15. Postpartum Care

Question 1

Describe: Postpartum Office Visit at 6 Weeks (10)

Answer 1

Care of Mother (The 10 Bs)

• Be careful: do not use douches or tampons for 4-6 wk post-delivery
• Be fit: encourage gradual increases in walking, Kegel exercises
• Birth control: assess for use of contraceptives
• Breastfeeding is NOT an effective method of birth control
• Bladder: assess for urinary incontinence, maintain high fluid intake
• Blood pressure: especially if gestational HTN
• Blood tests: CBC (for anemia if had PPH)
• Blues
• Bowel: fluids and high-fibre foods, bulk laxatives; for hemorrhoids/perineal tenderness: pain meds, doughnut cushion, sitz baths, and ice compresses
• Breast and pelvic exam: watch for Staphylococcal or Streptococcal mastitis/abscess, ± Pap smear at 6 wk if due for screening

Question 2

What to ask about when rounding on postpartum care? (7)

Answer 2

The acronym “BUBBLES” for what to ask about when rounding on postpartum care. Modify this for C/S or vaginal delivery

• Baby care and breastfeeding–- Latch? Amount?
• Uterus – firm or boggy?
• Bladder function – Voiding well? Dysuria?
• Bowel function – Passing gas or stool? Constipated?
• Lochia or discharge – Any blood?
• Episiotomy/laceration/incision – Pain controlled?
• Symptoms of venous thromboembolism (VTE) – Dyspnea? Calf pain?

Question 3

Describe: Physiological Changes Postpartum (4)

Answer 3

• uterus weight rapidly diminishes through catabolism, cervix loses its elasticity and regains firmness
  
  • should involute ~1 cm below umbilicus per day in first 4-5 d, reaches non-pregnant state in 4-6 wk postpartum
• ovulation resumes in ~45 d after giving birth, non-lactating women usually ovulate sooner than lactating women
• lochia: normal vaginal discharge postpartum, uterine decidual tissue sloughing
  
  • decreases and changes in colour from red (lochia rubra; presence of erythrocytes, 3-4 d) s pale (lochia serosa) s white/yellow (lochia alba; residual leukorrhea) over 3-6 wk
• foul-smelling lochia suggests endometritis

Question 4

Describe: Breastfeeding Problems (6)

Answer 4

• inadequate milk: consider domperidone
• breast engorgement: cool compress, manual expression/pumping
• nipple pain: clean milk off nipple after feeds, moisturizer, topical steroid if needed
• mastitis: treat promptly
• inverted nipples: makes feeding difficult
• maternal medications: may require pediatric consultation

Question 5

Describe: Bladder Dysfunction Postpartum (3)

Answer 5

• pelvic floor prolapse can occur after vaginal delivery
• stress or urge urinary incontinence common
• increased risk with instrumental delivery or prolonged second stage

Question 6

Describe: Conservative management for stress and urge incontinence (3)

Answer 6

• pelvic floor retraining with Kegel exercises/ pelvic physiotherapy
• vaginal cones or pessaries
• and lifestyle modifications (e.g. limit fluid, caffeine intake)

Question 7

Describe surgical management for stress incontinence (3)

Answer 7

• midurethral slings including retropubic tension free vaginal tape (TVT) or transobturator tape (TOT)
• retropubic urethropexy (Burch)
• urethral bulking

Question 8

Name safe drugs during Breastfeeding (9)

Answer 8

• Analgesics (e.g. acetaminophen, NSAIDs) Anticoagulants (e.g. heparin)
• Antidepressants (e.g. sertraline, fluoxetine, tricyclic antidepressants)
• Antiepileptics (e.g. phenytoin, carbamazepine, valproic acid)
• Antihistamines
• Antimicrobials (e.g. penicillins, aminoglycosides, cephalosporins)
• β-adrenergics (e.g. propanolol, labetalol)
• Insulin
• Steroids
• OCP (low dose) – although may decrease breast milk production

Question 9

Name contraindicated drugs during Breastfeeding (10)

Answer 9

• Chloramphenicol (bone marrow suppression)
• Cyclophosphamide (immune system suppression)
• Sulphonamides (in G6PD deficiency, can lead to hemolysis)
• Nitrofurantoin (in G6PD deficiency, can lead to hemolysis)
• Tetracycline
• Lithium
• Phenindione
• Bromocriptine
• Anti-neoplastics and immunosuppresants
• Psychotropic drugs (relative contraindication)