Postpartum Care Flashcards
Define Postpartum
when is it
immediate, early and remot
Postpartum (otherwise known as puerperium) is the time period between childborth and the return of the uterus to its normal size
the duration is not exact…. lasting somewhere between 4-6 weeks
often times woman who deliver vaginally remain in the hospital for 24 hours, c-section for 72hours, thus postpartum care is a hosptial delivery!
Immediate PP = first 24 horus
Early PP = the first week
Remots PP = the next 3-5 weeks
Placental Implantation : site of implantation and how the placenta is birthed & not hemorrhaging!
Placental Implantations
- after about 20-30mins after baby, the placenta will be birthed
- immediate contractions occur and the placental site becomes 1/2 of its original size
due to this forceful contraction in size, the risk of bleeding becomes much less as smooth arterial muscle contractions create hemostasis
the location where the placenta was will regenerate with endometrial tissue = finished at 6 weeks PP
Subinvoluation of the Placenta
- if the placenta fails to involute, bleeding & hemorrhage can occur
- symptoms: + persistant lochia (bright red blood) with brisk hemorrhagic episodes
- can be treated with uterotonics: oxytoxin
Uterine Involuation
- timeline
Uterin involuation
- after delivery of the placenta, the uterine fundus will contract back to the level of the umblicus
Timeline
1 week PP: decreased to 12 weeks size (fundus at the level of the pubic bone/hairline)
2 weeks PP: decreased into the pelvis
4 weeks PP: the uterus has mostly returned to its pre-pregnant size
- note: uterus will not be completely the same size, will always be a slight bit larger
it will take up to 5-6 weeks for the uterine cavity to regress completely
Uterine Involuation
- role of the myometrium in involuation
Myometrial Involvment
- myometrium contracts which leads to uterine involution
occurs during days 1-3 PP
first 12 hours: regualr, strong, coordinated contractions
24 hours PP: intesnity/frquency and regularity will decrease
pain with these contractions will be worse in those who have had multiple children
Oxytocin: facilitates PP contractions: naturally, the horomone is released by the hypothalmus adn the posterior pituitary
Triggered by: labor, lactation, uterine dilation and vaginal distection
Act to: allow milk “let down” and uterine contraction
Post Partum Hemorrhage
what is it
defintion
due to waht
assocaited sequelae
Post Partum Hemorrhage
- the leading cause of maternal mortality worldwide (not in the us because we have resources)
Definition
- the cumulative loss of > 1,000 mL of blood accompanied by signs and symptoms of hypovolemia within 24 hours of delivery
Due to
- Uterine Atony: uterus is not involuting as it should be
Results in
- ARDs
- shock
- DIC
- acute renal failure
- loss of fertility
- pitutary necrosis (sheehan syndrome)
Post Partum Hemorrhage
treatment : inital , meds and other treatments
Initial Treatment = fundal massage
- through the abdomen, in order to stimulate the uterus to contract on its own (since the issue is uterine atony)
- if no response to abd. = move to bimanual
Uterotonics agents = first line medical treatment
- specifically oxytocin (pitocin)
if utertonics fail to adequately control PP hemorrhage
- prompt escalation to other intervention: tamponade (pressure/ballooning) or surgery
Examples of Tamponade
- intrauterine balloon tamponade: Bakri Ballonr, Ebb tampondae, foley catheter
- uterine packing in 3rd world
Second line medications: tranexamic acid (TXA) can be used
Post Partum Hemorrhage
workup for PP hemorrhage : determine the cause
Tone
- soft, boggy uterus = give oxtocin
Trauma
- lacteration or uterine inversion = drain, suture, etc.
Tissue
- retained placenta or clo t= maunaul removal, urettage, inspect placenta
Thrombin
- observe clotting, cehck coags, replace coags and plasma as needed
Lochia
what is it
lochia rubra
lochia serosa
lochia alba
Lochia = sloughing of the uterine decidual tissue
- this persists for 5-6 weeks
Lochia Rubra = the first few days PP
- blood, tissue, decidua
- bright red
Lochia serosa = labeled when the discharge becomes
- mucopurulent, paler, and often malodorous
- pink
Lochia Alba = 14-21 days PP
- pale yellow/white
- leukocytes
physiological changes to the vagina PP
Vagina
- streched, no rugae during pregnancy
- will return to rugae on vaginal walls in week 3 PP : not to the same level as pre-pregnancy
Lacerations or streching of the perineum can result in relaxation of the vaginal opening: vaginal tightness decreased
- can be fixed with kegals, balls, etc.
