POSTPARTUM

1. POSTPARTUM

3. Physiologic and Physical Changes A review

4. Cardiovascular system changes Hypervolemia during pregnancy allows woman to withstand blood loss at delivery Cardiac output remains elevated for 48� postdelivery Cardiac output decreases to normal levels by 24 weeks postdelivery

5. As the body rids itself of the excess plasma volume it�s accumulated during pregnancy, 2 things occur: Diuresis Diaphoresis

6. Plasma fibrinogen (coagulation/clots) increases during pregnancy Plasminogen (lysis of clots) does not ? mobility Therefore, higher risk for thrombus formation

8. Gastrointestinal System Bowel tone remains sluggish for the first few days Restricted food/fluids in labor Perineal trauma/hemorrhoids Result could be constipation

10. 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)

12. Musculoskeletal system Levels of hormone relaxin decrease, causing pelvis to return to prepregnant position = hip/joint pain Abdominal muscles weak/flabby Diastasis recti

13. 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!

15. 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

16. Breast Changes If breastfeeding, improper baby positioning may result in redness, blisters, cracked and bleeding nipples

17. Breast Engorgement Breastfeeding or bottlefeeding

18. Thrush

19. 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

20. 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!

21. Assessing Uterus

23. Assessing Uterus

24. Assessing Uterus

25. 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

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

27. 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

28. 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

29. Lochia Lochia should not exceed moderate amount 4-8 pads/day If heavy bleeding or large clots may need to prescribe methergine po

30. Scant: 1 inch in 1 hr. Light: < 4 inch stain 1 hr. Moderate: < 6 inch 1 hr. Heavy: Saturated pad in 1 hr.

34. Episiotomy Perineum may be swollen May have lacerations or episiotomy Observe for: REEDA redness edema ecchymosis/bruising discharge approximation

36. Emotion Baby Blues Postpartum Depression Postpartum Psychosis Postpartum Panic Disorder Postpartum Obsessive-Compulsive Disorder

37. Psychological Changes Labile emotions following birth Range from mild forms of feeling sad with frequent crying to full blown psychosis

38. Physiologic bases Rapid hormone shifts as body returns to non-pregnant state Fatigue Discomfort

39. Psychological bases Sense of physical loss that may result in a mild grief reaction Loss of center stage Feelings of insecurity

40. 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

41. Endocrine system Placental hormones decline Estrogen, progesterone, HCG If not breastfeeding, pituitary hormone prolactin disappears in about 2 weeks.

42. 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!

43. Postpartum Rounds Examine chart for: Time of delivery Type of delivery Episiotomy/lacerations Complications Infant feeding method Labs Blood type CBC Rubella

44. �BUBBLE HE� B= Breasts U= Uterus B= Bladder B= Bowels L= Lochia E= Episiotomy H= Homan�s E= Emotions Also�assess heart and lungs!

45. 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)

46. Postpartum Office Visit Ask about her delivery Her feelings about it Any complications?

47. 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

48. Postpartum Office Visit Ask about the baby Problems at birth? Problems now? How is feeding going?

49. 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

50. 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

51. Postpartum Office Visit Labs Thyroid studies, if enlarged 1 hr GTT if had gestational diabetes Medications Prenatal vitamins if breastfeeding OCPs if desired

52. Postpartum Woman at Risk

53. Postpartum Hemorrhage Definition: > 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

54. 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

55. Symptoms Fever Chills Malaise Anorexia Feels like she has the �flu� Abdominal pain Uterine tenderness Purulent, foul-smelling lochia Tachycardia subinvolution

56. 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

57. Treatment Antibiotics: Cipro, Doxycycline, Metronidazole, Zithromax, Erythromycin Rest Increase fluids

58. Mastitis Inflammation usually due to Staphylococcus Aureus Due to: Poor drainage of milk Tight clothing Missed feedings Milk stasis Lowered maternal defenses

59. Symptoms Feels flu-like Fatigue Myalgia Fever (100.4� F or higher) Chills malaise Headache Localized area of redness/inflammation

62. 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

63. Thrush Nystatin suspension Gentian violet Keep nipples clean and dry

64. Urinary Tract Infection Overdistention of bladder Decreased bladder sensitivity Increased bladder capacity Trauma, edema Catheterization Bacturia during pregnancy

65. 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)

67. 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

68. SOAP Note Practice

69. 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

70. 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

71. 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