POSTPARTUM CARE

I. In-Hospital Postpartum Care Immediate postpartum care: monitoring of vital signs, pain management, and surveillance for complications e.g.: postpartum hemorrhage. Particular attention should be paid to patients who have had a cesarean section, recognizing that they are postsurgical patients and should receive appropriate additional care. As concern for postpartum complications eases, increasing attention should be turned to parental education. Important issues to cover during this time include maternal self-care, appropriate sexual and physical activity, and infant nutrition.

Common Postpartum Complications o Postpartum Hemorrhage. Postpartum hemorrhage has various definitions: (a) estimated blood loss 500 mL for a vaginal delivery and1,000 mL for a cesarean delivery; (b) a 10% change in hematocrit between admission and the postpartum period (1); and (c) excessive bleeding that produces symptoms and requires erythrocyte transfusion. Excessive blood loss that occurs within 24 hours of delivery is termed primary or acute postpartum hemorrhage; more than 24 hours after delivery (up to 6 weeks) is termed secondary or late postpartum hemorrhage. The incidence of postpartum hemorrhage is approximately 4% with vaginal delivery and 6% with cesarean delivery (1). See Chapter 7, Complications of Labor and Delivery, for more information. o Postpartum febrile morbidity is defined as a temperature higher than 38.0C on at least two occasions, at least 4 hours apart, after the first 24 hours postpartum. The differential diagnosis includes breast engorgement, atelectasis, urinary tract infection, and endomyometritis. This topic of breast engorgement is discussed later in more detail. Urinary tract infections can occur in the postpartum period and should be considered in the febrile patient. Endomyometritis complicates 1% to 3% of vaginal deliveries and is up to 10 times more common after cesarean deliveries (2). Clinically, endometritis presents as fever, uterine tenderness, malaise, or foulsmelling lochia and is usually a polymicrobial infection of gram-positive aerobes (groups A and B streptococci, enterococci), gram-negative aerobes (Escherichia coli), and anaerobes (peptostreptococcus, peptococcus, bacteroides) from the genital tract. Bacteremia may be present in 10% to 20% of cases (2). Endomyometritis should be treated with intravenous antibiotics until the patient is clinically improved and afebrile for 24 to 48 hours. The American College of Obstetricians and Gynecologists (ACOG) recommends initial treatment with gentamicin (1.5 mg/kg every 8 hours) and clindamycin (900 mg every 8 hours), with the addition of ampicillin (2 g every 4 to 6 hours) if Enterococcus is suspected or if fever persists after initial treatment. Some practitioners begin initial

therapy with the triple antibiotic regimen. Further treatment with oral antibiotic therapy is unnecessary (3). Response to antibiotic treatment is usually prompt. See Chapter 7 for more details on endomyometritis. Finally, patients with persistent fevers after 48 to 72 hours of antibiotic treatment should be assessed for other complications, such as retained products of conception (especially if their bleeding is heavier than usual), P.246

pelvic abscess, wound infection, ovarian vein thrombosis, and septic pelvic thrombophlebitis (SPT). SPT is rare, occurring 1 in 2,000 deliveries (4), and is characterized by high, spiking fevers despite appropriate doses of antibiotics. Patients tend to feel well between fevers and have no complaint of pain. Imaging is frequently obtained to look for an abscess. The pelvic clots associated with SPT are not always seen on CT or MRI, thus the diagnosis is traditionally made based on the previously mentioned signs and because fevers resolve within 24 to 48 hours of initiation of heparin therapy (5). However, recent studies suggest that even the addition of heparin therapy should not be part of the diagnosis (4). All maternal fevers should be reported to the newborn nursery. Hypertension is defined as BP of 140/90 or higher, taken with the patient in a seated position on two or more occasions, 4 or more hours apart. Some women may develop pre-eclampsia or eclampsia postpartum, even in the absence of antenatal complications, so particular attention should be paid to maternal BP postpartum. Any pressure reading of 140/90 or higher should be evaluated by repeating BP measurements, checking urine protein, and evaluating for signs/symptoms of pre-eclampsia. In those women who had antenatal preeclampsia, effective postpartum diuresis as well as normalization of BP should be documented. However, hypertension resulting from pre-eclampsia can persist for up to 6 weeks. See Chapter 14 for more details. Immunizations. The peripartum period is an appropriate time to offer vaccination against rubella, hepatitis A, hepatitis B, or both, to women at risk for these diseases. o Rh Immunoglobulin. An unsensitized Rh-negative woman who delivers an Rhpositive infant should receive 300 mg of Rh immunoglobulin within 72 hours of delivery even if Rh immunoglobulin was given in the antepartum period. Additional doses may be necessary if there is evidence of antepartum fetalmaternal hemorrhage. The blood bank that provides the Rh immunoglobulin should perform testing to assess the potential need for additional doses. o Rubella Vaccine. Mothers who are not immune to the rubella virus should receive the measles-mumps-rubella (MMR) vaccine just before discharge because it is a live virus, and exposure to pregnant women should be avoided. Use of monovalent rubella vaccine (e.g., Rubivax) is no longer considered appropriate because MMR is more cost-effective and because many of the women without
o

