Postnatal care can be given at all levels by a skilled provider appropriately supported. Postnatal care is the care of the woman in the immediate postpartum period and within 6 weeks of delivery. This is the time the woman is returning to her normal pre-pregnancy status. Targeted postnatal care has a minimum of 3 check ups. The emphasis is starting early in the postpartum period, with the 1st review 24 to 48 hours after delivery, the 2nd review within 2 weeks after delivery, and the 3rd review between 4 and 6 weeks after delivery.
The aim of the postnatal care is to protect and promote maternal and infant health, support breastfeeding, and provide family planning counseling and services.
IMMEDIATE POSTPARTUM CARE
This include the following:
Repairing the episiotomy as soon as possible.
Observing and monitoring maternal BP, pulse and temperature closely for 1-2 hours.
Ensuring that the uterus is well contracted, lochia loss is normal, and urine has been passed.
Encouraging the mother to establish bonding and initiate breastfeeding.
Giving paracetamol 2 tablets TDS for after pain and episiotomy pain and providing rapid counseling and testing for HIV for those whose status is unknown and also giving the prophylactic ARVs to the baby (within 72 hours) if the mother is positive.
Transferring the mother to the postnatal ward.
Continuing the above observations at least twice daily.
Encouraging rooming-in (or “bedding-in”) of mother and baby.
Continuing to give paracetamol 2 tablets TDS.
Advising on nutritious diet, and generous fluid intake for successful lactation.
Giving the baby first immunizations (BCG and first polio).
Documenting and notifying the birth to the civil registrar.
If no problem, discharging after 24-48 hours to avoid ward congestion. Women who deliver at home should come for check up with their babes within 24-48 hours
FOLLOW UP VISITS AND REVIEW
A follow up is carried out at 1-2 weeks to check and treat for secondary PPH, subinvolution of the uterus, puerperal infection, and whether the baby is well and breastfeeding. For those not breastfeeding, the visit and review should be at 1 month for family planning.
Otherwise 3rd visit is at 4-6 weeks to check:
For any problem in mother or baby
Whether periods and/or intercourse has resumed and to provide counseling on family planning, babycare, breastfeeding and immunizations.
At 6 weeks provide family planning service if required. Suitable methods for lactating mothers include:
Progesterone-only pill (e.g., microlut)
Intrauterine device IUCD (“coil”)
Depo-provera or noristerat (“injection:)
Voluntary surgical contraception (VSC): Tubal Ligation
Norplant/jadelle
COMPLICATIONS OF PUERPERIUM
The puerperium is defined as the time period 6 weeks following parturition. This is a time when complex adaptations of physiology and behavior occur in women. Although usually a low risk period, life threatening emergencies or serious complications may occur that must be recognized and managed efficiently. For the majority, however, a minimum of interference is warranted.Those caring for women postpartum should be sensitive to the initiation of family bonding, a special process not to be disturbed unless maternal or neonatal complications arise.
Some of the maternal complications include postpartum haemorrhage, puerperal sepsis, deep venous thrombosis, psychosis, , breast engorgement, mastitis or breast abscess.
POSTPARTUM HAEMORRHAGE (PPH)
Postpartum haemorrhage is a condition that can sometimes be preventable by proper management of all stages of labor. An understanding of the factors that predispose to postpartum hemorrhage will lead to the practice of precautionary measures that minimizes its occurrence. All levels managing labour and delivery (1-6) should be able to diagnose the condition. The skilled health provider should be supported by an effective referral system.. Level 1-3 should refer to level 4-6 after first aid and should send donors.
Postpartum haemorrhage is defined as bleeding from the genital tract after delivery. It is further defined as primary or secondary postpartum haemorrhage.
In primary postpartum haemorrhage: Bleeding of more than 500 ml within the first 24 hours postpartum.
In secondary postpartum haemorrhage: Abnormal bleeding occurring after 24 hours and upto 6 weeks postpartum.
Clinical experience and empiric estimates of blood loss are important for diagnosis of postpartum hemorrhage to be made.
Patients at high risk of developing postpartum haemorrhage include the following:
Prolonged or obstructed labour
Grand multiparity
Past history of PPH
Past history of retained placenta
Multiple pregnancy
Polyhydramnios
Antepartum haemorrhage either placental abruptio or placenta praevia.
The commonest causes of PPH are:
Uterine atony
Failure of adequate contraction and retraction of uterus after delivery associated with:
Prolonged labour
Precipitate labour
Over-distension of the uterus by e.g multiple pregnancy and/or polyhydramnios
Grand multiparity
Fibroids
Halothane use in general anaesthesia
Concealed haemorrhage in placenta abruption leading to intramyometrial haemorrhage and manifested as Couvelaire uterus
Uterine subinvolution.
