Postpartum care/complications

Question 1

Newborn immediate postpartum assessment: if Mag used for mom….

Answer 1

Watch for decreased respiratory effort (may require bagging)

Question 2

Newborn immediate postpartum assessment: septic infant appearance

Answer 2

E.g. chorio, GBS unknown, etc
Often pale, lethargic, high temperature
A foul smell at delivery can be a warning sign

Question 3

Newborn immediate postpartum assessment: No respiratory effort

Answer 3

→ 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)

Question 4

APGAR

Answer 4

Activity (muscle tone)
Pulse (heart rate)
Grimace (response to smell or foot slap)
Appearance (color)
Respiration (breathing)

Question 5

Activity (muscle tone)

Answer 5

0 points = limp
1 point = limbs flexed
2 points = active movement

Question 6

Pulse (heart rate)

Answer 6

0 points = absent
1 point = <100/min
2 points = >100/min

Question 7

Grimace (response to smell or foot slap)

Answer 7

0 points = absent
1 point = grimace
2 points = cough or sneeze (nose) cry and withdrawal of foot (foot slap)

Question 8

Appearance (color)

Answer 8

0 points = blue
1 point = body pink, extremities blue
2 points = pink all over

Question 9

Respiration (breathing)

Answer 9

0 points = absent
1 point = irregular weak crying
2 points = good strong cry

Question 10

Postpartum hemorrhage definition

Answer 10

Defined as 500cc if vaginal delivery, 1000cc if c/s

Question 11

Postpartum hemorrhage management

Answer 11

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

Question 12

DDX for postpartum hemorrhage

Answer 12

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).

Question 13

Uterotonics - route of administration

Answer 13

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.

Question 14

Uterotonics: contraindications

Answer 14

Methylergotavine (methergine) - hypertension & preeclampsia (constricts smooth muscle and exacerbates HTN)

Hemeabate (prostaglandin f2) - asthma (bronchoconstrictor)

Question 15

Endomyometritis

Answer 15

Polymicrobial infection, more common after C/S, higher risk if chorio / meconium / prolonged ROM

Question 16

Endomyometritis presentation

Answer 16

Fever, high WBC, uterine tenderness, esp 5-10d after delivery but can be several weeks

Question 17

Endomyometritis workup

Answer 17

R/o retained POC with U/S

If retained POC, do blunt curettage (PP uterus can rupture!)

Question 18

Rx of endomyometritis

Answer 18

Broad spectrum IV abx until afebrile x 48h, no uterine pain / tenderness, normal WBC

Question 19

Breastfeeding: how to suppress lactation

Answer 19

Breast binders, ice packs, analgesics, avoid nipple stimulation (not bromocriptine or other meds which can cause rebound engorgement and thromboembolic events!)

Question 20

Breastfeeding candidiasis:

Answer 20

Onset of pain in breast when feeding, sore / sensitive nipples
Exam: pink shiny nipples with peripheral peeling.

Question 21

Signs that a baby is getting sufficient milk:

Answer 21

3-4 stools in 24 hours
6 wet diapers in 24 hours
Weight gain and sounds of swallowing.

Question 22

Management of breast engorgement

Answer 22

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)

Question 23

____ causes milk production, ____ causes milk letdown

Answer 23

Prolactin causes milk production, oxytocin causes milk letdown

Question 24

What type of contraceptives are best in puerperium?

Answer 24

Progesterone-only contraceptives are best in puerperium- 6 wks PP (don’t interfere with milk let-down) - like Depo

Question 25

Postpartum depression

Answer 25

If longer than 2 weeks, ambivalence towards newborn, etc. (vs blues)

Can use SSRIs, safe for breastfeeding.

Question 26

Postpartum fever ddx

Answer 26

Endometritis
Mastitis
Breast engorgement
Septic thrombophlebitis

Question 27

Endometritis

Answer 27

Uterine tenderness, hx of d&c or c/s, fever and tachycardia

Question 28

Mastitis

Answer 28

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.

Question 29

Septic thrombophlebitis

Answer 29

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.