Post-partum Care
Postpartum is a general term for the period of time following childbirth. “Postpartum,” as defined by the World Health Organization (WHO), starts one hour after the delivery of the placenta and includes the first six weeks after childbirth.
The “postpartum” period can be divided into the following 4 stages:
- Postplacental the first ten minutes following delivery of the placenta
- Early postpartum the first seven days following delivery of the placenta
- Later postpartum from one week, to four to six weeks following delivery of the placenta
- Extended postpartum up through twelve months following delivery of the placenta
For obstetrics purposes, puerperium lasts at the very least from delivery to 8 weeks thereafter.
The goal of routine post-partum management is to ensure the well-being of the mother and baby and to educate her on how to take care of the baby. Most women remain admitted for at least 48 hours post-partum for observation as well as standard care for the neonate. Vitals, uterine involution, and voiding should be monitored regularly. Routine labs are generally not warranted in uncomplicated stable patients.
Shivering
Shivering is a very common complaint (25-50% of normal deliveries) that usually begins immediately after delivery and lasts no longer than an hour. Pathogenesis is unclear. This can be due to anaesthesia.
- Treatment
- Conservative management with blankets
- Medical management is the cause is anesthesia
Perineal pain
Perineal pain is a very common complaint after vaginal delivery d/t swelling and pain in the perineum. Worse if there are lacerations or episiotomy. Incisional site pain is common with C-sections.
- Treatment
- Ice packs in the first 24 hours
- Heating pads and/or Sitz baths after 24 hours
- NSAIDs (non-narcotics, e.g. 600mg Ibuprofen
Cramping
“Afterpains” due to hypertonic uterine contractions. More severe in multiparas. Commonly occurs during nursing (oxytocin release causes cramping to coincide with breastfeeding)
- Differential
- Endometritis: Lower abdominal tenderness + fever + offensive lochia
- Treatment
- NSAIDs
- Spontaneously resolves by one week post-partum
Lochia
Lochia is shedding of the superficial portion of the decidua basalis. Continuous shedding occurs for about a month after delivery. Should be only 200-500 mL total. Profuse discharge may be a sign of post-partum haemorrhage. Lochia should never be foul-smelling!
| Lochia | Colour | Occurrence |
|---|---|---|
| Lochia rubra | Red to red-brown | First few days |
| Lochia serosa | Pink | 1-2 weeks postpartum |
| Lochia alba | Yellow-white | 2-4 weeks post-partum |
Hypotonic bladder and urinary retention
Common. Due to neurologic injury to the pudendal nerve which stuns the bladder. Dysuria may occur independently.
- Signs and symptoms
- Difficulty urinating
- Urinary frequency/urgency
- Weak stream
- Straining
- Small voiding volumes
- Sense of incomplete volumes
- Investigations
- Bladder scan for post-void residual
- 250mL post-void residual
- Bladder scan for post-void residual
- Treatment
- Intermittent Catheterization (to prevent post-renal failure)
- Discontinue catheter is post-void residual is <150mL and symptoms have improved
- If there is Dysuria
- Get a urinalysis to exclude UTI
- Give urinary analgesic (phenazopyridine) or manage expectantly
Constipation and hemorrhoids
Constipation is commonly seen d/t normal physiologic changes including decreased GI tract motility. Hemorrhoids precede delivery but are worsened especially with longer vaginal deliveries and post-partum constipation. Both are self-limited.
- Treatment
- PO hydration, Ambulation and avoiding opioid pain meds
- Stool softeners
- Sitz baths and topical anaesthetics (Hydrocortisone/lidocaine) for Hemorrhoids
Breastfeeding
Breastfeeding is the ideal means of nutrition for infants and should begin ASAP after delivery. Ideally, breastfeeding education should begin before delivery with lactation consultants and educational material.
81% of mothers attempt to breastfeed, but many quit because they encounter problems.
- The most common reasons for “quitting” breastfeeding
- Sore nipples
- Perception of inadequate milk supply
- Concerns that the infant is not feeding properly or is not satisfied
- Risk factors associated with failure to initiate breastfeeding
- Young mothers (<25 yo)
- Unmarried
- Less educated
- Women who smoke cigarettes
- LBW baby (tend to be in the NBU and away from mom)
- Post-partum depression
- Unwanted pregnancy
- Caesarean delivery
Discharge and post-partum follow-up visit
During discharge appointments for post-partum follow-up and pediatric visits should be scheduled. RhoGAM can be given within 72 hours of delivery and all vaccines needed by mom but couldn’t get in pregnancy can be given.
- Discharge instructions
- Take daily baths
- Keep perineum clean
- Continue exercise/activity tolerated
- Intercourse as long as there is no active bleeding
- Consider contraception (Progesterone mini-pill/Implanon/Depo-provera. Typically not going to menstruate for 4-6 months post-partum but ovulation may occur as early as 25 days post-partum)
- Take care of breasts and nipples
- Return for immunization
- Discharge on Iron and folate supplements
- Warning signs to look out for on discharge
- Significant bleeding
- Fever
- New or worsening perineal pain
- Dysuria
- Breast problems
- Leg pain or swelling
- Significant mood disturbances
- Severe headache (pre-eclampsia/eclampsia)
Post-partum follow-up visit
Post-partum follow-up visit is scheduled within 6 weeks of delivery. Complications that occurred during pregnancy can be addressed during this visit (e.g. women w/GDM get OGTT to ensure resolution
- Routine topics discussed
- Health of the infant
- Mother’s mood (screen for post-partum depression)
- Contraceptive plan
- Return of sexual activity
- Any difficulties with breastfeeding
- Physical exam
- Vitals
- Thyroid
- Breast
- Abdomen
- External genitalia
- Pelvis