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Antepartum (UPenn) > Postpartum > Flashcards

Postpartum Flashcards

1
Q

Describe postpartum anatomic and physiologic changes:

Uterus

A
  • Involution - reduction of size of uterine cells. Starts at 2 days post birth → finished by about 10 – 14 days
    • Uterus weighs 1000 g at birth → 500 g at 1 week after → 300 g at 2 weeks → approximately 100 g at 4 weeks
    • Uterus at/slightly above umbilicus immediately after birth → below pubic symphysis by 14 days
      • firmly contracted, consistency/size of softball
  • Afterpains - contractions strongest first 3 days post birth.
    • Worse in parous women, multiple gestation and with breastfeeding (oxytocin)
    • Important for hemostasis (ligates bleeding vessels at placenta site)
    • Can lie prone or use NSAIDS (ie ibuprofen 600 mg q 6)
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2
Q

Describe postpartum anatomic and physiologic changes:

Cervix

(vaginal delivery)

A
  • Healing begins within hours after birth
    • Begins to remodel as uterus contracts and pulls it back into normal position (shortens/thickens/epithelial remodeling)
  • Nearly closed by 1 week
  • Almost back to pre-pregnant size/shape by 6 weeks.
  • Os looks more like a transverse slit
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3
Q

Describe postpartum anatomic and physiologic changes:

Lochia

A
  • Vaginal discharge resulting from the sloughing of decidual tissue and debris
  • Lochia rubra – vaginal discharge (debris from placenta, membranes, lanugo, vernix, and decidual tissue ). May have dime-sized clots and fleshy odor. Lasts about 3 days
  • Lochia serosa – paler version of lochia rubra, begins as uterus regenerates endometrium and remodel placental site. Can smell bad. Lasts 7 – 10 days (median 22-27 days) and transitions to linea alba
  • Lochia alba – pink, yellow, or white discharge. Lasts up to 4 weeks

***May see a sudden, transient increase in bleeding around day 7 - 14 post partum → sloughing of eschar over area of previous placental attachment. Self-limiting (a few hours)

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4
Q

Describe postpartum anatomic and physiologic changes:

Endocrine changes

(estrogen, progesterone, thyroid, prolactin, FSH, ADH)

A
  • Estrogen and progesterone drop
    • Estradiol to 2% of pregnant levels by 24 hours
    • Estrogen withdrawl → rapid diuresis
    • Progesterone to nonpregnant levels by 24-48 hours → removal of fluid from tissues and return of vascular tone
    • Estrogen to almost prepregnant levels by 7 days
  • Thyroid regresses and BMR is normal by 7 days
    • T3/T4 normal by 4 weeks
  • Non-lactating
    • Prolactin - normal range within 3 weeks
    • Estrogen levels start rising within 2 weeks
    • Ovulation - mean 70 - 75 days (early as 27)
  • Lactating
    • Prolactin - elevated x 6 weeks
    • Ovulation - mean 6 months
  • FSH same regardless of lactation
  • Increased antidiuretic hormone (ADH) immediately post partum → increased water/Na retention → mild 3rd spacing/pedal edema. Resolves 4-7 days.
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5
Q

Describe postpartum anatomic and physiologic changes:

Vagina/Labia/Perineum

A
  • Labial/perineal edema usually resolved by 3-4 days. Lacerations take days to weeks to heal
  • Immediately post partum - slack vagina and no rugae
    • Rugae appear by 3 weeks (less prominent than prepregnant).
  • Vaginal epithelium starts to proliferate at 4 weeks, completed by 6 weeks and tone nearly restored (but never fully recovers).
    • Drop in progesterone helps impove tone
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6
Q

Describe postpartum anatomic and physiologic changes:

Cardiovascular

A
  • Estrogen withdrawal → rapid diuresis x 48 hours → return to normal Hct and plasma levels
  • Progesterone decreased → improved vascular tone and water removal from tissues
    • takes up to 6 weeks to get to prepregnancy levels (vessel diameter/flow) → increased risk for clots
  • CO - elevated 1 hour after birth x 2 days → usually back to prepregnant in 1 week
  • BP - slightly elevated x 4 days after birth
  • Coagulation increased significantly x 2 days → elevated x 2 weeks
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7
Q