- C section pt. also have this physiological lost of tightness
Increase uterine blood flow and increased blood vessel size will decreased over time
Physiological changes of the cervix PP
Cervical Changes PP
- cervix will gradually close: 1 week PP it will be back to < 1cm dilated
External Os: will transition to a slit shape, no longer a holr
- transverse slit appearance
- nullparious women who delivery via Csection: will still have circle (no slit)
Cervical Epithelium
- considerable remodeling
- thus, those with high grade dysplasia in pregnanyc may not need intervention: as the cervical remodeling changes and gets rid of these cells to replace with healthy new ones
Physiolgical abdomen and pelvic floor changes in PP
Abdomenal Changes
- return of the abdomenial wall musculture to its orignal position between week 6-8 PP
- vigorous exercise not recommended until week 6-8
- overdistention of the abd. wall = ruputre of elastic fibers in skin = striae
- marked separtion of the rectus muscles = diastasis recti
Pelvic Floor Changes
- broad and round ligaments take time to recover; but may never be as strong as they were pre-pregnancy due to elastin changes
tearing or overstretching of the musculature and fascia during delivery = increased risk of genital prolaspse and hernias (cystocele MC, rectocele, enteroceles)
widening of the symphysis and SI joint during pregnancy is returned
Urinary System Changes during Pregnancy and return PP
Baldder
- trauma may occur during delivery, over distention, incomplete empying (due to weakened muscle activity) and excessive residual urine may result
Urinary Stasis: can persist in >50% of women 12 weeks PP!!!!
- watch for UTI!!!!
dilated ureters and renal pelvis return to noral size by 6-8 weeks PP
GFR which was increased by 50% returnrs to normal by 8weeks PP
- transient proteinuria resolves in days, glucosuria resolves in 1 week PP
Fluid Volumn Management PP
PP diuresis
fluid lost in first week
blood volume returns when
CO and HR changes back to prepreg. levels when
Average Plasma volume Increase: by 50% during pregnancy
in the first week PP: fluid loss can be up to 2 liters, then the remainied 1.5 L over the next 5 weeks
postpartum diuresis is a response to extracellular fluid in pregnancy, patinets experience periods of profuse sweating for weeks
- way to get rid of the fluid
blood volume returns to normal prepreg. leves by 3 weeks PP
Cardaic output and HR reamin elevated for 24-48 hours PP but decline to their prepregnant levels by day 10
Hematopoesis during pregnacy and PP
during pregnancy: we know there is an increase in blood volume and increase in RBC mass by about 25%
in the days following delivery: decline in blood volume results in increased in HCT = 3-7 days PP
- because at devliery: there is only a 14% loss of RBC: from a 25% increase = net change is still increased RBCs PP
during delivery: there is a sudden loss of blood upon delivery = reticulocytosis initially (peaking day 4 PP)
then there is some elevated erythropoetin levels during first week of PP
Bone Marrow Production
- hyperactive in pregnancy and PPto delievery lots of young cells into peripheary: partly due to prolactin levels
leukocytosis seen in delivery: during labor and into the early PP period (potentially due to stress response)
- can be as high as 25,000 WBC with increased % of granulocytes: so need to be aware of this if looking for infection
Blood Coagulation and Fibrinolysis during pregnancy and PP
Pregnancy
- a state of hypercoagulability with increased clotting factors : physiological response to the need to clot of placenta after delivery
- thus, risk of thrombosis/embolism formation is high if there are addition thromobtic factors (example: trauma, immobility, sepsis)
there is a seoncdayr increased in fibrinogen, factor VIII and platelets (remains until 1 week PP) which also puts these women at increased risk of clotting
Cholesterol in pregnancy and PP period
Cholesterol
- both cholesterol and triglycerides will be high in pregnnacy, then decrease significantly in the first 24 hours PP
triglycerides
- fall fastest in the first 24 hours
- then continue to fall for 6-7 weeks PP
- dont check levels until then
Cholesterol
- falls fastest in teh first 24 hours: but slower to return to baseline pre pregnancy levels
- LDL cholesterol can remain elevated for at least 7 weeks PP
- diet modifications will help post-pregnancy, but will not impact levels during pregnancy
Gluocse during pregnancy and PP period
when to recheck those with GDM
Glucose
- glucose (blood glucose) levels are elevated slightly in prenancy as that is babies food source
PP Period
- early PP: fasting and postprandial levels tend to fall below the pregnancy levels : biggest drop days 2-3 PP
only after 1 week PP will insulin sensitiviy and blood glucose levels begin to return to their prepreg. state
a GTT done too early will not be accurate!!!
