Continuing Education Activity

The postpartum period begins soon after the delivery of the baby and usually lasts six to eight weeks and ends when the mother’s body has nearly returned to its pre-pregnant state. The postpartum period for a woman and her newborn is very important for both short-term and long-term health and well-being. This activity should help the interprofessional team on how to provide comprehensive postpartum care for the new mother.

Objectives:

• Review the guidelines regarding comprehensive postpartum care.
• Summarize the components of the postpartum care of the new mother.
• Outline the common medical conditions that women encounter during the postpartum period.
• Describe how interprofessional team coordination and communication can enhance patient outcomes when rendering a new mother's postpartum care.

Introduction

The postpartum period begins soon after the baby's delivery and usually lasts six to eight weeks and ends when the mother’s body has nearly returned to its pre-pregnant state.[1] The weeks following birth lay the foundation of long-term health and well-being for both the woman and her infant. Therefore, it is critical to establish a reliable postpartum (afterbirth) period that should be tailored into on-going, continuous, comprehensive care.  Most maternal and infant deaths occur in the first month after birth. Hence effective postpartum care is mandatory to improve both short-term and long-term health consequences of mother and newborn.[2]

Function

Timing of Postnatal Visits

In April 2018, The American College of Obstetrics and Gynecology (ACOG) recommends12 weeks of support, rather than a single six-week postpartum visit. ACOG also recommends postpartum evaluation within the first 3 weeks after delivery in-person or by phone, which later is followed up with ongoing care as needed, concluding with a comprehensive postpartum visit no later than 12 weeks.[3]

Components of Postpartum Care

1. Vaginal pain: Genital tract trauma is obvious with spontaneous vaginal delivery.[4] Mild vaginal tears occur during delivery and take a few weeks to heal, whereas extensive tears might take longer to heal. Advice women to take over-the-counter medications such as ibuprofen or acetaminophen for pain, sit on a padded ring, or cool the area with an ice pack to relieve the pain. Health care providers should inform women about the signs of infection such as fever and encourage them to seek medical attention for persistent, severe pain.[5] 
2. Vaginal bleeding/discharge: Bloody vaginal discharge (lochia rubra) is heavy for the first 3-4 days, and slowly it becomes watery in consistency and color changes to pinkish-brown (lochia serosa). After the next 10-12 days, it changes to yellowish-white (lochia alba).  Advise women to seek medical attention if heavy vaginal bleeding persists (soaking a pad or more in less than an hour). Women with heavy, persistent postpartum bleeding should be evaluated for complications such as retained placenta, uterine atony, rarely invasive placenta, or coagulation disorders.[6]  Endometritis may also occur, presenting as fever with no source, maybe accompanied by uterine tenderness and vaginal discharge. This usually requires intravenous antibiotics. This also should be explained and advise the mother to seek immediate medical attention.
3. Breastfeeding: Breastfeeding is beneficial for the mother and the newborn.[7] Breastfeeding women are less likely to get breast cancer, ovarian cancer, and type 2 DM.[8] Providers should evaluate latch, swallow, nipple type and condition, and hold of infants for any problems.  Interventions include professional support, peer support, and formal education.[9] Health care providers should strongly encourage women to breastfeed the newborn unless it is contraindicated. The World Health Organization (WHO) recommends at least four to six months, every three to four hours daily. Breastfeeding reduces the newborn’s risk for gastrointestinal tract infections, pediatric cancers, and atopic eczema.[8] Breastfeeding should be evaluated at each postnatal visit. 
4. Nutrition and exercise: Women at higher risk for postpartum weight retention are those with higher gestational weight gain, black race, and lower socioeconomic status, which at the same time increase their risk of future obesity and type 2 diabetes.[10] Advise women to take a variety of healthy balanced diets and resume their normal dietary habits. All breast-feeding mothers need to take extra 500 calories per day. Avoid strenuous activities in the early postpartum period and take plenty of rest for the first 2-3 weeks and slowly start with non-impact activities such as walking and a gradual return to previous activities is recommended.[11]
5. Breast engorgement: Women may experience full, firm, and tender breasts after the delivery. Frequent breastfeeding on both breasts is recommended to avoid engorgement.[12] Advise women to use warm washcloths or warm showers or place cold washcloths between feedings to relieve the pain. For women who are not going to breastfeed, encourage them to use cold packs, using firm support of the breasts, take analgesics as needed, and mechanical extraction of milk.[13]
6. Bladder and bowel function: Voiding must be encouraged and monitored to prevent asymptomatic bladder overfilling. Women are encouraged to use mild laxatives such as docusate, psyllium, bisacodyl if defecation has not occurred within 3 days of delivery. Another consideration is Osmotic laxatives as polyethylene glycol and lactulose.[14]
7. Sexual relations: Libido may decrease after the delivery because of decreased estrogen levels. This may not return for as long as 1 year postpartum, particularly in women who are breastfeeding. Reassurance is usually appropriate.  Advice women to wait for their perineal area to heal before resuming sexual activity, and it may take 4-6 weeks for the perineal tears to heal completely. Health care providers should be more comfortable discussing women about sexuality during the early postpartum period.[15] Address earlier return of sexual activity with contraception to avoid unintended, closely spaced pregnancy.[15]
8. Contraception: The prenatal period is the best time to discuss postpartum contraception. In adolescents begin motivational interviewing, discussion of long-acting reversible contraception during pregnancy.[16]  For breastfeeding women, nonhormonal modalities are usually preferred. The American College of Obstetrics and Gynecologists (ACOG) recommend progestin-only contraceptives are the best hormonal contraceptive modality for breastfeeding women. Breastfeeding mothers should not use combination estrogen-progestin contraceptives as it can interfere with breast milk production.[17] Among hormonal methods, combined estrogen-progestin vaginal rings can be used after 4 weeks postpartum. Hormonal methods such as progestin-only oral contraceptives, depot medroxyprogesterone acetate injections, and progestin implants are preferred, as they do not affect milk production. A vaginal diaphragm and cervical cap should be fitted only after complete involution of the uterus, at 6 to 8 weeks after delivery. Intrauterine devices are typically best placed after 4 to 6 weeks after delivery. Breastfeeding is not an effective contraceptive choice.  Lactational amenorrhea method alone or other forms of contraception has a failure rate of 2%, but a specific criterion has to be fulfilled. The woman must have to be breastfeeding exclusively on demand, be amenorrheic) i.e., no vaginal bleeding after 8 weeks postpartum), and have an infant younger than 6 months. This becomes less reliable as the infant starts to eat solid foods.  Both breastfeeding and non-breast-feeding women can use barrier contraceptives, intrauterine devices (IUDs; copper-releasing and hormone-releasing), and progestin-only contraception. WHO recommends breastfeeding women wait six weeks postpartum before starting progestin-only contraceptives. ACOG recommends combination hormonal contraceptive use should not start until 3 weeks postpartum because of the increased risk of thromboembolism. Women should wait at least 6-18 months before trying to become pregnant again.
9. Education: Health care providers should provide essential education regarding newborn care, such as umbilical cord care, bathing, breastfeeding, and the importance of immunizations.
10. Miscarriage, stillbirth, or neonatal death: For mothers who experience any pregnancy loss, it is essential to ensure follow-up. Key elements are to provide emotional support and bereavement counseling; referral, if appropriate, to counselor and support groups. Also review of any laboratory or pathology studies related to the loss and counseling regarding recurrent risk and future pregnancy planning.[18]

