postpartum (1)

POSTPARTUM

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

Physiologic and Physical Changes

A review

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

As the body rids itself of the excess plasma volume it’s accumulated during pregnancy, 2 things occur:

Diuresis

Diaphoresis

Plasma fibrinogen (coagulation/clots) increases during pregnancy

Plasminogen (lysis of clots) does not mobility

Therefore, higher risk for thrombus formation

Gastrointestinal System

Bowel tone remains sluggish for the first few days

Restricted food/fluids in labor

Perineal trauma/hemorrhoids Result could be constipation

www.aafp.com

www.mediawars.ne.jp

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)

Musculoskeletal system

Levels of hormone relaxin decrease, causing pelvis to return to prepregnant position = hip/joint pain

Abdominal muscles weak/flabby Diastasis recti

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!

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

Breast Changes

If breastfeeding, improper baby positioning may result in redness, blisters, cracked and bleeding nipples

Breast Engorgement

Breastfeeding or bottlefeeding

Thrush

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

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!

Assessing Uterus

Palpating fundus of uterus during the fourth stage of labor

Assessing Uterus

Assessment of involution of uterus after childbirth– 2 days after childbirth (Courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, Calif.)

Assessing Uterus

Assessment of involution of uterus after childbirth– 4 days after childbirth (Courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, Calif.)

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

Lochia

Vessels at the placental site become thrombosed and slough into lochia (uterine discharge of the puerperium)

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

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

Lochia

Lochia should not exceed moderate amount 4-8 pads/day

If heavy bleeding or large clots may need to prescribe methergine po

Scant: 1 inch in 1 hr.

Light: < 4 inch stain 1 hr.

Moderate: < 6 inch 1 hr.

Heavy: Saturated pad in 1 hr.

Episiotomy

Perineum may be swollen May have lacerations or episiotomy

Observe for: REEDA

redness edema ecchymosis/bruising discharge approximation

Emotion

Baby BluesPostpartum DepressionPostpartum PsychosisPostpartum Panic DisorderPostpartum Obsessive-Compulsive

Disorder

Psychological Changes

Labile emotions following birth Range from mild forms of feeling sad with

frequent crying to full blown psychosis

Physiologic bases

Rapid hormone shifts as body returns to non-pregnant state

Fatigue

Discomfort

Psychological bases

Sense of physical loss that may result in a mild grief reaction

Loss of center stage Feelings of insecurity

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

Endocrine system

Placental hormones decline

Estrogen, progesterone, HCG

If not breastfeeding, pituitary hormone prolactin disappears in about 2 weeks.

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!

Postpartum Rounds

Examine chart for: Time of delivery Type of delivery Episiotomy/lacerations Complications Infant feeding method Labs

Blood type CBC Rubella

“BUBBLE HE”

B= Breasts U= Uterus B= Bladder B= Bowels L= Lochia E= Episiotomy H= Homan’s E= Emotions

Also…assess heart and lungs!

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)

Postpartum Office Visit

Ask about her delivery

Her feelings about it

Any complications?


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


Ask about the baby

Problems at birth?

Problems now?

How is feeding going?


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


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


Labs Thyroid studies, if enlarged 1 hr GTT if had gestational diabetes

Medications Prenatal vitamins if breastfeeding OCPs if desired

Postpartum Woman at Risk

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

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

Symptoms

Fever Chills Malaise Anorexia Feels like she has the

“flu”

Abdominal pain Uterine tenderness Purulent, foul-

smelling lochia Tachycardia subinvolution

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

Treatment

Antibiotics: Cipro, Doxycycline, Metronidazole, Zithromax, Erythromycin

RestIncrease fluids

Mastitis

Inflammation usually due to Staphylococcus Aureus

Due to: Poor drainage of milk Tight clothing Missed feedings Milk stasis Lowered maternal defenses

Symptoms

Feels flu-likeFatigueMyalgiaFever (100.4° F or higher)Chills malaiseHeadacheLocalized area of redness/inflammation

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

Thrush

Nystatin suspensionGentian violetKeep nipples clean and dry

Urinary Tract Infection

Overdistention of bladderDecreased bladder sensitivityIncreased bladder capacityTrauma, edemaCatheterizationBacturia during pregnancy

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)

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

SOAP Note Practice

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

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

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

postpartum (1)

Documents