Gestational context
After delivery
booking
12w
anatomy
24w
28w
36w
term
The postpartum round
- Bleeding: lochia rubra to serosa to alba over weeks; heavy bleeding or clots after the first day is secondary PPH (retained tissue, endometritis).
- Fundus: firm, descending about a fingerbreadth a day; tender or boggy is a sign.
- Perineum or wound: pain, healing, signs of infection; a caesarean wound is checked and the dressing removed at 24 to 48 hours.
- Bladder and bowels: retention after epidural or a long labour; constipation; haemorrhoids.
- Breasts: engorgement (day 3 to 5), latch, nipple trauma, the red wedge of mastitis.
- Legs: calf tenderness or swelling; VTE risk assessment and prophylaxis where indicated.
- Vital signs and, in hypertensive disorders, blood pressure that can peak on day 3 to 6.
- Mood, sleep, support, safety at home. Rh status and anti-D within 72 hours if the infant is Rh positive. Rubella and varicella vaccination if non-immune.
Postpartum fever
| Cause | Clues |
|---|---|
| Endometritis | Fever, uterine tenderness, foul lochia, usually day 2 to 5, more after caesarean; broad-spectrum antibiotics |
| Wound infection | Erythema, discharge, day 4 to 7 |
| Urinary tract infection | Dysuria, catheter, frequency; pyelonephritis if flank pain |
| Mastitis | A red painful wedge of breast, usually week 2 to 3; continue feeding, antibiotics; abscess if fluctuant |
| Venous thromboembolism | Unexplained fever with leg symptoms or dyspnoea; septic pelvic thrombophlebitis if fever persists despite antibiotics |
| Retained products | Fever with heavy bleeding; ultrasound and evacuation |
Mood
| Postpartum blues | Postpartum depression | Postpartum psychosis |
|---|---|---|
| Up to 80 percent; days 3 to 10; tearful, labile, resolves within two weeks | 10 to 15 percent; within the first year; the same criteria as major depression; screen with the Edinburgh scale | 1 to 2 per 1000; first two weeks; confusion, delusions, hallucinations, mania |
| Reassurance and support | Psychotherapy, SSRIs (sertraline is compatible with breastfeeding), support; ask about thoughts of self-harm and of harming the baby | A psychiatric emergency: admission, usually to a mother-and-baby unit; high suicide and infanticide risk |
Contraception and the next pregnancy
- Ovulation can return by 3 to 4 weeks in a non-breastfeeding patient; contraception is discussed before discharge.
- Lactational amenorrhoea is reliable only with exclusive feeding, amenorrhoea and under 6 months.
- Oestrogen-containing methods are avoided for the first 3 weeks (VTE) and for 6 weeks in breastfeeding; progestin-only methods, IUDs (immediately postplacental or from 4 weeks) and implants are unrestricted.
- An interpregnancy interval under 18 months carries higher risks of preterm birth and, after caesarean, of rupture in a trial of labour.