postpartum and lactation Flashcards
postpartum is traditionally defined as…
the first 6 weeks post-birth
early postpartum normal vs abnormal
-mood
-temperature
-pulse
NORMAL: tired but happy, Temp between 98.6-100.4, pulse 65-80, RR 12-16, between 90/60 - 140/90, nipples may be sore from nursing but not painful, diastasis recti expected; MILD urinary burning/retention/incontinence common in first 2 days; perineum mildly swollen and bruised, lochia decreasing each day
ABNORMAL: unhappy, dissatisfied, temp > 100.4, pulse > 80, RR < 12 (narcotic overuse, atelectasis, pneumonia), RR > 16 (anxiety, pain) , less than 90/60 evaluate for hypotension causes (blood loss, medication reaction), if > 140/90 evaluate for pp hypertensive disorder, palpitations/chest pain, SOB, painful/cracked/bleeding nipples, BMs return 2-3 days postpartum, N/V, distended abdomen, constipated, dysuria, distended bladder; malodorous lochia, presence of hematoma, deep blue or purple hemorrhoid; unilateral leg pain/calf tenderness
T/F there is a transient increase in BP of as much as 5% in the first 4 days after delivery
TRUE
when are nipples/breast experiencing the most fullness/filling
3-5 days after delivery
Fundus in the postpartum period should be…
firm and midline
uterus involution process
-3 steps
-the uterus is returning to the pre-pregnant state!
1. contraction of the uterus
2. autolysis of myometrial cells
3. regeneration of the epithelium
**results from reduction in cell SIZE, not reduction in cell number
location of uterus is determined with respect to umbilicus
-descends about ____ cm per day
-“fundus at U-1” denotes…
-immediately after delivery, the uterus contracts to the size of a _____ and is located….. but then 12 hours postdelivery the fundus is located at…
-1 cm per day
-that the fundus is 1 cm below the umbilicus
-should always be midline
-grapefruit; immediately after delivery fundus is located halfway between umbilicus and symphysis pubis but then 12 hours postdelivery is at the level of the umbilicus
a fundus that is displaced to the side may indicate…
a distended bladder or sub-involution
by two weeks the fundus is…
no longer palpated abdominally
by 6 weeks, the fundus…
returns to slightly larger than pre-pregnant size
Lochia
-three stages: rubra, serosa, alba
-what days pp? what is the color? d/c make up?
-the breakdown of myometrial placental bed, eschar, and decidual cells
- RUBRA: first 3-7 days; red or red brown with fleshy odor; d/c contains superficial layer of decidua that has sloughed off the uterus
- SEROSA: from day 14 to 21 pp, pinkish-brown color; serous to serosanguinous secretion; d/c contains blood, cervical mucus, erythrocytes, leukocytes, decidual tissue
- ALBA: until cessation of flow in about 4-6 weeks pp; yellowish to white discharge, flow increases with additional activity initially bu decreases progressively over the puerperium
the cervix
-immediately pp
-by day 7:
-by 4 weeks
-in multiparous
-immediately pp: edematous, dilated 3-4 cm and bruised; may have lacerations
-by day 7: dilation down to 1 cm
-by 4 weeks: cervix no longer dilated
-in multiparous: never returns to pre pregnant appearance; somewhat wider with transverse opening, “fish mouth”
vagina
-by 3-4 weeks
-by 6-10 weeks pp
3-4 weeks: rugae returns, edema vascularity and bruising decrease
6-10 weeks: vaginal epithelium returns
**in pp period there is decreased lubrication, can lead to painful intercourse (Esp in lactating women)
when should perineum skin appear well healed?
by day 7 with only linear scarring at 6 weeks and ALWAYS well approximated
how many hours after birth does engorgement occur?
72 hours/3 days
-milk production starts in upper-outer glands, filling then occurs medially and inferiorly
-distention and stasis of vascular and lymphatic circulation cause engorgement as the ducts, lobules, alveoli fill with milk
“let down reflex” or milk ejection reflex develops within…
the first 1-2 weeks
how much does cardiac output increase within first couple hours post-delivery
60-80%
over first 48 hours, as diuresis occurs, plasma volume decreases, causing cardiac output to normalize within
2 weeks
renal system changes in the pp period
-diuresis
-bladder tone
-diuresis occurs within first 5 days
-bladder can be hypotonic and edematous immediately after birth; resolves within 24 hours
caloric intake should be at least….
1800 kcal/day
recommended weight loss after first month post-delivery is
4.5 lb/month
ALT and AST levels return to pre pregnant values within
2 weeks
T/F diastasis recti is found in 75-80% of women
TRUE!
these women are at risk for back pain in future pregnancies; striae also common
breastfeeding women
-resumption of menses variable… but generally:
1. ovulation returns ____ days after weaning
2. first menses
3. mean time to ovulation
-lactation secretes prolactin and oxytocin; prolactin suppresses estrogen halting menstruation and ovulation
- ovulation returns 14-30 days after weaning
- first menses 14 days later
- mean time to ovulation is 190 days
NON breastfeeding women
-prolactin levels
-hormonal shifts stimulate ovulation how many weeks pp?
