Postpartum Flashcards
1
Q
normal peurperium
A
- Postpartum period, lasting 6-12 weeks
- Changes of pregnancy are reversed
- Immediate puerperium
- First 24 hours after parturition
- Early puerperium
- 24 hours to 1 week postpartum
- Remote puerperium
- Period of time required for genital organ involution and return of menses; usually 6 wks
2
Q
immediate puerperium
A
- Dictated by events of delivery, type of anesthesia or analgesia, complications during delivery
- BP and pulse every 15 minutes
- Maternal temperature at least every 4 hours
- Post anesthesia care provided by anesthesiologist or obstetrician
- Placental delivery and involution begins
- Uterine involution
- Uterine contractions regular, strong, coordinated, begin to decrease about 12 hours postpartum; “after pains”
- Contractions occur with breastfeeding
- Postpartum chills may last up to 60 min
- Urinary stasis, proteinuria, incomplete bladder emptying for 1-2 days
- Uterine involution to prevent hemorrhage; uterine fundus @ umbilicus at 24 hrs post-delivery, midway btw umbilicus and symphysis pubis at 1 week, not palpable abdominally at 2 weeks, and normal size at 6-8 weeks postpartum
3
Q
immediate puerperium complications
A
- Postpartum hemorrhage (acute/primary)
- EBL >500mL vaginal or >1000mL C-section
- 10% drop in Hct
- Excessive bleeding resulting in symptoms or requiring transfusion
- Postpartum febrile morbidity
- T >38°C at least twice, 4 hrs apart
- Common: Breast engorgement, atelectasis, UTI, endometritis, drug rxn, wound infxn
- Hypertension (Preeclampsia/Eclampsia)
- PPH most commonly caused by atony, trauma or coagulation disorder
4
Q
early puerperium
A
- Cervix gradually closes
- Vagina, perineum, and pelvic musculature decrease to normal size, increase in tone
- Episiotomy or tears heal
- Postpartum vaginal discharge heaviest in the first 3-4 days, lochia rubra
- Lochia serosa more serous, mucopurulent from 3-4 days to 2-3 weeks postpartum
- Lochia alba thicker, mucoid, yellowish-white, from 2-3 weeks to 5-6 weeks postpartum
5
Q
early puerperium complications
A
- Postpartum hemorrhage (Secondary/Late)
- Bleeding occurs more than 24 hrs after delivery
- Can occur up to 6 weeks postpartum
- Hypertension
- Can persist up to 6 weeks postpartum
- PPH may be due to infection, retained POC, bleeding disorder
6
Q
remote puerperium
A
- Uterine involution complete by 6-8 wks
- Lochia ceases about 5-6 weeks postpartum
- Striae fade from red to silver but are permanent
- Hair pattern returns to normal over 6-15 months postpartum
- Ovulation begins as early as 27 days after delivery
- Avg 70-75 days in nonlactating mothers
- Avg 6 months in lactating mothers
- Menstruation begins at 7-12 weeks in nonlacting mothers and as late as 36 months in breastfeeding mothers
7
Q
postpartum care
A
- Encourage early father or partner involvement
- Skin-to-skin contact between mother and baby should occur immediately (<1 hr)
- Rooming-in should be encouraged and supported
- Support and reassurance to the new parents is important
- Important for mother to sleep and regain her strength, recover from labor
- Regular diet ad lib; stool softener PRN
- Early ambulation encouraged to prevent thrombophlebitis
- with assistance if needed
- Shower ad lib
- IV rehydration may be needed
8
Q
care of the vulva
A
- Teach patient to cleanse vulva from anterior to anus, look for signs of infection
- Application of an ice bag to the perineum during first 24 hours post delivery
- Warm sitz baths beginning 24 hrs after delivery; frozen pads for swelling
- Oral analgesics often required
- Pelvic muscle exercises may be helpful
9
Q
care of the bladder
A
- Encourage patient to void as soon as possible after delivery
- Peribottle to cleanse after voiding
- Catheter placement may be necessary if voiding is too difficult
- Trauma to the bladder during L&D
- Regional anesthesia
- Vulvar/perineal pain/swelling or episiotomy
10
Q
care of the breasts
A
- Breastfeeding decision helps determine care of the breasts
- Ideally begin on-demand breastfeeding <1 hr post delivery
- Well-fitting brassiere is very important
- Ice packs and analgesics for engorgement if not breastfeeding
- Lactation suppression meds discouraged
- Avoid nipple stimulation
- Milk production should stop within a week
11
Q
postpartum immunizations
A
- An unsensitized, Rh(D)-negative woman who delivers an Rh(D)-positive baby should receive 300 µg of anti-Rh(D) immune globulin (RhoGAM) within 72 hours of delivery
- May protect up to 14-28 days after delivery
- A woman who is not protected against rubella virus should receive the rubella (MMR) vaccine postpartum
- Tdap recommended if due
- Hep B may be given
12
Q
contraception and sterilization
A
- Lactational pregnancy rate is 1% at 1 year postpartum
- Combination oral contraceptives can be used in non-breastfeeding women as early as 2-3 weeks postpartum
- Progestin-only contraceptives are safe in lactating women, and can be started immediately postpartum