ACOG = recommends those with GDM: recheck with 2hour GTT test between week 6-12 PP to assess DM and preDM status
Pituitary, Ovarian and bHCG levels PP
b-HCG concentrations
- will fall below 1000 within 48-96 hours after delivery (normalnonpreg. = < 5)
- on Day 7 PP: bHCG will fall below 100
super specific test will detect teh fall of bHCG and disappearance between day 11-16 PP
Discharging Baby home depends on what factors, PE and screenings completed
Discahrge Baby after the following ahve been completed
- stable VS
- urination and stooling spontaneously (1x for each)
- ability to feed
- if circumzied: healing
- bilirubin levels checked
- infant blood tests for type & direct coombs done
- HBV vaccine
- moms ability to care
- auto safety: car seat rear facing
- medical care and follow up established
PP care for mom in the hopsital
- skin to skin
- OOB for mom
- GI considerations
Skin-Skin Contact: mom and baby
- establish the bond between the two after devliery and establish/encourage nursing
OOB
- mother should be OOB a few hours after delivery: good for bladder and bowel health
- early ambulation decreased DVT risk
- encourage good level of rest and activity
- helps with GI motility and function in vaginal and c-section pts.
note: c-section pts should not have solid foods intul flatuence has occured
PP care for mom in hospital
Urinary Concerns
reasons for urinary issues
cathertization when
Urinary Concerns
- monitor abiity to urinary and assess for any other signs of bladder trauma 2/2 delivery
- mechanical outlet obstruction can develop into secondary edema or hematoma
- functional obstruction can be due to pain
- detrusor undeactivit can be doe to overdistenstion (strech) of bladder during labor
catheterization
- intermittent Q6 hours after delivery is the cannot self-void or cannot empty bladder completely
PP care for mom in hospital
GI Concerns
contipation tx. and hemorroids tx.
GI Concerns
Mild Illeus: (stasis of the SI) with perineal discomfort and fluid loss = high risk of constipation
Treatment: reduce constipation
- stoll softeners: Docusate sodium
- magnesium (milk of magnesia)
- enema
- dietary fiber increased intake
Hemorrhoids very common
- astrigents/vasoconstrictors: witch hazel pads to aply
- Sitz baths (comfort + clean)
- lidocaine (for itch or burn)
- topical steroids for severe cases
weight loss in PP period
-what is normal, expected time frame
immediate and long term losses
Weight Loss in PP
you only should be increase caloric intake about 300 cals. daily
Weight Loss: average loss of about 10-13 occurs immediately PP
- due to amniotic fluid, blood, infant and placenta
Additional 9 lbs. during PP and for the following 6 months
- due to excretion of fluids and elecrtolyes which accumulated in pregnancy
Breastfeeding has minimal effects on hastening weight loss PP
the amount gained during pregnacy relates to how much and how fast weight will be lost PP
- more weight = longer to come off
Immediate Postpartum Care
pericare
pain
infection
Pericare
- to be performed after every bowel/bladder movement
Pain
- those with episotomy: (mediolateral) 3rd or 4th degree tears, extensive brusings or edema will have up to severe perineal pain: of which is expected
episotomy tears and repairs rearely get infected
Persistant and Unusual Pain
- warrents a perineal, vaginal, rectal exam:
- identify hematoma, infection
- dont miss potentially fatal infections: angioedema, necrotizings fascitis or perineal cellulitis
Infection
- local heat and irrigation can help resolve the issue
