Medical School · Year 3 · Obgyn · includes a quiz and discussion video

Seminar 03: Postpartum Care

Year 3: Obstetrics and Gynecology Clerkship

Learning Objectives

By the end of this seminar, students will be able to:

1. Describe normal postpartum physiologic changes
2. Recognize and manage postpartum hemorrhage
3. Identify postpartum infections
4. Support breastfeeding and recognize complications
5. Screen for and manage postpartum mood disorders
6. Apply postpartum contraception counseling

Seminar Outline

I. Postpartum Physiology

The postpartum period represents a time of remarkable physiologic adaptation as the maternal body transitions from supporting pregnancy to returning to its pre-gravid state. Uterine involution begins immediately after delivery, with the fundus palpable at the level of the umbilicus in the first hours postpartum. The uterus decreases approximately one centimeter per day, becoming non-palpable abdominally by day ten and returning to near pre-pregnancy size by six weeks postpartum. This process occurs through myometrial contraction, ischemia of the placental site, and autolysis of cellular components that accumulated during gestation.

Lochia represents the normal vaginal discharge following delivery and progresses through predictable stages that clinicians must recognize. Lochia rubra, occurring during days one through three, appears bright red and consists primarily of blood, decidual tissue, and amniotic membrane fragments. Lochia serosa follows from days four through ten, appearing pinkish-brown as the red blood cell content decreases. Lochia alba, the final stage lasting from days eleven through twenty-eight, appears white or yellowish as it contains primarily leukocytes, decidual cells, and mucus.

Cardiovascular changes during the immediate postpartum period create a temporary hypervolemic state that has important clinical implications. Cardiac output increases substantially immediately after delivery due to autotransfusion from the contracting uterus and relief of inferior vena cava compression. Blood volume gradually returns to normal over two weeks, and blood pressure may fluctuate during the first one to two days postpartum. The risk of venous thromboembolism remains elevated for six to twelve weeks postpartum, necessitating vigilance for symptoms and appropriate prophylaxis in high-risk patients.

Return of menses and fertility varies significantly based on breastfeeding status and has important contraceptive implications. Non-breastfeeding women typically experience return of menses by six to eight weeks postpartum, with ovulation potentially preceding the first menstrual period. Breastfeeding women experience variable return of menses, potentially delayed for months, though this should not be relied upon as sole contraception. The first postpartum ovulation is unpredictable, emphasizing the need for early contraceptive counseling regardless of breastfeeding status.

<image>Panel A: Diagram of uterine involution showing fundal height at umbilicus immediately postpartum descending to non-palpable by day 10 and pre-pregnancy size by 6 weeks. Panel B: Timeline illustration of lochia progression from rubra (red, days 1-3) to serosa (pink-brown, days 4-10) to alba (white-yellow, days 11-28). Panel C: Graph depicting cardiovascular changes including increased cardiac output immediately postpartum with gradual normalization over 2 weeks. Panel D: Comparison chart of fertility return in breastfeeding versus non-breastfeeding women showing earlier return in non-breastfeeding patients.</image>

II. Postpartum Care

Hospital care during the postpartum period focuses on maternal-infant bonding, identification of complications, and preparation for discharge. Vital signs are monitored every four to eight hours per institutional protocol, with concurrent assessment of fundal firmness, position, and tenderness. Lochia quantity and characteristics are documented at each assessment, noting any malodorous discharge or excessive bleeding. Perineal care includes assessment of lacerations, episiotomy sites, swelling, and hematoma formation, with appropriate pain management and hygiene instruction.

Postpartum orders address several critical preventive and therapeutic needs. Rh-negative mothers who deliver Rh-positive infants receive Rh immune globulin within 72 hours to prevent alloimmunization. Women found to be rubella non-immune during prenatal testing receive the MMR vaccine before discharge, with counseling to avoid pregnancy for one month. Tdap vaccination is administered if not given during pregnancy to provide pertussis protection for the newborn through passive immunity. Pain management typically includes scheduled ibuprofen and acetaminophen, with stool softeners to prevent constipation and straining.

