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Clinical manifestations during the puerperium (6-wk period after delivery) generally reflect reversal of the physiologic changes that occurred during pregnancy. These changes are mild and temporary and should not be confused with pathologic conditions.
Within the 1st 24 h, the woman's pulse rate drops, and her temperature may be slightly elevated. Because WBCs increase during labor, marked leukocytosis (up to 20,000 to 30,000/μL) occurs in the 1st 24 h postpartum; WBC count returns to normal within 1 wk. Vaginal discharge is grossly bloody (lochia rubra) for 3 to 4 days; over the next 10 to 12 days, it changes to pale brown (lochia serosa) and finally to yellowish white (lochia alba). About 1 to 2 wk after delivery, eschar from the placental site sloughs off and bleeding occurs; bleeding is usually self-limited. Total blood loss is about 250 mL; comfortably fitting intravaginal tampons (changed frequently) or external pads may be used to absorb it. Tampons should not be used if they might inhibit healing of perineal or vaginal lacerations.
Urine temporarily increases in volume and may contain protein and sugar. Because blood volume is redistributed, Hct may fluctuate, although it tends to remain in the prepregnancy range if women do not hemorrhage. Plasma fibrinogen and ESR remain elevated during the 1st wk postpartum.
The uterus involutes progressively; after 5 to 7 days, it is firm and no longer tender, extending midway between the symphysis and umbilicus. By 2 wk, it is no longer palpable abdominally. Contractions of the involuting uterus, if painful (afterpains), may require analgesics.
Management
in the Hospital
Risk of infection, hemorrhage, and pain must be minimized. The woman is typically observed for at least 1 h after the 3rd stage of labor, and the uterus is massaged periodically to ensure that it contracts and remains contracted, preventing excessive bleeding. If the uterus does not remain contracted with massage alone, oxytocin 10 units IM or a dilute oxytocin IV infusion (10 or 20 units/1000 mL of IV fluid) at 125 to 200 mL/h is given immediately after delivery of the placenta. The drug is continued until the uterus is firm; then it is decreased or stopped. Oxytocin should not be given as an IV bolus because severe hypotension may occur, subsequently increasing cardiac output. If general anesthesia was used for operative delivery (by forceps, vacuum extractor, or cesarean section), the woman is monitored (preferably in a recovery room or a labor, delivery, recovery, and postpartum room) for 2 to 3 h after delivery. For all women, O2, type O-negative blood or blood tested for compatibility, and IV fluids must be available during the recovery period.
After the 1st 24 h, recovery is rapid. A regular diet should be offered as soon as the woman requests food. Full ambulation is encouraged as soon as possible. When to start an exercise routine depends on the woman; its safety depends on whether complications or disorders are present. Usually, exercises to strengthen abdominal muscles can be started once the discomfort of delivery (vaginal or cesarean) has subsided, typically within 1 day for women who deliver vaginally and later for those who deliver by cesarean section. Curl-ups, done in bed with the hips and knees flexed, tighten only abdominal muscles, usually without causing backache. If delivery was uncomplicated, showering and bathing are allowed, but vaginal douching is prohibited in the early puerperium. 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; later, warm sitz baths several times a day can be used. Commonly used analgesics include codeine 30 to 60 mg, aspirin 650 mg, acetaminophen 650 mg, and ibuprofen 400 mg po q 4 to 6 h.
Urine retention, bladder overdistention, and catheterization should be avoided if possible. Rapid diuresis may occur, especially when oxytocin is stopped. Voiding must be encouraged and monitored to prevent asymptomatic bladder overfilling. A midline mass palpable in the suprapubic region or abnormal 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. 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 can be given. Maintaining good bowel function can prevent or help relieve existing hemorrhoids, which can be treated with warm sitz baths. Regional (spinal or epidural) anesthesia delays ambulation and may delay defecation and spontaneous urination.
A CBC to verify that women are not anemic is required before discharge only if peripartum blood loss was excessive. Women seronegative for rubella should be vaccinated against rubella on the day of discharge. If women with Rh-negative blood have an infant with Rh-positive blood but are not sensitized, they should be given Rh0(D) immune globulin 300 μg IM within 72 h of delivery to prevent sensitization (see Abnormalities of Pregnancy: Prevention).
The breasts may become painfully engorged during early lactation, when the amount of milk is beginning to increase. Breastfeeding helps reduce engorgement. If the woman is not going to breastfeed, firm support of the breasts can suppress lactation; gravity stimulates the let-down reflex and encourages milk flow. For many women, tight binding of the breasts, cold packs, and analgesics prn followed by firm support effectively control temporary symptoms while lactation is being suppressed.
Transient depression (“baby blues”) is very common during the 1st week after delivery. Symptoms are typically mild and usually subside by 7 to 10 days. Treatment is supportive care and reassurance. Persistent symptoms, lack of interest in the infant, suicidal or homicidal thoughts, hallucinations, delusions, or psychotic behavior may require intensive counseling and antidepressants or antipsychotics. Women with a preexisting mental disorder are at high risk of recurrence or exacerbation during the puerperium and should be monitored closely.
Management at
Home
The woman and infant can be discharged within 24 to 48 h postpartum; many family-centered obstetric units discharge them as early as 6 h postpartum if major anesthesia was not used and no complications occurred. Analgesics may be offered as necessary but should be limited if a woman is breastfeeding because most drugs are secreted in breast milk (see also Approach to the Care of Normal Infants and Children: Drugs). Normal activities may be resumed as soon as the woman feels ready. Major problems are rare, but a home visit or close follow-up regimen is necessary.
Intercourse may be resumed as soon as desired and comfortable. However, a delay in sexual activity should be considered for those who need to heal a laceration or episiotomy repair. Pregnancy must be delayed for 1 mo if the woman was vaccinated against rubella at hospital discharge; also, preventing pregnancy for several months to allow complete recovery is in the woman's best interest. Because pregnancy is possible, contraception is required and can be started at discharge. If women are not breastfeeding, ovulation usually occurs about 4 wk postpartum, 2 wk before the 1st menses. However, conception may occur as early as 2 wk postpartum, so ovulation can occur earlier. Women who are breastfeeding tend to ovulate and menstruate later, usually at 10 to 12 wk postpartum, although a few ovulate and menstruate (and become pregnant) as quickly as those who are not breastfeeding.
Breastfeeding status affects choice of hormonal contraceptives. For breastfeeding women, progestin-only oral contraceptives, depot medroxyprogesterone acetate injections, and levonorgestrel implants are preferred because they do not affect milk production. Estrogen-progesterone contraceptives can interfere with milk production and should not be initiated until production is well established.
A diaphragm should be fitted only after complete involution of the uterus, at 6 to 8 wk; meanwhile, foams, jellies, and condoms should be used.
Last full review/revision November 2005
Content last modified November 2005
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