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Early puerperal rising
EARLY PUERPERAL RISING* ARTHUR
G.
KING,
M.D.,
CINCINNATI,
OHio
by the success which has attended the early ambulation of S. TIMULATED general surgical patients, a study was undertaken of the effects of similar treatment on women immediately after childbirth. The careful basic work of Bernard Newburger,l published posthumously in 1943, showed that in experimental rats postoperative activity accelerated the early phase of healing of incised tissues, and it was felt that the physiology of the pregnant and parturient woman did not differ sufficiently from that of other surgical conditione to anticipate a less favorable result than that obtained either in experimental animals or human surgical cases. A total of 221 women were studied between December, 1944, and December, 1945, at the Regional Hospital, Fort Knox, Kentucky; McCaw General Hospital, Walla, Walla, Washington; and Bushnell General Hospital, Brigham City, Utah. The need for early postpartal activity came about both because of the shortage of beds allotted in Army hospitals to dependents of officers and men in the service, and the necessity on the part of the young wives of reducing to a minimum the period of invalidism following their deliveries. These girls lived near Army posts far from mothers and relatives who might help them on their discharge from the hospital, and home nursing help, either trained or practical, as well as domestic help, was almost impossible to obtain. Their living conditions were often substandard, and most of the young mothers lived in constant expectation of sudden changes in station or overseas' orders for their husbands. Thus, almost the entire group was impelled by circumstances to forego the luxury of ten days in the hospital and three more weeks of semi-invalid care and consideration as convalescents. At first the cases for early rising were selected, but because of the encouraging results, a routine was gradually developed which was used on all uncomplicated parturitions. The exceptions included any general medical or surgical condition, toxemia, severe anemia, the loss of over 500 c.c. of blood at the time of delivery, and any unusual circumstances of labor that offered potentialities of infection. The use of forceps and episiotomy, which was almost routine, was not a contraindication. The procedure consisted of: 1. Standing, assisted, by the side of the bed for one full minute within the first twenty-four hours after delivery. The patient was allowed to lie on her abdomen as desired, and a full diet was offered to her. 2. On the second day she sat on a chair for five minutes. 3. On the third day (a) the patient sat up in a chair some distance from the bed, and to which she walked for five minutes twice during the day; (b) abdominal exercises in bed 'vere started, consisting of tensing the abdomen and alternately raising and lowering the head and shoulders (unassisted by the arms) to the easily tolerated height, ten times, 3 to 5 times a day. •Presented at a meeting of the Cincinnati Obstetrical Society, May 16, 1946.
657
658
AMERICAN' .JOURNAL OF OBSTETRICS AND GYNECOLOGY
4. On the fourth day (ninety to one hundred hours post partum), in addition to the abdominal exercises which were continued daily, the twice daily use of the knee-chest position (without spreading the buttocks) for two minutes was begun. The patient spent thirty minutes in a chair in the morning (while the bed was being made) and, if the response was good, was allowed to eat her evening meal sitting up at a card table. 5. She was allowed up and about twice for thirty minutes each time on the fifth day and, if she had a private room, was given toilet privileges. 6. On the sixth day all patients were given toilet privileges and permitted three one-hour periods out of hed. She was instructed in perineal care and practiced it herself. 7. On the seventh day the patient was permitted to take a shower and spend half the hours of the da~· up. Because of the nursing shortage she was encouraged to make her own heel. She ate all her meals at a table, and received instruction in the nursery. 8. On the eighth day she was allowed to wash her hair herself, and was encouraged to walk through the corridors of the wing. If she desired to go home. or if there was a shortage of beds, she was discharged. 9. Her instructions included the continuation of the abdominal and kneechest exercises, and the addition over the next two weeks of others involving.the leg, abdomen, and flank muscles. She was permitted to go up and down stairs cautiously and with limitations that varied with the circumstances. Douches were begun with the appearance of lochia alba. The patient was advised to be gradual in her resumption of work, and in a few eases was allowed to travel. even across the country, when the baby was three weeks old. No harmful effects were noted as long as five months post partum. On the contrary, the benefits of this regimen were striking. The women consistently had a high morale and a sense of well-being, and multiparas compared their status daily with that of the previous pregnancies with actual enthusiasm. The degree of involution of the uterus was not recorded, but the impression remains that it was faster than usual. 