Discharge criteria ensure that mothers are physiologically stable and prepared for home recovery. Vital signs should be stable with the patient afebrile and normotensive, and adequate urine output should be documented with voiding without difficulty. Pain should be well-controlled on oral medications, and the patient should be able to ambulate independently. Breastfeeding should be established or an appropriate formula feeding plan in place, and comprehensive education regarding warning signs and follow-up appointments must be completed.

The postpartum visit schedule has evolved to address the specific needs of recovering mothers. High-risk patients benefit from early follow-up within three to seven days, particularly those with hypertensive disorders, cesarean delivery, or complicated pregnancies. The traditional comprehensive visit at four to six weeks addresses mood assessment, breastfeeding evaluation, contraceptive counseling, and incision or laceration healing. A pelvic examination is performed at six weeks if indicated, though routine examination may be deferred based on clinical judgment and patient symptoms.

<image>Panel A: Checklist format showing hospital postpartum assessment components including vital signs, fundal checks, lochia assessment, perineal care, and voiding status. Panel B: Flow diagram of postpartum orders including Rh immune globulin criteria, vaccination requirements, and analgesia protocol. Panel C: Discharge readiness checklist with criteria for vital signs, voiding, pain control, ambulation, and feeding establishment. Panel D: Timeline illustration of postpartum follow-up schedule showing early visit at 3-7 days for high-risk and comprehensive visit at 4-6 weeks.</image>

III. Postpartum Hemorrhage

Postpartum hemorrhage represents a leading cause of maternal morbidity and mortality worldwide and requires rapid recognition and systematic management. The traditional definition of greater than 500 mL blood loss for vaginal delivery and greater than 1000 mL for cesarean delivery has been replaced by a single threshold of cumulative blood loss of 1000 mL or greater, or blood loss accompanied by signs of hypovolemia. Primary PPH occurs within 24 hours of delivery and is most commonly addressed by obstetric providers. Secondary PPH, occurring from 24 hours to 12 weeks postpartum, often presents in outpatient settings and requires different diagnostic considerations.

The etiology of postpartum hemorrhage is organized by the four Ts mnemonic to guide systematic evaluation and treatment. Tone abnormalities, specifically uterine atony, account for approximately 70% of cases and result from failure of the myometrium to contract adequately after delivery. Trauma includes lacerations of the cervix, vagina, or perineum, hematomas, and uterine rupture. Tissue refers to retained placental fragments or abnormal placentation such as accreta spectrum disorders. Thrombin represents coagulopathy, whether pre-existing or acquired, including dilutional coagulopathy from massive resuscitation.

Risk factors for postpartum hemorrhage should be identified during prenatal care to allow preparation. Uterine overdistension from multiple gestation, macrosomia, or polyhydramnios predisposes to atony. Prolonged labor results in uterine muscle fatigue with impaired contractility after delivery. Chorioamnionitis causes uterine inflammation that impairs effective contraction. Prior postpartum hemorrhage confers significant recurrence risk, and operative vaginal delivery increases the risk of traumatic hemorrhage.

Prevention of postpartum hemorrhage through active management of the third stage of labor has become standard practice. Prophylactic oxytocin administration after delivery of the anterior shoulder or immediately after delivery of the placenta significantly reduces hemorrhage risk. Risk assessment during prenatal care allows identification of patients who may benefit from additional preparation such as type and screen or crossmatch. Ensuring adequate intravenous access with 18-gauge or larger catheters facilitates rapid resuscitation if hemorrhage occurs.

