23.5 Postpartum Care & Complications: Normal Puerperium, Postnatal Visits, Breastfeeding, Puerperal Fever and Infection, Mastitis, Late Hemorrhage, Mood Disorders, VTE and Postpartum Contraception

Why this area matters

TOS area K asks you to:

• identify illnesses and complications of the postpartum period;
• correlate the signs of common morbidity and causes of death after delivery;
• plan prompt postpartum care: follow-up schedule, repeat laboratory tests, breastfeeding, early latching and late cord clamping;
• diagnose complications early, including by the syndromic approach.

Most maternal deaths occur in the first days after birth, mostly from hemorrhage, hypertensive disorders and sepsis. A woman who goes home within 24 hours needs to know the danger signs and when to return.

The normal puerperium

• Duration: the puerperium lasts 6 weeks after delivery.
• Uterine involution:
  • the fundus is at about the umbilicus right after delivery;
  • it descends about 1 cm (one fingerbreadth) per day;
  • it is no longer palpable abdominally by about 2 weeks;
  • it returns almost to its pre-pregnancy size by 6 weeks.
• Afterpains from contractions are stronger in multiparas and during breastfeeding, because of oxytocin.
• Lochia:
  • rubra (red) for the first 3 to 4 days;
  • serosa (pink-brown) until about day 10;
  • alba (yellowish-white) for up to 6 weeks.
  • Foul-smelling lochia suggests infection, and heavy fresh bleeding after the first week suggests retained products or subinvolution.
• Physiologic changes:
  • diuresis in the first days;
  • a fall in blood volume;
  • rapid fall of hCG, estrogen and progesterone;
  • a rise in prolactin.
  • Menses return at about 6 to 8 weeks in women who do not breastfeed. Ovulation can occur before the first period.
• Early care in the first 24 hours:
  • check vital signs, uterine tone and bleeding frequently for the first 2 hours, then regularly;
  • encourage early ambulation and voiding;
  • check hemoglobin if blood loss was significant;
  • give anti-D to Rh-negative mothers of Rh-positive babies;
  • give rubella vaccine to nonimmune mothers;
  • continue iron-folic acid supplementation for up to 3 months.

Postnatal visits and danger signs

• Visit schedule (WHO): within 24 hours, on day 3, at 1 to 2 weeks and at 6 weeks. The 6-week visit reviews recovery, mood, blood pressure, glucose (OGTT after gestational diabetes), breastfeeding, family planning and immunizations.
• Danger signs that need immediate care:
  • heavy bleeding or large clots;
  • fever;
  • foul discharge;
  • severe headache, blurred vision or convulsions;
  • difficulty breathing or chest pain;
  • calf pain and swelling;
  • painful, red breasts;
  • severe abdominal pain;
  • thoughts of self-harm.

Breastfeeding

• Essential intrapartum and newborn care (EINC):
  • immediate and thorough drying;
  • early skin-to-skin contact;
  • delayed cord clamping (1 to 3 minutes), which improves the infant's iron stores;
  • non-separation of mother and baby;
  • breastfeeding initiated within the first hour, when the baby shows feeding cues.
• Recommended duration: exclusive breastfeeding for 6 months, then continued breastfeeding with complementary foods to 2 years and beyond.
• Benefits:
  • for the infant: fewer infections, especially diarrhea and pneumonia, and better outcomes;
  • for the mother: less bleeding, lactational amenorrhea, lower breast and ovarian cancer risk and less diabetes.
• Philippine laws:
  • the Milk Code (EO 51, 1986) restricts marketing of breastmilk substitutes;
  • RA 10028 (Expanded Breastfeeding Promotion Act of 2009) requires lactation stations and lactation breaks in workplaces;
  • RA 11210 (2019) grants 105 days of paid maternity leave.
• True contraindications are few:
  • classic galactosemia in the infant;
  • certain drugs such as chemotherapy and radioactive agents;
  • illicit drug use;
  • herpes lesions on the breast (feed from the other breast);
  • untreated active TB: the mother and infant are separated, and expressed milk is given, until she is no longer infectious (about 2 weeks of treatment);
  • HIV, where safe replacement feeding is available. In many settings, WHO supports breastfeeding with ART.
• Common problems:
  • sore nipples, usually from a poor latch;
  • engorgement: frequent feeding, expressing milk and cold compresses;
  • low milk supply: frequent feeding and correct positioning.