Describe postpartum anatomic and physiologic changes:

Renal

A
  • Progesterone falls → renal dilation resolves
  • Transient bladder control issues due to stress of labor
  • GFR returns to normal by 8 weeks
  • Medications with renal dosage adjustments for pregnancy need to be reassessed at 4 - 6 weeks
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8
Q

Describe postpartum anatomic and physiologic changes:

Immune system

A
  • Immune system suppressed during pregnancy rebounds quickly after delivery
  • May see “flare-ups” of autoimmune disease and latent infections with inflammatory reactions.
    • Inflammatory reactions → clinical symptoms.
    • Examples: autoimmune thyroiditis, multiple sclerosis, and lupus erythematosus
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9
Q

Describe postpartum anatomic and physiologic changes:

GI changes

A
  • Progesterone decrease → improved heartburn/reflux.
  • Constipation may persist due to fear of pain or immobilization after surgery
  • Fasting blood sugars return to normal by 48 hours and are stable by 6 weeks
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10
Q

Define: telogen effluvium

A
  • More rapid hair turnover is seen for up to 3 months after birth
  • As a greater percentage of hair begins to undergo the growth phase, more hair falls out with combing and brushing.
  • Loss of hair in diffuse, not balding, pattern
  • Reassure patient its transient
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11
Q

Components of early (2 week) post-partum visit

vs 6 week post-partum

A

NUTSHELL

  • 2 weeks: assess involution process, psych/physical adaptations
  • 6 weeks: assess involution complete, continuing psych adjustment, family planning

DETAILED

Subjective:

  • Physical and emotional adjustment
  • Birth experience
  • Family adaptation
  • Infant feeding
  • Exercise/activity/Rest/sleep
  • Diet/Fluids/Constipation/hemorrhoids
  • Lochia/Perineal comfort/
  • Sexuality/Resumption of intercourse/Contraception
  • At two week visit include: Afterbirth pains and Diuresis/diaphoresis

Objective:

  • Vital signs/Weight
  • Heart/lungs
  • Breasts
  • Uterus/Perineum/bleeding prn
  • CVAT
  • Extremities/edema
  • Postpartum depression screening

Plan:

  • Teaching: Family adaptation, Maternal role attainment, Infant feeding, Normal involution, Exercise/activity, Rest/sleep, Diet/fluids, Birth control, Warning signs, Resumption of menses (at 6 week)
  • Follow-up at 6 weeks/annual and prn
  • Consult, collaborate, refer prn
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12
Q

Post partum blues

A
  • 80% of women, often appears within 1st week after birth
  • Etiology unknown, associated with: fatigue, decreased support, hormonal changes, social isolation, marital/relationship conflict
  • Common sx: crying, anxiety, overly fatigued, sleep difficulty, appetite changes, mood swings, conflicted feelings about birth experience
  • Symptoms > 2 weeks → evaluate for postpartum depression
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13
Q

“Taking in” vs “Taking hold” phases of post partum adjustment

A
  • Taking in - reviews labor and birth and clarifies experience for new parent/family and allows to go to next phase
  • Taking hold - parent assumes task of parenting, care of baby and self, along with attention to family and support network
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14
Q

Define: bonding

A
  • the emotional tie pregnant person develops with the unborn baby and later the newborn
  • Also occurs with other important family members and baby
  • Develops over time
  • Powerful source of ongoing care activities
  • Affected by a number of factors: parent’s perceptions of their own abilities, childhood experiences
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15
Q

Family adjustment

A
  • Lots of differnt types of families today…structure affects function
  • Healthy newborn should not be seperated from family at birth
  • Parents often interact differently with baby and baby’s reaction shapes responses
  • Sibling adjustment affected by variety of factors:
    • NOT age (according to Jordan)
      • Newborn mimicry for attention common
      • Depends on developmental milestones
    • family culture, size setting, support network
    • parental competance, relationship with each other
  • Providers should reframe as period of adjustment rather than rivalry
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16
Q

