Routine Postpartem Care


Although the average length of hospitalization for an uncomplicated vaginal delivery is 1-3 days, the postpartum period is currently defined as lasting until six weeks after delivery. The main focus of routine care during this period consists of mother-baby bonding, establishing breast-feeding, and education regarding routine newborn and self-care. While most obstetrical problems resolve after delivery, the clinician must also be aware of the possibility of continuing gestational diabetes, eclampsia, venous thromboembolism, infection, or hemorrhage.

Postpartum Physical Exam

Immediate postpartum:

  • Assess the extent of bleeding,
  • Palpation of the uterine fundus for size and firmness, and
  • Assessment of the cervix and perineum for the presence of trauma (see the discussion on repair of vaginal lacerations).

Prior to discharge:

  • The quantity and quality of continuing lochia,
  • Lower extremity edema, and
  • Uterine tenderness or breast/nipple abnormalities.

After Discharge:

  • A complete physical, including a pelvic exam, should be conducted at approximately six weeks postpartum.


Postpartum Labs

  • Recheck hematocrit the day after delivery or sooner in the presence of postpartum hemorrhage.
  • A fasting blood glucose should be obtained the day after delivery and a two-hour 75-g glucose challenge obtained at six weeks after delivery to ensure resolution of GDM if applicable.
     

Postpartum Counceling

  • Ask about common discomforts (e.g., urinary retention, constipation, perineal care).
  • Determine the frequency of breast-feeding and commonly encountered problems.
  • Counsel patients with regard to routine newborn care, including how to take the baby's temperature, anticipate URIs, use car safety seats, and perform jaundice checks.
  • Offer information about postpartum depression, family support, and emotional self-care.
  • Counsel patients with regard to birth control methods (estrogen-containing methods can potentially ↓ the quantity of breast milk and/or pass to the baby).
  • Discuss the duration of normal bleeding, and recommend pelvic rest for six weeks.

Postpartum blues/Depression

  • "Postpartum blues" occure in up to 85% of all women
    • Symptoms begin in the first wk. & include sadness, fatigue, insomnia, anxiety, headaches, irritability, poor appetite & mood swings.
    • Usually rsolve spontaneously during first 2-4 wks.
  • Postpartum depression occurs in 10-20% of all women within the first 6 months
    • Symptoms may include anhedonia, poor concentration, or indecisiveness, fatigue, guilt, anorexia, agitation, anxiety, psychomotor retardation, sleep disturbance, tearfulness and feelings of hopelessness or worthlessness.
    • Mothers often find it difficult to function and to take care of their infants.
    • Adolescent mothers 3 x  more likely to to abuse drugs or alcohol if depressed.
    • Cognitive therapy has been shown to be efficacious for treatment.
    • SSRI are antidepressants of choice & can be used in breast feeding mothers
      • Zoloft 50-200mg 1 PO qam
      • Paxil 20-40mg PO qam
    • Depression after delivery hotline: 1-800-944-4PPD or Online support @ http://www.postpartum.net

Exercise

  • Post-Cesarean Section:
    • Women should avoid lifting > 10 lbs for at least 6 weeks.
    • Avoid sit-ups, jumping jacks or high-impact aerobics for at least 6 weeks.
    • Recommend against driving for at least 2 weeks
  • Following Vaginal Delivery:
    • May resume light exercise immediately
    • Gradually increase to pre-pregnancy level of exercise over first month

Constipation/Hemorrhoids

  • Drink 8-10 glasses of water daily and eat high fiber foods.
  • May benefit from a stool softner such as Colace 100mg 1 PO bid.
  • Anusol cream or witch hazel pads can help soothe hemorrhoid discomfort
    • AnaMantle HC (hydrocortisone/lidocaine topical) 0.5% / 3% , 1% / 3% crm; 2.5% / 3% gel; apply bid
    • Analpram HC (hydrocortisone/pramoxine topical) 1% / 1% crm apply tid-qid
    • Preparation H Ceam Max Strength pain relief (phenylephrine/pramoxine/glycerine/petrolatum rectal); apply prn: max 4x/day.

Episiotomy Care

  • Avoid Constipation
  • Sitz baths 3-4x/day for perineal discomfort. Cold witch hazel is also helpful.
  • Avoid intercourse until the perineal discomfort has completely resolved.

Breast Engorgement

  • If breast feeding: frequency of nursing or pump breast(s) between feeds.
  • If bottle feeding:
    • Tight-fitting bra or bind breasts with an ace wrap,
    • Avoid any nipple stimulation or hot water on the breasts.
    • Ice packs to the affected breast(s) 3x/day

Inadequate Milk Supply

  • Increase hydration by drinking 8-10 glasses of water daily
  • Can pump breasts between sessions of nursing.
  • Warm compressions to help encourage let down.
  • Reglan 10mg PO tid-qid can help stimulate milk production.
    • Avoid with depression.
    • Can cause diarrhea, sedation or extrapyramidal symptoms.
    • Effects on infants are unknown (although thought to be safe).
  • Avoid combination OCP or patches for at least 6 weeks.

Late Endometritis

  • Generally presents with low-grade fever, pelvic pain and foul-swelling lochia.
  • Onset is between 2-6 weeks postpartum.
  • Treat with Doxycycline 100mg PO bid or Clindamycin 300mg PO qid x 14 days
  • May need to hospitalize if pt. appears toxic.

Mastitis

  • Presents with fever, breast pain, warmth, redness, +/- flu-like symptoms.
  • Breast feeding women should continue to nurse.
  • Tx with warm compresses to affected area 3-4x/day.
  • Dicloxacillin or Keflex 250-500mg PO qid x 10 days.
  • Exclude possibility of a breast abscess and hospitalize if pt. appreas toxic.