Chapter 109: Postnatal care

Education for the puerperium and caring for the baby should begin during pregnancy so that a new mother is familiar with the basic principles of motherhood, especially infant feeding.¹ The puerperium is defined as the period of approximately 42 days from the completion of the third stage to the return of the normal physiological state.

It is important to educate postpartum women on care of the baby and breastfeeding, self-care, healing of the genital tract, sexual life and contraception, nutrition and what happens to their bodies and preventive issues. The uterus involutes to non-pregnant size by 6 weeks and the cervical os should be closed by 2–3 weeks post delivery.²

The two-week consultation

Mother:

• take history of birth and any perinatal complications

• check blood pressure, weight (BMI)

• assess how she is adjusting to motherhood

• look for signs/symptoms of postpartum depression

• provide encouragement and advice

• check breastfeeding

Baby:

• measure weight, height and head circumference

• routine baby examination by checking the following:

• – fontanelles

• – eyes (observation, corneal reflexes, white pupil)

• – cardiovascular examination

• – femoral pulses

• – hip tests for dislocation

• – testes fully descended

• – genitalia

• – anal region

• – skin

• – reflexes

The six-week consultation

This is basically a repeat of the previous consultation—a checklist is presented in TABLE 109.1.

Lactational amenorrhoea method (LAM) (CHAPTER 99) is an effective contraceptive for the first 6 months, but only if the woman remains amenorrhoeic. Because some women ovulate before their period returns, breastfeeding women are usually advised to use an additional method of contraception if they wish to avoid pregnancy.

Oral contraception

Delay to after 21 days because of the risk of thrombosis (COC) and bleeding (POP).

• The progestogen-only pill (mini pill) norethisterone 350 mcg/day

  or

  levonorgestrel 30 mcg/day

• While breastfeeding, it is safe to transfer to COC at 6 months

The POP is effective after 3 tablets have been taken. Adherence may be difficult with the POP given the strict daily 3-hour timeframe for maximum efficacy.

Etonogestrel implant (Implanon) can be inserted in the immediate postpartum period. An IUD, if used, should be fitted at or after 6 weeks.²

After-pains, which are more common and most intense after the second and subsequent pregnancies, are characterised by intermittent lower abdominal pains, like period pains, which are often worse during and after feeding in the first 2 weeks. They are caused by oxytocin released from the posterior pituitary, which also causes the milk ejection (let-down) reflex of nursing. Suspect endometritis if there is offensive lochia, fever and poor involution of uterus.

Treatment, after examination, is reassurance and analgesics in the form of paracetamol every 4 hours for 3 days or as long as necessary.

Insufficient milk supply

Studies have shown that many women wean because of low milk supply. The problem is due mainly to lactation mismanagement such as poorly timed feeds, infrequent feeds and poor attachment. A milk ejection reflex (formerly called ‘let-down reflex’) is necessary to get the milk supply going. Sometimes this reflex is slow and inhibited by pain from the birth canal or breasts, stress, shyness or lack of confidence about breastfeeding. Another factor in low milk supply is the mother underestimating her production capacity. If there is insufficient supply, the baby tends to demand frequent feeds, may continually suck its hand and will be slow in gaining weight.¹ Also consider tongue tie as a cause, especially if breast attachment is affected (see CHAPTER 92).

Important factors in establishing breastfeeding:

1. positioning and attachment of the baby on the breast

2. the milk ejection reflex

3. supply and demand

4. intact milk ducts and sensory nerves

5. sufficient glandular breast tissue

6. infant being able to feed

The breasts produce milk on the principle of supply and demand. This means that the more the breasts are emptied, the more milk is produced.

Signs of low supply:

• poor weight gain

• dark, hard, infrequent stools

• <6 wet nappies per day

Advice to the mother

• Try to practise relaxation techniques.

• Put the baby to your breast as often as it demands, using the ‘chest to chest, chin on breast’ method.

• Feed more often than usual.

• Feed at first signs of baby’s readiness to feed.

• Express after feeds if possible, because the emptier the breasts and the more nipple stimulation, the more milk will be produced.

• Make sure you get adequate rest, eat well and drink ample fluids (drink to thirst).

