post-partum care arouzi

8/6/2019 Post-partum Care ARouzi

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Physiology of the PuerperiumPhysiology of the Puerperium

Anatomic changesAnatomic changes

UterusUterus

LochiaLochia--name given to blood and other necroticname given to blood and other necrotic

debris shed from the uterusdebris shed from the uterus

Uterus does not scarUterus does not scar-- tissue replaced by new growthtissue replaced by new growth

from the basal endometriumfrom the basal endometrium

Proliferative endometrium persists for about sixProliferative endometrium persists for about six

weeks and first menses normally anovulatoryweeks and first menses normally anovulatory


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CervixCervix

Returns to normal within hours of deliveryReturns to normal within hours of delivery

Transverse slit like external os persists due to lacerationTransverse slit like external os persists due to laceration

Vaginal and perineal tears may remain inflamed for severalVaginal and perineal tears may remain inflamed for several

days but rapidly healdays but rapidly heal

Vagina appears normal in 6 weeks in non lactating womenVagina appears normal in 6 weeks in non lactating women

Breast feeding women are hypoestrogenic resulting inBreast feeding women are hypoestrogenic resulting invaginal mucosa being pale and smooth (causes dryness &vaginal mucosa being pale and smooth (causes dryness &

friction dysparunia)friction dysparunia)


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BreastsBreasts

Decline in Estrogen and Progesterone result inDecline in Estrogen and Progesterone result in

breast engorgement by day 3breast engorgement by day 3


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Cardiovascular changesCardiovascular changes

Changes of pregnancy reversed over threeChanges of pregnancy reversed over three

weeksweeks

Marked increase stroke volume immediatelyMarked increase stroke volume immediately

post partumpost partum

500500--1000ml blood loss in normal delivery1000ml blood loss in normal delivery


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LeukocytosisLeukocytosis of labor persists for severalof labor persists for several

daysdays

Reduces the value of leukocyte count toReduces the value of leukocyte count to

determine infectiondetermine infection

Serial counts may still be useful to followSerial counts may still be useful to follow

infectioninfection


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Weight changesWeight changes

55--6 kg weight loss expected at delivery6 kg weight loss expected at delivery

Additional 3Additional 3--4 kg over the next two weeks due4 kg over the next two weeks due

to diuresis & loss of extracellular fluidto diuresis & loss of extracellular fluid

GFR returns to normal within several daysGFR returns to normal within several days


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Complications of PuerperiumComplications of Puerperium

Blood loss & infection most commonBlood loss & infection most common

complicating 1complicating 1--5% of pregnancies5% of pregnancies

Blood lossBlood loss

Weigh bed clothes and pads for semiWeigh bed clothes and pads for semi--quantitativequantitative

method of determining blood lossmethod of determining blood loss

VSVS-- Q 15 minutes for 1 hour, Q 30 minutes forQ 15 minutes for 1 hour, Q 30 minutes for

two hours then q4hours for the first daytwo hours then q4hours for the first day

Failure to identify early post partum hemorrhageFailure to identify early post partum hemorrhage

remains leading cause of maternal mortalityremains leading cause of maternal mortality


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Blood lossBlood loss

Early post partum hemorrhageEarly post partum hemorrhage

Most common cause uterine AtonyMost common cause uterine Atony

Normal uterine blood flow 500 ml/minNormal uterine blood flow 500 ml/min

If effective contraction of myometrium does notIf effective contraction of myometrium does notoccur significant blood loss can occuroccur significant blood loss can occur

Risk factors include:Risk factors include: Use of oxytocin during laborUse of oxytocin during labor

High parityHigh parity

Distended uterusDistended uterus


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Uterine Atony (Contd)Uterine Atony (Contd)

TreatmentTreatment

Uterine compressionUterine compression

OxytocicsOxytocics

Early suckling causes endogenous release of oxytocinEarly suckling causes endogenous release of oxytocin

Oxytocin IV/IM 10 unitsOxytocin IV/IM 10 units

MethylergonovineMethylergonovine

Methyl prostoglandin FMethyl prostoglandin F


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Retained products of conceptionRetained products of conception

Causes early post partum hemorrhageCauses early post partum hemorrhage

Requires manual exploration of the uterusRequires manual exploration of the uterus

May require anesthesia and curettageMay require anesthesia and curettage


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LacerationsLacerations

Repair immediatelyRepair immediately

Uterine ruptureUterine rupture

Abdominal exploration and repairAbdominal exploration and repair


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Blood replacement based on estimated lossBlood replacement based on estimated loss

Alterations in vitals signs may occur as lateAlterations in vitals signs may occur as late

finding (Do not wait for hypotension tofinding (Do not wait for hypotension to

occur)occur)

