What is the recommended management plan for a postpartum patient?

Postpartum Patient Management: FDAR Framework

Focus (Assessment Priorities)

All postpartum patients require systematic monitoring for hemorrhage, hypertensive complications, thromboembolism, mental health disorders, and cardiovascular instability during the critical first 3 days and extending through 6 weeks postpartum. 1, 2

Immediate Postpartum (First 24-72 Hours)

Hemodynamic Monitoring:

• Monitor blood pressure every 4-6 hours while awake for at least 3 days postpartum 1, 3
• The first 12-24 hours are critical due to auto-transfusion from contracted uterus and lower extremities, which can precipitate heart failure in women with structural cardiac disease 2
• Continue hemodynamic monitoring for at least 24 hours after delivery, particularly in high-risk patients 3

Hemorrhage Assessment:

• Assess uterine tone, fundal height, and vaginal bleeding continuously 4, 5
• Monitor for signs of postpartum hemorrhage using the "Four T's" framework: Tone (uterine atony), Trauma (lacerations, hematomas), Tissue (retained placenta), and Thrombin (coagulopathy) 5
• Do not wait for laboratory results if clinical presentation suggests hemorrhage—treat based on hypotension and clinical signs 4

Mental Health Screening:

• Screen for depressive symptoms using a validated tool 1, 2
• Assess for anxiety, posttraumatic stress disorder symptoms, and postpartum psychosis risk 1
• Evaluate coping strategies and interpersonal relationships 1

Thromboembolism Risk:

• Assess for signs of venous thromboembolism, which occurs in 57.5% of cases during the postpartum period (1.4 per 1000 women overall) 1, 2
• Evaluate for additional risk factors: BMI ≥30 kg/m², emergency cesarean section, blood loss >1L, preeclampsia, prolonged immobility 1

Cardiovascular Assessment:

• Screen for peripartum cardiomyopathy symptoms (dyspnea, fatigue, edema), which affects 33.5-77.6 per 100,000 live births with 10% mortality at 6 months 1, 2
• Monitor for vasovagal episodes, particularly during position changes 3

Extended Postpartum Assessment (Days 3-42)

Clinical Surveillance:

• Assess wound healing and signs of infection 1
• Evaluate bowel and bladder function 2
• Check for persistent headache, back pain, breast discomfort 1
• Monitor for non-specific symptoms that may indicate complications 1

Data (Key Monitoring Parameters)

Laboratory Monitoring:

• Blood count is NOT routinely recommended in general population 6
• Obtain hemoglobin, platelets, creatinine, and liver enzymes only if bleeding occurred, symptoms of anemia present, or preeclampsia was diagnosed 1, 4
• Repeat labs daily until stable if abnormal before delivery 1
• Monitor coagulation panel if hemorrhage or septic shock occurred 4

Vital Signs:

• Blood pressure every 4-6 hours for first 3 days 1
• Temperature monitoring for infection surveillance 1
• Keep patient warm (>36°C) if hemorrhage occurred, as hypothermia impairs clotting 4

Specific Conditions Requiring Enhanced Monitoring:

For Preeclampsia:

• Continue monitoring for at least 3 days as eclampsia may develop de novo postpartum 1
• Repeat labs second daily until stable 1
• Continue magnesium sulfate for 24 hours postpartum 1

For Hemorrhage/Septic Shock:

• Transfer to ICU for intensive monitoring for at least 24 hours 4
• Monitor for DIC, renal failure, liver failure, ongoing coagulopathy 4

Action (Management Interventions)

Routine Postpartum Care

Uterotonic Administration:

• Administer oxytocin 5-10 units by slow IV infusion or intramuscular injection immediately after delivery of anterior shoulder 7, 5
• For postpartum bleeding control: add 10-40 units oxytocin to 1000 mL non-hydrating diluent and run at rate necessary to control atony 7
• Avoid methylergonovine due to vasoconstrictive effects and risk of hypertension (>10% risk) 2, 3

Hypertension Management (if preeclampsia present):

• Continue oral antihypertensives started during labor 1
• Treat urgently if BP ≥160/110 mmHg with oral nifedipine or IV labetalol/hydralazine 1
• Taper antihypertensives slowly only after days 3-6 postpartum unless BP <110/70 mmHg 1
• Avoid NSAIDs in women with preeclampsia, especially with AKI, and use alternative analgesia 1

