Postpartum Care and Lactation
Core concepts
Postpartum care covers hemorrhage prevention and recognition, infection, mood disorders, contraception, and lactation support. Understand the causes of postpartum hemorrhage (the four T's: tone, trauma, tissue, thrombin) and the stepwise uterotonic approach (oxytocin, then methylergonovine, carboprost, misoprostol) with contraindications (methylergonovine in hypertension; carboprost in asthma). Know endometritis (fever, uterine tenderness, foul lochia; polymicrobial; treat with clindamycin plus gentamicin) and mastitis (Staphylococcus aureus; continue breastfeeding). Screen for postpartum depression with a validated tool. Lactation counseling includes positioning, frequency, and recognizing insufficient intake (weight loss, low output).
Traps
A frequent trap is stopping breastfeeding during mastitis - current guidance supports continued drainage. Another is prescribing methylergonovine to a preeclamptic patient. Questions may also test that late postpartum hemorrhage (after 24 hours) is often due to retained products or subinvolution rather than uterine atony alone.
Rule of thumb
For postpartum hemorrhage, follow the four T's in order, start oxytocin, and add agents based on contraindications; escalate to surgery or transfusion for refractory bleeding.