Postpartum and Neonatal Overview*
*Neonatal Protocols contributed by Elizabeth Hawkins-Walsh.
The first trimester of pregnancy is characterized by tremendous physical and emotional changes. So, too, is the postpartum period. Many women’s health practices provide the patient with some postpartum teaching before the arrival of the baby, and most women receive postpartum teaching once they have delivered. However, with ever-shortening lengths of postpartum care, many women have difficulty absorbing and remembering this teaching. Consequently, it is common to receive calls from patients about postpartum changes and concerns.
From a telephone perspective, several issues are often encountered. Normal and abnormal bleeding during the postpartum period, postpartum infection, emotional changes associated with delivery, and questions about caring for a newborn frequently arise.
The postpartum uterine discharge, or lochia, normally will transition during the first few days from lochia rubra to lochia serosa. During the next 2 weeks, lochia serosa will be replaced by lochia alba. The patient can expect the lochia to change from bright red to pink to rust-colored and finally to white-yellow. Occasionally, there is a sudden transient increase in uterine bleeding between 7 and 14 days after delivery as the placental implantation site heals. The flow of blood normally stops between 4 and 6 weeks. A protocol is provided to assist with telephone assessment of lochia.
Breast pain and nipple soreness are common postpartum symptoms. Initial breast engorgement often occurs between the second and fifth postpartum day. This needs to be distinguished from postpartum mastitis, a breast infection characterized by breast pain with redness, fever, and flu-like symptoms.
Postpartum “blues” are a common psychological response after pregnancy. However, a minority of women may experience more serious symptoms, often resulting in postpartum depression or psychosis. Differentiating between these reactions is an important challenge to the triage provider. Depression issues take precedent throughout pregnancy and the postpartum period. There is a sense of urgency that this issue should not be dismissed or overlooked. You should see a common thread throughout all aspects of pregnancy and gynecology concerns emphasizing a team approach to management of the issues of anxiety and depression. Anxiety has been covered extensively in this book, and although it can be high for a new mother, we are not repeating the recognition and management of anxiety as a separate entity in this chapter due to the introduction of the continuum of baby blues to postpartum psychosis.
The postpartum patient frequently consults women’s health providers with concerns related to her newborn. The women’s health care team should answer only the most rudimentary of questions. Other questions should be referred to the patient’s pediatric provider. Protocols for the most basic of neonatal questions are provided in this section of the book.
» BASIC TRIAGE ASSESSMENT FORM FOR THE POSTPARTUM PERIOD
What date did you deliver? _________________________________________________________________
Was the baby term? _________________________________________________________________________
What type of delivery did you have (vaginal, vaginal with vacuum or forceps assistance, or cesarean section)? ____________________________________________________________________
Did you have any complications at the time of delivery?
___________________________________________________________________________________________________
Did you have a boy or a girl? (Note: Most practices have a method for flagging charts to avoid the trauma of asking a patient who has suffered a pregnancy loss questions pertaining to the infant and infant status.) _________________________________________________________
How is the baby doing? _____________________________________________________________________
How are you feeding the baby (breast, bottle, or combination)? _____________________________
Common Questions After Delivery
» Key Questions
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» Actions
STEP A: Activity Immediately After a Cesarean Section (C-Section)
Tailor the following advice to the philosophy of your practice:
Initial Postpartum Care: Instruct the patient to do the following:
Instruct the patient to begin to walk as soon as possible after delivery, maintaining good posture.
The patient should be advised to restrict lifting (greater than 15 lb), carrying more than the weight of her baby or doing housework until the initial postoperative visit. The goal is to increase activity without incurring increased fatigue.
If breastfeeding, advise the patient to ensure there is good physical support for her back and her baby; support by using a pillow or the side-lying position may be helpful.
Advise her to support her abdomen when coughing, laughing, or sneezing.
She should be advised to wash hands frequently, especially after urinating, following a bowel movement, before and after changing diapers, and before touching her C-section incision.
Instruct her to try to arrange her living situation to keep everything on one floor in the home for the first week. Tell her to have telephone access, bathroom access, baby care items, and access to hydration and food conveniently arranged on the same level.
The goal is to promote a speedy and safe recovery.