<image>Panel A: Anatomical illustration showing normal postpartum uterine contraction versus atonic uterus with pooling blood. Panel B: Diagram of the four Ts etiology with representative images: atonic uterus (Tone), cervical laceration (Trauma), retained placental fragment (Tissue), and coagulation cascade disruption (Thrombin). Panel C: Risk factor assessment matrix showing patient factors associated with increased PPH risk. Panel D: Active management of third stage protocol flowchart including oxytocin timing and dosing.</image>

IV. PPH Management

Initial management of postpartum hemorrhage requires simultaneous resuscitation and identification of the underlying cause. Calling for help to activate the hemorrhage response team brings additional personnel, equipment, and expertise to the bedside. Quantitative blood loss assessment using calibrated collecting bags and weighing blood-soaked materials provides objective measurement superior to visual estimation. Two large-bore intravenous lines allow rapid fluid and blood product administration, and laboratory evaluation including complete blood count, coagulation studies, and type and screen guides ongoing management.

Uterotonic agents form the first-line pharmacologic management of PPH from uterine atony. Oxytocin, administered as 10-40 units in intravenous fluids, promotes sustained uterine contraction without significant contraindications. Methylergonovine, 0.2 mg intramuscularly, causes tetanic uterine contraction but is contraindicated in hypertensive patients. Carboprost (15-methyl prostaglandin F2-alpha), 0.25 mg intramuscularly, is highly effective but contraindicated in asthmatic patients due to bronchospasm risk. Misoprostol, 800-1000 mcg rectally, provides prostaglandin effect without significant contraindications and is useful in resource-limited settings.

Second-line interventions are implemented when uterotonics alone fail to achieve hemostasis. Bimanual uterine compression and massage provide direct mechanical stimulus for contraction while uterotonics take effect. Examination under anesthesia allows thorough inspection for lacerations and ensures no retained products of conception. Uterine balloon tamponade using a Bakri balloon provides direct pressure on bleeding surfaces and serves as both treatment and temporizing measure. Uterine compression sutures such as the B-Lynch suture and uterine artery ligation represent surgical options when tamponade fails.

Massive transfusion protocols are activated for severe hemorrhage to optimize blood product replacement. The balanced ratio of packed red blood cells, fresh frozen plasma, and platelets at 1:1:1 approximates whole blood and improves outcomes. Tranexamic acid, an antifibrinolytic agent, administered within three hours of delivery reduces mortality and should be given early. Fibrinogen replacement is critical as it is the first clotting factor depleted in obstetric hemorrhage. Hysterectomy remains the definitive treatment when all conservative measures fail and is life-saving when performed in a timely manner.

<image>Panel A: Emergency response algorithm flowchart showing simultaneous actions for PPH including calling for help, quantifying blood loss, establishing IV access, and administering uterotonics. Panel B: Comparison table of uterotonic agents with dosing, mechanism, and contraindications for oxytocin, methylergonovine, carboprost, and misoprostol. Panel C: Illustration of second-line interventions including bimanual compression technique, Bakri balloon placement, and B-Lynch suture configuration. Panel D: Massive transfusion protocol diagram showing 1:1:1 ratio of blood products with TXA administration timing.</image>

V. Postpartum Infections

Endometritis is the most common serious postpartum infection and requires prompt recognition and treatment. This infection of the uterine lining occurs more frequently after cesarean delivery, prolonged rupture of membranes, and multiple vaginal examinations during labor. Patients present with fever, typically greater than 38 degrees Celsius, along with uterine tenderness and foul-smelling or purulent lochia. Treatment consists of broad-spectrum intravenous antibiotics, classically clindamycin plus gentamicin, continued until the patient has been afebrile for 24-48 hours, at which point oral antibiotics are not necessary.

Wound infections complicate cesarean and episiotomy sites and may present in early or late timeframes. Early wound infections, appearing three to five days postpartum, manifest with erythema, warmth, induration, and drainage from the surgical site. Late presentations may include wound dehiscence or abscess formation requiring opening and packing of the wound. Methicillin-resistant Staphylococcus aureus should be considered in treatment-resistant cases, and antibiotic coverage should be adjusted accordingly.

Mastitis represents breast infection typically occurring two to four weeks postpartum and requires specific management. Patients present with unilateral breast pain, erythema, warmth, and systemic symptoms including fever and malaise. Staphylococcus aureus is the most common causative organism, and treatment includes dicloxacillin or cephalexin for penicillin-allergic patients. Importantly, breastfeeding should continue as this promotes drainage and does not harm the infant. Breast abscess formation may complicate mastitis and requires incision and drainage or needle aspiration in addition to antibiotics.

