What is the recommended therapeutic regimen for postpartum (postpartum) care?

Postpartum Care: Therapeutic Regimen

All postpartum women should receive a multimodal therapeutic regimen that includes scheduled analgesia, early mobilization and feeding, thromboprophylaxis based on risk stratification, and close monitoring for at least 24 hours after delivery, with specific attention to blood pressure control in hypertensive patients and prevention of postpartum hemorrhage. 1

Immediate Postpartum Management (0-24 Hours)

Monitoring Requirements

• Women with preeclampsia require blood pressure and clinical monitoring at least every 4 hours while awake for the first 3 days postpartum, as eclamptic seizures can develop for the first time during this period. 1
• Continuous hemodynamic monitoring should be maintained for at least 24 hours after delivery in high-risk cardiac patients due to significant fluid shifts. 2, 3
• Complete blood count is not routinely recommended unless the woman has bleeding or symptoms of anemia. 4

Pain Management Protocol

• Implement scheduled multimodal analgesia with regular NSAIDs and acetaminophen starting within 2 hours postpartum, rather than waiting for pain complaints. 1, 5
• This regimen is opioid-sparing and reduces side effects while improving maternal satisfaction and early mobilization. 1
• NSAIDs should be avoided in women with preeclampsia unless other analgesics are ineffective, particularly if they have renal disease, placental abruption, acute kidney injury, sepsis, or postpartum hemorrhage. 1
• For breakthrough pain after cesarean delivery, low-dose oxycodone can be added to the scheduled regimen without increasing overall opioid consumption. 6, 5

Nutrition and Mobilization

• Resume a regular diet within 2 hours after cesarean delivery. 1
• Early feeding reduces thirst, hunger, accelerates return of bowel activity, improves maternal satisfaction and ambulation, and shortens length of stay without increasing complications. 1
• Early mobilization after cesarean delivery is recommended to facilitate recovery. 1

Catheter Management

• Remove urinary catheter immediately after cesarean delivery if placed during surgery. 1

Uterotonic Management and Hemorrhage Prevention

Standard Prophylaxis

• Administer oxytocin as a slow infusion at rates less than 2 U/min (approximately 33 mU/min) to avoid systemic hypotension and tachycardia. 2, 3
• Rapid IV bolus of oxytocin should never be given as it causes severe hypotension, tachycardia, and uterine hyperstimulation. 2
• In high-risk cardiac patients or those with obstructive valve lesions or hypertrophic cardiomyopathy, oxytocin must only be given as a slow infusion. 2

Contraindicated Medications

• Methylergonovine is contraindicated in the postpartum period due to risk (>10%) of vasoconstriction and hypertension. 2, 3
• Ergotamine should be avoided in patients with respiratory disease as it may cause bronchospasm. 2

Alternative Uterotonics

• Carbetocin may be preferable for cardiac patients as it shows better hemodynamic stability than oxytocin with less significant blood pressure drops. 7
• For postpartum hemorrhage due to uterine atony not responding to oxytocin and uterine massage, carboprost tromethamine (250 mcg IM) is indicated. 8

Thromboprophylaxis

Risk Stratification Approach

• Pneumatic compression stockings should be used for all women undergoing cesarean delivery. 1
• Heparin should not be used routinely for VTE prophylaxis after cesarean delivery. 1
• For women with additional major risk factors, add LMWH to mechanical prophylaxis; the specific regimen depends on individual risk factors. 1, 4
• Elastic stockings should be applied on the morning of surgery and kept for at least 7 postoperative days. 4

Postpartum Anticoagulation Regimens

• When indicated, postpartum anticoagulation consists of vitamin K antagonists for 6 weeks with target INR 2.0-3.0, with initial UFH or LMWH overlap until INR reaches 2.0, or prophylactic/intermediate-dose LMWH for 6 weeks. 1