C-section is major abdominal surgery; it may take as long as 6 months to make a complete recovery. However, there is no data to suggest that there are absolute timelines for a woman to return to her regular activities, such as driving, working, exercising, or intercourse. Most practices schedule an initial visit within 1 to 2 weeks after discharge from an uncomplicated C-section, and it is often at this initial visit that return to usual activities is discussed.
It is usually not advisable to drive until after an initial incision check. Many practices see a patient who has undergone a C-section within 2 weeks after delivery before
advising her she may drive. In actuality, the reason to delay driving is to be certain the new mother can quickly apply brakes in an emergency and is no longer taking narcotics that may have been prescribed postoperatively. This is a discussion for triage personnel to have with the obstetrical providers in order to properly advise patients.
advising her she may drive. In actuality, the reason to delay driving is to be certain the new mother can quickly apply brakes in an emergency and is no longer taking narcotics that may have been prescribed postoperatively. This is a discussion for triage personnel to have with the obstetrical providers in order to properly advise patients.
STEP B: Activity Immediately After a Vaginal Delivery
The goal is to promote a speedy and safe recovery.
Advise against heavy lifting (greater than 15 lb) for at least 2 weeks. Generally, the new mother should spend her time primarily concerned with her own recovery and care of her infant. However, this is not necessarily practical for women with busy families. The newly delivered patient should gradually increase activities within her level of tolerance and avoid excessive activities that will only add to the expected fatigue.
Advise limited stair climbing until comfortable doing so.
Usual advice limits driving for at least 1 week. In actuality, the reason to delay driving is to be certain the new mother can quickly apply brakes in an emergency and is no longer taking narcotics that may have been prescribed following delivery. This is a discussion for triage personnel to have with their obstetrical providers in order to properly advise patients.
STEP C: Exercise After Birth
Postpartum exercises are designed to assist in regaining muscle tone and body shape.
Toe stretch and pelvic floor exercises (Kegel) can be performed in bed during the immediate postpartum period.
Other exercises (such as abdominal muscle strengthening) are important and can be added after the first postpartum visit. Resources for postpartum exercise are listed at the end of this chapter.
STEP D: Sexual Intercourse
Sexual activity can be resumed after vaginal bleeding has stopped, the incision is healed, and the patient is mentally ready.
To reduce the risk of infection, most practices advise patients to avoid sexual intercourse until vaginal bleeding has stopped.
Because of hormonal changes, the patient may experience vaginal dryness.
If vaginal dryness occurs, prolonging foreplay or using a water-soluble lubricant may add to patient comfort.
Sexual intimacy can be achieved in ways other than sexual intercourse; if the patient is not ready for vaginal intercourse she can discuss with her partner expressing intimacy by conversation, kissing, hugging, and touching each other.
The demands of parenting are stressful on a relationship; recommend open, honest, and frequent communication between partners.
Some may find having intercourse in the morning when the patient may be more rested is helpful.
Pregnancy can occur within 2 to 4 weeks after delivery, so the patient should be sure to use contraception before resuming sexual intercourse if she wants to prevent a pregnancy.
STEP E: Contraception
Ovulation can occur as early as 4 weeks after delivery. The patient should not rely on breastfeeding as a method of reliable contraception.
Contraception ideally should be discussed with both partners during the last trimester of pregnancy and again during the immediate postpartum period.
If the patient is not using contraception and is having or considering having intercourse, advise the patient to use condoms and schedule an appointment for contraceptive counseling.
» Patient Education
There are several excellent resources on the Internet for new mothers. Topics from maternal physical recovery, to “baby basics,” to maternal depression are not hard to find. Most practices have their own links or may refer patients to the resources on the website of the facility where the patient delivered her baby. Here are two very reputable resources if others are not readily available:
http://www.webmd.com/parenting/baby/tc/postpartum-first-6-weeks-after-childbirth-recovery-at-home#1
https://www.cdc.gov/reproductivehealth/index.html
Postpartum Baby Blues/Depression/Psychosis
It is estimated that up to 85% of women experience some variation of mood disturbance during the postpartum period. The symptoms of postpartum baby blues appear during the first week after delivery and include symptoms such as crying for no reason, anxiety, and anger at partner or family, among myriad other symptoms. A woman experiencing the so-called “baby blues” may feel inadequate caring for her new child and/or older children, may have trouble eating, making decisions, and/or sleeping. These symptoms usually are resolved in a few days and most certainly should dissipate by postpartum day 14. The onset of postpartum depression is usually within 6 weeks after childbirth but may actually begin to surface in the period prior to delivery. Some experts feel depression for some women may be on a continuum throughout pregnancy, with as “crescendo” after delivery. The symptoms last from 3 to 14 months.
