EARLY CON'TROLLED A.

MBULATION Ilf THE ·Pt1BP·&RIUM*

WM. F. GuERRIERo, M.D., F.A.C.S., DALLAH, TKXAH

Tconsiderable
HE period for ambulation of obstetric patients for many years has aroused
differences of opinion.
White of Manchester, England, 1728-1813, stated ''as soon as the patient
gets out of bed the better and this should not be deferred beyond the second or
third day at the furtherest. '' 1
In 1820, Gooch cautioned that patients should be kept in bed for three weeks
after delivery because of the danger of prolapse of the tlterus. Between this era
of obstetrics and the present era, the period of ambulation has varied .from one
extreme to the other. It is the purpose of this treatise to record the gross data
of a large group of patients under controlledamhulation and a detailed report of
a smaller group of private patients, to show that the advantages of controlled
ambulation may he obtained without incurring any of the disadvantages in the
puerperal woman.
Repeated experience with the difficulty of keeping· in bed throughout the
early puerperium large numbers of Negro patients deliveredat home first called
our attention to the possibility of early controlled ambulation in obstetrics.
This experience was further accentuated when construction of new facilities
reduced the bed capacity of the obstetric service of Charity Hospital of New
Orleans for a period of two years. Because of this fact it became necessary to
send patients home by the fifth day and to allow them freedom of controlled
ambulation. Observation at the six weeks' examination of these patients re-
vealed no apparent differences in abnormalities as contrasted '\.\ith the previous
years when the patients had been maintained at absolute bed rest with exercise.
In 1940, with this experience as a background, a system of early discharge
of the puerperal patient from the third to fifth day under controlled ambulation
was instituted. There was a careful daily follow-up in the homes by the nursing
service of the Maternal and Child Health Division of the City Board of Health
of New Orleans. The initial survey of 2,926 of these patients revealed the f:aet
that only 30 developed immediate puerperal complications.~ These were in the
nature of two cases of endometritis, two of mild pyelonephriti<>, and twenty-six
with engorgement of the breast and/or fissured or cracked nipples.
Postpartum examination of these patients at six weeks revealed that the
general recovery rate was better in fOmparison to those cases that remained
nonambulatory in the hospital. Relaxations and/or uterine prolapse, malposi-
tions of the uterus, and subinvolution of the uterus were present in a smaller
number than in nonambulatory cases.
A further detailed study of 323 private cases was undertaken in order to
assay the advantages or disadvantages in a class of patients usually seen in
private practice. These patients are not as hearty individuals as most of the
patier~ts seen in teaching institutions even though they are probably in a better
state of general health.
•Presented before the Sci.entitlc Faculty of Southwestern Medical College.
210
 GUERRIERO: EARLY AMBULATIOK IN PUERPERIUM 211

Method of Ambulation
The criterion for allowing ambulation is that the patients are medically in a condition
to be allowed this privi1ege.
The patient is advised to move freely in hed immediately upon recovery from whatever
type of anesthesia may have been given. Every eight hours for the first twenty-four hours
following delivery she is asked to sit up on the side of the bed for a few minutes, to cough
vigorously to clear the respiratory system of any mucus and to stimulate the circulation
in lower extremities. At each voiding the patient sits upright on the bedpan. On the second
day tho patient stands upright on four different occasions for a few minutes, followed by
~itting upright in the chair for a period of fifteen to twenty minutes. Voiding is accom·
plished while sitting on the bedpan phtced on a chair. On the third day ambulation about
the room for short periods of time on three or four different occasions is permitted. Complete
bathroom privileges are granted. Thereafter, controlled ambulation is permitted with the
restriction that each hour of ambulation be terminated by an hour of bed rest. By the tenth
day the patient is completely ambulatory, requiring only intermittent periods of rest. At the
end of the twenty-first day the patient is allowed to resume complete outdoor ambulation with·
out unduly tiring herself.
Clinical Material
There were 227 primigravida cases and 9!3 mdltigravida, the. latter varying from gravida
ii to Yii. The duration of labor in the primipara averaged 12 hours, 32 minutes; and the
multipara, 7 hours, 18 minutes. There were 318 vertex and 5 breech presentations. Labor
was terminated in 285 instances by the application of outlet forceps, in 7 instances by the
application of midforceps, and in 5 instances by the use of Piper forceps for the aftercoming
head following 3 spontaneous breeeh deliveries, and 2 breech deliveries by manual aid.
Twenty-six cases delivered spontaneously.
Sedation of varying degrees was employed in all cases using nembutal and scopolamine.
Delivery was accomplished in 103 cases under caudal analgesia; 30 cases under local pudendal
block; and 190 cases with gas anesthesia. Left mediolateral episiotomies were performed
in 290 cases and repair accomplished using chromic 000 interrupted sutures. Twenty cases
were delivered without episiotomies. In three of these, first-degree lacerations occurred.
The third stage of labor was managed by the administration of ergonovine, %20 grain,
intravenously, with delivery of the anterior shoulder in other than caudal analgesia cases.
In the latter it was given after delivery of the placenta. In three instances more than average
bleeding occurred at this period.
Results
Immediate Puerperium (Two Weeks)
GeneraZ..-In all instances patients expressed the opinion that a general feeling of well·
being occurred from the ambulation. This was particularly true in the multigravida who felt
that recovery was hastened by ambulation in comparison to their previous puerperium.
Lochia.--There was the greatest drainage of lochia in the first three to five days with a
:rapid decrease in the amount until almost complete cessation by the tenth day when the lochia
IVas completely serous.
Bladder and Bowel.-In not a single instance was eatheterization necessary. Bowel func·
tion was normal without the use of enemas or cathartics. It was noted that the patient~
:.omplained less of hemorrhoids than had been observed previously in nonambulatory patients.
Uterus.--In all but six instances involution of the uterus was accelerated, and the fundus
by the seventh day was palpable between the symphysis and two fingerbreadths aboye it. By
the tenth day the uterus was no longer palpable, being in the pelvis. The six cases whieh
underwent slower involution exhibited a palpable uterus at the symphysis between the tenth
and twelfth days, it being in the pelvis by the fifteenth day.
Episiotomy.-Complete healing was present by the seventh day in all except two instances
in which dehiscence of a moderate degree was present, so that healing occurred by secondary
intention in these two cases by the twelfth day. There was a notable lack of complaint about
0pisiotomy pain after the first day of ambulation.
212 AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY

