MANAGEMENT OF THE IMMEDIATE POSTPARTUM PERIOD
In the absence of complications, the postpartum hospital stay ranges from 48 hours after a vaginal delivery to 96 hours after a cesarean delivery, excluding day of delivery. Shortened hos-pital stays are appropriate when certain criteria are met to ensure the health of the mother and baby, such as the ab-sence of fever in the mother; normal pulse and respiration rates and blood pressure level; lochia amount and color appropriate for the duration of recovery; absence of any abnormal physical, laboratory, or emotional findings; and ability of the mother to perform activities such as walking, eating, drinking, self-care, and care for the newborn. In addition, the mother should have adequate support in the first few days following discharge and should receive in-structions about postpartum activity, exercise, and com-mon postpartum discomforts and relief measures.
During the hospital stay, the focus should be on preparation of the mother for newborn care, infant feeding including the spe-cial issues involved with breastfeeding, and required newborn laboratory testing. When patients are discharged early, ahome visit or follow-up telephone call by a healthcare provider within 48 hours of discharge is encouraged.
Shortly after delivery, the parents become totally engrossed in the events surrounding the newborn infant. The mother should have close contact with her infant. Obstetric units should be organized to facilitate these interactions by min-imizing unnecessary medical interventions while increas-ing participation by the father and other family members. Nursing staff can observe the interactions between the in-fant and the new parents and intervene when necessary.
Infection occurs in approximately 5% of patients and sig-nificant immediate postpartum hemorrhage occurs in approximately 1% of patients. Immediately after the delivery of the pla-centa, the uterus is palpated bimanually to ascertain that it is firm. Uterine palpation through the abdominal wall is repeated at frequent intervals during the immediate post-partum period to prevent and/or identify uterine atony. Perineal pads are applied, and the amount of blood on these pads as well as the patient’s pulse and pressure are monitored closely for the first several hours after delivery to detect excessive blood loss.
Some patients will experience an episode of increased vaginal bleeding between days 8 and 14 postpartum, most likely associated with the separation and passage of the placental eschar. This is self-limited and needs no therapy other than reassurance. Bleeding that persists or is excessive is called delayed postpartum hemorrhage, and it occurs in approximately 1% of cases. Treatment includes oxytocic therapy or suction evacuation of the uterus. Suction is suc-cessful in most cases, whether or not there is retained pla-cental tissue, as is found in one-third of cases.
After vaginal delivery, analgesic medication (including topical lidocaine cream) may be necessary to relieve per-ineal and episiotomy pain and facilitate maternal mobility. This is best addressed by administering the drug on an as-needed basis according to postpartum orders. Most mothers experience considerable pain in the first 24 hours after cesarean delivery. Analgesic techniques include spinalor epidural opiates, patient-controlled epidural or intravenous analgesia, and potent oral analgesics.
Regardless of the route of administration, opioids can cause respiratory depression and decrease intestinal motility.
Adequate supervision and monitoring should be ensured for all postpartum patients receiving these drugs.
Postpartum patients should be encouraged to begin ambulation as soon as possible after delivery. They should be offered assistance initially, especially for patients who have delivered by cesarean section.
Early ambulation helps
avoid urinary retention and prevents puerperal venous thromboses and pulmonary
Breast engorgement in women who are not breastfeed-ing occurs in the first few days postpartum and gradually abates over this period. If the breasts become painful, they should be supported with a well-fitting brassiere. Ice packs and analgesics may also help relieve discomfort. Women who do not wish to breastfeed should be encouraged to avoid nipple stimulation and should be cautioned against continued manual expression of milk.
A plugged duct (galactocele) and mastitis may also re-sult in an enlarged, tender breast postpartum (Table 11.1). Mastitis, or infection of the breast tissue, most often occursin lactating women and is characterized by sudden-onset fever and localized pain and swelling. Mastitis is associ-ated with infection by Staphylococcus aureus, Group A or B streptococci, βHaemophilus species, and Escherichiacoli. Treatment includes continuation of breastfeeding oremptying the breast with a breast pump and the use of ap-propriate antibiotics. Breast milk remains safe for the full-term, healthy infant.
Symptoms of a breast abscess are similar to those of mastitis, but a fluctuant mass is also present. Persistent fever after starting antibiotic therapy for mastitis may also suggest an abscess. Treatment requires surgical drainage of the abscess in addition to antibiotic therapy.