immunity to rubella also lack immunity to rubeola (measles). Breast-feeding is not a contraindication to MMR vaccination. II. Discharge When no complications occur, mothers may be discharged 24 to 48 hours after vaginal delivery and 24 to 96 hours after cesarean delivery. The following criteria should be met:

Vital signs are sTable and within normal limits. Uterine fundus is firm and decreasing in size (within 24 hours postpartum; a uterus without fibroids should decrease to 20-week size). The amount and color of lochia is appropriatered, less than a heavy period, and decreasing. Urine output is adequate. Any surgical incisions or vaginal repair sites are healing well without signs of infection. The mother is able to eat, drink, ambulate, and void without difficulty. No medical or psychosocial issues are identified that preclude discharge. The mother has demonstrated knowledge of appropriate self-care and care of her infant. The issue of contraception has been addressed. Appropriate immunizations and Rh immunoglobulin, if appropriate, have been administered. Follow-up care has been arranged for mother and infant. Infant nutritional needs have been addressed.

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III. Outpatient Postpartum Care

Timing. Women should be seen 4 to 6 weeks postpartum unless a problem is identified in the early puerperium that requires closer follow-up. For example, women with hypertensive complications should have a BP check within 1 week of discharge. The postpartum visit should address the following: BP, breast, abdomen, and pelvic examination Vaginal repairs should be healing. At 2 weeks postpartum, the nonmyomatous uterus is usually not palpable abdominally. o By 6 weeks postpartum, the nonmyomatous uterus should return to 1.5 to 2.0 times its nonpregnant size.
o o o o o

Physical exam

Lochia (quantity and quality)

By 6 weeks postpartum, lochia should be essentially gone. If lochia is persistent, it should be re-evaluated at 10 to 12 weeks. If still bleeding, a full evaluation is warranted, including measurement of serum human chorionic gonadotropin.

Pain

Perineal discomfort can be treated with sitz baths, ice packs, and analgesics. o Women with significant pain deserve further evaluation for perivaginal hematomas or other complications.
o

Contraception Sexual activity

See section under Breast-Feeding and Chapter 28, Fertility Control. o When the perineum is healed and bleeding is decreased, sexual activity may be safely resumed. o Any significant dyspareunia should be evaluated.
o o o

Infant feeding method Depression screening

Attention to difficulties with either breast or bottle

Assess for psychosocial well-being. If there is evidence of depression, antidepressant medication should be considered, and the patient should be referred for mental health care. o Thyroid-stimulating hormone level should be determined to rule out postpartum hypothyroidism.
o o

Immunizations Antenatal complications

Discuss indicated vaccines before discharge.

Patients with pre-eclampsia should be followed to rule out chronic hypertension or nephrotic syndrome. o Women with gestational diabetes should be screened for diabetes (Table 20.1).

Table 20.1 Diabetic Screening in the Nonpregnant Patient Fasting glucose Glucose level 2 hours level (mg/dL) after 75-g load (mg/dL) Management Normal <110 <140 Annual screening Carbohydrate 110125 140199 Diet and exercise intolerant modification Annual screening Diabetic >126 >200 Treatment as indicated Random glucose level >200 with symptoms The fasting plasma glucose test is the preferred test for diagnosis of diabetes. An initial abnormal value must be confirmed, on a subsequent day, by measurement of fasting plasma glucose level, plasma glucose level after glucose load, or random plasma glucose level if symptoms are present. Adapted from the American Diabetes Association Clinical Practice Recommendations, 2001. P.248

