Volume 202, Issue 1 , Pages 1-4, January 2010
Postpartum care: we can and should do better
Article Outline
Extensive physiologic, endocrine, and immunologic adaptations occur in the mother in response to the demands of pregnancy, which includes support of the fetus, preparation of the uterus for labor, and protection of the mother from potential cardiovascular injury at delivery. Although these demands increase incrementally over many months, resumption of the prepregnancy physiologic state after childbirth occurs at a far more rapid pace. The postpartum period, which is also referred to as the postnatal period (Latin for “after birth,” from post meaning “after” and natalis meaning “of birth'”) or puerperium (Latin for “after childbirth,” from puerperal meaning “a woman in childbed”), refers to the period that begins immediately after delivery and continues for the next 6 weeks. Why this time period is defined as 6 weeks rather than 4 weeks or 8 weeks is not clear and appears to be a result of convention rather than science, although it may be related to the fact that uterine size and menstruation typically return to normal by this time.
See related article, page 35
Routine care in the immediate postpartum period includes meticulous awareness of the medical and social needs of the mother. For the family, the puerperium is a time of significant social adjustment. The new mother needs time for rest and recovery while she and her family focus on the needs of the baby, which include breastfeeding, bonding, bathing, and diaper care. Obstetric care providers should be aware of and sensitive to cultural differences that surround childbirth, such as traditional customs that surround postpartum confinement (also known as “sitting the month”) that may involve the eating of particular foods that are thought to promote wound healing, uterine contractions, and lactation or restrictions on select activities that are considered to be harmful to the mother.
Women face a number of potential obstacles as they return to their prepregnancy state. Some of these conditions, their major risk factors, and preventative strategies are listed in the Table. In the immediate postpartum period, careful attention must be paid to the mother's hemodynamic status, vaginal bleeding, and pain control. Additional risks include late postpartum hemorrhage, infection, and venous thromboembolism.1 Standardized protocols have been developed and implemented in some institutions to reduce the overall risk of pregnancy-related complications, to promote early identification, and to initiate effective therapy in a timely fashion.2, 3 Despite these advances, many postpartum complications remain underdiagnosed and suboptimally treated. Perhaps the best such example is postpartum depression, which is the single most common complication of childbearing.4 Despite extensive research and teaching, <50% of women are screened and treated appropriately for this debilitating condition.5
TABLE. Postpartum complications
| Potential complication | Major risk factors | Preventative strategies |
|---|---|---|
| Postpartum hemorrhage | Previous postpartum hemorrhage Obesity Advanced maternal age Cesarean or operative vaginal delivery (vacuum, forceps) Bleeding diathesis Anticoagulation (heparin) Retained products of conception Endometritis Uterine atony (polyhydramnios, multiple pregnancy) | Intravenous access Adequate analgesia Blood products and uterotonic agents readily available Perform episiotomy/operative vaginal delivery only if indicated Prophylactic antibiotics, when indicated Check complete blood count, coagulation studies to exclude coagulopathy |
| Endometritis | Diabetes mellitus Obesity Multiple vaginal examinations Lower genital tract infection Cesarean delivery Manual removal of placenta Prolonged rupture of membranes | Limit vaginal examinations in labor Prophylactic broad-spectrum antibiotics 20-30 min before cesarean delivery Avoid manual removal of placenta at cesarean |
| Urinary tract infection | Diabetes mellitus Sickle cell disease/trait Urinary tract anomaly Previous urinary tract infection/pyelonephritis Asymptomatic bacteriuria Bladder catheterization | Screen and treat for asymptomatic bacteriuria Minimize catheterization Void as soon as possible after delivery Check urinalysis culture and sensitivity if indicated |
| Breast engorgement or infection | Primiparity Preterm birth Previous breast surgery | Regular breast-feeding or pumping Referral to a lactation consultant, as indicated Avoid nipple stimulation if not planning on breast feeding (tight-fitting bra) |
| Episiotomy breakdown or infection | Diabetes mellitus Obesity Crohn's disease Inadequate surgical repair Chronic steroid therapy Anemia Nutritional deficiency | Avoid episiotomy, if possible Appropriate surgical repair Ice to perineum for 24 h to reduce pain and swelling Warm sitz baths daily until healed Keep area clean and dry |
| Cesarean incision breakdown or infection | Diabetes mellitus Obesity Inadequate surgical repair Chronic steroid therapy Anemia Nutritional deficiency | Appropriate surgical repair Close subcutaneous tissue if >2 cm in depth (to minimize seroma formation) Consider subcutaneous drain placement if adipose tissue is excessive |
