What is the appropriate postpartum evaluation and management for a 29-year-old woman, gravida 1 para 1, with a history of gestational hypertension, asymptomatic bacteriuria, uterine atony, and current symptoms of fatigue and light vaginal bleeding, who is exclusively breastfeeding?

From the Guidelines

This patient is experiencing a normal postpartum course following a vaginal delivery with some risk factors but no current complications, and she should continue routine postpartum care with attention to rest, nutrition, and hydration to support breastfeeding. At her three-week postpartum visit, she presents with appropriate vital signs, light lochia (postpartum vaginal bleeding) without clots or pain, and expected fatigue from newborn care. Her history includes gestational hypertension requiring induction, delivery of a macrosomic infant after prolonged labor, and immediate postpartum uterine atony that was successfully managed 1. The patient should be counseled that light vaginal bleeding (lochia serosa or alba) can persist for 4-6 weeks postpartum. Given her history of gestational hypertension, blood pressure monitoring should continue, though her current readings are normal, as systolic blood pressure > 160 mmHg is associated with an adverse maternal outcome 1. Contraception options should be discussed, as fertility can return as early as 4-6 weeks postpartum even while breastfeeding. The patient should be screened for postpartum depression, especially given her fatigue and sleep disruption. She should be advised to follow up immediately if she experiences heavy bleeding, fever, severe pain, or emotional distress. Her uterine atony risk factors included prolonged labor, macrosomic infant, and primiparity, but this appears to have been successfully managed during delivery. Some key points to consider in her care include:

• The importance of continued blood pressure monitoring, as her history of gestational hypertension puts her at risk for future cardiovascular complications 1
• The need for counseling on contraception options, as her fertility can return quickly even while breastfeeding
• The importance of screening for postpartum depression, given her risk factors of fatigue and sleep disruption
• The need for her to follow up immediately if she experiences any concerning symptoms, such as heavy bleeding, fever, or severe pain. It is also important to note that, according to the European Society of Hypertension, labetalol, nifedipine, enalapril, and metoprolol are considered safe for breastfeeding mothers 1.

From the Research

Postpartum Care and Hypertension

• The patient's blood pressure is 122/74 mm Hg, which is within the normal range, as defined by a systolic blood pressure less than 140 mm Hg and a diastolic blood pressure less than 90 mm Hg 2.
• Given the patient's history of gestational hypertension, it is essential to monitor her blood pressure closely in the postpartum period, as postpartum hypertension can have devastating consequences, including maternal death 2.
• The American College of Obstetricians and Gynecologists recommends that patients with hypertensive disorders of pregnancy should have a blood pressure check performed within seven days of delivery 3.

Postpartum Complications and Management

• The patient had uterine atony that resolved with intravenous oxytocin and bimanual massage, which is a common treatment for uterine atony 4.
• Postpartum hemorrhage is a significant contributor to maternal morbidity and mortality, and active management of the third stage of labor, including the administration of oxytocin, is crucial for preventing postpartum hemorrhage 4.
• The patient's symptoms of light vaginal bleeding, fatigue, and sleep interruption are common in the postpartum period, and it is essential to address these concerns to ensure the patient's physical and emotional well-being 3, 5.

Follow-up Care and Education

• The patient should be educated about the symptoms of postpartum preeclampsia and the importance of monitoring her blood pressure in the postpartum period 2.
• A biopsychosocial assessment, including screening for depression and intimate partner violence, should be performed in the postpartum period, and preventive counseling should be offered to women at high risk 3.
• The patient should be followed up closely in the postpartum period to address any concerns or complications that may arise, and to ensure a smooth transition to chronic care and health maintenance 3, 6.