Postpartum care case file

Postpartum Care Case File

Eugene C. Toy MD, Donald Briscoe, MD, FA  AFP, Bruce Britton, MD, Joel J. Heidelbaugh, MD, FA  AFP, FACG

Case 26

A 26-year-old GlPl001 woman presents for a routine postpartum visit 6 weeks following the vaginal delivery of a 7-lb baby girl. She had an uncomplicated prenatal course. She went into labor spontaneously at 39 2/7-week gestation. Her labor was augmented with oxytocin (Pitocin). The first stage of labor lasted for 9 hours, the second stage for 45 minutes, and the third stage for 15 minutes. She had a second-degree perinea! laceration that was repaired without difficulty. She started breast-feeding her baby immediately after delivery. Her postpartum course was uncomplicated and she was discharged from the hospital on the second postpartum day. She is exclusively breast-feeding her baby and reports that it is going well. She says that she felt "stressed, sad, and overwhelmed" during her first week at home, but that those feelings resolved after a week or so. She is now in excellent spirits and has strong support at home from her husband and her mother. She had some light vaginal bleeding that stopped about a week after delivery. She had minimal to moderate, white discharge for a couple of weeks that has also stopped and she has had no vaginal discharge since. On examination, she appears well and has normal vital signs. Her general physical examination is normal. A pelvic examination shows a well-healed laceration repair, no cervical or vaginal discharge, and no cervical motion tenderness. Her uterus is normal size, firm, and nontender, and there are no adnexal masses.

⯈ What are the maternal benefits of breast-feeding?

⯈ If the patient had been using a diaphragm for contraception prior to her pregnancy and wishes to use one again, what counseling should be given?

⯈ If she prefers oral contraception, which type would be most appropriate for this patient?

ANSWER TO CASE 26:

Postpartum Care

Summary: A 26-year-old first-time mother presents for a routine, 6-week postpartum examination. She is breast-feeding her baby. Her examination is normal. She had a brief period in which she felt sad and overwhelmed, but this has resolved. She requests counseling about contraception.

• Maternal benefits of breast-feeding: Along with benefits to the baby, the maternal benefits include (but are not limited to) a more rapid return of uterine tone with reduced bleeding and a quicker return to nonpregnant size; a more rapid return to prepregnancy body weight; a reduced incidence of ovarian and breast cancer; contraceptive effects; the convenience of alway s having a readily available feeding supply for baby; and lower cost (no need to purchase formula).
• Counseling regarding use of diaphragm: There is no contraindication to using a diaphragm but she should have a new fitting.
• Recommended oral contraception: In breast-feeding women, the progestin-only "minipill" is recommended, as combined hormonal contraceptives can interfere with milk supply.

ANALYSIS

Objectives

1. Know the normal changes that occur in the postpartum period.
2. Be familiar with the diagnosis and management of common postpartum complications.
3. Be able to counsel patients on common postpartum issues such as contraception, breast-feeding, and postpartum depression.

Considerations

The postpartum period is defined as the time starting after the delivery of the placenta and lasting for 6 to 12 weeks. The postpartum period is a time of great change for the woman and her family. There are numerous normal physiologic changes that occur during the change from the pregnant to the nonpregnant state. Just as important are the many personal, social, and family changes that occur, which can be magnified for first-time parents or when there are unforeseen complications.

The immediate postpartum period, while still in the delivery suite, is usually focused on the medical conditions of both the neonate and the mother. The delivery attendant examines the mother, repairs any lacerations or episiotomy, and monitors uterine tone and vital signs so that complications such as postpartum hemorrhage can be diagnosed and treated quickly. Simultaneous to this, the neonate is assessed and cared for during his or her initial transition to extrauterine life. The baby is often quite alert during this time, making it an ideal time to start breastfeeding efforts. Rh D-negative women who are not isoimmunized and whose infant is Rh D-positive should receive Rh D immunoglobulin shortly after delivery.

