This chapter deals primarily with APGO Educational Topic Areas:
TOPIC 13 POSTPARTUM CARE
TOPIC 14 LACTATION
TOPIC 29 ANXIETY AND DEPRESSION
Students should be able to list the normal anatomic and physiologic changes in the postpartum period and describe the key components of routine postpartum care including patient counseling regarding contraception, breastfeeding, and postpartum mood disorders. They should be able to outline a basic approach for evaluation and management of common breast complaints in the breastfeeding patient and be able to describe common challenges and barriers to breastfeeding as well as benefits of breastfeeding. They should be able to perform medication reconciliation for breastfeeding patients. They should be able to identify risk factors for postpartum mood disorders and outline a basic approach to their evaluation and management.
Clinical Case
Following a normal term pregnancy and spontaneous vaginal delivery, your new mother elects to breastfeed after an explanation of the benefits of breastfeeding for the baby as well as herself. She experiences moderately heavy, bloody vaginal discharge for the first 2 postpartum days and, during the next 3 days, progressively lighter bleeding to cessation of bleeding. She returns to your office at 3 weeks, however, complaining of a whitish non–foul-smelling vaginal discharge. She is concerned that she may have a postpartum infection although she has no fever, chills, or discomfort.
The puerperium is the 6- to 8-week period following birth during which the reproductive tract, as well as the rest of the body, returns to the nonpregnant state. Some of the physiologic changes of pregnancy have returned to normal within 1 to 2 weeks postpartum. The initial postpartum examination should be scheduled at 4–6 weeks after delivery.
PHYSIOLOGY OF THE PUERPERIUM
Involution of the Uterus
The uterus weighs approximately 1,000 g and has a volume of 5,000 mL immediately after delivery, compared with its nonpregnant weight of approximately 70 g and capacity of 5 mL. Immediately after delivery, the fundus of the uterus is easily palpable halfway between the pubic symphysis and the umbilicus. The immediate reduction in uterine size is a result of delivery of the fetus, placenta, and amniotic fluid. Further uterine involution is caused by autolysis of intracellular myo-metrial protein, resulting in a decrease in cell size but not in cell number. As a result of these changes, the uterus returns to the pelvis by 2 weeks postpartum and is at its normal size by 6 weeks postpartum. Immediately after birth, uterine hemostasis is maintained by contraction of the smooth muscle of the arterial walls and compression of the vasculature by the uterine musculature.
Lochia
As the myometrial fibers contract, the blood clots from the uterus are expelled, and the thrombi in the large vessels of the placental bed undergo organization. Within the first 3 days, the remaining decidua differentiates into a superficial layer, which becomes necrotic and sloughs, and a basal layer adjacent to the myometrium, which had contained the fundi of the endometrial glands. This basal layer is the source of the new endometrium.
The subsequent discharge, called lochia, is fairly heavy at first and rapidly decreases in amount over the first 2 to 3 days postpartum, although it may last for several weeks. Lochia is classically described as 1) lochia rubra, menses-like bleeding in the first several days, consisting mainly of blood and necrotic decidual tissue; 2) lochia serosa, a lighter discharge with considerably less blood in the next few days; and 3) lochia alba, a whitish discharge that may persist for several weeks. Lochia alba may be misunderstood as illness by some women, requiring explanation and reassurance. In women who breastfeed, the lochia seems to resolve more rapidly, possibly because of a more rapid involution of the uterus caused by uterine contractions associated with breastfeeding. In some patients, there is an increased amount of lochia 1 to 2 weeks after delivery, because the eschar that developed over the site of placental attachment has been sloughed. By the end of the third week postpartum, the endometrium is reestablished in most patients.
Cervix and Vagina
Within several hours of delivery, the cervix has reformed, and by 1 week, it usually admits only one finger (i.e., it is approximately 1 cm in diameter). The round shape of the nulliparous cervix is usually permanently replaced by a transverse, fish mouth–shaped external os, the result of laceration and dilation during delivery. Vulvar and vaginal tissues return to normal over the first several days, although the vaginal epithelium reflects a hypoestrogenic state if the woman breastfeeds, because ovarian function is suppressed during breastfeeding. The muscles of the pelvic floor gradually regain their tone. Vaginal muscle tone may be strengthened by the use of Kegel exercises, consisting of repetitive contractions of these muscles.
