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REFERENCES
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed.
Arlington, VA: American Psychiatric Publishing; 2013.
Eisendrath SJ, Cole SA, Christensen JF, Gutnick D, Cole M, Feldman MD. Depression. In: Feldman
MD, Christensen JF, Satterfield JM, eds. Behavioral Medicine: A Guide for Clinical Practice. 4th ed.
New York, NY: McGraw Hill; 2014: Chap. 25. http://accessmedicine.mhmedical.com/content.asp
x?bookid=1116§ionid=62688871. Accessed May 6, 2019.
Kovich H, DeJong A. Common questions about the pharmacologic management of depression in adults.
Am Fam Physician. 2015;92(2):94-100.
Maurer DM, Raymond TJ, Davis BN. Depression: screening and diagnosis. Am Fam Physician.
2018;98(8):508-515.
Shim RS, Primm A. Depression in diverse populations & older adults. In: South-Paul JE, Matheny SC,
Lewis EL, eds. CURRENT Diagnosis & Treatment: Family Medicine. 4th ed. New York, NY:
McGraw Hill; 2015: Chap. 56. http://accessmedicine.mhmedical.com/content.aspx?bookid=1415
&Sectionid=77061063. Accessed May 6, 2019.
CASE 26
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A 26-year-old gravida 1, para 1001 (G1P1001) woman presents for her 6-week
postpartum visit following the vaginal delivery of a 7-lb baby girl. She had an
uncomplicated prenatal course. She went into labor spontaneously at 39months,
2/7 weeks’ gestation. She had a second-degree perineal laceration that was
repaired without difficulty. She started breastfeeding 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 breastfeeding 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 have resolved. She is now in
excellent spirits and has strong support at home from her husband and her mother.
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, closed cervical os, and no cervical motion
tenderness. Her uterus is normal size, firm, and nontender, and there are no
adnexal masses. She is interested in birth control, but she is considering another
child next year.
▶ What additional tools can be used to assess mood and screen for depression?
▶ If she prefers oral contraception, which type would be most appropriate for
this patient?
▶ When can the patient resume sexual activity?
▶ What are the maternal benefits of breastfeeding?
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ANSWERS TO CASE 26:
Postpartum Care
Summary: A 26-year-old woman presents with
Status as a first-time mother presenting for a 6-week postpartum visit
Normal examination and reports of breastfeeding her baby going well
A brief period in which she felt sad and overwhelmed, but that has resolved
A request for contraception counseling
Depression Screening: Mood assessment is one of the most important aspects of
the postpartum visit. The nine-question Patient Health Questionnaire (PHQ9)
can be used to assess mood in a variety of patients, but the Edinburgh Postnatal
Depression Scale has been adjusted to reflect the unique life events of early newborn care such as lack of sleep.
Recommended oral contraception: Estrogen-containing oral contraceptive pills
(OCPs) must be avoided in all postpartum women for the first 30 days. In breastfeeding women, the progestin-only “minipill” is recommended, as combined hormonal contraceptives can interfere with milk supply.
Resumption of sexual activity: In general and in the absence of complications, postpartum women may resume sexual activity (vaginal intercourse) after 6 weeks.
Maternal benefits of breastfeeding: 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; a quicker return of the uterus to nonpregnant size; a more
rapid return to prepregnancy body weight; a reduced incidence of ovarian and
breast cancer; contraceptive effects; the convenience of always having a readily
available feeding supply for the baby; lower costs since formula does not need to
be purchased.
ANALYSIS
Objectives
1. Be able to discuss the diagnosis and management of common postpartum
complications. (EPA 1, 10)
2. Be able to counsel patients on common postpartum issues such as contraception, breastfeeding, and postpartum depression. (EPA 10, 12)
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 transition from the pregnant to the nonpregnant
state. Just as important are the many personal, social, and family changes that
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occur, which can be magnified for first-time parents or when there are unforeseen
complications.
