The postpartum period, or puerperium, starts about an hour after the delivery of the placenta and includes the following six weeks. Postpartum care should respond to the special needs of the mother and baby during this special phase (see tables 1 and 2) and should include: the prevention and early detection and treatment of complications and disease, and the provision of advice and services on breastfeeding, birth spacing, immunization and maternal nutrition.

Postpartum hemorrhage is the single most important cause of maternal death. It kills 150,000 women each year and nearly nine out of ten of these deaths take place within four hours of delivery. A woman who is anemic is usually less able to cope with blood loss than a woman who is well nourished. During the first hours after the birth, the care-giver has to make sure that the uterus remains well contracted and that there is no heavy loss of blood. If the bleeding is particularly severe blood transfusion may be the only way of saving a woman’s life.

Puerperal infections such as sepsis are still major causes of maternal mortality in many developing countries. Fever is the main symptom and antibiotics the main treatment, though prevention by ensuring cleanliness and hygiene at delivery is obviously the best course of action.

Eclampsia is the third most important cause of maternal mortality worldwide. A woman suffering from eclampsia or severe pre-eclampsia the first days postpartum should be hospitalized. The treatment of choice is magnesium sulphate.

Table 1 Needs of women

In the postpartum period, women need:
information/counseling on:
- care of the baby and breast feeding
- what happens to their bodies - including signs of possible problems
- self care - hygiene and healing
- sexual life
- contraception
- nutrition

support from
- health care providers
- partner and family: emotional, psychological

health care for suspected or manifest complications
time to care for the baby
help with domestic tasks
maternity leave
social reintegration into her family and community
protection from abuse/violence.
Women may fear:
- inadequacy
-loss of marital intimacy
-isolation
-constant responsibility of caring for the baby and others

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Table 2 Needs of newborn infants

In the postnatal period newborn infants need:
easy access to the mother
appropriate feeding
adequate environmental temperature
a safe environment
parental care
cleanliness
observation of body signs by someone who cares and can take action if necessary
access to health care for suspected or manifest complications
nurturing, cuddling, stimulation
protection from
- disease
- harmful practices
- abuse/violence

acceptance of
- sex
- appearance
- size

recognition by the state (vital registration system)

Other common postpartum complications include urinary tract problems such as infections, urine retention or incontinence. Many women also experience pain in the perineum and vulva for several weeks, especially if there was tissue damage or an episiotomy during the second stage of labor. The woman’s perineum should be regularly inspected to make sure it is not infected.

Psychological problems in the postpartum period are also not uncommon. These problems can be lessened by adequate social support and support from trained care-givers during pregnancy, labor and postpartum period.

The nutritional status of the woman during adolescence, pregnancy and lactation has a direct impact on maternal and infant health in the puerperium. Women’s intake postpartum should be increased to cover the energy cost of lactation. The three main vitamin or mineral nutritional deficiencies in the postpartum period are iodine deficiency disorders, vitamin A deficiency and iron deficiency anemia. The main causes of micronutrient malnutrition are inadequate intake of foods providing these micronutrients and their impaired absorption or utilization. Preventive and treatment measures include ensuring regular intake of appropriate foods, food fortification, giving supplements to pregnant and lactating women and infants and children.

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The newborn’s health and well-being can also be affected by a variety of conditions. The most common causes of death and disability in the postnatal period include prematurity, neonatal sepsis, respiratory infections, neonatal tetanus and cord infections, congenital anomalies, and birth trauma or asphyxia. Babies that are pre-term or have a low birth weight are more prone to low body temperature, more likely to succumb to infection, more often need to be resuscitated, and are more difficult to feed. Mothers and health workers can help avoid dangerous heat loss by making sure the room is warm and that the baby is kept next to its mother.

Infections are still a major threat to newborn infants in developing countries. Like puerperal sepsis in the mother, the extent can be reduced dramatically by making sure that the birth takes place in hygienic conditions and that those present observe basic rules of cleanliness such as hand washing.

