last authored: July 2011, David LaPierre
The puerperium is usually an exciting but exhausting time, as the mother and other family members bond with the infant. There are numerous conditions that can occur in the hours and days following delivery, however, and these need to be appropriately evaluated.
In the first few hours, the mother should be monitored for bleeding, blood pressure, pulse and respirations for at least 1-2 hours, or longer if general or spinal anaesthesia have been used.
The uterus should be palpated to ensure it has contracted well, and to ensure that blood is not collecting. If the uterus remains boggy, massage and ask for help. Assess for a distended bladder.
Bleeding, if present, should be quantified (eg, pad count).
After this, blood pressure should be checked every 12 hours for the first day or two. Complications such as pre-eclampsia, eclampsia, and infection warrant further monitoring.
The woman should ambulate within a few hours, though care should be taken to ensure she does not become syncopal. This reduces bladder infections, constipation, blood clots, and pulmonary embolism.
The woman should be taught about care of the vulva and perineum, wiping from front to back. A bottle may be used instead to irrigate. An ice pack may be helpful initially, with use up to 20 min, though warm packs can be soothing after one day. Extreme pain should always be investigated due to concern of hematoma or infection.
Voiding should occur within 4 hours of delivery. If it does not, examination for hematoma is warranted by palpating the uterus. A catheter may be helpful for initial voiding.
During hospitalization, the following should be monitored:
There are many specific conditions that can occur during the puerperium, and care should be exercised so as not to miss them.
The most postpartum concern is postpartum hemorrhage (main article).
Hypertension can be seen following administration of some medications, and should be treated with hydralazine.
Congenital or acquired heart disease can worsen following delivery, as cardiac output dramatically increases to compensate for increased venous return from the legs. A transient bradycardia can sometimes some seen with this.
Dilated cardiomyopathy can affect otherwise healthy women following childbirth, for unknown reasons. Signs of congestive heart failure begin days to weeks. Recovery is expected in approximately 50% of women after 6 months with concervative treatment.
Aneasthesia can cause airway obstruction with laryngospasm. Hypoventilation and hypotension may be present, and should be dealt with emergently.
Anaesthesia can also predispose women to vomiting and aspiration pneumonitis/pneumonia.
Thyroid disease is relatively common following childbirth, especially immune-mediated. Patients with Graves disease are especially at risk.
Mild hyperthyroidism begins 1-3 months after delivery, and is usually followed by a transient hypothyroidism. Supplementation may be offered, but most women have complete recovery after 6-9 months.
Early ambulation reduces the risk of clotting, which is exacerbated by thrombophlebitis.
Nerve palsy can follow obstructed labour or traumatic delivery, including use of forceps. A unilateral footdrop may be seen. Most spontaneously recover.
Seizure should prompt consideration of eclampsia if within 48 hours.
Postpartum depression (separate topic here) can occur due to the tremendous emotional, hormonal, and social fluctuations that follow childbirth. It is important to screen for, and treat, depression when it exists. Inquire into personal history, family history, and psychosocial risk factors.
Episodes of mania/hypomania and psychosis can also occur a few days after delivery, leaving the woman unable to care for herself or her infant.
Most women are discharged on post-delivery day 1 or post operative day 2, if no complications are present.
Information should be given regarding lochia, expected weight loss due to dieuresis, and breastfeeding. Warning signs, including bleeding, leg pain, fever, chest pain, or shortness of breath, should be mentioned.
As long as there have been no complications, most women who have had a vaginal delivery can return to most activities after hospital discharge. However, energy can take many weeks to return. Recovery from a C/S takes longer - up to 4-6 weeks. The woman should watch for signs of infection, and avoid bending, lifting, and climbing stairs for a few weeks.
A follow-up visit for the mother should be carried out within 4-6 weeks, to identify complications, address concerns, and discuss contraception.
Common symptoms that can occur after hospital discharge include (Glazener et al, 1995):
Family planning should be offered following childbirth. All women, but especially those who do not breastfeed, may become pregnant soon after delivery. A woman who is not breastfeeding usually resumes menstruation within 6-8 weeks, while breastfeeding women may ovulate from 2-18 months after delivery. It is important to discuss contraception at the first postpartum visit.
Common sense and comfort is important for resuming sexual activity after childbirth, but four - six weeks is a general guideline.