour, if you’re bleeding so much that you’re saturating a pad in an hour, we want you to come in and get checked out because there might be something we need to look further into.

Biggest things when you get home, I tell people:

  • Watch for any fevers. So, if you have a fever over a 100.4 especially if it won’t come down after Tylenol, we want to know about it.
  • If you’re saturating a pad in an hour or having multiple golf ball-size clots, we want you to come in and get checked out.
  • If you’re having any signs of mastitis, which is really hot, red spots on your breast, usually that’s accompanied by a fever, you kind of feel like you have the flu. If you get that, call your provider right away. Usually we can get some antibiotics pretty quick and it’ll heal up. Don’t stop breastfeeding though. Keep breastfeeding and then we’ll kind of clear up that infection.
  • If you have severe abdominal or perineal pain or all of a sudden, your swelling that you had after delivery, if that all of a sudden increases a lot, then I want you to come and get checked out also.

Courtney Collen:

Let’s move to tearing and the types of tearing as it relates to a vaginal birth. What types of tearing might we expect or what that care journey, that recovery journey specifically looks like and some of the supplies that could aid in that recovery?

Kayla Quinn, CNM:

Vaginal tearing is pretty variable. You can have everything just from little, little tiny, what we call almost skid marks or little tears by the urethra. Otherwise there’s first- and second-degree tears. Those are a lot more common where the muscle tears a little bit, but it’s not extremely deep. And then there’s third- and fourth-degree tears that really tear really deep into the perineal muscle and down into the rectum, and sometimes even involve the anal sphincter.

Care for each of those is a little different. With those superficial or those periurethral tears, we do recommend using your spray bottle, although you’re probably going to use that for all the tears. But those ones will really sting while you’re going to the bathroom that first few days.

So the hospital will provide you with what’s called a peri bottle, kind of just this little squirt bottle. You put warm water in it and really just squirting it on your perineal area while you’re urinating because it really takes that sting away. Keeps everything nice and clean down there for you. You’ll probably use that for the first one to two weeks when you go home.

So the hospital will give you that, all sorts of ice packs which will be great. We have ones that are pre-made. We can make some up for you. A lot of people have – a lot of kits now come with the gel ice packs. Honestly, I leave those at home. Keep them in your freezer. We’ll take care of all the stuff, especially with the real heavy bleeding the first few days. Let us use ours and the disposable stuff so you don’t have to worry about yours. And then there’s also numbing spray that we can give you afterwards that you use after using the bathroom and that can help.

Back to the tears, all of them are sutured if they’re bleeding especially. But the second, third, fourth degree almost always have some sewing involved. Those stitches do all dissolve, so it’s scary getting the stitches, but you don’t have to come back in and have them removed again, so they’ll just dissolve on their own. And the biggest thing is just especially with those third- and fourth-degree tears is making sure when you’re using the bathroom, you’re not doing any straining. And same with when you go home, not doing any heavy lifting because you don’t want any straining on those stitches, especially those first couple of weeks. As far as healing goes, the little ones, they heal up fast actually within a couple weeks. The second, or first- and second-degree tears take about two to three weeks to heal. Maybe a touch longer for all of the suture to dissolve. But within that first two, two to three weeks, they’re pretty well healed up.

The third and fourth degree, those can take anywhere from more of that four to six weeks before those are fully healed. With any of those, especially the more in-depth ones, you could have a little bit of like urinary or fecal, stool incontinence. Some of that’s just after delivery. Everything’s a little bit looser. Perineal are a little looser. And so if that happens for the first week or two, that’s OK. It’s if we’re getting past that about two weeks, we want to know about it.

Courtney Collen:

Is there any way, Kayla, to prevent even just those third- and fourth-degree tears that we can do ahead of time during the late stages of our pregnancy? Anything we can do to avoid any of that or is it pretty inevitable for most?