Return of Ovarian Function
The average time to ovulation is 45 days in nonlactating women and 189 days in lactating women. Ovulation is suppressed in the lactating women in association with elevated prolactin levels. In these women, prolactin remains elevated for 6 weeks, whereas in nonlactating women, prolactin levels return to normal by 3 weeks postpartum. Estrogen levels fall immediately after delivery in all patients, but begin to rise approximately 2 weeks after delivery if breastfeeding is not initiated. The likelihood of ovulation increases as the frequency and duration of breastfeeding decreases.
Abdominal Wall
Return of the elastic fibers of the skin and the stretched rectus muscles to normal configuration occurs slowly and is aided by exercise. The silvery striae gravidarum seen on the skin usually lighten in time. Diastasis recti, separation of the rectus muscles and fascia, also usually resolves over time.
Cardiovascular System
Pregnancy-related cardiovascular changes return to normal 2 to 3 weeks after delivery. Immediately postpartum, plasma volume is reduced by approximately 1,000 mL, caused primarily by blood loss at the time of delivery. During the immediate postpartum period, there is also a significant shift of extracellular fluid into the intravascular space. The increased cardiac output seen during pregnancy also persists into the first several hours of the postpartum period. The elevated pulse rate that occurs during pregnancy persists for approximately 1 hour after delivery, but then decreases. These cardiovascular events may contribute to the decompensation that some-times occurs in the early postpartum period in patients with heart disease.
Immediately after delivery, approximately 5 kg of weight is lost as a result of diuresis and the loss of extravascular fluid. Further weight loss varies in rate and amount from patient to patient.
Hematopoietic System
The leukocytosis seen during labor persists into the early puerperium for several days, thus minimizing the usefulness of identifying early postpartum infection by laboratory evidence of a mild-to-moderate elevation in the white cell count. There is some degree of autotransfusion of red cells to the intravascular space after delivery as the uterus contracts.
Renal System
Glomerular filtration rate represents renal function and remains elevated in the first few weeks postpartum, then returns to normal. Therefore, drugs with renal excretion should be given in increased doses during this time. Ureter and renal pelvis dilation regress by 6 to 8 weeks. There may be considerable edema around the urethra after vaginal delivery, resulting in transitory urinary retention. About 7% of women experience urinary stress incontinence, which usually regresses by 3 months. Urinary incontinence persisting more than 90 days may indicate a need for evaluation for other causes of incontinence.
MANAGEMENT OF THE IMMEDIATE POSTPARTUM PERIOD
Hospital Stay
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 hospital stays are appropriate when certain criteria are met to ensure the health of the mother and baby, such as the absence 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 discussing early discharge with the mother, it is essential that she understands that discharge of the newborn may not be possible early to ensure that the newborn receives all of the required testing (some of which may not be complete until after 24 hours of life), and follow-up appointments with the pediatrician must be confirmed. In addition, the mother should have adequate support in the first few days following discharge and should receive instructions about postpartum activity, exercise, and common 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 special issues involved with breastfeeding, and required newborn laboratory testing.When patients are discharged early, a home visit or follow-up telephone call by a health-care provider within 48 hours of discharge is encouraged.
Maternal–Infant Bonding
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 minimizing unnecessary medical interventions while increasing participation by the father and other family members. Nursing staff can observe the interactions between the infant and the new parents and intervene when necessary.
Postpartum Complications
Infection occurs in approximately 5% of patients, and significant immediate postpartum hemorrhage occurs in approximately 1% of patients (see Chapter 12). Immediately after the delivery of the placenta, 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 postpartum 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 occurs in less than 1% of cases. Most of these women do not have retained placental tissue; therefore, sharp curettage, which was a standard practice, may actually worsen the bleeding by traumatizing the implantation site. Some advocate for gentle suction curettage to remove tissue and also to decrease the intrauterine volume, allowing the myometrium to contract more efficiently. The mainstay of therapy is intravenous (IV) oxytocin, ergot derivatives, and prostaglandins, with sharp curettage reserved for persistent bleeding or failures of medical management. Postpartum hemorrhage usually responds to medical management and does not automatically require curettage.
Analgesia
After vaginal delivery, analgesic medication (including topical lidocaine cream) may be necessary to relieve perineal or 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 spinal or epidural opiates, patientcontrolled epidural or IV 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.
Ambulation
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 emboli.
Breast Care
Breast engorgement in women who are not breastfeeding 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 result in an enlarged, tender breast postpartum (Table 11.1). Mastitis, or infection of the breast tissue, most often occurs in lactating women and is characterized by sudden-onset fever and localized pain and swelling. Mastitis is associated with infection by Staphylococcus aureus, group A or B streptococci, β Haemophilus species, and Escherichia coli.Treatment includes continuation of breastfeeding or emptying the breast with a breast pump and the use of appropriate antibiotics. Breast milk remains safe for the full-term, healthy infant; in fact, cessation of breastfeeding will increase engorgement and delay resolution of the infection as well as worsen the pain associated with mastitis.