Expected postdelivery hospital stay is 24 to 48 hours for an uncomplicated vaginal delivery and 72 to 96 hours for a cesarean delivery. This time allows for recovery from the delivery or surgery, allows further monitoring for both maternal and neonatal problems, and can be used to provide education and support for the new mother and family. Only 3% of vaginal deliveries and 9% of cesarean deliveries result in complications that require a prolonged hospital stay. Goals of postpartum care include early ambulation, resuming a healthy regular diet, perineal and bladder care, bowel regimen, addressing postpartum blues, and breast-feeding support. Typical maternal problems that occur during this time frame include pain, bleeding, lactation problems, and urinary difficulties (infections, incontinence, and retention). Postpartum fever is most often a sign of endometritis (infection of the uterus), but can also be caused by urinary tract or wound infections, thromboembolic disease, and mastitis.

Prior to discharge, women should be instructed on normal physiologic changes after delivery, including lochia, diuresis, and milk letdown, as well as what to do in the case of alarming symptoms such as fever, excessive vaginal bleeding, leg pain or swelling, persistent headaches, shortness of breath, and chest pain. Women who are not already immune to rubella or rubeola should receive combined measlesmumps- rubella vaccination. A tetanus, diphtheria, and acellular pertussis (Tdap) vaccine is recommended for women who were not vaccinated during their pregnancies. Influenza vaccine is also recommended for women who have not yet been vaccinated.

The time following discharge from the hospital and for the subsequent 6 to 12 weeks usually represents the period of greatest adjustment. There are normal changes that occur, along with many potential medical and emotional complications. Future family planning and contraceptive issues need to be addressed as well. A 6-week postpartum examination is usually scheduled, but many of the issues that can occur during this time frame should be addressed prior to discharge from the hospital.

Approach To:

Postpartum Care

DEFINITIONS

ENDOMETRITIS: A polymicrobial infection of the endometrium, myometrium, and parametrial tissues of the uterus, usually caused by ascending infection from the vagina.

LOCHIA: Normal postpartum vaginal discharge which is initially reddish in color and consists of blood, decidua and epithelial cells, then becomes thicker and yellow- white as leukocytes predominate.

CLINICAL APPROACH

Normal Changes

The uterus increases significantly in size and weight during pregnancy. Immediately after delivery, it weighs approximately 1 kg and is the size of a 20-week pregnancy (fundus palpable at the umbilicus), and begins the process of involution, the return to its nonpregnant size. Regular contractions of the uterine musculature (which cause "afterpains"), promoted by endogenous oxytocin secretion, improve hemostasis by compressing the uterine blood vessels. Oxytocin release increases during breast-feeding, so early breast-feeding is encouraged to assist involution. Supplemental oxytocin (Pitocin) given by intravenous infusion during or immediately after the third stage of labor will also aid in increasing uterine tone. By the end of the first postpartum week, the uterus will be about the size of a 12-week gestation, palpable at the symphysis pubis and in most cases it will return to normal size (weighing <100 g) by the time of the 6-week follow-up visit. If the normal process of involution does not occur, the patient should be evaluated for infection and retained placenta.

Vaginal bleeding is usually heaviest in the hours following delivery, then decreases significantly. Brown or blood-tinged lochia occurs for about the next week. This is followed by white or yellow lochia, which continues for approximately 4 to 6 more weeks. In women who are not breast-feeding, menstruation usually restarts by the third postpartum month. In women who are breast-feeding, ovulation and menstruation can be suppressed for much longer. Anovulation will persist for longer periods of time in women who exclusively breast-feed their babies.

Breast engorgement, signaling increased milk production, typically occurs 1 to 4 days after delivery and can cause breast pain, milk leakage, and fever. In breastfeeding women, this is best managed by increased frequency of feedings. In women who are not breast-feeding, the use of ice packs, supportive bras, and nonsteroidal anti-inflammatory drugs (NSAIDs) can reduce discomfort.

