Department of Family Medicine, University of California, Riverside, Riverside, CA, USA
Immediate postpartum management falls largely within the domain of labor management and was discussed in detail in Chap. 19. The postpartum management of patients serves to identify early complications of the postpartum period as well as providing the basis for ongoing management of both the mother and new infant.
Postpartum Day 1
Evaluation on postpartum day 1 should begin with a brief review of the prenatal and labor and delivery course. Particular attention should be paid to those issues that may impact immediate postpartum care. Maternal laboratory values from the prenatal period should be reviewed. Particular note should be made of Rh status, maternal infection (urinary tract infections, sexually transmitted disease, and rubella and varicella immune status). Medical complications of pregnancy, such as hypertension, diabetes, and infection, should be noted.
Complications of delivery including prolonged labor and delivery method and immediate postpartum complications such as hemorrhage, uterine atony, or maternal fever should be reviewed. The management of these conditions and current status of each should be noted.
A variety of medical conditions such as an abnormal Pap smear may be uncovered in the prenatal course of management. These conditions will usually be deferred until after pregnancy. When present, these medical conditions should be noted. In addition, the management of a variety of medical conditions may have been modified during the course of pregnancy. Examples of this might include a change in hypertension medication or the discontinuation of antiseizure medications. When such changes have been made, the postpartum history should include prepregnancy treatment management as well as the management regimen implemented during pregnancy.
The history of postpartum day 1 focuses on a few key elements. Bowel and bladder function should be reviewed. When present, pain location and severity should be noted. Patient activity, including ambulation, should be noted. Patients should be asked about bleeding, discharge per vagina, and subjective fever.
The postpartum examination is comprehensive but focuses primarily on a few key elements. Vital signs should be reviewed for maternal tachycardia and blood pressure. In patients for whom fluid status is being monitored (e.g., those with pre-eclampsia or those who are postoperative), weight should be recorded daily. Cardiovascular examination should include a note of cardiac murmurs. Pulmonary examination should note the presence of rales, rhonchi, or wheezing.
The most important elements of the physical examination are the abdomen and the perineum. On abdominal examination, note should be made of the size and consistency of the uterus as well as any tenderness if present. In general, the uterus should feel firm and the fundal height should be at or below the umbilicus. For patients who underwent operative delivery, note should be made of the surgical wound status. In the perineum, the external genitalia should be examined for swelling and tenderness. For patients who had an episiotomy or laceration, the site of the repair should be noted.
On postpartum day 1, all patients will have both bleeding and discharge per vagina. Note should be made of the quantity and quality of the bleeding. Although the distinction between normal and abnormal bleeding postpartum is sometimes difficult to make, normal postpartum bleeding should, in general, be no more than heavy menstrual bleeding. Clots may be noted in the early postpartum course but should resolve relatively quickly. In addition to bleeding, all postpartum patients will have a normal discharge per vagina referred to as lochia. Lochia represents a mixture of decidual tissue and blood in varying contents that changes in a predictable manner over time. In the first 3–4 days postpartum, this lochia includes considerable red blood cells and therefore appears red (lochia rubra). On postpartum day 3 or 4, as bleeding diminishes, the lochia becomes more pale or straw colored. This is referred to as lochia serosa. As the quantity of discharge diminishes and the presence of leukocytes increases, the lochia becomes clear (lochia alba). Lochia alba is variable in quantity and may last up to 8 weeks postpartum.
As noted, all prenatal laboratory values should be reviewed. In the postpartum period, key laboratory values include hemoglobin or hematocrit (to assess for anemia) and rapid plasma reagin test (if not performed near term). In patients with fever or other signs of possible infection, a complete blood count with differential may assist in evaluation. White blood cell count must be interpreted with caution as it is often elevated in the postpartum period even in the absence of infection. In addition, urine, blood, and wound cultures should be obtained when appropriate.
In addition to those items just noted, management will consist of assessment of and education concerning newborn care. Newborns can be expected to perform five basic functions: sleeping, eating, crying, urinating, and defecating. In addition to noting the presence or absence of each, providers should educate new parents about normal expectations for each, signs or symptoms of concern in each area, and appropriate follow-up for such warning signs. Although it is beyond the scope of this chapter to discuss each of these in detail, a few basic facts should be noted. All infants can be expected to urinate within the first few hours of life and note should be made of the number of wet diapers. If questions arise concerning the adequacy of urine output, these diapers can be weighed to determine the quantity of urine produced. All infants can be expected to stool prior to discharge, although they may not have done so by the time of the first postpartum rounds. The initial stools consist of meconium, a grainy, green material with little or any odor. These will gradually transition to more typical stools as the infant increases oral intake of either breast milk or formula.
All infants cry and parents should be made aware of the fact that this is neither abnormal nor of significant concern as long as the infant can be consoled and assessment is made that possible infant needs (hunger, stool, comfort) are met. Infants can be expected to sleep up to 18 h each day. Parents should be made aware, however, that this likely represents short periods of sleeping interspersed with periods of being awake. That is to say, it will not feel to most parents as if their newborn is sleeping most of the time. Parents should be educated to sleep when their infants sleep in anticipation of being awake at times when they might not usually anticipate being awake.
In general, all mothers without a specific contraindication to breastfeeding should be encouraged to breastfeed their newborn. This may begin in the immediate postpartum period while the patient is still in the delivery room setting. Breastfeeding itself stimulates the production of breast milk and earlier initiation enhances the likelihood of success. In the first several days, the principle available breast product is colostrum rather than breast milk. Parents should be assured that this is sufficient for most infants’ needs in the period prior to the onset of breast milk production. New mothers may benefit from the assistance of skilled teaching in the breastfeeding technique by nursing staff, specialized lactation consultants, physicians, or other family members with breastfeeding experience.
Postpartum Day 2
For most patients with uncomplicated vaginal deliveries, postpartum day 2 represents the day of discharge to home. In addition to the elements just reviewed, providers should inquire about arrangements for transportation home (many institutions will not allow discharge of an infant unless the parents have a car seat) and arrangements at home.
The examination on postpartum day 2 is similar to that of the first day. Abnormal findings noted on day 1 should be reviewed and particular attention should be paid to those areas on day 2.
In general, there are no additional laboratory studies necessary on postpartum day 2, unless prior abnormal values require follow-up.
As noted, postpartum day 2 is often the day of discharge from the hospital. Management should focus on transition of care from the hospital setting to the home setting and any needs the patient may have in arranging for this transition.