Postpartum Care and Breast-feeding
Meghan E. Pratts
Shari Lawson
POSTPARTUM CARE
Immediate postpartum care includes monitoring vital signs, managing and relieving pain, and observing for complications. Patients who have had a cesarean section should receive special attention, recognizing that they are postsurgical patients. As the risk of postpartum complications decreases, attention should be turned to education. Important issues to cover include maternal self-care, appropriate sexual and physical activity, breast-feeding, and infant care and nutrition.
Common Postpartum Complications
Postpartum hemorrhage has various definitions: (a) estimated blood loss of greater than 500 mL for a vaginal delivery or greater than 1,000 mL for a cesarean delivery; (b) a 10% change in hematocrit between admission and the postpartum period; or (c) excessive bleeding that produces symptoms requiring transfusion of packed erythrocytes. Excessive blood loss that occurs within 24 hours of delivery is termed primary or acute postpartum hemorrhage, whereas bleeding that occurs more than 24 hours after delivery (up to 6 weeks) is termed secondary or late postpartum hemorrhage. The incidence of postpartum hemorrhage is approximately 4% with vaginal delivery and 6% with cesarean delivery.
Postpartum febrile morbidity is defined as a temperature higher than 38.0°C on at least two occasions at least 4 hours apart after the first 24 hours postpartum. Common causes include breast engorgement, atelectasis, urinary tract infection, endomyometritis, drug reaction (especially with misoprostol use), and wound infection. Less common causes of postpartum fever include retained products of conception (especially if bleeding is heavier than normal), pelvic abscess, infected hematoma, pneumonia (particularly if the patient received general anesthesia), ovarian vein thrombosis, and septic pelvic thrombophlebitis. All maternal fevers should be reported to the newborn nursery.
Urinary tract infection is common in pregnancy and after catheterization; culture should be considered based on clinical examination.
Endomyometritis complicates 1% to 3% of vaginal deliveries and is up to 10 times more common after cesarean delivery. It presents as fever, uterine fundal tenderness, malaise, or foul-smelling lochia and is usually a polymicrobial infection of Gram-positive aerobes (groups A and B streptococci, enterococci), Gram-negative aerobes (Escherichia coli), and anaerobes (Peptostreptococcus, Peptococcus, Bacteroides) from the genital tract. Bacteremia may be present in 10% to 20% of cases. Endomyometritis should be treated with intravenous antibiotics until the patient is clinically improved and afebrile for 24 to 48 hours. The American College of Obstetricians and Gynecologists (ACOG) recommends treatment with gentamicin (1.5 mg/kg every 8 hours) and clindamycin (900 mg
every 8 hours), with the addition of ampicillin (2 g every 4 to 6 hours) if fever persists after initial treatment. Some practitioners simply begin initial therapy with the triple antibiotic regimen. Daily dosing of gentamycin (5 mg/kg every 24 hours) has been shown to be as efficacious and more cost-effective than the low-dose regimen. Further treatment with oral antibiotic therapy is unnecessary once the patient has been afebrile for at least 24 hours and her symptoms have improved. Response to antibiotic treatment is usually prompt. Persistent fever after 48 to 72 hours of antibiotic treatment necessitates further evaluation.
Septic pelvic thrombophlebitis (SPT) is rare and is more frequently associated with cesarean section. It is characterized by high spiking fevers despite appropriate antibiotics. Patients tend to feel well between fevers and have no complaint of pain. Imaging is frequently obtained to look for an abscess, but the pelvic thromboses with SPT are not always seen on computed tomography or magnetic resonance imaging, so the diagnosis is made based on clinical examination and exclusion of other causes. Continuation of intravenous antibiotics and the potential addition of heparin anticoagulation have been suggested for treatment, although this treatment regimen remains controversial.
Hypertension is defined as blood pressure (BP) of 140/90 mm Hg or higher, taken with the patient in a seated position on two or more occasions at least 6 hours apart. Preeclampsia or eclampsia can present postpartum, even in the absence of antenatal complications. Any pressure reading of 140/90 mm Hg or higher should be evaluated by repeating BP measurement, testing urine for protein, and assessing for other signs and symptoms of preeclampsia. In those women who had antenatal preeclampsia, spontaneous postpartum diuresis and normalization of BP are generally expected. Hypertension from preeclampsia can persist for up to 6 weeks, however, and may require further evaluation and treatment.
