Postpartum Flashcards
Early Postpartum
What is normal temperature?
What is abnormal temperature?
Differentials for abnormal temp?
Normal: 98.6-100.4, stabilizes during the first 24 hours postpartum
Abnormal: > 100.4
DDX for abnormal: infection, pulmonary embolism
Early Postpartum
What is normal pulse?
What is abnormal?
Differentials for abnormal pulse?
Normal: 65-80
Abnormal: >80
DDx: infection, increased blood loss, pulmonary embolism
Early Postpartum
What is normal BP?
What is abnormal BP?
Differentials for abnormal BP?
Normal: same as pre-pregnant, although transient increase in BP as much as 5% of baseline in 4 days after delivery
Abnormal: >140/>90: DDX postpartum hypertensive disorder, PEC
<90/<60: DDX blood loss, med reaction
Early Postpartum
Normal Neurologic assessment
Abnormal Neurologic assessment
Normal: A&O x3
Abnormal: disoriented, excessive sedation
Early Postpartum
Normal Lung assessment
Abnormal Lung assessment
Normal: No SOB, able to breathe without difficulties, clear to auscultation
Abnormal: SOB, adventitious breath sounds on
Early Postpartum
Normal Cardio assessment
Abnormal Cardio assessment
Normal: No CP, RRR
Abnormal: chest pain, palpitations, tachycardia
Early Postpartum
Normal Breast assessment
Abnormal Breast assessment
Normal: Nipples may be sore from nursing, but NOT painful; colostrum and breast fullness x3-5 days
Abnormal: Painful,cracked, bruised, blistered, bleeding nipples; no breast filling by day 5
Early Postpartum
Normal GI/Abdomen assessment
Abnormal GI/Abdomen assessment
Normal:
- eating and drinking without difficulty
- Return of bowel movement day 2-3 PP
- Presence of bowel sounds
- Decreased muscle tone
- Diastasis recti is expected
- Firm fundus and midline; level of fundus appropriate according to process of involution
- surgical scar is well approximated, without s/s of infection
Abnormal:
- nausea and vomiting, abdominal pain, constipation or diarrhea
- distended abdomen, unable to palpate uterus
- Fundal height not midline and level is increasing not according to PP day
- surgical scar is not well approximated, showing signs of infection and dehiscense
Early Postpartum
Normal Urinary assessment
Abnormal Urinary assessment
Normal:
- voiding spontaneously and without difficulty,
- diuresis,
- mild external burning, retention, incontinence, lack of sensation or urge to void is common in first 2 days
Abnormal:
- dysuria, persistent retention or incontinence, distended bladder, CVA tenderness
Early Postpartum
Normal Perineum assessment
Abnormal Perineum assessment
Normal:
- mmild erythema, bruising, edema;
-laceration/episiotomy repair is well approximated and without drainage,
-lochia decreasing in amount each day
Abnormal:
-worsening perineal tenderness, erythema, edema,bruising
- Presence of hematoma
- laceration/episiotomy repair is not well approximates, showing signs of separation
- malodorous lochia; excessive amounts with clots, soaking pads
Early Postpartum
Normal Anus assessment
Abnormal Anus assessment
Normal: hemorrhoids may be present, pink in appearance
Abnormal: hemorrhoids deep blue or purple
Early Postpartum
Normal LE assessment
Abnormal LE assessment
Normal: muscle soreness from positioning in labor, bilateral/symmetric edema
Abnormal: unilateral leg pain, unilateral calf tenderness, one leg more edematous than the other
What is uterine involution?
Process of the uterus returning to the pre-pregnant state - results from reduction in cell size (not number)
What is the normal process of uterine involution?
- Immediately after delivery: uterus contracts to about the size of a grapefruit, located halfway between umbilicus and symphysis pubis
- By 12 hours post-delivery: uterus is at the level of the umbilicus; fundus should be midline of the abdomen, if displaced to the side, may indicate a full bladder
- The fundus then descends about 1 cm per day
- By 2 weeks: uterus no longer palpated abdominally
- By 6 weeks: uterus returns to slightly larger than pre-pregnant state
What is Lochia:
Vaginal discharge in the post-partum period. Consists of the breakdown of myometiral placenta bed, eschar and decidual cells.