'l'he lochia was more profuse the first three days, despite the exhibition of oral ergonovine. In only 17 cases was true lochia rubra noted on discharge from the hospital, and in only one did it persist for three weeks. Retained secundines were extracted in two cases of subinvolution at the hospital, and in a third case a roll of secundines was withdrawn at the six-week visit, there being, however, no bleeding during the interval. One woman developed a severe uterine hemorrhage on the eighth day, the cause hein~ undetermined, but, as she had had an identical episode with her first pregnancy during which she had been in bed for seven days post-partum, it was deemed irrelevant to the early rising. Episiotomies were repaired with No. 0 plain catgut in layers, subcuticularly for the skin. In three cases there was separation that included the muscle layers. One woman weighed 286 lbs., and tissue healing under the best circumstances would have been difficult; the second woman had a frank infection of the episiotomy area before the separation, and it is questionable what :part activity played; in the third case no specific cause was assignable. But the percentage of separations was not significantly greater than is found in ordinary cases. There were no frank pelvic infections, and during the hospital stay only five cases of true morbidity were recorded (100.4° F., lasting two or more
KING:
EARLY PUERPERAL RISING
659
days). One was the infected episiotomy, and one was accompanied by such terrific breast engorgement as to leave no doubt as to the cause. The other three represented low grade infections of the lochiametra type. Again, this incidence represented no increase in morbidity that might be ascribed to early r·ising. One woman only had any symptoms that might conceivably have indicated thrombophlebitis, but she had no fever .. The routine was interrupted in her ease, keeping her in bed; after three days, during which her symptoms disappeared, she was allowed up and was discharged on the tenth day. Lactation seemed to be unaffected by the early activity, although no specific studies were made. An unusually large number of these mothers preferred not to nurse, and lactation was suppressed easily with estrogenic substance. Unfortunately, only 140 of these 221 patients reported for examination six weeks post partum. Among these women, 23 had a uterus that was definitely retroverted (third degree), and another eight were described as having first or second degree retroversion. This is at most 26 per cent, which compares favorably with the 40 per cent of women ordinarily conceded to have retroversion at the six-week visit. There were no cases of descensus and no sequelae of childbirth that might be ascribed to straining of the ligaments or failure to rest the heavy puerperal uterus. This is to be expected, inasmuch as recumbency allows gravity to exercise the least favorable effect on the pelvic organs. While no exact figures are available for comparison, rell_larkably few women complained of leucorrhea, and only 21 had any cervicitis that warranted comment in the records. The women were enthusiastic without exception in their report of how they felt during the six-week interval. By the fourth week most of them were doing as much or more than they had done before pregnancy. They felt vigorous and energetic; the comments of the multiparas were of particular satisfaction, regarding not only the physical benefits, but the psychological results.
Summary Report is made of the experiences in three Army hospitals with 221 parturitions after which a regimen of early exercise and activity was directed. The routine included standing for one minute the first day post partum, sitting in a chair for five minutes the second day, abdominal exercises in bed, and two fiveminute sitting episodes the third day, knee-chest ex\)rcises and two thirty-minute sitting periods the fourth day, walking about and toilet privileges on the fifth or six day, a shower the seventh day, and discharge from the hospital on the eighth day when desired or necessary. The incidence of complications, subinvolution, prolonged lochia rubra, episiotomy breakdown, infections, and uterine retroversion was not greater than that found in any series of women treated puerperally with bed rest for six or seven days and hospitalization to the tenth day. It is felt that early puerperal rising in uncomplicated cases of childbirth is desirable and without danger or unfavorable sequelae. The women have a
660
AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY
sense of well-being and are benefited psychologically not only during the puerperium, but in their attitude toward the entire episode of pregnancy. They are prepared by the regimen of increasing activity to leave the hospital by the eighth day post partum, and their convalescence at home is shortened considerably.
Reference 1. Newburger, Bernard: Surgery 13: 692-695, 1943; and Surgery 14: 142-149, 1943. 701 UNION CENTRAL BLDG.