Retained placental fragments or membranes. This is a common complication in which there is a delay in completion of the 3rd stage of labour due to adherent placenta. Adherent placenta manifest usually as actual placental invasion of the myometrial wall in the following forms:
Placenta accreta: Which is superficial myometrial invasion.
Placenta increta: Which is deep myometrial inversion.
Placenta percreta: Which is uterine perforation by placenta.
Lacerations or tears of the birth canal: This can be cervical, vaginal, or vulvoperineal.
Other causes include disseminated intravascular coagulopathy (DIC), which is usually secondary to other causes like intrauterine foeatal death, amniotic fluid embolism, abruptio placentae, and pre-eclampsis/eclampsia.
Rupture of the uterus where there is a previous scar, oxytocin hyperstimulation, obstructed labour in multigravidae, and use of ecbolic herbs.
Uterine inversion and when there is excessive cord traction, adherent placentae, manual removal of placenta, and poor technique of placental delivery.
Investigations
Hb or PCV, most important
Bleeding time
Clotting time
Coagulation factors
Management
General measures include:
Put up an IV line
Take blood for group and cross-match
Put in a self-retaining catheter, Foley
Determine cause
Specific measures
These depend on the cause
UTERINE ATONY
Do a bimanual uterine massage and express any clots; this may also provoke contractions.
Put up an oxytocin drip 20 units in 500ml dextrose or normal saline to run at 20 drops per minute for about 2 hours.
Give prostaglandins when and where available, as there are also useful:
Misoprostol 600 mcg orally or per rectum
Surgery:
Subtotal hysterectomy if above measures do not achieve haemostasis.
RETAINED AND ADHERENT PLACENTA
Retained placenta also causes uterine atony. The following is recommended:
Apply general measures as above.
For manual removal of placenta in lithotomy position on the delivery couch, administer:
Morphine 10 mg IM STAT
10mg diazepam IV, then
Try manual removal of placenta using the ulnar surface of the right hand with the left hand supporting the uterus. If this is not possible see below.
ADHERENT PLACENTA
This will require management in the major theatre in some cases of placenta accreta for manual removal and limited instrument use.,e.g ovum forceps, blunt curette under general anaesthesia.
Other types will require surgery, i.e ., subtotal hysterectomy.
LACERATIONS/ TEARS OF GENITAL TRACT
Cervical Tear
The following is important for cervical tear:
Review in lithotomy position and in good light.
Secure a good exposure of cervix by two Sims’ speculums.
Carry out a careful evaluation of the extent of tear.
Repair cervix with No.1 chromic catgut under local anaesthesia lignocaine HCL 1%) and achieve haemostasis. Then give antibiotics (PO amoxicillin/clavulanate 625mg BD for 5 days) and PO paracetamol 1g 8 hourly for 3 days.
NB: General anaesthesia may be required if the upper limit of tear is not defined or laparotomy is further required.
Vaginal Tear
The following are important for vaginal tear:
Examine in lithotomy position.
Carry ligation of bleeders and repair of tears and lacerations with No.1 chromic catgut under local anaesthesia (lignocaine HCL 1%).
Carry out evacuation of haematoma. Then give antibiotics (PO amoxicillin/clavulanate 625 mg BD for 5 days) and PO paracetamol 1g 8 hourly for 3 days.
Vulvoperineal Tear
Proper management of episiotomy:
Define upper end.
Stitch vaginal epithelium with continuous Chromic catgut No.1 suture under local anesthesia (lignocaine HCL 1%):
Stitch muscle layer with the same interrupted stitch.
Stitch skin with interrupted catgut.
Repair all other tears.
Then give antibiotics (PO amoxicillin/clavulanate 625mg BD for 5 days) and PO paracetamol 1g 8 hourly for 3 days.
If disseminated intravascular coagulopathy (DIC) develops:
Administer fresh blood.
Administer fresh frozen plasma.
Carryout surgery as appropriate.
RUPTURED UTERUS
Carryout laparotomy and then:
Repair of the tear, or
Hysterectomy.
Give broad spectrum antibiotics ceftriaxone 1g OD for 3 days and analgesics, morphine 10 mg IM 4 hourly for 24 hours.
UTERINE INVERSION
Perform manual replacement:
If inversion is recognized before corpus is trapped,
Carry out manual compression and insertion
Initiate oxytocin drip 20 IU in 500ml 5% dextrose 30 drops per minute until the uterus is well contracted and haemorrhage well controlled.
The inserting fist should remain until the uterine cavity is well contracted.
If above is not possible then:
Give general anaesthesia using halothane to relax the uterus.
Replace and compress the uterus.
Use oxytocin as above.
Leave fist during the G/A till the uterus is well contracted.
If replacement is not successful with the above measures, then hysterectomy and appropriate treatment are recommended.