Module 8: (b) The 4th Trimester

Question 1

Postpartum Physiology

Answer 1

1. Postpartum begins with the delivery of the placenta and continues to 6-8 weeks postpartum
2. Most physical recovery takes place in the first 6 weeks postpartum

Question 2

Post-Birth Follow Up

Answer 2

1. Traditionally 1 follow up visit 4-6 weeks after birth
   - Many women have returned to work, initiated sexual activity, discontinued breastfeeding d/t complications
2. Care may be fragmented between inpatient/outpatient, maternal/pediatric
3. Postpartum paradigm shift… TEST
   - 1-3 week initial assessment (TELEMED or in person)
   - Follow-up care as needed
   - Conclude w/ a comprehensive well-woman exam no later than 12 weeks

Question 3

Pregnancy is a “Natural”Stress Test

Answer 3

1. PP follow up to ID and plan for future cardiovascular risk

RISK factors for future ASCVD

• Preterm Birth
• Gestational Diabetes
• Gestational HTN, Pre-eclampsia & Eclampsia

Question 4

Mortality after birth

Answer 4

1. More than 1/2 of maternal deaths occur after delivery
   - Within 1 week — Hemorrhage*, HTN, Infection
2. 6 weeks to 1 year PP
   - Cardiomyopathy*
   - Mental health — Homicide, suicide, overdose

Question 5

Postpartum Infection

Answer 5

1. Puerperal Infection - Pelvic pain, fever, abnormal vaginal discharge
   - **Fever greater than 100.4 in the first 10 days postpartum
   - Uterine infection (metritis)
   - Wound infection (Laceration, episiotomy, cesarean)
2. Also Consider
   - Cardiovascular or thomboembolic events
   - Respiratory infection
   - Mastitis
   - UTI

Question 6

Postpartum UTI

Answer 6

1. Urinary stasis d/t to reduce tone, pain, incomplete emptying
2. Catheterization d/t epidural, cesarean
3. Diagnose and treat as in non-pregnant clients

Question 7

Postpartum Hemorrhage

Answer 7

1. LEADING cause of maternal morbidity and mortality
2. Hemorrhage greater or equal to 1000ml’s w/in 24 hrs of birth
3. Secondary (Delayed) hemorrhage
   - Increased bleeding after 24 hrs up to 12 weeks postpartum
   - Persistent, heavy, cessation followed by sudden return
4. Causes - Uterine atony, retained placenta, infection

Question 8

PostPartum Thromboembolic Events

Answer 8

1. Hypercoagulability, Venous stasis, vascular trauma
2. Cesarean birth, infection, immobilization, hemorrhage
3. S/Sx’s
   - Localized extremity pain — firm, cordlike structutre, erythema, edema, warmth
   - Abrupt onset leg pain
   - Fever, mild tachycardia possible
4. Early and frequent ambulation leads to reduced risk
5. Pulmonary Embolism is a LEADING CAUSE of mortality

Question 9

Postpartum Thyroiditis

Answer 9

1. Inflammation of the thyroid gland
2. Presents up to 1 year PP; MOST LIKELY 1-4 months
3. Hyper-thyroiditis usually presents first, followed by hypo-thyroiditis
   - May present as either, both, alternating
4. Sx’s
   - Fatigue, anxiety, palpitations, insomnia, weight loss, goiter
   - Poor concentration, depression, dry skin, constipation, weight gain, goiter
   - R/O mood disorders
5. Thyrotoxicosis (Thyroid storm)
   - Potentially life threatening, occurs w/in 1 month PP
   - Abrupt fever, nausea, vomiting, diarrhea, tachycardia tremor

Question 10

Postpartum Mood and Anxiety Disorders

Answer 10

1. Screen with validated tool — Edinburgh postnatal depression scale
2. Postpartum blues — Transient, mild, occurs 7-10 days PP
3. Postpartum Depression — Occurs up to 12 months PP — Sx’s lasting longer than 2 weeks
4. Postpartum Psychosis **
   - More liely w/in 4 weeks
   - High risk suicide, infanticide
   - Immediate referral

Mental health may WORSEN in the postpartum time