The time following discharge from the hospital and the subsequent 6 to
12weeks 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. A 2-week postpartum visit mainly to assess mood is becoming the
standard of care.
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 that is initially reddish in color
and consists of blood, decidua, and epithelial cells and then becomes thicker and
yellow-white as leukocytes predominate.
PREECLAMPSIA: A pregnancy complication characterized by high blood pressure and signs of damage to another organ system, most often the kidneys (proteinuria). Preeclampsia usually begins after 20 weeks of pregnancy in women
whose blood pressure had been normal. It can present postdelivery, although less
commonly.
CLINICAL APPROACH POSTPARTUM WELLNESS
Inpatient Care of the Postpartum Patient
The 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, allows further monitoring for maternal and neonatal complications, and
can be used to provide education and support. 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 regular diet,
perineal and bladder care, establishing a bowel regimen, addressing postpartum
blues, and providing breastfeeding support.
Common Problems. Typical maternal problems that occur during this time frame
include pain, bleeding, lactation difficulties, and urinary problems (infections,
incontinence, and retention). Postpartum fever is most often a sign of endometritis (infection of the uterus), but it can also be caused by urinary tract or wound
infections, thromboembolic disease, and mastitis. Endometritis and mastitis are
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the most common postpartum infections and typically will present prior to the
6-week postpartum visit. Preeclampsia can present in the postpartum period, usually within 1 week but up to 4 weeks.
Discharge Instructions. Prior to discharge, women should be instructed on normal
physiological 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 should receive the combined
measles-mumps-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. Rh status must also be addressed. If the mother is Rh negative and the infant confirmed to be Rh positive, then the mother should receive
Rho(D) immune globulin (RhoGAM) in order to reduce the risk of isoimmunization affecting future pregnancies.
Normal Physiological Changes
Uterine Changes. The uterus increases significantly in size and weight during pregnancy. Immediately after delivery it weighs approximately 1 kg, is the size of a
uterus at 20 weeks’ gestation (fundus palpable at the umbilicus), and begins the
process of involution, the return to its nonpregnant size. Contractions of the uterus,
promoted by endogenous oxytocin secretion, improve hemostasis by compressing
the uterine blood vessels. Oxytocin release increases during breastfeeding, so early
breastfeeding is encouraged to assist involution. Supplemental oxytocin (Pitocin)
given by intravenous infusion during or immediately after the third stage of labor
also aids in increasing uterine tone. By the end of the first postpartum week, the
uterus will be about the size of a 12-week gestation and palpable at the symphysis
pubis; in most cases, it will return to normal size (weighing less than 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. 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 breastfeeding, menstruation usually
restarts by the third postpartum month. In women who are breastfeeding, ovulation and menstruation can be suppressed for much longer. Anovulation will persist
for longer periods of time in women who exclusively breastfeed their babies. This
confers a contraceptive benefit but, by itself, is not as reliable as other methods of
contraception.
Breast Changes. 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 breastfeeding, the use of ice packs, supportive bras, and nonsteroidal anti-inflammatory drugs (NSAIDs) can reduce
discomfort.
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CLINICAL APPROACH TO MEDICAL COMPLICATIONS
Hemorrhage
Pathophysiology. Postpartum hemorrhage is defined as loss of more than 500 mL of
blood after vaginal delivery and 1000 mL following a cesarean delivery. This occurs
in about 4% of vaginal deliveries. Early postpartum hemorrhage occurs within
24 hours of delivery and is most often immediately postpartum. Late postpartum
hemorrhage occurs between 24 hours and 12 weeks after delivery and is usually the
result of retained tissue or 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 and Prevention. 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.
General Treatment. As with all emergency situations, the first priority in
managing postpartum hemorrhage is assessment of cardiopulmonary stability.
