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The postpartum period covers a critical transitional time for a woman, her newborn, and her family on a physical, emotional and social level. In addition to responding to the mother's and baby's special needs, care should include the prevention, detection and early treatment of complications and disease and the provision of advice and services on breastfeeding, birth spacing and contraception, immunisation and maternal nutrition.
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Major causes of maternal death worldwide include postpartum haemorrhage, puerperal infections and pre-eclampsia / eclampsia. Other common complications include urinary tract problems and infections, perineal pain and infection and psychological problems.
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In the postpartum period women need information on:
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- Care of the baby and breastfeeding
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- What happens to their bodies including signs of possible problems
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- Self-care, hygiene and healing
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Women may fear inadequacy, loss of marital intimacy, isolation, constant responsibility of caring for the baby and others. All of this should be taken into account when considering the mother's psychological well-being.
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Postpartum assessment
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Postpartum assessment includes all of the following:
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Deviations from normal are considered in the following sections:
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Febrile illness postpartum
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This may be a presentation of endometritis, parametritis, pelvic abscess, salpingitis, septic pelvic thrombophlebitis or septicaemia, and also includes infections of the urinary tract, episiotomy, surgical wounds, respiratory system or breast.
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Breast engorgement can cause transient temperature elevation days 3-4 postpartum.
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DVT can present with low-grade fever.
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Risk factors include:
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- Prolonged rupture of membranes
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- Internal fetal monitoring
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- Multiple pelvic examinations
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Examination includes breasts, uterine fundus, chest, wound, speculum examination and full ward test.
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Investigations depend on examination findings.
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Typical investigations include:
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The most common cause is endometritis. Vaginal swabs may not be of benefit as infection is often caused by a commensal vaginal organism. Empiric therapy is with Amoxil and Flagyl. Additional therapy with gentamicin may be commenced if patient does not improve in the first 24 hours. IV antibiotics are continued until the patient is afebrile for 24 hours. There is no additional benefit from further oral antibiotic therapy (reference).
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Therapy should include cover for bacteroides fragilis which may cause invasive anaerobic endometritis (rare).
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Secondary postpartum haemorrhage
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Bleeding more than 24 hours after delivery. If the cervix has reformed patients require ultrasound to diagnose retained products of conception. Significant retained products MUST be evacuated by D&C. Antibiotic therapy is required at time of operation.
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If there are no retained products a diagnosis of endometritis is made and antibiotic therapy only is required.
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Mastitis
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Presentation includes fever, breast erythema, palpable blocked milk ducts. Treatment is aimed at thorough drainage of the breast so patients should be encouraged to continue breastfeeding or expressing. The most common organisms are staph. Aureus and streptococcus sp. Treatment is with oral antibiotics for erythema and low-grade fever, and IV antibiotics for systemic sepsis. The aim of treatment is to prevent the formation of a breast abscess. If an abscess is suspected it should be diagnosed by U/S. Refer to CPG: Lactational Mastitis (clinical algorithm).
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Anaemia
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Patients suspected of Hb <9.0 g/L either because of increased intrapartum loss or pre-existing anaemia should have an FBE taken day 2 to allow for fluid shifts postpartum. If patients are symptomatic they may be offered a transfusion. Asymptomatic patients should be commenced on oral iron therapy.
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Perineum
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The perineum should be examined prior to discharge to assess healing of episiotomy or tears.
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Perineal pain is very common following delivery even without tears or an episiotomy. A number of studies have assessed the effectiveness of topical analgesia such as lignocaine. In general these offer no more relief than placebo. The most effective treatments for perineal pain postpartum are Panadol and voltaren. Codeine is less satisfactory due to constipation.
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Urinary problems
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Urine output should be carefully monitored after delivery. Inability to void after 4-6 hours needs investigation for a palpable bladder or hypovolaemia. If the patient has urinary retention, this should be drained by passage of a catheter. After double voiding, an IDC should be left in situ if residual urine volume is >400mls. Urinary problems should be referred to the Continence Advisor for follow-up. Refer to CPG: Peri-partum Bladder Management
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Constipation and haemorrhoids
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Treatment for constipation is initially with bulking agents and fluids, followed by stimulants and finally enemas if necessary.
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Patients with haemorrhoids should be advised that they will improve over the puerperium. Patients should have regular fibre supplements to keep stools soft.
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Thyroid function
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The presence of antithyroid peroxidase antibodies (anti-TPO Ab), which are found in 10% of women at 16 weeks' gestation, is an indicator that 50% of such women will develop postpartum thyroid dysfunction. Most of these women will have symptomatic hypothyroidism, and in a significant percentage (20-30%) permanent hypothyroidism will follow during the first postpartum year. It has been reported that close to 50% of women who develop transient postpartum hypothyroidism will develop permanent hypothyroidism during the next 7 years.