Issues of Concern

Common Postpartum Concerns

1. Postpartum blues: Transient depression (baby blues) is very common during the first week after delivery.[19]  Women may notice feeling down, anxious, mood swings, crying spells, irritability, and difficulty sleeping. Postpartum blues typically resolve within 2 weeks. Health care providers should advise them to seek medical attention if depressive symptoms continue beyond 2 weeks and having difficulty taking care of themselves or taking care of the newborn or having thoughts of harming themselves or the newborn baby.[20]  All women should be screened for mood and anxiety disorders using a validated tool (Edinburgh Postnatal Depression Scale).  The American Academy of Pediatrics recommends screening at the one-, two-, four- and six-month well visit. Encourage the partner and family members at least for the first week of the postnatal period to provide emotional support and to take care of the newborn. The National Institute for Health and Care Excellence recommends screening all postpartum women for resolution of the postpartum blues at 10 to 14 days after delivery. 
2. Intimate partner violence: Use HARK (humiliation, afraid, rape, kick) or HITS (hurt, insult, threaten, scream) tools to evaluate for intimate partner violence.[21]Prioritize patient safety, consider referral to intimate partner violence prevention organizations.
3. Incontinence: Stress incontinence occurs due to extensive stretch or injury to pelvic floor muscles during labor. Risk factors for urinary incontinence three months postpartum include obesity, parity, smoking, longer duration of breastfeeding, and use of forceps during vaginal delivery. Advise women to do Kegel’s exercises regularly to strengthen pelvic floor muscles.[22] Other considerations also are bladder training and weight loss as part of first-line treatment. It is important to let the new mother know that more than ¼ of women experience moderate or severe urinary incontinence in the first year postpartum.
4. Hemorrhoids: Caused by constipation and/or by pushing during the second stage of labor.[23]The first line of treatment includes an increase in water and fiber intake and stool softeners. Some may need excision or ligation of refractory hemorrhoids or grade III or higher.

