The American Congress of Obstetricians and Gynecologists (ACOG) has released new recommendations for postpartum care, including developing a postpartum care plan prenatally; scheduling an initial postpartum contact in the first 3 weeks to address acute issues followed by a comprehensive visit no later than 12 weeks after delivery; and counseling women who had gestational diabetes, pregnancy-related hypertension, or a preterm birth (PTB) about their increased risk for cardiovascular disease. They also advise documenting pregnancy complications in the electronic medical record to inform future providers regarding screening for diabetes and risk assessment for cardiovascular disease.
Physical Examination
A.General assessment:
1.Vital signs.
2.Weight.
B.Breasts:
1.Issues with breastfeeding: Discomfort or pain associated with breastfeeding; adequate breast milk production; assess comfort and confidence with breastfeeding.
2.Engorgement: Breast fullness and firmness, which is accompanied by pain and tenderness. Primary engorgement is caused by interstitial edema and onset of copious milk production. It typically occurs between 24 and 72 hours postpartum, with a normal range of 1 to 7 days; peak symptomatology averages 3 to 5 days postpartum. Secondary engorgement typically occurs later if the mother’s milk supply exceeds the amount of milk removed by her infant. Breast engorgement usually resolves spontaneously over a few days, but supportive care (warm compresses or a warm shower before feeding to enhance let-down and facilitate milk removal, cool compresses after or between feedings, mild analgesics such as acetaminophen or ibuprofen) is appropriate. In women who are not breastfeeding, the use of a tight brassiere and avoidance of breast stimulation suppresses lactation in 60% to 70% of patients and is the recommended treatment.
3.Mastitis: Lactation mastitis typically presents as a firm, red, and tender area of one breast with a maternal temperature that exceeds 38.5°C. A tender, fluctuant area is more indicative of an abscess. Systemic complaints may be present and include myalgia, chills, malaise, and flulike symptoms. Differential diagnosis includes plugged ducts, galactocele, and in rare cases inflammatory breast cancer.
C.Heart:
1.Postpartum physiologic changes in the cardiovascular system are particularly important in women with underlying cardiac disease. The cardiac output and stroke volume increase by approximately 50% and 70%, while the heart rate decreases by 15% and blood pressure (BP) remains unchanged. The increases in stroke volume and cardiac output most likely result from improved cardiac preload from autotransfusion of utero placental blood to the intravascular space. As the uterus decompresses following delivery, a reduction in the mechanical compression of the vena cava allows for further increases in cardiac preload.
D.Abdomen:
1.Uterine involution: The uterus recedes by approximately 1 cm/d to lie midway between the symphysis pubis and umbilicus by the end of the first postpartum week. It is not palpable abdominally by 2 weeks postpartum and attains its normal nonpregnant size by 6 to 8 weeks postpartum.
2.Abdominal wall: The abdominal wall is lax postpartum and will regain its normal muscular tone over several weeks; however, separation (diastasis) of the rectus abdominis muscles may persist.
E.Skin:
1.Linea nigra will fade gradually, but may never completely disappear.
2.Striae fade from red to silvery by 6 to 12 months postpartum, but are permanent.
3.Abdominal skin may remain lax if extensive rupture of elastic fibers occurred during pregnancy.
4.Melasma gravidarum resolves spontaneously over a period of months.
F.Extremities:
1.Edema and varicose veins: Varicose veins may appear during the antepartum or postpartum period. Leg elevation, exercise, and compression therapy improve oxygen transport to the skin and subcutaneous tissues, decrease edema, reduce inflammation, and compress dilated veins.
2.Deep vein thrombosis (DVT) is more common in postpartum women than in antepartum and nonpregnant women. The risk is highest in the first few weeks postpartum and then gradually declines to baseline by 12 weeks postpartum. Risk factors include a previous DVT, thrombophilia, sickle cell disease, obesity, smoking, cesarean delivery, and postpartum hemorrhage.
G.Vagina:
1.The vagina slowly contracts and decreases in size postpartum, but never completely returns to its nulligravid size.
2.The vaginal walls appear smooth immediately postdelivery; rugae are restored in the third week as edema and vascularity subside.
3.Pelvic floor stretching and trauma during childbirth result in pelvic muscle relaxation, which may not return to the pregravid state.
4.Persistent vaginal bleeding: Vaginal bleeding that persists for more than approximately 8 weeks after delivery is unusual and may be caused by infection, retained products of conception, a bleeding diathesis, or, rarely, choriocarcinoma or a uterine vascular anomaly. A temporary increase in bleeding at this time may represent menses; in such cases, bleeding should stop within a few days.
5.Vaginal dryness: Symptoms of vaginal dryness can be managed by regular use of vaginal moisturizing agents with supplemental use of vaginal lubricants for sexual intercourse.
6.Surgical site infection (episiotomy, laceration, abdominal incision): Perineal infections, and subsequent breakdown of previously repaired lacerations or episiotomies, are usually localized to the skin and subcutaneous tissue. On examination, the area appears swollen and erythematous with a purulent exudate. Treatment consists of opening the wound, drainage, irrigation, and debridement of foreign material and necrotic tissue. Antibiotics are not necessary unless there is accompanying cellulitis. The area will heal by granulation, but large defects may be re-sutured when the wound surface is free from exudate and covered by pink granulation tissue.