- abx. canbe used if immediate response to the irrigation and heat are not observed
- rare cases: open wound and drainage
__________________________________________________
Treatments
ice= to the perineum for swelling and pain
analgesia: follwing vaginal devliery (APAP, NSAIDS, lidocine topical)
F/U instructions
- nosexual activity until they have had 6 week PP check
- resume exercise as toelrated after 6 week PP check
Immediate PP care: Rhogam delivery
Rh negative mothers should be given rhogam if the baby is Rh positive
Rohgam should be given to…
- unsensitized mothers at 28 weeks
- if baby is confirm Rh + = give mom rhogam within 72 hours
- given with any risk of bleed, trauma, bleeding, etc. during pregnancy to decrease mom’s ability to produce antibodies to Rh factor
this protects future babies because it stops mom from creating ab. which woud attack future baby if Rh+
this is not needed in moms who are Rh+
decreases risk of developing IPP in baby
Role of Estrogen, Prolactin and BF milk
Estrogen
- levels fall PP and will remain suppressed only in the presence of breastfeeding: lactation
- in non-BF mothers: ovariain function can return in as little as 4-6 weeks PP - 70% have return of menses within 7 weeks
Prolactin
- suppresses ovulation within the first 3 weeks of PP
- the suckling from baby triggers increases in prolactin: making milk
- thus, if there is no breastfeeding, no trigger of the prolactin, thus no suppression of estrogen
Breastmilk
- after devliery, the breasts begin to secrete colostrum
- this contains high levels of vitamins, minerals, AAs, & proteins with less sugar fat (hence they get lots of good, but initial BW can decrease)
- immunoglobulin, macrophages and other immune protects contained within this coslsrum: help baby mount an immune system
Educate and Suggestsions for Breastfeeding PP
breast is good, but fed is better!!
- encourage BF, but if not fesable do not push!!!
Timeframe
- recommendation is to breastfeed exculsively for 6 months, continue until up to 2 years or beyond depending on motehr preference
- at 6 months: solids are encouraged
Always consider barriers to BF
- education level, langugage, inforamtion, experiecnes
Benefits for Mom
- helps with subinvoluation of the uterus
- contracenption if using LAM (lactacional amenorrhea method)
- cheaper, promotes bonding
Benefits for Baby
- promotes GI function and growth of GI tract
- lower incidence of acute illnesses
- positive for decreasing obestiy, DM, cancer and potential cognitive benefits
assisst lactation consultants!!: get them invovled early
LAM: lactaional amenorrhea method
what three condtions must be met for proper utalization
LAM: lactional amenorrhea method
- in the presence od prolactin; there is an inhibtion of estrogen and therefore a hault in the regualr menstarul cycle
- can be considered extremely effective (98%) ONLY IF….
the following conditiosn MUST be met
- amenorrhea sustatined while LAM used
- fully or nearly fully breastfeeding: no intervals longer that 4-6 hours without breastfeeding
- < 6 months PP
POP (progesterone only pill) can be perscribed as a backup method
always councel on other methods and the future, barriers and inconsistency to breastfeeding
PP: the “Fourth trimester”
follow up visits: when to schedule follow ups
many women find the haredest part of PP time period is around the two week mark
currently, post-partum follow up visits are scheuleded 4-6 weeks out: after they’ve experienced the hard part…..
