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Early discharge after delivery may not be dangerous, if…

Every woman longs to experience the thrill of childbirth but it also comes with excruciating pains. How soon should a woman be allowed to return home and fall back into her normal routine after childbirth? VERA ONANA, with contributions from experts answers this question in this report.

 

Recently, it was reported that barely 24 hours after delivery, a new mother was released from the maternity centre to take part in a written examination. This has raised a lot of eye brows and questions have risen if it was right for the hospital to release her.

Dr Solomon Kupolati, Chief Medical Director of Iye Hospital, Ibadan and fertility expert has said that, “there is no medical law telling doctors not to discharge patients after 24 hours of delivery. The highest number of complications usually arises within 24 hours of delivery that is why more than 40 per cent of maternal deaths occur when patients are discharged before 24 hours including paediatric mortality but after 24 hours of delivery, patients are usually safe.”

In the same vein, Consultant Obstetrician and Gyneacologist, Professor Alexander Owolabi of the Department of Obstetrics and Gyneacology, Obafemi Awolowo University and Chief Medical Director of Balm of Gilead Specialist Hospital and Fertility Centre, Ilesa, Osun State, explained that though management after delivery is aimed at restoring the health of the mother, preventing post delivery infection and taking care of the breast, early discharge from the hospital is an almost universal procedure.

Owolabi added that if adequate supervision by trained health visitors is provided, there is no harm in early discharge. “Most women are discharged fit and healthy after two days of spontaneous vaginal delivery with proper education and instructions.

Reacting to the report, the expert said “if a mother is safe, under extreme circumstance of an examination, the mother may be allowed home same day of delivery especially if she is not a first timer and had no perineal injury or episiotomy. Such a mother must be kept under watch by health visitors.”

According to Owolabi, a mother without complications and especially those that have delivered before may be allowed to leave after two days, while first timers, after three days of observation.

However, the consultant explicitly stated that some women may need prolonged hospitalisation due to morbidities like infections of the urinary tract, perineal wound, pain or breast feeding problems.

He also stressed the need for mothers to be at alert after discharge, saying “if and when a mother is discharged, she must be educated and instructed to return on noticing any abnormalities such as poor breast feeding, malodorous vaginal discharge, fever, yellowness of eyes, body of the baby which may be indicative of jaundice and mood changes in the mother.”

In 2009, Rachida Dati, France’s glamorous justice minister, defied convention by returning to her office just five days after giving birth by caesarean section to her first child.

The question may therefore arise on why Dati as well as other new mothers who have been under the knife should be allowed to go home after such a short time. Dr. Kupolati on reacting to that stated that in the case of Caesarian section, the onus lies on health worker that took the delivery to decide if the patient should be released from the hospital and when.  “The doctor needs to use his initiative. However, the minimum period should be about 48 to 72 hours. After 72 hours which is three days, if the patient is stable and all vital signs are in order, then the patient can be discharged.”

Owolabi added that in cases of straight forward and uncomplicated Caesarian Sections, early feeding and discharge home is very common. “Even researches conducted in our centre confirm the safety of such methods. Such cases are discharged home after wound inspection shows no sign of complications on the fourth post operative day.”

 

Recovery after delivery

Speaking on the anatomy of a woman post partum, Owolabi explained the recovery process begins immediately after the placenta is expelled and lasts for approximately six weeks when the uterus regresses almost to the non pregnant size. “The period is arbitrarily divided into three: immediate, which takes 24 hours, early, which takes up to seven days and remote which takes up to six weeks.”

Dr Kupolati however, warned that the new mother must rest properly and ease gradually into normal activities.

“She must have lost some blood after delivery. So, it is important that she rests. Hence, the six weeks post partum period. Most patients are up and about after 24 hours. Some can walk about; some can even drive or go to the market.”

Buttressing with events from his hospital, the director said, “even in this hospital 48 hours after a Caesarian Section, most women go home and by the fifth day, are almost scar less. Things have really advanced in the medical world. In developed countries, women undergo caesarian sections in the morning and within 36 hours from the operation are home. The home is the most ideal place for recuperation better than the hospital. If there is no complication, and the delivery was smooth be it normal or via caesarian section, there is no point keeping the patient in the hospital.”

Kupolati further explained that since the patients would still be visiting the hospital for post natal care, there is continuous follow up. “The observation continues from there. It doesn’t end after discharge.”

However, Owolabi advised that doctors must exercise caution not to discharge women too early because the law generally expects the doctor to do things that will not cause the mother or baby harm or injury.  “Too early discharge can prevent the detection and delay in treatment of post delivery complications such as retained products of delivery leading to increased bleeding after delivery and post delivery infections.”

While adding that major causes of post partum complications could be puerperal sepsis, urinary tract infection, breast inflammation and abscess, cracked and retractile nipple, episiotomy, pulmonary infections and thromboembolism of the leg and pelvic region which is a very serious complication.

Dr Kupolati admonished that doctors should know their patients. “There is a need for doctors to individualise their patients; it shouldn’t be a generalised sweeping term that all patients can be released after 24 hours. As a doctor, one must understand the peculiarities of every patient. If a patient is anaemic, like sickle cell patients, their stay period in the hospital may have to be extended until they are fully stable. But if the patient is completely fine and there is no complication, there is no need to keep them.”