-first menses within how many weeks pp?
-prolactin levels fall
-hormonal shifts stimulate ovulation to begin about 3-4 weeks pp
-first period 6-8 weeks pp; 70% by 12 weeks
what should Rh women be screened with in the pp period?
the Kleihauer-Betke screen (tests for fetal blood in maternal circulation)
Immunizations in the PP period
1. RhoGAM
2. Rubella
3. Varicella
4. Influenza
5. HPV
6. Tdap
- RhoGAM: give within 72 hours of birth if mother Rh status is negative and infant is +
- Rubella: offer prior to d/c if nonimmune
- Varicella: offer prior to d/c with second dose given 6-8 weeks after; PP patients should be counseled to avoid pregnancy for 4 weeks after last dose (at second pp visit)
- Influenza: offer
- HPV: women ages 9-26 who have not completer primary series should receive three doses at 0, 2, 6 months; if series started prior to pregnancy, series can be completed pp without repeating the initial dose
HPV vaccines SHOULD be given to breastfeeding women 26 years and younger who have not previously been vaccinated - Tdap: offer if did not receive in pregnancy
Postpartal discomforts
-involution pain (increases with…(2))
^non pharm relief
-likely to increase with each subsequent birth
-increases with lactation
NON pharm: empty badder and bowels, change positions, apply heat
Pharm: acetaminophen, ibuprofen
Breast engorgement (for breastfeeding individuals)
-education on how to avoid this
-breastfeed early and often, correct positioning, proper latch
-express small amount of milk manually before each feeding to soften areola
-breast pump also works, but avoid excessive pumping (increases breastmilk production/worsens engorgement)
-supportive bra
-warm compress or warm shower right before feeding
breast engorgement advice for moms that are bottle feeding
tight bra, ice packs, analgesics, cold cabbage leaves
perineal pain should be evaluated by REEDA
-treatments?
Redness
Edema
Ecchymosis
Discharge
Approximation
Topical meds/treatments
-witch hazel pads
-dibucain, benzocaine
-ice packs first 24 hours, size baths after 24 hours
-topical anesthetics
risk factors for constipation
- lack of ambulation in labor and pp
- decreased intestinal peristalsis r/t anesthesia
- narcotic use for pain relief
-increase fluids, fiber, stool softener, ambulate, laxatives as needed
bonding theory states that…
to achieve optimal development outcomes, a “sensitive period” of bonding between mother and infant should be allowed in the immediate postpartum period; this sensitive period means close contact is necessary and avoidance of separation is goal
early skin to skin contact at birth or some after promotes this^^
postpartum blues vs postpartum depression
-time frame
-incidence
-s/sx
- pp blues
-80% affected
-begins 3-5 days pp
-vary labile emotions (giddiness, sadness, crying)
-generally time-limited over 1-2 weeks
-supportive, sensitive care is usually all thats required - pp depression
-6-12% affected
-DSM 5 defines as major depressive disorder: with peripartum onset if onset of mood symptoms occurs during pregnancy or within 4 weeks following delivery
-clinical practice: occurring anytime within 4 weeks after childbirth or 3, 6, 12 months after childbirth
risk factors for pp depression include…
-hx of mood or anxiety problems, particularly untreated depression and anxiety during pregnancy
-likely rapid decline and shift of hormones in postpartum period
-genetic
-social factors: IPV, prior abuse, lack of social support, negative life events
symptoms
-onset
-onset around 4-6 weeks pp; generally worsen over time
SX:
-sleep disturbance
-feeling overwhelmed
-anxiety
-irritability
-unable to perform activities of daily living
-obsession with infants health
-suicidal thoughts
screening for postpartum depression
-ALL PREGNANT WOMEN
-Edinburgh Postnatal Depression Scale (EPDS)
-r/o other causes: pp thyroiditis, anemia, infection, sleep deprivation
diagnostic criteria of pp depression according to the DSM-5
- at least on of the following:
-depressed mood
-loss of interest in or pleasure - in addition, 4 or more of the following:
-depressed mood most of the day, nearly every day
-marked diminished interest or pleasure in all or almost all activities
-significant unintentional weight loss or decrease or increase in appetite
-insomnia or hypersomnia
-psychomotor agitation or retardation
-fatigue or loss of energy
-feelings of worthlessness or excessive or inappropriate guilt
-diminished ability to think or concentrate
-suicidal ideation, with or without plan for committing suicide
pharm interventions for depression
- SSRIs
^most pass into breastmilk but usually compatible with breastfeeding babies - severe depression: benzodiazepine agents
postpartum psychosis symptoms
-management includes
a. disorganized thinking, bizarre behavior and speech
b. hallucinations with auditory or visual perceptual disturbances
c. delusions
PSYCH EMERGENCY- usually requires hospitalization
b. return to SA
-complete pelvic rest is recommended until 4-6 weeks pp
-but 50% usually have resumed sexual activity by 6 week postpartum visit
c. hyper coagulable state
-pp patients continue to be in a state of hypercoagulability for 3-4 weeks after birth as part of a physiologic adaptive mechanism to prevent pp hemorrhage
-estrogen containing contraceptive methods should be AVOIDED
d. lactation status
COCs should be avoided at least the first 21 days
what is the only contraception available to women immediately after delivery of the placenta?