R/O DIC by acquiring appropriateR/O DIC by acquiring appropriate

coagulation studies (split fibrin productscoagulation studies (split fibrin productsetc)etc)


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Placenta Accreta & Uterine InversionPlacenta Accreta & Uterine Inversion

UncommonUncommon

Accreta is when incomplete placentalAccreta is when incomplete placental

separation occursseparation occurs

Requires immediate hysterectomyRequires immediate hysterectomy

Uterine inversion requires immediate reductionUterine inversion requires immediate reduction

HematomasHematomas


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InfectionsInfections

EndomyometritisEndomyometritis

Foul smelling lochia and tender uterus within first fewFoul smelling lochia and tender uterus within first fewdays post partumdays post partum

Increased risk with cIncreased risk with c--section, PROM, Multiple exams duringsection, PROM, Multiple exams during

labor, & long laborlabor, & long labor

Polymicrobial including anaerobes (Ecoli, Gardnerella,Polymicrobial including anaerobes (Ecoli, Gardnerella,

Peptostreptococcus)Peptostreptococcus)

Treat with Gentamycin/Clindomycin (Gold Standard),Treat with Gentamycin/Clindomycin (Gold Standard),

extended spectrum penicillin or cephalosporinextended spectrum penicillin or cephalosporin


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FeverFever

UTI/PyelonephritisUTI/Pyelonephritis

DVT/ThrombophlebitisDVT/Thrombophlebitis

Milk fever (Lasts < 24 hours)Milk fever (Lasts < 24 hours)

Drug reactionDrug reaction

Perineal infection(

Day five)Perineal infection(

Day five) Pulmonary Atelectasis (48 hours)Pulmonary Atelectasis (48 hours)

Mastitis (2Mastitis (2--3 weeks post partum)3 weeks post partum)


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InfectionInfection

Maternal temperature best indicator of postMaternal temperature best indicator of post

partum infectionpartum infection

Monitor Q6 hours for first twenty four and haveMonitor Q6 hours for first twenty four and have

patient report chills, temperature post hospitalizationpatient report chills, temperature post hospitalization

Inspect episiotomy site regularly for infectionInspect episiotomy site regularly for infection

Monitor for return of bowel/bladder functionMonitor for return of bowel/bladder function


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AnalgesicsAnalgesics

AcetaminophenAcetaminophen

AspirinAspirin

NSAIDsNSAIDs

CodeineCodeine-- complicated by high incidence ofcomplicated by high incidence of

constipation & light headednessconstipation & light headedness

Afterpains especially problematic duringAfterpains especially problematic during

suckling due to oxytocin releasesuckling due to oxytocin release


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ImmunizationsImmunizations

Puerperium is ideal time to administerPuerperium is ideal time to administer

rubella vaccine for those found non immunerubella vaccine for those found non immune

RhRh-- women with Rh+ baby should receivewomen with Rh+ baby should receive

appropriate amounts of Rh immune globulinappropriate amounts of Rh immune globulin


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ContraceptionContraception

Ovulation may occur by week sixOvulation may occur by week six

Sexual intercourse often resumed by weekSexual intercourse often resumed by week

twotwo--threethree

Oral contraceptives may be started 1Oral contraceptives may be started 1--22

weeks post partum in non lactatingweeks post partum in non lactating

femalefemale2020


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Discharge InstructionsDischarge Instructions

Review infant careReview infant care

feedingfeeding

diaperingdiapering

Follow up visitsFollow up visits

ColicColic

Infant care and needsInfant care and needs

Resuming sexual intercourseResuming sexual intercourse


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Discharge InstructionsDischarge Instructions

Maternal follow up instructionsMaternal follow up instructions

Perineal carePerineal care

sits bathssits baths

green watergreen water

breast carebreast care

Post partum blues/depressionPost partum blues/depression

Support services due to early dischargeSupport services due to early discharge


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Medications & Breast FeedingMedications & Breast Feeding

Drugs and breast milk.Drugs and breast milk. Drugs concentrated inDrugs concentrated inbreast milk tend to be weak bases (such as metronidazole,breast milk tend to be weak bases (such as metronidazole,

antihistamines, erythromycin, or antipsychotics andantihistamines, erythromycin, or antipsychotics andantidepressants).antidepressants).

Drugs absolutely contraindicated in breast feeding.Drugs absolutely contraindicated in breast feeding.

