postpartum care.pdf

7/29/2019 Postpartum Care.pdf

1/10

POSTPARTUM CARE

I. In-Hospital Postpartum CareImmediate postpartum care:monitoring of vital signs,pain management, andsurveillance for complications e.g.: postpartum hemorrhage.Particular attention should be paid to patients who have had a cesarean section, recognizing thatthey are postsurgical patients and should receive appropriate additional care. As concern forpostpartum complications eases, increasing attention should be turned to parental education.Important issues to cover during this time include maternal self-care, appropriate sexual andphysical activity, and infant nutrition.

Common Postpartum Complicationso Postpartum Hemorrhage. Postpartum hemorrhage has various definitions: (a)

estimated blood loss 500 mL for a vaginal delivery and1,000 mL for acesarean delivery; (b) a 10% change in hematocrit between admission and thepostpartum period (1); and (c) excessive bleeding that produces symptoms andrequires erythrocyte transfusion. Excessive blood loss that occurs within 24 hoursof delivery is termed primary or acute postpartum hemorrhage; more than 24hours after delivery (up to 6 weeks) is termed secondary or late postpartumhemorrhage. The incidence of postpartum hemorrhage is approximately 4% withvaginal delivery and 6% with cesarean delivery (1). See Chapter 7, Complications

of Labor and Delivery, for more information.o Postpartum febrile morbidity is defined as a temperature higher than 38.0C onat least two occasions, at least 4 hours apart, after the first 24 hours postpartum.The differential diagnosis includes breast engorgement, atelectasis, urinary tractinfection, and endomyometritis. This topic of breast engorgement is discussedlater in more detail.

Urinary tract infections can occur in the postpartum period and should beconsidered in the febrile patient.

Endomyometritis complicates 1% to 3% of vaginal deliveries and is up to10 times more common after cesarean deliveries (2). Clinically,endometritis presents as fever, uterine tenderness, malaise, or foul-

smelling lochia and is usually a polymicrobial infection of gram-positiveaerobes (groups A and B streptococci, enterococci), gram-negativeaerobes (Escherichia coli), and anaerobes (peptostreptococcus,peptococcus, bacteroides) from the genital tract. Bacteremia may bepresent in 10% to 20% of cases (2). Endomyometritis should be treatedwith intravenous antibiotics until the patient is clinically improved andafebrile for 24 to 48 hours. The American College of Obstetricians andGynecologists (ACOG) recommends initial treatment with gentamicin (1.5mg/kg every 8 hours) and clindamycin (900 mg every 8 hours), with theaddition of ampicillin (2 g every 4 to 6 hours) if Enterococcus is suspectedor if fever persists after initial treatment. Some practitioners begin initial


2/10

therapy with the triple antibiotic regimen. Further treatment with oralantibiotic therapy is unnecessary (3). Response to antibiotic treatment isusually prompt. See Chapter 7 for more details on endomyometritis.

Finally, patients with persistent fevers after 48 to 72 hours of antibiotictreatment should be assessed for other complications, such as retainedproducts of conception (especially if their bleeding is heavier than usual),

P.246

pelvic abscess, wound infection, ovarian vein thrombosis, and septicpelvic thrombophlebitis (SPT). SPT is rare, occurring 1 in 2,000 deliveries(4), and is characterized by high, spiking fevers despite appropriate dosesof antibiotics. Patients tend to feel well between fevers and have no

complaint of pain. Imaging is frequently obtained to look for an abscess.The pelvic clots associated with SPT are not always seen on CT or MRI,thus the diagnosis is traditionally made based on the previously mentionedsigns and because fevers resolve within 24 to 48 hours of initiation ofheparin therapy (5). However, recent studies suggest that even the additionof heparin therapy should not be part of the diagnosis (4).

All maternal fevers should be reported to the newborn nursery.

o Hypertension is defined as BP of 140/90 or higher, taken with the patient in aseated position on two or more occasions, 4 or more hours apart. Some women

may develop pre-eclampsia or eclampsia postpartum, even in the absence ofantenatal complications, so particular attention should be paid to maternal BPpostpartum. Any pressure reading of 140/90 or higher should be evaluated byrepeating BP measurements, checking urine protein, and evaluating forsigns/symptoms of pre-eclampsia. In those women who had antenatal pre-eclampsia, effective postpartum diuresis as well as normalization of BP should bedocumented. However, hypertension resulting from pre-eclampsia can persist forup to 6 weeks. See Chapter 14 for more details.