MEDICAL COMPLICATIONS

Hemorrhage

Postpartum hemorrhage is defined as loss of more than 500 mL of blood after delivery and occurs in about 4% of vaginal deliveries. Early postpartum hemorrhage occurs within 24 hours of delivery, most often immediately postpartum; late postpartum hemorrhage occurs between 24 hours and 12 weeks after delivery and is usually the result of abnormal placental site involution. The causes of most cases of postpartum hemorrhage can be remembered with the mnemonic " The Four Ts" (Table 26-1). Careful examination focused on the likely causes should be performed promptly to identify the source of the bleeding in both early and late postpartum hemorrhage.

Risk factors for postpartum hemorrhage include prolonged third stage of labor, multiple delivery, episiotomy, fetal macrosomia, and history of postpartum hemorrhage, but any patient can develop postpartum hemorrhage so it is important to prepare for prevention and early management at all deliveries. Active management

of the third stage of labor is the best way to prevent postpartum hemorrhage. This involves administration of a uterotonic agent, such as oxytocin or misoprostol, coinciding with delivery of the anterior shoulder, gentle cord traction, and uterine massage.

As with all emergency situations, the first priority in managing postpartum hemorrhage is assessment of cardiopulmonary stability. It is important to ensure that adequate IV access is available, preferably two large-bore IV catheters. Fluid resuscitation with a crystalloid solution (normal saline, lactated Ringer solution) should be given as necessary and massive hemorrhage may require transfusion with packed red blood cells.

Uterine atony causes approximately 70% of postpartum hemorrhage. Failure of the uterus to contract adequately results in continued bleeding from uterine vasculature. Risks include prolonged labor, prolonged use of oxytocin during labor, a large baby, and grand multipara (five or more previous children). Initial management of uterine atony includes initiating bimanual uterine compression and massage, and administration of oxytocin, which may be given intravenously or intramuscularly. Additional options for continued bleeding include methylergonovine (Methergine), carboprost (Hemabate), and misoprostol (Cytotec). Methylergonovine is contraindicated in patients with preeclampsia or hypertension, as it may cause an abrupt increase in blood pressure. Carboprost is contraindicated in women with asthma . Misoprostol has limited use due to high gastrointestinal and other side effects.

Trauma (lacerations, hematomas, and inverted uterus) causes approximately 20% of bleeds and is managed procedurally. Retained placenta causes approximately 10% of bleeds and is also managed procedurally. Coagulopathies cause approximately 1% of bleeds and require clotting factor replacement for management.

Fever

Postpartum fever, especially if associated with uterine tenderness and foul-smelling lochia, is often a sign of endometritis. Endometritis complicates approximately 10% cesarean and 1 % to 2% of vaginal deliveries, even with antibiotics given prophylactically. When it does occur, endometritis following vaginal delivery should be treated with broad-spectrum antibiotics that cover vaginal and gastrointestinal flora, such as a combination of ampicillin and gentamicin. Following cesarean deliveries, antibiotics must also cover for anaerobes, and a combination of clindamycin and gentamicin may be used.

Urinary tract infections (UTIs) are another common cause of fever after both vaginal and cesarean deliveries. Urinary frequency, urgency, and burning are typical presenting symptoms. Catheterization of the urinary bladder, which occurs routinely during a cesarean delivery and frequently during vaginal deliveries, raises the risk of introducing bacteria into the normally sterile environment of the bladder.

Breast infections such as mastitis may occur as well. Symptoms include breast engorgement, erythema, induration, and tenderness. Prompt treatment with continued breast-feeding or pumping from the affected breast and antibiotics that cover staph infections are helpful in preventing breast abscess development. Mastitis should not result in discontinuation of nursing.

Other causes of fever in the postpartum period, especially in women delivered by cesarean, are identical to causes of fever in other postsurgical patients. These include atelectasis, wound infections, and venous thromboembolic disease.

