Dear Doctor,

I had my second baby six weeks ago, naturally. I ripped really badly and had to be stitched. However, the bleeding comes and goes, and sometimes is really heavy. The stitches haven’t fully healed either and it’s beginning to worry me because when I had my first child three years ago, both the bleeding and the stitches were fine by this point.

Also, I can’t seem to hold my pee, every time I get the urge to urinate, I have to run to the bathroom before I leak. Usually, I leak anyway because I can’t hold it in. I went to see a doctor near home but was told that this was normal with natural deliveries.

But it makes no sense because everything went well the first time. Do I have some sort of complication? I am seriously worried.

Rose

Dear Rose

I am sorry that you have had to suffer this much after your second child birth. Normally mild bleeding occurs for a few days after delivery, but in some women, it may occur for up to a few weeks. However if the bleeding is heavy, whether intermittent or persistent, it can be caused due to retained products of conception. Even a small piece of placenta if left behind in the uterus can cause vaginal bleeding for many days. There may be associated lower abdomen pain.

Placenta accrete is a condition where the placenta partially or fully gets attached to the muscular wall of the uterus. If not detected prior to delivery, its separation during delivery can cause bleeding immediately after delivery and also later on. Infection of the inner wall of the uterus around delivery time can also lead to intermittent bleeding after delivery but it will be associated with pain and or fever.

These conditions can be diagnosed by internal vaginal examination, vaginal ultrasound and a complete blood count. After diagnosis, any of these conditions is treatable. Rarely, disorders of bleeding or clotting can manifest as post-partum bleeding. Drugs like aspirin if taken for fever or pain can cause bleeding from anywhere in the body including vagina as an adverse effect.

Inability to hold back urine (incontinence) could be due to damage to the urinary sphincter (valve closing the bladder), resulting from the difficult labor and perineal tear. If small, this may heal over time. Perineal exercises (Kegel exercises) can help to strengthen the pelvic floor muscles and also the sphincter. Going to the toilet at fixed time intervals, helps to train the bladder, so that it evacuates at fixed intervals.

This helps to minimise risk of urine coming out involuntarily and trains the sphincter as well to open at fixed intervals. Avoid taking many fluids, in particular, those which irritate the bladder like caffeine and alcohol. If symptoms persist, minor surgical interventions are indicated.

Cystitis or infection of the urinary bladder can cause frequency of urination, for example, the urge to pass urine many times and also inability to hold back urine. A woman can develop cystitis immediately after delivery due to multiple factors. Pre-existing infection being aggravated, use of urinary catheter for some intervention temporarily, hospital acquired infections; these are some of the common factors implicated.

Untreated, the problem continues and can even aggravate. This can be diagnosed by microscopic examination of the urine. Complete course of a suitable antibiotic helps to cure this condition.

Dr. Rachna is a specialist in internal medicine at Ruhengeri Hospital.