| Venous thromboembolic event | Previous venous thromboembolic event Obesity Advanced maternal age Cesarean delivery Prolonged immobilization Antiphospholipid antibody syndrome Inherited thombophilia (eg, factor V Leiden mutation, prothrombin gene mutation) | Pneumatic compression boots in high-risk situations (eg, at the time of cesarean delivery) Early postpartum ambulation Prophylactic anticoagulation in the immediate postpartum period, if indicated (eg, after cesarean delivery in a morbidly obese woman) |
| Rh isoimmunization | Rh-negative blood type in the mother and Rh-positive blood type in the fetus (increased with vaginal bleeding in pregnancy or invasive procedure such as amniocentesis) Blood transfusion | Anti-D immune globulin 300 μg intramuscularly within 72 h of delivery or vaginal bleeding, if appropriate Check Kleihauer-Betke test (to determine whether additional anti-D immune globulin should be administered) |
| Constipation | Cesarean delivery Narcotic analgesia | Advance diet as tolerated Minimize narcotic analgesics Increase fiber in diet Consider prophylactic colace/pericolace therapy |
| Urinary retention | Cesarean or operative vaginal delivery (vacuum, forceps) Prolonged second state of labor Epidural analgesia Labial swelling or hematoma | Minimize catheterization Regular voiding after delivery Early intermittent catheterization, if needed |
| Rubella infection | Check rubella immune status in pregnancy | Rubella vaccination after delivery Rubella immune globulin and vaccination to neonate, if indicated |
| Peripartum cardiomyopathy | Previous cardiomyopathy Advanced maternal age Multiple pregnancy Preexisting cardiac disease Preeclampsia Ethnicity: white | None |
| Postpartum depression | Previous postpartum depression Preexisting psychiatric disease Discontinuation or poor compliance with psychiatric medications Polysubstance abuse Absence of social support network | Screen all women for postpartum depression Early referral for psychiatric evaluation and/or treatment (psychotherapy, medications), if appropriate |
| Postpartum thyroiditis | Prexisting thyroid disease Diabetes mellitus Presence of antithyroid peroxidase antibodies | Screen all women for symptoms of thyroid dysfunction Check thyroid function tests (thyroid-stimulating hormone, free T4), if clinically indicated |
Perhaps because of excitement surrounding the pregnancy, the puerperium has been overshadowed and largely ignored by clinicians and researchers alike. As such, few data exist that systematically examine the risks to women in the postpartum period after discharge from the hospital. In this issue of the Journal, Belfort et al6 attempt to address this deficiency. In a large, well-designed epidemiologic study of >220,000 women who were observed from delivery through 180 postpartum days (6½ months), the authors report an overall risk of readmission in the first 6 postpartum weeks of 1.2% (2655/222,751 women), most of which were infectious in origin. To exclude seasonal variation, 2 separate control groups were included: maternal age-matched nonpregnant women who were admitted to the same hospitals for the same infectious conditions from January 1–June 20, 2007, and a similar cohort who were admitted from July 1–December 31, 2007. Interestingly, women were more likely to be readmitted if they had experienced a cesarean delivery rather than a vaginal delivery (1.8% vs 0.8%, respectively; P < .001) and especially if they had had a primary rather than repeat cesarean delivery (2.1% vs 1.4%, respectively; P < .001). In large part, this was due to the increased rates of endometritis, sepsis, cellulitis, and necrotizing fasciitis (but not urinary tract infections) in women who delivered by cesarean. Although it should come as no surprise that readmissions for uterine and wound infections are more common in the first 6 postpartum weeks than in the subsequent 20 weeks (5 months) and that women who deliver by cesarean are at increased risk of these infectious complications, the novel observation in this study is that the same was true also for nonurogenital infections, which included pneumonia, appendicitis, and gall bladder disease. This observation suggests that the immediate postpartum period may be a time of generalized immune suppression, thereby placing women at increased risk of systemic disease. If true, this may have profound implications for such issues as peripartum antibiotic chemoprophylaxis, postpartum vaccination, and the development and course of chronic rheumatologic and immunologic conditions. An alternative and equally reasonable explanation might be that the physiologic changes that occur in the pulmonary and gastrointestinal systems in the postpartum period, which include a reduction in minute ventilation and resumption in normal gastrointestinal motility,7 may predispose to symptomatic infection. These questions serve only to highlight our lack of insight into the pathophysiology of the postpartum period.