copper IUD!!
LNG-IUD can be inserted too BUT risk of perforation is higher
both totally fine to insert after 4 weeks pp (typically we insert around 6 weeks pp)
Postpartum breastfeeding patient contraception
a. < 21 days postpartum
a. don’t recommend anything
how many weeks pp should we initiate contraception in the pp BREASTFEEDING patient? what kind of contraception is best?
between 30-42 days (about 6 weeks; initiate around 6 week pp visit)
-Nexplanon, DMPA, POP all great options! just want to avoid CHC because estrogen will limit the milk supply
postpartum contraception in the non breastfeeding client
-initiate at
-options
-should wait at least three week, 42 days (6 weeks) is best
-Nexplanon, DMPA, IUD, POP, CHC
T/F you must wait until involution to use cervical cap/diaphragm for barrier emethod
true!
T/F male and female condoms may be used immediately
true
lactation amenorrhea method
a. full or nearly full breastfeeding:
-feeding an avg of 4 hours during the day
-feeding an avg of every 6 hours at night
-has not substituted solid foods for breastfeeding for any meals
b. infant less than 6 months old
c. no menses
d. choose alternative method if woman and infant do not fit all three criteria
what postpartum patient MUST be followed up on in 1-2 weeks after being discharged from hospital following delivery??
any high risk patient (hypertensive patients, GDM)
follow up for GDM patients in the postpartum period
fasting 2-hour, 75 gram OGTT
follow up for hypertension (pregestational or gestational)
-follow up with primary care!
-for severe hypertensive status, referral to cardiology
separated symphysis pubis referral
- physical therapy
- occupational therapy
anticipatory guidance
-vaginal bleeding
-lochia
-menses return
- lochia: at 4-6 weeks, may continue to have scant amount of lochia (alba) but typically resolved by this time
- resumption for menses
-non breastfeeding women: 4-6 weeks pp
-breastfeeding women: depends when baby weans
T/F vaginal dryness during lactation may contribute to dyspareunia
TRUE
Postpartum Complications
1. urinary retention
-diagnosis (s/sx)
-risk factors
-complications
-management
a. inability to void spontaneously within 6-8 hours after birth or removal of urinary catheter (post-residual void > 150 ml), palpable bladder, fundus displaced
b. risk factors: epidural, operative vaginal delivery, episiotomy, LGA baby
c. complications: UTI, bladder dysfunction
d. MNGMNT
-intermittent cath
Postpartum Complications
2. postpartum fever and infection
-definition
-differential diagnoses
-s/sx
-> 100.4 x 2 during pp days 2-10
differentials: endometritis, wound infection, UTI
s/sx: flu-like, tachycardia, abdominal pain, malodorous lochia
risk factors for endometritis
Gold standard tx??
- prolonged rupture of membrane
- prolonged labor
- multiple cervical exam
- cesarean section
- chorioamnionitis
TX: clindamycin and gentamicin
Vancomycin only added if Staph aureus suspected
risk factors for abdominal infection
-obesity (think about skin folds)
-diabetes (think about sugar)
-corticosteroid therapy
-immunosuppression
-anemia
T/F postpartum hemorrhage is the leading cause of maternal mortality worldwide
TRUE
ACOG definition of pp hemorrhage vs traditional definition
estimated blood loss of 1000 ml regardless of route of delivery
blood loss accompanied by s/sx of hypovolemia within 24 hours after birth
TRADITIONAL
a. EBL of 500 ml after vaginal delivery
b. EBL of 1000 ml after c/s
risk factors of pp hemorrhage
- prolonged labor/prolonged use of oxytocin
- chorioamnionitis
- high parity
- twins, multiple gestation
- polyhydramnios
- macrosomia
- operative vaginal delivery
Etiology of pp hemorrage
a. primary/#1 cause
-other causes?