Women who do not have antirubella antibody should be immunized for rubella during the immediate postpartum period. Breastfeeding is not a contraindication to this immunization. If a patient has not already received the tetanus-diphtheria acellular pertussis vaccine, and if ithas been at least 2 years since her last tetanus-diphtheria booster, she should be given a dose before hospital dis-charge. If the woman is D-negative, is not isoimmunized, and has given birth to a D-positive or weak-D-positive in-fant, 300 micrograms of anti-D immune globulin should be administered postpartum, ideally within 72 hours of giving birth.
This dose may be inadequate in circumstances in which there is a potential for greater-than-average fetal-to-maternal hemorrhage, such as placental abruption, placenta previa, intrauterine manipulation, and manual removal of the pla-centa.
Universal immunization with hepatitis B surface antigen (HbSAg1) is recommended for all newborns weighing 2000 g. In addition, all newborns receive a full range of screening tests.
It is common for a patient not to have a bowel movement for the first 1 to 2 days after delivery, because patients have often not eaten for a long period. Stool softeners may be prescribed, especially if the patient has had a fourth-degree episiotomy repair or a laceration involving the rec-tal mucosa.
Hemorrhoids are varicosities of the hemorrhoidalveins. Surgical treatment should not be considered for at least 6 months postpartum to allow for natural involution. Sitz baths, stool softeners, and local preparations are use-ful, combined with reassurance that resolution is the most common outcome.
Periurethral edema after vaginal delivery may cause transitory urinary retention. Patients’ urinary output shouldbe monitored for the first 24 hours after delivery. If catheteriza-tion is required more than twice in the first 24 hours, place-ment of an indwelling catheter for 1 to 2 days is advisable.
During the first 24 hours, perineal pain can be minimized using oral analgesics and the application of an ice bag to minimize swelling. Local anesthetics, such as witch hazel pads or benzocaine spray, may be beneficial. Beginning 24 hours after delivery, moist heat in the form of a warm sitz bath may reduce local discomfort and promote healing.
Severe perineal pain unresponsive to the usual analgesics may signify the development of a hematoma, which requires careful examination of the vulva, vagina, and rectum.
Infection of the episiotomy is rare (<0.1%) and usually is limited to the skin and responsive to broad-spectrum anti-biotics. Dehiscence (rupture of the incision) is uncommon,with repair individualized on the basis of the nature and ex-tent of the wound.
Postpartum care in the hospital should include discus-sion of contraception.Approximately 15% of non-nursingwomen are fertile at 6 weeks postpartum. Combined estrogen–progestin oral contraceptive preparations are not con-traindicated by breastfeeding, although they may inhibit lactation slightly. Progestin preparations (oral norethin-drone or depo-medroxyprogesterone acetate) have no effect or may slightly facilitate lactation. Women may consider initiating progesterone-only contraceptives at 6 weeks if breastfeeding exclusively or at 3 weeks if not ex-clusively. Once lactation is established, neither the volume nor the composition of breast milk are adversely affected by the administration of hormonal contraceptives, and there is no effect on the growth of breastfed infants. Insertion of intrauterine contraceptive 4 to 6 weeks post-partum is acceptable in the appropriately selected patient.
Postpartum sterilization is performed at the time of cesarean delivery or after a vaginal delivery and should not extend the patient’s hospital stay. Ideally, postpartum minilaparotomy is performed before the onset of signif-icant uterine involution but following a full assessment of maternal and neonatal well-being. Postpartum minilaparotomy may be performed using local anesthesia with sedation, regional anesthesia, or general anesthesia. Postpartum sterilization requires counseling and informed consent before labor and deliv-ery. Consent should be obtained during prenatal care, when thepatient can make a considered decision, review the risks and ben-efits of the procedure, and consider alternative contraceptive methods. In all cases of intrapartum or postpartum medicalor obstetric complications, the physician should consider postponing sterilization to a later date. The federal and state regulations that address the timing of consent also are important to consider.
Coitus may be resumed when the patient is comfortable; however, the risks of hemorrhage and infection are minimalat approximately 2 weeks postpartum. Women should becounseled, especially if breastfeeding, that coitus may ini-tially be uncomfortable because of a lack of lubrication due to low estrogen levels, and that the use of exogenous, water-soluble lubrication is helpful. The lactating patient may also be counseled to apply topical estrogen or a lubricant to the vaginal mucosa to minimize the dyspareunia caused by coital trauma to the hypoestrogenic tissue. The female superior position may be recommended, as the woman is thereby able to control the depth of penile penetration.
