Postpartum Care and Lactation Support
Postpartum care questions test active third-stage management, recognition of haemorrhage and sepsis, breastfeeding assessment and common lactation problems. The exam favours practical decisions: what to do in the first hour, when to refer, and what to tell a mother about feeding.
Core rules and concepts
- Active management of the third stage: oxytocin 10 IU intramuscularly (or 5 IU slow IV) after delivery of the baby, controlled cord traction and uterine tone assessment. Postpartum haemorrhage is blood loss over 500 mL.
- Inspect the placenta and membranes for completeness. Retained products cause bleeding and infection.
- Lochia: rubra for 3–4 days, serosa to about 10 days, then alba. Offensive or prolonged lochia suggests infection or retained tissue.
- Breastfeeding: skin-to-skin contact and initiation within the first hour; exclusive breastfeeding for 6 months; feed on demand, at least 8–12 times in 24 hours.
- Effective feeding: wide gape, chin to breast, more areola visible above than below, slow deep sucks, audible swallowing and no nipple pain.
- Engorgement: bilateral fullness, mild fever below 38°C and no focal erythema. Manage with frequent feeding, cold packs and analgesia.
- Mastitis: focal redness, pain, fever of 38°C or higher and flu-like symptoms. Continue breastfeeding, give flucloxacillin and review in 24–48 hours.
- RhD-negative unsensitised woman with an RhD-positive baby: anti-D within 72 hours. Offer rubella vaccination postpartum if non-immune; assess venous thromboembolism risk and mental health.
Worked example
On day 4, a breastfeeding woman has a tense, painful left breast, temperature 38.4°C and a wedge-shaped red area. Reasoning: this is infective mastitis, not simple engorgement. She should continue feeding on that side, take regular analgesia and start flucloxacillin. If there is no improvement in 24–48 hours, refer for ultrasound to exclude an abscess.
Traps
- Advising a mother to stop breastfeeding with mastitis.
- Treating engorgement with antibiotics routinely.
- Missing retained placenta because lochia is still red.
- Forgetting anti-D after delivery when the baby is RhD-positive.
- Attributing all postpartum fever to breast engorgement.
Key points
- Active third stage: oxytocin, controlled cord traction and uterine tone check.
- Postpartum haemorrhage is over 500 mL; escalate early and use tranexamic acid.
- Mastitis: continue feeding, give flucloxacillin and review in 24–48 hours.
- Engorgement is usually bilateral; mastitis is focal and infective.
- Give anti-D within 72 hours of delivery if the baby is RhD-positive.