UNIT TWO: OBSTETRICS

SECTION A: NORMAL OBSTETRICS

OBJECTIVE 13: POSTPARTUM CARE

Rationale: Knowledge of normal postpartum events allows appropriate care, reassurance and
early recognition of abnormal events.

The student will be able to describe:

A. Normal maternal physiologic changes of the postpartum period
B. Normal postpartum care
C. Appropriate postpartum patient counseling
I. Definition
A. Care during period of confinement and after birth
B. Generally up to 6-8 wk. postpartum
C. Reproductive tract and physiologic changes of pregnancy regress
II. Normal maternal physiologic changes
A. Uterus
• At term 1000 g; volume 5000 mL
• In pelvis at 2 wk.
• Non-pregnant size by 4-6 wk.
• Changes due to autolysis of intracellular myometrial proteins, therefore,
decrease in cell size, not number
B. Endometrium
• Decidua basalis regenerates
• Complete by 3 wk.
C. Placental site
• Complete extrusion by 6 wk.
• Mechanism – exfoliation and endometrial regrowth
• May see increased lochia 2-3 wk. after delivery due to sloughing
placental site eschar
D. Uterine vessels
• Caliber of extrauterine vessels decreases by 50%
• Uterine vessels hyalinize and are reabsorbed
E. Cervix and lower uterine segment
• Contraction leaving wider external os
• Lower segment regresses
• By 1 wk. only admits one finger
F. Vagina and perineum
• Rugae reappear about 3 wk.
• Hymeneal scarring – myrtiform caruncles
• Vaginal relaxation
• Uterine prolapse – usually regresses
G. Abdominal wall
• Peritoneal wrinkling and folding initially
• Pelvic ligaments recover slowly
• Silvery striae lighten with time
• Initial muscle laxity, improves with exercise
• Diastasis recti
H. Urinary tract
• Bladder mucosa trauma – edema, hyperemia, extravasation of blood
• Increased capacity, hypotonia and decreased sensitivity can lead to
overdistension
• Residual urine common after regional anesthesia
• Ureter and renal pelvis dilation regress by 6-8 wk.

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 • Stress incontinence in about 7%, usually regresses by 3 mo.
III. Changes in maternal physiology
A. Cardiovascular
• Normalizes by 2-3 wk.
• Plasma volume drops 1000cc immediately postpartum
• Cardiac output drops
• Pulse rate drops
B. Hematopoietic – leukocytosis persists for several days
IV. Clinical aspects of the puerperium
A. Temperature
• Milk fever – vascular and lymphatic engorgement
• Presumptive evidence of infection until excluded
B. Afterbirth pains
• Hypertonic uterine contractions in first 3 days
• Worse with multiparity and breast feeding
• Analgesics
C. Lochia
• Constituents – erythrocytes, decidua, epithelial cells and bacteria
• Lochia rubra – days 1-3
• Lochia serosa – by days 4-10
• Lochia alba – after day 10
• Heavy or persistent warns of infection or retained placental tissue
D. Urine
• Physiologic diuresis of extravascular fluid after 2-5 days
• Lactosuria
E. Blood
• Leukocytosis
• Hematocrit decreases
• Volume non pregnant by 2 wk.
F. Weight loss
• Immediate – 5-6 kg
• Week – 2-3 kg
• Non-pregnant – 6 mo.
• Prenatal weight gain inversely related to excess non-pregnant weight
V. Normal postpartum care
A. Immediate care
• Monitor blood pressure
• Uterine contraction – watch for atony
• Vaginal bleeding – atony or genital trauma
• Post-anesthesia recovery
B. Ambulation
• Initially with assistance
• Avoids urinary retention and constipation