Breastfeeding is safe when postpartum mastitis occurs. If symptoms continue, however, evaluation for a postpartum breast abscess is often indicated. 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.
Immunizations
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 it has been at least 2 years since her last tetanus–diphtheria booster, she should be given a dose before hospital discharge. If the woman is D-negative, is not isoimmunized, and has given birth to a D-positive or weak-D-positive infant, 300 µg of anti–immunoglobulin D 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 placenta (see Chapter 23).
Universal immunization with hepatitis B surface antigen (HBsAg1) is recommended for all newborns weighing 2,000 g. In addition, all newborns receive a full range of screening tests.
Bowel and Bladder Function
It is common for a patient not to have a bowel movement for the first 1 to 2 days after delivery, because they have often not eaten for a long period. Stool softeners may be prescribed, especially if the patient has had a fourth-degree laceration repair. Although postpartum constipation may be alleviated by stool softener, it may be aggravated by opioid postpartum analgesics.
Hemorrhoids are varicosities of the hemorrhoidal veins. 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 useful, combined with reassurance that resolution is the most common outcome.
Periurethral edema after vaginal delivery may cause transitory urinary retention. Patients’ urinary output should be monitored for the first 24 hours after delivery. If catheterization is required more than twice in the first 24 hours, placement of an indwelling catheter for 1 to 2 days is advisable.
Care of the Perineum
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 an episiotomy or laceration is rare (<0.1%) and usually is limited to the skin and responsive to broad-spectrum antibiotics. Dehiscence (rupture of the incision) is uncommon, with repair individualized on the basis of the nature and extent of the wound.
Contraception
Postpartum care in the hospital should include discussion of contraception. Approximately 15% of non-nursing women are fertile at 6 weeks postpartum. Combined estrogen–progestin oral contraceptives or contraceptive devices should not be used postpartum. Progestin-only oral contraceptives may be initiated 3 to 6 weeks postpartum when exclusively breastfeeding or at 3 weeks if not exclusively breastfeeding. Once lactation is established, neither the volume nor the composition of breast milk is adversely affected by progestin contraceptives. See Chapter 26 for a discussion of postpartum use of progestin devices.
Postpartum Sterilization
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 significant uterine involution but following a full assessment of maternal and neonatal well-being (see Chapter 27). 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 delivery. Consent should be obtained during prenatal care, when the patient can make a considered decision, review the risks and benefits of the procedure, and consider alternative contraceptive methods. In all cases of intrapartum or postpartum medical or obstetric complications, the physician should consider postponing sterilization to a later date. The federal and state regulations that address the timing of consent are also important to consider.
Sexual Activity
Coitus may be resumed when the patient is comfortable; however, the risks of hemorrhage and infection are minimal at approximately 2 weeks postpartum. Women should be counseled, especially if breastfeeding, that coitus may initially 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 epithelium 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
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 health care of both mother and infant. Follow-up care that has been arranged for the newborn and frequency of health care 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 topics of discussion. Postpartum follow-up of any preexisting medical conditions should also be reviewed and, when needed, the patient should be referred for care.
Weight Loss
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 (BMI) or total weight gain and weight retention. Aging, rather than parity, is the major determinant of increases in a woman’s weight over time.
Residual postpartum retention of weight gained during 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 BMI.
Lactation and Breastfeeding
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 decreased risks 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 cognitive 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 incidence of some hormonally sensitive cancers, including breast cancer.
Contraindications
There are few contraindications to breastfeeding. Women with HIV should not breastfeed due to the risk of vertical transmission. Women with active, untreated tuberculosis 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 undergoing 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 of any medication appears in breast milk. This should be considered when any medication is prescribed by a physician or when any over-the-counter medications are contemplated by the patient. Specific medications that would contraindicate breastfeeding include lithium carbonate, tetracycline, bromocriptine, methotrexate, and any radioactive substance. All substances of abuse are included as well, such as amphetamine, cocaine, heroin, marijuana, and phencyclidine.
Prolactin Release
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 neurohypophysis. The increased levels of oxytocin in the blood result in contraction of the myoepithelial cells and emptying of the alveolar lumen of the breast. The oxytocin also increases uterine contractions, thereby accelerating involution 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 corpuscles, which are probably epithelial cells that have undergone fatty degeneration. Colostrum also contains immunoglobulin A, which may offer the newborn some protection from enteric pathogens. Subsequently, on approximately the third to sixth day postpartum, milk is produced. Thus, colostrum is steadily replaced by milk around the fifth postpartum day, providing some nutrition as well as helping the newborn with immunologic response to enteric pathogens.