- suggest doing telehealth or visit at 2 weeks to check in (within the first 3 weeks of PP) : assess acute issues and most important concerns NOW
- then real PP visit at 4-6 weeks :more comprehensive PP visit to cover all else
no later than 12 weeks!! according to ACOG
- c-section: often come in for an incision check around 1-2 weeks
Discussion of the 4th trimester (PP period)
what should be disucussed
when
discussion about the PP period should be talked about during the 35-36 week period
Topics Included
materials to have at home
contraception & family planning
- discuss obstaining from sex until 6 weeks
- contraception: BF, etc. use the USMEC to determine which contraception is best
support system at home
- IPV: highest in first 2 months PP, espeically with increased kids
- baby blues v depression
breast v bottle
bladder and bowel preparations
PP Contraception Considerations
POP effiact
IUD specifics
Diaphgrams and caps
perminent methods
progesterone implants and shots
POP: can be used for BF moms
- no effect on breast milk
- differnet instructions: take at same time daily
IUDS
- can be inserted up to 10 minutes after delviery (of placenta)
- except in case of PP sepsis obv dont isnert soemthing in infection
Diaphgrams and caps
- need to be refitted and refitted againa fter PP weight loss
Perminent methods
- vasectomy or tubual ligation
Nexplanon (implant) and depo (injection) can be used after delivery
- bleeding, depression risk, weight gain and BMD risk with depo injections = watch this in PP moms
- opt for nexplanon
combined Oral contraceptions are a cat. 4 AVOID in PPmoms for first 21 days!!! due to DVT/VTE risk
- watch in BF: can be cat. 2 fpr those without DVT factors at 20 days (watch milk supply)
- in non BF: ok (cat 2) for non DVT risk pt. at 21 days PP
Baby Blues v Depression
Baby Blues
- seen in up to 85% of patients
- defined as; transient symptoms that occur within the first few days after delivery, usually disappating by PP day 10
- come and go feelings of sad ; but they DO PASS
Depression
- highest occurance of depression is PP
- suicide and overdose associated with disorders are the elading cause of maternal mortality in the US
Risk Factors for PP Depression
- personal or family hsitory of depression/anxiety
- depression or anxiety DURING pregnancy
- stressful life events
- poor social support
- martial issues
- lower SES
- neuroticism: negative affect
PP Depression
scale to use
treatment
PP Depression
edinburgh Depression Scale good to SCREEN for depression
- shouldve already been done prior to d/c from hospital & then give AGAIN in the inpt PP visit
Treatment
- can include pharm and behavioral therapy
- SSRI: often first line benefits > risk
- specifically sertraline and escitalopram
PP Psychosis
what is it
whos at risk
Symptoms
PP Psychosis
- rare but a OB and psych. emergecny
- assocaited wtih high risk of sucide and infanticide
Risk Factors
- women with bipolar disorder had marked increased in PP psychosis compared to normal
- history of PP psychosis at increased risk
Symptoms
- usually start suddenly:within 2week PP within hours to days
- hallucinations: seeing, hearing, feeling, smelling things not there
- delusions: beliefs or thoughr processes that arent liekly to be true
- manic: irritable, euphoric, quick thinking/speaking
- depressed/low modd
- mix of manic and depressed moods with cycling
- loss of inibition: inappropriate responses
- fearful, suspisious feelings
- restlessness
- abnormal behavior compared to baseline
PP Psychosis
screening tools
ACOG recommends everyone getting prenatal and postnatal care be screened for bipoalr, anxiety and depression using screening tools
ACOG recomeends screening for bipolar before intiating medication for anxiety or depression if not already done
Post Partum visit: In office
includes what
incision, suture sites care, bladder, bowel and vagina care
lochia and perneal issues
return to sex and libido return
- return to sex 6 weeks earliest
- libido return around week 12: estrogen return : varies widely
Social Support
- IPV screen!
- issues with baby
Breast and bottle feeing
- discuss at week 2 PP visit
Sleep
Return to work
6 weeks: driving, ligting, exercise and dietary needs can be incorporated back
Conceling and Seeing the Pt. in which devliery ended in fetal demise
Women who has experince fetal demise: always schedule follow up within 2 weeks
post delivery demise
- inform parents together
perinatal loss
- assist in the greiving process
- encourage them to see and touch baby at birth or later on (even if anomalies)
- memetnos like footprints and hair or photos can be given
Assisting Mom in the PP Period
- follow up at 2 weeks PP
- watch for abnormal greif: defined as inability to work through the loss within 3-4 months withfeelings of self esteem loss
for babies who are born with severe anomalies, emphazie the babys healthy/normal features & always talk about the postive treatments out there for assisting
PP Visit with mom
PE to do
PE should include…..
Vital signs, weight and BMI
assess mood
assess breast feeding and problems with breasts
assess abd. pain & check c section
pelvic exam and physical to assess
- episitomy/lacerations
- vagina
- cervix
- uterus
- bleeding/lochia
- pap only if due
- retacl if needed
Plan to include
- Tx.
- Dx. : iamginge, etc.
- education
- F/U:dispo : when to come back, when to go to ER
following postnatal visit: usualy GYN eamples can routinely begin 3 months later: set up appt ofr 3 months from that visit
