Postpartum care

Author: Anne McPherren Stover, Janet Griffith Marnejon
Date: Oct, 1995

The puerperium is considered to be the period of time after delivery when the physiologic changes of pregnancy resolve, generally by the sixth week postpartum. However, the postpartum period can be defined to include changes in all aspects of the mother's life that occur in the first year following delivery.

The content of postpartum care varies, particularly the care given after hospital discharge.[1] Traditionally, attention has been given to the biologic aspects of care while the mother and newborn are hospitalized for a few days, followed by an examination six weeks after delivery. This pattern is becoming less satisfactory as women spend less time in the hospital after delivery. Several studies have documented the safety, for both mother and infant, of hospital discharge within less than 48 hours, or even within less than 24 hours, following uncomplicated vaginal delivery.[1,2] Women who have undergone cesarean section often are discharged 48 to 72 hours after delivery. Early hospital discharge necessitates a shift of maternal and infant care to the primary care sector, as well as to the woman's family and friends.[1]

Virtually all feasibility studies of early discharge programs following delivery include plans for early follow-up.[1,2] The American Academy of Pediatrics guidelines emphasize the importance of a visit specifically for examination of the infant 48 hours after discharge.[3] Even if such a visit is not indicated, an office visit, a visit with a home nurse or phone follow-up within the first week is an opportunity for the exchange of valuable information between the parents and the physician, especially for first-time and nursing mothers.

The family physician often enjoys the unique opportunity to care for both the mother and her infant. Family physicians who provide prenatal care should begin educating parents about postpartum issues during prenatal visits. Well-child visits can be an optimal time to assess the health of both the infant and parents.

The amount of information given to new parents during the postpartum hospital stay can be overwhelming. To help mothers with potential information overload, many physicians and some hospitals have developed written materials about maternal and infant care. Brief postpartum hospital stays necessitate a specific plan for follow-up and effective communication with the physician. Supportive listening, anticipatory education and helping the patient develop realistic expectations will prove most helpful in allaying both immediate and long-term concerns.

Table 1 provides the titles of various books, pamphlets and videos that may be useful to new mothers.

TABLE 1Information for New MothersPamphlets

Issues of the Early Postpartum Period

BREAST ENGORGEMENT AND LACTATION SUPPRESSION

Breast engorgement usually occurs during the first week postpartum. In lactating mothers the remedy is frequent infant feedings with pumping just before feeding, to soften the breast so the infant can latch on more effectively.

In nonlactating women, breast engorgement is a self-limited phenomenon that disappears as increasing estrogen levels suppress milk formation. Treatment consists of having the patient apply ice packs, wear a supportive bra and take mild anal gesics such as acetaminophen. Most studies of pharmacologic methods of lactation suppression have focused on either various sex steroids or bromocriptine (Parlodel). Well-designed studies on methods of lactation suppression are lacking.[10] Recently, the pharmaceutical company that produces bromocriptine voluntarily stopped marketing this drug for lactation suppression because of litigation claiming drug side effects of stroke, heart attack and seizures.[11]

BREAST FEEDING

Breast feeding constitutes a significant adjustment in the postpartum period. It is important to offer support to nursing mothers by referring them to appropriate resources. Physicians also must be knowledgeable about ways to promote success in the skill of breast feeding.[12,13]

PERINEAL CARE

Discomfort due to an episiotomy or hemorrhoids is an immediate and potentially long-term problem. General perineal discomfort and dyspareunia may persist for up to three months postpartum.[14]

In the immediate postpartum period, perineal care includes topical therapy with ice packs and warm-water cleansing. The astringent witch hazel (Tucks Pads, Tucks Clear Gel) and topical anesthetics like benzocaine (Dermoplast, Americaine) give some relief.[15]

Hemorrhoid care consists of increased fluid intake and stool softeners such as docusate sodium (Colace, Dialose) to prevent further problems. Symptoms may be relieved with warm sitz baths (10 to 20 minutes two or three times daily) and anesthetic / antipruritic medications (Anusol Hemorrhoidal Ointment, ProctoFoam).[16] Acetaminophen or ibuprofen may be taken orally for pain relief, since little of either drug is excreted in breast milk.

RESUMPTION OF SEXUAL INTERCOURSE

Although couples may be reluctant to ask, they often want to know when they can safely resume sexual intercourse. Advising resumption after bright-red bleeding has stopped and the perineum is comfortable is reasonable. Women with perineal incisions or lacerations should wait at least three weeks after delivery.

The woman's personal readiness may preclude resumption of intercourse for a longer period.[8,17] The physician should be mindful of this issue and should offer anticipatory information to the couple, which may help prevent turmoil at home and distress calls to the office. Precoital vaginal lubrication may be impaired in the postpartum period, especially in women who are breast feeding. Use of water-based gel lubricants (KY Jelly, Surgilube) can be helpful.

