For 2 hours after delivery, blood pressure and pulse are taken every 15 minutes, or more frequently if indicated. Temperature is assessed every 4 hours for the first 8 hours and then at least every 8 hours subsequently (American Academy of Pediatrics, 2017). The amount of vaginal bleeding is monitored, and the fundus palpated to ensure that it is well contracted. If relaxation is detected, the uterus should be massaged through the abdominal wall until it remains contracted. Uterotonics are also sometimes required. Blood can accumulate within the uterus without external bleeding. This may be detected early by uterine enlargement during fundal palpation in the first postdelivery hours. Because the likelihood of significant hemorrhage is greatest immediately postpartum, even in normal births, the uterus is closely monitored for at least 1 hour after delivery. Postpartum hemorrhage is discussed in Chapter 41 (Uterine Atony). If regional analgesia or general anesthesia was used for labor or delivery, the mother should be observed in an appropriately equipped and staffed recovery area.
Women are out of bed within a few hours after delivery. An attendant should be present for at least the first time, in case the woman becomes syncopal. The many confirmed advantages of early ambulation include fewer bladder complications, less frequent constipation, and reduced rates of puerperal venous thromboembolism. As discussed in Peritoneum and Abdominal Wall, deep-vein thrombosis and pulmonary embolism are common in the puerperium (see Fig. 36-3). In an audit of puerperal women at Parkland Hospital, the frequency of venous thromboembolism was found to be 0.008 percent after a vaginal birth and 0.04 percent following cesarean delivery. We attribute this low incidence to early ambulation. Risk factors and other measures to diminish the frequency of thromboembolism are discussed in Chapter 52 (Pathophysiology).
There are no dietary restrictions for women who have been delivered vaginally. Two hours after uncomplicated vaginal delivery, a woman is allowed to eat. With breastfeeding, the level of calories and protein consumed during pregnancy are increased slightly as recommended by the Food and Nutrition Board of the National Research Council (Chap. 9, Dietary Reference Intakes—Recommended Allowances). If the mother does not breastfeed, dietary requirements are the same as for a nonpregnant woman. We recommend oral iron supplementation for at least 3 months after delivery and hematocrit evaluation at the first postpartum visit.
As noted earlier, profound drops in estrogen levels follow removal of the placenta. Reminiscent of the menopause, postpartum women may experience hot flushes, especially at night. Importantly, the patient’s temperature is assessed to differentiate these physiological vasomotor events from infection.
In women with migraines, dramatic hypoestrogenism may trigger headaches. Importantly, severe headaches should be differentiated from spinal headache or hypertensive complications. Care varies depending on migraine severity. Mild headaches may respond to analgesics such as ibuprofen or acetaminophen. Alternatively, Midrin combines isometheptene mucate, which is a sympathomimetic agent; dichloralphenazone, which is a mild sedative; and acetaminophen and is compatible with breastfeeding. For more severe headaches, oral or systemic narcotics can be used. Instead of Midrin, a triptan, such as sumatriptan (Imitrex), can effectively relieve headaches by causing intracranial vasoconstriction.
The woman is instructed to clean the vulva from anterior to posterior—the vulva toward the anus. A cool pack applied to the perineum may help reduce edema and discomfort during the first 24 hours if there is a perineal laceration or an episiotomy. Most women also appear to obtain a measure of relief from the periodic application of a local anesthetic spray. Severe perineal, vaginal, or rectal pain always warrants careful inspection and palpation. Severe discomfort usually indicates a problem, such as a hematoma within the first day or so and infection after the third or fourth day (Chap. 37, Perineal Infections and Chap. 41, Puerperal Hematomas). Beginning approximately 24 hours after delivery, moist heat as provided by warm sitz baths can be used to reduce local discomfort. Tub bathing after uncomplicated delivery is allowed. The episiotomy incision normally is firmly healed and nearly asymptomatic by the third week.
Rarely, the cervix, and occasionally a portion of the uterine body, may protrude from the vulva following delivery. This is accompanied by variable degrees of anterior and posterior vaginal wall prolapse. Symptoms include a palpable mass at or past the introitus, voiding difficulties, or pressure. Puerperal procidentia typically improves with time as the weight of the uterus lessens with involution. As a temporizing measure in those with pronounced prolapse, the uterus can be replaced and held in position with a suitable pessary.