Thromboprophylaxis:

• For women WITHOUT family history of VTE and no additional risk factors: clinical surveillance only (no prophylaxis) 1
• For women WITH family history of VTE: postpartum prophylaxis with prophylactic- or intermediate-dose LMWH for 6 weeks 1
• For women with ≥2 risk factors (BMI ≥30, smoking >10 cigarettes/day, preeclampsia, emergency cesarean, blood loss >1L, preterm delivery, stillbirth): prophylaxis for 6 weeks 1
• Apply elastic stockings on morning of cesarean delivery and maintain for at least 7 days 6
• Encourage early mobilization 2, 6

Breastfeeding Support:

• Promote exclusive breastfeeding on demand for 4-6 months due to decreased neonatal morbidity and improved cognitive development 6
• Do NOT routinely give pharmacological lactation inhibition 6
• If lactation inhibition requested after counseling on risks, use lisuride or cabergoline (NOT bromocriptine, which is contraindicated) 6

Vasovagal Prevention:

• Teach physical counterpressure maneuvers (isometric contractions) 3
• Keep patient lying flat for 5 minutes after procedures, then gradually raise head 3
• Implement environmental modifications (calming music, temperature control) 3

Emergency Management

Postpartum Hemorrhage:

• Activate massive transfusion protocol immediately 4
• Establish large-bore IV access for aggressive fluid resuscitation 4
• Transfuse blood products in 1:1:1 ratio (pRBC:FFP:platelets) rather than crystalloid alone 4
• Administer slow IV oxytocin (<2 U/min) to avoid systemic hypotension 4
• Give 1g tranexamic acid IV within 1-3 hours of bleeding onset 2
• Perform uterine massage and bimanual compression 2, 5
• Avoid manual placental removal except in severe uncontrolled hemorrhage 2
• Have low threshold for hysterectomy if bleeding uncontrollable 4

Hemorrhage with Septic Shock:

• Administer broad-spectrum antibiotics immediately 4
• Proceed urgently to manual placental removal or surgical evacuation once hemodynamically stabilized 4
• Do NOT delay intervention waiting for cervical dilation 4
• Position with left uterine displacement to optimize venous return 4

Peripartum Cardiomyopathy:

• Initiate standard heart failure therapy 2
• Administer anticoagulants due to high systemic emboli risk 2
• Do NOT advise breastfeeding due to negative effects of prolactin subfragments 2

Response (Follow-Up and Monitoring)

Short-Term Follow-Up (1 Week)

For Women on Antihypertensives:

• Review within 1 week if still requiring medications at discharge 1

For Persistent Vasovagal Symptoms:

• Schedule follow-up within 1 week 3
• Assess for underlying cardiac arrhythmias or structural heart disease 3

Medium-Term Follow-Up (6-8 Weeks)

Universal Postpartum Visit:

• Schedule visit at 6-8 weeks with obstetrician, gynecologist, general practitioner, or midwife 6
• Ensure BP, urinalysis, and laboratory abnormalities have normalized 1
• Initiate further investigation if persistent hypertension or proteinuria 1

Contraception Counseling:

• Start effective contraception before 21 days postpartum to prevent closely-spaced pregnancy 6
• Avoid combined hormonal contraceptives before 6 weeks postpartum due to VTE risk 6
• Prescribe contraception at maternity discharge 6

Pelvic Floor Assessment:

• Do NOT perform routine rehabilitation in asymptomatic women 6
• Recommend pelvic floor muscle exercises if urinary incontinence persists at 3 months 6
• Recommend rehabilitation for anal incontinence 6
• Do NOT recommend for prolapse or dyspareunia prevention 6

Long-Term Follow-Up (3+ Months)

3-Month Assessment:

• Review all women with preeclampsia to ensure complete normalization 1
• Assess for depression, anxiety, or PTSD symptoms 1
• Perform cardiovascular risk assessment 3

Lifelong Surveillance:

• Counsel women with gestational hypertension or preeclampsia about 15% recurrence risk and increased lifetime cardiovascular disease risk 1
• Recommend annual medical review lifelong 1
• Advise healthy lifestyle: exercise, ideal body weight by 12 months, limit interpregnancy weight gain 1
• Counsel on increased risks of stroke, diabetes, venous thromboembolism, and chronic kidney disease 1

Vaccination Status:

• Assess and update vaccination status for patient and family in early postpartum 6