Postpartum Care

Breastfeeding is often the primary source of nutrition for the newborn. During pregnancy, hormonal stimulation causes the number and size of mammary glands in the breast to significantly increase. After delivery, prolactin stimulates milk production, while oxytocin stimulates milk expulsion through the lactiferous ducts, where it is sucked out through the nipple by the infant. Breastfeeding has many benefits for the mother and baby, including a decreased risk of infections, GI distress, and atopic disease for the infant; and a decreased risk of anemia, cardiovascular disease, and breast and ovarian cancer for the mother. True contraindications to breastfeeding exist but are quite rare. Important clinical conditions associated with breastfeeding include engorgement, mastitis, galactocele, breast abscess, and infant jaundice.

The breasts are found on the anterior thoracic wall and consist of mammary glands surrounded by connective tissue. The mammary glands are modified apocrine sweat glands that produce milk, which serves as nutrition for infants. Breasts are rudimentary and usually nonfunctioning in men. The shape and size of the breasts change during a woman’s life and menstrual cycles. Breasts are supplied by the axillary, internal thoracic, and intercostal arteries, and they are innervated by branches of the cervical plexus.

Benign breast epithelial lesions are grouped histologically as nonproliferative, proliferative without atypia, and atypical hyperplasia. The classifications are based on subsequent cancer risk in either breast. The nonproliferative type carries no risk, while fibroadenoma, the most common benign tumor, is a proliferative breast lesion (i.e., has a slight increase in malignancy risk). Because atypical hyperplasia shares some features with breast carcinoma in situ, future cancer potential is increased. Management ranges from frequent monitoring to surgical excision, depending on certain factors, including the inherent risk of the pathologic diagnosis. Other breast disorders without malignant possibility are associated with underlying infection or systemic disease, so treatment differs. Benign breast diseases are common but present diversely. It is important to distinguish between them to determine the likelihood of cancer and the best course of treatment.

The postpartum period is typically defined as the first 6–12 weeks following delivery of an infant. During this time, postpartum complications can occur either as a result of the normal physiologic changes the body undergoes to return to its prepregnancy state or as complications of the labor and delivery process. These changes include those in the reproductive, urinary, cardiovascular, GI, and endocrine systems. In addition, postpartum hemorrhage, postpartum fever, and psychiatric disorders are common complications during this time frame. Because of the complexity and clinical importance of these topics, they are each discussed in separate concept articles.

Nonhormonal contraception does not affect the reproductive hormones in women. Nonhormonal contraception includes physiological methods, barrier methods, surgical methods, or the use of a copper intrauterine device. Each method has a different mechanism and extent of efficiency in preventing pregnancy. It is important to note that most physiologic methods are associated with high failure rates. On the other hand, surgical methods are permanent and highly effective.

Mastitis is inflammation of the breast tissue with or without infection. The most common form of mastitis is associated with lactation in the first few weeks after birth. Non-lactational mastitis includes periductal mastitis and idiopathic granulomatous mastitis (IGM). Lactational mastitis is most commonly caused by Staphylococcus aureus that is introduced into the breast milk during breastfeeding. The etiology of non-lactational mastitis is poorly understood, but periductal mastitis is commonly associated with smoking, and IGM is frequently associated with Corynebacterium. Patients present with edema, erythema, tenderness, and, possibly, a mass in the breast. Diagnosis is usually clinical, although ultrasound, cultures, and biopsy may be required in some cases. Management involves antibiotics, analgesics, drainage of any abscesses, and surgical duct excision for periductal mastitis.

A neonate, or newborn, is defined as a child less than 28 days old. A thorough physical examination should be performed within the first 24 hours of life to identify abnormalities and improve outcomes by offering timely treatment. Physical examination of the newborn is typically performed sequentially from head to toe, keeping in mind common neonatal pathologies based on family and prenatal history, risk factors, and geographic region.

The postpartum (PP) period is a common time for the emergence or exacerbation of psychiatric disorders. Postpartum blues, PP depression, and PP psychosis are 3 of the most common psychiatric disorders experienced in the PP period. Although both genders are affected, PP is more common in women. Postpartum blues and PP depression affect up to 80% and 25% of women, respectively. Postpartum psychosis is less common but can be more serious. Unfortunately, perinatal mental illness is largely underdiagnosed and undertreated. Diagnosis is clinical, and management typically involves psychotherapy and antidepressants. Antipsychotics are used in the management of PP psychosis.