• If you feel more tired than expected, consider investigations: FBE, iron studies, TFTs, blood glucose and vitamin B12.

Lactation stimulation

Lactation can be improved by more frequent breastfeeding and correct position and attachment. Consider domperidone as a galactagogue for increasing milk supply.

• domperidone 10 mg (one tablet) tds for 2–4 weeks, reducing slowly once an adequate breast-milk supply is established. Women with persistent low milk supply may increase to 20 mg three times a day (maximum 60 mg day).

Engorged breasts

Engorgement occurs when the milk supply comes on so quickly that the breasts become swollen, hard and tender. There is an increased supply of blood and other fluids in the breast as well as milk. The breasts and nipples may be so swollen that the baby is unable to latch on and suckle. Once again, lactation mismanagement is a key factor. If a newborn is attached properly and feeds often and liberally, engorgement should not happen.

Advice to the mother

• Feed your baby on demand from day 1 until the baby has had enough.

• Finish the first breast completely; maybe use one side per feed rather than some from each breast. Offer the second breast if the baby appears hungry.

• Soften the breasts before feeds or express with a warm washcloth or shower, which will help to get the milk flowing.

• Express a little milk before putting the baby to your breast (especially if the baby has trouble latching) and express a little after feeding from the other side if it is too uncomfortable.

• Massage any breast lumps gently towards the nipple while feeding.

• Apply cold packs after feeding and cool washed cabbage leaves (left in the refrigerator) between feeds. Change the leaves every 2 hours.

• Consider waking your baby for a feed if your breasts are uncomfortable or if the baby is sleeping longer than 4 hours.

• Use a good, comfortable bra.

• Take ibuprofen or paracetamol regularly for severe discomfort.

Regular feeding and following demand feeding is the best treatment for engorged breasts.

Suppression of lactation^3,4

Women may seek suppression of lactation for a variety of reasons such as weaning the baby, not wishing to breastfeed initially, or after stillbirth.

Mechanical suppression

The simplest way of suppressing lactation once it is established is to transfer the baby gradually to a bottle or a cup over a 3-week period. The decreased demand reduces milk supply, with minimal discomfort. If abrupt cessation is required, it is necessary to avoid nipple stimulation, refrain from expressing milk and use a well-fitting bra. Use cold packs and analgesics as necessary. Engorgement will gradually settle over a 2–3 week period.

Hormonal suppression

Hormonal suppression can be used for severe engorgement but only as a last resort. It is more effective if given at the time of delivery but may produce side effects. Avoid oestrogens. cabergoline 1 mg (o) statim (once only)

Drugs affecting lactation

Drugs that can affect lactation or a breastfed infant are listed in TABLE 109.2. Most drugs can be compatible and tolerated, but check with prescribing guidelines. Consider risk versus benefit.

Nipple problems with breastfeeding

Causes of nipple trauma:

• attachment problems (most common)

• infection—bacterial, ‘thrush’ or viral

• vasospasm

• dermatitis (e.g. contact dermatitis)

Sore nipples⁴

Sore nipples are a common problem, thought to be caused by the baby not taking the nipple into its mouth properly, often because of breast engorgement. The problem is preventable with careful attention to the feeding position of the baby. A well-attached baby sucking strongly should not cause nipple trauma.

Advice to the mother

It is important to be as relaxed and comfortable as possible (with your back well supported) and for your baby to suck gently.

• Try to use the ‘chest to chest, chin on breast’ feeding position.

• Vary the feeding positions (make sure each position and attachment is correct).

• Start feeding from the less painful side first if one nipple is very sore.

• Express some milk first to soften and ‘lubricate’ the nipple.

• Gently break the suction with your finger before removing the baby from the breast.

• Apply covered ice to the nipple to relieve pain.

• Keep the nipples dry by exposing the breasts to the air and/or using a hair dryer on a low setting.

• Try soothing hydrogel pads inside the bra.

Note: Raynaud phenomenon, i.e. nipple vasospasm, can affect the nipple and cause painful breastfeeding. It is often mistaken for Candida albicans infection.

Cracked nipples

Cracked nipples are usually caused by the baby clamping on the end of the nipple rather than applying the jaw behind the whole nipple. Not drying the nipples thoroughly after each feed and wearing soggy breast pads are other contributing factors. Untreated sore nipples may progress to painful cracks.

