Postpartum care & complc'ns Flashcards
what is the puerperium?
first 6 w after delivery
what are common p-p complc’ns of vag deliveries? Mgt of each?
pain - NSAIDs & tylenol, maybe low-dose narcs
perineal & labial edema - ice packs
episiotomies or lacs - make sure no hematomas, keep wound clean
hemorrhoids - resolve w/time. Stool softeners, OTC hemorrhoidal creams
what are common p-p complc’ns of c/s? Mgt of each?
wound care
pain mgt - NSAIDs, tylenol, low-dose narcs
post-op ileus - stool softeners, maybe laxatives
p-p breast care?
may have low-grade fever warmth, tenderness, firmness relief w/breastfeeding. If not breastfeeding: ice packs tight bra analgesics anti-inflam
how much pelvic rest is needed p-p?
6 w
what forms of hrm’l b.c. are safe during breastfeeding?
mini-pill
Norplant
Depo-Provera
why aren’t ES-containing OCPs used p-p?
dries up milk supply. Can try them 4-6w after establishing breastfeeding.
other forms of contraception recomm’d p-p?
condoms. Avoid cervical cap & diaphragm b/c cervix hasn’t returned to normal shape yet.
IUD is ok but has higher rates of extrusion b/c of dilated cervix
how long are vag deliveries kept in hosp? c/s?
1 day for vag, 3 for c/s
what are the primary p-p complications?
pph
endomyometritis
mastitis
pp depression
what is pph?
> 500mL blood loss in a vag delivery, > 1000mL in c/s.
if w/in first 24h of delivery = early.
if after 24h, = late
causes of pph:
uterine atony retained POCs placenta accreta cervical lacs vag lacs
mgt of pph:
IVF
have blood ready
may need plts & coag factors
what is Sheehan syndrome?
pituitary infarction 2/2 hypotension from pph. P/w absence of lactation or amenorrhea due to lack of pit hrms.
how does a vag hematoma dvp?
trauma of delivery damages an a. w/o damaging overlying skin
how do vag hematomas present?
unexplained drop in hct. Need to do a vag exam to look for hematoma
mgt of vag hematomas?
expectant mgt. If it becomes tense or expanding, open it & ligate the bleeding bv.
what is a rare complc’n of vag hematoma?
retroperitoneal bleed
dx & mgt of retroperitoneal hematoma?
CT or u/s
expectant mgt, maybe surgery if unstable
mgt of cervical lacs?
anesthesia (epidural, spinal, or pudendal)
repair w/interrupted or running absorbable suture
what is the leading cause of pph?
uterine atony
dx of uterine atony?
uterus is enlarged, soft, boggy.
mgt of uterine atony:
IV pitocin
strong uterine massage
methylergonovine if no response to pitocin & massage
prostin (PGF2alpha) intrauterine injection if still no response
if still no response, D&C to r/o retained POC
if rate of bleeding is not too fast, can have IR do uterine a. embolization.
if this fails, need ex lap to ligate pelvic vessels, maybe hysterectomy.
methylergonovine is CI’d in who?
HTN’ves
prostin is CI’d in who?
asthmatics
what to do if suspect retained POC?
manual exploration of uterus if cervix hasn’t ctr’d down yet, or D&C.
If bleeding continues and you’ve r/o retained POC, what should you suspect?
placent accreta
mgt of placenta accreta
ex lap, place hemostatic sutures in placental bed. May need hysterectomy if bleeding persists.
CP of placenta accreta?
pph that has not responded to oxytocin, uterine massage, ergonovines, prostaglandins. Maybe pt had long 3rd stage and/or placenta came out in pieces.
CP of uterine rupture:
most likely a pt w/previous uterine scar, but can be a pt w/no scar (rare in nullips).
“popping” sensation
mgt of uterine rupture
ex lap, hysterectomy if can’t control bleeding
RF’s for uterine inversion:
fundal implantation of placenta
uterine atony
placenta accreta
excessive traction on cord during 3rd stage
mgt of uterine inversion:
manual replacement. NTG may help.
pts may have a vasovagal response and become unstable - need anesthesiologist stat. Ex lap.
operative mgt of pph:
1) r/o vag & cervical lacs with exam
2) if bleeding still doesn’t stop, do D&C
3) if bleeding still doesn’t stop, do ex lap. If blood in abdomen, dx is uterine rupture. Need to tie off uterine a’s.
what is an alternative to ex lap w/hysterectomy in stable pts?
IR uterine a. embolization
what is endomyometritis?
polymicrobial infection of uterine lining that often invades the underlying wall.
RFs for endomyometritis?
meconium
chorioamnionitis
PROM
CP of endomyometritis?
fever
elevated WBC
uterine tenderness
about 5-10d after delivery
dx of endomyometritis
u/s to look for retained POCs as nidus of inf’n
tx of endomyometritis?
broad-spec abx, continued until pt is afebrile for 48h and WBc is normal.
D&C if POCs were seen on u/s - use blunt, not sharp currette, post-partum to avoid rupture.
CP of mastitis:
focal tenderness, erythema & warmth over one region of breast. Fever, WBC.
(diff from diffusely tender, warm, firm breasts - common w/milk letdown)
tx of mastitis
dicloxacillin
I&D abscess if present
continue to breastfeed or pump (prevents intraductal accuml’n of infected stuff)
why does p-p deps’n occur?
rapid changes in ES, PG, Prl, lack of sleep, psychosocial stress of being a new mom.
RFs for pp deps’n
PMHx of depression or mental illness, poor social support
CP of p-p deps’n:
low E level anorexia insomnia hypersomnolence extreme sadness for > a few weeks feel like can't care for baby SI
mgt of p-p deps’n
reassurance most of the time.
if SI or psychosis, get counselor, SW, rx SSRI