Kayla Quinn, CNM:

I don’t want to say inevitable because it just depends on your body tissue and how viable it is. The biggest thing is we don’t recommend a ton of like trying to stretch yourself before. Sometimes that can cause more swelling. A lot of it is going to be listening to your provider at the end when you’re pushing. If you just start pushing, pushing, pushing and don’t take any breaks and you might be a little more likely to have a little deeper tear, whereas it feels awful, there’s a lot of pressure at the end, but letting your pressure stay there and letting that perineum stretch naturally. Listen to your provider during that point, because we can prevent some of it just by not going too fast at the end.

Some of it’s going to be inevitable though. And it just really depends on body type. Hopefully it’s not too bad, but we’ve got all the fun stuff. Medications and ice packs will be your friend. We really recommend using ice packs, especially that first 24 hours just to kind of get the swelling down. Help with some of that, help numb up things up a little bit after that.

Taking warm tub baths or sitz baths, a lot of people have heard of those. Sitz baths specifically are like a basin you can buy, and it sits on the toilet and warm water kind of flushes over the perineal area. But if you have a bath at home, enjoy the full bath experience. You just want to fill your tub up with warm water. Our facilities have tubs also to use after delivery. It’ll be filled with some warm water.

If you’re at home, Epsom salts are great for healing. The recommendation is about half a cup of Epsom salts per gallon of water. So pour those in and really just make sure your whole bottom is soaked. But hey, if you take the whole bath, that’s great. And relax a little bit. And really soaking that bottom though for about 15 to 20 minutes, one to two times a day. I usually say try two, especially with those worst tears. It’s just sometimes hard to do if you’ve got a baby who wants to feed constantly too. But shooting for at least one a day can really help with the healing and help those stitches heal a little easier. Make it less painful for you and just make the whole process a little smoother.

Courtney Collen:

I’m learning so much. Kayla, thank you for all the information. So, the next topic I want to talk about Kayla – C-section birth or cesarean section. For our listeners preparing for a C-section or cesarean birth the recovery process may be a little bit longer. I understand because this is a major surgery. So first, what are your biggest tips to prepare for a C-section birth and then we’ll move to recovery and what to expect after that?

Kayla Quinn, CNM:

Yeah, so preparing is a little bit different, especially if it’s a planned cesarean, right? You’ve got food picked out, there’s usually a time that they’ll schedule you. And so, the biggest thing is they’ll tell you before, “nothing to eat or drink before your surgery.” And I like to tell people like, just remember it is a major abdominal surgery, like you said. So, there is going to be some pain. We don’t expect your pain to be zero afterwards, obviously we want it to be as low as possible and we’re going to help you get there. But to be expecting that there will be some. Abdominal binders are my favorite thing after cesarean section for mamas to use, so if you have one that you really like at home or say you’ve researched or a friend or someone really loved one, bring it with you to the hospital.

The hospital does have them also, but if you have your own and you really like it, awesome, bring it with you and we can help you get it situated on after that first day. But bring that with you.

If preparing for a C-section your hospital bag, loose clothes. You can wear the hospital gown as long as you want, but if you want your own clothes, make sure that they’re high-waisted, loose leggings or sweatpants, something that’s not going to rub against that incision. Same thing, loose underwear that sits higher, high-waisted everything. Because you just don’t want to be rubbing against that incision.

Things kind of to expect, there’s multiple different ways that surgeons cover that incision. Some will have glue and that’s just going to dissolve on its own or kind of flake off on its own after about 10 to 14 days. Some put steri strips or like butterfly strips over the incision and those just fall off on their own after about seven to 10 days. Some use it like a dressing that stays on for about seven days and you keep that on until you go home, and you peel it off about seven days later your own.

And so the biggest thing is people always are worried, can I shower after I have a C-section? Absolutely. We recommend getting you up and into the shower the next day and water can run over your incision. Soap can run over the incision. We just don’t want you scrubbing at it. So don’t rub, don’t scrub at it. And even more importantly, just make sure to pat it dry very well afterwards. Keeping it dry and clean is the best thing you can do for healing with an incision.