Before we embark on a national effort to increase awareness about postpartum infectious morbidity, we have to understand some of the limitations of the current study. The study used discharge codes to identify disease cases without confirming the diagnosis in the medical record, which is a study design that is known to have inherent inaccuracies because of case omission or misclassification.8 Moreover, potential confounding variables (such as obesity, diabetes mellitus, and the indication for cesarean delivery) were not controlled for adequately. Regardless of these concerns, the fact that this dataset included >220,000 ethnically diverse women at both high- and low-risk for postpartum complications who delivered in the year 2007 at 114 hospitals across 21 states suggests that these observations are current, robust, and generalizable.
In summary, the first 6 weeks after delivery should continue to be regarded as a high-risk period for women, regardless of the outcome of the pregnancy. The risk of readmission to the hospital during this time period is not insignificant (approximately 1-2%) and is increased after cesarean delivery. In this issue of the Journal, Belfort et al6 report that the risk of readmission for nongenital infectious complications (pneumonia, appendicitis, gall bladder disease) is especially high in the first 6 weeks after delivery, compared with the subsequent few months, which suggests that this period may represent a time of increased susceptibility for systemic infection. The conclusions of this study should not be viewed as the final word on this topic but rather as the beginning of an exciting new avenue of research. More systematic data are needed about the actual risks to both mother and baby in the postpartum period, and more comprehensive strategies must be developed to screen for these potential complications. Although much attention is focused on antepartum and peripartum management, obstetric care providers rarely spend much time with their postpartum patients. Our responsibilities as care providers do not end once the Apgar scores are assigned. We can and should do better.
References
- . Trends in the incidence of venous thromboembolism during pregnancy or postpartum: a 30-year population-based study. Ann Intern Med. 2005;143:697–706
- Impact of a comprehensive patient safety strategy on obstetric adverse events. Am J Obstet Gynecol. 2009;200:492.e1–492.e8
- . Improved outcomes, fewer cesarean deliveries, and reduced litigation: results of a new paradigm in patient safety. Am J Obstet Gynecol. 2008;199:105.e1–105.e7
- . Clinical practice: postpartum depression. N Engl J Med. 2002;347:194–199
- . Are family physicians appropriately screening for postpartum depression?. J Am Board Fam Med. 2005;18:104–112
- Hospital readmission after delivery: evidence for an increased incidence of nonurogenital infection in the immediate postpartum period. Am J Obstet Gynecol. 2010;202:35.e1–35.e7
- . Gastrointestinal transit time in human pregnancy: prolongation in the second and third trimesters followed by postpartum normalization. Gastroenterology. 1985;89:996–999
- The reporting of pre-existing maternal medical conditions and complications of pregnancy on birth certificates and in hospital discharge data. Am J Obstet Gynecol. 2005;193:125–134
Reprints not available from the authors.
PII: S0002-9378(09)00954-5
doi:10.1016/j.ajog.2009.08.028
© 2010 Mosby, Inc. All rights reserved.
Refers to article:
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Hospital readmission after delivery: evidence for an increased incidence of nonurogenital infection in the immediate postpartum period
, 05 November 2009
Volume 202, Issue 1 , Pages 1-4, January 2010