Chemotherapeutic or cytotoxic agents, all drugs used recreationallyChemotherapeutic or cytotoxic agents, all drugs used recreationally

(including alcohol and nicotine), radioactive nuclear medicine tracers,(including alcohol and nicotine), radioactive nuclear medicine tracers,

lithium carbonate, chloramphenicol, phenylbutazone, atropine,lithium carbonate, chloramphenicol, phenylbutazone, atropine,

thiouracil, iodides, ergotamine and derivatives, and mercurialsthiouracil, iodides, ergotamine and derivatives, and mercurials..


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Medications & Breast FeedingMedications & Breast Feeding

Drugs to strongly avoid or consider bottle feeding.Drugs to strongly avoid or consider bottle feeding.

Antipsychotics, antidepressants, metronidazole, tetracycline,Antipsychotics, antidepressants, metronidazole, tetracycline,sulfonamides, diazepam, salicylates, corticosteroids ,phenytoin,sulfonamides, diazepam, salicylates, corticosteroids ,phenytoin,

phenobarbital, or warfarinphenobarbital, or warfarin..Drugs safe to use in normal doses.Drugs safe to use in normal doses. Acetaminophen, insulin, diuretics,Acetaminophen, insulin, diuretics,digoxin, betadigoxin, beta--blockers, penicillins, cephalosporins, erythromycin, birth controlblockers, penicillins, cephalosporins, erythromycin, birth controlpills, OTC cold preparations, and narcotic analgesics (short term in normalpills, OTC cold preparations, and narcotic analgesics (short term in normal

doses).doses).

LactationLactation--suppressing drugs.suppressing drugs.

Levodopa, anticholinergics, bromocriptine, trazodone, and largeLevodopa, anticholinergics, bromocriptine, trazodone, and large--dosedoseestradiol birth control pills.estradiol birth control pills.


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Breast Problems DuringBreast Problems During

LactationLactation

MastitisMastitis

S/SS/S

OrganismsOrganisms RxRx

Obstructed ductsObstructed ducts

S/SS/S RxRx

OtherOther


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Examples of Post Partum OrdersExamples of Post Partum Orders

Pitocin 10 units IMPitocin 10 units IM

BedrestBedrest

Vital signs Q15 minutes for 1 hour, QVital signs Q15 minutes for 1 hour, Q

1hour x 4, Then QID if stable1hour x 4, Then QID if stable

Consider NPO for 1Consider NPO for 1--2 hours2 hours

Ice packs to perineumIce packs to perineum


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Ambulate as tolerated when stable (cautionAmbulate as tolerated when stable (caution

check for orthostatic hypotension)check for orthostatic hypotension)

DietDiet-- as appropriateas appropriate

Tucks to perineum prnTucks to perineum prn

Sitz baths QIDSitz baths QID

IVIV-- discontinue when VS stable and uterinediscontinue when VS stable and uterine

bleeding is normalbleeding is normal


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Urethral catherization if unable to void in 6Urethral catherization if unable to void in 6--8 hours8 hours

Breast binder if not nursingBreast binder if not nursing CBC post partum day 2CBC post partum day 2

MedicationsMedications

Continue prenatal vitaminsContinue prenatal vitamins FeSOFeSO44 Acetaminophen 650 mg Q4h prn/IbuprofenAcetaminophen 650 mg Q4h prn/Ibuprofen


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BowelsBowels

Ducosate sodium 100 mg BID;MOMDucosate sodium 100 mg BID;MOM-- 30 ml30 ml

PO QD PRNPO QD PRN

Follow upFollow up

Post partum check 4Post partum check 4--6 weeks6 weeks

Newborn checkup 1Newborn checkup 1--2 weeks2 weeks


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Post Partum PsychiatricPost Partum Psychiatric

SyndromesSyndromes

UnderrecognizedUnderrecognized

UndertreatedUndertreated

UnderresearchedUnderresearched

First recognized with publication ofDSM IVFirst recognized with publication ofDSM IV

because they were not felt to havebecause they were not felt to have

distinguishable features from other psychiatricdistinguishable features from other psychiatricdisordersdisorders

Most classified as mood disorder subsetsMost classified as mood disorder subsets


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SyndromesSyndromes

EpidemiologyEpidemiology

Post partum psychosisPost partum psychosis

1:5001:500

Risk for previously affected 1:3Risk for previously affected 1:3

Non psychotic depressionNon psychotic depression

1:101:10--1515 Risk of previously affected 1:2Risk of previously affected 1:2

In patients with history of mood disorder andIn patients with history of mood disorder and

previous post partum depression ~ 100%previous post partum depression ~ 100%


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SyndromesSyndromes

Post partum blues affects 50Post partum blues affects 50--80%80%

due to lack of major symptoms not classified asdue to lack of major symptoms not classified as

a disordera disorder


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