Define: maternal role attainment

A
  • historic concept used to describe process a mother goes through to attain a new role
  • Influenced by culture, experience with being parented, physical condition, socioeconomic status, readiness for life event, and attitude
  • Starts in prengnacy and continues through birth of baby and subsequent children
  • Not a 1 time event, but a lifelong transformation
17
Q

Describe signs, symptoms and management strategies for:

Fever

A
  • Aka puerperal fever
  • Temperature > 100.4° F (38° C)
  • Potential causes: often genital tract infection, also breast engorgement, dehydration, pyelonephritis, or respiratory illness
    • Fever rarely > 24 hours for breast engorgement or dehydration and is < 39°C
    • Rarely DVT can cause elevated temp
    • C/S < 24 hours and temp > 39° C → group A strep
  • Management → investigate for infection
18
Q

Resumption of menses

A
  • Important to know lochial flow patterns to determine if bleeding/spotting is lochia or resumption of menses
  • Different if bottle or breast feeding (even if breast was only for short time)
    • Bottle: within 4-6 weeks after birth
    • Breast: varies 2 - 18 months after birth
  • ***Can ovulate before 1st menses*** - crucial for contraceptive counseling
19
Q

Physical Exam:

Breast

A
  • Breast - recommended due to increase cancer found during pregnancy/lactation
  • Not breastfeeding - expect engorgement 2-4 days postpartum, may take several weeks for prolactin to decrease
    • Wear form-fitting bra even at night
    • Cold compresess
    • NSAIDS
    • Avoid breast stimulation of any kind
  • Breastfeeding: look for breast/nipple redness/breakdown
  • Follow-up, collaboration, or referral for any abnormal finding/persistent areas of concern
20
Q

Physical Exam:

Abdomen

A
  • Route of birth important
  • Cesarean - incision inspection for signs of infection (warmth, redness, drainage) or wound dehiscence
  • Involution assessment: compare level of fundus to # days post partum
    • Expect 1 fingerbreadth of descent per day from umbilicus to pubic symphysis
    • Should be pelvic organ by 2 weeks
    • ***Make sure bladder is empty***
    • Further investigation if exam isn’t as expected
    • Fundus should be firm (contracted)
  • Diastasis recti - expected finding, degree depends on parity, multiple gestation, abdominal condition before pregnancy
    • Patient lies supine → place examining fingers midline on abdomen → ask patient to tighten abs and put chin to chest → measure gap in fingerbreadths
21
Q

Physical exam:

Perineum

A
  • Inspection of episiotomy or laceration at 2 weeks and 6 weeks
  • Should be healed by 2-3 weeks, can take months if tearing extensive
    • Well-healed: faint, pinkish line where tissue is approximated
    • Infection: redness, edema, purulent exudate, fever
  • Granulation tissue → can use silver nitrate
22
Q

Physical exam:

Vaginal and uterine

A
  • Bruises, lacerations, edema expected after vaginal birth
  • Tone returns with decreased edema
  • Ruggae return 3 - 4 weeks post partum
  • Vaginal exam not necessary at 2 weeks unless concerning symptoms
  • If uterus is larger than expected → subinvolution → investigate cause
  • Saturating > 1 pad/hour → exam to investigate cause
  • 6 weeks: speculum exam
    • Cultures/pap as indicated
    • Examine internal tissues
    • Assess uterine size, palpate ovaries, assess muscle tone
    • Assess for cystocele or rectocele
23
Q

Physical Exam:

Rectal

A
  • As needed for hemorrhoid evaluation
  • Indicated after 3rd or 4th degree laceration
    • Assess healing, integrity, tone of internal and external sphincters
  • Reports of fecal incontinence → assess rectovaginal wall
24
Q

Physical Exam

Leg

A
  • Do at 2 and 6 week visits
  • Look for varicosities and DVT symptoms
    • Cord-like vessel, warmth over area, edema, complaints of pain/tenderness → referral
    • Homan’s sign could be + or -
  • Normal leg edema should be disappated by 2 weeks
25
Q

