Postpartum Care Flashcards

1
Q

Puerperium

A

6 to 8 week period following birth dring which the reproductive tract and physiology of the mother returns to the non-pregnant state

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2
Q

Mechanism of postpartum uterine involution

A

Caused by autolysis of intracellular myometrial proteins, resulting in a decline in trophy but not in plasticity (smaller cells, same cell number)

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3
Q

Lochia alba

A

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.

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4
Q

Return of ovulatory function following delivery

A

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.

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5
Q

Abdominal wall changes in the post-partum state

A

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.

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6
Q

When does the increased cardiac output during pregnancy begin to regress post-partum?

A

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.

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7
Q

Return to normal WBC levels in postpartum period

A

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

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8
Q

Post-partum autotransfusion

A

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.

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9
Q

When do we start to get worried that post-partum urinary stress incontinence may be non resolving?

A

After 90 days postpartum

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10
Q

Placental eschar passage

A

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.

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11
Q

What is the last thing you want to do to someone who may have postpartum hemorrhage?

A

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.

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12
Q

Mainstays of postpartum hemorrhage

A
  • 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)
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13
Q

Postpartum analgesia

A
  • 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
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14
Q

Postpartum patients should be encouraged to begin walking again . . .

A

. . . as soon as possible, INCLUDING for C section patients

They may need assistance at first though.

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15
Q

Postpartum breast pain

A
  • 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)
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16
Q

Galactocele

A

Plugged duct

May result in mastitis and a unilaterally enlarged, tender breats post-partum

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17
Q

Mastitis

A

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.

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18
Q

Breast abscess

A

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.

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19
Q

Postpartum immunizations for mom

A
  • 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)
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20
Q

Postpartum bowel function

A

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.

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21
Q

Postpartum hemorrhoids

A

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.

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22
Q

Postpartum urinary retention

A

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.

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23
Q

In order to reduce risks of postpartum hemorrhage and infection, it is wise to advise patients to wait ___ postpartum before resuming sexual activity.

A

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.

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24
Q

Benefits of breastfeeding for the infant (particularly within the first 6 months)

A
  • 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
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25
Q

Contraindications to breastfeeding

A
  • 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
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26
Q

Specific, commonly perscribed drugs that women should not take while breastfeeding

A
  • Lithium carbonate
  • Tetracycline
  • Bromocriptine
  • Methotrexate
  • Any radioactive substance
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27
Q

Colostrum

A

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.

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28
Q

For breast milk to be produced on an onging basis, there must be. . .

A

. . . adequate insulin, cortisol, thyroxine, prolactin, and adequate maternal nutrition.

29
Q

Vitamin content of breast milk

A

Contains all vitamins in some proportion, EXCEPT vitamin K

This is why we give the K shot to newborns. However, we also recommend supplementation of vitamins for newborns since variable vitamin content may be inadequate in one or two vitamins.

30
Q

Nipple care

A

An important part of breastfeeding

Nipples should be washed with water and exposed to air for 15-20 minutes after each feeding.

A water-based cream such as lanolin or A or D ointment may be applied if nipples are tender.

31
Q

Postpartum blues

A

Common phenomenon experienced first on day 2-4 postpartum.

May come and go throughout the day, are fairly mild in terms of degree of mood alteration, and abate within 1/2 weeks.

Main differential is for postpartum depression.

32
Q

Postpartum depression

A

Average onset is 2 weeks to 12 months postpartum, and average duration is 3-14 months. Symptoms usually occur later than would be expected for “postpartum blues”, and get worse rather than abating over weeks.

This is true depression and requires antidepression pharmacotherapy and psychiatric therapy.

33
Q

Postpartum psychosis

A

Most commonly manifests as a decompensation of pre-existing bipolar disorder or schizophrenia.

This is a medical emergency requiring immediate inpatient treatment.

Onsets 2-3 days postpartum (like postpartum blues) and has variable duration.