Hemorrhoidal veins are often congested at term. Thrombosis is common and may be promoted by second-stage pushing. Treatment includes topically applied anesthetics, warm soaks, and stool-softening agents. Nonprescription topical preparations containing corticosteroids, astringents, or phenylephrine are often used, but no randomized studies support their efficacy compared with conservative management.
In most delivery units, intravenous fluids are infused during labor and for an hour or so after delivery. Oxytocin, in doses that have an antidiuretic effect, is typically infused postpartum, and rapid bladder filling is common. Moreover, both bladder sensation and capability to empty spontaneously may be diminished by local or conduction analgesia, by trauma to the bladder, by episiotomy or lacerations, or by operative vaginal delivery. Thus, urinary retention and bladder overdistention is common in the early puerperium. The incidence in more than 5500 women studied with a bladder scanner was 5.1 percent (Buchanan, 2014). In another study, Musselwhite and coworkers (2007) reported retention in 4.7 percent of women who had labor epidural analgesia. Risk factors that increased the likelihood of retention were primiparity, cesarean delivery, perineal laceration, oxytocin-induced or augmented labor, operative vaginal delivery, catheterization during labor, and labor duration >10 hours.
Prevention of bladder overdistention demands observation after delivery to ensure that the bladder does not overfill and that it empties adequately with each voiding. The enlarged bladder can be palpated suprapubically, or it is evident abdominally indirectly as it elevates the fundus above the umbilicus. The use of an automated bladder scanner sonography system has been studied to detect high bladder volumes and thus postpartum urinary retention (Buchanan, 2014; Van Os, 2006).
If a woman has not voided within 4 hours after delivery, it is likely that she cannot. If she has trouble voiding initially, she also is likely to have further trouble. An examination for perineal and genital-tract hematomas is completed. With an overdistended bladder, an indwelling catheter should be left in place until the factors causing retention have abated. Even without a demonstrable cause, it usually is best to leave the catheter in place for at least 24 hours. This prevents recurrence and allows recovery of normal bladder tone and sensation.
When the catheter is removed, a voiding trial is completed to demonstrate an ability to void appropriately. If a woman cannot void after 4 hours, she should be catheterized and the urine volume measured. If more than 200 mL, the bladder is not functioning appropriately, and the catheter is left for another 24 hours. Although rare, if retention persists after a second voiding trial, an indwelling catheter and leg bag can be elected, and the patient returns in 1 week for an outpatient voiding trial. Intermittent self-catheterization is another option (Mulder, 2017).
During a voiding trial, if less than 200 mL of urine is obtained, the catheter can be removed and the bladder subsequently monitored clinically as described earlier. Harris and coworkers (1977) reported that 40 percent of such women develop bacteriuria, and thus a single dose or short course of antimicrobial therapy against uropathogens is reasonable after the catheter is removed.
Pain, Mood, and Cognition
Discomfort and its causes following cesarean delivery are considered in Chapter 30 (Postoperative Care). During the first few days after vaginal delivery, the mother may be uncomfortable because of afterpains, episiotomy and lacerations, breast engorgement, and at times, postdural puncture headache. Mild analgesics containing codeine, aspirin, or acetaminophen, preferably in combinations, are given as frequently as every 4 hours during the first few days.
It is important to screen the postpartum woman for depression (American College of Obstetricians and Gynecologists, 2016b). It is fairly common for a mother to exhibit some degree of depressed mood a few days after delivery. Termed postpartum blues, this likely is the consequence of several factors. These include emotional letdown that follows the excitement and fears experienced during pregnancy and delivery, discomforts of the early puerperium, fatigue from sleep deprivation, anxiety over the ability to provide appropriate newborn care, and body image concerns. In most women, effective treatment includes anticipation, recognition, and reassurance. This disorder is usually mild and self-limited to 2 to 3 days, although it sometimes lasts for up to 10 days. Should these moods persist or worsen, an evaluation for symptoms of major depression is done (Chap. 61, Postpartum Depression). Suicidal or infanticidal ideation is dealt with emergently. Because major postpartum depression recurs in at least a fourth of women in subsequent pregnancies, some recommend pharmacological prophylaxis beginning in late pregnancy or immediately postpartum.