Post partum depression

A
  • Occurs in 10 - 20% of pregnancies, varies in severity
  • Can 1st appear as post partum blues that persists, or even during pregnacy
  • Commonly occurs around 4 weeks, but can appear anytime during 1st year (or longer)
  • Symptoms mimic postpartum blues but include extremes of appetite and sleep disturbances + more severe symptoms (ie suicide ideations)
  • Risk factors:
    • Highest risk: previous or present dx of depressive or anxiety disorder
    • Personal or family hx of mental health disorder
    • Social factors like isolation
  • Edinburgh Postnatal Depression Scale
    • Validated screening tool
    • Patient can complete in exam room while waiting for provider
    • May assist someone who is reluctant to disclose negative feelings
  • Other screening tools: Postpartum Depression Screening Scale (PDSS), Center for Epidemiological StudiesDepression Scale (CED-D), Patient Health Questionnaire (PHQ-9), and Beck Depression Inventory (BDI)
26
Q

Post-traumatic stress disorder

(as it relates to labor/birth experience)

A
  • Prevalence 1.5% - 5.6%
  • Extreme fear and helplessness when exposed to the same or similar environment where the trauma occurred.
  • May be plagued by recurring thoughts and dreams
  • May have relationship discord and attachment concerns.
  • Some births may be psychologically traumatic regarless of physical outcome
  • Provider role: encourage birth debriefing/counseling and reflection.
    • Opportunity for the patient to describe her experience, discuss her feelings, define occurrences, and obtain validation.
    • Opportunity for the healthcare provider to correct misinformation/understanding about the birth event and to help the patient reframe her narrative to assist in the integration of what she had hoped would happen with what really happened.
  • PTSD has also been linked to postpartum mood and anxiety disorders.
27
Q

Describe signs, symptoms and management strategies for:

Uterine Infection

A
  • One of the most common puerperal infections
  • Often referred to as endometritis, but other areas of uterus can be infected, ie myometrium (endomyometritis), parametrium (endoparametritis)
  • 1-2% post vaginal, up to 27% post c-section
  • Clinical presentation:
    • Fever (chills if severe)
    • General malaise
    • Abdonimal pain with uterine tenderness on bimanual
    • Lochia with or without foul odor
    • Subinvolution
  • Differentials: pyelonephritis, pneumonia, appendicitis
  • Managment:
    • Exam, CBC, blood cultures, aerobic uterine culture, U/A and urine culture, CXR or U/S if indicated
    • Mild cases: oral antibiotics
      • Consult MD if post-cesarean
    • Moderate-severe: hospitalization with IV antibiotics (obvious MD consult)
      • usually see improvement in 48 - 72 hours
      • D/C home once no fever/symptoms for 24 hours off antibiotics
28
Q

Most common reasons for post partum readmission: (regardless of method of delivery)

A
  • Uterine or wound infection
  • Hypertension
29
Q

Describe signs, symptoms and management strategies for:

Wound Infection

A
  • Often in cesarean incision or perineal laceration
  • Abdominal:
    • Clinical presentation: localized edema, induration, and erythema, often with exudates and occasionally fever.
    • Management: wound care, antibiotic treatment, and drainage (prn).
      • Reclosure of dehiscence vs healing by secondary intention - depends on size, drainage, and other wound characteristics
      • Culture is rarely necessary for treatment.
      • Common pathogens include Staph aureus, strep, and both an/aerobic bacilli.
  • Perineal:
    • Clinical presentation: localized edema, erythema, and exudates.
    • Management: similar to other wound infections
      • Drainage, removal of sutures, and debridement of the infected area.
      • Cellulitis → broadspectrum antimicrobials
      • Most heal without needing additional sutures.
      • Sutures breakdown for a 3rd or 4th° → repair after infection gone.
        • Use prophylactic antimicrobials initially to reduce infection rates.
  • Persistent fever, tachycardia, pain, and tenderness, despite several days of tx → assess for complications such as pelvic abscess, septic pelvic thrombophlebitis, and septic shock (severe cases)
30
Q