Postpartum Immunizations
Immunizations/injections that may be offered postpartum include hepatitis A and B, rubella, rubeola, pertussis, and varicella, all as indicated.
Rh D immunoglobulin: An unsensitized Rh-negative woman who delivers an Rh-positive infant should receive 300 µg of Rh D immunoglobulin within 72 hours of delivery even if Rh immunoglobulin was given antepartum. If there is laboratory evidence of excessive maternal-fetal hemorrhage, additional doses may be required. The blood bank should perform a rosette test or the Kleihauer-Betke test to assess the amount of maternal-fetal blood mixing and to calculate the additional amount of Rh D immunoglobulin to administer.
Rubella vaccine: Mothers who are rubella nonimmune should receive the measles-mumps-rubella (MMR) vaccine prior to discharge after delivery. Use of monovalent rubella vaccine (i.e., Rubivax) is generally not appropriate because MMR is more cost-effective and because many women without immunity to rubella also lack immunity to rubeola (measles). Breast-feeding is neither a contraindication to MMR vaccination nor should breast-feeding be discouraged after MMR injection.
Discharge from Hospital
When no complications occur, mothers may be discharged 24 to 48 hours after vaginal delivery and 24 to 96 hours after cesarean delivery. The following criteria should be met:
Vital signs are stable and within normal limits.
Uterine fundus is firm and involuting (within 24 hours, a postpartum uterus without fibroids should decrease to 20-week size).
The amount and color of lochia are appropriate—red, less than a heavy period, and decreasing.
Urine output is adequate.
Perineal pain is adequately controlled with sitz baths, ice packs, and analgesics.
Any surgical incisions or vaginal repair sites are healing well without signs of infection.
The mother is able to eat, drink, ambulate, and void without difficulty.
No medical or psychosocial issues are identified that preclude discharge.
The mother has demonstrated knowledge of appropriate self-care and care of her infant.
The issue of contraception has been addressed.
Appropriate immunizations and Rh D immunoglobulin, if appropriate, have been administered.
Follow-up care has been arranged for mother and infant.
Infant nutritional needs have been addressed.
Outpatient Postpartum Visit
The postpartum visit can be scheduled for 4 to 6 weeks postpartum unless a problem that requires closer follow-up is identified. For example, women with hypertensive complications should have a BP check and brief assessment within 1 week of discharge. For women with a history of postpartum depression or a known mood disorder, closer follow-up is warranted. Immunization status should be reviewed and vaccines that were not given immediately postpartum may be offered. The following are other important elements of routine postpartum visits:
Physical Exam
BP, breast, abdomen, and pelvic examination (including vaginal repair assessment)
At 2 weeks postpartum, the nonmyomatous uterus is usually not palpable abdominally.
By 6 weeks postpartum, the uterus should return to 1.5 to 2.0 times its nonpregnant size.
By 6 weeks postpartum, lochia should be essentially absent.
If lochia is persistent, it should be reevaluated at 10 to 12 weeks. If still bleeding, evaluation is warranted, including measurement of serum human chorionic gonadotropin.
Sexual Activity and Contraception
See discussion in “Breast-feeding” section and Chapter 32 for contraception topics.
When the perineum is healed and bleeding decreased, sexual activity may be safely resumed.
Any significant dyspareunia should be evaluated.
Depression Screening
Assess psychosocial well-being; consider depression screening surveys.
If there is evidence of depression, antidepressant medication should be considered, and the patient should be referred for mental health care. If you elect to start antidepressant medication, the patient should also be screened for a personal history or a family history of bipolar disorder.
Thyroid-stimulating hormone level may be determined to evaluate postpartum hypothyroidism.
Antenatal Complications
Patients with preeclampsia should be followed to ensure resolution of symptoms and exclude underlying hypertensive or renal disease.
Women with gestational diabetes should be screened for diabetes at their postpartum visit due to their increased risk of underlying diabetes outside of pregnancy.
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