CONTRACEPTION

Infertility due to anovulation lasts from five weeks in nonlactating women to eight or more weeks in women who breast feed their infants without supplementation.[18] Contraception should be discussed before hospital discharge, but a new mother may not be ready for a lengthy discussion during her hospital stay.[7] It may be more appropriate to ask her to think about contraceptive needs and preferences and advise her to use a barrier method (condom with spermicidal gel or foam) until another form of birth control is chosen. This advice is especially important if follow-up will not occur for six weeks or more.

Nonlactating mothers may resume use of oral contraceptive agents two weeks after delivery[19] A wait of at least two weeks is generally advised in an effort to reduce the incidence of phlebitis in the postpartum period. Nursing mothers should wait four weeks after delivery to begin oral contraceptives, to allow establishment of milk supply.[20] Diaphragm fitting/refitting should be performed at or after six weeks, to allow for resolution of pregnancy-induced changes in pelvic anatomy. Levonorgestrol (Norplant), medroxyprogesterone (Depo-Provera) and intrauterine devices are also effective contraceptive alternatives. Fewer side effects are encountered with these methods when they are started after uterine involution is complete.

POSTPARTUM DEPRESSION

A common experience for new mothers is a period of mildly depressed mood that occurs within one week after delivery. Symptoms may vary and may include mood swings, difficulty with concentration and sleep, and negative feelings toward the infant. The mother continues to be able to function and will generally note spontaneous resolution within one to two weeks. Mothers are best served by an anticipatory explanation and support from their physician and family members. More severe depression is distinguished by greater functional impairment and longer duration of symptoms.[21]

Issues of the Later Postpartum Period

MASTITIS

Mastitis may occur in nursing mothers. It is often associated with nipple irritation, cracks or fissures. Breast infection begins several weeks to months postpartum, and the patient characteristically presents with fever, malaise and localized breast signs (warmth, redness and tenderness). Symptoms and signs vary from mild to severe; severe symptoms suggest the possibility of abscess. Culture of breast milk is recommended by some authorities, although it is recognized that culture results will rarely affect management.[22]

Empiric antibiotic therapy should eradicate Staphylococcus aureus. A 10-day course of a penicillinase-resistant penicillin, such as dicloxacillin (Pathocil) in a dose of 250 to 500 mg every six hours, or a first-generation cephalosporin, such as cephalexin (Keftab) in a dose of 250 to 500 mg every six hours, is recommended.[23] Women should ensure regular emptying of both breasts, either by nursing (which has no adverse effect on the infant) or pumping if the infected breast is too sore for breast feeding. Significant clinical improvement is common within 48 hours after beginning antibiotic therapy.