Other postpartum infections require consideration in febrile patients who do not respond to initial treatment. Urinary tract infections present with dysuria, frequency, and suprapubic pain and are diagnosed with urinalysis and culture. Septic pelvic thrombophlebitis should be suspected in patients with persistent fever despite appropriate antibiotic therapy, characterized by "picket fence" fever pattern and requiring anticoagulation. Necrotizing fasciitis, though rare, is a surgical emergency presenting with rapidly progressive soft tissue infection, severe pain, and systemic toxicity requiring emergent surgical debridement.

<image>Panel A: Clinical presentation illustration of endometritis showing fever, uterine tenderness location, and characteristic lochia appearance. Panel B: Wound infection progression diagram showing early erythema/drainage versus late dehiscence and abscess formation with management algorithms. Panel C: Anatomical illustration of mastitis showing wedge-shaped area of erythema, comparison to normal breast, and progression to abscess. Panel D: Differential diagnosis flowchart for persistent postpartum fever including UTI, septic pelvic thrombophlebitis, and necrotizing fasciitis with distinguishing features.</image>

VI. Breastfeeding

Breastfeeding provides optimal nutrition and numerous health benefits for both infant and mother that should be communicated during counseling. For the infant, breast milk provides passive immunity through immunoglobulins, optimal nutrition tailored to developmental needs, and promotes mother-infant bonding. Breastfed infants experience reduced rates of respiratory and gastrointestinal infections, and long-term cognitive benefits have been observed. For the mother, breastfeeding promotes faster uterine involution, reduces postpartum bleeding, aids in weight loss, and decreases lifetime risk of breast and ovarian cancers.

The physiology of lactation involves coordinated hormonal signaling that begins during pregnancy. Prolactin, released from the anterior pituitary, stimulates milk production in the mammary alveoli and is suppressed during pregnancy by high progesterone levels. After delivery and placental expulsion, the decrease in progesterone allows prolactin to stimulate milk production. Oxytocin, released in response to nipple stimulation, causes contraction of myoepithelial cells surrounding the alveoli, resulting in the let-down reflex. The supply-demand principle dictates that more frequent nursing increases milk production through increased prolactin release.

Common breastfeeding problems require recognition and appropriate management to support continued breastfeeding. Engorgement occurs as milk production increases and may be managed with frequent feeding, warm compresses before feeding, cool compresses after, and expressing small amounts for comfort. Sore or cracked nipples typically result from improper latch and improve with latch correction, air drying, and lanolin application. Low milk supply concerns are common and often addressed by increasing feeding frequency, ensuring adequate hydration and nutrition, and occasionally using galactogogues. Plugged ducts present as focal tender areas and respond to massage, warm compresses, and continued nursing.

Contraindications to breastfeeding are limited but important to recognize. In developed countries, HIV infection is an absolute contraindication due to transmission risk through breast milk. Human T-lymphotropic virus type 1 (HTLV-1) infection similarly contraindicates breastfeeding. Active, untreated tuberculosis requires separation until the mother has received appropriate treatment for at least two weeks. Mothers receiving chemotherapy or certain other medications should not breastfeed. Galactosemia in the infant is a contraindication as the infant cannot metabolize galactose in breast milk.

<image>Panel A: Comparison infographic showing benefits of breastfeeding for infant (immunity, nutrition, bonding) and mother (involution, cancer risk reduction, bonding). Panel B: Hormonal diagram illustrating prolactin-mediated milk production and oxytocin-mediated let-down reflex with feedback loops. Panel C: Visual guide to common breastfeeding problems showing proper versus improper latch, engorgement appearance, and plugged duct location with management steps. Panel D: Decision tree for breastfeeding contraindications including HIV status, medications, and infant conditions.</image>

VII. Postpartum Mood Disorders

Baby blues represents the most common postpartum mood disturbance and should be distinguished from more serious conditions. Occurring in up to 80% of postpartum women, symptoms typically begin on days two to five following delivery. Manifestations include mood swings, tearfulness, anxiety, irritability, and difficulty sleeping beyond that caused by newborn care. Symptoms spontaneously resolve by two weeks postpartum, and treatment consists of reassurance, support, and normalization of the experience. Persistent symptoms beyond two weeks warrant evaluation for postpartum depression.