What are the 3 stages of lochia discharge?
Rubra, Serosa, Alba
Lochia Rubra:
Lasts: 3-7 days
Color: Red or red-brown
Description: Fleshy odor, contains superficial layer of decidua that has sloughed off the uterus, debris (cellular remains from vernix, lanugo, mec, necrotic placenta remains)
Lochia Serosa
Lasts: from day 14-21
Color: Pinkish-brown color
Description: Serous to serosanguinous secretion; contains blood, cervical mucus, erythrocytes, leukocytes, decidual tissues
Lochia Alba
Lasts: Until cessation of flow in about 4-6 weeks postpartum
Color: Yellowish to white discharge
Description: Flow increases with additional activity initially but decreases progressively
Normal Transition of the Cervix postpartum?
- Immediately after vaginal birth the cervix appears edematous dilated 3-4 cmand bruised, may have lacerations
- Day 2-3 PP: Continues to be dilated 2-3 cm
- By day 7: 1 cm
- By 4 weeks: No longer dilated
What does Multiparous Cervix look like at completion of involution?
External os does not return to its pre-pregnant appearance, remains somewhat wider with transverse opening, resembling a fish mouth
Normal Transition of the vagina Postpartum?
Immediately PP: edematous, relaxed, sometimes bruised with decreased tone
By 3-4 weeks PP: rugae return; edema, vascularity, and bruising decrease
By 6-10 weeks postpartum, vaginal epithelium
** Decreased Lubrication can lead to pain with sex, especially with breastfeeding***
Normal Transition of the Perineum Postpartum:
Immediately after birth: edematous with decreased tone, laceration and episiotomy repair should be well approximated
7 days PP: skin should appear healed with only linear scarring by 6 weeks
Normal Transition of Breast postpartum:
- colostrum is produced upon birth of baby, may even have colostrum production in 3rd trimester
- engorgement occurs approximately 72 hours after birth
- milk ejection reflex develops within the first 1-2 weeks
Normal transition of the hematologic system postpartum:
Immediately postpartum in the fist hours post birth: Cardiac output increases 60-80%
Over first 48 hours: diuresis occurs, plasma volume decreases and cardiac output normalizes by 2 weeks
Normal changes of Renal system PP:
Diuresis occurs within first 5 days as result of extravascular fluid shifts
Bladder can be hypotonic and edematous immediately after the birth: resolves in 24 hours
Prolonged labor, trauma to vulva, urethra or bladder, use of anesthesia during c/s can cause urinary retention
Normal Weight loss/caloric intake pp:
Caloric intake at least 1800 calories per day +500 cal if breastfeeding (more if twin breastfeeding)
No more than 4.5 lb/month of weight loss
Normal abdominal changes PP:
-decreased peristalsis in first 24 hours pp
- AST/ALT return to pre-preg levels by week 2
- diastasis recti found in 75-80% of pp women
-striae common
Endocrine changes in breastfeeding women:
- Lactation is stimulated and prolactin and oxytocin are secreted
- By negative feedback, ovulation and menstruation are inhibited by increased prolactin, resulting in estrogen suppression
- If exclusively breastfeeding, there is a 1-3% change of ovulation within the first 6 months PP
When will Menses return after weaning breastfeeding?
- generally ovulation 14-30 days after weaning, first menses 14 days later!
What is efficacy of LAM?
1-3% chance of ovulation in first 6 months PP if exclusively breastfeeding
Endocrine changes in non-breastfeeding women
Prolactin levels fall after initial engorgement
Hormonal shifts to stimulate ovulation begin 3-4 weeks pp
First menses: 6-8 weeks pp, 70% by 12 weeks
When to expect return to menses if NOT breastfeeding (never started)?