Breast-Feeding

I. Recommendations The American Academy of Pediatrics (6) recommends breast-feeding exclusively for the first 6 months of life and partial breast-feeding (plus complementary foods) for at least 12 months. The World Health Organization (WHO) recommends that partial breast-feeding continue for 2 or more years. Breast-feeding should be encouraged as soon as possible after delivery. Infants and mothers who initiate breast-feeding within the first hour after delivery have a higher success rate than those who delay it. Newborns should be fed every 2 to 3 hours until satiety. Feeding for at least 5 minutes at each breast at each feeding on postpartum day 1, and gradually increasing feeding time over the next few days, will allow optimal milk let-down without resulting in sore nipples. Nondemanding infants should be aroused every 4 hours for feeding, and limiting feeding time is not necessary. Frequent breast-feeding helps establish maternal milk supply, prevents excessive engorgement, and minimizes neonatal jaundice. Breast-feeding may be associated with initial minor discomfort, but painful breasts should be assessed and positioning should be re-evaluated. Nipple tenderness can be treated with lanolin cream. In addition, women should begin nursing on the less sore breast, change nursing position to rotate stress points on nipples, and be instructed to break suction before removing the infant from the breast. Women who are breast-feeding require 500 to 1,000 kcal per day more than nonlactating women. Breast-feeding women are at increased risk of deficiencies in magnesium, vitamin B6, folate, calcium, and zinc. Human milk may not provide adequate iron for premature newborns or infants who are older than 6 months. Supplemental iron should be given to these infants and to infants whose mothers are iron deficient. Women who are not breast-feeding will experience breast engorgement about 3 days postpartum. Breast engorgement is often uncomforTable and may be treated with techniques, such as breast binding, ice packs, and avoidance of nipple stimulation. II. Statistics on Breast-Feeding

In 1971, 24.7% of all mothers initiated breast-feeding (7). In 2003, 70.9% of all mothers in the United States initiated breast-feeding, including 54.9% of African American mothers (8). In 2003, 36.2% of mothers breast-fed at 6 months (8). Women with the highest breast-feeding rate are college-educated, married, older than age 30, residents of the Mountain or Pacific census regions, and are not enrolled in the Women, Infants, Children (WIC) program. Women with the lowest breast-feeding rate are African American, did not complete high school, are younger than age 20, are residents in the East-South-Central census regions, have lower income, and are enrolled in the WIC program. Healthy People 2010 goals are 75% of all mothers breast-feeding in early postpartum period, 50% at 6 months and 25% at 12 months (9).

III. Benefits for Newborns For the baby, breast-feeding provides excellent nutrition with changing nutritional content to match nutritional needs. For example, breast milk includes increased protein and minerals shortly after delivery and increased water, fat, and lactose later. Breast milk's nutritional content changes during pregnancy as well, so that a baby born prematurely will receive nutrition more appropriate to his or her needs.

Breast-feeding also provides protection against infection. Postneonatal infant mortality rates in the United States are reduced by 21% in breast-fed infants (6). Secretory immunoglobulin A is present in high quantities in colostrum and thus provides the baby with passive immunity to the infections to which the mother has immunity. Breast milk promotes phagocytosis by macrophages and leukocytes, thus boosting cellular immunity. Bifidus factor is present in breast milk and promotes proliferation of Lactobacillus bifidus, which decreases colonization by pathogens that cause diarrhea. P.249

Based on research in developed countries among middle-class populations, breast-feeding decreases the rate and/or severity of bacterial meningitis, bacteremia, diarrhea, respiratory tract infection, necrotizing enterocolitis, otitis media, urinary tract infections, and late-onset sepsis in preterm infants (6). Because the protein in breast milk is species (human) specific, the delayed introduction of foreign protein also delays and reduces the development of allergies to some environmental allergens. Breast-feeding has been shown to decrease the incidence and severity of eczema. IV. Benefits for Mothers Oxytocin release during milk let-down causes increased uterine contractions, hastens uterine involution, and thus decreases postpartum blood loss. Women who breast-feed experience a decreased risk of ovarian and premenopausal breast cancer that is proportional to the time that they spent breast-feeding. Breast-feeding mothers may also experience a decreased incidence of osteoporosis and postmenopausal hip fracture and a decreased incidence of pregnancy-induced long-term obesity. Breast-feeding supports bonding between mother and child and clearly results in decreased costs compared to formula feeding (6). Breast-feeding also facilitates child spacing secondary to lactational amenorrhea (see chapter on Fertility Control). V. Contraindications Although not contraindications, some structural problems make breast-feeding difficult and sometimes impossible. These include tubular breasts, hypoplastic breast tissue, true inverted nipples (very rare), and surgical alterations that sever the milk ducts. The following are strict contraindications to breast-feeding (6):

