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    Information for mothers of newborns

    Congratulations – you have become a parent! The purpose of this booklet is to provide information on the changes that occur in a woman's body after childbirth and recommendations for coping with them. In addition, this booklet provides information on how to successfully breastfeed your baby and tips for caring for your newborn at home.

    POSTPARTUM BLEEDING

    Postpartum bleeding or lochia lasts for 6-8 weeks. It is due to the healing of the inner lining of the uterus. In obstetrics, this process is known as uterine clearing. Dangerous bleeding can occur within 24 hours of delivery. Major bleeding from the birth canal can occur in the first week after delivery.

    Only unscented sanitary pads may be used during postpartum bleeding.

    Postpartum bleeding is characterised by an odour similar to that of menstrual blood. In the case of heavy bleeding, bright red blood or foul-smelling discharge, a midwife or gynaecologist should be consulted. If haemorrhage occurs, please seek emergency care at the Women's Clinic.

    ABDOMINAL PAIN

    Abdominal pain due to uterine contractions may occur in the first few weeks after delivery. Painful uterine contractions are more common in subsequent pregnancies. Abdominal pain may increase during breastfeeding. This is due to the release of the hormone oxytocin, which causes the uterus to contract. Complete uterine involution occurs within a few weeks.

    If necessary, 1000 mg of paracetamol three times daily or 400 mg of ibuprofen three times daily may be used for short-term pain relief.

    URINATION

    After delivery, the bladder is relatively insensitive, which can lead to the overfilling or incomplete emptying of the bladder. The bladder should be emptied regularly (about once every three hours) to prevent urinary tract infection. If you experience trouble urinating for the first time after delivery, pour warm water over your vaginal area while urinating. Always wash the external genitalia with warm running water after going to the toilet. Occasionally, spontaneous urinary incontinence may occur, which usually resolves within 3-6 months with pelvic floor muscle training.

    CARE OF PERINEAL TEARS AND THE EPISIOTOMY WOUND

    Mild swelling and pain in the perineum area may occur in the first few days after delivery. This is due to the stretching and tearing of the soft tissues. Within a couple of weeks, the sutures absorb and perineal swelling resolves. The pain caused by the sutures may last from a few days to a few weeks.

    • For the first two to three days after giving birth, try to avoid direct pressure on your perineum when sitting down. Instead, try sitting on one buttock only.

    • Every time you go to the toilet, wash your perineum with clean running water, moving from front to back to avoid wound infection.

    • Gently pat the area dry.

    • If possible, let the wound air-dry.

    • In the case of swelling, a cold compress can be applied to the wound using a towel.

    • Once the pain and swelling subside, you can start training your pelvic floor muscles.

    CONSTIPATION

    There is no need to be worried about going to the toilet as a bowel movement usually does not cause the sutures to tear. Drink plenty of fluids – at least one and a half litres a day. A well-balanced diet will help against constipation. The food should contain bran, whole grains, fruit and vegetables and/or fermented milk products.

    If you have not had a bowel movement within three days after giving birth, a laxative available in a pharmacy without a prescription may be used, if necessary.

    HAEMORRHOIDS

    Haemorrhoids are enlarged veins in the lower rectum and the anus. There are two types of haemorrhoids: internal and external. Haemorrhoids that develop during pregnancy or from pushing during childbirth can be very painful.

    • To relieve the pain, an ice bag can be placed on the sore area or over-the-counter medications can be used (please consult your pharmacist for a suitable medication).

    • Wash the anal area after going to the toilet.

    • It is recommended to drink plenty of fluids and eat high-fibre foods to prevent constipation and make it easier to pass stool.

    PELVIC FLOOR MUSCLE TRAINING

    The pelvic floor muscles can be consciously controlled. By practicing, it is possible to learn how to contract and relax them. To gain better control over your pelvic floor muscles, you need to do pelvic floor exercises.

    Regular pelvic floor exercises improve bladder control and prevent urinary incontinence.