- Depo-Provera, Levonorgestrel
- Tubal ligation is 2nd most common method of contraception used in the US
- May be performed at the time of Cesarean section, 24-48 hrs after a normal vaginal delivery, or immediately postpartum in a women with epidural anesthesia in place
- IUD insertion can be done at the first postpartum visit (4-6 wks postpartum)
- Copper IUD or progestin-containing IUD
13
Q
hospital stay
A
- Without complications
- 48 hours for vaginal delivery
- 96 hours for Cesarean delivery
- Not including day of delivery
- Short stay criteria for early discharge
- 24-48 hrs for vaginal delivery
- 24-96 hrs for cesarean delivery
14
Q
short stay criteria
A
- Mother afebrile, stable vital signs
- Amount and color of lochia appropriate
- Firm uterine fundus
- Adequate urine output
- No evidence of infection in wound or repair sites
- Mother able to ambulate with ease
- No abnormal physical or emotional findings
- Mother able to eat and drink
- Postpartum follow-up care arranged
- Mother ready to care for self and baby
- Postpartum hemoglobin or hematocrit are normal
- ABO and Rh type are known
- Immunizations have been administered as needed
- Mother has instructions for home care and follow-up
- Support persons are available in the home
15
Q
postpartum nutrition
A
- Minimal caloric requirement for adequate milk production on average is 1800 kcal per day
- Fluid intake is important
- Balanced, nutritious diet ensures healthy mother and baby
- Vitamin supplements routinely not needed; may recommend to continue PNV
- Calcium, vitamin B12, vitamin D most important
- Iron given only if mother needs it
Mom needs about 500 Calories/day above baseline for milk production
16
Q
postpartum considerations
A
- Resumption of coitus no sooner than 2 weeks postpartum
- Contraception method should be reviewed
- At discharge, mother should be given contact information if she has any questions or problems
- Typically women wait 2-3 months postpartum to resume sexual intercourse
17
Q
postpartum discharge
A
- Discharge discussion should include:
- Condition of the newborn
- Immediate needs of the newborn
- Feeding techniques, skin/umbilical cord care
- Recognition of neonatal illnesses (eg: jaundice)
- Support systems available
- Instructions in case of emergency or complications
- Importance of childhood immunizations
18
Q
postpartum follow-up care
A
- Support and reassurance are extremely important in the postpartum period
- Involvement of the newborn’s father and extended family
- Community and hospital support should be easily available for mother and newborn
19
Q
postpartum visits
A
- Visit and exam 4-6 weeks after an uncomplicated vaginal delivery
- Visit and exam 7-14 days after a Cesarean or complicated delivery
- Most women may resume regular work and activities by 4-6 weeks postpartum
- California allows 6 weeks for vaginal delivery, 8 weeks for Cesarean delivery for standard disability (this is not paid, but protects a woman’s job)
- Paid Family Leave (FMLA) allows another 6 weeks, which can be used for up to 1 year after the baby is born (can also be used for adoption, other family circumstances); FMLA can also be used by father/partner, which can extend parental leave time if used sequentially
- Interval history, physical exam
- Weight, BP, thyroid, extremities, breasts, abdomen, pelvic
- Adaptation to newborn
- Breastfeeding issues discussed
- Birth control reviewed
- Postpartum Depression evaluation
- Labs as needed (Hgb, Pap smear, TSH)
- Counseling/Education as needed
- Vaccines
20
Q
maternal self-care
A
- Social support
- Sleep
- Breaks from baby
- Enjoyable, replenishing activities
- Nutrition (iron, calcium, folate, EFA’s)
- Meal train, cook/freeze before birth
- Aerobic exercise
- Break isolation
- Be with friends, partner, and/or other mothers with or without baby
- Take time for yourself (even if only 5 minutes)
- Protect yourself and your energy
- Turn off phones, limit visitors, eat frozen food, etc.
21
Q
recruiting social support
A
- Examples of places people often find support
- Partner
- Family & Extended family
- Neighbors
- Co-workers
- Religious communities
- Professionals (doulas, lactation consultants, etc)
- Postpartum support groups
- Family community agencies
22
Q
postpartum recovery
A
- Postpartum period lasts 12 months
- Zombie period lasts 3-6 weeks
- Depends a lot on baby, mom’s experience (other kids), support from partner/family, individual reserve
- Hair falls out around 2-6 months
- Line nigra, melasma fade around 8-12 months
- Continue to support mom & baby
- Breastfeeding can last 2 years or longer
- Affects maternal hormones, return to menses, recovery period
- Zombie period lasts 3-6 weeks
23
Q
what is the new normal
A
- Mummy tummy
- Diastasis recti and ways to improve it
- Stretch marks
- Feet/ribs stretching
- Sex
- Fatigue
- Social life & isolation
- A whole new perspective on life!
