Managing Postpartum Care

Documents to Request

• Delivery summary (vaginal or operative report)
• Intrapartum hemorrhage documentation (if applicable)
• Postpartum nursing flowsheets (vital signs, fundal checks, lochia assessment)
• Lactation consultation notes
• EPDS or PHQ-9 screening results
• Blood bank records (if transfusion administered)
• Contraception counseling documentation
• Discharge summary

Step 1: Hemorrhage Risk Assessment and Staged Response

Apply the CMQCC hemorrhage risk stratification at admission to L&D and re-assess postpartum:

CMQCC Staged PPH Response

Step 2: Immediate Postpartum Recovery (0–24 Hours)

Document the following at standardized intervals:

Key assessment elements:

• Fundal height and tone — should be firm at or below umbilicus; boggy fundus = atony → fundal massage + uterotonics
• Lochia — scant/small/moderate/heavy/excessive; color (rubra → serosa → alba progression)
• Perineal assessment — laceration repair integrity, hematoma formation, ice/analgesics
• Cesarean incision — dressing dry and intact, no signs of infection or separation
• Voiding — first spontaneous void within 6 hours (vaginal) or after Foley removal (cesarean), assess for urinary retention
• Ambulation — encourage early mobilization, assess DVT risk, apply SCDs if immobile
• Hemoglobin — check postpartum day 1 if EBL > 500 mL or symptomatic

Step 3: Mood and Psychosocial Screening

Administer validated screening tools before discharge and at the postpartum visit:

Edinburgh Postnatal Depression Scale (EPDS)

• 10-question self-report instrument, score range 0–30
• Score < 10: Low risk — provide anticipatory guidance
• Score 10–12: Possible depression — repeat screening in 2–4 weeks, consider referral
• Score ≥ 13: Probable depression — initiate treatment referral (therapy ± pharmacotherapy)
• Question 10 (self-harm ideation) positive at any score: Immediate safety assessment and psychiatric referral

Document: screening tool used, score, interpretation, referrals initiated, and safety plan if indicated.

Also screen for:

• Postpartum anxiety (GAD-7)
• Postpartum psychosis (rare but emergent: hallucinations, delusions, disorganized behavior — immediate psychiatric emergency)
• Intimate partner violence (standardized screening at every visit)

Step 4: Postpartum Visit Documentation (3–12 Weeks)

Per ACOG Committee Opinion No. 736, structure the comprehensive postpartum visit:

1. Mood and emotional well-being — repeat EPDS, assess bonding, social support
2. Infant feeding — breastfeeding assessment, formula use, supply concerns, mastitis screening
3. Recovery from birth — incision healing (cesarean), laceration healing, perineal pain, urinary/fecal incontinence, sexual function
4. Chronic disease management — blood pressure follow-up (preeclampsia patients require BP monitoring for 72 hours postpartum and at 7–10 days), glucose screening (GDM patients require 75 g OGTT at 4–12 weeks postpartum)
5. Contraception — method selected, initiated, or planned (see contraception counseling skill)
6. Interpregnancy interval counseling — recommend ≥ 18 months to next conception (≥ 24 months ideal)
7. Immunizations — Tdap if not given prenatally, MMR and varicella if non-immune
8. Return to activity — exercise clearance, pelvic floor rehabilitation referral if indicated

Checkpoint B: Post-Draft Alignment (Mandatory)

1. Is hemorrhage risk tier documented with the CMQCC staging applied if PPH occurred?
2. Is the EPDS score documented with interpretation and follow-up plan?
3. Are postpartum vital sign trends consistent with recovery (stable BP, no tachycardia)?
4. Is contraception addressed before discharge and at the postpartum visit?
5. Are chronic disease follow-up plans documented (BP monitoring for preeclampsia, OGTT for GDM)?

Quality Audit

• Delivery type and EBL/QBL documented
• Hemorrhage risk tier assigned per CMQCC criteria
• Uterotonic administration documented for active management of third stage
• Postpartum vital signs documented at protocolized intervals
• Fundal tone and lochia documented at each assessment
• Rh immunoglobulin administered (if indicated) and documented
• EPDS score documented with date, score, and interpretation
• Self-harm question (EPDS Q10) specifically addressed
• Breastfeeding assessment documented (latch, frequency, concerns)
• Contraception plan documented before discharge
• Postpartum visit scheduled (early contact within 3 weeks per ACOG)
• GDM patients have 75 g OGTT ordered for 4–12 weeks postpartum
• Preeclampsia patients have BP follow-up plan at 72 hours and 7–10 days
• VTE prophylaxis assessed and documented (especially post-cesarean)

Guidelines

1. Use quantitative blood loss (QBL) over estimated blood loss (EBL) — calibrated drapes and gravimetric measurement are more accurate.
2. Screen for PPD at every encounter — not just the 6-week visit; the highest-risk window is 2–6 weeks postpartum.
3. Never discharge without a contraception plan — immediate postpartum LARC (IUD or implant) is the most effective strategy for reducing unintended short-interval pregnancies.
4. Follow preeclampsia patients postpartum — hypertension can worsen in the first 72 hours; readmission for postpartum preeclampsia is common and preventable with surveillance.
5. Document the interpregnancy counseling — short intervals (< 18 months) are associated with preterm birth, FGR, and uterine rupture in VBAC candidates.
6. Address pelvic floor symptoms proactively — urinary incontinence, fecal incontinence, and pelvic pain should be asked about rather than waiting for the patient to report.
7. Coordinate with pediatrics — document infant weight gain trajectory, jaundice concerns, and metabolic screening status.