Last, postpartum hormonal changes in some women may affect brain function. Bannbers and colleagues (2013) compared a measure of executive function in postpartum women and controls and observed a functional decline in postpartum subjects.
Pressure on branches of the lumbosacral nerve plexus during labor may manifest as complaints of intense neuralgia or cramp- like pains extending down one or both legs as soon as the head descends into the pelvis. If the nerve is injured, pain may continue after delivery, and variable degrees of sensory loss or muscle paralysis can result. In some cases, there is footdrop, which can be secondary to injury at the level of the lumbosacral plexus, sciatic nerve, or common fibular (peroneal) nerve (Bunch, 2014). Components of the lumbosacral plexus cross the pelvic brim and can be compressed by the fetal head or by forceps. The common fibular nerves may be externally compressed when the legs are positioned in stirrups, especially during prolonged second-stage labor.
Obstetrical neuropathy is relatively infrequent. Wong and associates (2003) evaluated more than 6000 puerperas and found that approximately 1 percent had a confirmed nerve injury. Lateral femoral cutaneous neuropathies were the most common (24 percent), followed by femoral neuropathies (14 percent). A motor deficit accompanied a third of injuries. Nulliparity, prolonged second-stage labor, and pushing for a long duration in the semi-Fowler position were risk factors. The median duration of symptoms was 2 months, and the range was 2 weeks to 18 months.
Nerve injuries with cesarean delivery include the iliohypogastric and ilioinguinal nerves (Rahn, 2010). These are discussed further in Chapter 2 (Innervation).
Pain in the pelvic girdle, hips, or lower extremities may follow stretching or tearing injuries sustained at normal or difficult delivery. Magnetic resonance (MR) imaging is often informative (Miller, 2015). One example is the piriformis muscle hematoma shown in Figure 36-6. Most injuries resolve with antiinflammatory agents and physical therapy. Rarely, there may be septic pyomyositis such as with iliopsoas muscle abscess (Nelson, 2010; Young, 2010).
Inhomogeneous mass of the right piriformis muscle consistent with a hematoma (yellow cursor measurements) is compared with the normal-appearing left piriformis muscle (yellow arrow).
Separation of the symphysis pubis or one of the sacroiliac synchondroses during labor leads to pain and marked interference with locomotion (Fig. 36-7). Estimates of the frequency of this event vary widely from 1 in 600 to 1 in 30,000 deliveries (Reis, 1932; Taylor, 1986). In our experiences, symptomatic separations are uncommon. Their onset of pain is often acute during delivery, but symptoms may manifest either antepartum or up to 48 hours postpartum (Snow, 1997). In suspected cases, radiography is typically selected. The normal distance of the symphyseal joint is 0.4 to 0.5 cm, and symphyseal separation >1 cm is diagnostic for diastasis. Treatment is generally conservative, with rest in a lateral decubitus position and an appropriately fitted pelvic binder (Lasbleiz, 2017). Surgery is occasionally necessary in some symphyseal separations of more than 4 cm (Kharrazi, 1997). The recurrence risk is high in subsequent pregnancy, and Culligan and coworkers (2002) recommend consideration for cesarean delivery.
Pubic symphyseal separation found on the first postpartum day following vaginal delivery of a 2840-g newborn. The patient had pain over the pubic bone and pain with ambulation. A shuffling gait was noted, and she had difficulty with leg elevation when supine. The patient was treated with physical therapy and analgesics. A pelvic binder was applied, and a rolling walker was provided. She improved quickly and was discharged home on postoperative day 5.
In rare cases, fractures of the sacrum or pubic ramus are caused by even uncomplicated deliveries (Alonso-Burgos, 2007; Speziali, 2015). As discussed in Chapter 58 (Hypoparathyroidism), the latter are more likely with osteoporosis associated with heparin or corticosteroid therapy (Cunningham, 2005). In rare but serious cases, bacterial osteomyelitis—osteitis pubis—can be devastating. Lawford and coworkers (2010) reported such a case that caused massive vulvar edema.
