What are the key components of a postpartum assessment?

Postpartum Assessment: Key Components

The postpartum assessment should begin within 3-10 days after delivery with focused evaluation of blood pressure and acute complications, followed by a comprehensive visit at 4-6 weeks addressing physical recovery, mental health screening, chronic disease management, and preventive care. 1

Early Postpartum Visit (3-10 Days After Delivery)

Primary Focus Areas

• Blood pressure measurement is the highest priority, particularly for women with hypertensive disorders of pregnancy, as peak postpartum blood pressure typically occurs 3-7 days after delivery 2, 1
• For women with hypertensive disorders, blood pressure should be checked within 72 hours of discharge, with home blood pressure monitoring twice daily during the first week 2, 1
• Assessment of postpartum bleeding patterns to identify abnormal hemorrhage (normal bleeding lasts up to 6 weeks with gradual volume decrease) 1
• Medication titration for women on antihypertensive therapy or other medications requiring adjustment 2, 1

Vital Signs Assessment

• Blood pressure should be measured with properly validated devices, particularly for women monitored during pregnancy 2
• Heart rate monitoring (normal postpartum range: median 84 bpm on day of birth, decreasing to 75 bpm by day 14; 3rd-97th centile: 55-110 bpm) 3
• Temperature assessment (normal median: 36.7°C; 3rd-97th centile: 35.6-37.6°C) 3
• Oxygen saturation (normal median: 96%; 3rd-97th centile: 93-98%) 3

Comprehensive Postpartum Visit (4-6 Weeks After Delivery)

Physical Health Assessment

• Blood pressure measurement remains essential, as systolic and diastolic pressures peak at days 5-6 postpartum (median increase of 5 mm Hg for both) before returning to baseline by day 14 3
• Weight and waist circumference measurement to establish baseline for postpartum weight management 2, 1
• Complete blood count is not routinely recommended unless the woman has bleeding symptoms or signs of anemia 4

Laboratory Testing for High-Risk Conditions

• For women with gestational diabetes: 75-g oral glucose tolerance test between 4-12 weeks postpartum (preferably 6-12 weeks), as 35-60% develop type 2 diabetes within 10 years 1, 5
• For women with hypertensive disorders: lipid profile after 12 weeks postpartum if not performed in the year prior to pregnancy 2, 1
• Thyroid function tests (TSH and free T4) for women with anxiety or mood symptoms, as postpartum thyroiditis occurs in up to 10% of women 6
• Ferritin and complete blood count if anemia is suspected based on fatigue or other symptoms 6
• Comprehensive metabolic panel if metabolic concerns exist 6

Mental Health Screening

• Depression screening using the Edinburgh Postnatal Depression Scale (EPDS) is the gold standard, with a cutoff score ≥10 indicating possible depression (sensitivity 94%, specificity 98% at score ≥80 for the Postpartum Depression Screening Scale) 2
• The EPDS is a 10-item questionnaire covering the past 7 days, freely available, with scores ranging 0-30 2
• Anxiety screening using GAD-7 (Generalized Anxiety Disorder-7) 2, 1
• Patient Health Questionnaire-9 (PHQ-9) is an alternative 9-item tool covering the past 2 weeks, with scores 0-27 (minimal depression: 1-4; mild: 5-9; moderate: 10-14; moderately severe: 15-19; severe: 20-27) 2

Biopsychosocial Assessment

• Screening for intimate partner violence 5
• Assessment of social determinants of health including housing stability, food security, transportation access, and social support 2, 1
• Evaluation of breastfeeding status and challenges 1, 5
• Assessment of sexual function and dyspareunia 5

Contraception Counseling

• Contraception should be initiated before 21 days postpartum for women not desiring closely-spaced pregnancies 1, 4
• Combined hormonal contraceptives are not recommended before 6 weeks postpartum due to venous thromboembolism risk 4
• Long-acting reversible contraceptives are strongly recommended for appropriate candidates (<1% failure rate, safe in hypertension) 1
• Contraception prescription should ideally occur at the maternity hospital before discharge 4

Pelvic Floor Assessment

• Pelvic floor rehabilitation is NOT routinely recommended for asymptomatic women to prevent incontinence 4
• Pelvic floor muscle contraction exercises ARE recommended for persistent urinary incontinence at 3 months postpartum 4
• Pelvic floor rehabilitation is recommended for anal incontinence but not for prolapse or dyspareunia prevention 4

Chronic Disease Management and Preventive Care

Cardiovascular Risk Assessment

• 10-year, 30-year, or lifetime cardiovascular disease risk estimation using ASCVD or PREVENT calculators for women over age 40 2
• Assessment of all cardiovascular risk factors including blood pressure, lipids, glucose, smoking status, and family history 2, 1
• Women with hypertensive disorders of pregnancy require transition to cardiology or primary care for long-term cardiovascular monitoring 2, 1

Diabetes Prevention

• For women with gestational diabetes, initiate primary prevention strategies for type 2 diabetes 1
• After initial postpartum testing at 6-12 weeks, repeat glucose tolerance testing at 1 year and at minimum every 3 years thereafter 1

Vaccination Status

• Assess vaccination status for the woman and her family in the early postpartum period 4

Special Considerations for Cesarean Delivery

• Thromboprophylaxis with elastic stockings applied on the morning of surgery and maintained for at least 7 postoperative days 4
• Low molecular weight heparin may be added based on additional risk factors 4
• Multimodal analgesia protocol with preference for oral medications 4
• Early postoperative rehabilitation is encouraged 4

Common Pitfalls to Avoid

• Do not delay blood pressure assessment beyond 72 hours for women with hypertensive disorders, as this is the highest-risk period for stroke 2, 1
• Do not use combined hormonal contraceptives before 6 weeks postpartum due to thromboembolism risk 4
• Do not routinely order complete blood counts in asymptomatic women without bleeding or anemia symptoms 4
• Do not prescribe bromocriptine for lactation inhibition due to serious adverse effects 4
• Do not assume normal postpartum checking behaviors are OCD—OCD symptoms are time-consuming, cause significant distress, and impair functioning 6
• Do not limit postpartum care to a single visit—optimal care requires multiple contacts to address all physical, mental health, and preventive needs 2, 5