Postpartum depression affects 10-20% of new mothers and requires systematic screening and treatment. Symptoms typically emerge within the first year postpartum, most commonly between four and six weeks, and include depressed mood, anhedonia, sleep and appetite disturbances, fatigue, and feelings of worthlessness or guilt. The Edinburgh Postnatal Depression Scale provides validated screening and should be administered at postpartum visits. Treatment includes psychotherapy (particularly cognitive behavioral therapy), selective serotonin reuptake inhibitors that are safe during breastfeeding, and social support. Severe cases may require psychiatric referral and consideration of hospitalization.

Postpartum anxiety disorders encompass several conditions that may occur independently or with depression. Generalized anxiety disorder, panic disorder, and obsessive-compulsive disorder may all emerge or worsen in the postpartum period. Intrusive thoughts about harm coming to the baby are common in postpartum OCD and are distressing to the mother but are not associated with intent to harm. Treatment includes psychotherapy and appropriate anxiolytic or antidepressant medications. Distinguishing pathologic anxiety from normal new-parent worry requires assessment of functional impairment and symptom severity.

Postpartum psychosis is a psychiatric emergency requiring immediate intervention. This rare condition, affecting 1-2 per 1000 deliveries, typically emerges within the first days to weeks postpartum. Symptoms include delusions, hallucinations, confusion, disorganized behavior, and rapid mood fluctuations. Women with a history of bipolar disorder are at significantly elevated risk, and this history should prompt close monitoring. Treatment requires psychiatric hospitalization to ensure safety of both mother and infant, with pharmacotherapy including mood stabilizers and antipsychotics.

<image>Panel A: Timeline diagram comparing baby blues (days 2-5, resolving by 2 weeks) with postpartum depression onset (weeks to months, requiring treatment). Panel B: Edinburgh Postnatal Depression Scale sample items with scoring interpretation guide. Panel C: Comparison chart of postpartum anxiety disorders showing distinguishing features of GAD, panic disorder, and OCD with intrusive thoughts. Panel D: Emergency recognition guide for postpartum psychosis showing warning signs, risk factors (bipolar history), and immediate management steps.</image>

VIII. Postpartum Contraception

Understanding the return of fertility after delivery is essential for appropriate contraceptive counseling. Non-breastfeeding women may ovulate as early as three weeks postpartum, making early contraceptive initiation critical. Breastfeeding delays ovulation variably, but this effect is unpredictable and should not be relied upon as sole contraception unless strict lactational amenorrhea criteria are met. All postpartum women should receive contraceptive counseling, ideally beginning during prenatal care, with method initiation before three weeks postpartum or hospital discharge when possible.

The lactational amenorrhea method (LAM) provides effective contraception when strict criteria are met. Three conditions must all be present: complete amenorrhea since delivery, exclusive or nearly exclusive breastfeeding (no supplementation), and less than six months postpartum. When all criteria are maintained, LAM provides 98% effectiveness comparable to other contraceptive methods. Once any criterion is no longer met, another contraceptive method must be initiated. LAM is not appropriate for women who cannot exclusively breastfeed or who anticipate early return to work with pumping.

Contraceptive options in the postpartum period are influenced by breastfeeding status and timing. Progestin-only methods, including the progestin-only pill, injection (DMPA), implant, and hormonal IUD, can be initiated immediately postpartum and are safe during breastfeeding. Combined hormonal contraceptives containing estrogen should be delayed until four to six weeks postpartum due to increased venous thromboembolism risk during the early postpartum period and theoretical concerns about milk supply reduction in breastfeeding women. Copper IUD can be placed immediately postpartum, at the postpartum visit, or any time in between. Barrier methods can be resumed when the patient resumes intercourse, and sterilization can be performed immediately postpartum or as an interval procedure.