    When training the pelvic floor muscles, it is important to do the right exercises using the correct technique. To do this, keep your body as relaxed as possible. Start by tightening the muscles around the rectum. Then tighten the muscles around the urethra as if trying to stop the flow of urine. It is important to contract your pelvic floor muscles on the exhale and relax your pelvic floor muscles on the inhale.

    Pelvic floor muscle training exercises

    • Lie on your back with your knees bent and your feet together. Inhale. As you exhale, slowly raise your buttocks while tightening your pelvic floor muscles. Inhale and relax. Repeat the exercise 5-10 times.

    • Stand up straight, cross the right leg over the left leg and keep the soles of your feet on the floor. Inhale. As you exhale, pull the pelvis inwards, tighten the buttocks and pull in the lower abdomen. Squeeze your thighs together and continue tightening for a few seconds. Inhale and relax. Repeat the exercise 5-10 times. Then cross the left leg over the right leg and repeat the exercise 5-10 times.

    • Try to stop the flow of urine repeatedly when you go to the toilet. This way, you can check if you are tightening the right muscles. PLEASE NOTE: Stopping the flow of urine during urination is only allowed as a control exercise three months after beginning with the exercises. This should not be done every time you urinate as it may prevent the bladder from emptying.

    POSTPARTUM SELF-CARE AND RECOVERY

    The postpartum period begins with the delivery of the placenta and ends approximately 6-8 weeks after childbirth. During this time, the hormonal and physiological changes that occurred during pregnancy and childbirth are reversed.

    If desired, a postpartum girdle/belly wrap can be used to support the abdomen immediately after delivery. If you had a caesarean section, wait until the wound has healed and consider using postpartum support panties.

    Intense abdominal exercises (e.g. sit-ups) should be avoided for two months after a vaginal delivery and four months after a caesarean section.

    Take a shower once a day. Baths, saunas and swimming pools are not recommended for 8 weeks after delivery.

    MENSTRUATION AND SEXUAL INTERCOURSE

    If you are not breastfeeding, you can expect menstruation to return between 4-8 weeks after delivery. If you are breastfeeding, menstruation may be absent for up to two years. Menstruation usually returns shortly after you stop breastfeeding.

    Sexual intercourse can be resumed 4 weeks after delivery when bleeding has ceased. You can get pregnant while breastfeeding. If you resume sexual intercourse before having a postpartum check-up but do not want to become pregnant again right away, be sure to use a condom.

    FOLLOWING A CAESAREAN SECTION

    A caesarean section is a surgical procedure in which, instead of giving birth naturally, the baby is delivered through an incision in the abdominal wall and uterus.

    At home, you can take 1000 mg of paracetamol 3-4 times a day and/or 400 mg of ibuprofen not more than 3 times a day to manage the pain. If you weigh less than 66 kg, the dose of paracetamol should be reduced to 750 mg (1.5 tablets). Taking this dose of paracetamol is allowed for up to six days from the day of surgery.

    The wound dressing will be removed 24 hours after surgery.

    The sooner you start moving around, the faster the recovery from surgery.

    You must shower at least once a day and wash the wound with running water and soap or shower gel.

    After a caesarean section, you may experience shoulder or neck pain. In this case, analgesic ointments which are available in pharmacies without a prescription are suitable.

    Your doctor will tell you if the sutures need to be removed or if the sutures are absorbable. Air promotes wound healing. Also, make sure that trousers or underpants do not rub against the wound area.

    For 6-8 weeks, it is not recommended to lift items heavier than your baby. It is also not recommended to be sexually active, use tampons, take baths or go swimming during this time.

    POSTPARTUM EMOTIONAL DISTURBANCES

    Childbirth and the postpartum period are associated with a variety of emotions. Two-thirds of new mothers experience the so-called baby blues. A few days to a few weeks after giving birth, you may experience mood swings, crying, excessive anxiety or a feeling of emptiness.

    The birth of a child comes with responsibilities that can lead to worry and anxiety as well as fatigue. It is normal to feel this way.

    If the baby blues last longer than two weeks or the emotions become more intense, postpartum depression may develop. Postpartum depression usually begins within 2-3 months after delivery and affects around 10% of mothers.