Blood Pressure Management in Hypertensive Disorders

Medication Continuation

• Continue antihypertensives administered antenatally and treat any hypertension before day 6 postpartum. 1
• After day 6, antihypertensive therapy may be withdrawn slowly over days but never ceased abruptly. 1
• Blood pressure targets of 120-160/80-105 mmHg are suggested to optimize long-term maternal health while minimizing impaired fetal growth effects. 1

Follow-up Requirements

• All women with hypertensive disorders should be reviewed at 3 months postpartum to ensure blood pressure, urinalysis, and laboratory abnormalities have normalized. 1
• If proteinuria or hypertension persists at 3 months, initiate appropriate referral for further investigation. 1

Immunizations and Preventive Care

Vaccination Status

• Assess vaccination status of the woman and her family in the early postpartum period. 4
• Administer measles-mumps-rubella, varicella, human papillomavirus, and tetanus-diphtheria-pertussis vaccines to nonimmune individuals. 9
• Avoid smallpox and yellow fever vaccines. 9

Rh Immune Globulin

• Administer anti-D immune globulin to Rh-negative individuals who have given birth to an Rh-positive infant. 9

Contraception Initiation

Timing and Method Selection

• Start effective contraception before 21 days postpartum in women who do not want closely spaced pregnancies, and prescribe it before maternity discharge. 4
• Combined hormonal contraceptives should not be used before 6 weeks postpartum due to VTE risk. 4
• Intrauterine devices placed immediately postpartum (postplacental placement) result in higher utilization at 6 months compared to delayed outpatient placement. 9
• Contraceptive implants are safe and effective for immediate postpartum use. 9

Breastfeeding Support

Promotion Strategies

• Exclusive breastfeeding is recommended for 4-6 months due to decreased neonatal morbidity and improved cognitive development. 4
• Promote breastfeeding on demand and provide close support from health professionals to increase initiation rates and duration. 4
• Combined interventions with professional provider-led support, available protocols, and implementation during both prenatal and postnatal periods increase exclusive breastfeeding rates at 6 months. 9

Lactation Inhibition (When Needed)

• Do not routinely give pharmacological treatments for lactation inhibition to women who do not wish to breastfeed. 4
• Bromocriptine is contraindicated for lactation inhibition due to potentially serious adverse effects. 4
• For women aware of risks who choose pharmacological inhibition, lisuride and cabergoline are preferred. 4

Postpartum Visit and Long-term Care

Timing and Scope

• Schedule the postpartum visit 6-8 weeks after delivery, which can be performed by an obstetrician, gynecologist, general practitioner, or midwife after normal pregnancy and delivery. 4
• This visit should address physical, psychological, social, and somatic health. 4

Pelvic Floor Considerations

• Pelvic floor rehabilitation is not recommended routinely for asymptomatic women to prevent urinary or anal incontinence. 4
• For persistent urinary incontinence at 3 months postpartum, pelvic floor muscle contraction exercises are recommended. 4

Diabetes Follow-up

• Women with gestational diabetes should be tested for persistent diabetes or prediabetes at 4-12 weeks postpartum with a 75-g OGTT using nonpregnancy criteria. 1
• Use OGTT rather than A1C at this visit because A1C may be falsely lowered by increased red blood cell turnover or blood loss at delivery. 1
• If normal, retest every 1-3 years thereafter based on other risk factors. 1

Cardiovascular Risk

• Women with chronic hypertension, gestational hypertension, or preeclampsia have significant long-term cardiovascular risks requiring annual medical review lifelong. 1
• Recommend achieving prepregnancy weight by 12 months and limiting interpregnancy weight gain through healthy lifestyle including exercise and ideal body weight maintenance. 1

Common Pitfalls to Avoid

• Never administer oxytocin as a rapid bolus - this causes severe hemodynamic instability. 2
• Never use methylergonovine in postpartum patients - the vasoconstriction risk is too high. 2, 3
• Never delay feeding after cesarean delivery - early nutrition improves outcomes without increasing complications. 1
• Never stop antihypertensives abruptly - taper slowly over days after the first postpartum week. 1
• Never assume eclampsia risk ends at delivery - seizures can occur for the first time postpartum. 1