34
Q

Risk factors for postpartum depression

A
  • FHx or personal Hx of depression or anxiety disorder
  • Presence of acute stressors
  • Presence of multiple children under 2 at home
  • Young maternal age
  • Conventional depression risk factors
35
Q

___ is the strongest predictor of postpartum depression

A

Depression during pregnancy is the strongest predictor of postpartum depression

36
Q

Criteria for diagnosing postpartum hemorrhage

A
  • Drop in hematocrit by 10% or more
  • Need for transfusion due to blood loss
  • Signs and symptoms of blood loss
37
Q

“Primary” vs “Secondary” postpartum hemorrhage

A

Primary: Early. Within first 24 hours. Serious.

Secondary: Late. After first 24 hours. Less serious.

38
Q

Risk factors for postpartum hemorrhage

A
  • Prolonged labor
  • Abnormal labor
  • Rapid labor
  • History of PPH
  • Episiotomy
  • Preeclampsia
  • Overdistended uterus (macrosomia, multiple gestation, hydramnios)
  • Operative delivery
  • Asian or Hispanic ethnicity
  • Chorioamnionitis
39
Q

Most common cause of postpartum hemorrhage

A

Uterine atony

40
Q

Indications for beginning 1:1:1 transfusion ratio in a patient with postpartum hemorrhage

A
  • 4 or more units RBC required over 1 hour
  • 10 or more units RBC required over 12-24 hours
41
Q

Immediate general measures for a patient with suspected postpartum hemorrhage

A
  • Insert 2 large bore IVs
  • Type/screen/crossmatch
  • Begin or increase crystalloid infusion
  • Assess coagulation profile
42
Q

What is uterine atony?

A
  • Lack of constriction of the uterus following delivery of the placenta
    • This constriction usually cuts off the blood supply to the spiral arteries which were supplying the placenta and prevents bleeding
    • It is a major risk factor for postpartum hemorrhage
    • On exam the uterus is characretistically “soft and boggy” following delivery of the placenta, indicating poor tone
    • The cervix is frequently open in uterine atony
    • Uterus often responds to massage by contraction only to become relaxed again after a few moments
43
Q

Active management of the third stage of labor

A
  • Reduces risk of PPH by 70%, mostly by reducing risk of uterine atony
  • Measures include:
    • Infusion of oxytocin, 20 units in 1L saline at 200 to 500 mL/hr started immediately following delivery of infant’s anterior shoulder
    • Gentle cord traction
    • Uterine massage
44
Q

Uterotonic agents given in cases of uterine atony

A
  • Oxytocin
  • Methylergonovine maleate (very potent, given intramuscularly since IV infusion may lead to hypertension – it is an ergotamine)
  • Misoprostol (prostaglandin E1 analogue)
  • Dinoprostone (prostaglandin R2 analogue, rectal suppository)
  • 15-methyl prostaglandin F2a (given intramuscularly or directly into myometrium – avoid in cardiac, pulmonary, liver renal disease)
45
Q

Surgical solutions for uterine atony

A
  • Arterial compression techniques:
    • Uterine compression sutures (B-Lynch or multiple squares)
    • Sequential arterial ligation (uterine, then utero-ovarian, then internal iliac)
  • Selective arterial embolization
  • Hysterectomy
46
Q

Periurethral lacerations

A

In vulvar lacerations involving tissue near the urethra, edema may cause urethral occlusion.

This is an indication for Foley catheter insertion.

47
Q

Separation of the uterus from the placenta occurs because of cleavage between. . .

A

. . . the zona basalis and zona spongiosa

48
Q

Placental retention is most likely to occur with a ___ placenta.

A

Placental retention is most likely to occur with a succenturiate placenta.

The smaller lobe is often retained

49
Q

Curettage during retained placenta removal is a significant risk factor for postpartum development of ___.

A

Curettage during retained placenta removal is a significant risk factor for postpartum development of Asherman’s syndrome

50
Q

Patient presents with full placental retention following successful stage II labor. Placenta accreta is suspected. What is the therapy?

A

Hysterectomy is most appropriate

In women who wish to avoid hysterectomy and pursue future chilren, an attempt at curettage removal or surgical compression/arterial ligation may be made.

51
Q

Signs/symptoms of vulvar or vaginal hematoma

A

Exquisite vulvar or vaginal pain without signs of shock

52
Q

Amnionic fluid embolism

A
  • Signs/symptoms:
    • Respiratory distress
    • Cyanosis
    • Cardiovascular collapse
    • Hemorrhage
    • Coma
  • Amnionic fluid ebolism often results in severe coagulopathy (DIC)
  • Treatment is directed at support of cardiovascular and coagulation systems
53
Q

Uterine inversion and postpartum hemorrhage

A

Uterine inversion often leads to postpartum hemorrhage that is sudden and severe.