It is important to ensure that adequate intravenous access is available, preferably two large-bore intravenous 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. Uterine atony causes approximately 70% of postpartum hemor-
rhage. 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 methylergono-
vine (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
Table 26–1 • THE FOUR Ts OF POSTPARTUM HEMORRHAGE
Tone Uterine atony
Trauma Cervical, vaginal, or perineal lacerations; uterine inversion
Tissue Retained placenta or membranes
Thrombin Coagulopathies
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women with asthma. Misoprostol has limited use due to high gastrointestinal and
other side effects.
Trauma. Trauma (lacerations, hemotomas, and inverted uterus) causes approxi-
mately 20% of bleeds and is managed procedurally. Retained placenta causes approxi-
mately 10% of bleeds and is also managed procedurally. Coagualopathies cause
approximately 1% of bleeds and require clotting factor replacement for management.
Fever
Postpartum Fever. Postpartum fever, especially if associated with uterine tenderness
and foul-smelling lochia, is often a sign of endometritis. Endometritis complicates
approximately 10% of 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.
Urinary Tract Infection. 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.
Mastitis. Breast infections such as mastitis may occur as well. Symptoms include
breast engorgement, erythema, induration, and tenderness. Prompt treatment with
continued breastfeeding 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. 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.
Postpartum Preeclampsia
Up to 5% of preeclampsia can present in the postpartum period, usually within
1week but up to 4 weeks after delivery. Symptoms and signs include headaches,
right upper quadrant abdominal pain, edema, blurry vision, elevated blood pressure, and proteinuria. These patients should have their blood pressure treated and,
if they have severe features, should be sent urgently back to the labor floor for
postpartum magnesium treatment.
Mood Disorders
Up to three-fourths of women have some change in mood following the delivery of
a child. In most cases, the symptoms are mild and self-limited. However, a small but
significant percentage can have a severe reaction requiring medical or psychiatric
intervention.
Baby Blues. Approximately 30% to 70% of women develop a temporary state
known as the “baby blues.” This condition develops within the first week after
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delivery and typically resolves by the 10th postpartum day. Symptoms include
tearfulness, sadness, and emotional lability. 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 as
a mother.
Postpartum Depression. Postpartum depression occurs in 10% to 20% of
women following pregnancy and can occur following gestations of any length—
term, preterm, miscarriages, or abortions. The onset is defined by the Diagnostic
and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as occurring
within 4weeks’ postpartum, but it may occur as late as 1 year postpartum. Up
to 50% of “postpartum” major depressive episodes may actually begin prior to
delivery. The symptoms of postpartum depression are the same as those of major
depression (see Case25). 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 is 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-week and 6-week
postpartum visits.
The treatment of postpartum depression 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 breastfeeding. Counseling
and general supportive measures at home are also important adjuncts to treatment.
Postpartum Psychosis. 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.
CLINICAL APPROACH TO BREASTFEEDING
Benefits of Breastfeeding. Counseling and encouragement regarding both the
maternal and infant benefits of breastfeeding should start during the prenatal
period. Neonatal benefits include ideal nutrition, increased resistance to infection, and a reduced risk of gastrointestinal tract infections, food allergies, ear
infections, and atopic dermatitis. Maternal benefits include improved motherchild bonding, more rapid uterine involution, quicker return to prepregnant body
weight, convenience, decreased costs, and long-term reduced risks of ovarian and
breast cancer. Breastfeeding promotion and education can increase the rate of
breastfeeding and the duration for which women breastfeed their babies (see
Table 26–2).
Initial Feedings. Women should be allowed to nurse their newborns as soon
as possible following delivery. During this time, the newborns are often very
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Table 26–2 • TEN STEPS FOR SUCCESSFUL BREASTFEEDING
1. Have a written breastfeeding policy that is regularly communicated to all health care staff.
2. Train all staff in skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of breastfeeding.
4. Help mothers initiate breastfeeding within an hour of birth.
5. Show mothers how to breastfeed and how to sustain lactation, even if they are separated from
their infants.
6. Feed newborn infants nothing but breast milk, unless medically indicated, and under no
circumstances provide breast milk substitutes, feeding bottles, or pacifiers free of charge or
at low cost.