H.Cervix:
1.The cervix remains 2 to 3 cm dilated for the first few postpartum days and is less than 1 cm dilated at 1 week.
2.The external os never resumes its pregravid shape; the small, smooth, regular circular opening of the nulligravida becomes a transverse, stellate slit after childbirth.
3.Histologically, the cervix does not return to baseline for up to 3 to 4 months postpartum.
I.Lochia:
1.Lochia rubra: Normal shedding of blood and decidua is a red/red-brown vaginal discharge that lasts 3 to 5 days following delivery.
2.Lochia serosa: A watery, pinkish brown discharge that lasts for 2 to 3 weeks.
3.Lochia alba: In the final stage, the discharge turns yellowish white, and may last 4 to 6 weeks.
J.Rectal:
1.Symptomatic hemorrhoids are common postpartum, occurring in approximately one-third of
women. The treatment approach depends on the specific symptoms—pruritus, bleeding, pain, or prolapse.
2.Postpartum incontinence of urine, flatus, or feces is common in the immediate postpartum period and generally improves over the subsequent weeks, but may persist long term. Women should be asked about incontinence as they may not bring the issue up themselves.
Common Diagnostic Tests
A.Complete blood count (CBC) with platelets.
B.2-hour postload glucose (patients with gestational diabetes mellitus [GDM]).
Pharmaceutical Therapies
All household members in the newborn’s home should also have up-to-date immunizations to create a protective cocoon
around the infant and thus minimize newborn exposure to infection; Tdap and influenza vaccines are particularly important in this respect.
Patient Education
A.Weight loss:
1.The mean weight loss from delivery of the fetus, placenta, and amniotic fluid is 13 pounds.
2.Contraction of the uterus and loss of fluid (lochia) and excess intra- and extracellular fluid leads to an additional loss of 5 to 15 pounds in the first 6 weeks postdelivery.
3.Approximately one-half of gestational weight gain is lost in the first 6 weeks after delivery, with a slower rate of loss through the first 6 months postpartum.
B.Activity:
1.There are no evidence-based data on which to base recommendations regarding postpartum physical activity. In particular, there are no high-quality data on which to base restrictions on lifting, climbing stairs, bathing, swimming, driving, or resuming vaginal intercourse, exercise, or work after delivery.
C.Depression: Screen all women for postpartum depression, as recommended by ACOG, the American Academy of Pediatrics, and the United States Preventive Service Task Force Recommendation Statement. The validated questionnaire most commonly used for screening pregnant and postpartum women is the Edinburgh Postnatal Depression Scale (EPDS), but other validated tools can be used. Screening is important because postpartum depression is common, the combination of screening and adequate support improves clinical outcomes, and treatment (especially with cognitive behavioral therapy) is associated with symptom remission. Depression screening is performed at the routine postpartum visit, but consideration should be given to additional earlier screening and follow-up in patients at high risk for depression.
D.Intimate partner violence: Screen all postpartum women for intimate partner violence. Ideally, screening should be performed at the initial prenatal visit, at least once per trimester, and again during postpartum care. Screening should be routinely performed for women who have not accessed prenatal care or who have concerning signs or symptoms.
E.Screen for tobacco use; counsel regarding relapse risk in the postpartum period.
F.Screen for substance use disorder and refer as indicated.
Complications
A.Postpartum depression.
B.Diabetes: Approximately 6 to 8 weeks after delivery, women with GDM should undergo an oral glucose tolerance test (OGTT). They should be counseled about the increased risk of future diabetes, even when the postpartum glucose tolerance test is normal. These women may benefit from lifestyle changes, such as weight loss if they are obese.
C.Complications that occurred during the pregnancy or postpartum should be reviewed in terms of the cause, risk of recurrence, and prevention.
Consultations
A.Behavioral health counseling for postpartum depression.
B.Any underlying medical conditions that were present prior to or during the pregnancy should be addressed at the postpartum visit.
C.Cardiovascular risk: Women with gestational diabetes, pregnancy-related hypertension, or PTB are at increased risk of future cardiovascular disease, even if postpartum BP and glucose tolerance testing are normal.
D.ACOG recommends that clinicians make women with these complications of pregnancy aware of their increased risk for developing cardiovascular disease. Including this information in their health record can facilitate ongoing monitoring and risk assessment. For women with preeclampsia, this may include yearly assessment of BP, lipids, fasting blood glucose, and body mass index (BMI). Increased awareness about her cardiovascular risk may increase the woman’s motivation to reduce modifiable risk factors, if present, by adopting a healthy lifestyle.
Emergent Issues/Instructions
A.Severe abdominal pain and/or afebrile with temperature above 100.4°F needs to be evaluated in the ER.
B.Excessive vaginal bleeding soaking one pad per hour after the first 3 to 5 days after delivery needs to be evaluated in the clinic. If the patient complains of weakness, cold intolerance, dizziness, nausea, and rapid heart rate, she needs to go to the ER.
C.Foul-smelling drainage from the vagina and/or incision needs to be evaluated in the clinic.
D.Separation of wound or incision needs to be evaluated in the ER.
E.Elevated BP with complaints of headaches and/or blurry vision need to be evaluated for preeclampsia in the ER.