Avg: 6-8 weeks pp, 70% by 12 weeks
When to give Rhogam?
Anti-Rho(D) immune globulin (Rhogam) should be given within 72 hours of birth if mom is Rh neg and baby is Rh +
Vaccines to give immediately PP if not already received/immune?
Tdap, MMR, varicella, Flu, HPV, COVID
Common PP Discomfort: Involutional PAIN
Comfort measures?
- likely to increase with each subsequent birth and with nursing
NONPHARM: - maintain empty bladder and bowels
- relaxation and breathing techniques
- changing positions, sitting up, walking,
- applying heat,
- using abdominal support binder, lying flat on the abdomen
PHARM:
- ibuprofen
- acetaminophen
-Avoid opioids (some women are ultrametabolizers of codeine, which causes rapid conversion to morphine, which puts babies at risk of respiratory depression)
Common PP Discomfort: Diuresis
Comfort measures?
stay well hydrated to prevent dehydration
Maybe sleep with a towel under you/change of clothes nearby so you can quickly change out of wet clothes
Common PP Discomfort: Breast Engorgement
Comfort measures?
- Initiate breastfeeding early and often
- assess that infant is positioned correctly and properly latched
- at times, infants can’t latch to severely engorged breasts –> instruct patient to express small amount of milk manually before each feeding to soften the areola and allow the infant to latch properly
- can use pump to assist with softening the breasts before feeding by releasing enough milk for infant be able to latch
- avoid excessive pumping, as this increases breastmilk production and worsens engorgement
- supportive Bra
- warm compress or warm shower before feeding
IF bottle feeding:
- tight bra
- ice pack
-analgesics
- reassurance about time limitation
- cold cabbage leaves in bra for comfort
Common PP discomfort: Perineal Pain
Comfort measures?
- evaluate by REEDA (redness, edema, ecchymosis, discharge, approximation)
Topical meds/treatment:
- witch hazel pads
- dibucaine, benzocaine
- ice packs for first 24 hours
- sitz baths after 24 hours
- topical anesthetics
Common PP Discomfort: Constipation
Risk factors?
Comfort Measures?
Risk factors: lack of ambulation in labor and pp period (esp after c/s); decreased intestinal peristalsis due to anesthesia, narcotic use for pain
Comfort:
- increase fluids, fiber
- stool softener
-encourage ambulation
- laxatives if needed
Common PP Discomfort: Hemorrhoids
Prevention?
Comfort?
Prevention: bowl regimen of scheduled use of stool softeners to avoid constipation; avoid straining with bowel movement
Comfort: ice packs, topical anesthetics, referral if thrombosed
Postpartum blues
-affects 80% of women
- begins within 3-5 days of birth, concurrent with profound hormonal shifts
- Very labile emotions (giddiness, sadness, crying)
- generally time-limited over 1-2 weeks
- supportive, sensitive care is usually all that is needed
Postpartum Depression: Definition
Depression occurring anytime within 4 weeks after childbirth and up to 12 months
Risk factors for Postpartum Depression:
- hx of depression/anxiety, esp if untreated in pregnancy
- genetic
- social factors: IPV, prior abuse, lack of social support, negative life events
When is the most common onset of symptoms of PP depression?
usually 4-6 weeks, worsens overtime
can be anytime within 12 month after birth
Symptoms of PP depression:
- sleep disturbance
- feeling overwhelmed
- anxiety
-irritability - unable to perform ADLs- symptoms can be incapacitating to women
- preoccupation and obsession with infant health
- can have suicidal, infanticidal, homicidal ideation
- apathy toward self/infant
- symptoms DO NOT improve over time, likely worsen
What other illnesses should you rule out with PP depression?
- postpartum thyroiditis
- anemia
- infection
- sleep deprivation
Diagnosis of PP depression?