Like I said, you’ll have some pain afterwards and so that first 24 hours sometimes isn’t so bad because you’ve got all the great surgical medications on board still. It’s after that. So we have oral medications, we have IV medications. It’s really just being honest and open with your nurse and not trying to be too tough. Because like we said, major abdominal surgery. We want you to not take too much, but also don’t think you don’t have to take anything either. After vaginal birth, we usually expect to discharge home after about 48 hours. And a C-section will be after about 72 hours. So three days, expect about three days in the hospital. The recovery time is a little bit longer. Vaginal delivery we expect you to kind of be up and moving and feeling pretty good within about three to four weeks.

C-section could be closer to those six to eight weeks. Most people though still feel a lot closer to their normal by about two to three weeks. So, I don’t want people thinking, “eight weeks I’m going to feel this much pain and it’s going to be awful.” No, the first week is probably going to be the worst. And where you’re going to be kind of just slow moving and need a lot more help. I recommend having someone at home with you that first one to two weeks, because bending to get diapers or change diapers, all of like those bending motions and even just diaper changes in general can be a little more difficult right away. So having somebody there to help you most of the time, that first one to two weeks, we recommend no driving that first week due to pain and if you’re taking any narcotic medication, obviously.

And so again, making sure you’ve got someone on board to help with catering you around. We recommend no heavy lifting over 20 pounds when you get home. So, a baby in the car seat is usually OK. But I like to tell parents who have other kiddos at home to kind of start preparing for that because that’s a hard, hard thing to come home and then say, “Mama can’t lift you up anymore.” So, teaching your little ones to be monkeys before you go in and really just kind of making, having those conversations with your younger kiddos before you go in that, especially those first few weeks, mama’s got a big owie and we need to limit some of that lifting.

Being a lot more careful too with signs of infections. So we talked about some of those earlier. The fever, the heavy bleeding, but also at the C-section, if there’s any like redness or drainage around your incision, that’ll be an extra thing to watch for after a C-section or really, really severe abdominal pain that won’t go away.

Courtney Collen:

Good information again, Kayla. Thank you. So with regard to a C-section or vaginal birth, let’s talk about some other common symptoms that women can experience in that early postpartum period, that maybe we don’t always hear about or talk about but should be on the lookout for or should expect. I hear about urinary and bowel incontinence, vaginal discharge, constipation – talk about a couple of those things, and maybe when to seek care if something isn’t normal or something that we feel should be cared for.

Kayla Quinn, CNM:

We kind of touched on the urinary and fecal incontinence. If it’s lasting more than one to two weeks, definitely kind of want to check on that. Kegel exercises are great. We don’t do a ton of physical therapy before about six weeks, so kind of knowing that it is normal, all those muscles take some time to strengthen up again. But if it’s constant after about two weeks, we want to make sure nothing is damaged there.

Constipation’s a big one, and everybody’s terrified of that first bowel movement. Your nurses, they think it’s great, right? But everyone else is terrified of that. Usually it’s not as bad as you were worried that it’s going to be. But at the hospital we do have stool softeners that we’ll give you. I do recommend, especially with a second degree or more, second, third or fourth degree (tear) to having a stool softener at least the two to four weeks.

If you have a third- or fourth-degree tear, we’re going to recommend having more than one. Maybe adding MiraLax, adding more of laxative too to help keep things really, really soft. Because the biggest thing is just to not strain. Whether you have a X-section or a vaginal delivery with tears, we just don’t want you straining those muscles. So common things if you want to have on hand at home, Colace is a common stool softener, MiraLax a lot of people like. The other thing we’re really going to recommend is just tons of fluid intake. Eating a high fiber diet, all of that will help.