For milk to be produced on an ongoing basis, there must be adequate insulin, cortisol, and thyroid hormone as well as adequate nutrients and fluids in the mother’s diet. The minimal caloric requirement for adequate milk production in a woman of average size is 1,800 kcal/day. In general, an additional 500 kcal of energy daily is recommended throughout lactation. All vitamins except vitamin K are found in human milk, but, because they are present in varying amounts, maternal vitamin supplementation is recommended. Vitamin K may be administered to the infant to prevent hemorrhagic disease of the newborn (see Chapter 10). To maintain breastfeeding, the alveolar lumen must be emptied on a regular basis.
Lactational Amenorrhea
The natural contraceptive effect of exclusive breastfeeding (elevated prolactin levels and associated anovulation) may be used to advantage in what is known as the lactational amenorrhea method. If not exclusive, breastfeeding provides less contraceptive effect, and it is prudent to use additional methods of contraception (see Chapter 26).
Nipple Care
Nipple care is also important during breastfeeding. The nipples should be washed with water and exposed to 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.
ANXIETY, DEPRESSION, AND THE POSTPARTUM PERIOD
Although pregnancy and childbirth are usually joyous times, depression to some degree is actually common in the postpartum period. There is a wide spectrum of response to pregnancy and delivery, ranging from mild postpartum blues to postpartum depression (PPD; Table 11.2). Approximately 70% to 80% of women report feeling sad, anxious, or angry beginning 2 to 4 days after birth. These postpartum blues may come and go throughout the day, are usually mild, and abate within 1 to 2 weeks. Supportive care and reassurance are helpful in ensuring that symptoms are self-limited. Approximately 10% to 15% of new mothers experience PPD, which is a more serious disorder and usually requires medication and counseling. PPD differs from postpartum blues in the severity and duration of symptoms. Women with PPD have pronounced feelings of sadness, anxiety, and despair that interfere with activities of daily living. These symptoms do not abate but, instead, worsen over several weeks. Postpartum psychosis is the most severe form of mental derangement and is most common in women with preexisting disorders, such as bipolar disorder or schizophrenia. This condition should be considered a medical emergency, and the patient should be referred for immediate, often inpatient, treatment.
Although the exact cause of PPD is unknown, several associated factors have been identified. The normal hormonal fluctuations that occur following birth may trigger depression in some women. Women who have a personal or family history of depression or anxiety may be more likely to develop PPD. Acute stressors, including those specific to motherhood (childcare), or other stressors (e.g., death of a family member) may contribute to the development of PPD. Having a child with a difficult temperament or health issues may lead the mother to doubt her ability to care for her newborn, which can lead to depression. The age of the mother may influence susceptibility to PPD, with younger women more likely to experience depression than older women. Toxins, poor diet, crowded living conditions, low socioeconomic status, and low social support may also play a role. A strong predictor of PPD is depression during pregnancy. It is estimated that half of all cases of PPD may begin during pregnancy. PPD may also be a continuation of a depressive disorder that existed prior to pregnancy, rather than a new disorder.
Treatment must be tailored to the patient’s individual situation. Postpartum blues do not require treatment other than support and reassurance. Women with PPD should receive mental health counseling and medication, if warranted. Effective therapies for the treatment of PPD include cognitive–behavioral and interpersonal therapies.
THE POSTPARTUM VISIT
At the time of the first postpartum visit, inquiries should be made into the status of breastfeeding, return of menstruation, resumption of coital activity, use of contraception, interaction of the newborn with the family, and resumption of other physical activities such as return to work. Observation about and appropriate questions concerning sadness and depression, anxiety, the parents’ concerns about infant care, and the relationship of mother and her partner are also part of the first postpartum visit. Involutional changes will have occurred in most instances. Inflammatory changes because of the healing of the cervix may result in minor atypia on a Pap smear performed at this time. Unless there is a history of significant cervical dysplasia, repeating the Pap smear in 3 months is appropriate.
Clinical Follow-Up
No infection is discovered on pelvic examination with wet preparation, and you are confident to reassure the new mother that she has experienced a normal lochia rubra and then lochia serosa (explaining each kind of normal lochia), and that she is now experiencing lochia alba. You explain that this may persist as long as a few weeks and is simply a longer expression of the end of a normal birth process. She is reasonably reassured but more so when the lochia alba ceases in the following week.
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