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 • Prevents puerperal venous thromboses and pulmonary emboli
C. Vulva and perineum
• Cleansing properly
• Ice packs initially
• Local heat or sitz bath
D. Bladder function
• Watch closely for involuntary retention
• Periurethral trauma or hematoma
• Void by 4 hr. or insert Foley catheter
E. Bowel function
• Constipation common 1-2 days
• Stool softener
• Fourth degree perineal injury
F. Discomfort
• Systemic analgesics every 3-4 hr.
Codeine 60 mg
Aspirin 600 mg
Acetaminophen 500 mg
• Perineal topical anesthetics
Minimal benefit
Episiotomy pain and healing over by 3 wk.
G. Postpartum depression
• Distinct diagnosis
• Often prenatal depression
• Adjustment reaction
• Transient depression – postpartum blues for 2-3 days and less than 10
days
H. Abdominal wall relaxation
• Abdominal binder unnecessary
• Girdle
• Exercise
I. Diet
• Nonrestrictive
• Breastfeeding – increase protein and calories
• Iron supplementation – 3 mo.
J. Immunizations
• Anti-D (passive)
• Rubella – live, attenuated (if non-immune)
• Tetanus toxoid (if > 10 yr. since last shot)
• Measles (if susceptible)
• Hepatitis B (if susceptible)
K. Timing of discharge
• When physically, mentally and emotionally ready
• Vaginal delivery – 48 hr. (sometimes less)

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 • Cesarean delivery – 3-4 days
• Early discharge – encourage in multiparous
L. Contraception
• Begin consideration in hospital
• 15% non-nursing women fertile by 6 wk. postpartum
• Coitus – permissible at 2-3 wk.
Risk of infection
Discomfort or injury
Decreased sexual satisfaction for up to a year
Breastfeeding
– Vaginal dryness
– Decreased arousal and vaginal lubrication
– Water-based vaginal lubricant recommended
M. Ovulation and menstruation
• Menses within 6-8 wk.
• Breastfeeding – 2-18 mo. to menses
• Amenorrhea of lactation due to lack of ovarian stimulation by low FSH
and LH
N. Follow-up care
• Infant
• No activity restrictions
• Many resume work in 2-6 wk.
• Examination at 2-3 wk.
Physical examination
Contraceptive counseling
Cervical cytology screening

References

(*Texts targeted at medical students and general women’s health care providers)

*Beckmann CRB, Ling FW. “Postpartum care” in Obstetrics and Gynecology 4th ed., 2002;
chapter 10: 151-163.

* Beckmann CRB, Ling FW. “Contraception” in Obstetrics and Gynecology 4th ed., 2002;
chapter 25: 327-346.

*Beckmann CRB, Ling FW. “Sterilization” in Obstetrics and Gynecology 4th ed., 2002; chapter
26: 347-355.

*Boardman A. “The puerperium” in Ling FW, Duff P. Obstetrics & Gynecology Principles and
Practices, 2001: chapter 22: 545-571.

Cunningham FG, Gant NR, Leveno KJ, Gilstrap LC, Hauth JC, Wenstrom KD. “The
puerperium” in Williams Obstetrics, 21st ed, 2001: chapter 17: 403-421.

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Cunningham FG, Gant NR, Leveno KJ, Gilstrap LC, Hauth JC, Wenstrom KD. “Obstetrical
hemorrhage” in Williams Obstetrics, 21st ed., 2001: chapter 25: 619-669.

Cunningham FG, Gant NR, Leveno KJ, Gilstrap LC, Hauth JC, Wenstrom KD. “Puerperal
infection” in Williams Obstetrics, 21st ed., 2001: chapter 26: 671-688.

Cunningham FG, Gant NR, Leveno KJ, Gilstrap LC, Hauth JC, Wenstrom KD.
“Sterilization” in Williams Obstetrics, 21st ed, 2001: chapter 59: 1555-1562.

Bowes WA, Katz VL. “Postpartum care” in Gabbe SG, Obstetrics Normal and Problem
Pregnancies, 4th ed., 2001: chapter 21: 701-726.

Newton ER. “Physiology of lactation and breastfeeding” in Gabbe SG, Obstetrics Normal and
Problem Pregnancies, 4th ed., 2001: chapter 5: 105-136.

Adapted from Association of Professors of Gynecology and Obstetrics Medical Student Educational Objectives, 7th edition,
copyright 1997.