Treatment includes manual replacement of uterus, which may require administering an agent to temporarily relax the uterus (sublingual nitroglycerin, tertbutaline, magnesium sulfate, halogenated general anesthetics). If this fails, surgery is required.

Once in place, uterine tone should be restored with uterotonic agents.

54
Q

Postpartum hair loss

A
  • High levels of estrogen during pregnancy increases the synchronicity of hair growth, and consequentially also the shedding
  • Affects ~50% of postpartum women and occurs between 1-5 months postpartum
  • Will be a diffuse hair loss without male or female pattern
55
Q

Order of interventions for postpartum hemorrhage

A
  • First line:
    • Uterine massage
    • IV dilute pitocin
  • Second line (one of):
    • Rectal misprostol (preferred agent)
    • PGF2a (contraindicated in asthma)
    • Methylergonovine maleate (contraindicated in hypertension, pre-eclampsia, eclampsia)
  • Third line:
    • Two large bore catheters, IV fluids
    • Foley catheter
    • Call for blood
    • Move patient to OR
  • Fourth line:
    • Intrauterine balloon embolization
  • Fifth line:
    • Laporotomy with stitches/ligation or hysterectomy
56
Q

Postpartum hemorrhage with firm uterus on exam is likely to be due to. . .

A

. . . genital tract laceration

57
Q

Pre-eclampsia is a risk factor for uterine atony mostly because. . .

A

. . . it indicates treatment with magnesium sulfate, which can in turn cause uterine atony

58
Q

Possible postpartum hemorrhage etiologies in a patient with a firm uterus and no lacerations

A
  • Coagulopathy
  • Placenta accreta
  • Retained placenta
  • Uterine inversion
59
Q

Treatment for late/delayed postpartum hemorrhage

A

This is caused by clot dissolution and usually occurs ~2 weeks post-delivery. Much more mild than early PPH. Treatments: Oral ergot alkaloid, dilute IV oxytocin, or intramuscular PGF2a are usually first-line options in this case.

If there is foul smelling lochia and fever, this may represent retained placental tissue which has become necrotic. Ultrasound can confirm this diagnosis. Treat this with D&C, antibiotics.

60
Q

Contraindication to ergot alkaloids for uterine atony

A

Hypertension

61
Q

Contraindication to PGF2a for uterine atony

A

Asthma

62
Q

Therapy for postpartum hemorrhage with uterine atony that is refractory to pharmacologic methods in women who still desire fertility

A
  • Ligation of the ascending branch of the uterine artery or the internal iliac artery (aka the hypogastric artery)
  • These are methods for decreasing pulse pressure to the uterus
63
Q
A
64
Q

Postpartum thyroiditis

A
  • In the postpartum population, this is the most common form of new onset hyperthyroidism (higher incidence than Grave’s)
  • Aka “destructive lymphocytic thyroiditis”
  • Characterized by antimicrosomal and antiperoxidase antibodies
  • Often occurs 1-4 months postpartum
  • May be followed by a period of hypothyroidism before return to normal thyroid function
65
Q

In differentiating postpartum blues and postpartum depression, ___ is often useful

A

Ambivalence to the newborn

This makes the diagnosis much more likely to be postpartum depression

66
Q

Postpartum dyspareunia is often due to. . .

A

. . . atrophic vaginitis secondary to lactational inhibition of GnRH

67
Q

Safest way to suppress lactation

A

Breast binding, ice packs, analgesics, avoidance of nipple stimulation

68
Q

Breatfeeding too often or too infrequently should not cause. . .

A

. . . bleeding or cracked nipples

As long as the infant’s latch is sufficient, this should not be the case. Position is the most important factor in avoiding this, with nipple care following breastfeeding (washing and air drying) also being important.

69
Q

Gentian violet may be used to treat __ of the breast in breastfeeding mothers

A

Gentian violet may be used to treat candidal infection of the breast in breastfeeding mothers