G.
KING,
M.D.,
CINCINNATI,
OHio
by the success which has attended the early ambulation of S. TIMULATED general surgical patients, a study was undertaken of the effects of similar treatment on women immediately after childbirth. The careful basic work of Bernard Newburger,l published posthumously in 1943, showed that in experimental rats postoperative activity accelerated the early phase of healing of incised tissues, and it was felt that the physiology of the pregnant and parturient woman did not differ sufficiently from that of other surgical conditione to anticipate a less favorable result than that obtained either in experimental animals or human surgical cases. A total of 221 women were studied between December, 1944, and December, 1945, at the Regional Hospital, Fort Knox, Kentucky; McCaw General Hospital, Walla, Walla, Washington; and Bushnell General Hospital, Brigham City, Utah. The need for early postpartal activity came about both because of the shortage of beds allotted in Army hospitals to dependents of officers and men in the service, and the necessity on the part of the young wives of reducing to a minimum the period of invalidism following their deliveries. These girls lived near Army posts far from mothers and relatives who might help them on their discharge from the hospital, and home nursing help, either trained or practical, as well as domestic help, was almost impossible to obtain. Their living conditions were often substandard, and most of the young mothers lived in constant expectation of sudden changes in station or overseas' orders for their husbands. Thus, almost the entire group was impelled by circumstances to forego the luxury of ten days in the hospital and three more weeks of semi-invalid care and consideration as convalescents. At first the cases for early rising were selected, but because of the encouraging results, a routine was gradually developed which was used on all uncomplicated parturitions. The exceptions included any general medical or surgical condition, toxemia, severe anemia, the loss of over 500 c.c. of blood at the time of delivery, and any unusual circumstances of labor that offered potentialities of infection. The use of forceps and episiotomy, which was almost routine, was not a contraindication. The procedure consisted of: 1. Standing, assisted, by the side of the bed for one full minute within the first twenty-four hours after delivery. The patient was allowed to lie on her abdomen as desired, and a full diet was offered to her. 2. On the second day she sat on a chair for five minutes. 3. On the third day (a) the patient sat up in a chair some distance from the bed, and to which she walked for five minutes twice during the day; (b) abdominal exercises in bed 'vere started, consisting of tensing the abdomen and alternately raising and lowering the head and shoulders (unassisted by the arms) to the easily tolerated height, ten times, 3 to 5 times a day. •Presented at a meeting of the Cincinnati Obstetrical Society, May 16, 1946.
657
658
AMERICAN' .JOURNAL OF OBSTETRICS AND GYNECOLOGY
4. On the fourth day (ninety to one hundred hours post partum), in addition to the abdominal exercises which were continued daily, the twice daily use of the knee-chest position (without spreading the buttocks) for two minutes was begun. The patient spent thirty minutes in a chair in the morning (while the bed was being made) and, if the response was good, was allowed to eat her evening meal sitting up at a card table. 5. She was allowed up and about twice for thirty minutes each time on the fifth day and, if she had a private room, was given toilet privileges. 6. On the sixth day all patients were given toilet privileges and permitted three one-hour periods out of hed. She was instructed in perineal care and practiced it herself. 7. On the seventh day the patient was permitted to take a shower and spend half the hours of the da~· up. Because of the nursing shortage she was encouraged to make her own heel. She ate all her meals at a table, and received instruction in the nursery. 8. On the eighth day she was allowed to wash her hair herself, and was encouraged to walk through the corridors of the wing. If she desired to go home. or if there was a shortage of beds, she was discharged. 9. Her instructions included the continuation of the abdominal and kneechest exercises, and the addition over the next two weeks of others involving.the leg, abdomen, and flank muscles. She was permitted to go up and down stairs cautiously and with limitations that varied with the circumstances. Douches were begun with the appearance of lochia alba. The patient was advised to be gradual in her resumption of work, and in a few eases was allowed to travel. even across the country, when the baby was three weeks old. No harmful effects were noted as long as five months post partum. On the contrary, the benefits of this regimen were striking. The women consistently had a high morale and a sense of well-being, and multiparas compared their status daily with that of the previous pregnancies with actual enthusiasm. The degree of involution of the uterus was not recorded, but the impression remains that it was faster than usual. 