Symptoms

At first, the crack may be so small that it cannot be seen. The crack is either on the skin of the nipple or where it joins the areola. A sharp pain in the nipple with suckling probably means the crack has developed. Feeding is usually very painful, and bleeding can occur.

Advice to the mother

Cracked nipples should heal if the baby begins to latch onto the breast fully and properly. They usually take only 1–2 days to heal.

• Follow the same rules as for sore nipples.

• Do not feed from the affected breast—rest the nipple for 1–2 feeds.

• Express the milk from that breast by hand.

• Feed that expressed milk to the baby.

• Start feeding gradually with short feeds.

• Seeking the opinion of an expert lactation consultant may be of benefit. Consider use of a nipple shield only after seeking face-to-face expert advice.

• Take paracetamol or ibuprofen just before feeding to relieve pain.

Inverted nipples

An inverted nipple is one that inverts or moves into the breast instead of pointing outwards when the baby tries to suck from it. When the areola is squeezed, the nipple retracts inwards.

Treatment⁴

The best approach is good preparation with prolonged breast contact and feeding prior to milk ‘coming in’ and knowledgeable helpers giving advice and confidence. If a baby continues to have ongoing problems with attachment, a nipple shield may be helpful.

Mastitis, which has a high incidence (up to 20%), is basically cellulitis of the interlobular connective tissue of the breast (see CHAPTER 100). Usually restricted to lactating women, it is caused mainly by a cracked nipple or poor milk drainage. Not all mastitis is infective. Many instances are related to milk not being drained adequately and will improve if appropriate breastfeeding technique is followed. A blocked duct or ducts may be the cause. It is a serious problem and requires early treatment. Breastfeeding from the affected side can continue as the infection is confined to interstitial breast tissue and doesn’t usually affect the milk supply.

Note: Mastitis must be treated vigorously—it is a serious condition. Refer to CHAPTER 100.

Bacterial mastitis

Clinical features

• A lump and then soreness (at first)

• A red, wedge-shaped, possibly tender, area

• Fever, tiredness, muscle aches and pains

Management

Prevention (in lactation).

Rule: ‘Heat, rest and drain the breast’.

• Keep feeding and frequently.

• Maintain free breast drainage.

• Attend to breast engorgement and cracked nipples. If symptoms persist >24 hours or patient is unwell, commence antibiotics.⁵

• Antibiotics: resolution without progression to an abscess will usually be prevented by antibiotics:

  dicloxacillin 500 mg (o) qid for at least 5 days

  or

  flucloxacillin 500 mg (o) qid for at least 5 days

  or

  cephalexin 500 mg (o) qid for at least 5 days

  If severe cellulitis:

  flucloxacillin 2 g IV 6 hourly

• Ibuprofen or paracetamol for pain

Instructions to patients

• Keep the affected breast well drained.

• Continue breastfeeding: do it frequently and start with the sore side or begin feeding from the normal side until the milk comes and then switch to the sore side.

• Heat the sore breast before feeding (e.g. hot shower or hot washcloth).

• Cool the breast after feeding: use a cold face washer from the freezer.

• Massage any breast lumps gently towards the nipple while feeding.

• Empty the breast well: hand express if necessary.

• Get sufficient rest.

• Keep to a nutritious diet and drink ample fluids.

Breast and nipple candidiasis

Clinical features

• Painful breasts—often exquisite pain especially during and after feeding

• No fever

• Nipple pain and sensitivity

• Usually but not always bilateral

• Nipples can be pink and shiny

• ± Pink haloes around the base of the nipple

• Breasts usually normal: no heat, lumps or tender points

Note: May follow a course of antibiotics. Swabs are of limited value.

Treatment

• fluconazole 150 mg (o) every second day for 3 doses⁵ then oral nystatin (o) tds for 10 days miconazole gel qid to nipple after feeds

Treat the baby with oral nystatin drops or miconazole oral gel.

Breast abscess

If tenderness and redness persist beyond 48 hours and an area of tense induration develops, then a breast abscess may have formed. It can be treated with needle aspiration or may require surgical drainage under general anaesthesia.

For a description of surgical and other management refer to CHAPTER 100.