Mood Disorders

Up to three-fourths of women develop some type of psychological reaction following the delivery of a child. In most cases, the symptoms are mild and self-limited. However, a smaller but significant percentage can have a reaction of such severity as to require medical or psychiatric intervention.

Approximately 30% to 70% of women develop a temporary state known as the "maternity blues" or " baby blues:' This condition develops within the first week after delivery and typically resolves by the 10th postpartum day. Symptoms include tearfulness, sadness, and emotional !ability. The etiology is not entirely clear, but may be multifactorial and include hormonal changes following delivery, nutritional deficiencies, stress, sleep deprivation, and adjustment to the new role of mother.

Postpartum depression occurs following 10% to 20% of pregnancies and can occur following gestations of any length-term, preterm, miscarriages, or abortions. The onset is defined by the DSM-V as occurring within 4 weeks' postpartum, but may occur as late as 1 year postpartum, and 50% of "postpartum" major depressive episodes may actually begin prior to delivery. The symptoms of postpartum depression are the same as in major depression. The severity can vary from mild to severe and suicidal. There is a high recurrence rate in subsequent pregnancies and an increased risk in women with a history of depression unrelated to pregnancy. Untreated, postpartum depression can last for 6 months or more and can be a significant cause of morbidity.

All women should be screened for a history of psychiatric disorders during their prenatal care and should be questioned about symptoms of depression at 2- and 6-week postpartum visits. Treatment is similar to the treatment of nonpregnancy related depression. Women who are a risk to themselves, or to others, or who are unable to care for themselves should be admitted to the hospital. Selective serotonin reuptake inhibitors (SSRIs) are first-line therapy because of their efficacy and safety. They also are considered safe in breast-feeding. Counseling and general supportive measures at home are also important adjuncts to treatment.

Postpartum psychosis is a rare, but potentially devastating, complication following pregnancy. Manic or frankly delusional behaviors may present within a few days to a few weeks of delivery in up to 1 in 1000 postpartum patients. All women with postpartum psychosis should be hospitalized and comanaged with a psychiatrist. Without proper treatment, there is a high risk of suicide and infanticide associated with this diagnosis.

BREAST-FEEDING

Counseling and encouragement regarding both the maternal and infant benefits of breast-feeding should start during the prenatal period. Neonatal benefits include ideal nutrition, increased resistance to infection, and a reduced risk of gastrointestinal tract infections and atopic dermatitis. Maternal benefits include improved mother-child bonding, more rapid uterine involution, quicker return to prepregnant body weight, convenience, decreased costs, contraception while the mother remains amenorrheic, and long-term reduced risks of ovarian and breast cancer. Breast-feeding promotion and education can increase the rate of breast-feeding and the duration for which women breast-feed their babies (See Table 26-2).

Women should be allowed to nurse their newborns as soon as possible following delivery. During this time, the newborns are often very alert and have strong rooting and sucking reflexes, which promote latching on to the nipple. Initial feedings provide colostrum, a yellow fluid which is rich in immunoglobulin A, minerals, amino acids, and proteins. Breast engorgement and milk letdown commonly occurs between the second and fourth postpartum days. Mature milk contains fats, proteins, carbohydrates, vitamins, minerals, and hormones.

There are few contraindications to breast-feeding. HIV infection, miliary tuberculosis, acute hepatitis B, herpetic breast lesions, and chemotherapy are contraindications. Abuse of substances, such as cocaine, heroin, PCP, and alcohol are contraindications. Women who have had breast-reduction surgery with nipple transplantation will be unable to breast-feed.

Common maternal complications of breast-feeding include sore or cracked nipples and mastitis. Sore nipples can be managed by ensuring proper latch-on, frequent position changes, alternating breasts during feedings, nipple shields,

Reproduced, with permission, from Cunningham F, Leveno KJ, Bloom SL, et al. Williams Obstetrics. 24th ed. New York,

NY: McGraw-Hill; 2013, Table 36-3.

keeping the nipples clean and dry between feedings, and applications of lanolin or the patient's own breast milk as a salve. Vitamin E, herbal rubs, and other creams and topical agents should be avoided because of risk of absorption by the infant.