[1.] Rush J, Chalmers I, Enkin M. Care of the new mother and baby. In: Enkin M, Keirse M, Chalmers I, eds. A guide to effective care in pregnancy and childbirth. New York: Oxford University Press, 1989:1433-46. [2.] Welt SI, Cole JS, Myers MS, Sholes DM Jr, Jelovsek FR. Feasibility of postpartum rapid hospital discharge: a study from a community hospital population. Am J Perinatol 1993;10:384 7. [3.] Guidelines for perinatal care. 3d ed. Elk Grove Village, Ill.: American Academy of Pediatrics, American College of Obstetricians and Gynecologists, 1992:108-16. [4.] Gjerdingen DK, Fontaine P. Family-centered postpartum care. Fam Med 1991;23:189-93. [5.] Romito P. Unhappiness after childbirth. In: Enkin M, Keirse M, Chalmers I, eds. A guide to effective care in pregnancy and childbirth. N- w York: Oxford University Press, 1989:1333-46. [6.] Gjerdingen DK, Froberg DG, Fontaine P. The effects of social support on women's health during pregnancy, labor and delivery, and the postpartum period. Fam Med 1991;23:370 5. [7.] Guidelines for health supervision II. 2d ed. Elk Grove Village, Ill.: Committee on Psychosocial Aspects of Child and Family Health, American Academy of Pediatrics, 1988:19-40. [8.] Bowes WA Jr. The puerperium and its complications. Curr Opin Obstet Gynecol 1990;2:780-4. [9.] Depp R. Cesarean section and other surgical procedures. In: Gabbe SG, Niebyl JR, Simpson JL, eds. Obstetrics: normal and problem pregnancies. 2d ed. New York: Churchill Livingstone, 1991:666. [10.] Parazzini F, Zanaboni F, Liberati A, et al. Relief of breast symptoms in women who are not bleastfeeding. In: Enkin M, Keirse M, Chalmers [, eds. A guide to effective care in pregnancy and childbirth. New York: Oxford University Press, 1989:1390-1402. [11.] Drug newsletter/Facts and comparisons 1994;13(10). [12.] Bedinghaus JM, Melnikow J. Promoting successful breast-feeding skills. Am Fam Physician 1992; 45:1309-18. [13.] Stashwick CA. Overcoming obstacles to breastfeeding. Patient Care 1994;28:88-112. [14.] Winikoff B, Mensch B. Rethinking postpartum family planning. Stud Fam Plan 1991;22:294-3C7. [15.] Grant A, Sleep J. Relief of perineal pain and discomfort after childbirth. In: Enkin M, Keirse M, Chalmers I, eds. A guide to effective care in pregnancy and childbirth. New York: Oxford University Press, 1989:1347-59. [16.] Benson have any questions or concerns? 8th ed. Los Altos, Calif.: Lange, 1983:683-4. [17.] Reamy K, White SE. Sexuality in pregnancy and the puerperium: a review. Obstet Gynecol Surv 1985;40:1-13. [18.] Perez A, Vela P, Masnick GS, Potter RG. first ovulation after childbirth: the effect of breast-feeding. Am J Obstet Gynecol 1972;114:1041-7. [19.] Hume AL, Hijab JC. Oral contraceptives in the immediate postpartum period. J Fam Pract 1991;32(4):423-5. [20.] Briggs GG, Freeman RK, Yaffe SJ, eds. Drugs in pregnancy and lactation: a reference guide to fetal and neonatal risk. 3d ed. Baltimore: Williams & Wilkins, 1990:468. [21.] Bright DA. Postpartum mental disorders. Am Fam Physician 1994;50:595-8. [22.] Gibbs RS, Sweet RL. Clinical disorders. In: Creasy RK, Resnik R. Maternal-fetal medicine: principles and practice. 2d ed. Philadelphia: Saunders, 1989:674-5. [23.] Sanford JP, Gilbert DN, Gerberding J, et al. The Sanford guide to antimicrobial therapy, 1994. Dallas: Antimicrobial Therapy, 1994:1,50,52. [24.] Bowes WA. Postpartum care. In: Gabbe SG, Niebyl JR, Simpson JL, eds. Obstetrics: normal and problem pregnancies. 2d ed. New York: Churchill Livingstone, 1991:753-79. [25.] Druelinger L. Postpartum emergencies. Emerg Med Clin North Am 1994-12:219-34. [26.] Briggs GG, Freeman RK, Yaffe SJ. Drugs in pregnancy and lactation: a reference guide to fetal and neonatal risk. 3d ed. Baltimore: Williams & Wilkins, 1990:130. [27]. Bygdeman SM, Mardh PA. Antimicrobial susceptibility and susceptibility testing of Mycoplasma hominis: a review. Sex Transm Dis 1983;10(Suppl 4):366-70. 28. Gerstein HC. How common is postpartum thyroiditis? A methodologic overview of the literature. Arch Intern Med 1990;150:1397-400. [29.] Roti E, Emerson CH. Postpartum thyroiditis. J Clin Endocrinol Metab 1992;74:3-5. [30.] Snooks SJ, Swash M, Mathers SE, Henry MM. Effect of vaginal delivery on the pelvic floor: a 5year follow-up. Br J Surg 1990;77:1358-60 [31.] Sultan AH, Kamm MA, Hudson CN. Pudendal nerve damage during labour: prospective study before and after childbirth. Br J Obstet Gynaecol 1994;101:22-8. [32.] MacArthur C, Lewis M, Knox EG, Crawford JS. Epidural anaesthesia and long term backache after childbirth. BMJ 1990;301:9-12.

Each year members of a different medical faculty prepare articles for "Practical Therapeutics." This is the fourth in a series from Northeastern Ohio Universities College of Medicine, Rootstown. Guest editor of the series is Jay C. Williamson, M.D.

ANNE MCPHERREN STOVER, M.D. is currently an assistant professor in the Department of Family Medicine at the Northeastern Ohio Universities College of Medicine, Rootstown. After receiving a medical degree from Oral Roberts University School of Medicine, Tulsa, Okla., Dr. Stover served a family practice residency at St. Elizabeth Hospital Medical Center, Youngstown, Ohio.

JANET GRIFFITH MARNEJON, D.O. is currently an assistant professor in the Department of Family Medicine at the Northeastern Ohio Universities College of Medicine. After graduating from the Philadelphia College of Osteopathic Medicine, Dr. Marnejon served an internship at St. Joseph's Hospital in Philadelphia and completed a family practice residency at St. Elizabeth Hospital Medical Center.

Address correspondence to Anne M. Stover, M.D., Family Health Center, St. Elizabeth Hospital Medical Center, 1053 Belmont Ave., P.O. Box 1790, Youngstown, OH 44501-1790.

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