Although there is very poor data on the consistent prevalence of postpartum mood disorders due to variations in populations studied and numerous cofactors, this is particularly true for unipolar depression in the postpartum period. There is inconsistency among studies on whether or not postpartum depression has definite subsets or is itself a subset disorder of depression. This is certainly an area where it is crucial for triage personnel to stay current on new findings.
For our purposes (as described in Chapter 5: 1st Trimester Depression protocol), it is necessary that some general statistics are adopted. Postpartum blues are reported to occur in as many as 70% of all women, whereas postpartum depression occurs in approximately 9% (compared with 8% in the general nonpregnant female population). Women with a history of postpartum depression may have a 50% risk of recurrence. Postpartum psychosis is characterized by a desire to harm oneself and/or the baby and is estimated to occur about 0.1% to 0.2% of the time. It requires immediate attention. Any reports of hallucination or delusion from a recently delivered patient (or confirmed by someone close to her) need to be taken extremely seriously.
» Key Questions
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» Actions
STEP A: Treatment of Postpartum Blues
The symptoms generally are self-limiting and require no pharmacologic treatment. However, triage nurses need to be sensitive and attuned to these complaints, and initial contact from a patient experiencing these symptoms needs to trigger a system for active monitoring and follow-up according to a practice-wide protocol. One may not know from the first call from a postpartum patient if this is “only” the “baby blues” or the beginning of a more serious mood disorder. A monitoring system should include the following:
A system that flags the patient’s record and outlines plans for continued contact with her.
Initiation of a practice-wide system that has as its goal enhancing team communication and continuity of care by documenting all patient conversations, interventions, and referrals in the patient record per protocol.
All practices should have a mechanism for alerting other providers to patients experiencing symptoms of depression. There should be open communication between practitioners providing obstetric care, pediatric care, psychological/psychiatric support, and general family medicine.
All practices should have a mechanism for following up on patients identified early in the postpartum period as “at greater risk” for worsening postpartum problems.
In our practice, we use the following system for identifying and following postpartum patients experiencing mood disorders: __________________________________________________ ________________________________________________________________________________________.
In general, if the patient is calling within the first 2 weeks since delivery, the triage nurse can reassure the mother and family that these feelings are common and usually go away without treatment, but if they persist past 2 weeks, however mildly, the patient should call back to report her symptoms.
Give the patient permission at the onset to call back immediately if symptoms worsen at any time.
Advise the mother to get as much rest as possible, to sleep when the baby sleeps, and to get help with housework and other child care responsibilities, if possible.
The special needs some mothers may have such as lack of social supports, mothers with an infant in the neonatal intensive care unit (NICU), and mothers who have suffered a perinatal loss or trauma need to be addressed by nursing staff. Providers need to be particularly sensitive to these issues.
New mothers need to be advised to avoid trying to do too much or trying to be perfect.
Educate the patient during any initial call that fatigue often is at the root of worsening symptoms and advise her not to push herself beyond reasonable limits.
Encourage the patient to eat regular meals and a well-balanced diet.
Advise the patient that mild exercise, such as walking, may be helpful.
Encourage her to plan time for some activities she enjoys and for private time with her partner or other support systems.
Encourage her to continue breastfeeding if she is doing so.
Advise the patient to make time to go out, visit friends, or spend time alone with her partner.
She should be advised to not feel guilty about talking to others and actively discuss her feelings with her partner, family, and friends.
She should be encouraged to talk with other mothers who have had a successful postpartum period so that she can learn from their experiences.
Encourage her to join a support group. Part of a practice or clinic’s overall plan for dealing with mood disorders should include knowledge of community resources, and these should be frequently updated.