Special considerations influence postpartum contraceptive selection. Venous thromboembolism risk remains elevated for several weeks postpartum, making combined hormonal contraceptives inappropriate for women with additional VTE risk factors even beyond six weeks. Breastfeeding mothers may experience breakthrough bleeding with progestin-only methods but should be counseled that this is common and does not indicate contraceptive failure. Cesarean delivery provides an excellent opportunity for immediate postpartum IUD insertion with good expulsion rates. Discussions about future fertility desires should guide method selection, particularly when considering permanent sterilization.

<image>Panel A: Fertility return timeline showing earliest ovulation at 3 weeks non-breastfeeding with variable delay during breastfeeding, emphasizing need for early contraception. Panel B: LAM criteria diagram showing three required conditions (amenorrhea, exclusive breastfeeding, less than 6 months) with effectiveness when all are met. Panel C: Postpartum contraceptive options chart organized by timing of safe initiation for progestin-only, combined hormonal, IUDs, barrier, and sterilization. Panel D: Decision support algorithm for method selection based on breastfeeding status, VTE risk, and future fertility desires.</image>

IX. Cesarean Delivery Postpartum Care

Recovery after cesarean delivery requires attention to pain management, mobility, and surgical site care. Multimodal analgesia combining scheduled non-steroidal anti-inflammatory drugs with acetaminophen reduces opioid requirements and improves recovery. Opioids are reserved for breakthrough pain, with awareness of their sedating effects and constipation potential. Early ambulation, typically beginning on the day of surgery, reduces venous thromboembolism risk and promotes return of bowel function. Diet is advanced as tolerated, with most patients progressing quickly to regular diet. Foley catheter removal typically occurs when the patient is ambulatory, usually 12-24 hours postoperatively.

Incision care education prepares patients for appropriate wound management at home. While hospitalized, the incision is kept clean and dry, and dressings may be removed after 24-48 hours if the wound appears intact. Patients are instructed to clean the incision daily during shower, avoid soaking, and pat dry. Signs of infection requiring evaluation include increasing redness, warmth, drainage, wound separation, or fever. Staples, if used, are typically removed at three to seven days at a follow-up visit, while absorbable sutures do not require removal.

Activity restrictions after cesarean delivery aim to prevent wound complications while promoting recovery. Driving should be avoided while taking narcotic pain medications and until the patient can perform emergency braking maneuvers comfortably, typically one to two weeks. Lifting restrictions advise nothing heavier than the baby for the first two weeks, with gradual resumption of normal activities. Stair climbing is permitted with caution, and patients should be advised to take their time. Formal exercise and intercourse are typically resumed at six weeks or when comfortable, with discussion at the postpartum visit.

Future pregnancy considerations after cesarean delivery warrant anticipatory counseling. Eligibility for trial of labor after cesarean (TOLAC) depends on the type of uterine incision, with low transverse incisions having the lowest rupture risk. Women should be counseled that repeat cesareans carry cumulative risks including placenta accreta spectrum, which increases substantially with each additional cesarean. An interpregnancy interval of at least 18 months is recommended to allow complete healing and reduce uterine rupture risk in subsequent pregnancies. These considerations should be discussed to inform contraceptive choices and future family planning.

<image>Panel A: Multimodal analgesia pyramid showing scheduled NSAIDs and acetaminophen at base with PRN opioids at top, including dosing schedules. Panel B: Incision care instruction visual showing proper cleaning technique, signs of infection to report, and staple/suture timeline. Panel C: Activity restriction timeline from immediate postpartum through 6 weeks showing progression of driving, lifting, exercise, and intercourse. Panel D: Counseling diagram for future pregnancy after cesarean including TOLAC eligibility, repeat cesarean risks, and interpregnancy interval recommendations.</image>

X. Postpartum Complications

Venous thromboembolism risk remains elevated throughout the postpartum period and requires vigilance for symptoms. The risk of VTE is four to five times higher during pregnancy and remains elevated for up to 12 weeks postpartum. Deep venous thrombosis presents with unilateral leg swelling, pain, warmth, and tenderness, most commonly affecting the left lower extremity. Pulmonary embolism manifests as dyspnea, chest pain, tachycardia, and hypoxia and can be rapidly fatal. Diagnosis is confirmed with lower extremity Doppler ultrasound for DVT and CT pulmonary angiography for PE, with treatment consisting of anticoagulation.