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These data suggest that postpartum thyroid dysfunction should be added to the list of common persisting disorders that may occur in the postpartum period
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Pap smear
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Postpartum pap smears are best postponed until 6 or even 8 weeks postpartum in order to allow cervical inflammatory processes to return to normal. Patients should be reminded (during their hospital stay) regarding the need for a postpartum pap smear .
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Vitamin supplementation
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Women known to be deficient in vitamin D or B12 should be advised to continue supplementation during breastfeeding. Refer to CPG Vitamin D - Antenatal Screening
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Postpartum counselling
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Physiological changes
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- The uterus involutes to nonpregnant size by 4-6 weeks and the cervical os should be closed by 2-3 weeks after delivery.
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- Blood loss continues until approximately day 14 (lochia rubra).
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- A diuresis occurs about 2-3 days after birth however oedema may worsen up until this time. Plasma volume returns to normal within 2 weeks.
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Contraception
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Although it is variable, women seldom resume intercourse before 4 weeks postpartum. A discussion of intended contraception method should be held on the ward prior to discharge. Some forms of contraception such as implanon or IUD may require referral to Choices clinic.
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Options for postpartum contraception
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Lactation may be effective contraception if:
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- The woman is fully demand breastfeeding.
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- The woman is amenorrhoeic. Recommencement of periods is evidence of ovulation. Once the patient is menstruating breastfeeding alone is obviously insufficient.
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- Lactational amenorrhoea is 97% effective in the first six months. Patients should use alternative methods after this time as the first ovulation may occur without a preceding period. From anthropological studies it appears that the most important factor in ovulation suppression is frequency of suckling.
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condoms are an easily available form of contraception. Their effectiveness can be increased by use of a spermicide. Diaphragms cannot be fitted until 4-6 weeks postpartum. Women should not use a diaphragm from before pregnancy.
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usually inserted about 6 weeks postpartum. Insertion at delivery is associated with higher expulsion rates.
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the progesterone only pill is associated with the lowest dose of circulating progesterone. Its effectiveness is dependent on the regularity of the patient taking the tablet. An interval of 27 hours only is allowed between each tablet. Patients take the tablets continuously without break. After the return of menstrual cycles it may cause irregular cycles and spotting. Injectable progestogen is a safe and effective option although it may be associated with irregular bleeding. Implanon can be used in breast feeding.
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- Combined oral contraceptive pill:
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not recommended with breastfeeding. In the puerperium it may increase thrombosis and it decreases lactation. If lactation is suppressed the pill may be commenced as early as 3 weeks postpartum.
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can be performed after 6 weeks in appropriate patients.
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Discussion: Post delivery
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It is recommended that all women who have operative deliveries and many of those who have a normal delivery are given the opportunity to discuss details of their delivery after birth. This discussion should be carried out by the accoucheur if possible and should take place more than 24 hours after the delivery. Although this debriefing has not been shown to be effective in preventing postnatal depression (Small R et al, 2000), it is of benefit in informing women's choices regarding future deliveries.
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Postnatal Depression
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Blues
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Minor self-limiting condition with peak incidence day 3-5 postpartum reported to occur in 80% of patients.
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Postnatal depression
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The prevalence of postnatal depression ranges from 4.5% to 28% of women in the postnatal period (Scottish Intercollegiate Guidelines Network (SIGN), 2002). The management of postnatal depression can be improved by antenatal identification of high risk patients.
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Risk factors include:
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- Past history of depression
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- Recent significant life event (apart from birth)
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- Low socio-economic status
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Management involves assessment by psychiatric services and liaison with appropriate community services and supports. Antenatal discharge planning is helpful.
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Postpartum psychosis
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Overall incidence of postpartum psychosis is 1 in 1000. Presents with delusions and hallucinations.
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It is most often due to mood disorder such as depression or bipolar disorder. As compared to non-postpartum psychotic mood episodes, there is more disorientation and lability in postpartum episodes. Women with postpartum psychotic depression can appear well temporarily, misleading health professionals and caregivers into thinking they have recovered. As compared to episodes of non-psychotic depression, women with postpartum psychosis who harbour thoughts of harming their infants are more likely to act on them. There is no increased long-term risk to offspring after episodes have been successfully treated. Postpartum psychotic depression has a high incidence of recurrence.
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Causes other than mood disorders should be considered including:
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Psychiatric disorders
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- major depression with psychotic features
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- Schizophreniform disorders
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Medical conditions
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- Thyroiditis, hypothyroidism
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Substances
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Women with postpartum psychosis should be referred for psychiatric care
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Such women require a comprehensive approach to treatment including crisis intervention, pharmacotherapy, psychotherapy and social support.
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Links
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References
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References
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Royal Women's Hospital Clinical Practice Guidelines (CPGs) are intended to provide guidance to health care professionals, based on a thorough evaluation of research evidence, on the practical assessment and management of specific clinical issues or situations. The guidelines allow some flexibility on the part of the health care professional based on the needs of the specific patient for whom they are caring.
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