FAMILY PLANNING

Most women resume sexual activity by 3 months' postpartum. Numerous options are available to women for contraception and family planning. Discussion of these options ideally should occur in the prenatal period and again before discharge from the hospital.

Oral contraceptive pills (OCPs) are the most widely used reversible form of contraception. Available OCPs contain both estrogen and progestin or are progestin only. In breast-feeding women, the progestin-only pills are preferred because combination OCPs might reduce lactation. Both the American College of Obstetricians and Gynecologists and the World Health Organization recommend waiting for 6 weeks' postpartum to start oral contraceptives in breast-feeding women. Injectable long-acting depot medroxyprogesterone (Depo-Provera) may also be used in breast-feeding women and should also be given at or after 6 weeks' postpartum. Non-breast-feeding women should wait 3 weeks after delivery to start combined OCPs, as the risk of thromboembolic disease is higher in those who start at earlier times.

Barrier methods of contraception may also be used regardless of breast-feeding status. An intrauterine device (IUD) may be placed at the 6-week postpartum visit; earlier placement is associated with an increased rate of expulsion of the device. Diaphragms and cervical caps can be used, but should be refitted at the 6-week visit to ensure an appropriate fit.

Lactation-induced amenorrhea provides a high level of natural contraception in the first 6 months; postpartum. Women who breast-feed exclusively and who are amenorrheic have a 99% contraceptive protection for 6 months. After 6 months, if menses restart, or if breast-feeding is reduced, the risk of pregnancy increases and alternate forms of contraception should be used.

CASE CORRELATION

• See also Cases 4 (Prenatal Care) and 16 (Labor and Delivery).

COMPREHENSION QUESTIONS

26.1 You are called by the postpartum nurse to see a 20-year-old woman who delivered an 8-lb 9-oz newborn boy approximately 6 hours ago. The nurse noted that the patient is continuing to bleed more than expected. The patient is awake and talking, but feels dizzy. Her blood pressure is 90/40 mm Hg and her pulse is 110 beats/min. You see that her perineal pad is soaked with blood. Which of the following is your most appropriate initial intervention?

A. Add 20 units of oxytocin (Pitocin) to the IV of 0.45% saline that is currently running at 125 mL/h.

B. Perform bimanual uterine massage.

C. Place a large-bore IV and give a 1 L bolus of 0.9% saline.

D. Give an IM injection of methylergonovine (Methergine).

26.2 A 29-year-old first-time mother comes to you for her routine 6-week postpartum visit. Her husband, who accompanied her to the visit, reports that his wife is tearful much of the time. She has not been sleeping well, has little energy, and a reduced appetite. She denies any suicidal thoughts, hallucinations, or feelings that she wants to harm her baby. Which of the following is the most appropriate intervention?

A. Reassurance that these feelings will pass within a week or so

B. Referral to a psychiatrist for outpatient management

C. Institution of SSRI therapy and close follow-up

D. Admission to the hospital and urgent psychiatric consultation

26.3 You see a 30-year-old woman for an acute visit 16 days' postpartum. She has been nursing her baby daughter, but has developed a very sore left breast. On examination, the patient has a temperature of 101.3°F (38.5°C). The breast is diffusely tender, but primarily in the upper inner quadrant. The skin overlying the area of most tenderness is erythematous and warm. There is no nipple discharge and the remainder of the examination is normal. Which of the following is the best treatment?

A. This condition is self-limited, but she should stop nursing the baby on the left breast until this condition resolves.