Jaundice is quite common in newborns and usually clears up without treatment, but it can be especially dangerous in pre-term or low birth weight babies. Ophthalmia neonatorum is a discharge from the eyes that occurs within the first two weeks of life but can be prevented by application of ointment or eye drops in the first hour after birth.

The establishment and maintenance of breastfeeding should be one of the major goals of postpartum care. Breast milk provides optimal nutrition for newborn infants, protects them against infections and allergies and promotes mother-infant bonding. The baby should be given to the mother to hold immediately after delivery, to provide skin-to-skin contact and for the baby to start suckling as soon as s/he shows signs of readiness - normally within ½-1 hour after birth. In institutions babies should be kept with their mother and unrestricted breastfeeding should be allowed. Mothers need help and advice on how to breastfeed. Supplementary feeds should be avoided.

During the postpartum period women need counseling on contraception. Methods include the progestin-only pill, a depot-medroxyprogesterone acetate (DMPA) injection, an intrauterine device (IUD), or barrier methods such as a diaphragm or condoms. Combined oral contraceptives should be avoided during the first months of lactation.

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The postpartum period is an important opportunity to counsel women, their partners and their families about the decision to carry out an HIV test if the opportunity was missed during pregnancy. If a test is positive, counseling needs to be given on possible treatment or preventive measures. In many resource-poor settings, the risks of diarrhoeal disease or malnutrition due to improper or inadequate preparation of artificial milk outweigh the risk of contracting HIV through breastfeeding. Maternity services should take the necessary preventive measures to protect health care workers and mothers against infection.

All mothers should be immunized with at least two doses of tetanus oxide to protect both themselves and their newborns. The third dose is given 6 months after the second and the last two doses are given after at least one year or during a subsequent pregnancy. Where there is a high risk of tuberculosis infection, BCG immunization should be given to infants soon after birth. Diphtheria-pertussis-tetanus vaccine is recommended for all children at 6, 10 and 14 weeks. A single dose of oral polio should be given at birth or within the first two weeks of life, and the normal polio immunization schedule should follow at 6, 10 and 14 weeks. Where perinatal transmission of hepatitis B is frequent, the first dose of hepatitis B vaccine should be given as soon as possible after birth and should be followed by further doses at 6 and 14 weeks.

Postpartum services should be based on the needs and health challenges outlined above, incorporate all the essential elements required for the health of the mother and her newborn, and should be provided in an integrated fashion. Skilled care and early identification of problems could reduce the incidence of death and disability, together with the access to functional referral services with effective blood transfusion and surgical capacity. With regard to timing of postnatal visits, there seem to be "crucial" moments when contact with the health system or caregiver could be instrumental in identifying and responding to needs and complications. These can be resumed in the formula (which should not be interpreted rigidly) of "6 hours, 6 days, 6 weeks and 6 months". Table 3 below summarizes the broad lines of care that can be offered at each point of contact during the puerperium. More important than a rigid but unfeasible visiting schedule is the possibility for all women to have access to a health care provider when she needs it.

There is a need to provide a solid infrastructure for the provision of a service which is comprehensive, culturally sensitive and which responds to the needs of childbearing women and their families. Elements of this infrastructure include policy, service and care provision, tool development, training and human resource issues, health protection and promotion and research

Key elements of postpartum care:

6-12 hours	3- 6 days	6 weeks	6 months
For Baby: breathing warmth feeding cord immunization	feeding infection routine tests	weight/feeding immunization	development weaning
For Mother: blood loss pain BP advice/warning signs	breast care temperature/infection lochia mood	recovery anemia contraception	general health contraception continuing morbidity

If questions arise during your pregnancy that are not answered here, please contact us during office hours or via our secure on-line form.

If a question or problem is urgent or a emergency, a physician on call will be able to help you 24 hours a day by calling 508-730-1666. Rhode Island patients can reach us by calling 888-543-4121.

Extreme emergency - Dial 911

If your concern is not an emergency, remember to write it down and bring it to your next office visit. We look forward to helping you to have a safe pregnancy and a healthy, beautiful baby.

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