    Such feelings are facilitated by the rapid change in reproductive hormone levels after childbirth and many changes in the postpartum period: lack of sleep, fatigue and isolation (from both work and social life).

    As a result of major life changes and adjustments, fathers too may experience emotions that are difficult to cope with. It occurs in about 5% of fathers.

    Signs of postpartum depression include:

    • difficulty sleeping at night (even when the baby is asleep);

    • excessive worrying (inability to stop worrying even when the baby is fine);

    • guilt;

    • feeling a lot of emotions (especially anger and sadness);

    • lack of emotions (not feeling attached to the baby, feeling of emptiness).

    Anxiety disorders (restlessness, tension and/or agitation) can also occur after childbirth and interfere with daily life.

    Signs of anxiety disorder include:

    • sense of inner tension and restlessness;

    • worry (fear of illness and death).

    If you experience any signs of anxiety or depression, consult your midwife, family doctor or mental health professional.

    Postpartum mood and anxiety disorders can be treated.

    POSTPARTUM COMPLICATIONS that occur within two months after delivery and require emergency care at the Women's Clinic:

    • The use of epidural analgesia for pain relief can cause postpartum headaches that do not respond to painkillers.

    • Infection (body temperature above 37.8 °C accompanied by chills).

    • Uterine bleeding.

    • Acute abdominal pain.

    • Redness and swelling around the c-section incision.

    • Foul-smelling or purulent vaginal discharge.

    • Two to three weeks after giving birth, the breasts are very sore and swollen; localised redness, high fever and chills are present.

    POSTPARTUM CHECK-UP WITH A DOCTOR OR MIDWIFE

    You should see your midwife or doctor within two months after giving birth to assess postpartum recovery. During your postpartum check-up, birth control options are discussed, sutures are checked and your vagina is examined. Occasionally, a pelvic examination is performed to check the condition of the cervix and, if necessary, to collect samples from the cervix. Recommendations for breastfeeding are also provided.

    BREASTFEEDING

    Breastfeeding is the best and easiest way to feed your baby during the first year of life. The World Health Organization recommends exclusive breastfeeding for the first six months of life, followed by continued breastfeeding in the second year of life.

    Breast milk and its production is a natural phenomenon. After giving birth, a change in the body's hormone levels causes milk to be produced. Depending on the baby's nursing dynamics, the volume of milk increases and its composition changes between the second and fourth day after delivery.

    Colostrum is the first milk produced by the breasts during pregnancy and the first days after delivery. The amount of colostrum is not large. It is excreted in small drops and it contains everything a baby needs in the first days of life – nutrients, vitamins and antibodies.

    In addition, colostrum:

    • protects the baby from infections;

    • prepares the baby's immature digestive system for digesting breast milk;

    • helps prevent jaundice due to its laxative effect.

    From the second day of life, the baby should be breastfed on demand and at least eight times a day. During the daytime, the interval between feedings should not exceed three hours and, if necessary, the baby should be woken up, for example, by changing a diaper or clothes.

    Frequent breastfeeding stimulates milk production and increases the fat content of the milk.

    The baby should not be offered a bottle or a pacifier in the first month of life as these may prevent the baby from learning how to latch on correctly.

    In the first six months of life, the baby gets everything needed for growth and development from breast milk. No extra fluids (water, tea, juice) are needed during this time.

    Your baby is getting enough breast milk if he or she:

    • urinates a lot, at least 6-8 times a day;

    • gains at least 500-600 grams per month (weight gain in the first month must be based on the lowest known weight, not birth weight);

    • grows in length;

    • eats at least eight times a day.

    Feeding

    • Your baby does not get the same amount of milk with each meal and his or her circadian (day/night) rhythm has not yet developed. Some babies spend 30-40 minutes at the breast and then rest for an hour. Others suckle only a bit but more often. And then there are babies who are fast eaters and are happy with being fed at three-hour intervals. Let your baby suckle for as long as he or she wants, provided that your baby is well attached at the breast.

    • Over time, your baby will develop a predictable feeding pattern, but care must be taken to ensure that he or she eats at least eight meals a day.