B. She may nurse from the unaffected breast, but should simply pump and discard the milk from the painful breast.

C. The patient should receive oral dicloxacillin or clindamycin.

D. She should have a fine-needle aspiration.

26.4 A 19-year-old woman is seen in the office 3 weeks' postpartum. She is exclusively breast-feeding and has not had a menstrual cycle since her delivery. She would like to have an IUD placed for contraception, as she would like to wait several years before having another baby. Which of the following actions would be most appropriate at this time?

A. Plan to insert the IUD at a 6-week postpartum visit.

B. Prescribe progestin-only minipills until she is no longer breast-feeding and then insert the IUD.

C. Advise that she needs no contraception until she is no longer breastfeeding and she should return after that time for the IUD.

D. Insert the IUD today.

ANSWERS

26.1 C. This patient is symptomatically hypovolemic, with dizziness, hypotension, and tachycardia. Fluid resuscitation must be your first intervention. Once you have started the management of this critical issue, you should turn your attention to identifying and correcting the source of the bleeding.

26.2 C. This is a picture of postpartum depression. The symptoms are identical to those of a major depressive episode. The maternity blues is a self-limited condition that starts in the first postpartum week and resolves in the second. Fortunately, this patient does not have signs of postpartum psychosismania, hallucinations, and delusions. Appropriate management includes the use of an SSRI, counseling, and close follow-up.

26.3 C. Mastitis is a common complication of breast-feeding. It is caused by gland obstruction and sometimes, as in this case, there also are signs of infection. Treatment is directed at relieving the obstruction, so increased breast-feeding or pumping is helpful. The antibiotics typically used for this complication are considered safe to use while nursing. Empiric staphylococcal coverage is recommended. Dicloxacillin, and cephalexin are appropriate for areas with low rates of methicillin-resistant staphylococcus aureus (MRSA). Clindamycin or sulfamethoxazole-trimethoprim is good choice for areas with high rates of MRSA.

26.4 A. IUDs provide highly effective, reversible contraception and are very useful for women who wish to space out pregnancies for several years. Postpartum insertion prior to 6 weeks is associated with a higher risk of expulsion of the IUD from the uterus as it involutes. Breast-feeding-induced amenorrhea provides a high degree of protection against pregnancy for about the first 6 months' postpartum, but an alternate form of contraception should be used after 6 months or when menses restart.

CLINICAL PEARLS

⯈ Many of the important postpartum issues-mood problems, contraception, and breast-feeding-are best managed by addressing them in the prenatal course first, and then readdressing or reinforcing them in the postpartum period.

⯈ Most causes of postpartum hemorrhage can be remembered with the four Ts: tone, trauma, tissue, and thrombin.

REFERENCES

Anderson JM, Etches D. Prevention and management of postpartum hemorrhage. Am Fam Physician. 2007 Mar 15;75(6):875-882. 

Blenning CE, Paladine H. An approach to the postpartum office visit. Am Fam Physician. 2005 Dec 15:72(12) :2491-2496. 

Conti TD, Patel M, Bhat S. Breastfeeding and infant nutrition. In: South-PaulJE, Matheny SC, Lewis EL, eds. Current Diagnosis & Treatment: Family Medicine. 4th ed. New York, NY: McGraw-Hill; 2015. Available at: http://accessmedicine.mhmedical.com. Accessed May 25, 2015. 

Cunningham F, Leveno KJ, Bloom SL, et al. The puerperium. In: Cunningham F, Leveno KJ, Bloom SL, et al., eds. Williams Obstetrics. 24th ed. New York, NY: McGraw-Hill; 2013. 

Cunningham F, Leveno KJ, Bloom SL, et al. Puerperal complications. In: Cunningham F, Leveno KJ, Bloom SL, eds. Williams Obstetrics. 24th ed. New York, NY: McGraw-Hill; 2013. 

Pessel C, Tsai MC. The normal puerperium. In: DeCherney AH, Nathan L, Laufer N, Roman AS, eds. Current Diagnosis & Treatment: Obstetrics & Gynecology. 11th ed. New York, NY: McGraw-Hill; 2013.

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