Mothers using drugs of abuse, including excessive alcohol Infant with galactosemia Maternal human immunodeficiency virus infection in the United States. In developing countries, the benefits of breast-feeding may outweigh the risk of HIV transmission. Maternal active, untreated tuberculosis or women with human T-cell lymphotropic virus type I- or II. Women can give their infant expressed breast milk and can breast-feed once their treatment regimen is well established. Maternal active, untreated varicella. Once the infant has been given varicella zoster immunoglobulin, the infant can receive expressed breast milk if there are no lesions on the breast. Within 5 days of the appearance of the rash, maternal antibodies are produced, and thus breast-feeding would be beneficial in providing passive immunity. Active herpes lesions on the breast Mothers who are receiving diagnostic or therapeutic radioactive isotopes or have had exposure to radioactive materials

Mothers receiving antimetabolites or chemotherapeutic agents

VI. Noncontraindications (6)

Congenital or acquired cytomegalovirus infection in an otherwise healthy, term infant. Such infants actually do better if they are breast-fed because maternal antibodies (and virus) are in breast milk. Maternal acute hepatitis A if the infant has received hepatitis A immunoglobulin and hepatitis A vaccine Mothers who are hepatitis B surface antigen-positive. Infant should receive appropriate immunoprophylaxis, including hepatitis B immune globulin (HBIG) and hepatitis vaccine. (Women who have had acute hepatitis B infection during pregnancy should not breast-feed.) Mothers with hepatitis C virus antibody or hepatitis C virus-RNA-positive blood (some providers discourage breast-feeding in women with hepatitis C; however, this is not supported by data).

VII. Breast-Feeding and Maternal Medications Use of nearly all antineoplastic, thyrotoxic, and immunosuppressive medications is contraindicated during breast-feeding P.250 (Table 20.2). In general, breast-feeding may be continued during maternal antibiotic therapy. Although all major anticonvulsants are secreted in breast milk, they need not be discontinued unless the infant shows signs of excessive sedation. The Web site of the American Academy of Pediatrics (http://www.pediatrics.org) contains updated information on medication use in breastfeeding. Table 20.2 Medications Contraindicated During Breast-Feeding Medication Reason for discontinuation Bromocriptine Lactation suppression mesylate Cocaine Cocaine intoxication of the newborn Ergotamine tartrate Vomiting, diarrhea, convulsions in the newborn Lithium One-third to one-half of maternal drug levels found in the newborn Phencyclidine Potent hallucinogen Radioactive elements Enter newborn bloodstream Cyclophosphamide Possible neutropenia and immune suppression in the newborn; unknown effect on growth or association with carcinogenesis Cyclosporine Same as for cyclophosphamide Doxorubicin Same as for cyclophosphamide hydrochloride Methotrexate sodium Same as for cyclophosphamide Adapted from the American Academy of Pediatrics, Committee on Medications, 1994. VIII. Contraception During Lactation

In the nonbreast-feeding woman, the average time to first ovulation is 45 days (range between 25 to 72 days). The mean time to ovulation is 190 days in women who are breast-feeding (see Fig. 20.1).

The lactational amenorrhea method has been shown to provide 95% to 99% protection in the first 6 months postpartum if strict criteria are followed. Feedings need to be every 4 hours during the day and every 6 hours at night. Supplemental feedings should not exceed 5% to 10% of the total.

Figure 20.1. Postpartum return of menstruation and ovulation.

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Nonhormonal methods (condom, intrauterine device, sterilization) are the preferred methods of contraception in lactating women. Progestin contraceptives (progestin-only mini-pill, progestin injectables, progestin implants) do not affect the quality of breast milk and may actually increase the volume of milk; thus, they are the preferred methods of hormonal contraception. The progestin from pills, injectables, and implants has been shown to be present in breast milk. Despite the lack of evidence that suggests adverse effects on infants, a theoretic risk exists of harmful consequences from exogenous steroids. Therefore, some question has emerged as to when to initiate progestin contraception. ACOG recommends initiating progestin pill use 2 to 3 weeks postpartum, administering injectables and implants at 6 weeks postpartum. Starting progestin contraceptives earlier may be accepTable for those patients who are unwilling or unable to use nonhormonal contraceptives and who are not willing to risk a repeat pregnancy. Of importance is the decreased efficacy of progestin-only pills and the need to take them at the same time every day (see Chapter 28, Fertility Control). The levonorgestrel intrauterine device (Mirena) is a progesterone-only option with greater efficacy and is recommended to insert at the 6-week postpartum visit. Combination Estrogen-Progestin Contraceptives. Estrogen-containing oral contraceptive pills (OCPs) have long been thought to reduce the quantity and quality of breast milk.

