Postpartum Care
Postpartum questions test your ability to recognize deterioration early and to know which medications are unsafe in which patient.
Hemorrhage
Use quantitative blood loss. Postpartum hemorrhage is more than 1000 mL or any bleeding with signs of hypovolemia. Think of the four Ts: tone, trauma, tissue, thrombin. Uterine atony is most common; begin with fundal massage, empty the bladder, and oxytocin. Second-line agents carry hard contraindications: methylergonovine with hypertension or preeclampsia, carboprost with asthma, and misoprostol with caution for fever. Tranexamic acid is given within 3 hours. Escalate to tamponade, balloon, embolization, or hysterectomy. Late hemorrhage at 1–2 weeks suggests retained products or subinvolution.
Preeclampsia and magnesium
Postpartum preeclampsia can appear up to 6 weeks after delivery, sometimes in patients with no antepartum hypertension. With magnesium sulfate, monitor deep tendon reflexes, respiratory rate at least 12, and urine output at least 30 mL/h. Early toxicity shows loss of reflexes, then respiratory depression and oliguria; the antidote is calcium gluconate.
Systematic assessment
Use a head-to-toe structure: breasts, uterus, bladder, bowel, lochia, episiotomy or incision, and extremities. A distended bladder displaces the uterus and promotes atony. Endometritis causes fever, uterine tenderness, and foul lochia and requires antibiotics. Encourage early ambulation and sequential compression devices for venous thromboembolism prevention. Give RhoGAM within 72 hours to an unsensitized Rh-negative patient with an Rh-positive infant, and MMR postpartum to a nonimmune patient with counseling to avoid pregnancy for 4 weeks. Screen for depression with a validated tool; postpartum psychosis is an emergency.
Worked example
Lochia that has turned serosa and then returns to bright red with increased flow is a warning sign of hemorrhage or retained products, not normal involution.