    • If you are producing enough breast milk, we recommend that you help your baby release air swallowed during feeding after each meal by holding your baby in an upright position in your arms, against your chest or over your shoulder for up to 10 minutes. Sometimes babies burp very audibly and quickly in an upright position, other times they burp just before the next feeding.

    • Avoid certain care routines (such as changing diapers or clothes) immediately after feeding as these may cause the baby to vomit excessively. However, if diapers or clothes need to be changed, care must be taken to ensure that the baby's legs are not pushed hard against his or her stomach and the baby is not vigorously rolled from side to side.

    • We recommend placing the baby on his or her side after feeding and changing sides after each feeding.

    • During breastfeeding, it is important to make sure that the baby is actively sucking and does not fall asleep with the nipple in his or her mouth. If the baby is starting to fall asleep while feeding, gently massage his or her back, arms or legs.

    • We recommend offering both breasts at each feeding and making sure that feedings do not last longer than 30-45 minutes to allow the baby to rest between meals.

    Signs of a good latch (Figure 1):

    • the baby's whole body is turned towards the mother – they are pressed against each other belly to belly

    • before attaching to the breast, the baby's nose is aligned with the mother's nipple

    • the baby's mouth is wide open and it looks like he or she has a double chin

    • the baby's chin and tip of the nose are pressed against the mother's breast

    • the baby's bottom lip is turned outwards

    • the baby's cheeks are full and round, not dimpled

    • sucking alternates with swallowing

    Figure 1. Author: Ülle Lember (Estonian Birth and Breastfeeding Support Society brochure "Mother's milk is best for a baby. Part II")

    Figure 1. Author: Ülle Lember (Estonian Birth and Breastfeeding Support Society brochure "Mother's milk is best for a baby. Part II")

    Remember:

    • Wash hands before feeding your baby.

    • The breast is always clean and no preparation is needed.

    Nipple soreness

    In the first few weeks after giving birth, your nipples may be sensitive or sore, even if the baby is latching on properly. In this case, an ointment containing lanolin may be applied to the nipples after each feeding.

    Nipple cracks indicate that the baby is not latching on properly. The baby's sucking technique should be carefully observed.

    Breast engorgement usually occurs between the second and fifth day after delivery when the amount of milk in the breast increases significantly. As a result, your breasts may feel heavy, warm, tender and hard. You may develop a low-grade fever (up to 37.5 °C) that usually subsides on its own if you breastfeed frequently. Engorgement tends to be less severe if the baby is breastfed frequently in the first days of life. The symptoms usually resolve in around seven days.

    How to alleviate the symptoms of breast engorgement?

    • The baby should be breastfed frequently.

    • Care must be taken to ensure that the latch is always correct.

    • Place clean, cold cabbage leaves on the engorged breast during feeding breaks. Change the leaves every 4-6 hours.

    • Express a little milk by hand before feeding to soften your breast and make it easier for your baby to latch on. This method works better in a warm shower or after applying a warm compress.

    • If the breasts remain sore and hard even after breastfeeding, place something cold on the breast for 15 to 20 minutes after feeding.

    How to increase milk supply?

    The more often your baby nurses, the faster your body learns to produce the amount of milk your baby needs. Breastfeeding is more successful if you give yourself and your baby time to learn.

    Rest with your baby. While still in the maternity hospital, learn how to breastfeed while lying down. Lying down with your baby makes it easier to get used to breastfeeding both at night and during the day. Breastfeeding at night increases milk production.

    Follow a balanced and varied diet. The composition of breast milk does not appear to be influenced by the mother's diet, but it is necessary to eat regularly and include a wide variety of foods to maintain wellbeing.

    You should drink at least one and a half litres of water a day to produce enough breast milk.

    Hand expression of breast milk

    Hand expression is a technique used to remove milk from the breasts using your fingers.

    Hand expression is an important skill as it helps to:

    • alleviate the symptoms of breast engorgement;

    • induce and maintain lactation if the baby is unable to nurse effectively;

    • increase the amount of breast milk in the breasts.

    Hand expression of breast milk

    • First, wash your hands thoroughly and have a suitable clean container to collect milk.