At least one of the following 2 symptoms:
(1) depressed mood
(2) loss of interest or pleasure
In addition 4+ of the following symptoms:
1. depressed mood most of the day, nearly every day (feels empty, sad, hopeless)
2. Marked diminished interest or pleasure in all or almost all activities
3. Significant unintentional weight loss or decrease in appetite
4. Insomnia or hypersomnia
5. Psychomotor agitation or retardation
6. fatigue/loss of energy
7. feelings of worthlessness or excessive or inappropriate guilt
8. Diminished ability to think or concentrate
9. suicidal ideation with or without a plan
Treatment for PP depression:
- consult psych team
- ensure safety of mom and infant
- Psychosocial strategies including peer support and counseling
- CAM: omega 3 fatty acids, folate, st john’s wort, bright light therapy, exercise, massage, acupuncture
Pharm: SSRIs are 1st line–> most SSRIs pass to breastmilk, but are usually compatible with breastfeeding a healthy, full-term infant
Postpartum psychosis:
s/s:
- disorganized thinking, bizarre speech and behavior
- hallucinations with auditory or visual perceptual disturbances
- delusions
THIS Is a PSYCH EMERGENCY:
- need psych team
-hospitalization usually
- patient may be a danger to self, infant, others
Return to ovulation in non-breastfeeding patients:
39 days pp
Return to ovulation in Breastfeeding patients
varies depending on frequency and duration of breastfeeding
Return to sexual activity
Clinicians typically recommend pelvic rest x 4-6 weeks, but studies have shown that 50% of women resume sexual activity before pp visit
How long does hypercoaguable state last pp?
PP patients are in a hypercoaguable state for 3-4 weeks pp
Estrogen containing conctraception needs to be avoided during this period
How long to wait postpartum before taking CHC (with estrogen)??
42 days (6 weeks) d/t hypercoaguable state
What types of BC are OK in PP period?
Cu-IUD and LNG-IUD can be given in postpartum period at any time, even immediately after placenta is delivered; they are only contraindicated with PP sepsis!
Implant, Depo, Pop can also be given at any time in pp period, controversy about effects on lactation
Tubal Ligation in hospital, generally consent prior to birth
What needs to happen for LAM method to be effective?
Exclusive breastfeeding
feeding at least q 4 hours during day and 6 hours at night
has not started solid foods for any meals
infant less than 6 months old
no menses
If a women does not meet this criteria, choose another method*
If had GDM, what test does pt need at 6 weeks pp?
fasting, 2-hour 75 g glucose tolerance test
Diagnosis of Urinary Retention
- Inability to void spontaneously within 6-8 hours after birth or after removal of urinary catheter after delivery
-post-void residual urine of > 150 mls - Palpable bladder
- fundus of uterus displaced and not midline in abdomen
Risk Factors for Urinary retention
- epidural anesthesia
- operative vaginal delivery
- episiotomy/laceration, esp periurethral lac
- LGA infant
- Primpip
Complications of Urinary Retention
UTI
bladder dysfunction
Management of Urinary Retention
Non-pharm:
- give pt privacy on the toilet to relax, not feel pressure to void
- few drops of peppermint oil in toilet water or bed pan
- sound of running water
- place hand in warm water
PHARM:
- intermittent catheterization
- indwelling catheter
- consult urology
What is the definition of a postpartum fever?
Temp of greater than or equal to 100.4 x 2 during postpartum days 2-10
What is the differential diagnosis for postpartum fever?
