Postpartum Care

Question 1

Endometritis

Answer 1

• MC occurs after c-section or when membranes are ruptured >24hr before delivery
• MC present 2-3d postpartum. Fever higher than 38.3 (101) and uterine tenderness are suspicious for endometritis. Adnexal tenderness, peritoneal irritation, and decreased bowel sounds may occur
• Dx: WBC count commonly more than 20,000, causative bacteria vary widely but anaerobic strep MC, UA
• tx: abx administered until afebrile for 24hrs (glinda plus gent = 1st line; ampicillin added if no response in 24-48h; metronidazole added if sepsis present)
  
  • single dose of abx at time of cord clamping reduces incidence of endometritis

Question 2

Puerperium

Answer 2

• defined as 6-wk period after delivery
• Immediately after deliver, the uterus is at the level of umbilicus
  
  • after 2d uterus involutes, 5-7d firm and no longer tender, after 2wk descends into pelvic cavity, by 6wk back to antenatal size
• lochia (bleeding) is sloughing off of decidual tissue - can last 4-5wk postpartum
  
  • lochia rubra: beginning, blood, shreds of tissue (serious, reddish/browh, lasts 3-4d)
  • lochia serosa: mucopurulent, pale, malodorous
  • lochia alba: thick, mucoid, yellowish white (2nd-3rdwk)
• in non breastfeeding women, menses resumes 6-8wk postpartum; breastfeeding women typically anovulatory and may remain amenorrheic for duration of lactation
• 1st PP visit should be 6wk after delivery
  
  • on pelvic exam, perineum well healed and uterus back to pregravid size
  • lactating mothers occasionally have atrophic vaginitis
  • get Hgb and Hct, fasting glucose, EPDS (edinburgh postnatal depression scale - >/= 10 receives further assessment/tx)
  • emphasize contraception, vit supplements for nursing moms
  • atrophic vag tx w/ E

Question 3

Perineal Laceration/Episiotomy Care

Answer 3

• Episiotomy: incision of perineum (midline or mediolateral) - ACOG recommends restricted use, increased risk 3rd and 4th degree lacs and fecal incontinence, increased postop pain and slower healing
  
  • indicated for shoulder dystocia, breech, forceps, vacuum
  • routine episiotomy associated with increased maternal blood loss, increased risk disruption of anal sphincter (3rd degree lac) and rectal mucosa (4th degree lac), and delay in pts resumption of sexual activity
• tx: immediately after delivery, cold compresses applied to perineum. Perineal area gently cleansed with plain soap at least once or twice per day and after voiding or defecation
  
  • repair of lacs using absorbable sutures (2-0 or 3-0)
  • cold or iced sitz baths for additional pain relief

Question 4

Perineal laceration degrees

Answer 4

• 1st: involves fourchette, perineal skin, vaginal mucous membrane
• 2nd (MC): fascia and muscles of perineal body
• 3rd: extends to external anal sphincter
• 4th: extends to rectal mucosa and includes internal anal sphincter
  
  • RF: midline episiotomy, mid/low forceps, nulliparity, second stage arrest of labor (pushing too long), persistent occiput posterior position, local anesthesia, Asian race

Question 5

Postpartum hemorrhage etiology, RF, and sxs

Answer 5

• RF: prolonged thrid stage of labor, multiple delivery, episiotomy, fetal macrosomia, prior hx of PPH
• MCC excessive blood loss in pregnancy
• sxs: pt returns to hospital a few days after delivery
  
  • brisk vaginal bleeding (>500mL)
• signs: enlarged uterus or vaginal mass (inverted uterus), uterine bleeding with good tone and normal size, hemorrhagic shock
• complications: uterine perf, orthostatic HoTN, anemia, fatigue

Question 6

Postpartum hemorrhage dx and tx

Answer 6

• dx: CBC, coag studies (PT, PTT, platelts), BUN, SCr, type and screen
• tx: insert fingers of one hand into vagina and compress uterus against abdominal wall
  
  • IV oxytocin (pitocin) 10-40units in 1L saline for atony
  • Misoprostol
  • emergent OB/GYN consult
  • D&C