The D-negative woman who is not isoimmunized and whose newborn is D-positive is given 300 μg of anti-D immune globulin shortly after delivery (Chap. 15, Prevention of Anti-D Alloimmunization). Women who are not already immune to rubella or varicella are excellent candidates for vaccination before discharge (Swamy, 2015). Those who have not received a tetanus/diphtheria or influenza vaccine should be given these (American College of Obstetricians and Gynecologists, 2017c). Morgan and colleagues (2015) reported that implementation of a best-practices alert in the electronic medical record was associated with a tetanus/diphtheria immunization rate of 97 percent at Parkland Hospital. Vaccination is also discussed in Chapter 9 (Automobile and Air Travel).
Following uncomplicated vaginal delivery, hospitalization is seldom warranted for more than 48 hours. A woman should receive instructions concerning anticipated normal physiological puerperal changes, including lochia patterns, weight loss from diuresis, and milk let-down. She also should receive instructions concerning fever, excessive vaginal bleeding, or leg pain, swelling, or tenderness. Persistent headaches, shortness of breath, or chest pain warrant immediate concern.
Hospital-stay length following labor and delivery is now regulated by federal law (Chap. 32, Rooming In and Hospital Discharge). Currently, the norms are hospital stays up to 48 hours following uncomplicated vaginal delivery and up to 96 hours following uncomplicated cesarean delivery (American Academy of Pediatrics, 2017; Blumenfield, 2015). Earlier hospital discharge is acceptable for appropriately selected women if they desire it.
During the hospital stay, a concerted effort is made to provide family planning education. Various forms of contraception are discussed throughout Chapter 38 and sterilization procedures in Chapter 39.
Women not breastfeeding have return of menses usually within 6 to 8 weeks. At times, however, it is difficult clinically to assign a specific date to the first menstrual period after delivery. A minority of women bleed small to moderate amounts intermittently, starting soon after delivery. Ovulation occurs at a mean of 7 weeks, but ranges from 5 to 11 weeks (Perez, 1972). That said, ovulation before 28 days has been described (Hytten, 1995). Thus, conception is possible during the artificially defined 6-week puerperium. Women who become sexually active during the puerperium, and who do not desire to conceive, should initiate contraception. Kelly and associates (2005) reported that by the third month postpartum, 58 percent of adolescents had resumed sexual intercourse, but only 80 percent of these were using contraception. Because of this, many recommend long-acting reversible contraceptives—LARC (Baldwin, 2013).
Women who breastfeed ovulate much less frequently compared with those who do not, but variation is great. Timing of ovulation depends on individual biological variation and the intensity of breastfeeding. Lactating women may first menstruate as early as the second or as late as the 18th month after delivery. Campbell and Gray (1993) analyzed daily urine specimens to determine the time of ovulation in 92 lactating women. As shown in Figure 36-8, breastfeeding in general delays resumption of ovulation, although as already emphasized, it does not invariably forestall it. Other findings in their study included the following:
Cumulative proportion of breastfeeding women who ovulated during the first 70 weeks following delivery. (Data from Campbell OM, Gray RH: Characteristics and determinants of postpartum ovarian function in women in the United States. Am J Obstet Gynecol 169:55, 1993.)
Resumption of ovulation was frequently marked by return of normal menstrual bleeding.
Breastfeeding episodes lasting 15 minutes seven times daily delayed ovulation resumption.
Ovulation can occur without bleeding.
Bleeding can be anovulatory.
The risk of pregnancy in breastfeeding women was approximately 4 percent per year.
For the breastfeeding woman, progestin-only contraceptives, such as progestin pills, depot medroxyprogesterone, or progestin implants, do not affect the quality or quantity of milk. Success with the progesterone-releasing vaginal ring has also been described (Carr, 2016). These may be initiated any time during the puerperium. Estrogen-progestin contraceptives likely reduce the quantity of breast milk, but under the proper circumstances, they too can be used by breastfeeding women. These hormonal methods are discussed in Chapter 38.