Most Common:
- Endometritis
- UTI
- Wound infection
Less common:
- transfusion reaction
- drug reaction
- septic pelvic thrombophlebitis (SPT)
Endometritis Definition
Uterine infection/inflammation or lining of uterus
Endometritis s/s
general malaise/flu-like symptoms
fever
tachycardia
abdominal pain
malodorous lochia
Risk factors for endometritis:
- prolonged ROM
- prolonged labor
- multiple cervical exams
- c/s
- choriomanionitis
- lower genital infection with GBS, Chlamydia, mycoplasma hominis, ureaplasma urealticum, Gardernella vaginalis
Treatment for endometritis:
(1) Gold standard: clindamycin and gentamicin
(2) Vancomycin should be added if staphylococcus aureus is suspected
Risk factors of abdominal incision infection
- obesity
-DM - corticosteroid therapy
- immunosuppression
- anemia
- hypetension
-hematoma
Treatment for abdominal incision infection:
antimicrobials
surgical drainage
Risk factors for Wound dehiscense
- wound infection
- obesity
Treatment for wound dehiscense
- treat underlying infection
- secondary closure of the incision in the operating room
Definition of Perineal Infection
Infection of the perineum due to infected episiotomy or lac, can lead to dehiscence of the repair
Perineal Infection treatment:
- drain and debridement
- antimicrobial therapy
- wound care
- secondary repair when episiotomy or lac has healed
What is Septic pelvic thrombophlebitis?
septic phlebitis along venous route,then causing thrombosis
Clinical manifestation of septic pelvic thrombophlebitis?
-pain in one or both lower abdominal areas
-chills
How to diagnose septic pelvic thrombophlebitis?
CT, MRI
What is the leading cause of maternal mortality worldwide?
Postpartum hemorrhage (PPH)
What is the ACOG definition of PPH?
- EBL of 1000 mL regardless of route of delivery
- Blood loss accompanied by s/s of hypovolemia within 24 hours after birth
Traditional def of PPH
EBL of 500 mls or more after vaginal birth, EBL of 1000 mls or more after c/s
Risk factors for PPH
- prolonged labor
- prolonged use of oxytocin
- chorioamnionitis
- high parity
- twins, multiple gestation
- polyhydramnios
-macrosomia
-operative vaginal delivery - precipitous delivery
Etiology of Primary PPH:
TONE: uterine atony: MOST COMMON 70-80%
TRAUMA: laceration, hematoma
TISSUE: retained placenta
THROMBIN: coagulation defects
Placenta accreta and uterine inversion can also cause PPH
What is Primary PPH
Occurs within 24 hours after delivery
What is Secondary PPH
Occurs between 24 hours and 12 weeks postpartum
PPH: what are s/s of uterine atony?
soft, boggy uterus
How to manage PPH cause by uterine atony?
Empty bladder, bimanual exam to remove intrauterine clots, perform fundal/uterine massage, administer uterotonics (oxytocin, methergine, hemabate, miso), intrauterine tamponade if needed
How to manage PPH cause by trauma?
Identify the source of lac/bleed: vaginal, vulvar, periclitoral, perineal, genital tract hematoma
- repair lac
- hematoma may need incision and drainage
- arterial embolization
S/S of PPH hemorrhage caused by obstetric trauma
- bleeding wound
- patient may complain of labial, rectal, pelvic pressure or pain (hemotoma esp)
- abnormal vital signs
How to manage PPH caused by retained placenta?
Diagnosis: visual insepction of placenta, u/s, intrauterine manual exam
Mgmt: removal of retained placenta, curettage with u/s guidance
Etiology of secondary PPH
Subinvolution
Retained placenta/products of conception
Infection
Coagulation defects
- Acute coagulopathy: caused by placental abruption, ambiotic fluid embolism, DIC, managed by volume replacement and initiating transfusion protocol
What are montgomery tubercles
sebaceous glands on the areola of the breast that provide protective secretion and lubrication to the nipple
Lactogenesis I:
WHEN: Occurs early pregnancy to 3rd day postpartum
WHY: Hormones of Pregnancy
WHAT: secretion of small amount of colostrum
- Approx 100 mls of breastmilk is produced on day 1 pp
- contains high concentration of immunoglobulins
Lactogenesis II
WHEN: 2-4 days PP
WHY: placenta delivers –> decrease in progestin hormone concentration, increase in prolactin hormone concentration
WHAT: Volume of milk increases
- about 500 mls of breastmilk is produced on pp day 4
- copious milk production begins
- typically referred to as “milk coming in”
Lactogenesis III
WHEN: begins between 7-14 days pp
WHY: Milk production depends on supply-demand relationship
- frequent milk transfer —> suckling stimulates the nipple and areola –> message sent to hypothalamous to secrete prolactin and oxytocin hormones
WHAT: mature milk is established, maintenance of milk supply
What does prolactin do in Breastfeeding?
stimulates milk production
What does oxytocin do in breastfeeding?
stimulates the contraction of myoepithelial cells; this contraction of cells causes milk ejection
AKA let-down reflex
Contraindications to breastfeeding?