Immunizations. The peripartum period is an appropriate time to offer vaccination againstrubella, hepatitis A, hepatitis B, or both, to women at risk for these diseases.

o Rh Immunoglobulin. An unsensitized Rh-negative woman who delivers an Rh-positive infant should receive 300 mg of Rh immunoglobulin within 72 hours ofdelivery even if Rh immunoglobulin was given in the antepartum period.Additional doses may be necessary if there is evidence of antepartum fetal-maternal hemorrhage. The blood bank that provides the Rh immunoglobulinshould perform testing to assess the potential need for additional doses.

o Rubella Vaccine. Mothers who are not immune to the rubella virus should receivethe measles-mumps-rubella (MMR) vaccine just before discharge because it is alive virus, and exposure to pregnant women should be avoided. Use ofmonovalent rubella vaccine (e.g., Rubivax) is no longer considered appropriatebecause MMR is more cost-effective and because many of the women without


3/10

immunity to rubella also lack immunity to rubeola (measles). Breast-feeding isnot a contraindication to MMR vaccination.

II. DischargeWhen no complications occur, mothers may be discharged 24 to 48 hours after vaginal deliveryand 24 to 96 hours after cesarean delivery. The following criteria should be met:

Vital signs are sTable and within normal limits. Uterine fundus is firm and decreasing in size (within 24 hours postpartum; a uterus

without fibroids should decrease to 20-week size). The amount and color of lochia is appropriatered, less than a heavy period, and

decreasing. Urine output is adequate. Any surgical incisions or vaginal repair sites are healing well without signs of infection. The mother is able to eat, drink, ambulate, and void without difficulty. No medical or psychosocial issues are identified that preclude discharge. The mother has demonstrated knowledge of appropriate self-care and care of her infant. The issue of contraception has been addressed. Appropriate immunizations and Rh immunoglobulin, if appropriate, have been

administered. Follow-up care has been arranged for mother and infant. Infant nutritional needs have been addressed.

P.247

III. Outpatient Postpartum Care

Timing. Women should be seen 4 to 6 weeks postpartum unless a problem is identified inthe early puerperium that requires closer follow-up. For example, women withhypertensive complications should have a BP check within 1 week of discharge.

The postpartum visit should address the following:

Physical exam

o BP, breast, abdomen, and pelvic examinationo Vaginal repairs should be healing.o At 2 weeks postpartum, the nonmyomatous uterus is usually

not palpable abdominally.o By 6 weeks postpartum, the nonmyomatous uterus should

return to 1.5 to 2.0 times its nonpregnant size.

Lochia (quantityand quality)

o By 6 weeks postpartum, lochia should be essentially gone.o If lochia is persistent, it should be re-evaluated at 10 to 12

weeks. If still bleeding, a full evaluation is warranted,including measurement of serum human chorionicgonadotropin.


4/10

Pain o Perineal discomfort can be treated with sitz baths, ice packs,and analgesics.

o Women with significant pain deserve further evaluation forperivaginal hematomas or other complications.

Contraception See section under Breast-Feeding and Chapter 28, Fertility Control.Sexual activity o When the perineum is healed and bleeding is decreased, sexual

activity may be safely resumed.o Any significant dyspareunia should be evaluated.

Infant feedingmethod

o Attention to difficulties with either breast or bottleDepressionscreening

o Assess for psychosocial well-being.o If there is evidence of depression, antidepressant medication

should be considered, and the patient should be referred formental health care.

o Thyroid-stimulating hormone level should be determined torule out postpartum hypothyroidism.

Immunizations o Discuss indicated vaccines before discharge.Antenatalcomplications

o Patients with pre-eclampsia should be followed to rule outchronic hypertension or nephrotic syndrome.

o Women with gestational diabetes should be screened fordiabetes (Table 20.1).

Table 20.1 Diabetic Screening in the Nonpregnant Patient

Fasting glucose

level (mg/dL)

Glucose level 2 hours

after 75-g load (mg/dL) Management

Normal 200Random glucose level>200 with symptoms

Treatment as indicated

The fasting plasma glucose test is the preferred test for diagnosis of diabetes. An initialabnormal value must be confirmed, on a subsequent day, by measurement of fastingplasma glucose level, plasma glucose level after glucose load, or random plasma glucoselevel if symptoms are present.Adapted from the American Diabetes Association Clinical Practice Recommendations,2001.