Puerperal infection and fever

Postpartum fever has a classic differential, the "5 Ws":

• womb: endometritis, days 2 to 3;
• wind: atelectasis or pneumonia, day 1;
• water: urinary tract infection;
• wound: cesarean or episiotomy infection, days 4 to 7;
• walking: deep vein thrombosis. Breast problems, drug fever and septic pelvic thrombophlebitis are added to the list.

Infections:

• Postpartum endometritis:
  • the most common puerperal infection, especially after cesarean delivery, prolonged labor and rupture of membranes, or retained tissue;
  • fever, uterine tenderness and foul lochia;
  • polymicrobial (anaerobes, streptococci, Gram-negatives);
  • treated with IV clindamycin plus gentamicin until the patient is afebrile for 24 to 48 hours;
  • prevented by prophylactic cefazolin before cesarean incision.
• Wound infection, necrotizing fasciitis and pelvic abscess need drainage. Group A streptococcal sepsis can progress rapidly to toxic shock.
• Septic pelvic thrombophlebitis causes persistent fever despite antibiotics and responds to anticoagulation.
• Maternal sepsis is managed with the first-hour sepsis bundle.

Breast complications

• Lactational mastitis:
  • a red, painful, warm wedge of breast with fever and myalgia, usually in the first weeks;
  • most often S. aureus;
  • management is continued breastfeeding or emptying of the breast, analgesia and dicloxacillin, flucloxacillin or cephalexin, or clindamycin or another MRSA-active drug if needed;
  • stopping breastfeeding worsens stasis.
• Breast abscess: a fluctuant, tender mass. Treat by needle aspiration under ultrasound or incision and drainage.

Other postpartum complications

• Secondary (late) PPH (24 hours to 12 weeks): caused by retained products, subinvolution or endometritis, and rarely by GTN or arteriovenous malformation.
• Postpartum blues: affect most mothers. Tearfulness and mood swings peak at about days 3 to 5 and resolve within 2 weeks. Reassurance and support are enough.
• Postpartum depression: lasts more than 2 weeks and impairs function and infant care. Screen with the Edinburgh Postnatal Depression Scale. Treat with psychotherapy and SSRIs such as sertraline, which are compatible with breastfeeding.
• Postpartum psychosis: usually within 2 weeks, with confusion, delusions and hallucinations. It is linked to bipolar disorder. It is an emergency with a risk of suicide and infanticide, and needs hospitalization.
• Venous thromboembolism: risk is highest postpartum, especially after cesarean delivery. Encourage early mobilization and use LMWH prophylaxis for women at risk.
• Sheehan syndrome: pituitary necrosis after severe PPH and shock. The first sign is failure of lactation, followed by amenorrhea, hypothyroidism and adrenal insufficiency.
• Postpartum preeclampsia, peripartum cardiomyopathy, urinary retention, incontinence, fistula and perineal pain are also assessed at visits.

Postpartum family planning

The DOH recommends spacing births by 3 to 5 years. Postpartum family planning is counseled before discharge:

• Lactational amenorrhea method: fully breastfeeding, no menses and an infant under 6 months.
• Postpartum IUD: within 48 hours, or after 4 weeks.
• Progestin-only methods: can start immediately.
• Combined hormonal contraceptives: delayed until 6 weeks in breastfeeding women, and 21 days in non-breastfeeding women without VTE risk factors.
• Tubal ligation after counseling.