Postpartum Care Flashcards
What is the primary cause of postpartum uterine atony?
Bladder distention. Evaluate and/or drain bladder
Retained products are another significant cause, particularly in delayed postpartum hemorrhage
What is the primary cause of postpartum hemorrhage?
Uterine atony: Is the bladder empty? Did she have a big baby? Long labor? Is the uterine fundus firm to the touch? Is there placental or membranous material left? Could her cervix be lacerated? Could she have a clotting problem?
Episiotomy/laceration care
With lacerations repair is dependent on bleeding and on likelihood of tissues staying approximated
Must be repaired and even with fewest stitches needed
If bright steady bleeding after delivery may have a vaginal side wall tear or a cervical tear
Uterine involution- postpartum physiologic changes
Uterus returns to pre-pregnant size by 6 weeks postpartum
Reduction in cell size
Uterine hemostasis is maintained by contraction of the uterine musculature
Breastfeeding causes uterine contractions that are beneficial in the process of involution
Lochia- postpartum physiologic changes
Heavy at first, then decreases over time
Lochia rubra- red bleeding, lasts 3-4 days, begins very heavy, then gradually decreases in amount
Lochia serosa- pink-tinged, lasts until approximately day 10 after delivery
Lochia alba- thinner, whitish-brown d/c which can last several weeks
Frequently will see another shorter episode of dark red bleeding around 2 weeks postpartum as eschar at old placental site is sloughed off
Postpartum hemorrhage
Defined as blood loss of >500 mL following vaginal delivery or >1,000 mL following Caesarean delivery
Early or primary postpartum hemorrhage
Postpartum hemorrhage within 24 hrs of delivery
Late or secondary postpartum hemorrhage
Postpartum hemorrhage that occurs 24 hrs after delivery
The four Ts of postpartum hemorrhage
Tone- prevent/treat uterine atony
Tissue- ensure all placental tissue is removed at time of delivery
Trauma- inspect for cervical, vaginal, vulvar tears which may cause bleeding or hematomas
Thrombosis- evaluate for clotting disorders, such as HELLP or DIC
What is the most common source of postpartum infection?
Endometritis
Endometritis
Infection of the lining of the uterus
Sx of endometritis
Fever
Malaise
Abd pain
Foul-smelling lochia
PE of endometritis
Lower abd pain
Uterine and adnexal tenderness on bimanual
Foul-smelling lochia
Fever greater than or equal to 100.4 within first 10 days postpartum
OR
Fever of 101.6 within the first 24 hrs postpartum
Workup of endometritis
CBC
BCx
Urine culture
GC/CT culture
Prognosis and complications
Should show clinical improvement within 36-48 hrs
Failure to improve is an indication to do a pelvic CT to r/o septic thrombophlebitis
Under-treated or untreated can cause fatal septic shock
Tx of uterine atony if fundal massage does not work
Oxytocin, prostaglandins, or ergonovine
Commonly isolated organisms of endometritis
Ureaplasma urealyticum Peptostreptococcus Gardnerella vaginalis Bacteroides bivius Group B strep Chlamydia has been associated with late-onset postpartum endometritis
Tx of endometritis after C-section
Clindamycin and gentamicin IV q8h
OR
Ceftriaxone IV daily and Flagyl IV q8h
Treat until afebrile >24 hrs then can d/c home
Tx of endometritis after vaginal delivery
PO abx should be sufficient unless severely ill or multiple co-morbidities
Cephalosporins, extended-spectrum PCNs, and fluoroquinolones can be used as monotherapy
Tx of endometritis after abortion
Cefoxitin 3 gm IV q6h and doxycycline 100 mg BID x 10
Ovarian function postpartum
If bottlefeeding, ovulation can occur as early as 4-5 weeks postpartum, with majority ovulating around 10 weeks
Definitely can be pregnant when they come for their 6 wk postpartum visit
If breastfeeding, ovulation is suppressed at least 6 weeks due to elevated prolactin levels. Suppression will continue as long as mom is nursing every 3-4 hours around the clock
Will generally regain fertility BEFORE first menses
Cardiovascular changes postpartum
Returns to nl within 2-3 weeks of delivery
Generally rapid resolution of edema
If pt has renal dz it may compromise normal diuresis, inability to diurese may cause cardiac overload
Urinary incontinence and postpartum
Occurs in around 7% of women
Generally resolves spontaneously
Kegel exercises beneficial