P.248

Breast-Feeding


5/10

I. RecommendationsThe American Academy of Pediatrics (6) recommends breast-feeding exclusively for the first 6months of life and partial breast-feeding (plus complementary foods) for at least 12 months. TheWorld Health Organization (WHO) recommends that partial breast-feeding continue for 2 ormore years. Breast-feeding should be encouraged as soon as possible after delivery. Infants andmothers who initiate breast-feeding within the first hour after delivery have a higher success ratethan those who delay it. Newborns should be fed every 2 to 3 hours until satiety. Feeding for atleast 5 minutes at each breast at each feeding on postpartum day 1, and gradually increasingfeeding time over the next few days, will allow optimal milk let-down without resulting in sorenipples. Nondemanding infants should be aroused every 4 hours for feeding, and limiting feedingtime is not necessary. Frequent breast-feeding helps establish maternal milk supply, preventsexcessive engorgement, and minimizes neonatal jaundice.Breast-feeding may be associated with initial minor discomfort, but painful breasts should beassessed and positioning should be re-evaluated. Nipple tenderness can be treated with lanolin

cream. In addition, women should begin nursing on the less sore breast, change nursing positionto rotate stress points on nipples, and be instructed to break suction before removing the infantfrom the breast.Women who are breast-feeding require 500 to 1,000 kcal per day more than nonlactating women.Breast-feeding women are at increased risk of deficiencies in magnesium, vitamin B 6, folate,calcium, and zinc. Human milk may not provide adequate iron for premature newborns or infantswho are older than 6 months. Supplemental iron should be given to these infants and to infantswhose mothers are iron deficient.Women who are not breast-feeding will experience breast engorgement about 3 days postpartum.Breast engorgement is often uncomforTable and may be treated with techniques, such as breastbinding, ice packs, and avoidance of nipple stimulation.

II. Statistics on Breast-Feeding

In 1971, 24.7% of all mothers initiated breast-feeding (7). In 2003, 70.9% of all mothers in the United States initiated breast-feeding, including

54.9% of African American mothers (8). In 2003, 36.2% of mothers breast-fed at 6 months (8). Women with the highest breast-feeding rate are college-educated, married, older than age

30, residents of the Mountain or Pacific census regions, and are not enrolled in theWomen, Infants, Children (WIC) program.

Women with the lowest breast-feeding rate are African American, did not complete highschool, are younger than age 20, are residents in the East-South-Central census regions,

have lower income, and are enrolled in the WIC program. Healthy People 2010 goals are 75% of all mothers breast-feeding in early postpartum

period, 50% at 6 months and 25% at 12 months (9).

III. Benefits for NewbornsFor the baby, breast-feeding provides excellent nutrition with changing nutritional content tomatch nutritional needs. For example, breast milk includes increased protein and minerals shortlyafter delivery and increased water, fat, and lactose later. Breast milk's nutritional content changesduring pregnancy as well, so that a baby born prematurely will receive nutrition moreappropriate to his or her needs.


6/10

Breast-feeding also provides protection against infection. Postneonatal infant mortality rates inthe United States are reduced by 21% in breast-fed infants (6). Secretory immunoglobulin A ispresent in high quantities in colostrum and thus provides the baby with passive immunity to theinfections to which the mother has immunity. Breast milk promotes phagocytosis bymacrophages and leukocytes, thus boosting cellular immunity. Bifidus factor is present in breastmilk and promotes proliferation of Lactobacillus bifidus, which decreases colonization bypathogens that cause diarrhea.P.249

Based on research in developed countries among middle-class populations, breast-feedingdecreases the rate and/or severity of bacterial meningitis, bacteremia, diarrhea, respiratory tractinfection, necrotizing enterocolitis, otitis media, urinary tract infections, and late-onset sepsis inpreterm infants (6).

Because the protein in breast milk is species (human) specific, the delayed introduction offoreign protein also delays and reduces the development of allergies to some environmentalallergens. Breast-feeding has been shown to decrease the incidence and severity of eczema.IV. Benefits for MothersOxytocin release during milk let-down causes increased uterine contractions, hastens uterineinvolution, and thus decreases postpartum blood loss. Women who breast-feed experience adecreased risk of ovarian and premenopausal breast cancer that is proportional to the time thatthey spent breast-feeding. Breast-feeding mothers may also experience a decreased incidence ofosteoporosis and postmenopausal hip fracture and a decreased incidence of pregnancy-inducedlong-term obesity. Breast-feeding supports bonding between mother and child and clearly resultsin decreased costs compared to formula feeding (6). Breast-feeding also facilitates child spacing

secondary to lactational amenorrhea (see chapter on Fertility Control).V. ContraindicationsAlthough not contraindications, some structural problems make breast-feeding difficult andsometimes impossible. These include tubular breasts, hypoplastic breast tissue, true invertednipples (very rare), and surgical alterations that sever the milk ducts.The following are strict contraindications to breast-feeding (6):

Mothers using drugs of abuse, including excessive alcohol Infant with galactosemia Maternal human immunodeficiency virus infection in the United States. In developing

countries, the benefits of breast-feeding may outweigh the risk of HIV transmission. Maternal active, untreated tuberculosis or women with human T-cell lymphotropic virus

type I- or II. Women can give their infant expressed breast milk and can breast-feed oncetheir treatment regimen is well established.