Secondary postpartum haemorrhage^2,6

Secondary postpartum haemorrhage is any bright bleeding from the birth canal 24 hours or more after delivery. It may vary from very slight to torrential and may occur at any time up to 6 weeks postpartum. It tends to peak at 5–10 days.

Causes

• Retained products of conception (PoC)

• Infection, especially at placental site

• Laceration of any part of the birth canal

• Coagulation disorder

• Rarely due to gestational trophoblastic disease

No cause is found in one-third of cases (i.e. idiopathic subinvolution).

Treatment

Rule: An empty and contracted uterus will not bleed.

• Investigation:

  • – ultrasound (? retained PoC)

  • – cervical swab for culture

  • – FBE

  • – beta hCG

• IV oxytocin 10 IU followed by infusion of 40 IU in Hartmann’s solution

• Ergometrine 250 mcg IM or 25–50 mcg slowly IV (if continuing heavy bleeding)

• Consider misoprostol, 4 or 5 × 200 mcg tablets per rectum or otherwise by intramyometrial injection of prostaglandin F2 alpha (caution: specialist supervision)

• Exploration under general anaesthetic if blood loss >250 mL:

  • – gentle blunt curettage required in the postpartum uterus (aim to prevent uterine adhesions—Asherman syndrome)

• Consider blood transfusion if Hb is <100 g/L

• Antibiotics (e.g. amoxycillin/clavulanate + metronidazole + gentamicin while awaiting culture)

• Consider Bakri balloon tamponade and uterine packing for major PPH

Note: Referral is necessary after the oxytocin/ergometrine injection. Occasionally a life-saving hysterectomy or ligation of the internal iliac arteries may be necessary.

Lochia discharge

The discharge of lochia, which is blood and sloughed-off tissue from the uterine lining, should be monitored.

Normal:

1. bloody loss = lochia rubra: 2–12 days

2. serous loss = lochia serosa: up to 20 days

3. white loss = lochia alba

4. offensive lochia = endometritis

Lochia loss persists for 4–8 weeks. Abnormal lochia rubra may indicate retained PoC or endometritis. If there is a problem, examine with a speculum and take cervical/vaginal swab.

Puerperal fever

Puerperal fever is defined as raised temperature of ≥ 38°C from day 1 to day 10. If fever, think of the three Bs—birth canal, breast, bladder. The cause is genital infection in about 75% of patients. Endometritis presents with offensive lochia, abdominal pain and a tender uterus. Other causes include urinary tract infection, mastitis and an intercurrent respiratory infection. Investigations include a vaginal swab for microscopy, culture and sensitivities and a midstream specimen of urine for microscopy and culture, blood culture and an FBE.

Treatment

• amoxycillin/potassium clavulanate plus metronidazole (while awaiting sensitivities)

Beware of severe puerperal sepsis such as gram-negative septicaemia or Clostridium welchii septicaemia and the rare Bacteroides fragilis.

Hormonal changes, fatigue, adjustment and physical changes can all contribute to mood changes in the postnatal period. There are three separate important problems:

1. postnatal blues

2. postnatal adjustment disorder

3. postnatal (or postpartum) depression

Postnatal blues

‘The blues’ is a very common problem (occurs in 80%) that arises in the first 2 weeks (usually days 3–10) after childbirth.

Clinical features

• Feeling flat or depressed

• Mood swings

• Irritability

• Feeling emotional (e.g. crying easily)

• Feeling inadequate

• Tiredness

• Sleep disturbance unrelated to baby’s sleep needs

• Lacking confidence (e.g. in bathing and feeding the baby)

• Aches and pains (e.g. headache)

Fortunately, ‘the blues’ is a passing phase and lasts about 4–14 days. Management is based on support, reassurance and basic counselling. Contact friends and relatives to help.

Advice to the mother³

• Rest as much as possible.

• Accept help from others in the house.

• Talk about your concerns with a good listener.

• This is common and should improve within a week or two.

If ‘the blues’ lasts longer than 14 days, it is very important to contact your doctor.