Marbidity.-In ten cases morbidity was present for an average of three days. Etiology
of such morbidity Wa8 pyelonephritiR in two eaRes, endometritifl in three, and mastitis in five
cases.
Postpartum Bleeding.-In six cases bleeding was exaggerated enough to require a short
course of oxytoeics. There was present no immediate severe bleeding.
Pulmonary and. Vascula,r Complications.--None were present.
Delayed Puerperium (Six Weeks)
General.-All patients when questioned had been completely ambulatory from the twenty·
first postpartum day without any evidence of general fatigue but with a state of well-being.
Uterus.-Subinvolution was present in four cases to the extent that the uterus was twice
ita normal size at this period. Retroposition of the uterus was present in sixteen instances.
'l'here was an absence of relaxation of the anterior and posteriOT vaginal wallB and of uterine
prolapse at this time.
Pwlmonary and. Vascular Complications.-None were present.
Delayed Puerperium (SiX Months)
One hundred :fifteen of the above patients were re-examined at this period. The
patients again reiterated their satisfaction for their rapid return to normalcy without any dis·
comfort to them. There was an absence of any additional abnormality as compared with the
siX weeks examination. Particular referettc£> to the possibility of relaxation and/or prolapBe
revealed nothing of note.
Discussion
In advocating early controlled ambulation during the puerperium one
should be cognizant of its potential advantages and disadvantages.
The potential disadvantages expected (postpartum hemorrhage, excessive
relaxation and/or uterine prolapse, and dehiscence o:f episiotomy) were less in
these series than in previous series o:f nonambulatory patients. True, complete
elimination of prolapse and/or relaxation as a complication requires a lon~r
follow-up than in these series. However, if deliveries are accomplished in a
manner to avoid injury of the fascia propria, there should be ilo increase fu
relaxation and/or prolapse. When injury to the fascia propria bas occurred, it
is not conceivable that bed rest produces a return of fascial support. In the past
the obstetric patient has remained nonambulatory for long periods of time, yet
large numbers of cystocele, rectocele, and uterine prolapse are seen in gynecologic
clinics.
The advantages obtained from controlled ambulation of these two series
were beyond any expectation. Thert> was a complete absence of bladder and
bowel disturbances, phlebothrombosis and thrombophlebitis, with a marked re-
duction in uterine subinvolution and retropositions. The obtaining of these
advantages without the appearances of the expected disadvantages makes one
realize that controlled ambulation has much to offer the obstetric patient.
OomiusiODS
A gross report of 21926 cases and a detailed report of 323 ~cases who experi-
enced early controlled ambulation is given. Early controlled ambulation is
shown to offer advantages to the obstetric patient without impoSing any dis-
advantages.
~erences
1. Adluni, J. G.: J. Ob&t. lit; Gynaec. Brit. Emp. 29: 1, 1922.
2. Guerriero, W. F.: AM. J. 0BST. & GYNEC. ll6: 312, 1943.
3622 FAmMONT.