Postpartum Care
Core concepts
The postpartum period carries most of the catastrophic maternal events, so prioritize hemorrhage, hypertension, infection, and thromboembolism. Quantitative blood loss of ≥1000 mL, or bleeding with hypovolemic signs within 24 hours, defines postpartum hemorrhage; visual estimation underestimates loss. Manage uterine atony with fundal massage, oxytocin, then additional uterotonics, and escalate early to transfusion or surgery. Remember the four T's: tone, trauma, tissue, thrombin.
Know normal involution, lochia progression, perineal and cesarean wound care, breastfeeding support, and contraception timing-including that ovulation can precede the first menses. Screen for perinatal mood and anxiety disorders at every contact, and schedule a comprehensive visit within 3 weeks and again by 12 weeks.
Traps
Delayed postpartum preeclampsia can present up to 6 weeks after delivery, often with headache, visual change, or dyspnea rather than extreme hypertension. Endometritis after cesarean typically appears as fever plus uterine tenderness; mastitis is usually unilateral with a wedge-shaped erythema. Do not treat lochia that changes from serosa back to small amounts of red as automatically abnormal, but do evaluate heavy bleeding, foul odor, or fever.
Worked example
Day 5 postpartum, BP 158/102, headache, no prior hypertension: treat as postpartum preeclampsia-labs, magnesium sulfate for severe features, antihypertensives, and readmission. Do not attribute it to sleep deprivation.
Rule of thumb
Any postpartum fever, heavy bleeding, severe headache, or leg pain is a rule-out, not a wait-and-see.