However, clinical trials that evaluate the impact of combined OCPs on lactation supply and infant growth are conflicting and need further investigation (10). For now, WHO recommends waiting at least 6 months before initiating combination OCPs. The U.S. Food and Drug Administration labeling committee recommends not using combination OCPs until the child is completely weaned. ACOG recommends that, if combination OCPs are preferred, they should not be started before 6 weeks postpartum, and they should only be started after lactation is well established and the infant's nutritional status is well monitored (7). As with progestin-only contraceptives, some providers may initiate the use of combination OCPs earlier if lactation is well established, the patient declines other forms of contraception, and the risk of repeat pregnancy is significant. IX. Mastitis Mastitis is a breast infection that occurs in 1% to 2% of breast-feeding women, usually between the first and fifth weeks postpartum (7). This condition is characterized by a localized sore, reddened, and indurated area on the breast that is often accompanied by fever, chills, and malaise.

Etiology and Treatment. Forty percent of cases are due to Staphylococcus aureus infection. Other common offending organisms include B-hemolytic streptococci, E. coli, and Haemophilus influenzae. o Treatment consists of continued nursing, nonsteroidals, and antibiotics. Initial antibiotic therapy is often started with dicloxacillin, 500 mg four times daily for 10 days. Women should continue to express milk, starting on the affected side to encourage more complete emptying. If there is no improvement in 48 hours, antibiotic coverage should be changed to cephalexin or ampicillin with clavulanate (Augmentin). o Differential diagnosis includes the following (see Table 20.3): Clogged milk ducts: a tender lump in the breast not accompanied by systemic symptoms; resolves after application of warm compresses and massage. Unrelieved, clogged ducts can lead to galactoceles, cysts filled initially with milk but may convert to a thicker, cheesy substance that is difficult to drain. These can be treated with warm compresses and massage but may require ultrasound treatment or needle aspiration. Breast engorgement: bilateral, generalized tenderness of breasts, often occurring 2 to 4 days postpartum and associated with low-grade fevers. May be treated with application of warm compresses followed by hand or pump expression of milk and continued breast-feeding. Inflammatory breast cancer: a rare form of breast cancer that presents with breast tenderness and breast skin changes. Table 20.3 Differential Diagnosis of Enlarged, Tender Breasts Postpartum Finding Engorgement Mastitis Plugged duct Onset Gradual Sudden Gradual Location Bilateral Unilateral Unilateral Swelling Generalized Localized Localized

Pain Generalized Intense, localized Localized Systemic symptoms Feels well Feels ill Feels well Fever No Yes No From Beckmann CRB, Ling FW, Barzansky BM, et al. Obstetrics and Gynecology, 4th Ed. Baltimore: Lippincott Williams & Wilkins, 2002:158, with permission.

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Breast abscess: a firm, tender, usually well-circumscribed mass. Breast sonography may be required for diagnosis, and incision and drainage are necessary for treatment.

X. Decreased Milk Supply The normal amount of milk produced by the end of the first postpartum week is 550 mL per day. By 2 to 3 weeks, milk production is increased to approximately 800 mL per day. Milk production peaks at 1.5 to 2.0 L per day. Before gaining weight, newborns who are breast-fed may be expected to lose 5% to 7% of birth weight in the first week. If the loss is greater than 5% to 7%, or if the weight loss is rapid, adequacy of breast feeding should be assessed. Glycogen stores in full-term infants generally provide sufficient initial nutrition. Therefore, supplemental feeding should be avoided unless medically indicated. Frequent breast-feeding helps maintain milk stores. Maternal poor nourishment and psychological stress can decrease milk supply. Sheehan syndrome (postpartum pituitary necrosis) can also result in lack of milk production. Sheehan's syndrome is clinically characterized by development of lethargy, anorexia, weight loss, as well as inability to lactate.