'l'he lochia was more profuse the first three days, despite the exhibition of oral ergonovine. In only 17 cases was true lochia rubra noted on discharge from the hospital, and in only one did it persist for three weeks. Retained secundines were extracted in two cases of subinvolution at the hospital, and in a third case a roll of secundines was withdrawn at the six-week visit, there being, however, no bleeding during the interval. One woman developed a severe uterine hemorrhage on the eighth day, the cause hein~ undetermined, but, as she had had an identical episode with her first pregnancy during which she had been in bed for seven days post-partum, it was deemed irrelevant to the early rising. Episiotomies were repaired with No. 0 plain catgut in layers, subcuticularly for the skin. In three cases there was separation that included the muscle layers. One woman weighed 286 lbs., and tissue healing under the best circumstances would have been difficult; the second woman had a frank infection of the episiotomy area before the separation, and it is questionable what :part activity played; in the third case no specific cause was assignable. But the percentage of separations was not significantly greater than is found in ordinary cases. There were no frank pelvic infections, and during the hospital stay only five cases of true morbidity were recorded (100.4° F., lasting two or more
KING:
EARLY PUERPERAL RISING
659
days). One was the infected episiotomy, and one was accompanied by such terrific breast engorgement as to leave no doubt as to the cause. The other three represented low grade infections of the lochiametra type. Again, this incidence represented no increase in morbidity that might be ascribed to early r·ising. One woman only had any symptoms that might conceivably have indicated thrombophlebitis, but she had no fever .. The routine was interrupted in her ease, keeping her in bed; after three days, during which her symptoms disappeared, she was allowed up and was discharged on the tenth day. Lactation seemed to be unaffected by the early activity, although no specific studies were made. An unusually large number of these mothers preferred not to nurse, and lactation was suppressed easily with estrogenic substance. Unfortunately, only 140 of these 221 patients reported for examination six weeks post partum. Among these women, 23 had a uterus that was definitely retroverted (third degree), and another eight were described as having first or second degree retroversion. This is at most 26 per cent, which compares favorably with the 40 per cent of women ordinarily conceded to have retroversion at the six-week visit. There were no cases of descensus and no sequelae of childbirth that might be ascribed to straining of the ligaments or failure to rest the heavy puerperal uterus. This is to be expected, inasmuch as recumbency allows gravity to exercise the least favorable effect on the pelvic organs. While no exact figures are available for comparison, rell_larkably few women complained of leucorrhea, and only 21 had any cervicitis that warranted comment in the records. The women were enthusiastic without exception in their report of how they felt during the six-week interval. By the fourth week most of them were doing as much or more than they had done before pregnancy. They felt vigorous and energetic; the comments of the multiparas were of particular satisfaction, regarding not only the physical benefits, but the psychological results.
Summary Report is made of the experiences in three Army hospitals with 221 parturitions after which a regimen of early exercise and activity was directed. The routine included standing for one minute the first day post partum, sitting in a chair for five minutes the second day, abdominal exercises in bed, and two fiveminute sitting episodes the third day, knee-chest ex\)rcises and two thirty-minute sitting periods the fourth day, walking about and toilet privileges on the fifth or six day, a shower the seventh day, and discharge from the hospital on the eighth day when desired or necessary. The incidence of complications, subinvolution, prolonged lochia rubra, episiotomy breakdown, infections, and uterine retroversion was not greater than that found in any series of women treated puerperally with bed rest for six or seven days and hospitalization to the tenth day. It is felt that early puerperal rising in uncomplicated cases of childbirth is desirable and without danger or unfavorable sequelae. The women have a
660
AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY
sense of well-being and are benefited psychologically not only during the puerperium, but in their attitude toward the entire episode of pregnancy. They are prepared by the regimen of increasing activity to leave the hospital by the eighth day post partum, and their convalescence at home is shortened considerably.
Reference 1. Newburger, Bernard: Surgery 13: 692-695, 1943; and Surgery 14: 142-149, 1943. 701 UNION CENTRAL BLDG.