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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 48ş 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