    • Get into a comfortable position.

    • Before you begin, have a warm drink, apply something warm to your breast, gently massage your breast and stroke the breast towards the nipple to encourage breast milk to flow.

    • Place your thumb and forefinger about 3 cm away from the base of the nipple so that your hand forms the shape of a letter 'C' and the nipple is in the middle of a straight line between your fingers (Figure 2).

    Sõrmede asend rinnapiima lüpsmisel käsitsi.

    Sõrmede asend rinnapiima lüpsmisel käsitsi.

    Figure 2. Position of fingers when expressing breast milk by hand.

    • Compress the breast between your fingers towards your chest, press your fingers together towards the nipple and collect the milk drops in the container. Release and repeat rhythmically. (Figure 3).

    Rinnapiima käsitsi lüpsmine.

    Rinnapiima käsitsi lüpsmine.

    Figure 3. Hand expression of breast milk.

    It may take a few minutes for the milk to flow, so be patient. After a while, change the position of your fingers on the breast to empty other milk ducts. Then move to the other breast and repeat the process.

    Storage of breast milk

    Expressed milk must be stored in a clean and closed container. The container should be marked with the date and time of collection.

    • Breast milk can be stored at room temperature (up to +26 oC) for six to eight hours.

    • Breast milk can be stored in the refrigerator at +4 oC for up to 72 hours.

    • Breast milk can be stored in the freezer at -18 oC for at least three months.

    Freshly expressed warm breast milk should not mixed with cold milk from the refrigerator or freezer but must first be cooled in a separate container.

    Thawing and administration of breast milk

    Thaw frozen milk at room temperature in a container of fresh cold water. It usually takes 2-3 hours to thaw 100-200 ml of milk. Thawed breast milk should be used within two hours.

    Do not use a microwave oven or bottle warmer as the milk may heat unevenly.

    The milk given to the baby should be at body temperature (not more than +37 oC). Check the temperature with a thermometer or by pouring a few drops of milk onto the back of your hand.

    All babies are different and therefore you may have questions about breastfeeding. Seek help before problems arise!

    BREASTFEEDING COUNSELLING

    If possible, bring your baby with you to the appointment with a midwife-breastfeeding counsellor. Breastfeeding counselling is free of charge and provided in Estonian, Russian and English. You can register for an appointment and for counselling over the phone by calling 666 1900 on weekdays.

    The breastfeeding counselling office provides help to mothers who have problems with breastfeeding or the health of their breasts. The breastfeeding counselling office can be contacted for any issues regarding breastfeeding – condition of the breasts, pain, baby's breastfeeding behaviour, baby's weight gain, age-appropriate supplementary food, weaning, etc. Additional information is available at: https://www.sunnitusmaja.ee/sunnitus/sunnitusosakond/imetamisnoustamine/

    Breastfeeding counselling offices:

    Room 128 on the ground floor of the maternity hospital at the Ravi Street unit (Ravi 18).

    • The office is open on weekdays.

    • To have a phone consultation, call 620 7453.

    Room 118 on the ground floor of the Järve unit (Energia 8).

    • The office is open on weekdays.

    • To have a phone consultation, call 606 7606.

    CARING FOR YOUR BABY AT HOME

    Digestion

    The frequency of bowel movements in breastfed babies varies widely. During the first month of life, the baby should have a bowel movement at least once a day. A breastfed baby whose weight gain is normal does not need any supplementary food or drinks during the first six months of life. However, if it is necessary to feed your baby with both breast milk and infant formula to ensure normal weight gain, we recommend feeding the baby at least eight times a day for 30-45 minutes and consulting our breastfeeding counsellor.

    Eye and cord care

    The purpose of eye care is to keep the eye area clean and support the opening of congenital tear duct obstruction by means of a special massage technique. In most cases, congenital tear duct obstruction resolves spontaneously during the third week of life. The symptoms of congenital tear duct obstruction include excessive tearing and sticky discharge from one or both eyes.

