Postpartum Care

Question 1

What is the primary cause of postpartum uterine atony?

Answer 1

Bladder distention. Evaluate and/or drain bladder

Retained products are another significant cause, particularly in delayed postpartum hemorrhage

Question 2

What is the primary cause of postpartum hemorrhage?

Answer 2

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?

Question 3

Episiotomy/laceration care

Answer 3

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

Question 4

Uterine involution- postpartum physiologic changes

Answer 4

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

Question 5

Lochia- postpartum physiologic changes

Answer 5

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

Question 6

Postpartum hemorrhage

Answer 6

Defined as blood loss of >500 mL following vaginal delivery or >1,000 mL following Caesarean delivery

Question 7

Early or primary postpartum hemorrhage

Answer 7

Postpartum hemorrhage within 24 hrs of delivery

Question 8

Late or secondary postpartum hemorrhage

Answer 8

Postpartum hemorrhage that occurs 24 hrs after delivery

Question 9

The four Ts of postpartum hemorrhage

Answer 9

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

Question 10

What is the most common source of postpartum infection?

Answer 10

Endometritis

Question 11

Endometritis

Answer 11

Infection of the lining of the uterus

Question 12

Sx of endometritis

Answer 12

Fever
Malaise
Abd pain
Foul-smelling lochia

Question 13

PE of endometritis

Answer 13

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

Question 14

Workup of endometritis

Answer 14

CBC
BCx
Urine culture
GC/CT culture

Question 15

Prognosis and complications

Answer 15

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

Question 16

Tx of uterine atony if fundal massage does not work

Answer 16

Oxytocin, prostaglandins, or ergonovine

Question 17

Commonly isolated organisms of endometritis

Answer 17

Ureaplasma urealyticum
Peptostreptococcus
Gardnerella vaginalis
Bacteroides bivius
Group B strep
Chlamydia has been associated with late-onset postpartum endometritis

Question 18

Tx of endometritis after C-section

Answer 18

Clindamycin and gentamicin IV q8h
OR
Ceftriaxone IV daily and Flagyl IV q8h
Treat until afebrile >24 hrs then can d/c home

Question 19

Tx of endometritis after vaginal delivery

Answer 19

PO abx should be sufficient unless severely ill or multiple co-morbidities
Cephalosporins, extended-spectrum PCNs, and fluoroquinolones can be used as monotherapy

Question 20

Tx of endometritis after abortion

Answer 20

Cefoxitin 3 gm IV q6h and doxycycline 100 mg BID x 10

Question 21

Ovarian function postpartum

Answer 21

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

Question 22

Cardiovascular changes postpartum

Answer 22

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

Question 23

Urinary incontinence and postpartum

Answer 23

Occurs in around 7% of women
Generally resolves spontaneously
Kegel exercises beneficial