Postpartum Care Flashcards
Puerperium
6 to 8 week period following birth dring which the reproductive tract and physiology of the mother returns to the non-pregnant state
Mechanism of postpartum uterine involution
Caused by autolysis of intracellular myometrial proteins, resulting in a decline in trophy but not in plasticity (smaller cells, same cell number)
Lochia alba
Appears ~1 week after delivery (after a few days of lochia rubra and lochia serosa) and is often misunderstood as an infection by new mothers since it looks like pus. It may require some explanation and resassurance.
Lasts several weeks. Resolves more rapidly in women who breastfeed.
Return of ovulatory function following delivery
Average of ~45 days for non-lactating women and ~189 days for lactating women (due to prolactin suppression of the HPO axis, lactational amenorrhea)
Likelihood of ovulation increases as the frequency and duration of breastfeeding decreases.
Abdominal wall changes in the post-partum state
Elastic fibers of skin return and stretched rectus muscles return to normal configuration.
Silvery striae gravidarum often seen, but usually lighten in time.
Diastasis recti (sepratation of rectus muscles and fascia) may be present, but also often resolves over time.
When does the increased cardiac output during pregnancy begin to regress post-partum?
Quite quickly, with heart rate returning to the non-pregnant norm within a couple hours of delivery
This contributes to heart disease decompensation within the first hours of delivery. So patients with history of CHF or CAD need special observation during this period.
Return to normal WBC levels in postpartum period
Takes several days to weeks, and so mild-moderately elevated WBC counts are a somewhat unreliable diagnostic clue for infection during the first couple weeks postpartum
Post-partum autotransfusion
The uterus is a highly vascular organ during pregnancy. Once delivery occurs and the uterus begins to involute, all of that blood is put back into circulation.
This is one of the mechanisms by which blood counts recover from the physiologic anemia of pregnancy, along with the postpartum diuresis.
When do we start to get worried that post-partum urinary stress incontinence may be non resolving?
After 90 days postpartum
Placental eschar passage
Experienced by some patients 8-14 days post-partum
Episode of increased vaginal bleeding thought to be associated with separation and passage of the placental eschar.
Self limited and requires no therapy other than resassurance.
In the extremely rare event that it persists (<1%), it may be a sign of delayed postpartum hemorrhage.
What is the last thing you want to do to someone who may have postpartum hemorrhage?
Dilation and sharp curretage
This may only make the bleeding worse! Instead, if you want to remove potential stuck necrotic tissue and allow the uterus to contract and compress bleeding vessels, do a soft vacuum / suction curretage.
Mainstays of postpartum hemorrhage
- Medical management (first line):
- IV oxytocin, prostaglandins (induce uterine contraction)
- IV ergot derivatives (vasoconstriction of uterine vessels)
- Noninvasive surgical management (second line)
- Dilation and soft vacuum curettage (remove residual tissue or clots, allowing uterus to contract in volume and compress vessels)
Postpartum analgesia
- Spinal or epidural opiates
- Patient controlled epidural analgesia
- IV analgesia
- potent oral analgesics
- Note: careful attention should be paid to opioids by any mechanism since they can all reduce respiratory drive
Postpartum patients should be encouraged to begin walking again . . .
. . . as soon as possible, INCLUDING for C section patients
They may need assistance at first though.
Postpartum breast pain
- In women who are not breastfeeding, breast engorgement and mastalgia will occur within the first few days postpartum, but gradually abates over this period
- Recommendations to avoid/reduce pain:
- Well-fitting brassiere
- Ice packs
- Analgesics
- Avoiding nipple stimulation and manual expression of milk (if they do not wish to breastfeed, this will prolong mastalgia)
Galactocele
Plugged duct
May result in mastitis and a unilaterally enlarged, tender breats post-partum
Mastitis
Infection of breast tissue
Most often occurs in lactating women
Sudden-onset fever and localized pain and swelling.
Usually caused by S. aureus, groups A or B strep, beta Haemophilus species, and E. coli.
Treat w/ continuation of breastfeeding or emptying breast with a pump, along w/ antibiotics. The breast milk remains safe for a full-term, healthy infant, and not breastfeeding during mastitis actually worsens pain and delays resolution.
If non-resolving within a few days, breast abscess should be considered.
Breast abscess
Symptoms similar to mastitis, but a fluctuant mass is also present.
Resistance to contentional antibiotic therapy also suggests an abscess.
Treatment requires surgical drainage along with continual antibiotics.
Postpartum immunizations for mom
- Rubella, if non-immune
-
Varicella, if non-immune
- Note: Both of the above live attenuated strains are safe even if breastfeeding
- tDAP, if non-immune
- T booster (if >2 years since last)
- Rhogam (kind of immunization, KB test to determine how much is needed but 300 micrograms is standard dose)
Postpartum bowel function
Common for patients not to have a bowel movement up to 48 hours after delivery
Stool softeners may be perscribed, especially in the case of 4th degree laceration repair. Be aware that opioids may also aggravate constipation.
Postpartum hemorrhoids
Fairly common. Do not consider surgery for at least 6 months postpartum, as many will involute on their own during this period.
Sitz baths, stool softeners, and local preparations are useful.
Postpartum urinary retention
Urinary output in first 24 hours postpartum must be monitored carefully
If catheterization is required more than twice in 24 hours, then placement of a Foley for 1-2 days is advisable.
In order to reduce risks of postpartum hemorrhage and infection, it is wise to advise patients to wait ___ postpartum before resuming sexual activity.
In order to reduce risks of postpartum hemorrhage and infection, it is wise to advise patients to wait 2 weeks postpartum before resuming sexual activity.
Benefits of breastfeeding for the infant (particularly within the first 6 months)
- Decreased risk of otitis, respiratory infection, diarrhea, SIDS
- Decreased risk of atopic disease, juvenile diabetes, and childhood cancer
- Fewer hospital admissions in first year of life
- Improved long-term cognitive function
Contraindications to breastfeeding
- Maternal HIV (risk of transmission)
- Active, untreated tuberculosis is a contraindication to being close to the infant, but breast milk may be expressed and delivered to the infant (except in the rare case of tuberculous mastitis)
- Mothers undergoing chemotherapy, particularly with antimetabolites
- Mothers who recently received radiation
- Infants with galactosemia (heritable galactose metabolism defect)
- Mothers who use recreational drugs
Specific, commonly perscribed drugs that women should not take while breastfeeding
- Lithium carbonate
- Tetracycline
- Bromocriptine
- Methotrexate
- Any radioactive substance
Colostrum
Produced within the first 5 days postpartum, then replaced by breastmilk.
Colostrum contains more minerals and protein, but less fat and sugar than maternal milk. However, it does contain fat globules, called “colostrum corpuscles” as well as IgA.
It is still recommended to breastfeed the infant during this period to provide IgA and non-carbohydrate nutrition.