Advise the patient to avoid making any major life changes during pregnancy or right after giving birth. Major changes can cause unneeded stress. Sometimes, big changes can’t be avoided. When this is unavoidable, try to arrange support and help in any new situation by preplanning as much as possible.
STEP B: Requires Immediate Action and Referral to a Mental Health Professional
This woman could be experiencing postpartum psychosis or major postpartum depression. She requires immediate assistance.
Ask whether she is feeling like harming herself or her baby at that time (Question 5). Ask if she has thought about how she would do it. Ask whether anyone is home with her. If yes, ask her if you can talk with that person. If no, ask for the name and telephone number of a family member or friend you can reach immediately.
If it is necessary to call a family member or friend who is not at the patient’s house, have someone else call the contact person so you can remain on the line with the patient.
Per your practice team’s protocol, have emergency procedures in place for mobilizing your community resources to get to the patient. This may involve a Mobile Mental Health Team or the Police or Fire Department based on your community. Immediately inform a provider in your practice that an emergency situation exists. If the threat of suicide or infanticide seems immediate, have someone else in your practice call emergency services.
Keep the woman on the telephone and talking until emergency services arrive.
Reassure her that help is on the way.
If you are able to talk to a family member, ask them to make sure the patient is not left alone until she can see a mental health professional.
Make a same-day appointment with a mental health professional and ensure that she is accompanied by a family member or other responsible person.
Keep the providers in your practice informed about the problem and the actions taken.
Be certain to document accurately and completely.
STEP C: Requires Prompt Action and Referral to a Mental Health Professional
Even if there does not appear to be a risk of suicide or infanticide, this woman may be experiencing severe postpartum depression or psychosis and needs prompt assistance.
Refer her to a mental health professional for an appointment within the next 24 hours.
Reassure her that many women have psychological problems after childbirth and that this does not mean she is a bad mother.
Explain to the woman and her family that the prospect for recovery is excellent but that she will recover more quickly with treatment, which might include medication and counseling.
Make an appointment with her provider to rule out physical causes of symptoms that may resemble depression, such as anemia or hypothyroidism.
Refer her to community resources, such as support groups for new parents. Identify which of the following resources in your community that may be helpful. Here are some suggestions of individuals and facilities that might assist:
Family doctor
Counselor or social worker
Family service, social service agencies, or clergy person
Employee assistance programs (EAP)
Psychologists and psychiatrists
Emergency departments that have mental health coverage
Your practice or clinic may have to check the yellow pages (or Google) mental health, health, social services, suicide prevention, crisis intervention services, hotlines, hospitals, or physicians for phone numbers and addresses in your particular community. It is preferable to have names and numbers to give to the woman in crisis or a list to e-mail her (with her permission). This should be part of developing a team response and an emergency protocol for mental health crises.
If the patient is receptive, and crisis does not seem eminent, encourage her in the following:
To immediately report worsening symptoms or if she feels like harming herself, the baby, or anyone else.
To maintain a healthy diet and get mild/moderate exercise.
To discuss her feelings with her partner or another significant person in her life.
To do some activities that she enjoys and to plan for some private time with her partner.
To continue breastfeeding if she is doing so but to discuss this with her provider and pediatrician if she begins taking medication.
Inform a provider in your practice about the problem and the actions taken per your clinic or practice protocol.
» Patient Education
Postpartum blues is a common reaction after childbirth, occurring in the first week to 14 days in as many as 70% of new mothers. The major symptoms are mild anxiety or weepiness.
Postpartum depression, experienced by approximately 10% of new mothers, usually has a more insidious onset, often after the third week following delivery. A gradual increase in depressed mood, with marked lack of energy and multiple physical symptoms, often is seen. Women may feel like a failure at motherhood, and suicide is a risk. Risk factors include prenatal or previous postpartum depression, poor relationship with the father of the baby, and lack of support systems. These women also need professional help.
Postpartum psychosis is a relatively rare disorder, occurring in 1 to 2 of 1000 women, with the onset often during the same time that postpartum blues is found. It may begin with confusion, insomnia, anxiety, and panic and may progress rapidly to delusions and hallucinations. Risk factors include primiparity or a personal or family history of mental disorder. It may recur with subsequent pregnancies. On rare occasions, a woman may harm herself or her baby. This condition requires immediate attention.
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