Urinary retention is a common postpartum complication, particularly following epidural anesthesia and operative delivery. Risk factors include prolonged labor, operative vaginal delivery, epidural analgesia, and delivery of a large infant. Signs include inability to void, suprapubic discomfort, and palpable bladder distension on examination. Management begins with in-out catheterization to decompress the bladder, with Foley catheter placement if large volumes are obtained or retention recurs. Most cases resolve within 24-48 hours as the effects of regional anesthesia dissipate and perineal swelling decreases.

Late postpartum hemorrhage, occurring between 24 hours and 12 weeks postpartum, has different etiologic considerations than immediate PPH. Subinvolution of the placental site, where the vessels at the former placental attachment fail to undergo normal thrombosis and remodeling, is a common cause. Retained products of conception may be present and are evaluated with pelvic ultrasound. Endometritis may contribute to delayed postpartum bleeding. Treatment includes uterotonics, antibiotics if infection is suspected, and dilation and curettage if retained tissue is identified on imaging or if medical management fails.

Sheehan syndrome is a rare but important late complication of severe postpartum hemorrhage. This condition results from pituitary necrosis due to hypovolemic shock, as the enlarged pituitary gland of pregnancy is vulnerable to ischemia. The earliest manifestation is typically failure of lactation due to loss of prolactin secretion. Subsequent features include amenorrhea from gonadotropin deficiency and fatigue from hypothyroidism and adrenal insufficiency. Diagnosis may be delayed months to years after the inciting hemorrhage. Treatment consists of lifelong hormone replacement for all deficient pituitary axes.

<image>Panel A: VTE risk timeline showing elevated risk during pregnancy continuing through 12 weeks postpartum, with clinical presentations of DVT (leg findings) and PE (cardiopulmonary findings). Panel B: Urinary retention diagnostic and management algorithm showing risk factors, physical findings, catheterization thresholds, and expected resolution timeline. Panel C: Late postpartum hemorrhage evaluation flowchart including ultrasound findings, differential diagnosis (subinvolution, retained products, endometritis), and treatment options. Panel D: Sheehan syndrome progression diagram showing initial hemorrhage, pituitary necrosis mechanism, and sequential hormone deficiency manifestations.</image>

Summary

• Uterine involution: fundus at umbilicus immediately postpartum, descending one centimeter daily to non-palpable by day 10
• Lochia progression: rubra (days 1-3, red), serosa (days 4-10, pink-brown), alba (days 11-28, white-yellow)
• PPH definition: cumulative blood loss of 1000 mL or greater, or blood loss with signs of hypovolemia
• PPH etiology (Four Ts): Tone (uterine atony, 70%), Trauma (lacerations), Tissue (retained placenta), Thrombin (coagulopathy)
• PPH management: uterotonics first-line, then bimanual compression, balloon tamponade, surgical intervention if needed
• Endometritis: fever plus uterine tenderness and foul lochia; treat with clindamycin plus gentamicin intravenously
• Mastitis: unilateral breast pain, erythema, and fever; continue breastfeeding; treat with dicloxacillin or cephalexin
• Baby blues: days 2-5 postpartum, resolves by 2 weeks; supportive care only
• Postpartum depression: screen with Edinburgh scale; treat with therapy and SSRIs safe in breastfeeding
• Postpartum contraception: initiate before 3 weeks; progestin-only methods safe immediately; delay combined hormonal until 4-6 weeks

Key Terms

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