- UTERINE ATONY
-soft, boggy uterus (accounts for 70-80%)
-MNGMNT: empty bladder, bimanual exam, MASSAGE THE FUNDUS, uterotonics - obstetric trauma
-identify source of bleeding and manage it - lacerations
- retained placenta***
-visually inspect the placenta!! - placenta accreta
- coagulation defects
- inversion of the uterus
Lactation
1. cooper’s ligaments
2. milk ducts
3. basic glandular unit
4. nipples and areola
5. montgomery tubercles
- cooper’s ligaments: support shape of breasts
- milk ducts: each contains 4-18 primary milk ducts that converge at the nipple
- basic glandular unit: contains 4-18 lobules, each containing alveoli for milk ejection
- nipples and areola: become darker during pregnancy
- montgomery tubercles: located IN areola; sebaceous glands that provide protective secretion and lubrication to the nipple
physiology of lactation
1. mammary changes during pregnancy
2. lactogenesis I
3. lactogenesis II
4. lactogenesis IV
- mammary changes during pregnancy
- lactogenesis I
-early pregnancy to third day postpartum
-dependent on HORMONAL changes
-secretion of small amounts of colostrum: high concentrations of immunoglobulins, oligosaccharides
-approx. 100 ml of breastmilk produced on pp day 1 - lactogenesis II
-days 2-4 postpartum
-second stage initiated by: delivery of placenta, decrease in progestin, increase in prolactin
-VOLUME: increases; no approx. 500 mL on day 4 pp, COPIOUS milk production, “milk coming in” - lactogenesis IV
-begins between 7-14 days pp
-mature milk established
-maintenance of milk supply depends on supply-demand relationship (frequent milk transfer –> suckling stimulated nipple –> sends message to hypothalamus to secrete prolactin and oxytocin –> prolactin stimulates milk production) –> oxytocin is the hormone responsible for stimulating contraction of myoepithelial cells; the contraction of cells causes milk ejection aka “the let-down reflex”
what is responsible for milk ejection/the let down reflex
OXYTOCIN
what is responsible for stimulating milk production
PRO lactin!
contraindications to breastfeeding
-infections, drugs, specific medications
a. maternal infections:
1. HIV
2. Herpes. active lesions on nipple and breasts
3. flu
4. untreated TB
5. varicella infection developed 5 days prior to birth to 2 days after birth
b. illicit drug use
c. specific medications
1. antiretrovirals (again, HIV)
2. anticonvulsants (valproate)
3. chemotherapy agents
4. radiation therapy
5. retinoids
6. statins
breast engorgement prevention
a. proper position and attachment
b. emptying one breast at each feeding
c. alternating which breast is offered first
d. frequent milk transfer
treatment of breast engorgement
-acupuncture, warm compress PRIOR to feeding, cold packs after, breast massage, hand expression, cabbage leaves
T/F there is no scientific evidence for effectiveness and safety herbal products, foods and beverages used as galactagogues
TRUE
includes: Fenugreek, Goat’s rue, milk thistle, dandelion, seaweed
pharm galactagogues
a. Domperidone
2. Metoclopramide
-warnings??
a. domperidone: increases QT interval and implicated in ventricular arrhythmias and sudden cardiac death
b. Metoclopramide: CNS effects like sedation, depression, extrapyramidal symptoms
mastitis
-incidence
-s/sx
-1 in 5
-erythematous, edematous, wedge-shaped area in the breast, typically UNILATERAL
-fever > 101.3
-flu like symptoms
risk factors for mastitis
-damaged nipples
-infrequent feedings
-ineffective milk transfer and removal
-poor latch
-oversupply of milk
-bra that is too tight
-previous mastitis
treatment of mastitis
a. analgesia
b. antibiotics
a. analgesia
i. NSAIDS like ibuprofen to help reduce inflammation
b. antibiotics:
i. Docloxacillin or flucloxacillin 500 mg PO QID x 10-14 days
ii. Cephalexin (Keflex) 500 mg QID x 10-14 days
iii. if penicillin allergic, clindamycin: 300 mg QID or 500 mg QID x 10-14 days
symptoms typically resolves within 48 hours of antibiotic initiation
breast abscess
-the most likely infecting organism?
S. aureus
management of breast abscess
surgical drainage, needle aspiration, antibiotics
Raynaud’s phenomenon is where…
there’s a vasospasm of the nipple after breastfeeding or when the nipples are exposed to cool air
nipple color changes to purple or blanches
severe pain; sharp, burning sensation
Fungal infection
-s/sx in infant
-clinical manifestations
-s/sx in infant: may have signs of thrush or diaper rash
-manifestations: shiny, red nipple, flaky skin around the nipple, burning, itching, stabbing pain like “shards of glass” in the breasts
treatment of fungal infection on breasts include
i. topical nystatin, miconazole, clotrimazole
ii. Gentian violent 1% in 10% alcohol applied to nipple x 4 days
iii. APNO (Dr. Newman’s formula)