Patient education at the time of discharge should not be solely focused on postpartum and contraceptive issues. It is also a good opportunity to reinforce the value and need for healthcare of both mother and infant. Follow-up care that has been arranged for the newborn and frequency of healthcare for the new mother should be reviewed. High-risk behaviors such as alcohol, tobacco, and drug abuse should be discussed, along with appropriate interventions. Physicians should also assess the patient’s mental state and her ease with care of the newborn. Infant safety concerns (e.g., automobile child restraints) are also appropriate top-ics of discussion. Postpartum follow-up of any preexisting medical conditions should also be reviewed and, when needed, the patient should be referred for care.
Maternal postpartum weight loss can occur at a rate of 2 lb per month without affecting lactation. On average, a woman will retain 2 lb more than her prepregnancy weight at 1 year postpartum. There is no relationship between body mass index or total weight gain and weight retention. Aging, rather than parity, is the major determinant of in-creases in a woman’s weight over time.
Residual postpartum retention of weight gained dur-ing pregnancy that results in obesity is a concern. Special attention to lifestyle, including exercise and eating habits, will help these women return to a normal body mass index.
Because breast milk is the ideal source of nutrition for the neonate, it is recommended that women breastfeed exclusively for the first 6 months and continue breastfeeding for as long as mutually desired. Benefits of breastfeeding include decreasedrisks of otitis and respiratory infections, diarrheal illness, sudden infant death, allergic and atopic disease, juvenile-onset diabetes, and childhood cancers; fewer hospital admissions in the first year of life; and improved cogni-tive function. For premature infants, breast milk reduces the risk of necrotizing enterocolitis. Maternal benefits include improved maternal–child attachment, reduced fertility due to lactational amenorrhea, and reduced in-cidence of some hormonally sensitive cancers, including breast cancer.
There are few contraindications to breastfeeding. Women with HIV should not breastfeed due to the risk of vertical transmission. Women with active, untreated tuber-culosis should not have close contact with their infants until they have been treated and are noninfectious; their breast milk may be expressed and given to the infant, except in the rare case of tuberculosis mastitis. Mothers under-going chemotherapy, receiving antimetabolites, or who have received radioactive materials should not breastfeed until the breast milk has been cleared of these substances. Infants with galactosemia should not be breastfed due to their sensitivity to lactose. Mothers who use illegal drugs should not breastfeed their infants.
Drugs in the breast milk are a common concern for the breastfeeding mother. Less than 1% of the total dosage ofany medication appears in breast milk. This should be considered when any medication is prescribed by a physi-cian or when any over-the-counter medications are con-templated by the patient. Specific medications that would contraindicate breastfeeding include lithium carbonate, tetracycline, bromocriptine, methotrexate, and any radio-active substance. All substances of abuse are included as well, such as amphetamine, cocaine, heroin, marijuana, and phencyclidine (PCP).
At the time of delivery, the drop in estrogen levels and other placental hormones is a major factor in removing the inhibition of the action of prolactin. Also, suckling by the infant stimulates release of oxytocin from the neuro-hypophysis. The increased levels of oxytocin in the blood result in contraction of the myoepithelial cells and empty-ing of the alveolar lumen of the breast. The oxytocin also increases uterine contractions, thereby accelerating invo-lution of the postpartum uterus. Prolactin release is also stimulated by suckling, with resultant secretion of fatty acids, lactose, and casein. Colostrum is produced in the first 5 days postpartum and is slowly replaced by maternal milk. Colostrum contains more minerals and protein but less fat and sugar than maternal milk, although it does contain large fat globules, the so-called colostrum corpus-cles, which are probably epithelial cells that have undergone fatty degeneration. Colostrum also contains immuno-globulin A, which may offer the newborn some protection from enteric pathogens. Subsequently, on approximately the third to sixth day postpartum, milk is produced.
For milk to be produced on an ongoing basis, there must be adequate insulin, cortisol, and thyroid hormone, and adequate nutrients and fluids in the mother’s diet. The minimal caloric requirement for adequate milk pro-duction in a woman of average size is 1800 kcal per day. In general, an additional 500 kcal of energy daily is recom-mended throughout lactation. All vitamins except K are found in human milk, but because they are present in vary-ing amounts, maternal vitamin supplementation is recom-mended. Vitamin K may be administered to the infant to prevent hemorrhagic disease of the newborn. To maintain breastfeeding, the alveolar lumen must be emptied on a regular basis.
Nipple care is also important during breastfeeding.The nipples should be washed with water and exposed to the air for 15 to 20 minutes after each feeding. A water-based cream such as lanolin or A and D ointment may be applied if the nipples are tender. Fissuring of the nipple may make breastfeeding extremely difficult. Temporary cessation of breastfeeding, manual expression of milk, and use of a nipple shield will aid in recovery.