postpartum (1)
TRANSCRIPT
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POSTPARTUM
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Definitions
Postpartum Period from delivery of the placenta & membranes until
the involution of uterus is complete, usually 6 weeks post delivery
Involution The return of the uterus to normal size after childbirth
Subinvolution Incomplete return of the uterus to normal size after
childbirth
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Physiologic and Physical Changes
A review
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Cardiovascular system changes
Hypervolemia during pregnancy allows woman to withstand blood loss at delivery
Cardiac output remains elevated for 48º postdelivery
Cardiac output decreases to normal levels by 24 weeks postdelivery
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As the body rids itself of the excess plasma volume it’s accumulated during pregnancy, 2 things occur:
Diuresis
Diaphoresis
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Plasma fibrinogen (coagulation/clots) increases during pregnancy
Plasminogen (lysis of clots) does not mobility
Therefore, higher risk for thrombus formation
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Gastrointestinal System
Bowel tone remains sluggish for the first few days
Restricted food/fluids in labor
Perineal trauma/hemorrhoids Result could be constipation
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www.aafp.com
www.mediawars.ne.jp
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Urinary system
Trauma during delivery could cause swelling of the urinary meatus
Decreased sensation of having to void could cause urinary retention/stasis – could lead to a UTI
Urinary retention/bladder distention a primary cause of excessive bleeding Displaced uterus results in inability of uterus to contract
(atony)
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Musculoskeletal system
Levels of hormone relaxin decrease, causing pelvis to return to prepregnant position = hip/joint pain
Abdominal muscles weak/flabby Diastasis recti
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Integumentary system
Decrease in melanocyte-stimulating hormone causes a decrease or disappearance of chloasma or linea nigra
Striae gravidarum fade to silvery lines, but don’t completely go away!
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Neurologic system
Investigate headache!
Could be secondary to regional anesthesia….report to anesthesiologist
Could be due to development or worsening of PIH/preeclampsia, especially if accompanied by blurred vision/ photophobia/abdominal pain
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Breast Changes
If breastfeeding, improper baby positioning may result in redness, blisters, cracked and bleeding nipples
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Breast Engorgement
Breastfeeding or bottlefeeding
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Thrush
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Uterine involution
Immediately after delivery – uterus is midway between symphysis and umbilicus
Then rises to the umbilicus where it remains for about 24 hours
Then gradually descends ( 1 cm/day—or one fingerbreath “fb” per day)
• Document in terms of umbilicus (U, U-2, etc.)
• Usually not palpable by day 10
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Assessing Uterus Have pt. void
Feel fundal height related to umbilicus If fundus is displaced to side may be full bladder
Should feel firm, not overly tender
Pain/infection or full of blood
Massage and check amount of lochia Don’t over massage…overstimulation can cause atony!
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Assessing Uterus
Palpating fundus of uterus during the fourth stage of labor
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Assessing Uterus
Assessment of involution of uterus after childbirth– 2 days after childbirth (Courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, Calif.)
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Assessing Uterus
Assessment of involution of uterus after childbirth– 4 days after childbirth (Courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, Calif.)
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Vagina and Perineum
Introitus stretched and gaping
Hemorrhoids and edema by 2-3 days as circulation and movement
Episiotomy/perineal discomfort most marked 2-3 days PP, greatly improved by 4-7 days
By 6 weeks pelvic floor has regained tone, sutures are absorbed, perineum is healed
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Lochia
Vessels at the placental site become thrombosed and slough into lochia (uterine discharge of the puerperium)
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Normal progression
Rubra (red): from delivery to 2-3 days PP
Serosa (pink/brown):median duration is 22 days, but can still be present at 6 weeks exam
Alba (white/yellow): follows serosa
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Common to have 1-2 hours of bright red flow when eschar sloughs
Red lochia after 2 weeks - subinvolution/retained placenta
Subinvolution• Slower rate of involution• Can be from retained products/placental fragments,
clots, atony, infection
Variations in lochia
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Lochia
Lochia should not exceed moderate amount 4-8 pads/day
If heavy bleeding or large clots may need to prescribe methergine po
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Scant: 1 inch in 1 hr.
Light: < 4 inch stain 1 hr.
Moderate: < 6 inch 1 hr.
Heavy: Saturated pad in 1 hr.
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Episiotomy
Perineum may be swollen May have lacerations or episiotomy
Observe for: REEDA
redness edema ecchymosis/bruising discharge approximation
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Emotion
Baby BluesPostpartum DepressionPostpartum PsychosisPostpartum Panic DisorderPostpartum Obsessive-Compulsive
Disorder
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Psychological Changes
Labile emotions following birth Range from mild forms of feeling sad with
frequent crying to full blown psychosis
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Physiologic bases
Rapid hormone shifts as body returns to non-pregnant state
Fatigue
Discomfort
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Psychological bases
Sense of physical loss that may result in a mild grief reaction
Loss of center stage Feelings of insecurity
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Levels Blues – 1-10 days after birth…weepy
Depression – lasts at least 2 weeks…tense, irritable, sleeplessness, sees infant as demanding, feels inept at mothering
Psychosis – rare, within 3 weeks pp; bipolar or major depression
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Endocrine system
Placental hormones decline
Estrogen, progesterone, HCG
If not breastfeeding, pituitary hormone prolactin disappears in about 2 weeks.
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Ovulation and menstruation
Non-breastfeeding: usually resume periods within 7-9 weeks post delivery
Breastfeeding (6 or more times/day): usually resume periods by 12 weeks post delivery
Ovulation usually occurs BEFORE menses resumes….don’t rely on breastfeeding for contraception!
