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LEARNING OBJECTIVES

  1. Review the normal physiologic adaptations that occur during the postpartum period, including changes to the uterus, cardiovascular system, and urinary tract.

  2. Describe components of the comprehensive postpartum examination, including benefits and complications associated with breastfeeding.

  3. Identify contraceptive options and discuss clinical considerations when initiating contraception in the postpartum period.

  4. Distinguish between the normal and abnormal postpartum psychological reactions and explain how to identify depression with peripartum onset.

INTRODUCTION

Puerperium is referred to as the 6-week period following the delivery of an infant. Postpartum women will undergo a number of physical and emotional changes during this time. There are also medical problems that are unique to this period. This chapter will review the management of women postdelivery as the body begins to recover from pregnancy and childbirth.

Patient Case (Part 1)

A 19 year-old Hispanic woman, pregnant for the first time, presented to the hospital at term complaining of a headache. She stated that the headache started that morning and was unrelieved with two doses of acetaminophen. She had no history of headaches.

History of Present Illness: Three weeks ago, she was admitted to the hospital and underwent a long induction after it was discovered that she had severe preeclampsia. She developed an intra-amniotic infection, delivered vaginally, and was treated for endomyometritis. Endomyometritis is a postpartum infection involving the endometrium, myometrium, and parametrial tissues characterized by maternal temperature elevation and uterine tenderness. She went home on postpartum day 3 and presents now for her first postpartum visit. She says she has been breastfeeding, but initially she had difficulty with milk production and then developed an infection. She even has a picture of what her breast looked like. You look at the picture and make out the redness around the areola, and how this seems to spread along the medial breast tissue (see Figure 23-1). She went to the emergency room because her breast was red, swollen, tender, and she was having fevers. She was given antibiotics and the infection, which she was told was called mastitis, went away. She was going to bottle-feed, but she has run out of the formula that was given to her and cannot afford anymore, so she is breastfeeding again. Prior to beginning the physical examination, she tells you that she has had a rough postpartum course. She is tearful and reports having had little sleep lately. She has not been sleeping well, even when the infant is asleep. Her interest in daily activities is minimal and she is very tired. She is frustrated, feels overwhelmed with having to take care of the infant, and feels she is doing “nothing right” and she feels “hopeless.”

Past Medical History: Unremarkable, noncontributory

Family History: She had no family history of headaches. Her mother had been diagnosed with depression for which she takes a medicine she obtains from Mexico and her father has hypertension. She is unsure ...

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