    Eye care should be performed at least twice a day (for example, in the morning and in the evening). To do this, moisten a cleaning pad with plain water (pre-boiled water cooled to room temperature can be used). Use a separate moistened and clean pad for each eye.

    PLEASE NOTE: We recommend using cosmetic cleaning pads that are sold at a pharmacy and do not shed pieces of lint. Avoid wiping the eye several times with the same moistened cleaning pad. Clean the less affected eye first. Clean the eye by wiping from the outer corner of the eye towards the inner corner of the eye. If the same eye needs to be cleaned again, a new moistened pad should be used. In the case of eye discharge, clean the affected eye last. When cleaning this eye, you can gently press with your fingertip between the nasal bridge and the eye. In case of yellow discharge, clean the eye (eyes) more often (for example, every time you notice the discharge).

    The umbilical cord stump dries and falls off within 3-45 days (usually within 8 and 14 days). The area around the stump should be dry and there should be no redness. Wash your hands before handling the cord stump. Use cooled boiled water. Make sure to clean the base of the cord stump and the area surrounding it, by gently pulling the stump from the clamp. Handling the stump is not painful for your baby. Clean the area a few times a day and after bathing. When using disposable diapers, try not to cover the stump with the diaper. There may be some blood around the stump before it falls off. After the stump falls off, the exposed area should be cleaned 3-4 times a day for about one week until healing is complete. If the area around the stump becomes red, the inflammation has spread to the subcutaneous tissue and umbilical cord infection has developed. In this case, consult your GP.

    We recommend carrying out care routines during a diaper change before breastfeeding.

    Body temperature

    Inside the womb, the foetus is surrounded by 37 °C amniotic fluid. Foetal temperature is around 0.5 °C higher than the mother's body temperature. If the mother has a fever during childbirth, the baby's body temperature rises as well.

    After birth, the newborn's body temperature depends on the temperature of their environment. A baby's normal body temperature is between 36.5 °C and 37.3 °C. If the ambient temperature is comfortable for the baby, he or she will neither sweat nor become restless due to the cold. Comfortable temperature varies from baby to baby and changes during the first weeks of life.

    Hypothermia is defined as body temperature below 35 °C. Hypothermia is more common in preterm babies and babies with low birth weight.

    Hyperthermia is diagnosed when the body temperature is above 38 °C. If hyperthermia is not caused by a medical condition (e.g. sepsis or brain damage), it is probably due to environmental conditions (breastfeeding, too many layers of clothes, etc.).

    Bathing

    Your baby can be bathed on the day of discharge from the hospital unless your baby was vaccinated on the same day. The bath water should be warm (37 °C) and the room temperature should be at least 25 °C. Tap water is suitable for bathing your baby. You do not need to add anything to the water. You can bathe your baby every day. However, we recommend using a baby soap only once a week as it may cause the skin to become overly dry. It is safe to get the umbilical cord stump wet during bathing. You can bathe your baby at any time, but not before going outside. An evening bath usually brings a good night's sleep. If possible, bathe your baby at the same time each day. If your baby's skin is dry, a baby-friendly body lotion or moisturiser can be applied to the skin. After bathing, your baby should wear a hat until his or her head is dry.

    Vitamin D

    From the seventh day of life, your baby should be given 400 IU (international units) of oil-based vitamin D drops once daily in the first half of the day before feeding. See the patient information leaflet to determine how many drops should be given each day. Oil-based vitamin D is available in pharmacies without a prescription. We recommend that you continue to give your baby vitamin D in the second year of life.

    Taking your baby outside

    The time of the first walk depends on the time of year your baby was born. In summer, you can take your baby outside when he or she is just a few days old. The baby should be around a week old in spring and autumn and around 10 days old in winter to be taken outside. In winter, let your baby sleep near an open window with clothes on so that he or she can get used to cold air. In winter, we recommend going for a first walk when the temperature outside is higher than -10 °C. Do not take your baby outside if the temperature is lower than -15 °C. Your baby is wearing enough clothes if the nape of the neck feels warm.

    ITK773

    Approved by the decision of the Care Quality Commission of East Tallinn Central Hospital on 27.01.2021 (protocol no. 2-21)