managing-postpartum-care

# Managing Postpartum Care

Structures postpartum assessment with hemorrhage surveillance, lactation support, mood screening, and recovery milestones per ACOG Committee Opinion No. 736 (the "fourth trimester" framework).

## Why This Skill Exists

The postpartum period accounts for over 60% of maternal deaths in the United States, with hemorrhage, cardiomyopathy, and hypertensive disorders as leading causes. ACOG's Fourth Trimester initiative (Committee Opinion No. 736) redefined postpartum care from a single 6-week visit to an ongoing process with early contact within 3 weeks and a comprehensive visit by 12 weeks. Postpartum hemorrhage (PPH) remains the most common cause of severe maternal morbidity, and the California Maternal Quality Care Collaborative (CMQCC) OB Hemorrhage Bundle provides the standard of care for staged response.

Equally critical is screening for postpartum depression (PPD), which affects 10–20% of postpartum women. The Edinburgh Postnatal Depression Scale (EPDS) is the validated screening tool, with scores ≥ 10 indicating possible depression and ≥ 13 indicating probable depression requiring intervention.

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## Checkpoint A: Pre-Draft Intake (Mandatory)

1. **Delivery type** — vaginal (spontaneous, operative) or cesarean? Indication? (Default: from delivery summary)
2. **EBL/QBL** — quantified blood loss at delivery? (Default: from operative/delivery note)
3. **Hemorrhage risk tier** — low, medium, or high per CMQCC assessment? (Default: calculate from intake data)
4. **Lacerations or surgical complications** — degree of laceration, wound closure method, complications? (Default: from delivery note)
5. **Infant feeding method** — breastfeeding, formula, combination? (Default: from nursing notes)
6. **Rh status** — RhoGAM administered if Rh-negative and infant Rh-positive? (Default: from lab records)
7. **Psychiatric history** — prior PPD, anxiety, bipolar disorder, current medications? (Default: from prenatal record)
8. **Social support assessment** — partner support, housing stability, domestic violence screening? (Default: from social work intake)

### Documents to Request

- Delivery summary (vaginal or operative report)
- Intrapartum hemorrhage documentation (if applicable)
- Postpartum nursing flowsheets (vital signs, fundal checks, lochia assessment)
- Lactation consultation notes
- EPDS or PHQ-9 screening results
- Blood bank records (if transfusion administered)
- Contraception counseling documentation
- Discharge summary

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## Step 1: Hemorrhage Risk Assessment and Staged Response

Apply the CMQCC hemorrhage risk stratification at admission to L&D and re-assess postpartum:

| Risk Level | Criteria | Preparation |
|---|---|---|
| **Low** | No prior uterine surgery, singleton, ≤ 4 prior births, no bleeding disorder | Type and screen, active management of 3rd stage |
| **Medium** | Prior cesarean, multiple gestation, grand multiparity, large fibroids, prior PPH, chorioamnionitis, prolonged oxytocin, magnesium | Type and screen, active management, 2 IV access lines, oxytocin running |
| **High** | Placenta previa/accreta spectrum, platelets < 100K, active bleeding at admission, known coagulopathy, 2+ risk factors for medium | Type and crossmatch 2 units pRBCs, massive transfusion protocol on standby, notify blood bank and anesthesia |

### CMQCC Staged PPH Response

| Stage | Cumulative Blood Loss | Actions |
|---|---|---|
| **Stage 0** | Normal | Active management of 3rd stage — oxytocin 10–40 units IV in 1 L LR or 10 units IM |
| **Stage 1** | > 500 mL (vaginal) or > 1000 mL (cesarean) | Fundal massage, uterotonics (methylergonovine 0.2 mg IM, carboprost 250 mcg IM, misoprostol 800–1000 mcg PR), IV access ×2, labs (CBC, fibrinogen, coags), notify provider |
| **Stage 2** | Continued bleeding or hemodynamic instability | Intrauterine balloon tamponade, tranexamic acid 1 g IV, activate massive transfusion, prepare for OR |
| **Stage 3** | Refractory hemorrhage | Surgical intervention: B-Lynch suture, uterine artery ligation, hysterectomy. Interventional radiology (UAE) if available |

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## Step 2: Immediate Postpartum Recovery (0–24 Hours)

Document the following at standardized intervals:

| Timeframe | Assessments |
|---|---|
| Q15 min × 1 hour | Vital signs, fundal tone, lochia volume, bladder distension |
| Q30 min × 1 hour | Vital signs, fundal tone, lochia |
| Q1 hour × 2 hours | Vital signs, fundal tone, pain assessment |
| Then Q4 hours | Routine postpartum assessment |

