Postpartum Care

Question 1

Define Postpartum
when is it
immediate, early and remot

Answer 1

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

Question 2

Placental Implantation : site of implantation and how the placenta is birthed & not hemorrhaging!

Answer 2

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

Question 3

Uterine Involuation
- timeline

Answer 3

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

Question 4

Uterine Involuation
- role of the myometrium in involuation

Answer 4

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

Question 5

Post Partum Hemorrhage
what is it
defintion
due to waht
assocaited sequelae

Answer 5

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)

Question 6

Post Partum Hemorrhage
treatment : inital , meds and other treatments

Answer 6

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

Question 7

Post Partum Hemorrhage

workup for PP hemorrhage : determine the cause

Answer 7

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

Question 8

Lochia
what is it
lochia rubra
lochia serosa
lochia alba

Answer 8

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

Question 9

physiological changes to the vagina PP

Answer 9

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

Question 10

Physiological changes of the cervix PP

Answer 10

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

Question 11

Physiolgical abdomen and pelvic floor changes in PP

Answer 11

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

Question 12

Urinary System Changes during Pregnancy and return PP

Answer 12

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

Question 13

Fluid Volumn Management PP
PP diuresis
fluid lost in first week
blood volume returns when
CO and HR changes back to prepreg. levels when

Answer 13

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

Question 14

Hematopoesis during pregnacy and PP

Answer 14

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

Question 15

Blood Coagulation and Fibrinolysis during pregnancy and PP

Answer 15

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

Question 16

Cholesterol in pregnancy and PP period

Answer 16

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

Question 17

Gluocse during pregnancy and PP period
when to recheck those with GDM

Answer 17

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

Question 18

Pituitary, Ovarian and bHCG levels PP

Answer 18

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

Question 19

Discharging Baby home depends on what factors, PE and screenings completed

Answer 19

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

Question 20

PP care for mom in the hopsital
- skin to skin
- OOB for mom
- GI considerations

Answer 20

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

Question 21

PP care for mom in hospital
Urinary Concerns
reasons for urinary issues
cathertization when

Answer 21

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

Question 22

PP care for mom in hospital
GI Concerns
contipation tx. and hemorroids tx.

Answer 22

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

Question 23

weight loss in PP period
-what is normal, expected time frame
immediate and long term losses

Answer 23

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

Question 24

Immediate Postpartum Care
pericare
pain
infection

Answer 24

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

Question 25

Immediate PP care: Rhogam delivery

Answer 25

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

Question 26

Role of Estrogen, Prolactin and BF milk

Answer 26

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

Question 27

Educate and Suggestsions for Breastfeeding PP

Answer 27

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

Question 28

LAM: lactaional amenorrhea method
what three condtions must be met for proper utalization

Answer 28

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

Question 29

PP: the “Fourth trimester”
follow up visits: when to schedule follow ups

Answer 29

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

Question 30

Discussion of the 4th trimester (PP period)
what should be disucussed
when

Answer 30

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

Question 31

PP Contraception Considerations
POP effiact
IUD specifics
Diaphgrams and caps
perminent methods
progesterone implants and shots

Answer 31

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

Question 32

Baby Blues v Depression

Answer 32

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

Question 33

PP Depression
scale to use
treatment

Answer 33

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

Question 34

PP Psychosis
what is it
whos at risk
Symptoms

Answer 34

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

Question 35

PP Psychosis
screening tools

Answer 35

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

Question 36

Post Partum visit: In office
includes what

Answer 36

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

Question 37

Conceling and Seeing the Pt. in which devliery ended in fetal demise

Answer 37

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

Question 38

PP Visit with mom
PE to do

Answer 38

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