Hemorrhoids are everybody else’s least favorite thing and sometimes we can’t do anything about them. Some people get them during pregnancy. They’re everybody’s least favorite thing. So, if they’re really bad, they’re really irritating after delivery, talk to your provider. We can possibly get you like a kind of a more of a numbing cream for a while. We use witch hazel pads for healing in the hospital also along with that spray in the ice packs. And so those or Tucks pads, those are great for hemorrhoids too. So, we’ll show you how to put those in your pad and keep wearing those for a few weeks. With the hemorrhoids, sometimes we can’t prevent them. They do take time to heal. You’re not going to just go home, and your hemorrhoids will be gone. They can take a couple months even to heal. So don’t stress too much.

The biggest thing is if the constipation is getting so bad, you’re going like three days, and you can’t go, we want to know about it. If you’ve tried all the laxatives and the stool softeners and it’s not working, let your provider know. But the hemorrhoids, if they’re growing and really seeming like they’re blood filled, something like that and getting bigger and bigger and not smaller necessarily, then let your provider know. And try not to let those things go. We schedule you an appointment for six weeks out and everyone figures, “OK, I’m good for six weeks. No one needs to see me.” But if you’re having those things, please call and reach out. We’re more than happy to see you before the six weeks.

Courtney Collen:

Good to know. Thank you. And shifting to mental health for a moment, which I know is just as important as that physical health in recovery and postpartum. I recently recorded an episode with longtime social worker here at Sanford Health, Karla Salem, who specializes in postpartum mental health as part of our podcast series, “Her Kind of Healthy.”

But Kayla, for those who may not be familiar, let’s talk briefly about the difference between the ever-common baby blues and what might lead to a more serious diagnosis, say postpartum depression, for example.

Kayla Quinn, CNM:

Yeah, baby blues are a rollercoaster experience when those come. Crying over commercials, and then laughing, and having no idea why you’re sad. We expect that kind of rollercoaster to happen for about the first two weeks. If it’s those little minor ups and downs that first two weeks, that’s usually more baby blues.

Where we start to get worried about postpartum depression would be if it’s longer than two weeks where you don’t want to take care of yourself, don’t want to take care of your baby, you’re lethargic, don’t want to get out of bed. That’s different than just being exhausted with being up all night with your baby. But just don’t want to get out or take care of yourself. Be more irritable, just snappier and shorter with people. I really recommend that partners pay attention to moms’ mood – she isn’t going to notice first, just figure they’re tired or everything’s normal.

But if you start to notice a decline and where they’re just getting really snappy or just really in this funk and won’t come out of it, if it’s lasting past that first two weeks, I really recommend being seen at about that two-to-three-week mark. Just to even talk about options and talk about counseling or do we need a short-term medication to help with this. Sometimes just talking about their fears is enough where people are like, “OK, I’m feeling a little better.” So, making that appointment with either your OB(GYN) provider, your midwife, or a counselor in that first two to three weeks, is important.

Courtney Collen:

You brought up that support person, whether it’s the father of the child, or it’s a partner, a family member or friend. What are some tips that you have Kayla for that specific person during the transition to postpartum and really into those first days and weeks at home?

Kayla Quinn, CNM:

Really just being present, being there as much as possible. Especially with breastfeeding moms. Sometimes partners feel left out or hopeless because there’s not a lot they can do. But really doing the diaper changes so that mom gets just that, even that three more minutes of rest is kind of nice. Doing the diaper changes. Being prepared to get up with mom too. During breastfeeding, you’re going to be really, really thirsty. And so, as the partner, making sure mom has a full water jug and has some snacks available, just being there with those little things and having them ready because she might not even think about them. She’s so worried about getting baby latched and then all of a sudden you’re stuck and you’re like, I’m really, really thirsty. So, having some of that available.