Key assessment elements:
- **Fundal height and tone** — should be firm at or below umbilicus; boggy fundus = atony → fundal massage + uterotonics
- **Lochia** — scant/small/moderate/heavy/excessive; color (rubra → serosa → alba progression)
- **Perineal assessment** — laceration repair integrity, hematoma formation, ice/analgesics
- **Cesarean incision** — dressing dry and intact, no signs of infection or separation
- **Voiding** — first spontaneous void within 6 hours (vaginal) or after Foley removal (cesarean), assess for urinary retention
- **Ambulation** — encourage early mobilization, assess DVT risk, apply SCDs if immobile
- **Hemoglobin** — check postpartum day 1 if EBL > 500 mL or symptomatic

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## Step 3: Mood and Psychosocial Screening

Administer validated screening tools before discharge and at the postpartum visit:

### Edinburgh Postnatal Depression Scale (EPDS)
- 10-question self-report instrument, score range 0–30
- **Score < 10:** Low risk — provide anticipatory guidance
- **Score 10–12:** Possible depression — repeat screening in 2–4 weeks, consider referral
- **Score ≥ 13:** Probable depression — initiate treatment referral (therapy ± pharmacotherapy)
- **Question 10 (self-harm ideation) positive at any score:** Immediate safety assessment and psychiatric referral

Document: screening tool used, score, interpretation, referrals initiated, and safety plan if indicated.

Also screen for:
- Postpartum anxiety (GAD-7)
- Postpartum psychosis (rare but emergent: hallucinations, delusions, disorganized behavior — immediate psychiatric emergency)
- Intimate partner violence (standardized screening at every visit)

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## Step 4: Postpartum Visit Documentation (3–12 Weeks)

Per ACOG Committee Opinion No. 736, structure the comprehensive postpartum visit:

1. **Mood and emotional well-being** — repeat EPDS, assess bonding, social support
2. **Infant feeding** — breastfeeding assessment, formula use, supply concerns, mastitis screening
3. **Recovery from birth** — incision healing (cesarean), laceration healing, perineal pain, urinary/fecal incontinence, sexual function
4. **Chronic disease management** — blood pressure follow-up (preeclampsia patients require BP monitoring for 72 hours postpartum and at 7–10 days), glucose screening (GDM patients require 75 g OGTT at 4–12 weeks postpartum)
5. **Contraception** — method selected, initiated, or planned (see contraception counseling skill)
6. **Interpregnancy interval counseling** — recommend ≥ 18 months to next conception (≥ 24 months ideal)
7. **Immunizations** — Tdap if not given prenatally, MMR and varicella if non-immune
8. **Return to activity** — exercise clearance, pelvic floor rehabilitation referral if indicated

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## Checkpoint B: Post-Draft Alignment (Mandatory)

1. **Is hemorrhage risk tier documented** with the CMQCC staging applied if PPH occurred?
2. **Is the EPDS score documented** with interpretation and follow-up plan?
3. **Are postpartum vital sign trends consistent** with recovery (stable BP, no tachycardia)?
4. **Is contraception addressed** before discharge and at the postpartum visit?
5. **Are chronic disease follow-up plans documented** (BP monitoring for preeclampsia, OGTT for GDM)?

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## Quality Audit

- [ ] Delivery type and EBL/QBL documented
- [ ] Hemorrhage risk tier assigned per CMQCC criteria
- [ ] Uterotonic administration documented for active management of third stage
- [ ] Postpartum vital signs documented at protocolized intervals
- [ ] Fundal tone and lochia documented at each assessment
- [ ] Rh immunoglobulin administered (if indicated) and documented
- [ ] EPDS score documented with date, score, and interpretation
- [ ] Self-harm question (EPDS Q10) specifically addressed
- [ ] Breastfeeding assessment documented (latch, frequency, concerns)
- [ ] Contraception plan documented before discharge
- [ ] Postpartum visit scheduled (early contact within 3 weeks per ACOG)
- [ ] GDM patients have 75 g OGTT ordered for 4–12 weeks postpartum
- [ ] Preeclampsia patients have BP follow-up plan at 72 hours and 7–10 days
- [ ] VTE prophylaxis assessed and documented (especially post-cesarean)

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## Guidelines

1. **Use quantitative blood loss (QBL)** over estimated blood loss (EBL) — calibrated drapes and gravimetric measurement are more accurate.
2. **Screen for PPD at every encounter** — not just the 6-week visit; the highest-risk window is 2–6 weeks postpartum.
3. **Never discharge without a contraception plan** — immediate postpartum LARC (IUD or implant) is the most effective strategy for reducing unintended short-interval pregnancies.
4. **Follow preeclampsia patients postpartum** — hypertension can worsen in the first 72 hours; readmission for postpartum preeclampsia is common and preventable with surveillance.
5. **Document the interpregnancy counseling** — short intervals (< 18 months) are associated with preterm birth, FGR, and uterine rupture in VBAC candidates.
6. **Address pelvic floor symptoms proactively** — urinary incontinence, fecal incontinence, and pelvic pain should be asked about rather than waiting for the patient to report.
7. **Coordinate with pediatrics** — document infant weight gain trajectory, jaundice concerns, and metabolic screening status.