Describe signs, symptoms and management strategies for:

Delayed postpartum hemorrhage

A
  • Occurs after 24 hours and until 12 weeks postpartum
  • Prevalence 1-2%
  • Screen for vWD if occurs 2-5 days post birth
  • Management:
    • Uterotonic agents or curretage
      • Ergonovine, methylergonovine, oxytocin, or a prostaglandin analog
    • Consider U/S for retained placental fragments but not always accurate and retained frags dont usually cause hemorrhage
      *
31
Q

Describe signs, symptoms and management strategies for:

Subinvolution

A
  • Differential diagnosis: retained placental fragments, uterine infection, or excessive maternal activity prohibiting proper recovery.
  • Clinical presentation:
    • Irregular bleeding (can be profuse)
    • Abdominal and bimanual exam → enlarged and often boggy uterus.
  • Management
    • R/o retained placental fragments and infection
      • Methylergonovine (0.2 mg PO q 4 hrs) x 24– 48 hrs
      • Encourage rest, proper nutrition, fluid intake, and help at home
      • Follow-up in 1– 2 wks
32
Q

Describe signs, symptoms and management strategies for:

Thrombophlebitis (SVT, DVT, PE)

A
  • Incidence 1 in 1000-2000 womem
  • Risk factors: hypercoagulability, venous stasis, and inflammation from venous trauma caused by distension during pregnancy (Virchow’s triad)
  • Superficial thrombophlebitis (SVT):
    • Presents with increased leg pain, localized edema, erythema, and warmth over the thrombotic site.
    • Exam → enlarged, hard, cord-like structure.
    • Management: support stockings, NSAIDS, leg rest, and elevation.
  • Deep vein thrombosis (DVT)
    • Mimics SVT (leg pain/inflammation), but usually abrupt onset with increased pain with mvmnt or standing.
      • Homan’s sign (calf pain elicited with foot dorsiflexion) could also be muscle strain from childbirth and absence of Homan’s does not r/o DVT.
      • Edema may be more generalized over leg/thigh
    • Differential diagnosis includes SVT, trauma, ruptured Baker’s cyst, muscle strain, vasculitis, or lymphedema.
    • Management:
      • Physician referral for management
      • Venous ultrasonography with or without a color Doppler, labs like D-dimer
      • Anticoagulant therapy, bed rest with leg elevation, and analgesia.
      • Support stockings should be worn up when ambulation resumes.
33
Q

Identify appropriate time periods for initiating different contraceptive methods

A
  • COCs
    • Contraindicated for everyone x 21 days
    • Contraindicated if risk for VTE x 42 days
    • Contraindicated if breastfeeding x 30 days
      • May interfer with milk production
      • Watch out if risk for VTE → still 42 days
  • POPs
    • Start anytime (no concerns with clotting or breastfeeding)
  • DMPA
    • Can be given immediately, milk production not affected, not associated with PPD
  • IUDs
    • May be done post-placental (within 10 minutes is best, but higher expulsion rate 20% (lower in cesarean vs vaginal)
    • Contraindicated if postpartum sepsis
  • Implant
    • Can be placed immediately - milk production not affected
  • Diaphragm
    • Wait to fit until 6 weeks
34
Q

CDC MEC conditions for increased risk of post partum VTE

(no COC’s for ____days?)

A
  • > 35 yrs
  • Previous VTE
  • Thrombophilia
  • Immobility
  • Transfusion at delivery
  • Peripartum cardiomyopathy
  • BMI > 30
  • Postpartum hemorrhage
  • Post cesarean
  • Preeclampsia
  • Smoking

No COC’s for first 42 days

35
Q

7 W’s of Febrile Morbitity in Postpartum Period

A
  1. Wound (infection)
  2. Womb (endometritis)
  3. Water (UTI/pyelo)
  4. Weaning (mastitis)
  5. Wind (PE)
  6. Walking, not (thrombophlebitis)
  7. Wonder drug (example: misoprostol)

Antepartum (UPenn) (26 decks)

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