Postpartum care/complications Flashcards
Newborn immediate postpartum assessment: if Mag used for mom….
Watch for decreased respiratory effort (may require bagging)
Newborn immediate postpartum assessment: septic infant appearance
E.g. chorio, GBS unknown, etc
Often pale, lethargic, high temperature
A foul smell at delivery can be a warning sign
Newborn immediate postpartum assessment: No respiratory effort
→ bag, prepare to intubate
suction a good idea, but won’t cause respiratory effort
stimulation might not be enough if baby really down.
Naloxone contraindicated if possible hx of opiate abuse by mother (baby would go into
withdrawal, which could be life threatening)
APGAR
Activity (muscle tone) Pulse (heart rate) Grimace (response to smell or foot slap) Appearance (color) Respiration (breathing)
Activity (muscle tone)
0 points = limp
1 point = limbs flexed
2 points = active movement
Pulse (heart rate)
0 points = absent
1 point = <100/min
2 points = >100/min
Grimace (response to smell or foot slap)
0 points = absent
1 point = grimace
2 points = cough or sneeze (nose) cry and withdrawal of foot (foot slap)
Appearance (color)
0 points = blue
1 point = body pink, extremities blue
2 points = pink all over
Respiration (breathing)
0 points = absent
1 point = irregular weak crying
2 points = good strong cry
Postpartum hemorrhage definition
Defined as 500cc if vaginal delivery, 1000cc if c/s
Postpartum hemorrhage management
First step: fluids, type & cross for blood, send coags (consumptive coagulopathy/ DIC)
If hypotensive, worry about Sheehan syndrome
If bleeding won’t stop in OR, can try B-lynch sutures to compress, then may start having to tie off bigger vessels
DDX for postpartum hemorrhage
Vaginal lacs / hematomas, cervical lacs (fix),
Uterine atony (everybody gets Pit (oxytocin) ppx postpartum, uterotonics below)
Retained POC (examine / may need D&C)
Accreta
Rupture (rare)
Inversion (too much cord traction; need to replace manually; if not GETA → laparotomy).
Uterotonics - route of administration
Oxytocin is administered as a rapid infusion of a dilute solution (20-80 units in a liter) and not as an IV bolus.
Prostaglandin F2 should be administered intramuscularly. It could also be injected directly into the uterine muscle.
Neither prostaglandin F2 nor methylergonovine should ever be administered IV, as they can lead to severe bronchoconstriction and stroke, respectively.
Uterotonics: contraindications
Methylergotavine (methergine) - hypertension & preeclampsia (constricts smooth muscle and exacerbates HTN)
Hemeabate (prostaglandin f2) - asthma (bronchoconstrictor)
Endomyometritis
Polymicrobial infection, more common after C/S, higher risk if chorio / meconium / prolonged ROM
Endomyometritis presentation
Fever, high WBC, uterine tenderness, esp 5-10d after delivery but can be several weeks
Endomyometritis workup
R/o retained POC with U/S
If retained POC, do blunt curettage (PP uterus can rupture!)
Rx of endomyometritis
Broad spectrum IV abx until afebrile x 48h, no uterine pain / tenderness, normal WBC
Breastfeeding: how to suppress lactation
Breast binders, ice packs, analgesics, avoid nipple stimulation (not bromocriptine or other meds which can cause rebound engorgement and thromboembolic events!)
Breastfeeding candidiasis:
Onset of pain in breast when feeding, sore / sensitive nipples
Exam: pink shiny nipples with peripheral peeling.
Signs that a baby is getting sufficient milk:
3-4 stools in 24 hours
6 wet diapers in 24 hours
Weight gain and sounds of swallowing.
Management of breast engorgement
Try feeding more often, taking showers, NSAIDs before feeding
Can actually lead to fever (low grade, with breast engorged and/or hx of trouble breastfeeding)
____ causes milk production, ____ causes milk letdown
Prolactin causes milk production, oxytocin causes milk letdown
What type of contraceptives are best in puerperium?
Progesterone-only contraceptives are best in puerperium- 6 wks PP (don’t interfere with milk let-down) - like Depo
Postpartum depression
If longer than 2 weeks, ambivalence towards newborn, etc. (vs blues)
Can use SSRIs, safe for breastfeeding.
Postpartum fever ddx
Endometritis
Mastitis
Breast engorgement
Septic thrombophlebitis
Endometritis
Uterine tenderness, hx of d&c or c/s, fever and tachycardia
Mastitis
Fever, elevated WBC, focal tenderness & erythema, one breast warmer
Use dicloxacillin as first line abx, keep breastfeeding!
Admit if no response to abx in 48h; suspect breast abscess & get imaging.
Septic thrombophlebitis
Absence of other findings, no uterine tenderness but just a fever without other signs
May be able to dx on lower extremity / pelvic ct - involves pelvic veins
Rx abx and anticoagulants.