Postnatal adjustment disorder

• Occurs in first 6 months

• Similar symptoms to ‘the blues’

• Anxiety with handling baby

• Psychosomatic complaints

• Fearful of criticism

Treatment

• Support and reassurance

• Cognitive therapy

• Parentcraft support

• Settles with time

Postnatal depression

Some women develop a very severe depression after childbirth. Always consider it in the frequent attender. Symptoms are present for at least 2 consecutive weeks, with onset in the first few days postpartum. It should be treated as for major depression. (See CHAPTER 19 for an overview.)

• Occurs in 10–30% women

• In first 6–12 months (usually first 6 months: peaks about 12th week)

• Anxiety and agitation common

• Marked mood swings

• Poor memory and concentration

• Typical depressive features

Use the Edinburgh Postnatal Depression Scale (a score of 12 or more is significant).

Treatment

• Support, reassurance, counselling

• Group psychotherapy and support group (e.g. <www.panda.org.au>)

• Couple therapy (must involve partner)

• Postnatal depression support group

• Parentcraft support

• Hospitalisation may be necessary (especially if suicidal or infanticidal ideations)

• Medication—SSRIs (sertraline, paroxetine—agents of choice)

• Closely monitor any risk of self-harm

• Consider referral if poor response to treatment in 2 weeks

Note: Beware of puerperal psychosis with onset usually within first 2 weeks.

The most common postpartum psychosis is an affective disorder: mania or agitated depression. It is treatable and requires urgent attention. Symptoms that appear within the first month include unusual behaviour, agitation, delusions, hallucinations, mania and suicidal ideations.

It is rare, occurring in about 1:500 births.

Past history may be a pointer. Suspect if severe depression not responding to treatment. An important differential diagnosis is delirium with puerperal fever. Check thyroid function and organise inpatient psychiatric care. There is an increased risk of further episodes with subsequent pregnancies.

Sleep deprivation

Give advice and counselling. Use the ‘sleep when baby sleeps’ rule. Avoid sedatives. Insomnia experienced when the baby finally sleeps should raise suspicion of postnatal depression.

Tiredness

Tiredness is very common in the first few months after delivery. It may be a presenting symptom of anaemia, depression, hypothyroidism, anxiety or depression (in particular).

Perform FBE, TFTs, iron studies, B12, blood glucose and urinalysis.

Postpartum thyroid dysfunction⁶

Postpartum thyroiditis may be misdiagnosed as postpartum depression and should always be considered in the tired, apparently depressed woman in the first 6 months after delivery. It is common in women with pre-existing autoimmune thyroid disorders and often flares up in this period. It must be differentiated from new onset or relapsing Graves disease indicated by positive anti-thyroid stimulating hormone receptor antibodies. Women who have had postpartum thyroid dysfunction are at greater risk of developing hypothyroidism within 10 years postpartum.

The initial phase of hyperthyroidism is often followed by a phase of temporary hypothyroidism, with eventual return towards normality. Beta blockers are useful during the hyperthyroidism phase, while short-term replacement with thyroxine can be required in the hypothyroid phase.

Hair loss

Increased hair shedding as telogen effluvium is common about 3–4 months after delivery. Large clumps of hair with white bulbs come out easily with combing or shampooing. Reassure that it reverts to normal in 3–6 months.

Sexual difficulties

Decreased libido is a common problem and often related to sleep deprivation, as well as hormonal changes. Decreased libido can also be due to one of the postnatal depressive disorders or to tension in adjusting to the new relationships.²

Dyspareunia is common, especially following an episiotomy or vaginal tear, and should be treated symptomatically and with education. Simple lubrication or vaginal oestrogens can help until perineal healing is achieved. A topical corticosteroid may be appropriate for scar tissue that appears inflamed.

Early intercourse is risky with deaths from air embolism reported in the first 2 weeks. Intercourse is not advisable in the first 6 weeks.

Elimination disorders³

Always enquire how the patient is coping with her bowels and urination. Simple advice such as stool softening and pelvic floor exercises will help. However, serious problems such as faecal incontinence secondary to a fistula from a third-degree tear or urinary retention due to neuropraxia of the pelvic floor can develop and need urgent attention.

Hand-out sheets from Murtagh’s Patient Education 7th edition:

• Breastfeeding and milk supply

• Establishing breastfeeding

• Mastitis with breastfeeding

• Nipple problems with breastfeeding

• Postnatal depression