gynecology and obstetrics
Postpartum Care
Initial Management
Risk of infection, hemorrhage, and excessive pain must be minimized. Women are typically observed for at least 1 to 2 hours after the 3rd stage of labor and for several hours longer if regional or general anesthesia was used during delivery (eg, by forceps, vacuum, or cesarean) or if the delivery was not completely routine. (For further information, see Postpartum Hemorrhage .) Minimizing bleeding is the first priority; measures include Uterine massage Sometimes parenteraloxytocin During the first hour after the 3rd stage of labor, the uterus is massaged periodically to ensure that it contracts, preventing excessive bleeding. If the uterus does not contract after massage alone,oxytocin10 units IM or a diluteoxytocinIV infusion (10 or 20 [up to 80] units/1000 mL of IV fluid) at 125 to 200 mL/hour is given immediately after delivery of the placenta. The drug is continued until the uterus is firm; then it is decreased or stopped.Oxytocinshould not be given as an IV bolus because severe hypotension may occur. If bleeding increases, methergine 0.2 mg IM every 2 to 4 hours ormisoprostol600 to 1000 mcg given orally, sublingually, or rectally once can be used to increase uterine tone. Methergine 0.2 mg orally every 6 to 8 hours can be continued for up to 7 days if needed.Tranexamic acid1 g IV can be given in addition; it must be given within 3 hours of delivery to be effective. For all women, the following must be available during the recovery period Oxygen Type O-negative blood or blood tested for compatibility IV fluids If blood loss was excessive (≥ 500 mL), a complete blood count (CBC) to verify that women are not anemic is required before discharge. If blood loss was not excessive, CBC is not required. After the first 24 hours, recovery is rapid. A regular diet should be offered as soon as women desire food. Full ambulation is encouraged as soon as possible. Exercise recommendations are individualized depending on the presence of other maternal disorders or complications. Usually, exercises to strengthen abdominal muscles can be started once the discomfort of delivery has subsided, typically within 1 day for women who deliver vaginally and later (typically after 6 weeks) for those who deliver by cesarean. Whether pelvic floor (eg, Kegel) exercises are helpful is unclear, but these exercises can begin as soon as the patient is ready. If delivery was uncomplicated, showering and bathing are allowed, but vaginal douching is prohibited. The vulva should be cleaned from front to back. Immediately after delivery, ice packs may help reduce pain and edema at the site of an episiotomy or repaired laceration; sometimeslidocainecream or spray can be used to relieve pain. Later, warm sitz baths can be used several times a day. Nonsteroidal anti-inflammatory drugs (NSAIDs), such asibuprofen400 mg orally every 4 to 6 hours, work effectively on both perineal discomfort and uterine cramping.Acetaminophen500 to 1000 mg orally every 4 to 6 hours can also be used.Acetaminophenandibuprofenappear to be relatively safe during breastfeeding. Many other analgesics are secreted in breast milk. reduces the opioid requirement ( Initial management references ). Some women require opioids to relieve discomfort; the lowest effective dose should be used. If pain is significantly worsening, women should be evaluated for complications such as vulvar hematoma. Urine retention, bladder overdistention, and catheterization should be avoided if possible. Rapid diuresis may occur, especially whenoxytocinis stopped. Voiding must be encouraged and monitored to prevent asymptomatic bladder overfilling. A midline mass palpable in the suprapubic region or elevation of the uterine fundus above the umbilicus suggests bladder overdistention. If overdistention occurs, catheterization is necessary to promptly relieve discomfort and to prevent long-term urinary dysfunction. If overdistention recurs, an indwelling or intermittent catheter may be needed. Women are encouraged to defecate before leaving the hospital, although with early discharge, this recommendation is often impractical. If defecation has not occurred within 3 days, a mild cathartic (eg,psyllium,docusate,bisacodyl) can be given. Avoiding constipation can prevent or help relieve existing hemorrhoids, which can also be treated with warm sitz baths. Women with an extensive perineal laceration repair involving the rectum or anal sphincter can be given stool softeners (eg,docusate). Regional (spinal or epidural) or general anesthesia may delay defecation and spontaneous urination, in part by delaying ambulation. (See also Vaccines During Pregnancy , Women who are seronegative for rubella should be vaccinated against rubella on the day of discharge. Ideally, the Diphtheria-Tetanus-Pertussis Vaccine is given between week 27 and 36 of each pregnancy; the Tdap vaccine helps boost the maternal immune response and passive transfer of antibodies to the neonate. If women have never been vaccinated with the Tdap vaccine (not during the current or a previous pregnancy nor as an adolescent or adult), they should be given Tdap before discharge from the hospital or birthing center, regardless of their breastfeeding status. If family members who anticipate having contact with the neonate have not previously received Tdap, they should be given Tdap at least 2 weeks before they come into contact with the neonate to immunize them against pertussis ( Pregnant women who do not have evidence of immunity should be given the first dose of the varicella vaccine after delivery and the 2nd dose 4 to 8 weeks after the first dose. Additional vaccines may be recommended depending on maternal vaccination and health history. If women with Rh-negative blood have an infant with Rh-positive blood but are not sensitized, they should be given Rho(D) immune globulin 300 mcg IM within 72 hours of delivery to Prevention . Milk accumulation may cause painful breast engorgement during early lactation. Forwomen who are going to breastfeed, the following are recommended until milk production adjusts to the infant's needs: Expressing milk by hand in a warm shower or using a breast pump between feedings to relieve pressure temporarily (however, doing so tends to encourage lactation, so it should be done only when necessary) Breastfeeding the infant on a regular schedule Wearing a comfortable nursing bra 24 hours/day Forwomen who are not going to breastfeed, the following are recommended: Firm support of the breasts to suppress lactation because gravity stimulates the let-down reflex and encourages milk flow Refraining from nipple stimulation and manual expression, which can increase lactation Tight binding of the breasts (eg, with a snug-fitting bra), cold packs, and analgesics as needed, followed by firm support, to control temporary symptoms while lactation is being suppressed Suppression of lactation with drugs is not recommended. Transient depressive symptoms (baby blues) are very common during the first week after delivery. Symptoms (eg, mood swings, irritability, anxiety, difficulty concentrating, insomnia, crying spells) are typically mild and usually subside by 7 to 10 days. 2 weeks or interfere with daily activities or if women have suicidal or homicidal thoughts. In such cases, Postpartum Depression or another mental disorder may be present. During the comprehensive postpartum visit, all women should be screened for postpartum mood and anxiety disorders using a validated tool ( A preexisting mental disorder, including prior postpartum depression, is likely to recur or worsen during the puerperium, so affected women should be monitored closely. 1.Altenau B, Crisp CC, Devaiah CG, Lambers DS: Randomized controlled trial of intravenousacetaminophenfor postcesarean delivery pain control.Am J Obstet Gynecol217 (3):362.e1–362.e6, 2017. doi: 10.1016/j.ajog.2017.04.030 Epub 2017 Apr 25. 2.American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice, Immunization and Emerging Infections Expert Work Group: Committee Opinion No. 718: Update on Immunization and Pregnancy: Tetanus, Diphtheria, and Pertussis Vaccination.Obstet Gynecol130 (3):e153–e157, 2017. doi: 10.1097/AOG.0000000000002301 3.American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice: Committee Opinion No. 757: Screening for Perinatal Depression.Obstet Gynecol130 (3): 132 (5):e208–e212, 2018. doi: 10.1097/AOG.0000000000002927 