Maternal active, untreated varicella. Once the infant has been given varicella zosterimmunoglobulin, the infant can receive expressed breast milk if there are no lesions onthe breast. Within 5 days of the appearance of the rash, maternal antibodies are produced,and thus breast-feeding would be beneficial in providing passive immunity.

Active herpes lesions on the breast Mothers who are receiving diagnostic or therapeutic radioactive isotopes or have had

exposure to radioactive materials


7/10

Mothers receiving antimetabolites or chemotherapeutic agentsVI. Noncontraindications (6)

Congenital or acquired cytomegalovirus infection in an otherwise healthy, term infant.Such infants actually do better if they are breast-fed because maternal antibodies (andvirus) are in breast milk.

Maternal acute hepatitis A if the infant has received hepatitis A immunoglobulin andhepatitis A vaccine

Mothers who are hepatitis B surface antigen-positive. Infant should receive appropriateimmunoprophylaxis, including hepatitis B immune globulin (HBIG) and hepatitisvaccine. (Women who have had acute hepatitis B infection during pregnancy should notbreast-feed.)

Mothers with hepatitis C virus antibody or hepatitis C virus-RNA-positive blood (someproviders discourage breast-feeding in women with hepatitis C; however, this is notsupported by data).

VII. Breast-Feeding and Maternal MedicationsUse of nearly all antineoplastic, thyrotoxic, and immunosuppressive medications iscontraindicated during breast-feedingP.250

(Table 20.2). In general, breast-feeding may be continued during maternal antibiotic therapy.Although all major anticonvulsants are secreted in breast milk, they need not be discontinuedunless the infant shows signs of excessive sedation. The Web site of the American Academy of

Pediatrics (http://www.pediatrics.org) contains updated information on medication use in breast-feeding.

Table 20.2 Medications Contraindicated During Breast-Feeding

Medication Reason for discontinuation

Bromocriptinemesylate

Lactation suppression

Cocaine Cocaine intoxication of the newbornErgotamine tartrate Vomiting, diarrhea, convulsions in the newbornLithium One-third to one-half of maternal drug levels found in the newbornPhencyclidine Potent hallucinogenRadioactive elements Enter newborn bloodstream

Cyclophosphamide Possible neutropenia and immune suppression in the newborn; unknowneffect on growth or association with carcinogenesis

Cyclosporine Same as for cyclophosphamideDoxorubicinhydrochloride

Same as for cyclophosphamide

Methotrexate sodium Same as for cyclophosphamideAdapted from the American Academy of Pediatrics, Committee on Medications, 1994.VIII. Contraception During Lactation


8/10

In the nonbreast-feeding woman, the average time to first ovulation is 45 days (range between 25to 72 days). The mean time to ovulation is 190 days in women who are breast-feeding (see Fig.20.1).

The lactational amenorrhea method has been shown to provide 95% to 99% protection inthe first 6 months postpartum if strict criteria are followed. Feedings need to be every 4hours during the day and every 6 hours at night. Supplemental feedings should notexceed 5% to 10% of the total.

Figure 20.1. Postpartum return of menstruation and ovulation.

P.251 Nonhormonal methods (condom, intrauterine device, sterilization) are the preferred

methods of contraception in lactating women. Progestin contraceptives (progestin-only mini-pill, progestin injectables, progestin

implants) do not affect the quality of breast milk and may actually increase the volume ofmilk; thus, they are the preferred methods of hormonal contraception. The progestin frompills, injectables, and implants has been shown to be present in breast milk. Despite thelack of evidence that suggests adverse effects on infants, a theoretic risk exists of harmful

consequences from exogenous steroids. Therefore, some question has emerged as towhen to initiate progestin contraception. ACOG recommends initiating progestin pill use2 to 3 weeks postpartum, administering injectables and implants at 6 weeks postpartum.Starting progestin contraceptives earlier may be accepTable for those patients who areunwilling or unable to use nonhormonal contraceptives and who are not willing to risk arepeat pregnancy. Of importance is the decreased efficacy of progestin-only pills and theneed to take them at the same time every day (see Chapter 28, Fertility Control). Thelevonorgestrel intrauterine device (Mirena) is a progesterone-only option with greaterefficacy and is recommended to insert at the 6-week postpartum visit.