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Postpartum Rounds
Examine chart for: Time of delivery Type of delivery Episiotomy/lacerations Complications Infant feeding method Labs
Blood type CBC Rubella
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“BUBBLE HE”
B= Breasts U= Uterus B= Bladder B= Bowels L= Lochia E= Episiotomy H= Homan’s E= Emotions
Also…assess heart and lungs!
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Postpartum Rounds
Discharge instructions Report symptoms of infection Continue prenatal vitamins and iron If CBC low (< 10, if not on iron, can add it) Pain (especially if multigravida or 3rd or 4th degree
lacerations Choice of pain meds (Motrin 800 mg works well) Nupercainal ointment/Tucks for hemorrhoids
Contraceptive choice? Can get Depo Provera before leaving hospital Can start on OCPs after delivery
• Progesterone only/mini pill if BF (immediately)• Combined OCPs if bottle feeding (3 weeks)
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Postpartum Office Visit
Ask about her delivery
Her feelings about it
Any complications?
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Postpartum Office Visit
General state of mother and family How is she coping with the baby
Mood Appetite Exercise activities Rest/sleep
Involvement and interest of father Reactions of siblings to new baby
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Postpartum Office Visit
Ask about the baby
Problems at birth?
Problems now?
How is feeding going?
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Postpartum Office Visit
Ask her about: Fever, vaginal bleeding, cramping, discharge,
episiotomy pain, breast soreness or discharge, swelling, headaches, urinary symptoms, and bowel movements
Medications currently taking
Contraception method desired
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Postpartum Office Visit
Physical exam VS HEENT (as indicated) Heart and Lungs Thyroid Breast exam (review BSE) Abdomen – diastasis, softness Extremities – don’t forget homan’s Perineum inspection Pelvic exam, including pap smear
Note lochia Uterine size – should be normal size and nontender GC & Chlamydia culture if desires IUD
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Postpartum Office Visit
Labs Thyroid studies, if enlarged 1 hr GTT if had gestational diabetes
Medications Prenatal vitamins if breastfeeding OCPs if desired
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Postpartum Woman at Risk
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Postpartum HemorrhageDefinition: > 500 ml blood loss during the first 24
hours postpartum (vaginal birth)May occur
immediately after delivery during the early postpartum period may be “late postpartum hemorrhage”
which occurs up to a month after delivery
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Endometritis
Caused by bacteria that normally inhabit the vagina and cervix E. coli, Staphylococcus, Group B streptococcus
Process of delivery causes vagina to change from acidic environment to alkaline, which encourages bacterial growth
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Symptoms
Fever Chills Malaise Anorexia Feels like she has the
“flu”
Abdominal pain Uterine tenderness Purulent, foul-
smelling lochia Tachycardia subinvolution
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Risk Factors
History of previous infections
Colonization of lower genital tract pathogens
Cesarean delivery Trauma (I.e. vacuum
delivery) Prolonged ROM Prolonged labor
Multiple vaginal exams/internal monitors
Catherization Retained placental
fragments Hemorrhage Poor general
health/hygiene Poor nutritional status Low SES
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Treatment
Antibiotics: Cipro, Doxycycline, Metronidazole, Zithromax, Erythromycin
RestIncrease fluids
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Mastitis
Inflammation usually due to Staphylococcus Aureus
Due to: Poor drainage of milk Tight clothing Missed feedings Milk stasis Lowered maternal defenses
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Symptoms
Feels flu-likeFatigueMyalgiaFever (100.4° F or higher)Chills malaiseHeadacheLocalized area of redness/inflammation
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Treatment of Mastitis
Bedrest Increased fluids Frequent feeding of infant/empty milk ducts Supportive bra Local application of heat Analgesics Antibiotics –
Dicloxicillin/Ampicillin/Amoxicillin/Augmentin/
Keflex
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Thrush
Nystatin suspensionGentian violetKeep nipples clean and dry
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Urinary Tract Infection
Overdistention of bladderDecreased bladder sensitivityIncreased bladder capacityTrauma, edemaCatheterizationBacturia during pregnancy
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Cystitis (Lower Urinary Tract)
E-coli usual organism Ascending infection from urethra to bladder to
kidneys Get clean catch urine specimen Bacterial concentration > 100,000 colonies per
milliliter/sensitivity Antibiotics/sulfonamides Peri-care Increase fluids/ (3 liters)
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References
Lesnewski, R., & Prine, L. (2006). Initiating hormonal contraception. American Family Physician, 74 , 105-12.
http://www.searo.who.int/LinkFiles/Pregnancy_Childbirth_e.pdf
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SOAP Note Practice
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Hospital Note
S: Ready to go home. Breastfeeding is going well. Having some afterbirth pains. + BM
O: VSS. Breasts soft, nontender; nipples intact Heart: RR Lungs clear bilaterally Fundus firm, U-2; abdomen soft Lochia Rubra/serosa; scant Episiotomy intact without redness or exudate Voiding qs
A: Stable Afterbirth pains
P: Discharge home Discharge instructions reviewed Motrin 800 mg po Q 8 hrs prn
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6 Weeks PP Exam
S: Feeling well; breastfeeding without difficulty; siblings adjusting well to new infant. Voiding without difficulty and having regular BMs. Has not resumed intercourse but desires OCPs.
O: Thyroid: WNL Heart: RR Lungs: CTAB Abdomen: no diastasis; soft Back: straight; no CVAT Extremities: no swelling; - Homans Perineum: healed; no lesions Uterus: small; anteverted No adnexal masses Cervix: transverse os; closed; no exudate
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A: normal pp exam Contraceptive needs
P: BSE reviewed Micronor 1 po q day, #3, RF X3 OK to begin exercise F/U in one year or prn