If mom has fed and has tried everything then, just being there to help rock and hold (the) baby a little bit while she gets some rest and taking those trade-off times. And when you get home, same thing. Having somebody there to help with a little bit more of the housework and easy meals. Don’t shoot for perfection once you get home. That’s your time to huddle in those first two weeks because they’re a little rough. Being helpful, being up at night and helping with the diaper changes. And really paying attention to mom.

That’s the biggest thing I can stress is paying attention to what her mood is, and having the open conversation of what do you want me to do to help you? Feeling able to say, what do you need from me? Because it’s hard. A lot of our partners feel helpless when moms are doing everything and there’s not as much they can do. So just really asking like, what do you need from me? What can I do for you? And moms – be OK with delegating that. That’s a hard thing for us to do. But let them do it for you.

Courtney Collen:

Being present, communicating, having that ability to delegate – all such great reminders. And again, such valuable information. Thank you. Having someone there is so important, whoever it may be. So it’s good to learn more about what they can do to provide the best support possible. So thanks for that.

Kayla, any last bits of insight or things that we can add to our list as we plan for postpartum? In hopes to make that transition as smooth as possible?

Kayla Quinn, CNM:

We talked about the preparing parts. Leave all your stuff at home for the most part. Don’t stress over packing your bag too much. Bring your comfy clothes, but you don’t need a ton, right? We’re going to give you all the pads, we’re going to give you all the medications and the squirt bottles and all the stuff, all that postpartum kit stuff. Leave yours at home because you’ll want it when you get there. So, try not to stress about that too much, but just having comfy clothes or slippers, things that are comforting for you. The open communication between you and your partner, support persons, whoever’s going to be with you, is going to be key to a lot of it: to the labor process, to the postpartum process. And, letting your partner see some of this like, “yep, there’s going to be a lot of blood,” realizing that this is normal.

Maybe I’m not going to want to go and do a whole lot that first week because I don’t know what’s going to be happening down there. And same thing with visitors, just being prepared to say, “we’re not comfortable going to do anything, or I’m not sure how I’m going to be feeling, so let’s play it by ear.” And just remember that you are this new family unit, and you get to make the rules. It should be an exciting time, right? And really just make the most of it and learn from your baby. Open communication’s going to be a huge thing and realize that it’s supposed to be a little bit stressful, and it will be, but it’s also very exciting.

Something we do see a lot, especially in first time moms is we talk about discharge times, right? Being about 48 hours or 72 hours. And those are, they’re kind of imperfect scenarios too, right? We see a lot of mothers whose blood pressure gets elevated, or babies who have jaundice, things like that. And so to really prepare yourself that, yep, the 48 hours or the 72 hours, that’s our normal, right? That’s what we’re shooting for. But if anyone tells you have high blood pressure or baby’s struggling with blood sugars or struggling with jaundice, to really start preparing yourself that 48 hours might not be a thing. Your 48 hours might turn 72 or even more than that. And being prepared. Because that’s really hard. It’s a really hard thing when your provider has to come in and say, “Hey, the safest thing for you to be would be to stay – stay longer.”

And you were so dead set on going home. And so just realizing that might change based on how the postpartum process goes. But high blood pressure is one that a lot starts happening and everyone wants to know why. And it’s a hormonal shift. We don’t have necessarily a huge why. And so, just realizing you’re not doing anything wrong – it’s just your body reaction to the postpartum period. And we want to keep you to watch you a little closer and make sure we get you home and safe with your baby.

Courtney Collen:

Yes. And that speaks so beautifully to our comments at the beginning of this conversation that everyone’s care journey will look a little bit different. No two experiences are the same. But one thing is for certain Kayla, it is so wonderful to have a network of Sanford Health providers who can educate and make us feel comfortable and prepared, which is exactly how I will be leaving this conversation today. So with that, I thank you Kayla Quinn, certified nurse midwife at Sanford Health in Fargo. Thanks so much for your time, your insight, expertise, and all that you do for women in this space. We appreciate you.

Kayla Quinn, CNM:

Thank you. Appreciate it.

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