Combination Estrogen-Progestin Contraceptives. Estrogen-containing oral contraceptivepills (OCPs) have long been thought to reduce the quantity and quality of breast milk.


9/10

However, clinical trials that evaluate the impact of combined OCPs on lactation supplyand infant growth are conflicting and need further investigation (10). For now, WHOrecommends waiting at least 6 months before initiating combination OCPs. The U.S.Food and Drug Administration labeling committee recommends not using combinationOCPs until the child is completely weaned. ACOG recommends that, if combinationOCPs are preferred, they should not be started before 6 weeks postpartum, and theyshould only be started after lactation is well established and the infant's nutritional statusis well monitored (7). As with progestin-only contraceptives, some providers may initiatethe use of combination OCPs earlier if lactation is well established, the patient declinesother forms of contraception, and the risk of repeat pregnancy is significant.

IX. MastitisMastitis is a breast infection that occurs in 1% to 2% of breast-feeding women, usually betweenthe first and fifth weeks postpartum (7). This condition is characterized by a localized sore,

reddened, and indurated area on the breast that is often accompanied by fever, chills, andmalaise.

Etiology and Treatment. Forty percent of cases are due to Staphylococcus aureusinfection. Other common offending organisms include B-hemolytic streptococci, E. coli,and Haemophilus influenzae.

o Treatment consists of continued nursing, nonsteroidals, and antibiotics. Initialantibiotic therapy is often started with dicloxacillin, 500 mg four times daily for10 days. Women should continue to express milk, starting on the affected side toencourage more complete emptying. If there is no improvement in 48 hours,antibiotic coverage should be changed to cephalexin or ampicillin with

clavulanate (Augmentin).o Differential diagnosis includes the following (see Table 20.3):

Clogged milk ducts: a tender lump in the breast not accompanied bysystemic symptoms; resolves after application of warm compresses andmassage. Unrelieved, clogged ducts can lead to galactoceles, cysts filledinitially with milk but may convert to a thicker, cheesy substance that isdifficult to drain. These can be treated with warm compresses and massagebut may require ultrasound treatment or needle aspiration.

Breast engorgement: bilateral, generalized tenderness of breasts, oftenoccurring 2 to 4 days postpartum and associated with low-grade fevers.May be treated with application of warm compresses followed by hand or

pump expression of milk and continued breast-feeding. Inflammatory breast cancer: a rare form of breast cancer that presents with

breast tenderness and breast skin changes.

Table 20.3 Differential Diagnosis of Enlarged, Tender Breasts

Postpartum

Finding Engorgement Mastitis Plugged duct

Onset Gradual Sudden GradualLocation Bilateral Unilateral UnilateralSwelling Generalized Localized Localized


10/10

Pain Generalized Intense, localized LocalizedSystemic symptoms Feels well Feels ill Feels wellFever No Yes NoFrom Beckmann CRB, Ling FW, Barzansky BM, et al. Obstetrics andGynecology, 4th Ed. Baltimore: Lippincott Williams & Wilkins,2002:158, with permission.

P.252 Breast abscess: a firm, tender, usually well-circumscribed mass. Breast

sonography may be required for diagnosis, and incision and drainage arenecessary for treatment.

X. Decreased Milk SupplyThe normal amount of milk produced by the end of the first postpartum week is 550 mL per day.By 2 to 3 weeks, milk production is increased to approximately 800 mL per day. Milk productionpeaks at 1.5 to 2.0 L per day. Before gaining weight, newborns who are breast-fed may beexpected to lose 5% to 7% of birth weight in the first week. If the loss is greater than 5% to 7%,or if the weight loss is rapid, adequacy of breast feeding should be assessed. Glycogen stores infull-term infants generally provide sufficient initial nutrition. Therefore, supplemental feedingshould be avoided unless medically indicated. Frequent breast-feeding helps maintain milkstores. Maternal poor nourishment and psychological stress can decrease milk supply. Sheehansyndrome (postpartum pituitary necrosis) can also result in lack of milk production. Sheehan'ssyndrome is clinically characterized by development of lethargy, anorexia, weight loss, as well

as inability to lactate.

postpartum care.pdf

Documents