7. Practice rooming-in, which allows mothers and infants to remain together 24 hours a day.
8. Encourage breastfeeding on demand.
9. Give no artificial pacifiers to breastfeeding infants.
10. Help start breastfeeding support groups and refer mothers to them.
Reproduced with permission, from Cunningham F, Leveno KJ, Bloom SL, et al, eds. Williams Obstetrics. 25th ed. 2018.
http://accessmedicine.mhmedical.com. Copyright © McGraw Hill LLC. All rights reserved.
alert and have strong rooting and sucking reflexes, which promote latching on
to the nipple. Initial feedings provide colostrum, a yellow fluid that is rich in
immunoglobulin A, minerals, amino acids, and proteins. Breast engorgement
and milk letdown commonly occur between the second and fourth postpartum
days. Mature milk contains fats, proteins, carbohydrates, vitamins, minerals, and
hormones.
Contraindications. There are few contraindications to breastfeeding, but they
include HIV infection, miliary tuberculosis, acute hepatitis B, herpetic breast
lesions, and chemotherapy. Substance use disorders with substances such as
cocaine, heroin, PCP (phencyclidine), and alcohol are contraindications. Women
who have had breast-reduction surgery with nipple transplantation will be unable
to breastfeed.
Complications. Common maternal complications of breastfeeding 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, 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.
CLINICAL APPROACH TO FAMILY PLANNING
Most women resume sexual activity by 3 months’ postpartum, and pelvic rest is recommended for the first 6 weeks. 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.
Hormonal Contraception. OCPs are the most widely used reversible form of contraception. Available OCPs contain both estrogen and progestin or are progestin
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only. In breastfeeding women, the progestin-only pills are preferred because combi-
nation OCPs might reduce lactation. Both the American College of Obstetricians
and Gynecologists and the World Health Organization recommend waiting for
30 days postpartum to start estrogen-containing OCPs. Progesterone-only pills,
injectable long-acting depot medroxyprogesterone (Depo-Provera), progestineluting birth control implants, and any intrauterine device (IUD) may be used in
the immediate postpartum period by breastfeeding women. IUDs have a significant risk of expulsion if placed prior to 6 weeks’ postpartum.
Barrier Contraception. Barrier methods of contraception may also be used
regardless of breastfeeding status. While not widely used, diaphragms and cervical
caps must be refitted at the 6-week visit to ensure an appropriate fit since the cervix
has changed in size and shape.
Breastfeeding as Contraception. Lactation-induced amenorrhea provides a high
level of natural contraception in the first 6 months’ postpartum. However, this pro-
tection wanes if breastfeeding is reduced or if menses restart. As ovulation precedes
the return of menses, this method should not be considered as reliable as other
methods. After 6 months, if menses restart or if breastfeeding is reduced, alternate
forms of contraception should be used.
CASE CORRELATION
See also Case 25 (Major Depression and Other Mood Disorders) and
Case 28 (Family Planning—Contraceptives).
COMPREHENSION QUESTIONS
26.1 You are on call for your practice and receive a page to speak to a 20-year-
old woman who delivered a 6 lb, 9 oz baby boy 3 days ago. When you talk
to the patient, she reports passing bright red blood and blood clots, requiring more than two heavy pads per hour over the past 2 days. She is awake
and talking but feels dizzy. You arrange for transportation to the hospital. In
the emergency center, the patient appears slightly confused but responds to
instructions. Her blood pressure is noted to be 90/60 mm Hg, and her pulse
is 110 beats/min. Which of the following is your most appropriate initial
intervention?
A. Add 20 units of oxytocin (Pitocin) to the intravenous line of 0.45% saline
that is currently running at 125 mL/h.
B. Perform bimanual uterine massage.
C. Place a large-bore intravenous line and give a 1-L bolus of 0.9% saline.
D. Give an intramuscular injection of methylergonovine (Methergine).
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