Maternal infection:
-HIV
-Active herpes lesion on nipple
-flu
-untreated TB
-Varicella infection developed 5 days prior to birth and 2 days after birth
Illicit drug use
Specific meds
- anticonvulsants
- chemo/radiation
-statins
- retinoids
-some antiretrovirals
Breast Engorgement
How to prevent
How to treat
Prevention:
- proper breastfeeding positioning and attachment
- emptying one breast at each feed
- alternating which breast is offered first
- frequent milk transfer
Treatment:
- Acupuncture
-hot/warm pack prior to feeding followed by cold pack after feeding
- Cold cabbage leaves after feeding
- breast masage
- hand expression
Insufficient Milk Supply
How to evaluate
How to treat
Eval:
- eval for medical causes of low milk, medication
- assess frequency and effectiveness of milk removal and transfer
Treat:
- increase frequency of feeds
- galactagogues
- eliminate meds that may decrease supply
Galactagogues
CAM:Fenugreek, goat’s rue, milk thistle, oats, dandelion, seaweed, blessed thistle, fennel seeds, beer (hops/barely, but alcohol can decrease supply)
PHARM:
- domperidone: warning - increases QT interval and implicated in ventricular arrhythmias and sudden cardiac death
- Metoclopramide: warning: CNS sedation, depression, extrapyramidal symptoms
Mastitis Diagnosis:
- Erythematous, edematous, wedge-shaped area in the breast, typically unilateral
- fever >/= 101.3
- flu-like symptoms
Mastitis risk factors
- damaged nipples
-infrequent feedings - ineffective milk transfer and removal; (poor latch, uncoordinated suck)
- Oversupply of milk
- rapid weaning
-bra too tight - maternal fatigue
- hx of mastitis
Mastitis tx:
Analgesia:
- NSAIDs
- alleviating pain may help pt relax and facilitate let-down
ABX:
- dicloxacillin or flucloxacillin 500 mg PO QID x 10-14 days
- Keflex (cephalexin) 500 mg QID x 10-14 days
- If PCN allergic: clindamycin 300 mg QID or erythromycin 250 mg QID x 10-14 days
** should improve/resolve within 48 hours of starting antibiotics**
Breast abscess
collection of pus in breast, surrounded by inflammation
Breast abscess diagnosis:
PE and u/s
Breast Abscess likely organism
S. aureus
Management of Breast Abscess
surgical drainage, needle aspiration, abx
Raynaud’s phenomenon of the breast:
What is is?
S/S
Treatment
WHAT: Vasospasm of the nipple after breastfeeding or when nipples are exposed to cool air
S/S:
- nipple color changes to purple or blanches, may be unilateral or bilateral
- severe pain - sharp/burning sensation
Tx: nifedipine, avoid exposure to cold air
Fungal infection of breast:
What is it?
S/S
Treatment
WHAT: infecting organism candida, diagnosis is based on history of PE
S/S:
- infant may have thrush or diaper rash
- shiny and red nipple and areola
- flaky skin around nipple
- burning, itching, stabbing pain like “shards of glass” in breast
Tx:
- topical nystatin, miconazole, or clotrimazole
- APNO cream (mupirocin 2% ointment, betamethasone 0.1% ointment, miconazole 2%)
-Gentian violet 1% in 10% alcohol to nipple x 4 days
What is the max dose of acetaminophen per day for an adult?
4000 mg/day
What is the max dose of ibuprofen per day for an adult?
3200 mg/day