Clinical Significance

According to ACOG, at least 40% of women do not seek postpartum care. Several factors contribute towards this trend, such as cultural differences, lack of insurance, lack of adequate family support, low socioeconomic status, poor anticipatory guidance, race, lack of good transitional care management, and poor access to home visits. According to the Pregnancy Mortality Surveillance System (PMSS), Nonhispanic blacks have the highest maternal mortality.[24][25][26]

During the first week of the postnatal period, severe hypertension, severe bleeding, and infection are the most common contributors to maternal deaths, while the cardiovascular cause is the leading cause of late deaths.[27] When compared with other developed countries such as Norway and New Zealand, the US has significantly lagged behind with providing adequate prenatal care and US mortality and morbidity is significantly higher ( 17.4 % vs. 1.7 % ), and the US has a significantly lower number of maternal health care providers such as obstetricians and midwives ( 19 vs. 65 per 1000 live births ). Earlier postpartum visits are mandatory to evaluate for resolution of postpartum blues and other chronic medical conditions such as hypertension and diabetes and to improve both maternal and neonatal mortality and morbidity.

Other Issues

Health Issues that Arise During Pregnancy

1. Pregnancy-induced hypertension: Hypertensive disorder risk is higher < 48hrs after delivery. An office visit is recommended within the first 7 days after delivery. Blood Pressure (BP) ≥150/100 mmHg can be treated with oral medication such as nifedipine or labetalol. Hospitalize if signs of end-organ (liver injury or pulmonary edema) or BP ≥ 160/110. Recommend lifestyle modification and annual BP and bodyweight monitoring follow-ups.  

2. Gestational diabetes mellitus (GDM): Women with GDM are at a very high risk of developing diabetes. ACOG recommends women with GDM should have a 75-g, 2-hour fasting oral glucose tolerance test 4 to 12 weeks postpartum to screen for type 2 DM.[28] 

3. Thyroid disorders: Mother can experience symptoms of hypo- or hyperthyroidism. The diagnosis of postpartum thyroiditis depends on clinical presentation and elevated free T4 and low TSH. Hyperthyroidism is transient and usually not treated. Beta-blocker can be used if needed for symptoms. Hypothyroidism is treated with levothyroxine. The American Thyroid Association recommends annual testing in women with hypothyroidism with a history of postpartum thyroiditis.[29]

Enhancing Healthcare Team Outcomes

In 2013, WHO released the following  recommendations regarding the postpartum care:

1. Provide postnatal care in the first 24 hours to all mothers and babies-regardless of where the birth occurs.2. Ensure healthy women and their newborns stay at a health care facility for at least one day after the delivery. 3. All mothers and newborns need at least four postpartum visits in the first 6 weeks.4. If birth is at home, the first postnatal contact should be as early as possible, within 24 hours of birth.5. Ensure at least 3 postnatal visits for all mothers and babies, on day 3 (48 to 72 hours), between days 7 to 14, and 6 weeks after birth.6. All women should be educated about the physiological process of recovery after birth and mention that some health problems are common, with advice to report any health concerns to a health care provider, in particular, signs and symptoms of infection, postpartum hemorrhage, pre-eclampsia/eclampsia, and thromboembolism.7. The use of prophylactic antibiotics among women with a vaginal delivery and a third or fourth-degree perineal tear is recommended to prevent wound complications.8. Advise women to apply topical chlorhexidine application to the umbilical cord stump daily during the first week of life is recommended for newborns born at home in settings with high neonatal mortality (30 or more neonatal deaths per 1,000 live births).

Nursing, Allied Health, and Interprofessional Team Interventions

Ultimately, providing the optimum level of healthcare and support for postpartum families will require local, state-wide, and national-level policy changes. Even though the affordable care act improved maternal care access, the US still needs a major change in policies to provide appropriate, evidence-based, and culturally competent universal access to maternity care.[30]

Expanding eligibility for Medicaid, which pays for almost half of U.S. deliveries, can improve postpartum coverage.[31] This should be facilitated through mutual support between healthcare providers and insurance platforms by appropriate reimbursement levels that support—and indeed fosters—postpartum care as a continuous, rather than an isolated, process, which undoubtedly leads to positive outcomes for the community as a whole.[32]